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Cutaneous tuberculosis

Cutaneous tuberculosis. Epidemiology. Cutaneous tuberculosis occurs worldwide; incidence of different forms varies globally.

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Cutaneous tuberculosis

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  1. Cutaneous tuberculosis

  2. Epidemiology • Cutaneous tuberculosis occurs worldwide; incidence of different forms varies globally. • India: Affected 2% of all skin outpatients (1950s and 1960s) and then 0.1% by 1980s; due to the availability of effective drugs and improvement in the living standards. • In India, scrofuloderma is common in children; lupus vulgaris commonest in adults. • Resurgence in tuberculosis, and consequently in cutaneous tuberculosis; due to the HIV pandemic, resistant strains of M. tuberculosis, use of immunosuppressive therapy, ease of global travel and migration, poverty, malnutrition.

  3. Aetiology • Caused by M. tuberculosis, M. bovisand under certain conditions, the bacillus Calmette-Guérin (BCG), an attenuated strain of M. bovis. • M. tuberculosis and M. boviscause identical skin manifestations in humans. • In HIV-infected individuals, even atypical saprophytic strains of Mycobacterium may cause infection and bizarre forms of disease.

  4. Cutaneous tuberculosis • Spectrum of cutaneous changes induced by M. tuberculosis depend upon: • Route of infection • Immunological state of the host • Mere presence of mycobacteria in the skin does not lead to the clinical disease.

  5. Routes of infection • Exogenous • From an external source, through breach in the skin at the site of trauma. • Endogenous • Through contiguous involvement of skin • Through lymphatic spread • Through haematogenous dissemination • Autoinoculation

  6. Classification (Modified from Beyt et al.) • Inoculation tuberculosis (exogenous source) • Secondary tuberculosis (endogenous source) • Haematogenous tuberculosis • Eruptive tuberculosis (tuberculides)

  7. Classification (Modified from Beyt et al.) • Inoculation tuberculosis (exogenous source) • Tuberculosis chancre • Warty tuberculosis (verrucosa cutis) • Lupus vulgaris (some)

  8. Classification (Modified from Beyt et al.) • Secondary tuberculosis (endogenous source) • Contiguous spread: Scrofuloderma • Auto-inoculation: Orificial tuberculosis

  9. Classification (Modified from Beyt et al.) • Haematogenous tuberculosis • Acute miliary tuberculosis • Lupus vulgaris (some) • Tuberculousgumma

  10. Classification (Modified from Beyt et al.) • Eruptive tuberculosis (tuberculides) • Micropapular • Lichen scrofulosorum • Papular • Papular or papulonecrotictuberculide • Nodular • Erythemainduratum (Bazin) • Nodular tuberculide • Erythemanodosum

  11. Tuberculous chancre • Occurs following M. tuberculosis inoculation through breach in the skin of an individual, not previously infected with tuberculosis. • Initially, a small papule, scab, nodule or a poorly healing wound; gradually forms a painless ulcer with a shallow, granular or haemorrhagic base and undermined edges. • Spontaneous healing within 3 to 12 months, with atrophic scar and often, calcified nodes.

  12. Warty tuberculosis(Syn: Tuberculosis verrucosa cutis Pathogenesis • Previously infected individual with moderate or high immunity • Accidental superinfection from exogenous sources: physician, pathologists • Autoinoculation with sputum • Common sites • Adults - fingers and hands • Children - ankles and buttocks

  13. Warty tuberculosis Clinical features Small, solitary, indurated, red or brown, papule or nodule Verrucous plaque (finger-like projections; fissured surface) Spontaneous involution with atrophic scarring Regional lymph nodes may enlarge due to secondary bacterial infection.

  14. Warty tuberculosis Course • Verrucous lesions persist; but seldom ulcerate. • Lesions run a chronic course, and if untreated, remain inactive for months or years. • Lesions may involute spontaneously, resulting in sunken, atrophic scars.

  15. Warty tuberculosis Differential diagnosis • Common warts • Hypertrophic lichen planus • Verrucous epidermal nevus • Blastomycosis • Chromomycosis • Actinomycosis

  16. Lupus vulgaris Pathogenesis • Most common form of cutaneous tuberculosis • Occurs in sensitized individuals with moderate to high immunity • Affects all age groups

  17. Lupus vulgaris Pathogenesis • Lesions arise by: • Haematogenous dissemination • Lymphatic spread • Contiguous spread from tuberculous tissue • Exogenous inoculation

  18. Lupus vulgaris Clinical features Small, solitary reddish-brown nodule Plaque Elevated, infiltrated, deep brown in colour Slowly expands at one end; heals with scarring at the other end Asymptomatic lesions, commonly affects the buttocks and trunk

  19. Lupus vulgaris Clinical forms • Plaque forms • Ulcerative and mutilating forms • Vegetating forms • Tumor-like forms • Papular and nodular forms

  20. Lupus vulgaris Course • Chronic, indolent course over years, if left untreated. • Lesions undergo ulceration, and superficial scarring. • Characteristically thin, white, smooth scars; may break down or become keloidal. • Complications comprise scarring, contractures, tissue destruction, development of squamous cell carcinoma in the scars (8%).

  21. Lupus vulgaris Differential Diagnosis • Borderline tuberculoid leprosy • Psoriasis • Sarcoidosis • Discoid lupus erythematosus • Syphilitic gumma • Deep fungal infections

  22. Scrofuloderma Pathogenesis • Contiguous involvement of the skin overlying a tuberculous focus, usually a lymph node, an infected bone or joint or epididymis. • Common in children, adolescents and aged; may affect all age groups. • Usually affects the face and neck, often bilaterally. • Commonly involves the cervical, parotid, submandibular and supraclavicular lymph nodes; less commonly, axillary and inguinal.

  23. Scrofuloderma Clinical features Initially, a firm, subcutaneous nodule, fixed to the overlying skin Cold abscess formation Secondary ulceration, sinus tract formation Ulcer has undermined edges and granulating floors

  24. Scrofuloderma Course • Numerous sinus tracts and fistulae develop over a period of several months. • Spontaneous healing may occur, with puckered and cord-like scars. • Scar tracts characteristically bridge the areas of ulceration or even normal skin.

  25. Scrofuloderma Differential Diagnosis • Atypical mycobacterial infection • Lymphogranulomavenereum • Actinomycosis • Sporotrichosis • Syphilitic gummas • Acne conglobata • Hidradenitissuppurativa • A rare form of tuberculosis of the mucous membranes and skin adjoining the orifices. • Presents as a nodule which ulcerates with undermined edges

  26. Orificial tuberculosis • A rare form of tuberculosis of the mucous membrane and skin adjoining the orifices • Presents as a nodule which ulcerates with undermined edges

  27. Orificial tuberculosis • Site affected depends on the site of internal tuberculosis: • Pulmonary tuberculosis: mouth • Tuberculosis of pharynx, larynx: lips • Intestinal tuberculosis: external genitalia; anus; perianal • Genitourinary tuberculosis in women: vulva • Prognosis: poor due to advanced internal disease and compromised immunity.

  28. Acute miliary tuberculosis of the skin • Rare manifestation of fulminating tuberculosis due to haematogenous dissemination of mycobacteria into the skin, from a meningeal or pulmonary focus. • Crops of numerous, minute, erythematous to bluish, macules, papules, vesicles, pustules or purpuric lesions occur on all parts of the body, especially the trunk. • Usually occurs in infants, young children or immunosuppressed patients, co-existing HIV infection, measles.

  29. Tuberculousgumma • Haematogenous dissemination of mycobacteria from a primary tuberculous focus, during periods of lowered resistance. • Commonly involves the trunk, extremities or head. • Lesions arise as a single or multiple, firm subcutaneous nodule or fluctuant abscesses. • Ulcers with undermined edges, sinuses and fistulae may occur • Healing occurs with cord-like and puckered scarring.

  30. Tuberculides • Occur as a hypersensitivity reaction to • M. tuberculosis or its products in a patient with moderate to high immunity, following haematogenous spread of the mycobacteria. • Salient features: • A positive tuberculin test • Evidence of obvious or past tuberculosis • A positive response to anti- tuberculous therapy

  31. Tuberculides Types • Micropapular: lichen scrofulosorum • Papular: papulonecrotictuberculide • Nodular: Erythemainduratum of Bazin Erythemanodosum

  32. Erythemainduratum of Bazin(Nodular tuberculide) • A chronic, recurrent, nodular and ulcerative disorder • Commonly affects young, or middle-aged, obese women; men affected occasionally • Predominantly affects calves; may also occur on upper limbs, thighs, buttocks and trunk • The nodules run an indolent course and form ulcers • Ulcers are ragged, irregular and shallow, with bluish edge

  33. Diagnosis Absolute diagnosis established by: • A positive culture of M. tuberculosis from the lesion • Identification of mycobacterial DNA by Polymerase Chain Reaction (PCR) technique

  34. Other diagnostic criteria The diagnosis is suggested by: • Clinical history and physical signs • A positive reaction to tuberculin • Demonstration of tuberculoidgranuloma on histolopathology • Demonstration of acid-fast bacilli in the lesion • Presence of culture-proven active tuberculous focus elsewhere in the body • Effect of specific therapy

  35. Cutaneous tuberculosis treatment General principles • Notification • Identification and treatment of the underlying tuberculous focus • Identification and treatment of co-existent infections such as HIV • Specific chemotherapy • Ancillary measures

  36. Cutaneous tuberculosis Drug regimen The standard regimens comprise: • Initial intensive phase (Phase I) Rapidly destroys large populations of multiplying mycobacteria. • Continuation phase (Phase II) Eliminates persistent dormant organisms.

  37. Drug therapy: 6 months regimen (for adults) 1. Rifampicin 450mg/600mg (wt </> 50kgs) - 6 months 2. Isoniazid (300mg daily) - 6months (add pyridoxine 10mg/day) 3. Pyrazinamide - for 1st 2months 1.5gm daily for patient <50 kg 2gm daily for patient >50 kg 4. Ethambutol for the 1st 2 months Dose: 15mg/kg body weight daily All drugs taken on empty stomach once daily

  38. Re-introduction of AKT following drug reactions (WHO) If severe reactions, start with smaller dosage (1/10th)

  39. Revised National TuberculosisControl Programme (RNTCP) Extra-pulmonary tuberculosis: Diagnosis One culture-positive specimen from extrapulmonary site, or Histological evidence, or Strong clinical evidence consistent with active extrapulmonary TB

  40. Revised National TuberculosisControl Programme (RNTCP) Cutaneous TB: Category III (sputum smear negative) Regimen: 2(HRZ)3 + 4(HR)3 Category II (sputum smear positive) 2(HRZES)3 + 1(HRZE)3 + 5(HRE)3

  41. Cutaneous tuberculosis treatment Special considerations • Surgical intervention coupled with AKT in scrofuloderma; small lesions of lupus vulgaris; tuberculosis verrucosa cutis. • Plastic Surgery in cases of disfigurement due to lupus vulgaris • Standard regimens: effective in HIV-positive. • HIV-infected individuals: higher drug reaction and infection rates.

  42. Thank you

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