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

<p>Chronic Perioral Tuberculosis Skin Lesions in a 21-Year-Old Male</p>

Cutaneous tuberculosis is a rare form of tuberculosis infection that may lead to chronic lesions of skin and be missed in diagnosis due to location of the appearance of the lesions. This is a very rare case of peri-oral cutaneous tuberculosis in a 21-year-old man with no other specific sign of symptoms of tuberculosis infection but mimics signs of Herpesviridae family infection. The biopsy of the lesions and Ziehl–Neelsen stain revealed the diagnosis of cutaneous tuberculosis. By the beginning of the treatment of this unusual form of tuberculosis, the lesions had begun to fade and after 8 months, they were totally faded.

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.

[Cutaneous tuberculosis of the ear due to Mycobacterium bovis]

INTRODUCTION

Isolated cutaneous tuberculosis is uncommon, accounting for only 0.14 to 5% of Mycobacterium tuberculosis infections. We report a rare case of ear cutaneous tuberculosis due to Mycobacterium bovis in an immunocompetent woman.

CASE REPORT

A 59-year-old woman presented an erythematous and scaly lesion of the ear present for two years. The histological findings were compatible with a diagnosis of sarcoidosis, with non-necrotic granuloma. After failure of dermal corticosteroid therapy, a further biopsy identified M. bovis; the patient was cured following anti-tubercular treatment.

DISCUSSION

Ear lesions are predominantly associated with tumors, fungal infections, chondritis, lupus and sarcoidosis. The ear, like the face in general, is a classic localization of lupus vulgaris, a chronic form of confined tuberculosis infection with progressive evolution. The paucibacillary nature of these lesions is the reason why their diagnosis is based in some cases on clinical, histological and immunological findings without bacteriological evidence. However, given the potential therapeutic implications, it is important to push the microbiological analysis as far as possible. In our case, culture and identification provided evidence of M. bovis infection, enabling suitable and effective therapy to be given.

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.

Nonoperative management of craniovertebral junction and cutaneous tuberculosis

Background:

Craniovertebral junction (CVJ) and cutaneous tuberculosis (TB) are both rare, each occurring in 0.3–1.0% of patients. To our knowledge, there are no existing cases reporting these manifestations of TB simultaneously. We report a case of TB involving the left CVJ as well as the skin, and discuss our management while providing a review of the literature.

Case Description:

An adult patient was presented with progressive nocturnal neck pain associated with the development of several skin lesions. Investigations revealed multiple osseous lesions including the left CVJ. Biopsy of the CVJ lesion was unamenable due to proximity of the vertebral artery; therefore, the patient underwent biopsy of the other sites. Histological examination demonstrated features consistent with TB infection and the patient commenced 12 months of standard anti-TB therapy with cervical spine immobilization. At 2-month review, the patient was well with a near-complete resolution of neck pain and cutaneous lesions. Repeat imaging at 6 months follow-up demonstrated a stable C1 lesion with no evidence of instability.

Conclusion:

CVJ TB may be treated solely with anti-TB therapy and immobilization to good effect if there is no gross instability or neurological deficit. Similarly, cutaneous TB responds well to standard anti- TB therapy. Our experience suggests that co-existing tuberculous lesions in the CVJ and skin can be simultaneously managed with standard therapy without significant alterations to treatment regimes or prognosis.

Genetic risk factors for human susceptibility to infections of relevance in dermatology

BACKGROUND

In the pre-microbiological era, it was widely accepted that diseases, today known to be infectious, were hereditary. With the discovery of microorganisms and their role in the pathogenesis of several diseases, it was suggested that exposure to the pathogen was enough to explain infection. Nowadays, it is clear that infection is the result of a complex interplay between pathogen and host, therefore dependant on the genetic make-up of the two organisms. Dermatology offers several examples of infectious diseases in different stages of understanding of their molecular basis. In this review, we summarize the main advances towards dissecting the genetic component controlling human susceptibility to infectious diseases of interest in dermatology. Widely investigated diseases such as leprosy and leishmaniasis are discussed from the genetic perspective of both host and pathogen. Others, such as rare mycobacterioses, fungal infections and syphilis, are presented as good opportunities for research in the field of genetics of infection.

Delayed diagnosis of scrofuloderma misdiagnosed as a bacterial abscess

An 82-year-old woman presented with a four-month history of an ulcerative plaque overlying her left neck. This lesion had developed as a subcutaneous nodule, gradually increased in size, and evolved into ulcers. Before visiting our Dermatology clinic, the patient had been diagnosed as having a bacterial abscess, but treatments with antibiotics were unsuccessful. The presence of a purulent discharge and prominent ulceration caused further confusion as bacterial abscess, and radiologic evaluation on computed tomography also led to the possibilities of secondary lesions from an abscess or malignancy. However, the characteristic appearance of her lesion allowed us to discern cutaneous tuberculosis, especially scrofuloderma. Based on clinical examinations, staining for acid-fast bacilli, and positive findings of polymerase chain reaction, a quick diagnosis of scrofuloderma was made. After that, she was treated successfully with anti-tuberculosis therapy and the ulcer healed. Our case highlights the problem of delayed diagnosis of scrofuloderma presenting as a bacterial abscess. In conclusion, having a high index of suspicion is needed to diagnose cutaneous tuberculosis correctly.

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.

Cutaneous Tuberculosis : A Clinico-morphological Study

BACKGROUND

Cutaneous tuberculosis forms a small subset of extrapulmonary tuberculosis. The present study is an attempt to observe the clinico morphological pattern seen in cases of cutaneous tuberculosis over a period of 5 years, and to correlate them with mantoux reactivity and human immunodeficiency virus (HIV) status.

METHODS

All cases of cutaneous tuberculosis observed among the dermatology in patients and those attending out patient department were included in the study. The basis of diagnosis was clinical, histopathological and microbiological. Intradermal mantoux test and serological test in the form of enzyme-linked immunosorbent assay (ELISA) for tuberculosis was done. HIV screening was carried out in 32 cases. CD4 counts were done in all HIV positive cases.

RESULTS

A total 0.02% patient attending the dermatology centre had cutaneous tuberculosis. The spectrum of infection included 19 (51%) cases of lupus vulgaris, 7 (19%) cases of papulonecrotic tuberculids, six cases each of tuberculosis verrucosa cutis and scrofuloderma. One case had scrofuloderma and lupus vulgaris and another both scrofuloderma and papulonecrotic tuberculide. One case of lichen scrofulosorum was seen in a seven year old boy. 11 cases revealed evidence of systemic tuberculosis. Seven cases of HIV with CD4 counts between 50-500 cells/μl were observed in this study.

Imported tropical infectious ulcers in travelers

Skin ulcers are a commonly encountered problem at departments of tropical dermatology in the Western world. Furthermore, the general dermatologist is likely to be consulted more often for imported chronic skin ulcers because of the ever-increasing travel to and from tropical countries. The most common cause of chronic ulceration throughout the world is probably pyoderma. However, in some parts of the world, cutaneous leishmaniasis is one of the most prevalent causes. Mycobacterium ulcerans is an important cause of chronic ulcers in West Africa. Bacterial infections include pyoderma, mycobacterial infections, diphtheria, and anthrax. Pyoderma is caused by Staphylococcus aureus and/or beta-hemolytic streptococci group A. This condition is a common cause of ulcerative skin lesions in tropical countries and is often encountered as a secondary infection in travelers. The diagnosis is often made on clinical grounds. Antibacterial treatment for pyoderma should preferably be based on culture outcome. Floxacillin is generally active against S. aureus and beta-hemolytic streptococci. Infection with Mycobacterium ulcerans, M. marinum, and M. tuberculosis may cause ulcers. Buruli ulcers, which are caused by M. ulcerans, are endemic in foci in West Africa and have been reported as an imported disease in the Western world. Treatment is generally surgical, although a combination of rifampin (rifampicin) and streptomycin may be effective in the early stage. M. marinum causes occasional ulcerating lesions in humans. Treatment regimens consist of combinations containing clarithromycin, rifampin, or ethambutol. Cutaneous tuberculosis is rare in travelers but may be encountered in immigrants from developing countries. Treatment is with multiple drug regimens consisting of isoniazid, ethambutol, pyrazinamide, and rifampin. Cutaneous diphtheria is still endemic in many tropical countries. Cutaneous diphtheria ulcers are nonspecific and erythromycin and penicillin are both effective antibacterials. Antitoxin should be administered intramuscularly in suspected cases. Anthrax is caused by spore-forming Bacillus anthracis. This infection is still endemic in many tropical countries. Eschar formation, which sloughs and leaves behind a shallow ulcer at the site of inoculation, characterizes cutaneous anthrax. Penicillin and doxycycline are effective antibacterials. Cutaneous leishmaniasis is caused by different species belonging to the genus Leishmania. The disorder is one of the ten most frequent causes of skin diseases in travelers returning from (sub)tropical countries. The clinical picture is diverse, ranging from a painless papule or nodule to an ulcer with or without a scab. Treatment depends on the clinical manifestations and the species involved.Sporotrichosis, chromo(blasto)mycosis, and mycetoma are the most common mycoses that may be accompanied by ulceration. Infections are restricted to certain regions and often result from direct penetration of the fungus into the skin. Anti-mycotic treatment depends on the microorganism involved. The most common causes of infectious skin ulceration encountered in patients from tropical countries who present at a department of tropical dermatology are reviewed in this article.

Escrofulodermia con tuberculosis osteoarticular en el área sanitaria de Ferrol

INTRODUCTION

Scrofuloderma results from direct extension of an underlying tuberculous focus such as bone, joint or even the epididymis to the overlying skin, but is more frequent over a lymph node, mainly in the cervical region.

METHODS

We analysed all cases of scrofuloderma with a bone or joint focus evaluated in the sanitary area of Ferrol, with a current population of 220,000, during a 15-year period. We describe the clinical, histopathological, and microbiological data of patients.

RESULTS

We found 6 cases of scrofuloderma with osteoarticular tuberculosis. This series includes five men and one woman, aged 37 to 80. Visceral involvement was found in 3 patients (50 %).

CONCLUSION

Osteoarticular tuberculosis comprises 10 % of all extrapulmonary tuberculous infections. There is a high probability of visceral involvement in patients with scrofuloderma. Underlying bone involvement should be rule out in all patients with scrofuloderma, especially in those with incomplete response to medical treatment.

Abcès tuberculeux métastatiques (gommes tuberculeuses) : un diagnostic rare en France

INTRODUCTION

Cutaneous tuberculosis is rare in the developed countries. We report a case of tuberculous gumma in an immunocompetent patient diagnosed late.

CASE-REPORT

A 33-year-old Moroccan woman was diagnosed with tuberculous gumma after presenting cutaneous nodules and subcutaneous abscesses that had developed during pregnancy and were present for 11 months. Cutaneous and pulmonary tuberculosis was discovered. The patient recovered under antimycobacterial treatment.

COMMENTS

Cutaneous tuberculosis presents with a wide spectrum of clinical lesions. It should be considered in the presence of poorly known lesions such as gumma, which require investigation for underlying tuberculosis.

Tuberculose cutanée de l'enfant au Maroc : étude de 30 cas

In Morocco, tuberculosis is still endemic. Cutaneous tuberculosis is ranged the fifth after the pleuro-pulmonary, lymphe node, urogenital and digestive tuberculosis. It mainly affects young people. Few studies of cutaneous tuberculosis are available in this age group. The aim of our study is to emphasize its epidemiological features.

PATIENTS AND METHODS

It is a retrospective study including all cases of childhood cutaneous tuberculosis observed between January 1981 and December 2004. The diagnosis was based on the confrontation of clinical, immunological, bacteriological and histological data.

RESULTS

Thirty cases were collected. The mean age was 11 years. The clinical features are as follows: gumma 46.6%, scrofuloderma 36.6%, lupus vulgaris 13.3% and skin tuberculosis chancre 3.3%. The Mantoux test was positive in 67%, tuberculoid granuloma was observed in 78% and the search of Mycobacterium tuberculosis was positive in 13%.

DISCUSSION

Gumma and scrofuloderma were the most frequent forms as in other Moroccan series. These results attest the endemicity of this affection in our country. The diagnosis relies on the discovery of Mycobacterium tuberculosis; as this situation is rare for the cutaneous location, the diagnosis relies then on the association of clinical and paraclinical criteria.

Specific health issues in ethnic minority groups

The study of disease patterns in ethnic minority groups offers insights into the causation of disease. Ethnic minorities have wide variations in health conditions and behaviors, and stereotyping can lead to spurious assumptions in caring for patients. This article presents basic information relating to major illnesses such as cardiovascular disease, diabetes, and cancer and common health disorders observed among ethnic groups primarily in the United Kingdom and United States.

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 (</= 16 years). There were 32 (42.7%) boys and 43 (57.3%) girls with a boy : girl ratio of 0.74 : 1. The majority of the children, 41 (54.7%) were in the 10-14 years age group. There was no significant boy or girl preponderance in any group other than in scrofuloderma (SFD), where girls significantly outnumbered boys at all ages. Of the various patterns of cutaneous tuberculosis seen, 40 (53.3%) had SFD, 30 (40.0%) had lupus vulgaris (LV), 3 (4.0%) had tuberculosis verrucosa cutis (TVC), 1 (1.3%) child each had tuberculids and tubercular gumma. No child had a tubercular chancre or acute miliary cutaneous tuberculosis. The neck was the commonest site afflicted with SFD and the face was the commonest site affected with LV. No child had generalized lymphadenopathy. Eighteen (60.0%) of the 30 children with LV had regional lymphadenopathy of which 15 (83.3%) had localized disease and 3 (16.7%) had disseminated disease. Of the 16 children with systemic organ involvement, 12 (75.0%) had regional lymphadenopathy. Of the 62 children in whom the data regarding vaccination status was available, 31 (50.0%) had been vaccinated and 31 (50.0%) had not. Among the vaccinated group no child had disseminated disease. Three (9.7%) children in the nonvaccinated group had disseminated disease. Information regarding Mantoux reactivity was available in 71 (94.7%) children, 61 (86.0%) with localized disease and 10 (14.1%) with disseminated disease. Of the 61 children with localized disease, 56 (91.8%) were Mantoux positive and of the 10 children with disseminated disease, only 5 (50.0%) were Mantoux positive (> 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.

Cutaneous inoculation tuberculosis in a child

Cutaneous tuberculosis remains a rare entity in the United States. We describe a case of cutaneous tuberculosis in a child.