Unlocking the mystery of persistent skin ulcers in a young man and successful treatment with a simple regimen

Despite the high prevalence of pulmonary tuberculosis worldwide, extrapulmonary tuberculosis especially cutaneous and osteoarticular tuberculosis occurs rarely, both of which are often difficult to be recognized since their symptoms mimic those of many other cutaneous and osteoarticular diseases. Here, we present a rare case of cutaneous tuberculosis potentially accompanied by osteroarticular tuberculosis in a 36‐year‐old Chinese man who presented with multiple persistent skin ulcers for one year and were nonresponsive to multiple therapeutic approaches. A single anti‐tuberculous regimen with rifampicin resulted in healing of all skin lesions and excellent recovery of the general condition.     

Cutaneous tuberculous gummas in a patient with polymyositis

Metastatic tuberculous abscesses or cutaneous tuberculous gummas occur mostly by reactivation of ancient cutaneous foci and is triggered mainly by pharmacological immunosuppression, diabetes mellitus, alcoholism or acquired immunodeficiency syndrome. The present case report refers to a 33-year-old male patient with polymyositis and a previous diagnosis of treated pulmonary tuberculosis. He presented cutaneous abscesses and fever months after the tuberculosis regimen. The patient was diagnosed as metastatic tuberculous abscesses associated with immunosuppression as result of polymyositis treatment.     

Relevant diagnostic implications of the therapeutic challenge with antitubercular therapy in an unusual case of sarcoidosis mimicking lupus vulgaris

Cutaneous manifestations in sarcoidosis are seen in 25–35% of patients with systemic disease and may be the sole manifestation in few patients. It is known that isolated cutaneous sarcoidosis is a great mimicker and can be easily misdiagnosed as other granulomatous conditions especially lupus vulgaris in regions with high burden of tuberculosis (TB). Here we present a case with cutaneous sarcoidosis who was initially misdiagnosed and treated as bifocal lupus vulgaris with antitubercular therapy (ATT) for 6 months. This nonresponsiveness to therapy prompted us to investigate the patient further for other differentials, failing which a diagnosis of cutaneous sarcoidosis was made and the patient was treated with oral steroids and methotrexate with complete clearance of lesions after 14 weeks of therapy. Our case reemphasizes the value of therapeutic trial of ATT in diagnosis of cutaneous TB and highlights the remarkable clinical mimic of sarcoidosis with lupus vulgaris.     

Cutaneous manifestations of tuberculosis

Cutaneous involvement is a rare manifestation of tuberculosis (TB). The correct diagnosis is often significantly delayed because cutaneous TB is not routinely considered in the differential diagnosis or because investigations fail to reveal the presence of Mycobacterium tuberculosis. The clinical features of cutaneous TB are diverse, and result from exogenous and endogenous spread of M. tuberculosis and from immune-mediated mechanisms. The recognition of cutaneous TB is important, as the diagnosis is frequently overlooked resulting in delayed treatment.     

Polymerase chain reaction compared to other laboratory findings and to clinical evaluation in the diagnosis of cutaneous tuberculosis and atypical mycobacteria skin infection

Background   Cutaneous tuberculosis has re-emerged in the last 15 years together with the higher incidence of pulmonary tuberculosis and multidrug resistance. The choice for a single diagnostic tool among the many available today is a challenge. Our objective was to compare polymerase chain reaction (PCR) with other exams in the diagnosis of cutaneous tuberculosis and atypical mycobacteria skin infection.
Methods   PCR and a set of five different exams were performed in 32 patients (34 samples of paraffin-embedded tissue) evaluated for 3 years in a university hospital, considering the response to mycobacterial infection treatment as a positive case.
Results   PCR was the most sensitive (88%) and specific (83%) exam. Culture, immunohistochemistry and acid-fast bacilli were not in agreement with clinical response to treatment.
Conclusions   Although PCR is a useful tool, careful clinical exam is still the gold standard for the evaluation and treatment of cutaneous tuberculosis and mycobacteria skin infection.     

Cutaneous tuberculosis in Indian children: the importance of screening for involvement of internal organs

AIMS AND OBJECTIVES: Resurgence of skin tuberculosis especially with drug-resistant strains has been well documented in recent years, but this problem has not received much attention in the paediatric age group. Hence, we carried out the present study to analyse the clinical and therapeutic aspects of cutaneous tuberculosis in children. MATERIALS AND METHODS: A detailed clinical examination, investigations, such as haemogram, serology for HIV, Mantoux test, chest X-ray, cytology, culture and histopathology were carried out in all children. They were treated with antitubercular therapy (WHO regimen), and the clinical response was followed up. RESULTS: Of 142 patients with cutaneous tuberculosis, 68 were children (40 females, 28 males). These children were aged from 9 months to 14 years. The duration of the disease varied from 1 month to 6 years. Family history of tuberculosis was present in 28 (41.2%) of the patients. Scrofuloderma was the most common presentation encountered in 30 (44.1%) patients with preferential involvement of the cervical (56.2%) and inguinal (20%) regions. Fifteen (22.1%) patients had lupus vulgaris, of which the keratotic type was the most common (46.7%), 16 had lichen scrofulosorum, three had tuberculosis verrucosa cutis, and four had more than one type of tuberculosis. Involvement of the lung in 14 (20.6%), bone in seven (10.2%), and both in four (5.9%) was found. Histopathology corroborated the clinical diagnosis in 54 (80.6%), culture was positive in six (8.8%). Fifty (73.5%) patients completed the treatment with an excellent response, no multidrug resistant cases were seen. CONCLUSIONS: Cutaneous tuberculosis in children continues to be an important cause of morbidity, there is a high likelihood of internal involvement, especially in patients with scrofuloderma. A search is required for more sensitive, economic diagnostic tools. Response to treatment at 4 weeks often helps in substantiating the diagnosis of tuberculosis in doubtful cases.     

Incidence of cutaneous tuberculosis in patients with organ tuberculosis

BACKGROUND: Tuberculosis continues to be a health problem in some countries. The development of resistance to antituberculitic drugs and the increase in diseases and conditions associated with immunodeficiency such as AIDS and chemotherapy have caused tuberculosis to increase recently. As a result, the incidence of cutaneous tuberculosis has been increasing as well. AIM: To detect cutaneous tuberculosis in patients with organ tuberculosis and to establish some characteristics of the relation between organ and cutaneous TB. MATERIAL AND METHODS: A total of 370 patients (145 females and 225 males), aged 2-76 years (mean age 27.5), enrolled for this screening study. These patients were hospitalized patients who already had pulmonary or extrapulmonary tuberculosis diagnosed before admission. All patients underwent a general skin examination, and, if needed, cutaneous biopsies were taken from involved skin areas. RESULTS: Three hundred and forty-seven (93.78%) out of 370 patients had pulmonary tuberculosis only or in association with one of other organ tuberculoses. Twenty-three patients had extrapulmonary TB: nine were TB adenitis, six were TB peritonitis, three were bone tuberculosis, and five were TB meningitides. Of 370 patients, only 13 (3.51%) had cutaneous TB: seven scrofuloderma (SCD; 2.16%), four lupus vulgaris (LV; 1.35%), one LV and SCD, and one Bacille Calmette-Guerin (BCG) adenitis (0.027%). Cutaneous tuberculosis was observed in seven out of 260 patients with parenchymal tuberculosis (2.96%). Four out of nine patients with TB adenitis (44.4%), one out of 12 pulmopleuretic (8.3%), and one out of 67 pleuresic patients (1.40%) had cutaneous TB as well. Mean age of the 13 patients was 32.46 years: mean age of SCD and LV was 24.8 and 48 years, respectively. The one patient with BCG adenitis was 7 months old. Five (62.5%) out of eight patients with SCD, and only one (20%) out of five patients with LV were new cases. Four patients with SCD had a positive family history, while LV patients did not. CONCLUSIONS: Organ tuberculosis is rarely associated with cutaneous tuberculosis. Scrofuloderma and LV are the most frequent forms of skin TB associated with organ TB in this population. Tuberculosis adenitis is the organ TB that causes cutaneous TB most often among other organ tuberculoses. More than one form of cutaneous TB affected only one patient with pulmonary TB; therefore, it is very rare. Tuberculids were not observed in any of the patients.     

Cutaneous tuberculosis in children and adolescents: a clinicohistological study

BACKGROUND AND OBJECTIVES: Resurgence of tuberculosis (TB) in the era of human immunodeficiency virus (HIV) has rejuvenated the interest in this global health problem. Cutaneous TB, an important extra-pulmonary form in children, is commonly seen in our dermatological practice. As detection of acid-fast bacillus (AFB) on smear or culture is not always positive, histopathology is necessary to help in diagnosing and classifying the variants of skin TB. The current study was conducted to analyse the clinicopathological characteristics of cutaneous TB in children and adolescents. MATERIALS AND METHODS: This prospective study included 103 patients (age<19 years). A detailed history and clinical examination was followed by complete investigative work up including fine needle aspiration cytology and culture. Histopathological evaluation was performed specifically noting the epidermal and dermal features. The patients were followed up regularly for one year after the start of treatment. RESULTS: The different patterns of cutaneous TB seen were, scrofuloderma 38 (36.9%), lichen scrofulosorum 34 (33%), lupus vulgaris 22 (21.3%), TB verrucosa cutis 4 (3.9%), papulonecrotic tuberculid 4 (3.9%) and erythema nodosum 3 (2.9%). Systemic associations were seen in 55 (53.4%) patients, namely TB lymphadenitis in 30 (29.2%), pulmonary TB in 13 (12.6%), abdominal TB in 6 (5.8%) and TB arthritis in 6 (5.8%). The histopathological corroboration of clinical diagnosis was seen in 65.7% of cases of scrofulodermas, 72.7% of cases of lupus vulgaris and 67.6% of cases of lichen scrofulosorum. CONCLUSIONS: A large spectrum of clinical patterns and histological characteristics of cutaneous TB exists in children. Lichen scrofulosorum is more commonly seen in comparison to adults. Systemic involvement was a feature in a major proportion of our patients.     

Multidrug resistant miliary tuberculosis during infliximab therapy despite tuberculosis screening

We describe an unusual case of multidrug‐resistant miliary tuberculosis diagnosed 9 months after the commencement of infliximab treatment for psoriasis despite negative pretreatment tuberculosis screening, including chest X‐ray and interferon‐gamma release assay. After 4 months' treatment with amikacin, ethambutol, pyrazinamide and moxifloxacin, infliximab was restarted with concomitant anti‐TB medications. No recurrence of tuberculosis has been detected 12 months after recommencing infliximab.     

Perianal ulceration in a "healthy" Chinese man with disseminated tuberculosis

Orificial tuberculosis (OTB) is a rare form of cutaneous Mycobacterium tuberculosis infection affecting the mucosa and skin around orifices in patients with advanced internal tuberculosis and poor general health. We report a 72-year-old Chinese man who had a 10-year history of OTB with disseminated tuberculosis infection of the lungs and urinary tract. He appeared surprisingly healthy and had been free from systemic symptoms all along despite widespread tuberculosis. The diagnosis of OTB was established by the microscopic presence of acid-fast bacilli (AFB) in the tissue section and was rapidly confirmed by polymerase chain reaction (PCR) to be Mycobacterium tuberculosis. PCR shortens the time of diagnosing rare presentations of cutaneous tuberculosis and prevents delays in treatment. Conventional culture is still important in confirming the diagnosis and screening for drug resistance.     

近25年结节性红斑患者中结核感染特点的Meta分析

目的：明确1993-2018年结节性红斑(EN)患者中结核(TB)感染特点。方法：2位研究者独立检索1993年1月至2018年9月PubMed、Embase、MEDLINE、CNKI、CBM、万方数据库筛选出符合纳入标准的文献，采用STATA 12.0软件通过Meta分析方法进行单个率的合并分析。结果：共纳入27篇文献，包括国内11篇（1019例患者，其中结核性结节性红斑患者277例，感染率25.4%），国外16篇（995例，其中结核性结节性红斑患者52例，感染率6%）。国内亚组分析显示东部、中部及西部地区EN患者中结核感染率分别为16.0%、27.9%和32.5%，Meta回归显示地区因素而非年份因素可解释异质性来源(P=0.02)。结节性红斑患者结核病灶为肺结核、淋巴结核、其他类型结核（如：结核性胸膜炎、卵巢结核等）、仅PPD强阳性，分别占44.4%、11.1%、7.1%及38.2%。结论：大多数EN患者没有明显的结核症状，因此应尽量寻找潜在的结核病感染病灶。     

实时荧光定量 PCR 在皮肤结核诊断中的应用

目的：比较实时荧光定量 PCR (qPCR)技术在皮肤结核(CTB)石蜡包埋组织及新鲜组织中的敏感性,以探讨在CTB石蜡包埋组织中开展结核分枝杆菌(MTB)检测的可行性。方法：应用qPCR技术检测临床确诊为CTB的6例新鲜组织样本和20例石蜡包埋组织样本的MTB阳性率。结果：新鲜组织敏感性为50%，石蜡包埋组织敏感性为35%。结论：qPCR技术可检测CTB新鲜组织和石蜡包埋组织中的MTB，前者的敏感性高于后者。     

皮肤结核2例

报告2例皮肤结核,例1全身皮肤散在红斑,结节7年,例2左肩背部有暗红色斑块18年,2例患者皮损组织病理检查示真皮内有上皮样细胞团块,团块内及团块周围有淋巴细胞浸润,皮损组织真菌培养均阴性。皮损组织液抗酸染色涂片见点状或短棒状杆菌,组织液培养8-10周见阳性菌落生长。对菌落行PCR检测,结果检测出结核杆菌。     

Time for a change? Updated guidelines using interferon gamma release assays for detection of latent tuberculosis infection in the office setting

Treatment with tumor necrosis factor-alfa inhibitors and other systemic medications increases the risk of reactivating a latent tuberculosis (TB) infection. Therefore, screening for latent TB infection is important in dermatology patients eligible for treatment with these medications. Although the tuberculin skin test (TST) has its limitations, it has been the standard choice for diagnosis of latent TB infection. Since the development of interferon gamma release assays (IGRAs), the role of the TST has been re-evaluated and IGRAs have increasingly been incorporated into national guidelines. Although there are situations when either test may be performed, in individuals who have received a BCG vaccination and in those who are unlikely to return for a TST reading, IGRAs may be particularly helpful in distinguishing patients at risk for TB. This article discusses the advantages and disadvantages of both the TST and the IGRA and presents a summary of the Centers for Disease Control and Prevention 2010 guidelines for using IGRAs.     

A clinicoepidemiological study of 50 cases of cutaneous tuberculosis in a tertiary care teaching hospital in pokhara, Nepal

Background:

Cutaneous tuberculosis (TB) is essentially an invasion of the skin by Mycobacterium tuberculosis, the same bacteria that causes pulmonary tuberculosis.

Aim:

This study was conducted to study the common types of cutaneous TB and to find the management pattern in a tertiary teaching hospital in Pokhara, Nepal.

Materials and Methods:

All the cases of cutaneous TB were biopsied and furthermore investigated by performing Mantoux test, sputum examination, fine needle aspiration cytology, chest X-ray and ELISA.

Results:

In this study, we found that tuberculosis verrucous cutis (48%) had a higher incidence than other types of cutaneous TB. More males were affected than were females (1.2:1). Commonly affected sites were the limb and the buttock (48%). The most commonly affected age group was 16–25 years (40%). All cases (except two) were more than 15 mm in size in the Mantoux test. The histopathological picture was typical in all except three cases. All patients were treated with antitubercular treatment as per the national guidelines.

Conclusion:

The most common type of cutaneous TB was tuberculosis verrucous cutis and the most commonly affected sites were the limb and the buttock. As cutaneous TB sometimes reflects the presence of pulmonary tuberculosis, its incidence should not be ignored.     

Comparison of the radiometric BACTEC 460 TB culture system and Löwenstein-Jensen medium for the isolation of mycobacteria in cutaneous tuberculosis and their drug susceptibility pattern

Background Mycobacterial isolation from cutaneous tuberculosis on Löwenstein–Jensen (L–J) medium has been reported to be low. The radiometric BACTEC 460 TB culture system (BACTEC system) has shown better isolation rates in pulmonary tuberculosis. There has been a progressive increase in the prevalence of multidrug resistance in pulmonary tuberculosis, but similar studies are lacking for cutaneous tuberculosis. Therefore, this study was undertaken to compare mycobacterial isolation on conventional L–J medium vs. the BACTEC system, and to determine the prevalence of multidrug resistance in cutaneous tuberculosis. Methods Thirty‐five untreated, clinically diagnosed, and histopathologically documented patients with cutaneous tuberculosis constituted the study material. Lesional skin biopsy specimens were cultured on both L–J medium and the BACTEC system. The isolates obtained were identified and subjected to sensitivity to rifampicin, isoniazid, ethambutol, and streptomycin using the BACTEC system. Results Twenty‐six mycobacterial isolates were recovered from 35 patients. Nine isolates (25.7%) grew on L–J medium after a mean period of 31.5 days, and 22 (62.8%) on the BACTEC system in 17.3 days. All of the isolates were identified as Mycobacterium tuberculosis. Drug susceptibility testing demonstrated 12 isolates to be resistant, seven multidrug resistant. Discussion The BACTEC system demonstrated an improved mycobacterial isolation rate and substantially reduced detection time when compared with L–J medium. The combined isolation rate on both media was 74.3% (26/35), greater than that of either used separately. Drug resistance was observed in 46.2% of isolates. Conclusion Radiometric liquid culture medium together with conventional L–J medium may be recommended in practice to enable the institution of appropriate antituberculous therapy modifications in drug‐resistant cases of cutaneous tuberculosis.     

A case of lupus vulgaris with unusual location

Tuberculosis (TB) is one of the oldest diseases of our planet; today, it still is a serious medicosocial problem in both developing and developed countries. Cutaneous tuberculosis is part of the small percentage of extrapulmonary forms of the disease and has considerable morphological variability. It is often confused with various cutaneous disorders and some other granulomatous processes of the skin. Here, we present a case of long-standing and atypically-located lupus vulgaris in an old man. The patient was successfully treated with triple antituberculous therapy.     

Unusual presentation of tuberculosis in an infliximab-treated patient – which is the correct TB screening before starting a biologic?

Infliximab is an anti-TNFα chimeric monoclonal antibody, commonly used in the treatment of moderate to severe psoriasis. TNFα is a pro-inflammatory cytokine which play a key role in host defense from infections by intracellular bacteria, such as Listeria monocytogenes , Histoplasma Capsulatum and especially Mycobacterium Tuberculosis . Infliximab therapy increases the risk of tuberculosis due mainly to the reactivation of latent TB infection (LTBI) and, therefore, it is mandatory to screen patients for LTBI prior to starting a treatment with anti-TNFα agents. We report the case of a psoriatic patient, who, despite a negative screening for infection by M. tuberculosis including both tuberculin skin test (TST) and chest X-ray, developed after 4 months of infliximab treatment, a severe pulmonary, lymphnodal and intestinal tuberculosis during infliximab treatment.     

结核感染T细胞检测在结核感染相关皮肤病的应用价值

结核病常用的实验室检测方法,包括抗酸染色涂片镜检、组织分离培养、组织病理、PCR检测等.结核感染T细胞检测是实验室检测结核病较新的辅助手段,属γ干扰素释放试验的一种,现已被越来越广泛地应用于临床.回顾结核感染T细胞检测的原理、特性及结核感染T细胞检测在诊断皮肤结核、探讨与结核感染相关的皮肤病的发病机制、药物治疗前评估潜伏结核激活的风险等方面的应用价值.     

Severe psoriasis entering remission after treatment for latent tuberculosis with isoniazid: Report of two cases

Psoriasis is a multifactorial systemic disease with predominantly cutaneous manifestations. The role of tuberculosis infection in the pathogenesis of psoriasis has not been consistently proven. Current guidelines recommend screening for tuberculosis infection in any patient with psoriasis when the initiation of biologic therapy is being considered. Isoniazid is an antibiotic with high bactericidal effect on replicating mycobacteria and constitutes the most commonly prescribed treatment for latent tuberculosis infection. Here, we report two cases of patients with psoriasis who presented at our clinic with extensive cutaneous involvement despite previous treatments with topical and systemic therapies. Both were considered as candidates for biologic therapy. As part of the screening protocol, a tuberculin test was performed with a positive result. In the absence of symptoms and chest radiography findings, isoniazid 300 mg/day for 6 months was prescribed to treat latent tuberculosis infection. This resulted in significant clearing of their skin lesions in the absence of any other concurrent treatment, apart from emollients. Both patients remained clinically stable and with no need of further systemic treatment. This situation has only been described twice before in the English‐language published work. These cases highlight the possible role of tuberculosis infection in the pathogenesis of psoriasis, suggesting the possible existence of a link between untreated infection and skin lesions. This can lead to consideration of novel therapeutic strategies and new lines of investigation.