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.     

A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam

Background:

Cutaneous tuberculosis forms a small subset of extra pulmonary tuberculosis and has a worldwide distribution.

Aims:

The present study is an attempt to find out the incidence, clinical spectrum, and histopathological features of cutaneous tuberculosis.

Materials and Methods:

A total of 42 cases of newly diagnosed patients of cutaneous tuberculosis attending dermatology out patient department over a period of 1 year were included in the study. A detailed clinical examination and investigations including histopathological examination were carried out.

Results:

Scrofuloderma was the most common form seen in 50% cases followed by lupus vulgaris in 42.86%, tuberculosis verrucosa cutis in 4.76%, and lichen scrofulosorum in 2.38% cases. The Mantoux test was positive in 83.33% cases. Characteristic tuberculoid granulomas were seen in 72.22% cases of lupus vulgaris, 42.86% cases of scrofuloderma and all cases of tuberculosis verrucosa cutis and lichen scrofulosorum.

Conclusion:

Cutaneous tuberculosis is still highly prevalent in upper Assam. Early diagnosis and treatment are essential to prevent its complications.     

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.     

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.     

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.     

Coexisting Bacillus Calmette–Guérin‐Induced Lupus Vulgaris Involving the Vaccination Site and Lichen Scrofulosorum in an Immunocompetent Boy

The coexistence of Bacillus Calmette–Guérin (BCG)‐induced lupus vulgaris involving the site of vaccination with lichen scrofulosorum is rare. Herein we report a 3‐year‐old boy who presented with lupus vulgaris at the vaccination site 3 weeks after neonatal BCG vaccination followed by the development of lichen scrofulosorum approximately 2.5 years later. Characteristic clinical morphology, typical histopathology, and positive DNA polymerase chain reaction for Mycobacterium bovis confirmed the clinical diagnosis.     

Cutaneous tuberculosis: A great imitator

Tuberculosis (TB) is still prevalent in many developing countries and can pose a new potential threat to global health due to international migration. As an uncommon form of extrapulmonary TB, cutaneous TB is complicated in its clinical manifestation, pathogenesis, and classification. Cutaneous TB can be divided into two major categories, true cutaneous TB and tuberculid, depending on the source of infection, the route of transmission, the amount of bacteria, and the immune state of the host. Clinical manifestations may include patches and plaques (lupus vulgaris, TB verrucosa cutis), macules and papules (acute miliary TB, papulonecrotid tuberculid, lichen scrofulosorum), nodules, and abscesses (erythema induratum of Bazin, tuberculous gumma), erosions, and ulcers (tuberculous chancre, orificial TB, scrofuloderma), mimicking diverse skin diseases. Uncommon localizations such as external genitalia, unusual presentations such as nodular granulomatous phlebitis, and coexistence with other morbidities such as Behçet disease and acne inversa or hidradenitis suppurativa deserve special attention. Treatment of both true and tuberculid cutaneous TB follows the same drug regimens of the World Health Organization’s recommendation for treatment of new cases of pulmonary TB. Erythema induratum of Bazin may need longer treatment duration and adjuvants such as dapsone, potassium iodide, doxycycline, and corticosteroids to tackle inflammation. Misdiagnosis and undertreatment in daily practice are likely, and contemplation of this classic great imitator in dermatology is warranted.     

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 tuberculosis and phlyctenular keratoconjunctivitis: a forgotten association

Cutaneous tuberculosis may be associated with concurrent systemic foci in the body such as lung, lymph node, bone or CNS. Phlyctenular keratoconjunctivitis (PKC) is a manifestation of immunological response to a variety of antigens in the eye, tubercular focus (evident or occult) being the commonest in India. Reports in the existing literature have shown lungs and lymph nodes to be the predominant underlying focus associated with PKC, whereas cutaneous tuberculosis has seldom been found in this situation. We report this forgotten association in two children with cutaneous tuberculosis, one each with lupus vulgaris and scrofuloderma, who also had PKC. Interestingly, one of the cases also had simultaneous lichen scrofulosorum, which is also an immunological response to tubercular antigen and manifests in the skin, thus showing immunological manifestation in two different organ systems along with cutaneous focus of tuberculosis.     

Lupus erythematosus and other autoimmune diseases related to statin therapy: a systematic review

BACKGROUND: Statins have been increasingly associated with drug-induced autoimmune reactions, including lupus erythematosus. OBJECTIVE: To identify and determine the clinical and biological characteristics of statin-induced autoimmune reactions. MATERIAL AND METHODS: The MEDLINE database (1966 to September 2005) was used to identify all reported cases of statin-induced autoimmune diseases. The keywords used were statins, 3-hydroxy-3-methylglutaryl coenzyme A reductase inhibitors, adverse effects, autoimmune disease, lupus erythematosus, dermatomyositis and polymyositis. RESULTS: Twenty-eight cases of statin-induced autoimmune diseases have been published so far. Systemic lupus erythematosus was reported in 10 cases, subacute cutaneous lupus erythematosus in three cases, dermatomyositis and polymyositis in 14 cases and lichen planus pemphigoides in one case. Autoimmune hepatitis was observed in two patients with systemic lupus erythematosus. The mean time of exposure before disease onset was 12.8+/-18 months; range 1 month-6 years. Systemic immunosuppressive therapy was required in the majority of cases. In many patients, antinuclear antibodies were still positive many months after clinical recovery. A lethal outcome has been recorded in two patients despite aggressive immunosuppressive therapy. CONCLUSION: Long-term exposure to statins may be associated with drug-induced lupus erythematosus and other autoimmune disorders. Fatal cases have been reported despite early drug discontinuation and aggressive systemic immunosuppressive therapy.     

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.     

Lichen scrofulosorum in a patient with lepromatous leprosy after BCG immunotherapy

Lichen scrofulosorum is a rare form of tuberculid seen in children and young adults. The cutaneous lesions are typically symptomless papular eruptions, associated with a strong Mantoux reaction, tuberculosis of lymph nodes and/or other organs or rarely following BCG vaccination. We describe an unusual case of occurrence of lichen scrofulosorum following BCG immunotherapy in a patient with lepromatous leprosy.     

Lupus vulgaris, caries of the spine and lichen scrofulosorum—an intriguing association

An unusual association of lupus vulgaris, caries of the spine and lichen scrofulosorum is reported in a young boy. An attempt has been made to explain these findings on the basis of the immunoprorile, which indicated unstable immune responses.     

Clinical and epidemiological observations of cutaneous tuberculosis in Larkana,Pakistan

BACKGROUND: Cutaneous tuberculosis is widespread in Pakistan but has not been fully documented. This study was conducted to determine the clinical pattern, nature and existence of the disease in Larkana, Sindh province, Pakistan. METHODS: We are reporting 153 cases of patients with cutaneous tuberculosis who visited our department from 1996 to 1999. All cases were diagnosed at the clinic, and the biopsies were examined for histopathological evidence. The patients received three antituberculous treatments during a 9 month course. RESULTS: Clinically, 63 (41.2%) cases of lupus vulgaris, 54 (35.3%) of scrofuloderma, 29 (19.59%) of lupus verrucosa cutis, six (3.92%) of tuberculosis cutis orificialis and one (0.64%) case of disseminated cutaneous tuberculosis were observed in our department from 1996 to 1999. All patients were aged between 3 and 50 years and had experienced the present complaints for 1 to 12 years. Sixty-nine (45.1%) cases were children aged under 10 years, 50 cases (37.25%) were aged between 10 and 20 years, and 27 cases (17.65%) were aged over 20 years. There was no considerable ratio difference of the disease between male and female patients. Histopathologically, all the specimens showed chronic granulomatous changes; the majority was infiltrated with epitheloid cells, langhans giant cells, plasma cells and other inflammatory cells, such as lymphocytes, eosinophils and neutrophils in ulcerated lesions. Increased numbers of mast cells were seen in upper and lower dermis in two-thirds of the specimens. Caseating necrosis was visible in half of the specimens while Ziehl-Neelsen stain was negative in all the sections. CONCLUSIONS: The observed number of patients was moderately large, thus indicating a high incidence of cutaneous tuberculosis in Larkana. Lupus vulgaris, a form of cutaneous tuberculosis, was widespread in this area and prevalent in adults, while scrofuloderma was prevalent in children. Moreover, the existing rate of the disease was higher in children aged under 10 years and lower in adults. This indicates that children are more prone to this disease than adults.     

Evolution of cutaneous tuberculosis over the past 30 years in a tertiary hospital on the European Mediterranean coast

Background. There have been few studies on cutaneous tuberculosis (TB) in Europe in recent years. Objective. To retrospectively analyse the evolution of the various types of cutaneous TB over the past 30 years in an adult population in Spain. Methods. Patients with cutaneous TB diagnosed between 1981 and 2011 at Bellvitge Hospital, Barcelona, Spain, were included in the study. Chest radiography was performed for all patients, and the presence of TB elsewhere in the body was excluded when clinically suspected. Results. In total, 36 patients (15 male, 21 female, mean age 53.72 years) were diagnosed with cutaneous TB. There were 22 patients with lupus vulgaris (LV), 4 with scrofuloderma, 4 with miliary TB, 3 with tuberculous abscess/ulcer, and 1 each with orificial TB, warty TB, and an iatrogenic inoculation from underlying visceral focus. Of the 36 patients, 16 (38.88%) had TB presenting simultaneously in other organs. Mycobacterial culture from skin biopsies was positive for Mycobacterium tuberculosis complex in 17 of the 32 cases tested (53.12%), whereas stains for acid‐fast bacilli in skin samples were positive in only 3 of 36 patients (8.33%). Conclusions. Although the number of cases of cutaneous TB diagnosed yearly in our population has declined over the past 30 years, cutaneous TB still exists in Europe, and its incidence is expected to increase, owing to the increased immigration into the continent in recent years. The most common type of cutaneous TB in our adult population was LV. It should be noted that despite being considered a benign form of TB, cutaneous TB can be accompanied by TB in internal organs, and severe complications can occur, such as the development of squamous cell carcinoma in long‐lasting lesions.     

LICHEN PLANUS IN INDIA: AN APPRAISAL OF 441 CASES

ABSTRACT: An analytical study of 441 patients with lichen planus is presented. Lichen planus occurrence was 76% of conditions seen at this institution. The sex ratio was 3:2. Most patients having the disease were in the 3rd decade of life. Lichen planus vulgaris (common type) was seen in 329 (74%) patients, lichen planus hypertrophicus in 56 (13%), lichen planus actinicus in 33 (7.5%), lichen planus fol-licularis in 8 (2%), lichen planus atrophi-cus in 8 (2%) and lichen planus pemphi-goides in 7 (1.5%) patients. Mucous membrane involvement was seen in 127 (29%) cases and nail involvement in only 7 (1.5%).     

Lupus vulgaris: report of two cases

Although there has been a steady decline in the incidence of tuberculosis in recent years, it persists in some regions, and where AIDS is especially prevalent, the number of new cases has been increasing. Thus, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multidrug-resistant pulmonary tuberculosis. Lupus vulgaris has been and remains the most common form of cutaneous tuberculosis. Cutaneous manifestations of disseminated tuberculosis are unusual, being seen in less than 0.5% of cases. Scrofuloderma, tuberculosis verrucosa cutis and lupus vulgaris comprise most cutaneous tuberculosis cases. Bacillus Calmette-Guerin (BCG) is derived from an attenuated strain of Mycobacterium bovis and is employed beneficially as a relatively safe vaccination in Poland and other countries in which the prevalence of tuberculosis is high. However, BCG vaccination may produce complications, including disseminated BCG and lupus vulgaris, the latter seen in one of our two patients in whom lupus vulgaris at the inoculation site followed a second vaccination with BCG 12 years after the initial one. A similar phenomenon has been described after immunotherapy with BCG vaccination. Re-infection (secondary) inoculation cutaneous tuberculosis may also occur as a result of BCG vaccination, producing either lupus vulgaris or tuberculosis verrucosa cutis, probably depending upon the patient's degree of cell-mediated immunity. However, most lupus vulgaris cases are not associated with vaccination with BCG, as occurred in our first patient. For those who do develop lupus vulgaris, it can be persistent for a long period, in some cases for many decades. In the second patient we describe a lengthy duration and cutaneous reactivation at distant sites after more than 40 years.     

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 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.     

Multifocal Childhood Cutaneous Tuberculosis: Report of Two Interesting Cases from Sikkim,India

Abstract: Cutaneous tuberculosis is an important health problem in developing countries such as India. Poverty, overcrowding, malnutrition, and ignorance are predisposing factors. The commonly seen variants of cutaneous tuberculosis are scrofuloderma, lupus vulgaris, and tuberculosis verrucosa cutis. Malnourished children may present with unusual forms of cutaneous tuberculosis. Herein we report two interesting cases of multifocal cutaneous tuberculosis in malnourished children.