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.     

Cutaneous tuberculosis: diagnosis and treatment

As we move into the 21st century, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary tuberculosis. Mycobacterium tuberculosis, Mycobacterium bovis, and the BCG vaccine cause tuberculosis involving the skin. True cutaneous tuberculosis lesions can be acquired either exogenously or endogenously, show a wide spectrum of morphology and M. tuberculosis can be diagnosed by acid-fast bacilli (AFB) stains, culture or polymerase chain reaction (PCR). These lesions include tuberculous chancre, tuberculosis verrucosa cutis, lupus vulgaris, scrofuloderma, orificial tuberculosis, miliary tuberculosis, metastatic tuberculosis abscess and most cases of papulonecrotic tuberculid. The tuberculids, like cutaneous tuberculosis, show a wide spectrum of morphology but M. tuberculosis is not identified by AFB stains, culture or PCR. These lesions include lichen scrofulosorum, nodular tuberculid, most cases of nodular granulomatous phlebitis, most cases of erythema induratum of Bazin and some cases of papulonecrotic tuberculid. Diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with diagnostic testing; in addition to traditional AFB smears and cultures, there has been increased utilization of PCR because of its rapidity, sensitivity and specificity. Since most cases of cutaneous tuberculosis are a manifestation of systemic involvement, and the bacillary load in cutaneous tuberculosis is usually less than in pulmonary tuberculosis, treatment regimens are similar to that of tuberculosis in general. In the immunocompromised, such as an HIV infected patient with disseminated miliary tuberculosis, rapid diagnosis and prompt initiation of treatment are paramount. Unfortunately, despite even the most aggressive efforts, the prognosis in these individuals is poor when multi-drug resistant mycobacterium are present. An increased awareness of the re-emergence of cutaneous tuberculosis will allow for the proper diagnosis and management of this increasingly common skin disorder.     

Tuberculosis verrucosa cutis with liver involvement

A 40-year-old male peasant with a long-lasting (33-year) lesion of tuberculosis verrucosa on his right buttock is reported. Mycobacterium tuberculosis var. hominis was cultured from the lesion. Epithelioid cell granuloma was detected on the biopsy of the enlarged liver with normal I unction tests. The cutaneous lesion healed under systemic specific chemotherapy and local cryotherapy. Asymptomatic liver involvement is relatively common in the course of pulmonary and extrapulmonary tuberculosis and probably is nor sis uncommon on virulent forms of cutaneous tuberculosis as the scarcity of reports suggests.     

Multifocal tuberculosis verrucosa cutis

Tuberculosis has been a well-known affliction of human kind, since antiquity. Cutaneous tuberculosis constitutes only a small proportion of extra pulmonary tuberculosis and multifocal involvement of cutaneous tuberculosis is an even rarer manifestation. We report one such case of multifocal tuberculosis verrucosa cutis in a 17-year old male patient in the absence of any primary tuberculous focus.     

A clinical and histopathological profile of patients with cutaneous tuberculosis

Extrapulmonary tuberculosis constitutes about 10% of all cases of tuberculosis, and cutaneous tuberculosis makes up only a small proportion of these cases. Despite prevention programs, tuberculosis is still progressing endemically in developing countries. Commonest clinical variant of cutaneous tuberculosis in our study was lupus vulgaris seen in 55% patients followed by scrufuloderma seen in 25% patients followed by orificial tuberculosis, tuberculosis verrucosa cutis, papulonecrotic tuberculid, and erythema induratum seen in 5% each. The commonest site of involvement was limbs seen in 50% patients followed by neck seen in 25% patients, face in 15%, and trunk in 10% patients. Maximum percentage of patients (55%) had duration of cutaneous tuberculosis between 6-12 months followed by 35% between 13-24 months, 5% had duration of cutaneous tuberculosis less than 6 months, and the rest 5% had duration more than 24 months. The commonest histopathological feature in our study was tuberculoid granuloma with epitheloid cell and Langhans giant cells seen in 70% patients, hyperkeratosis was seen in 15% patients and AFB bacilli were seen in 5% patients.     

Skin tuberculosis in children: learning from India

Cutaneous tuberculosis in children is a major health problem in India. It accounts for about 1.5% of all the cases of extrapulmonary tuberculosis. Scrofuloderma and lupus vulgaris are the two most common forms of tuberculosis. However, the trend in the pattern of cutaneous tuberculosis is changing, as the tuberculid, lichen scrofulosorum, has become more common in recent years. Overall, the clinical patterns are comparable with adults. However, children can have widespread and severe involvement because many unusual and uncommon patterns are known to occur in children. Underlying systemic involvement is more common in children, compared with adults.     

A Case of Extensive Multifocal Tuberculosis Verrucosa Cutis

Tuberculosis is probably as old as the human race itself. Cutaneous tuberculosis constitutes a very small proportion of extra pulmonary tuberculosis. Extensive, multifocal involvement of cutaneous tuberculosis is a very rare manifestation. We report one such case of extensive, multifocal tuberculosis verrucosa cutis in a 30-year-old immunocompetent male patient in the absence of any primary tubercular focus.     

Management of cutaneous tuberculosis

ABSTRACT:   Cutaneous tuberculosis (TB) is an extrapulmonary form of tuberculosis, which may be classified based on the immunologic state of the host. Chemotherapy still remains the treatment of choice. The management of cutaneous TB follows the same guidelines as that of TB of other organs, which can be treated with a short course four-agent chemotherapeutic regimen given for 2 months followed by a two-drug regimen for the next 4 months. This chapter highlights current treatment recommendations for cutaneous TB. The important factors to consider in the choice of optimal treatment includes the type of cutaneous involvement, stage of the disease, level of immunity, and general condition of the patient. The highest priority in any cutaneous TB control program is the proper, accurate, and rapid detection of cases and the availability of chemotherapy to all tuberculosis patients until cure. Contact tracing is also an important component of efficient tuberculosis control.     

Multifocal tuberculosis revealed by multiple cutaneous gummas in the immunocompetent

Cutaneous tuberculosis is rare. Its occurrence in multifocal tuberculosis (MT) is uncommon and happens frequently in the context of immunosuppression. We report the case of MT with multiple cutaneous gummas and bone and lung involvement that occurred in an apparently immunocompetent patient.     

Cutaneous tuberculosis in Blackburn district (U.K.): a 15-year prospective series, 1981–95

Data collected prospectively on all 1065 cases of tuberculosis occurring in the Blackburn district, U.K. (population 265.000), over a 15-year period have been analysed, and from these 47 cases of cutaneous tuberculosis have been identified. The most common form was scrofuloderma, skin involvement with adjacent structural disease, of which there were 2b cases (55. 3%). There was no ethnic bias in this group. The eight white patients with scrofuloderma were of average age 66 years, and are thought to represent reactivation disease.Six palients (12.8%) had lupus vulgaris, four (8.5%) had metastatic tuberculosis and 10 (21.3%) were diagnosed as having one of the tuberculides, of which Bazin's disease (erythema induratum) was the most common. In addition, one patient (2.2%) had orificial tuberculosis. In contrast to scrofuloderma. all other forms of cutaneous tuberculosis occurred almost exclusively in patients from the Indian Subcontinent (ISC).The high incidence of tuberculosis in Blackburn is mainly linked to its significant proportion of residents of ISC ethnic origin. There were no cases of HIV infection coexisting with either cutaneous or other forms of tuberculosis. Recommendations for the treatment of cutaneous tuberculosis are made.     

Cutaneous Tuberculosis in Children

Abstract: Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis that accounts for 1% to 2% of cases. Childhood skin tuberculosis represents 18% to 82% of all cutaneous tuberculosis cases. Scrofuloderma and lupus vulgaris are the two most common clinical forms in children. An increase in the number of tuberculids, especially lichen scrofulosorum, has been observed in the last several years. Cutaneous tuberculosis in children can be severe and have a protracted course. Multiplicity of lesions and multifocal disseminated involvement in scrofuloderma and lupus vulgaris is common. Scrofuloderma progressing to gummatous lesions (scrofulous gumma) is mostly described in children. Morbidities and deformities are more severe in children.     

Multifocal scrofuloderma with disseminated tuberculosis in a severely malnourished child

Tuberculosis and malnutrition continue to be significant health problems in developing countries. Moderate to severe malnutrition can cause immunosuppression and predispose children to various infections. We report disseminated tuberculosis in a severely malnourished Indian child who presented primarily with cutaneous involvement.     

Long-standing scrofuloderma

We present the case of a 26-year-old Ecuadorian woman who presented with multiple hypertrophic scars along the lower left limb, secondary to a cutaneous process that she had had for 11 years, previously diagnosed and treated in her country as cutaneous leishmaniasis. It had been clinically worsening for 9 months with suppuration through the scars in the groin and thigh, associated with local pain and systemic symptoms. As we suspected cutaneous tuberculosis, we performed a number of complementary examinations to confirm the diagnosis and rule out bone involvement. Finally, a lymph node culture confirmed that it was scrofuloderma.     

Cutaneous tuberculosis in children a clinico-microbiological study

Twenty untreated patients of cutaneous tuberculosis varying from 2-12 years of age were included in the study. The incidence of cutaneous tuberculosis amongst the paediatric dermatological patients was 0.36%. Of these, 10 had lupus vulgaris, 8 had scrofuloderma, 3 had tuberculosis verrucosa cutis and 2 had lichen scrofulosorum. Three patients concomitantly had more than one type of skin tuberculosis. Systemic involvement in the form of pulmonary and osseous system was seen in 45% cases. The tuberculin test was uniformly positive. Affirmative clinico-histopathological correlation was observed in all the patients. However, acid fast bacilli could not be demonstrated in any of the sections. Only one patient (scrofuloderma) exhibited AFB on smear examination. In the same patient, M. tuberculosis could be cultured on L-J medium. However, Elisa for IgM antibodies in serum was positive in 12 (60%) cases. Need for newer techniques in the diagnosis is emphasised.     

Childhood cutaneous tuberculosis: a 20-year retrospective study in Tunis

Despite prevention programs, tuberculosis is still endemic in developing countries. We assessed the epidemiologic and clinical profiles of childhood cutaneous tuberculosis in our dermatology department from 1981 to 2000 and compared it to previous Tunisian reports and to the relevant literature. This is a retrospective study over a 20-year period (1981-2000) in a large teaching hospital of the capital. Patients included were below age 15 years. Diagnosis was based upon clinical examination, tuberculin reaction, histopathology and response to antitubercular therapy. There were 26 patients with cutaneous tuberculosis, 0.1 percent of the total number of dermatology outpatients for that time period. Of these 26, seven (27 %) were immunocompetent. There were four boys and three girls and the mean age was 9.5 years. Three patients had lupus vulgaris, three had scrofuloderma, and one child had orificial tuberculosis. Six out of seven children were BCG vaccinated. There was no family history of tuberculosis. The Mantoux reaction was positive in six children. There was no systemic organ involvement in all cases. All patients were treated successfully with triple or quadruple anti-tubercular drugs for 4-11 months. Compared to a previous Tunisian report conducted over an 8-year period in the seventies, the incidence of childhood cutaneous tuberculosis has decreased. In that report, scrofuloderma was the most frequent form. Currently the incidence of lupus vulgaris has reached that of scrofuloderma, demonstrating the increase of the clinical pattern associated with strong immunity. All children had localized disease and responded to antimycobcterial chemotherapy.     

Delayed diagnosis in a case of lupus vulgaris with unusual localization

Lupus vulgaris is the most common form of cutaneous tuberculosis, and the usual sites of involvement are the head and neck. We present a forty-six-year-old woman with lupus vulgaris on the external surface of the left leg and foot, an unusual site. Based on histopathological and clinical features, this case was diagnosed as lupus vulgaris with unusual localization.     

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.     

Childhood cutaneous tuberculosis: a study over 25 years from northern India

AIMS: We undertook this study to analyse the pattern of childhood cutaneous tuberculosis prevailing in northern India over the past 25 years and to highlight differences from and similarities to adult tuberculosis. MATERIALS AND METHODS: Clinical records of children with cutaneous tuberculosis who attended the Nehru Hospital attached to the Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 1975 to December 1999 were analysed. RESULTS: Four hundred and two patients with cutaneous tuberculosis were examined during the 25-year period of observation. These patients formed 0.1% of the total dermatology outpatients. Seventy-five (18.7%) of these 402 cases were children ( 10 mm). Histopathologic reports were available for evaluation in all 75 children. Out of 30 cases of LV, 24 (80%) showed classical tuberculous histology. In contrast, out of 40 cases with SFD, only 19 (47.5%) showed classical histology. Classical tuberculous histology was noted in all 3 (100%) cases of TVC and 1 (100%) case each with tuberculids and gumma. Tubercle bacilli could be demonstrated in 4/30 (13.3%) cases with LV and 9/40 (22.5%) cases with SFD. Systemic involvement was seen in 16 (21.3%) children, of whom 3 (18.8%) had LV and 13 (81.3%) SFD. The lungs were the most common organs involved in 8 (50.0%) children followed by bone(s) in 4 (25.0%), abdomen in 2 (12.5%), and both lung and bone in 1 (6.3%) child. In contrast to adults, girls outnumbered boys in the childhood series; SFD was a common form of presentation in contrast to LV and TVC, tuberculous gumma and tuberculids were noted less often. In both children and adults, Mantoux reactivity did not correlate with the extent of the disease; patients with disseminated disease were found to be less often vaccinated with BCG and regional lymphadenopathy was noted more often in patients with disseminated disease. CONCLUSIONS: In the whole spectrum of cutaneous tuberculosis, there is a proportion of patients with dissemination (systemic involvement) who are of great epidemiological significance as they require a change in the standard therapeutic regimens recommended for cutaneous tuberculosis.     

A Case of Tuberculosis Cutis Orificialis with Perianal Involvement

Tuberculosis cutis orificialis (TCO) is a rare manifestation of cutaneous tuberculosis that is caused by auto-inoculation of mycobacteria in patients with advanced internal tuberculosis. TCO occurs in oral, perianal, or genital mucosa and adjacent skin. The tongue is the most frequently affected site, but the perianal area can also be affected. A 39-year-old male presented with a 4-month history of painful ulcers on the perianal area. The histopathologic findings revealed granulomatous infiltrates composed of epithelioid cells and Langhans-type giant cells in the dermis, and a few acid-fast bacilli noted on Ziehl-Neelsen staining. The polymerase chain reaction (PCR) was positive for Mycobacterium tuberculosis and the chest X-ray showed findings consistent with active pulmonary tuberculosis in both upper lung zones. The skin lesion showed complete resolution 2 months after the start of treatment with antituberculosis agents. We report a case of TCO with perianal involvement in a patient with underlying active pulmonary tuberculosis.     

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.