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Spiliopoulos O, Solomos Z, Puchner KP. Buruli ulcer, tuberculosis and leprosy: Exploring the One Health dimensions of three most prevalent mycobacterial diseases: A narrative review. Trop Med Int Health 2024; 29:657-667. [PMID: 38994702 DOI: 10.1111/tmi.14024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/13/2024]
Abstract
ΟBJECTIVES: Although Buruli ulcer, tuberculosis, and leprosy are the three most common mycobacterial diseases, One Health dimensions of these infections remain poorly understood. This narrative review aims at exploring the scientific literature with respect to the presence of animal reservoir(s) and other environmental sources for the pathogens of these infections, their role in transmission to humans and the research on/practical implementation of One Health relevant control efforts. METHODS The literature review was conducted using the online databases PubMed, Scopus, ProQuest and Google Scholar, reviewing articles that were written in English in the last 15 years. Grey literature, published by intergovernmental agencies, was also reviewed. RESULTS For the pathogen of Buruli ulcer, evidence suggests possums as a possible animal reservoir and thus having an active role in disease transmission to humans. Cattle and some wildlife species are deemed as established animal reservoirs for tuberculosis pathogens, with a non-negligible proportion of infections in humans being of zoonotic origin. Armadillos constitute an established animal reservoir for leprosy pathogens with the transmission of the disease from armadillos to humans being deemed possible. Lentic environments, soil and other aquatic sources may represent further abiotic reservoirs for viable Buruli ulcer and leprosy pathogens infecting humans. Ongoing investigation and implementation of public health measures, targeting (sapro)zoonotic transmission can be found in all three diseases. CONCLUSION Buruli ulcer, tuberculosis and leprosy exhibit important yet still poorly understood One Health aspects. Despite the microbiological affinity of the respective causative mycobacteria, considerable differences in their animal reservoirs, potential environmental sources and modes of zoonotic transmission are being observed. Whether these differences reflect actual variations between these diseases or rather knowledge gaps remains unclear. For improved disease control, further investigation of zoonotic aspects of all three diseases and formulation of One Health relevant interventions is urgently needed.
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Affiliation(s)
- Orestis Spiliopoulos
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Zisimangelos Solomos
- School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Karl Philipp Puchner
- Laboratory of Primary Health Care, General Medicine and Health Services Research, Faculty of Health Sciences, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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2
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Tangcheewinsirikul S, Phuthongkam W, Kanjanaphan T. Unusual presentations of tuberculosis: A diagnostic challenge. IDCases 2024; 36:e01971. [PMID: 38711944 PMCID: PMC11070909 DOI: 10.1016/j.idcr.2024.e01971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/08/2024] Open
Affiliation(s)
- Sirikarn Tangcheewinsirikul
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Weena Phuthongkam
- Division of Dermatology, Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Thiraporn Kanjanaphan
- Division of Infectious Diseases, Department of Pediatrics, Faculty of Medicine Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
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3
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Nguyen KH, Alcantara CA, Glassman I, May N, Mundra A, Mukundan A, Urness B, Yoon S, Sakaki R, Dayal S, Chowdhury T, Harshavardhan S, Ramanathan V, Venketaraman V. Cutaneous Manifestations of Mycobacterium tuberculosis: A Literature Review. Pathogens 2023; 12:920. [PMID: 37513768 PMCID: PMC10385667 DOI: 10.3390/pathogens12070920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 07/01/2023] [Accepted: 07/06/2023] [Indexed: 07/30/2023] Open
Abstract
Tuberculosis is an ancient disease that humanity struggled with for centuries and continues to struggle with. The bacteria Mycobacterium tuberculosis often infects the lungs through respiratory transmission and manifests itself through various symptoms, including cutaneous infections. Cutaneous tuberculosis (CTB) comprises about 1% to 1.5% of all extrapulmonary manifestations and is often accompanied by polymorphous lesions, including papules, nodules, plaques, ulcers, gummas, and verrucous lesions. CTB is most commonly observed in low-income, HIV, and immunosuppressed populations, similar to intrapulmonary manifestations. The main pathogen for CTB is M. tuberculosis but less commonly with M. bovis and BCG vaccine, and the modes of transmission are largely classified into exogenous and endogenous CTB. Current treatment options for CTB include oral therapy of antibiotic medications such as rifampicin, streptomycin, ethambutol, isoniazid, and pyrazinamide, which is occasionally combined with surgical intervention.
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Affiliation(s)
- Kevin H Nguyen
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Cheldon Ann Alcantara
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Ira Glassman
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Nicole May
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Akaash Mundra
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Abinanda Mukundan
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Bianca Urness
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Sonyeol Yoon
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Roajhaan Sakaki
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Surbi Dayal
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Tanzila Chowdhury
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
| | - Shakila Harshavardhan
- Department of Molecular Microbiology, Madurai Kamaraj University, Tamil Nadu 625021, India
| | - Vadakupattu Ramanathan
- Department of Pathology, National Institute for Research in Tuberculosis, Chennai 600031, India
| | - Vishwanath Venketaraman
- Department of Basic Sciences, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, CA 91766, USA
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4
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Gharabaghi N, Sedokani A. <p>Chronic Perioral Tuberculosis Skin Lesions in a 21-Year-Old Male</p>. Infect Drug Resist 2020; 13:3273-3276. [PMID: 33061474 PMCID: PMC7524186 DOI: 10.2147/idr.s260796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 09/04/2020] [Indexed: 11/23/2022] Open
Abstract
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.
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Affiliation(s)
- Naser Gharabaghi
- Department of Infectious Disease, Taleghani Hospital, Urmia University of Medical Sciences, Urmia, Iran
| | - Amin Sedokani
- Department of Cardiology, School of Medicine, Seyedoshohada Hospital, Urmia University of Medical Sciences, Urmia, Iran
- Correspondence: Amin Sedokani Department of Cardiology, School of Medicine, Seyedoshohada Hospital, Urmia University of Medical Sciences, 17 Sharivar Street, Urmia571478334, IranTel +98 443 237 5907Fax +98 443 237 2917 Email
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5
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Williamson S, Auerbach J, Motaparthi K. Lichenoid granulomatous dermatitis as a tuberculid in association with spondylitis due to Mycobacterium tuberculosis. J Cutan Pathol 2020; 47:946-949. [PMID: 32352174 DOI: 10.1111/cup.13729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 04/21/2020] [Accepted: 04/24/2020] [Indexed: 11/28/2022]
Abstract
Lichenoid granulomatous dermatitis (LGD) is a histopathologic pattern with a band-like lymphocytic infiltrate, typical of lichenoid dermatitis, combined with dermal histiocytes and granulomatous inflammation. Prior reports have described cases of LGD caused by non-tuberculous mycobacteria, with evidence of intralesional acid-fast bacilli or mycobacterial DNA. Herein, we report a patient with pulmonary and extrapulmonary Mycobacterium tuberculosis infection who developed LGD. No evidence of M. tuberculosis was detected within the cutaneous lesions, suggesting a potential delayed-type hypersensitivity reaction to tuberculosis.
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Affiliation(s)
- Sarah Williamson
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Jena Auerbach
- Department of Pathology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Kiran Motaparthi
- Department of Dermatology, University of Florida College of Medicine, Gainesville, Florida, USA
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6
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Bourlond F, Velter C, Lipsker D. [A case of cutaneous tuberculosis evolving for 50 years]. Ann Dermatol Venereol 2020; 147:653-657. [PMID: 32386803 DOI: 10.1016/j.annder.2019.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/29/2019] [Accepted: 12/31/2019] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Tuberculosis is an infection caused by Mycobacterium (M.) tuberculosis. It is rare in France. Clinical presentations vary, making demonstration of the cause of M. Tuberculosis difficult and rendering diagnosis and management difficult. PATIENTS AND METHODS A 58-year-old man, born in Morocco, consulted for ulceration of the right forefoot that had been present since the age of 3 years. He had previously consulted at several dermatology departments. He had undergone numerous skin biopsies and bacteriological and mycobacteriological cultures but these did not contribute to the diagnosis. Slow extension and oozing were observed over time and resulted in functional disability. Given the evocative clinical aspect and despite further negative screening for mycobacteria, anti-TB quadrotherapy was prescribed and resulted in complete cure of the lesion. DISCUSSION This case underscores the difficulty of diagnosing cutaneous tuberculosis. Such a diagnosis must be clinically suspected in the presence of long lasting destructive or verrucous skin lesions that fail to heal, even where cultures are negative, and anti-TB therapy should be putatively prescribed.
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Affiliation(s)
- F Bourlond
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - C Velter
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France
| | - D Lipsker
- Clinique dermatologique, université de Strasbourg et hôpitaux universitaires de Strasbourg, 1, place de l'Hôpital, 67091 Strasbourg, France.
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7
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Gonda A, Zhao N, Shah JV, Calvelli HR, Kantamneni H, Francis NL, Ganapathy V. Engineering Tumor-Targeting Nanoparticles as Vehicles for Precision Nanomedicine. MED ONE 2019; 4:e190021. [PMID: 31592196 PMCID: PMC6779336 DOI: 10.20900/mo.20190021] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
As a nascent and emerging field that holds great potential for precision oncology, nanotechnology has been envisioned to improve drug delivery and imaging capabilities through precise and efficient tumor targeting, safely sparing healthy normal tissue. In the clinic, nanoparticle formulations such as the first-generation Abraxane® in breast cancer, Doxil® for sarcoma, and Onivyde® for metastatic pancreatic cancer, have shown advancement in drug delivery while improving safety profiles. However, effective accumulation of nanoparticles at the tumor site is sub-optimal due to biological barriers that must be overcome. Nanoparticle delivery and retention can be altered through systematic design considerations in order to enhance passive accumulation or active targeting to the tumor site. In tumor niches where passive targeting is possible, modifications in the size and charge of nanoparticles play a role in their tissue accumulation. For niches in which active targeting is required, precision oncology research has identified targetable biomarkers, with which nanoparticle design can be altered through bioconjugation using antibodies, peptides, or small molecule agonists and antagonists. This review is structured to provide a better understanding of nanoparticle engineering design principles with emphasis on overcoming tumor-specific biological barriers.
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Affiliation(s)
- Amber Gonda
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Nanxia Zhao
- Department of Chemical and Biochemical Engineering, Rutgers, The State University of New Jersey, 98 Brett Road, Piscataway, NJ 08854, USA
| | - Jay V. Shah
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Hannah R. Calvelli
- Department of Molecular Biology and Biochemistry, Rutgers, The State University of New Jersey, 604 Allison Road, Piscataway, NJ 08854, USA
| | - Harini Kantamneni
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Nicola L. Francis
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, 599 Taylor Road, Piscataway, NJ 08854, USA
| | - Vidya Ganapathy
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, 599 Taylor Road, Piscataway, NJ 08854, USA
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8
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Mann D, Sant'Anna FM, Schmaltz CAS, Rolla V, Freitas DFS, Lyra MR, Sampaio FMS, do Valle ACF, Lourenço MCS, Quintella LP, Teichner TC, Cavalcante SC, Galhardo MCG. Cutaneous tuberculosis in Rio de Janeiro, Brazil: description of a series of 75 cases. Int J Dermatol 2019; 58:1451-1459. [PMID: 31553059 DOI: 10.1111/ijd.14617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/12/2019] [Accepted: 08/08/2019] [Indexed: 12/31/2022]
Abstract
BACKGROUND Brazil is one of the highest tuberculosis (TB) burden countries of the world. Cutaneous tuberculosis (CTB) is a rare form of extrapulmonary manifestation of tuberculosis. This study aimed to describe the clinico-evolutive, laboratory and therapeutic aspects of CTB cases among patients from a cohort with TB in Rio de Janeiro, Brazil. METHODS Cases of diagnosed CTB with microbiologic confirmation or clinical response to anti-tuberculous treatment associated with positive smear or histopathological findings between the years 2000 and 2016 were selected. RESULTS Seventy-five patients with CTB were included, most were women (58.7%) with a median age of 42 years. CTB diagnosis was based on culture in only 42.7% of the cases. Scrofuloderma represented 50.7% of the cases, followed by erythema induratum of Bazin (EIB) (18.7%), tuberculous gumma (13.3%), lupus vulgaris (8%), TB verrucosa cutis (4%), orificial TB (2.7%) and associated forms (2.7%). Other TB presentations were pulmonary (22.7%), mammary (6.6%) and osteoarticular (4%). All patients who completed the treatment (97.3%) had their lesions healed. Only two patients (2.6%) needed to change the therapy due to adverse reactions. Fifty percent of EIB patients presented recurrence. CONCLUSIONS These data highlight the diversity of CTB presentations and the importance of the skin to assist in early identification and treatment of TB. More studies are necessary to improve the knowledge on EIB for a better approach towards these patients, mainly in cases of recurrence.
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Affiliation(s)
- Danielle Mann
- Post Graduation of Clinical Research on Infectious Diseases, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Flavia M Sant'Anna
- Laboratory of Clinical Research in Mycobacteriosis, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Carolina A S Schmaltz
- Laboratory of Clinical Research in Mycobacteriosis, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Valeria Rolla
- Laboratory of Clinical Research in Mycobacteriosis, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Dayvison F S Freitas
- Laboratory of Clinical Research in Infectious Dermatology, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Marcelo R Lyra
- Laboratory of Clinical Research in Leishmaniasis, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Felipe M S Sampaio
- Laboratory of Clinical Research in Infectious Dermatology, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Antonio C F do Valle
- Laboratory of Clinical Research in Infectious Dermatology, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Maria C S Lourenço
- Laboratory of Bacteriology and Bioassays, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Leonardo P Quintella
- Anatomical Pathology Service, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Tullia C Teichner
- Anatomical Pathology Service, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Solange C Cavalcante
- Laboratory of Clinical Research in Mycobacteriosis, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
| | - Maria C G Galhardo
- Laboratory of Clinical Research in Infectious Dermatology, Evandro Chagas National Institute of Infectious Diseases, Oswaldo Cruz Foundation, Rio de Janeiro, Brazil
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9
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Abstract
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.
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Affiliation(s)
- Qiquan Chen
- Department of Dermatology, Southwest Hospital, The Third Military Medical University, Chongqing, P.R. China
| | - WenChieh Chen
- Department of Dermatology and Allergy, Technische Universität München, Munich, Germany.
| | - Fei Hao
- Department of Dermatology, Southwest Hospital, The Third Military Medical University, Chongqing, P.R. China
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10
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Mervis JS, Machler BC, Hanly AJ, Federman DG. Down the Rabbit Hole: Cutaneous Tuberculosis. Am J Med 2019; 132:52-54. [PMID: 30201246 DOI: 10.1016/j.amjmed.2018.08.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Revised: 08/14/2018] [Accepted: 08/15/2018] [Indexed: 10/28/2022]
Affiliation(s)
| | - Brian C Machler
- Department of Dermatology, New York University Langone Health School ofMedicine, New York
| | - Andrew J Hanly
- Department of Dermatology, University of Miami School of Medicine, Miami, Fla
| | - Daniel G Federman
- Yale University School of Medicine, New Haven, Conn; VA Connecticut Healthcare System, West Haven.
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11
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Tadele H. Scrofuloderma with disseminated tuberculosis in an Ethiopian child: a case report. J Med Case Rep 2018; 12:371. [PMID: 30554566 PMCID: PMC6296023 DOI: 10.1186/s13256-018-1927-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 11/14/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cutaneous tuberculosis represents only 1-2% of extrapulmonary forms of tuberculosis. Scrofuloderma is an endogenous form of cutaneous tuberculosis and can present as isolated or coexist with pulmonary and disseminated forms of tuberculosis. Pathologically confirmed scrofuloderma coexisting with disseminated tuberculosis with a good treatment response is presented and discussed. CASE PRESENTATION A 12-year-old African Ethiopian girl presented with bilateral neck swelling with purulent discharge and skin ulceration of 3 months' duration. Dry cough, low-grade fever, decreased appetite, drenching night sweats, global throbbing headache, and a significant amount of weight loss were also reported. Biopsy of the skin identified scrofuloderma, and Mycobacterium tuberculosis was also identified by Xpert MTB/RIF assay. Cerebrospinal fluid analysis and brain computed tomographic scans showed tuberculous meningitis and tuberculoma. Antituberculosis therapy with rifampicin, isoniazid, pyrazinamide, and ethambutol; prednisolone; pyridoxine; and wound care were provided. The patient was discharged for outpatient directly observed antituberculosis therapy in a nearby health center after acute complications were treated and once the skin lesion had started to dry or heal. CONCLUSIONS Cutaneous tuberculosis should be considered in a child presenting with a skin lesion or discharge. Cutaneous tuberculosis cases should be investigated for coexisting pulmonary and extrapulmonary forms of tuberculosis. Histopathologic diagnosis should be considered to rule out other skin pathologies and also to prevent delay in treatment. Better tuberculosis prevention strategies, including vaccination scale-up, are warranted.
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Affiliation(s)
- Henok Tadele
- Department of Pediatrics and Child Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia.
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12
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Zaslavskij DV, Egorova YS, Chuprov IN, Olovyanishnikov IO, Gurkovskaya YY, Sydikov AA, Chuzhov AL, Ovchinnikova YE, Dovgalyuk IF, Starshinova AA. DISSEMINATED CUTANEOUS TUBERCULOSIS. VESTNIK DERMATOLOGII I VENEROLOGII 2018. [DOI: 10.25208/0042-4609-2018-94-2-69-77] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
Cutaneous tuberculosis is a clinically and morphologically heterogeneous group of skin diseases directly or indirectly caused by mycobacteria of the tuberculosis complex, occupying the 5th place among all localizations of extra-pulmonary tuberculosis. Manifestations of cutaneous tuberculosis are extremely diverse and depend on the immune status and ways of penetration of mycobacteria into the skin. Skin involvement can occur as a result of exogenous inoculation, contiguous spread from an adjacent focus, or hematogenous spread from other foci. Family cases of disseminated cutaneous tuberculosis are described. A combination of several clinical forms of cutaneous tuberculosis — scrofuloderma, tuberculosis cutis lichenoides (moniliformis scrophulosorum) and lupus — are observed in a 5 year old child with a family history of tuberculosis. The issues of pathogenesis and advanced methods of diagnosis of cutaneous tuberculosis are also discussed.
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13
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Laidler N. Cutaneous infection with paucibacillary Mycobacterium tuberculosis treated successfully with a modified antituberculous drug regimen. BMJ Case Rep 2017; 2017:bcr-2017-221938. [PMID: 29275384 DOI: 10.1136/bcr-2017-221938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
- Nicholas Laidler
- Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia
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14
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Unusual Sites of Cutaneous Tuberculosis: A Report of Two Cases. Case Rep Dermatol Med 2017; 2017:7285169. [PMID: 28348900 PMCID: PMC5350300 DOI: 10.1155/2017/7285169] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2016] [Revised: 12/19/2016] [Accepted: 01/09/2017] [Indexed: 12/02/2022] Open
Abstract
Cutaneous tuberculosis (CTB) is an uncommon small subset of extrapulmonary tuberculosis, comprising 1–1.5% of all extrapulmonary tuberculosis manifestations, which manifests only in 8.4–13.7% of all tuberculosis cases. Lupus vulgaris (LV) and tuberculosis verrucosa cutis (TBVC) are forms of reinfection tuberculosis and often occur in presensitized patients, by exogenous inoculation. We report two cases of cutaneous tuberculosis at unusual sites. A 35-year-old female having a forehead lesion for 2 years was diagnosed as having tuberculosis verrucosa cutis and another 16-year-old girl with lesion in left axilla for 10 years was proven to have lupus vulgaris. The delayed diagnosis was possibly due to lower clinical suspicion due to the presentation of CTB at unusual sites. This highlights the importance of keeping TB as an important differential as misdiagnosis or delayed diagnosis of this entity can lead to prolonged morbidity.
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15
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Mitteldorf C, Tronnier M. Histologic features of granulomatous skin diseases. J Dtsch Dermatol Ges 2016; 14:378-88. [PMID: 27027748 DOI: 10.1111/ddg.12955] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Granulomatous disorders affecting the skin belong to a heterogeneous group of diseases, which were predominantly classified based on pathogenetic features. In infections diseases a granuloma is formed if an agent could not be eliminated by the immune system. Typical agents which cause granulomatous reactions are mycobacteria, fungal infections, especially extra European agent, which could effect the skin by, dissemination (e.g. histoplasmosis) or parasites, like leishmaniasis.
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Affiliation(s)
- Christina Mitteldorf
- Department of Dermatology, Venereology, and Allergology, HELIOS Hospital, Hildesheim, Germany
| | - Michael Tronnier
- Department of Dermatology, Venereology, and Allergology, HELIOS Hospital, Hildesheim, Germany
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De Maio F, Trecarichi EM, Visconti E, Sanguinetti M, Delogu G, Sali M. Understanding cutaneous tuberculosis: two clinical cases. JMM Case Rep 2016; 3:e005070. [PMID: 28348793 PMCID: PMC5343121 DOI: 10.1099/jmmcr.0.005070] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2016] [Accepted: 10/18/2016] [Indexed: 11/24/2022] Open
Abstract
Tuberculosis (TB) is an ancient human disease and remains today one of the most important public health problems and the second most frequent cause of death from an infectious disease worldwide. While pulmonary TB is the most common form, extra-pulmonary TB is on the rise due to the increase in immunosuppressed subjects. Cutaneous TB manifestations are rare forms of extra-pulmonary TB due to systemic dissemination of bacilli or direct inoculation, involving skin or skin-associated tissue, more common in immunocompromised subjects. Some risk factors and the features of the lesion may prompt the suspicion of cutaneous TB, but only microbiological assays can confirm the diagnosis. Our work summarizes cutaneous TB manifestations and differences from other skin mycobacterial infections, also describes two characteristic clinical cases.
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Affiliation(s)
- Flavio De Maio
- Insitute of Microbiology, Università Cattolica del Sacro Cuore , Rome , Italy
| | | | - Elena Visconti
- Institute of Infectious Diseases, Università Cattolica del Sacro Cuore , Rome , Italy
| | | | - Giovanni Delogu
- Insitute of Microbiology, Università Cattolica del Sacro Cuore , Rome , Italy
| | - Michela Sali
- Insitute of Microbiology, Università Cattolica del Sacro Cuore , Rome , Italy
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Spelta K, Diniz LM. CUTANEOUS TUBERCULOSIS: A 26-YEAR RETROSPECTIVE STUDY IN AN ENDEMIC AREA OF TUBERCULOSIS, VITÓRIA, ESPÍRITO SANTO, BRAZIL. Rev Inst Med Trop Sao Paulo 2016; 58:49. [PMID: 27410909 PMCID: PMC4964318 DOI: 10.1590/s1678-9946201658049] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 01/20/2016] [Indexed: 12/03/2022] Open
Abstract
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.
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Affiliation(s)
- Karla Spelta
- Federal University of Espírito Santo, Medical Graduate Program. Vitória, ES, Brazil
| | - Lucia M Diniz
- Federal University of Espírito Santo, Medical Graduate Program. Vitória, ES, Brazil
- Federal University of Rio de Janeiro, Medical Graduate Program. Rio de Janeiro, RJ, Brazil
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18
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[Cutaneous tuberculosis of the ear due to Mycobacterium bovis]. Ann Dermatol Venereol 2016; 143:611-615. [PMID: 27375171 DOI: 10.1016/j.annder.2016.05.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 03/19/2016] [Accepted: 05/13/2016] [Indexed: 11/20/2022]
Abstract
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.
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Mitteldorf C, Tronnier M. Histologische Merkmale granulomatöser Hauterkrankungen: Teil 2: Infektiöse granulomatöse Erkrankungen. J Dtsch Dermatol Ges 2016. [DOI: 10.1111/ddg.12955_g] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Christina Mitteldorf
- Klinik für Dermatologie, Venerologie und Allergologie; HELIOS Klinikum; Hildesheim
| | - Michael Tronnier
- Klinik für Dermatologie, Venerologie und Allergologie; HELIOS Klinikum; Hildesheim
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20
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Scollard DM, Dacso MM, Abad-Venida ML. Tuberculosis and Leprosy: Classical Granulomatous Diseases in the Twenty-First Century. Dermatol Clin 2016; 33:541-62. [PMID: 26143431 DOI: 10.1016/j.det.2015.03.016] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Leprosy and tuberculosis are chronic mycobacterial infections that elicit granulomatous inflammation. Both infections are curable, but granulomatous injury to cutaneous structures, including cutaneous nerves in leprosy, may cause permanent damage. Both diseases are major global concerns: tuberculosis for its high prevalence and mortality, and leprosy for its persistent global presence and high rate of neuropathic disability. Cutaneous manifestations of both leprosy and tuberculosis are frequently subtle and challenging in dermatologic practice and often require a careful travel and social history and a high index of suspicion.
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Affiliation(s)
- David M Scollard
- National Hansen's Disease Programs, 1770 Physician Park Drive, Baton Rouge, LA 70816, USA.
| | - Mara M Dacso
- Center for Dermatology and Cosmetic Laser Surgery, 5026 Tennyson Parkway, Plano, TX 75024, USA; Department of Dermatology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9069, USA
| | - Ma Luisa Abad-Venida
- Department of Dermatology, Jose R. Reyes Memorial Medical Center, Rizal Avenue, Manila 1008, Philippines
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21
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Cutaneous tuberculosis overview and current treatment regimens. Tuberculosis (Edinb) 2014; 95:629-638. [PMID: 26616847 DOI: 10.1016/j.tube.2014.12.006] [Citation(s) in RCA: 121] [Impact Index Per Article: 12.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Accepted: 12/17/2014] [Indexed: 02/06/2023]
Abstract
Tuberculosis is one of the oldest diseases known to humankind and it is currently a worldwide threat with 8-9 million new active disease being reported every year. Among patients with co-infection of the human immunodeficiency virus (HIV), tuberculosis is ultimately responsible for the most deaths. Cutaneous tuberculosis (CTB) is uncommon, comprising 1-1.5% of all extra-pulmonary tuberculosis manifestations, which manifests only in 8.4-13.7% of all tuberculosis cases. A more accurate classification of CTB includes inoculation tuberculosis, tuberculosis from an endogenous source and haematogenous tuberculosis. There is furthermore a definite distinction between true CTB caused by Mycobacterium tuberculosis and CTB caused by atypical mycobacterium species. The lesions caused by mycobacterium species vary from small papules (e.g. primary inoculation tuberculosis) and warty lesions (e.g. tuberculosis verrucosa cutis) to massive ulcers (e.g. Buruli ulcer) and plaques (e.g. lupus vulgaris) that can be highly deformative. Treatment options for CTB are currently limited to conventional oral therapy and occasional surgical intervention in cases that require it. True CTB is treated with a combination of rifampicin, ethambutol, pyrazinamide, isoniazid and streptomycin that is tailored to individual needs. Atypical mycobacterium infections are mostly resistant to anti-tuberculous drugs and only respond to certain antibiotics. As in the case of pulmonary TB, various and relatively wide-ranging treatment regimens are available, although patient compliance is poor. The development of multi-drug and extremely drug-resistant strains has also threatened treatment outcomes. To date, no topical therapy for CTB has been identified and although conventional therapy has mostly shown positive results, there is a lack of other treatment regimens.
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Lewandowsky's Rosaceiform Eruption: a Form of Cutaneous Tuberculosis Confirmed by PCR in Two Patients. Dermatol Ther (Heidelb) 2014; 5:67-76. [PMID: 25518812 PMCID: PMC4374068 DOI: 10.1007/s13555-014-0066-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2014] [Indexed: 12/02/2022] Open
Abstract
Introduction Cutaneous tuberculosis (TBC) is a chronic disease caused by Mycobacterium tuberculosis, and is present in less than 1–2% of all TBC cases. The current problem with diagnosis is the demonstration of bacillus in the skin, especially paucibacillar forms, where sources like polymerase chain reaction (PCR) have improved diagnostic capacity. Case Presentation Two cases of cutaneous TBC are reported. The first patient was 52-year-old woman with facial erythematous papulo-nodular lesions which had been developing for 4 months, and had previously been treated as acne rosacea, with partial response. Histopathological studies showed chronic granulomatous inflammation. TBC was suspected, so PCR was performed, which showed positive for M. tuberculosis. The second case was a 43-year-old woman with a facial rosaceiform plaque which began 6 months previously, and was treated as rosacea without any change for 5 months. Skin biopsy and PCR were positive for TBC. Both cases were treated using primary schedule for TBC, and both presented a favorable response. Discussion A clinical profile called Lewandowsky’s rosacea-like eruption has been previously described. The condition has been questioned for years and was later removed from the spectrum of tuberculids and cutaneous TBC for not being able to isolate microorganisms in skin samples, a situation that might now change. In paucibacillar forms, when culture and staining are negative and TBC is still suspected, it is recommended to use DNA amplification by PCR for an accurate diagnosis. Both cases bring up the concern about once again bringing Lewandowsky’s rosaceiform eruption into the spectrum of cutaneous TBC, and the discussion about the current definition of tuberculid. Electronic supplementary material The online version of this article (doi:10.1007/s13555-014-0066-x) contains supplementary material, which is available to authorized users.
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Santos JBD, Figueiredo AR, Ferraz CE, Oliveira MHD, Silva PGD, Medeiros VLSD. Cutaneous tuberculosis: epidemiologic, etiopathogenic and clinical aspects - part I. An Bras Dermatol 2014; 89:219-28. [PMID: 24770496 PMCID: PMC4008050 DOI: 10.1590/abd1806-4841.20142334] [Citation(s) in RCA: 90] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2012] [Accepted: 04/10/2013] [Indexed: 10/31/2022] Open
Abstract
Cutaneous tuberculosis (CTB) is the result of a chronic infection by Mycobacterium tuberculosis, M. ovis and occasionally by the Calmette-Guerin bacillus. The clinical manifestations are variable and depend on the interaction of several factors including the site of infection and the host's immunity. This article revises the current knowledge about this disease's physiopathology and immunology as well as detailing the possible clinical presentations.
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Puri N. A clinical and histopathological profile of patients with cutaneous tuberculosis. Indian J Dermatol 2012; 56:550-2. [PMID: 22121276 PMCID: PMC3221221 DOI: 10.4103/0019-5154.87153] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Neerja Puri
- Department of Dermatology, Punjab Health Systems Corporation, Punjab, India
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25
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Sardinha JFJ, Tarlé RG, Fava VM, Francio AS, Ramos GB, Ferreira LCDL, Schriefer NAB, Mira MT, Talhari S. Genetic risk factors for human susceptibility to infections of relevance in dermatology. An Bras Dermatol 2012; 86:708-15. [PMID: 21987137 DOI: 10.1590/s0365-05962011000400013] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2010] [Accepted: 11/18/2010] [Indexed: 11/22/2022] Open
Abstract
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.
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Abstract
Cutaneous tuberculosis (TB) is a rare presentation of tuberculosis infection in childhood, especially in developed countries. The commonest forms of cutaneous TB, in declining order, are scrofuloderma, lupus vulgaris, lichen scrofulosorum, and TB verrucosa cutis. We described 2 cases of sporotrichoid-like cutaneous tuberculosis infection, 1 localized to a limb and regional nodes and 1 associated with disseminated disease.
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Affiliation(s)
- Wilson Shu Cheng Pau
- Division of Infectious Diseases, Department of Pediatrics, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
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Cho WC, Pai YC, Hsiung Y, Choi WM. Cutaneous Tuberculosis Presenting as Necrotizing Fasciitis in an Elderly Patient. INT J GERONTOL 2008. [DOI: 10.1016/s1873-9598(08)70016-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
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