Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis (Edinb). 2015;95:629-638. [PMID: 26616847 DOI: 10.1016/j.tube.2014.12.006]

Approach to skin and soft tissue infections in non-HIV immunocompromised hosts

PURPOSE OF REVIEW

Skin and soft tissue infections are frequent contributors to morbidity and mortality in the immunocompromised host. This article reviews the changing epidemiology and clinical manifestations of the most common cutaneous pathogens in non-HIV immunocompromised hosts, including patients with solid organ transplants, stem cell transplants, solid tumors, hematologic malignancies, and receiving chronic immunosuppressive therapy for inflammatory disorders.

RECENT FINDINGS

Defects in the innate or adaptive immune response can predispose the immunocompromised host to certain cutaneous infections in a predictive fashion. Cutaneous lesions in patients with neutrophil defects are commonly due to bacteria, Candida, or invasive molds. Skin lesions in patients with cellular or humoral immunodeficiencies can be due to encapsulated bacteria, Nocardia, mycobacteria, endemic fungal infections, herpesviruses, or parasites. Skin lesions may reflect primary inoculation or, more commonly, disseminated infection. Tissue samples for microscopy, culture, and histopathology are critical to making an accurate diagnosis given the nonspecific and heterogeneous appearance of these skin lesions due to a blunted immune response.

SUMMARY

As the population of non-HIV immunosuppressed hosts expands with advances in medical therapies, the frequency and variety of cutaneous diseases in these hosts will increase.

Recurrent cutaneous tuberculosis in an immunocompetent 7-year-old male

Cutaneous tuberculosis (TB) makes up a small proportion of the 10.4 million cases around the world. Although it is more commonly found in the developing world, cutaneous TB is rarely reported in the developed countries. It is fairly challenging to diagnose without histological examination. In this report, we present an immunocompetent 7-year-old male with a complex medical history diagnosed with cutaneous Mycobacterium tuberculosis after multiple ventriculoperitoneal shunt (VPS) revisions. This case of cutaneous TB in an immunocompetent patient is remarkable in its uncharacteristic presentation with no obvious source of TB infected contacts or travel history.

Cutaneous infection with paucibacillary Mycobacterium tuberculosis treated successfully with a modified antituberculous drug regimen

Tuberculosis is a serious infection that is increasing in prevalence, affecting many people worldwide. The diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with often inconclusive diagnostic testing. Extrapulmonary tuberculosis comprises approximately 10% of all cases of tuberculosis, and cutaneous tuberculosis makes up only a small proportion of these cases. Discussed here is the case of a 61-year-old immunocompetent female with a large cutaneous lesion on her index finger secondary to Mycobacterium tuberculosis Tissue cultures taken at biopsy were negative; however, empiric antimycobacterial therapy was initiated. The initial regimen was not tolerated, and antituberculous therapy was substituted for moxifloxacin and clarithromycin. The lesion improved significantly with a concurrent improvement in function.

New antituberculous drugs derived from natural products: current perspectives and issues in antituberculous drug development

Tuberculosis is one of the most common and challenging infectious diseases worldwide. Especially, the lack of effective chemotherapeutic drugs for tuberculosis/human immunodeficiency virus co-infection and prevalence of multidrug-resistant and extensively drug-resistant tuberculosis remain to be serious clinical problems. Development of new drugs is a potential solution to fight tuberculosis. In this decade, the development status of new antituberculous drugs has been greatly advanced by the leading role of international organizations such as the Global Alliance for Tuberculosis Drug Development, Stop Tuberculosis Partnership and Global Health Innovative Technology Fund. In this review, we introduce the development status of new drugs for tuberculosis, focusing on those derived from natural products.The Journal of Antibiotics advance online publication, 1 November 2017; doi:10.1038/ja.2017.126.

Isoniazid toxicosis in dogs: 137 cases (2004-2014)

OBJECTIVE To establish the minimum toxic dose of isoniazid in dogs, characterize the clinical signs and outcomes for dogs following isoniazid ingestion, and determine whether IV administration of pyridoxine to dogs with isoniazid toxicosis is protective against death. DESIGN Retrospective case series. ANIMALS 137 dogs with isoniazid toxicosis. PROCEDURES The electronic database of the American Society for the Prevention of Cruelty to Animals Animal Poison Control Center was reviewed from January 2004 through December 2014 to identify dogs with isoniazid toxicosis. For each dog identified, information extracted from the medical record included signalment, estimated dose of isoniazid ingested, clinical signs, treatment, and outcome. Follow-up communication with pet owners or primary care veterinarians was performed when necessary to obtain missing information. RESULTS Clinical signs of isoniazid toxicosis were observed in 134 of 137 (98%) dogs and included seizures (n = 104), CNS signs without seizures (94), and gastrointestinal (41), cardiovascular (19), urogenital (4), and respiratory (1) abnormalities. Of the 87 dogs for which the outcome was available, 61 survived, 18 died, and 8 were euthanized. Probability of survival was positively associated with body weight and IV administration of pyridoxine and negatively associated with dose of isoniazid ingested and presence of seizures. Dogs that received pyridoxine IV were 29 times as likely to survive as dogs that did not receive pyridoxine IV. CONCLUSIONS AND CLINICAL RELEVANCE Results indicated rapid diagnosis of isoniazid toxicosis and prompt treatment of affected dogs with pyridoxine and other supportive care were imperative for achieving a successful outcome.

Cutaneous Squamous Cell Carcinoma in Lupus Vulgaris Caused by Drug Resistant Mycobacterium Tuberculosis

Tuberculosis (TB) is still a major public health problem in the world, with many factors contributing to this burden, including poor living conditions, overcrowding, poverty, malnutrition, illiteracy, and rapid spread of human immunodeficiency virus infection. Cutaneous tuberculosis is a less common form of extrapulmonary tuberculosis, and in this paucibacillary form the diagnosis depends on histopathology, tuberculin positivity, and response to treatment. The diagnosis is even more difficult in cases with drug resistant Mycobacterium tuberculosis due to lack of awareness and lack of facilities to diagnose drug resistant tuberculosis. In this article, we describe an unusual case of multidrug resistant lupus vulgaris (LV), in a 34-year-old male who responded to anti-tubercular treatment (ATT) initially, but developed recurrent disease which failed to respond to standard four-drug ATT; subsequently, tissue culture showed growth of multidrug resistant M. tuberculosis. Subsequently, he also developed cutaneous squamous cell carcinoma. This article aims to exemplify a grave complication that can occur in long-standing case of LV, the limitations faced by clinicians in developing countries where tuberculosis is endemic, and classical methods of proving drug resistance are generally unavailable or fail.

Characterization of Mycobacterium marinum infections in zebrafish wounds and sinus tracts

The impaired healing of Mycobacterium tuberculosis-infected wounds is a clinical challenge, and the mechanisms involved are still not clear. The zebrafish model of Mycobacterium marinum infection has provided surprising insights into the pathogenesis of tuberculosis in humans. Similarly, the major principles and phases of cutaneous wound healing are conserved among adult mammals and adult zebrafish. Here, we injected Mycobacterium marinum into the dorsal muscles of adult zebrafish and observed the development of chronic wound pathology. Deep sequencing showed that gene expression related to muscles was down-regulated, whereas expressions of the IL-1β, TNF-α, dram1 genes and the transcript of mir1-2 gene were up-regulated in infected wounds of zebrafish compared with control zebrafish. Muscles are immune-responsive tissues. Thus, muscles may play a role in the anti-Mycobacterium tuberculosis immunologic process, which leads to apoptosis of the infected muscle cell and formation of the subcutaneous sinus tract.

Comparison of Transperitoneal and Retroperitoneal Laparoscopic Nephrectomy for Nonfunctional Tuberculous Kidneys: A Single-Center Experience

OBJECTIVES

To compare the effectiveness and safety between retroperitoneal laparoscopic nephrectomy (RLN) and transperitoneal laparoscopic nephrectomy (TLN) for nonfunctional tuberculous kidneys (NTK).

METHODS

From March 2013 to February 2016, 24 patients with NTK underwent laparoscopic nephrectomy in our department. Eleven patients underwent RLN, and 13 underwent TLN. The demographics and perioperative outcomes were compared retrospectively.

RESULTS

Characteristics, including gender, age, body mass index, and location, were similar in these two groups. All operations were successfully completed in the RLN group, while 1 case in the TLN group was converted to open surgery due to severe adhesions and excessive bleeding (1 of 13 patients). Time to oral intake after surgery in the TLN and RLN group was 43.85 ± 6.01 hours and 27.45 ± 6.83 hours (P < .05). No notable differences were found between two groups in terms of estimated blood loss, operative time, days of drain removal, and postoperative hospital stay. No local or disseminated recurrence was identified during the follow-up period.

CONCLUSION

Taking the same safety and effectiveness into consideration, TLN can be an alternative choice for experienced surgeons to deal with NTK. Also, further studies with a larger sample size should be performed to confirm this finding.

A 34-Year-Old Obese Woman with Rash, Finger Swelling and Fever

Disseminated tuberculosis first presenting as cutaneous lesion is uncommon and difficult to diagnose on account of its divers clinical forms. We present a 34-year-old obese woman with rash, finger swelling and fever. The patient was firstly manifested by fever and mass in palm and finger, gradually involving multisystems injury. She was diagnosed with disseminated tuberculosis in consideration of multiple system involvement, imaging characteristics, tuberculous granuloma in dermis and positive result of Mycobacterium culture. After two months of anti-tuberculosis treatment, fever and multisystems injury were controlled effectively, but skeletal and bone marrow involvement continued to progress, experiencing tuberculosis related acute hematopoietic stagnation. Continuing intensive therapy to one year, skeletal and hematological involvement improved and treatment was discontinued after two years. Follow-up to now with drug withdrawal for more than 1year, the patient remains in remission.

A Slowly Growing Orange Patch on the Cheek: Diagnosis of Lupus Vulgaris 20 Years After Onset of First Skin Changes

Tuberculosis is a worldwide occurring disease that affects approximately 20-40% of the world's population and in particular in developing countries. However, in times of migration, industrialised countries are again being more and more affected. Cutaneous tuberculosis is rare and lupus vulgaris represents its most common form. Preferentially, young adults in developing or low-income countries are affected from cutaneous tuberculosis, which usually occurs in previously sensitized persons with a high degree of tuberculin sensitivity and a good immunoresponse. In Europe, more elderly people are involved. We present a case of lupus vulgaris that was diagnosed with a delay of about 20 years after onset of first skin changes.

Sepsis, parenteral vaccination and skin disinfection

ASBSTRACT Disinfection should be required for all skin penetrative procedures including parenteral administration of vaccines. This review analyses medically attended infectious events following parenteral vaccination in terms of their microbiological aetiology and pathogenesis. Like 'clean' surgical site infections, the major pathogens responsible for these events were Staphylococcal species, implicating endogenous con-tamination as a significant source of infection. As 70% isopropyl alcohol swabbing has been shown to effectively disinfect the skin, it would be medico-legally difficult to defend a case of sepsis with the omission of skin disinfection unless the very low risk of this event was adequately explained to the patient and documented prior to vaccination. There was a significant cost-benefit for skin disinfection and cellulitis. Skin disinfection in the context of parenteral vaccination represents a new paradigm of medical practice; the use of a low cost intervention to prevent an event of very low prevalence but of significant cost.

The formulation of nanomedicines for treating tuberculosis

Recent estimates indicate that tuberculosis (TB) is the leading cause of death worldwide, alongside the human immunodeficiency virus (HIV) infection. The current treatment is effective, but is associated with severe adverse-effects and noncompliance to prescribed regimens. An alternative route of drug delivery may improve the performance of existing drugs, which may have a key importance in TB control and eradication. Recent advances and emerging technologies in nanoscale systems, particularly nanoparticles (NPs), have the potential to transform such approach to human health and disease. Until now, several nanodelivery systems for the pulmonary administration of anti-TB drugs have been intensively studied and their utility as an alternative to the classical TB treatment has been suggested. In this context, this review provides a comprehensive analysis of recent progress in nanodelivery systems for pulmonary administration of anti-TB drugs. Additionally, more convenient and cost-effective alternatives for the lung delivery, different types of NPs for oral and topical are also being considered, and summarized in this review. Lastly, the future of this growing field and its potential impact will be discussed.

[Latent-disseminated tuberculosis revealed by atypical skin ulcerations]

INTRODUCTION

Cutaneous tuberculosis (CT) is rare in industrialized countries. Given the clinicopathological polymorphism and the difficulty of isolating the pathogen, diagnosis can be difficult. The condition may be associated with other known locations of the disease or in rare cases, it may be a tell-tale sign, as in our case, in which leg ulcers revealed paucisymptomatic disseminated tuberculosis.

OBSERVATION

A 67-year-old man was referred for rapidly extensive ulcers of the right leg contiguous to debilitating arthritis of the knee of unknown aetiology for 18 months. Earlier investigations revealed thymoma and a pulmonary nodule considered to be sarcoidosis. A skin biopsy showed a granulomatous eosinophilic-rich infiltrate and vasculitis of the small vessels. Screening of the skin sample and gastric aspirate for Koch Bacillus (BK) was negative. A diagnosis of sarcoidosis was made. A positive QuantiFERON test eventually led to the correct diagnosis. On further testing of bronchoalveolar fluid and a synovial biopsy, culture for Mycobacterium tuberculosis (MT) was positive. The PET scan showed high metabolism in the prostate, bone, spleen, liver, nodes and heart. The quad- and then dual-antibiotic antitubercular therapies produced a rapid improvement but treatment was continued over 12 months, given the persistence of high metabolism on PET-CT scan and the low blood rifampicin concentration.

DISCUSSION

A CT should be considered in the presence of giant-cell granulomas, even in the absence of caseous necrosis, and where both direct examination and culture for the skin are negative. Our case also underlines the importance of an extensive workup to rule out disseminated disease even if the patient is not symptomatic.