Skin Tuberculosis in Children: Learning from India

A Clinico-Histopathological Study of Lupus Vulgaris at a Tertiary Care Centre

Background and objectives Lupus vulgaris is a chronic, progressive, paucibacillary form of cutaneous tuberculosis that occurs in persons with moderate to high immunity. Due to its varied clinical presentation, it can masquerade as different dermatological conditions. This study describes the demographic patterns and varieties of clinical manifestations that can be possible in this curable illness. Methods This study was conducted over two years and included 19 patients with histopathologically confirmed lupus vulgaris in Odisha, India. Demographic data, clinical features, and response to treatment are presented. Results Thirteen cases (68.4%) were seen in adults and six (31.6%) in pediatric patients. The lower limbs were the more affected (n=10), followed by the upper limb (6), the face (2), and the chest (1). All but one patient had plaque-type lesions. On histopathology, all showed a tuberculoid granuloma with no demonstration of acid-fast bacilli with Ziehl-Neelsen staining. Conclusion In the present study, the incidence was mostly observed in the young and higher activity age groups (5-40 years). Plaque-type lesions were most commonly encountered. In histopathology, all the cases had tubercular granuloma-type lesions without any incidence of malignant transformations. All the patients responded well to conventional multi-drug anti-tubercular chemotherapeutic regimens.

Cytomorphological spectrum of scalp lesions in the population of a developing country: A retrospective study

BACKGROUND

Scalp lesions are frequently encountered in clinical practice. Fine-needle aspiration cytology (FNAC) can characterize most of these lesions; however, there is little published work on cytology of scalp lesions.

METHODS

Records of all the patients subjected to FNAC from January 2011 to August 2016 were retrieved from the archives of the Cytopathology section of our Institute. Out of the 71 852 cases reviewed, 896 patients, who presented with palpable scalp lesions, were included in the study. Aspirates were obtained with a 23-gauge needle attached to a 10 mL disposable plastic syringe. May-Grünwald-Giemsa stained and Pap stained slides were prepared. Special stains and immunocytochemical analysis were done when necessary.

RESULTS

Out of the 896 cases of aspirates from scalp lesions, 155 (17.2%) aspirates were found to be inadequate for diagnosis. One hundred and fifty-seven (21%) out of 741 adequate aspirates showed features of inflammatory or reactive pathology comprising of abscesses (57), cystic lesions (24), tubercular lesions (16), and reactive lymphadenopathy (66). Four hundred and fifteen (56%) aspirates revealed a tumor-like etiology comprising of epidermal cyst (395), sebaceous cyst (4), dermoid cyst (1), calcinosis (7), vascular malformation (7), hematoma (5), and juvenile xanthogranulomatous lesion (1). Tumorous lesions formed 22.3% of the aspirates. Of these, 7 cases (4.2%) were of metastases to the scalp.

CONCLUSION

In a developing country, FNAC is a useful and cost-effective investigation for the diagnosis of a wide spectrum of scalp lesions. It allows rapid diagnosis and permits timely intervention thereby preventing complications due to delay in diagnosis.

Multifocal Skin Tuberculosis: Report of A Case

Tuberculosis (TB) is a severe problem in underdeveloped countries. Cutaneous TB is rare and often goes unrecognized. We report a Pakistani child with multifocal cutaneous and pulmonary TB. Microbiologic diagnosis was obtained when the abscesses were biopsied. Four-drug therapy produced rapid improvement of the lesions. A high level of suspicion must be maintained when evaluating children from countries at risk.

CUTANEOUS TUBERCULOSIS: A 26-YEAR RETROSPECTIVE STUDY IN AN ENDEMIC AREA OF TUBERCULOSIS, VITÓRIA, ESPÍRITO SANTO, BRAZIL

BACKGROUND

Tuberculosis is a serious health problem in Brazil so that the knowledge on the aspects of cutaneous tuberculosis is medically important.

OBJECTIVE

To assess the characteristics of patients with cutaneous tuberculosis treated at the Cassiano Antonio Moraes University Hospital, located in the city of Vitória, State of Espírito Santo, Brazil.

METHODS

This is a retrospective, descriptive, observational and cross-sectional study using the medical records of 29 patients with cutaneous tuberculosis treated at the Dermatology and Pulmonology services of the hospital from 1986 to 2011. The inclusion criterion was the confirmation of cutaneous tuberculosis taking into account clinical, epidemiological, immunological, and bacteriological findings, as well as the response to specific treatment.

RESULTS

Of the 29 studied patients; 18 (62%) were women with average age of 37 years; the predominant clinical condition was erythema induratum of Bazin in 12 (41.4%) cases; and the cutaneous lesions were in the lower limbs in 19 (65.8%) patients. Extra-cutaneous involvement occurred in eight (27.6%) cases. The tuberculin tests were positive in 15 (79%) individuals and the assessment of the infectious agent was negative in most of the investigated cases.

CONCLUSION

The study found a low frequency (0.44%) of cutaneous tuberculosis in an endemic area of tuberculosis. There was a predominance of infection in women aged thirty to forty years. Erythema induratum was the most common clinical condition, affecting mainly the lower limbs, in contrast to other Brazilian studies that found scrofuloderma as the most common manifestation, predominating in the cervical region of male children and adolescents.

Chronic oozing skin lesions in children: Possible tuberculosis? Two case reports

Cutaneous tuberculosis is frequently misleading and challenging, as it mimics a wide differential diagnosis. Here, we present two pediatric cases with chronic multiple ulcerating nodules. Proper history, physical examination, and histopathological analysis are included in the workup of suspected skin tuberculosis. Diagnosis was confirmed by positive culture for mycobacteria.

Ulcerative lupus vulgaris over nose, leading to cosmetic deformity

Lupus vulgaris (LV), is a chronic and progressive form of secondary cutaneous tuberculosis. In India, it is commonly seen over buttocks, thighs, and legs whereas involvement of nose is quite rare. Ulcerative variant particularly over nose causes destruction of cartilage, leading to irreversible deformities and contracture. High-index of suspicion is required for early diagnosis and prevention of cosmetic deformity. A case of LV over nose in a young male with ulceration is reported who responded well to anti-tubercular therapy, but left with scarring of nose, which could have been prevented if adequate awareness regarding extra-pulmonary cases would have been practiced.

Papulonecrotic tuberculid-clinicopathologic and molecular features of 12 Indian patients

BACKGROUND

Papulonecrotic tuberculid (PNT) is said to be a hypersensitivity reaction to M. tuberculosis. Some reports indicate that organisms are demonstrable by polymerase chain reaction (PCR).

METHODS

We describe 12 patients with PNT over 6 years. We reviewed the histopathologic features, clinical data and follow-up. PCR for M. tuberculosis DNA was done in all cases.

RESULTS

There were 7 men and 5 women. The ages ranged from 3-58 years. Upper limbs were commonly involved (8 cases). All patients had multiple papulonodular lesions, 5 showed ulceration and scarring. Mantoux test was strongly positive in all. Seven patients had systemic tuberculosis. On microscopy, necrosis was seen in 11 cases, varying from minimal to extensive. Epithelioid granulomas were common, except for 1 case with palisading and interstitial patterns. The infiltrate showed mostly lymphocytes, while 3 cases showed eosinophils. Vasculitis was seen in 8 cases. Two cases had dermal mucin, one also with interface dermatitis. This patient had concurrent LE. Mycobacterial DNA was detectable by PCR in 3 cases. Seven patients showed improvement/resolution of lesions on treatment.

CONCLUSIONS

PNT is a rare disease. A positive PCR reiterates the question whether these are "tuberculids". PNT may be better classified as true cutaneous tuberculosis and patients screened for systemic disease.

Cutaneous tuberculosis in children

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.

Psoriasiform type of lichen scrofulosorum: clue to disseminated tuberculosis

We present a 16-year-old girl with tuberculosis of the lungs, lymph nodes, and liver, who had extensive inflammatory lesions with pustules, which resembled psoriasis. A skin biopsy showed extensive tuberculoid granulomas surrounding hair follicles, consistent with lichen scrofulosorum. Antitubercular therapy led to resolution of skin lesions. This severe inflammatory type of lichen scrofulosorum is extremely rare.

Evaluation for granulomatous inflammation on fine needle aspiration cytology using special stains

Background. Tuberculosis is the commonest infectious disease in the developing world. Many diagnostic tests are devised for its detection including direct smear examination. This study was designed to determine the frequency of cases positive for AFB and positive for fungus in patients diagnosed to have granulomatous inflammation on Fine Needle Aspiration Cytology using special stains. Materials and Methods. A descriptive cross-sectional survey was done on 100 cases of granulomatous inflammation consistent with tuberculosis diagnosed on fine needle aspiration cytology at the Department of Pathology, King Edward Medical University, Lahore. After reporting granulomatous inflammation on Hematoxylin & Eosin staining of aspirates from FNAC, some unstained slides were subjected to special stains, like ZN, GMS, and PAS. Cases positive for AFB on ZN stain and fungus on GMS/PAS were noted down along with their frequency and percentages. Results. Forty-four cases (44%) of AFB positive smears were reported in granulomatous inflammation while only 5% cases of fungus were reported down. Cervical lymph nodes were the most commonly involved site (87%), and females were affected more (62%) than males. Most cases of AFB-positive smears were associated with caseation necrosis (93%). Conclusion. Special stains should be done on all granulomatous inflammation cases seen on FNAC for confirmation of TB and ruling out other infectious causes.

[Scrofuloderma: a misleading lesion]

We describe a case of scrofuloderma in an 8-year-old boy with a cutaneous tuberculosis lesion.

CASE REPORT

The child had spent holidays in Morocco. He presented a cutaneous lesion of the thigh which turned into an abscess with suppuration, in spite of surgical drainage. The lymph node analysis showed Koch bacilli and granuloma, leading to the diagnosis of scrofuloderma. Further exams found no other lesion. The course was favorable under treatment.

COMMENTS

With lupus vulgaris, scrofuloderma is the most common cutaneous tuberculosis lesion in children, particularly in developing countries. It is often associated with other organ lesions, such as bone or lung, and these must be sought. Scrofulodermas are unusual in Western countries, leading to misdiagnosis. Fortunately, adapted treatment most often results in recovery.

Tuberculosis of the breast with erythema nodosum: a case report

Introduction

There has been an increasing number of tuberculosis cases worldwide, but tuberculosis of the breast remains rare. In rare cases this is seen with a cutaneous manifestation of erythema nodosum.

Case presentation

We report the case of a 33-year-old Chinese woman with tuberculosis of the left breast accompanied by erythema nodosum on the anterior aspect of both lower legs. Due to her poor clinical response to conventional therapy, and the histopathological findings of fine needle aspiration cytology, there were strong indications of tuberculosis. Her clinical diagnosis was confirmed by molecular detection of Mycobacterium tuberculosis complex by polymerase chain reaction. The diagnosis was further confirmed by a second polymerase chain reaction test of erythema nodosum which tested positive for Mycobacterium tuberculosis complex. She received anti-tuberculous therapy for 18 months, and finally underwent residual lumpectomy. During her follow-up examination after 12 months, no evidence of either residual or recurrent disease was present.

Conclusion

Histopathological features and a high index of clinical suspicion are necessary to confirm a diagnosis of tuberculosis of the breast. Anti-tuberculous therapy with or without simple surgical intervention is the core treatment.