Update on cutaneous tuberculosis

Management of cutaneous tuberculosis in hand - Rare and disabling: A case report

INTRODUCTION AND IMPORTANCE

Cutaneous Tuberculosis (CTB), elicited by the Mycobacterium tuberculosis complex, manifests dermatologically. The scarcity of bacilli within CTB lesions renders their detection challenging. This study presents a case of CTB, underscoring its rarity and the potential for severe complications that can deteriorate patient quality of life. It aims to highlight the importance of CTB identification in dermatological diagnoses due to its capacity to cause considerable morbidity and affect patients' psychosocial health.

CASE PRESENTATION

An 18-year-old patient presented with a painful, well-defined reddish plaque on the right palm, originating five years prior, accompanied by contractures of the middle finger. The tender lesion, characterized by an irregular surface, exhibited purulent discharge upon light touch through fissures along its periphery. Management involved necrotomy, debridement, and tissue biopsy for diagnostic and reconstructive purposes.

CLINICAL DISCUSSION

CTB exhibits a wide range of clinical presentations, often resembling other dermatological infections, which complicates its diagnosis. Accurate diagnosis necessitates an integrated approach involving clinical assessment, the tuberculin skin test, histopathological analysis, and bacteriological investigations. The therapeutic regimen includes multidrug anti-tuberculosis treatment, with surgical intervention reserved for specific cases.

CONCLUSION

Long-term complications of untreated CTB encompass significant contractures, scarring, and the onset of carcinomas and sarcomas. Prompt diagnosis facilitates timely and effective treatment, averting these sequelae and yielding high patient satisfaction.

Scrofuloderma of the chest with mediastinal TB

Cutaneous tuberculosis is a rare manifestation of extrapulmonary tuberculosis caused by Mycobacterium tuberculosis in most cases and rarely by Mycobacterium bovis. Diagnosis may be challenging due to a wide range of clinical findings and similarities to other chronic dermatoses, leading to delayed treatment. We present a case of scrofuloderma in a 4-year-old girl that arose from a contiguous spread from the anterior mediastinum with associated pulmonary involvement.

Clinico-Laboratory Profile of Tuberculides: An Experience at a Tertiary Care Centre from Chandigarh, India

Background

Tuberculides are characterised by delayed-type of immunologic reactions to Mycobacterium tuberculosis or its products in immuno-competent individuals. We herein describe clinico-epidemiological features and response to treatment in patients with tuberculides from a tertiary care centre from North India.

Methods

This was a retrospective analysis of the clinical records of all the cutaneous tuberculosis (TB) patients (year 2000-2019) enrolled in the TB clinic. The patient records fulfilling the diagnostic criteria of tuberculides were considered for analysis.

Results

A total of 225 patients attended the tuberculosis clinic; out of this, 34 were diagnosed as tuberculides. Out of these 34 cases, 21 were identified as LS, 2 erythema induratum of Bazin, 1 papulonecrotic tuberculide, and 10 erythema nodosum. History of contact to open cases of TB was present in 15/34 (44.1%) patients. History of BCG vaccination was found in 15/34 (44.1%) patients. The focus of underlying TB could be identified in 20/34 (58.8%) patients. Skin biopsy was performed in all patients. In all patients, the diagnosis was confirmed by clinico-pathological correlation, positive TST, and the underlying focus of TB. All patients received 6 months regimen of anti-tubercular therapy with first-line drugs.

Conclusion

In this study, we demonstrated various forms of tuberculides; lichen scrofulosorum was the most common form. We also included erythema nodosum cases also, which responded well to ATT. Observation from our study showed that tuberculides are important cutaneous markers for underlying tuberculosis infection, which helps in early detection of occult tuberculosis and timely management.

Cutaneous tuberculosis. Part I: Pathogenesis, classification, and clinical features

Tuberculosis is an ancient disease that continues to affect an estimated 10 million people per year and is responsible for 1.4 million deaths per year. Additionally, the HIV epidemic and multidrug resistance present challenges to disease control. Cutaneous tuberculosis is an uncommon, often indolent, manifestation of mycobacterial infection that has a varied presentation. Its diagnosis is challenging, as lesions mimic other, more common conditions and microbiological confirmation is often not possible. Cutaneous tuberculosis can be broadly categorized into multibacillary and paucibacillary forms. Approximately one-third of skin tuberculosis is associated with systemic involvement. By recognizing cutaneous tuberculosis early, dermatologists can play an important role in disease control. The first article in this 2-part continuing medical education series describes the latest epidemiology, microbiology, and pathogenesis of tuberculosis. Furthermore, we review the classification, clinical manifestations, common clinical differentials, and systemic involvement that occur in cutaneous tuberculosis.

Cutaneous Manifestations of Mycobacterium tuberculosis: A Literature Review

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.

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.

Tuberculids: A Narrative Review

Tuberculids are a group of dermatoses with tuberculoid histology and the absence of tubercle bacilli. They are considered to be hypersensitivity reactions to circulating Mycobacterium tuberculosis (M. tb) or its antigens in individuals with good immunity. The objective of the review is to provide a detailed literature review of all available articles on tuberculids in the past 10 years and provide an update on epidemiology, etiopathogenetic mechanisms, clinical manifestations, and treatment. A search was performed on PubMed using the keywords lichen scrofulosorum, papulonecrotic tuberculid, erythema induratum, and erythema nodosum tuberculosis for all articles, with no restrictions on age, gender, or nationalities. An update on tuberculids, including some new concepts in pathogenesis, atypical presentations, new investigative modalities, and treatments are reviewed.

A case of scrofuloderma of the axilla presenting as hidradenitis suppurativa: A case report

Scrofuloderma is an uncommon cutaneous presentation of tuberculosis. It can be difficult to diagnose, as it can mimic various skin conditions, including hidradenitis suppurativa. We report a case of a 46-year-old female refugee patient with a history of nodules and sinus tracts in the left axilla treated for many years as hidradenitis suppurativa in her home country who was later found to have scrofuloderma. The diagnosis was based on a positive Mycobacterium tuberculosis polymerase chain reaction from an ultrasound-guided aspiration. Further investigation excluded pulmonary tuberculosis. In cases with an atypical presentation of hidradenitis suppurativa, imaging, along with histological and microbiologic examination are warranted to exclude scrofuloderma.

Tuberculosis of Finger Presenting As Non-healing Ulcer of Digit: A Case Report

Tuberculosis (TB) is a chronic granulomatous infection which most often localises to the respiratory system. Extra-pulmonary tuberculosis is prevalent in immunocompromised individuals, of which cutaneous tuberculosis is exceedingly rare (0.5-2%). Cutaneous TB presents with varied clinical morphologies, either acquired exogenously via direct inoculation on the skin or endogenously due to systemic dissemination. Diagnosis is particularly challenging due to the multitude of differential diagnoses of skin lesions. Microbiological evidence from biopsy and histopathological findings suggestive of granulomatous inflammation are needed to make a definitive diagnosis. Herein we present a rare case of tuberculosis of the finger in a middle-aged man who presented with an ulcerating and erythematous lesion. As cutaneous TB is usually misdiagnosed at the earlier stages, dermatologists and primary care physicians should keep high suspicion for cutaneous TB in any non-healing ulcers which are otherwise unexplained.

Pediatric Tuberculosis Management: A Global Challenge or Breakthrough?

Managing pediatric tuberculosis (TB) remains a public health problem requiring urgent and long-lasting solutions as TB is one of the top ten causes of ill health and death in children as well as adolescents universally. Minors are particularly susceptible to this severe illness that can be fatal post-infection or even serve as reservoirs for future disease outbreaks. However, pediatric TB is the least prioritized in most health programs and optimal infection/disease control has been quite neglected for this specialized patient category, as most scientific and clinical research efforts focus on developing novel management strategies for adults. Moreover, the ongoing coronavirus pandemic has meaningfully hindered the gains and progress achieved with TB prophylaxis, therapy, diagnosis, and global eradication goals for all affected persons of varying age bands. Thus, the opening of novel research activities and opportunities that can provide more insight and create new knowledge specifically geared towards managing TB disease in this specialized group will significantly improve their well-being and longevity.

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.

Cutaneous tuberculosis: epidemiological, clinical, diagnostic and therapeutic update

Tuberculosis is certainly one of the diseases considered to be ancient on planet Earth. The etiological agent of tuberculosis is Mycobacterium tuberculosis. This terrible bacterial infection still results in severe socioeconomic consequences to date, and its complete eradication represents a great challenge. It constitutes one of the most important public health problems in developing countries. According to the World Health Organization, this infection results in more than 4,000 deaths daily worldwide, with 10.4 million being affected annually and 1.5 million deaths from TB every year. With the emergence of the HIV/AIDS pandemic, the disease became the main cause of morbidity and mortality in patients infected with the human immunodeficiency virus. Cutaneous tuberculosis is a rare infection that represents 1% to 1.5% of extrapulmonary tuberculosis, whose etiological agents are Mycobacterium tuberculosis, Mycobacterium bovis, and the attenuated form of the bacillus Calmette-Guérin (BCG vaccine). Cutaneous tuberculosis can be exogenous; endogenous: caused by contiguity or autoinoculation and by hematogenous spread; induced by the Calmette-Guérin bacillus and manifest as a tuberculid. The diagnosis of the infection is carried out through the direct test, culture, histopathology, tuberculin skin test, polymerase chain reaction, interferon-gamma release assay, and genotyping. Drugs used comprise isoniazid, rifampicin, pyrazinamide and ethambutol.

Cutaneous Manifestations of "Lupus": Systemic Lupus Erythematosus and Beyond

Lupus, Latin for "wolf," is a term used to describe many dermatologic conditions, some of which are related to underlying systemic lupus erythematosus, while others are distinct disease processes. Cutaneous lupus erythematosus includes a wide array of visible skin manifestations and can progress to systemic lupus erythematosus in some cases. Cutaneous lupus can be subdivided into three main categories: acute cutaneous lupus erythematosus, subacute cutaneous lupus erythematosus, and chronic cutaneous lupus erythematosus. Physical exam, laboratory studies, and histopathology enable differentiation of cutaneous lupus subtypes. This differentiation is paramount as the subtype of cutaneous lupus informs upon treatment, disease monitoring, and prognostication. This review outlines the different cutaneous manifestations of lupus erythematosus and provides an update on both topical and systemic treatment options for these patients. Other conditions that utilize the term "lupus" but are not cutaneous lupus erythematosus are also discussed.

Granulomas in Dermatopathology: Principal Diagnoses - Part 2

Part 2 of this series on granulomatous diseases focuses on skin biopsy findings. Whereas the first part treated noninfectious conditions (metabolic disorders and tumors, among other conditions), this part mainly deals with various types of infectious disease along with other conditions seen fairly often by clinical dermatologists.

A Case Report of Tuberculosis in the Finger

Tuberculosis is a chronic, infectious disease that predominantly affects the respiratory system. Of the least common extrapulmonary forms of the disease is cutaneous tuberculosis. We present an unusual case, which is of cutaneous tuberculosis in the finger, manifesting as an ulcerating, erythematous lesion. This had later spread to the adjacent soft tissue and bones, causing osteomyelitis of the phalanges. It is important that physicians maintain a high index of suspicion when faced with atypical skin lesions to avoid the sequelae of the local and disseminated spread of a tuberculosis infection.

Gummatous cutaneous tuberculosis associated with the use of infliximab for Crohn's disease

As the treatment of infectious and parasitic diseases improved, the prevalence of these conditions declined. However, with the expansion of the use of immunobiologicals, opportunistic infections have emerged, especially under atypical presentations. The present study reports the case of a patient treated with infliximab for Crohn's disease, who presented diarrhea, weight loss, abdominal pain, fever, and subcutaneous erythematous nodules that evolved with spontaneous fluctuation and ulceration. With the finding of alcohol-resistant bacilli and Mycobacterium tuberculosis DNA in a cutaneous fragment, through polymerase chain reaction, the diagnosis of gummatous tuberculosis was confirmed, probably secondary to hematogenous dissemination from an intestinal focus.

Case for diagnosis. Cutaneous small vessel vasculitis (anti-proteinase 3 positive), fever, hemoptysis, and lung cavitation in an adult

Small vessel vasculitis with anti-proteinase antibodies 3 is an atypical clinical presentation of tuberculosis. The authors present the case of a 47-year-old male patient, with palpable purpura and palmoplantar hemorrhagic blisters, with subsequent dissemination. He presented severe pulmonary symptoms with cavitation, fever, hemoptysis, and high levels of anti-proteinase 3. Histopathological assessment of the skin revealed small vessel vasculitis; pulmonary histopathology showed granulomas with caseation. Bronchoalveolar lavage was positive for alcohol-acid-fast bacilli. In countries with a high prevalence of tuberculosis, the presence of autoantibodies in a patient with vasculitis, fever, and pulmonary cavitation requires investigation of infectious causes.

Mass migration and climate change: Dermatologic manifestations

Major changes in climate resulting in mass migrations have unique dermatologic implications for global vulnerable populations. Dermatologic manifestations commonly accompany the infectious and communicable diseases that proliferate in the settings of confinement, crowding, and limited sanitation associated with mass migration. Ectoparasitic infestations abound in refugee camps, and poor nutrition, hygiene, and compromised immunity put refugees at an increased risk for more dangerous infectious diseases carried by these ectoparasites. Climate change also profoundly affects the worldwide distribution of various vector-borne illnesses, thereby leading to the emergence of various communicable diseases in previously nonendemic areas. Natural disasters not only disrupt important lifesaving treatments, but also challenge various infectious disease control measures that are critical in preventing rapid transmission of highly infectious diseases. This article reviews the infectious diseases commonly found in these scenarios and provides an in-depth discussion of important implications for the dermatologist.

A large verrucous plaque on the buttocks: a case report of an atypical presentation of tuberculosis verrucosa cutis

Although the incidence of cutaneous tuberculosis (TB) has declined among all cases in dermatology outpatient settings, atypical cases are still being reported worldwide. These atypical forms can imitate other conditions hence delaying the diagnosis and increased morbidity. We report a case of an atypical presentation of extensive Tuberculosis Verrucosa Cutis (TVC) on the buttocks presenting as an annular hyperkeratotic plaque with central healing. Suspicious clinical manifestations and histopathological features followed by an excellent response with antituberculosis therapy confirmed the diagnosis of TVC. Recalcitrant chronic lesions even with adequate standard treatment should raise suspicion of cutaneous TB, especially in endemic areas.

Mycobacterium bovis and you: A comprehensive look at the bacteria, its similarities to Mycobacterium tuberculosis, and its relationship with human disease

While Mycobacterium tuberculosis is the primary cause of tuberculosis in people, multiple other mycobacteria are capable of doing so. With the World Health Organization's goal of a 90% reduction in tuberculosis by 2035, all tuberculous mycobacteria need to be addressed. Understanding not only the similarities, but importantly the differences between the different species is crucial if eradication is ever to be achieved. Mycobacterium bovis, while typically thought of as a disease of cattle, remains a possible source of human infection worldwide. Although this species' genome differs from Mycobacterium tuberculosis by only 0.05%, significant differences are present, creating unique challenges to address. This review focuses on features which distinguish this bacterium from Mycobacterium tuberculosis, including differences in origin, structure, environmental persistence, host preferences, infection and disease, host immune response, diagnostics and treatment.

Extrapulmonary Tuberculosis: Pathophysiology and Imaging Findings

Extrapulmonary tuberculosis (TB) represents approximately 15% of all TB infections. It is difficult to diagnose on the basis of imaging characteristics and clinical symptoms, and biopsy is required in many cases. Radiologists must be aware of the imaging findings of extrapulmonary TB to identify the condition in high-risk patients, even in the absence of active pulmonary infection. In extrapulmonary TB, the lymphatic system is most frequently affected. The presence of necrotic lymph nodes and other organ-specific imaging features increases the diagnostic probability of extrapulmonary TB. Disseminated infection and central nervous system involvement are the most frequent manifestations in immunosuppressed patients. Renal disease can occur in immunocompetent patients with very long latency periods between the primary pulmonary infection and genitourinary involvement. In several cases, gastrointestinal, solid-organ, and peritoneal TB show nonspecific imaging findings. Tuberculous spondylitis is the most frequent musculoskeletal manifestation. It is usually diagnosed late and affects multiple vertebral segments with extensive paraspinal abscess. Articular disease is the second most frequent musculoskeletal manifestation, and synovitis is its predominant imaging finding.^©RSNA, 2019.

Pyoderma gangrenosum: a review with special emphasis on Latin America literature

Pyoderma gangrenosum is a neutrophilic dermatosis characterized by chronic ulcers due to an abnormal immune response. Despite the existence of diagnostic criteria, there is no gold standard for diagnosis or treatment. In Latin America, recognizing and treating pyoderma gangrenosum is even more challenging since skin and soft tissue bacterial and non-bacterial infections are common mimickers. Therefore, this review aims to characterize reported cases of pyoderma gangrenosum in this region in order to assist in the assessment and management of this condition. Brazil, Mexico, Argentina, and Chile are the countries in Latin America that have reported the largest cohort of patients with this disease. The most frequent clinical presentation is the ulcerative form and the most frequently associated conditions are inflammatory bowel diseases, inflammatory arthropaties, and hematologic malignancies. The most common treatment modalities include systemic corticosteroids and cyclosporine. Other reported treatments are methotrexate, dapsone, and cyclophosphamide. Finally, the use of biological therapy is still limited in this region.

A 36-Year-Old Moroccan Man Presenting with Widespread Papules and Pustules

Cutaneous manifestations of tuberculosis are uncommon, can be nonspecific, and may demonstrate a wide variety of morphologies, including ulcerative papules, verrucous plaques, or nodules. We report the case of a 36-year-old Moroccan man who presented with nearly 2 years of generalized folliculocentric pustules and nodules, night sweats, and weight loss. Workup revealed necrotic right axillary lymphadenopathy, multiple ill-defined hepatic lesions, and a positive interferon-γ release assay. These findings were most consistent with papulonecrotic tuberculosis.

Cutaneous tuberculosis in Rio de Janeiro, Brazil: description of a series of 75 cases

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.

Cutaneous tuberculosis: A great imitator

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.

Scrofuloderma with disseminated tuberculosis in an Ethiopian child: a case report

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.

Regulatory T cells antagonize proinflammatory response of IL-17 during cutaneous tuberculosis

Background

The clinical forms of cutaneous tuberculosis (CTB) consist of a spectrum that reflects the host's immune response to Mycobacterium tuberculosis; it provides an ideal model to study the immunological dysregulation in humans. IL-17 plays an important role in initial immune response and is involved in both immune-mediated protection and pathology during M. tuberculosis infection. TGF-β producing regulatory T-cells (Tregs) are high in leprosy patients and responsible for immune suppression. However, in CTB, the involvement of Tregs and Th17 remains unevaluated.

Objective

To study the role of proinflammatory Th17 and Treg cells in the human CTB.

Methods

Blood and skin biopsies of CTB patients and healthy controls (HC) were included in the study. Flow cytometric analysis of IL-17, FOXP3, and TGF-β in blood was done followed by immunohistochemistry on paraffin-embedded skin sections. Expression of IFN-γ, TGF-β, and IL-17 was evaluated by quantitative real-time PCR.

Results

We found significant (P<0.0002) lower expression of proinflammatory IL-17 and IFN-γ (P<0.01) in CTB skins as compared to HC. However, the frequency of TGF-β producing Treg cells was found to be high in CTB patients (P<0.001) as compared to HC. A similar type of profile was observed by flow cytometric analysis. Treg cells produced suppressive cytokine TGF-β which showed a positive correlation with FOXP3 gene expression.

Conclusion

Our study found an increase in lineage-specific CD4⁺ Tregs in CTB as compared to the HC individuals. Such cells secrete TGF-β, a suppressive cytokine and may play a role in negatively regulating the T-cell immune responses in CTB. In addition, Tregs with TGF-β may downregulate Th17 cell responses leading to the antigen-specific anergy associated with CTB patients.

Cutaneous Tuberculosis: Clinicopathologic Arrays and Diagnostic Challenges

The clinicopathological manifestations of cutaneous tuberculosis are diverse. The precise diagnosis is often overlooked, due to clinical presentations as those of cutaneous diseases with different etiology and the relative paucity of the pathogens in the lesions. Meanwhile, almost all of the diagnostic methods confer lower sensitivity and specificities which augments further diagnostic challenges. This article revises the current scenario of the disease's physiopathology and underscores clinicopathological challenges, due to multifaceted presentations of cutaneous tuberculosis, in the diagnosis.

Vulvar Tuberculosis Cutis Orificialis Concomitant to Pulmonary Tuberculosis: A Case Report

Tuberculosis (TB) is a common condition with increasing incidence worldwide. Cutaneous TB represents a small portion of extrapulmonary TB. Health care professionals must be aware of cutaneous forms of TB to avoid delay in diagnosis and treatment. We present a case of a 59-year-old woman with vulvar TB cutis orificialis in association with pulmonary TB without any other involvement of genitourinary system. We discuss epidemiological aspects, classification, treatment, range of histopathological patterns, and use of ancillary techniques for diagnosis.

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

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

Mycobacterium bovis and Other Uncommon Members of the Mycobacterium tuberculosis Complex

Since its discovery by Theobald Smith, Mycobacterium bovis has been a human pathogen closely related to animal disease. At present, M. bovis tuberculosis is still a problem of importance in many countries and is considered the main cause of zoonotic tuberculosis throughout the world. Recent development of molecular epidemiological tools has helped us to improve our knowledge about transmission patterns of this organism, which causes a disease indistinguishable from that caused by Mycobacterium tuberculosis. Diagnosis and treatment of this mycobacterium are similar to those for conventional tuberculosis, with the important exceptions of constitutive resistance to pyrazinamide and the fact that multidrug-resistant and extremely drug-resistant M. bovis strains have been described. Among other members of this complex, Mycobacterium africanum is the cause of many cases of tuberculosis in West Africa and can be found in other areas mainly in association with immigration. M. bovis BCG is the currently available vaccine for tuberculosis, but it can cause disease in some patients. Other members of the M. tuberculosis complex are mainly animal pathogens with only exceptional cases of human disease, and there are even some strains, like "Mycobacterium canettii," which is a rare human pathogen that could have an important role in the knowledge of the evolution of tuberculosis in the history.

Understanding cutaneous tuberculosis: two clinical cases

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.