Cutaneous tuberculosis. Part II: Complications, diagnostic workup, histopathologic features, and treatment

Clinical relevance and prognostic impact of the classification between multibacillary and paucibacillary forms of cutaneous tuberculosis: A 24-year retrospective multicenter study

OBJECTIVES

Cutaneous tuberculosis (CTB) may be over-diagnosed due to imprecise diagnostic criteria or overlooked where mycobacterial investigations are negative. We evaluated the distinction between multibacillary and paucibacillary forms of CTB, as well as drug resistance and cure rates according to the results of mycobacterial investigations.

METHODS

We included retrospectively all patients diagnosed with CTB from 1995 to 2018 in two hospitals in Paris. Clinical forms were classified according to dermatological descriptions, into multibacillary (e.g. gumma, scrofuloderma, orificial TB) and paucibacillary forms (lupus vulgaris, verrucous tuberculosis, papulonecrotic tuberculids, nodular panniculitis). A distinction was made between microbiologically confirmed CTB and presumed CTB forms, which were treated presumptively. Cure was defined as the complete resolution of CTB in patients who completed anti-tuberculosis treatment.

RESULTS

Among the 124 patients with CTB, the most common forms were nodular panniculitis (30.6%), scrofuloderma (22.6%), gumma (18.6%), and lupus vulgaris (12.1%). Tuberculosis was confirmed in 78 patients (62.9%), among whom 13 (16.7%) exhibited resistance to anti-tuberculous drugs, and 46 were presumptively treated. Mycobacterial investigations were significantly more frequently positive for multibacillary (88.2%) than for paucibacillary CTB (39.3%) (p < 10-6). Patients with mycobacterial evidence of CTB exhibited significantly better cure rates than patients without (96.7% vs. 66.7%, p < 10-4), particularly among those with nodular panniculitis (100% vs. 63.0%, p < 10-3).

CONCLUSION

The distinction between paucibacillary and multibacillary CTB is relevant. Resistant strains may be isolated. Antituberculosis drugs should be prescribed with caution in cases of panniculitis in the absence of evidence of mycobacterial infection.

New-Onset Vulvar Edema in a Pediatric Patient

A female pediatric patient presents with asymptomatic vulvar edema and swelling, erythema, and palpable induration on the labia minora and majora of the vulva. What is your diagnosis?

Facial cutaneous tuberculosis infected by non-tuberculous mycobacteria

BACKGROUND

Cutaneous infections caused by non-tuberculous mycobacteria (NTM) are extremely rare, particularly when they are localized to the facial area. This condition presents significant diagnostic challenges due to its unusual presentation and the need for precise microbiological identification.

CASE PRESENTATION

A two-year-old male patient presented with a progressively enlarging reddish-brown mass on the left side of his face. Despite the absence of systemic symptoms, the lesion's growth warranted investigation due to its growth. Ultrasonography showed a hypoechoic mass in the dermis, indicating an underlying abscess. The subsequent aspiration resulted in pale yellow pus, which upon testing and culture, confirmed the presence of Mycobacterium avium complex infection, a species of NTM. This case exemplifies the synergy between imaging modalities and microbiological analysis, highlighting the crucial role of both in achieving favorable clinical outcomes in patients with suspected cutaneous NTM infections. Ultrasound can expedite diagnosis, improve treatment planning, and enhance patient care by enabling targeted interventions and monitoring response to therapy in these scenarios. However, it is the combination of pathogen-specific diagnostics that ensures accurate etiological attribution and appropriate antimicrobial stewardship.

CONCLUSION

Although rare, facial cutaneous infections caused by NTM still deserve thorough investigation to determine the exact cause. Ultrasound is used to identify cutaneous lesions, measure their extent, and guide surgical procedures. The ultimate diagnosis is based on microbiological confirmation.

Tuberculous Ulcerative Skin Lesion of the Penis: A Case Report

Genitourinary tuberculosis (GUTB), especially penile tuberculosis (PTB), is a disease often overlooked by urological specialists, especially in Europe, where the pathology is less frequent. In this report, we described a case of penile tuberculosis (PTB) characterized by ulcers on the penis. After the patient was administered three months of anti-tuberculosis treatment (isoniazid 0.3 g/qd, rifampicin 0.6 g/qw, and ethambutol 0.75 g/qd), the ulcer disappeared. The patient was followed up for seven months and showed no recurrence.

A Chronic Multiple Site of Scrofuloderma: Is It Reactivation or Treatment Failure of Tuberculosis?

We report a case of 32-year-old patient who presented with painless erythematous plaque gradually ulcerated for 9 years. He had a history of pulmonary tuberculosis 12 years ago and was cured by the treatment of 2HRZE/4HR. The laboratory examination of t-spot and PPD skin test was positive. Histopathology examinations of left cervical lymph node as well as skin revealed granulomatous inflammation with caseous necrosis. A diagnosis of scrofuloderma was made. Negative sputum culture and chest CT scan results excluded pulmonary tuberculosis. The patient was treated with a standard antituberculosis therapy and recovered well after 5 months' follow-up. Scrofuloderma is a rare manifestation of mycobacterial infection. Early diagnosis and treatment are very important.

Giant Lupus Vulgaris with Negative T-SPOT.TB, a Case Report and Literature Review

Lupus vulgaris is a paucibacillary form of cutaneous tuberculosis (CTB) which is accounting for 1–2% of all tuberculosis cases. Here, we report a rare huge lupus vulgaris misdiagnosed as sarcoidosis for 11 years. A 65-year-old man presented to dermatology outpatient with a large asymptomatic erythematous plaque and erosions on his neck. Sarcoidosis was initially diagnosed on the basis of negative interferon-gamma release tests and biopsies of lymph nodes and lesions. The patient was treated with long-term oral steroid and immunosuppressive agents, but the lesions expanded gradually. Lupus vulgaris was finally diagnosed by combining molecular detection and mycobacterial culture. The skin lesions were resolved after six months of standard antituberculosis therapy. We report this case to analyze the reasons for the misdiagnosis and review-related literature to further provide experience for the diagnosis and treatment of cutaneous tuberculosis with negative T-SPOT.TB.

Clinicoepidemiological characteristics of cutaneous tuberculosis in 1458 Indian patients: a retrospective analytical study from a tertiary care center

BACKGROUND

Tuberculosis (TB) has been one of the most challenging infectious diseases globally. Cutaneous tuberculosis (CTB) accounts for 0.5-2% of extrapulmonary TB and is often missed owing to its varying morphology and paucibacillary nature.

METHODS

In this retrospective analytical study, we share our 22-year experience to describe the clinicoepidemiological features and treatment response of CTB in 1458 Indian patients. In each patient, detailed history was followed by clinical examination, hematological and biochemical investigations, Mantoux testing, chest x-ray, and other specialized investigations to detect coexisting systemic foci. Clinical diagnosis of CTB was confirmed on histopathology/cytology and response to standard antitubercular treatment (ATT). All details were recorded on a predesigned proforma.

RESULTS

Of 1458 eligible patients, 803 were children. The mean disease duration was 15.3 months. Lupus vulgaris (40.4%) was the most common clinical variant, followed by scrofuloderma (32.7%) and lichen scrofulosorum (15.2%). Other variants included tuberculosis verrucosa cutis, gumma, tuberculids, and inoculation TB. Multiple clinical variants were observed in 3.6% of patients. A total of 41.4% of patients had coexistent systemic foci; in lymph nodes (50.4%), lungs (35.6%), bone (10.3%), and abdomen (5.8%). TB foci were also observed at uncommon locations like the eye, central nervous system, and genital organs. Treatment response to ATT was favorable in 99.2%.

INTERPRETATION

The burden of CTB still persists in developing countries. The diagnosis is often missed due to the wide spectrum of clinical and histological presentations. Awareness among clinicians of varying aspects of CTB is of paramount importance for early diagnosis and management and will significantly prevent morbidity and disease complications.