Cutaneous tuberculosis in Hong Kong: a 10-year retrospective study

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.

Lupus Vulgaris and Lichen Scrofulosorum with Disseminated Tuberculosis

Cutaneous tuberculosis (CTB) represents only 1%–2% of extrapulmonary forms of tuberculosis (TB). CTB can present in the isolation or coexist with pulmonary and disseminated forms of TB. Pathologically confirmed lupus vulgaris (LV) coexisting with lichen scrofulosorum with disseminated TB is presented and discussed. A 12-year-old boy presented with 2 years history of slowly progressive facial plaque and multiple skin colored papules on the neck. Tuberculin skin test was positive with a reading of > 20 mm. Histopathology revealed ulcerated areas with impetiginisation and keratopurulent debris. The entire skin showed pseudoepitheliomatous hyperplasia with numerous granulomas in the superficial dermis consisting of Langhans-type multinucleated macrophages. Lesions responded to anti-tuberculosis therapy (ATT) with residual facial scar. LV and lichen scrofulosurum are two forms of CTB which rarely occurs together. This case is being presented to highlight the occurrence of this rare presentation and the need to institute ATT to prevent scarring.

Management of Tuberculous Cutaneous Fistula

Tuberculosis is an endemic emergency that is prevalent in developing countries, particularly in sub-Saharan Black Africa, including Congo-Brazzaville. In addition to the pulmonary, ganglionic, and bone forms, there are other poorly documented locations. In the Congo, among these is cutaneous tuberculosis which is exceptional. A 9-year-old boy and two adult patients had persistent lesions of the left hip and thigh wounds, chest wall, and hypogastric wound with no healing for more than four months, respectively. Among these patients, one case of tuberculous contact was noted. Histopathological examination revealed a Koester follicle, suggesting a tuberculous skin fistula. A fistulectomy was performed, coupled with a quadruple antituberculous therapy combining rifampicin, isoniazid, ethambutol, and pyrazinamide for two months, relayed by a dual therapy consisting of isoniazid and ethambutol for 6 to 8 months. The evolution was favorable in all cases with healing of the lesions after 3 to 6 weeks. The existence of inexhaustible fistulas and the absence of scarring of a wound should make one suspect, among other things, cutaneous tuberculosis. The product of fistulectomy makes it possible to establish the histological diagnosis of cutaneous tuberculosis.

Bedside diagnostics in dermatology: Viral, bacterial, and fungal infections

Viral, bacterial, and fungal infections are frequently encountered in clinical practice, resulting in numerous cutaneous manifestations. Although diagnosis of these infections has changed over time because of technological advancements, such as polymerase chain reaction, bedside diagnostic techniques still play an important role in diagnosis and management, enabling rapid and low-cost diagnosis and implementation of appropriate therapies. This 2-part article will review both common and infrequent uses of bedside diagnostic techniques that dermatologists can incorporate into daily practice. This article examines the utility of bedside tests for the diagnosis of viral, bacterial, and fungal infections. The second article in this series reviews the use of bedside diagnostics for parasitic and noninfectious disorders.

CUTANEOUS TUBERCULOSIS: A 26-YEAR RETROSPECTIVE STUDY IN AN ENDEMIC AREA OF TUBERCULOSIS, VITÓRIA, ESPÍRITO SANTO, BRAZIL

BACKGROUND

Tuberculosis is a serious health problem in Brazil so that the knowledge on the aspects of cutaneous tuberculosis is medically important.

OBJECTIVE

To assess the characteristics of patients with cutaneous tuberculosis treated at the Cassiano Antonio Moraes University Hospital, located in the city of Vitória, State of Espírito Santo, Brazil.

METHODS

This is a retrospective, descriptive, observational and cross-sectional study using the medical records of 29 patients with cutaneous tuberculosis treated at the Dermatology and Pulmonology services of the hospital from 1986 to 2011. The inclusion criterion was the confirmation of cutaneous tuberculosis taking into account clinical, epidemiological, immunological, and bacteriological findings, as well as the response to specific treatment.

RESULTS

Of the 29 studied patients; 18 (62%) were women with average age of 37 years; the predominant clinical condition was erythema induratum of Bazin in 12 (41.4%) cases; and the cutaneous lesions were in the lower limbs in 19 (65.8%) patients. Extra-cutaneous involvement occurred in eight (27.6%) cases. The tuberculin tests were positive in 15 (79%) individuals and the assessment of the infectious agent was negative in most of the investigated cases.

CONCLUSION

The study found a low frequency (0.44%) of cutaneous tuberculosis in an endemic area of tuberculosis. There was a predominance of infection in women aged thirty to forty years. Erythema induratum was the most common clinical condition, affecting mainly the lower limbs, in contrast to other Brazilian studies that found scrofuloderma as the most common manifestation, predominating in the cervical region of male children and adolescents.

Lichen scrofulosorum

Tuberculosis is a common disease. The cutaneous form of tuberculosis known as tuberculid is an uncommon disease and is easily misdiagnosed. Lichen scrofulosorum is a rare form of tuberculid seen in children and young adults with or without other manifestations of tuberculosis. We report a case of a young adult with lichen scrofulosorum along with tuberculous lymphadenitis. The skin lesions responded promptly to antitubercular therapy with complete clearance of the lesions. Identification of the skin manifestation was especially important in this case because the lymph node biopsy was inconclusive, with tissue culture proving the diagnosis only after 4 weeks.

A case of lupus vulgaris with rare localization diagnosed 30 years after onset

Cutaneous tuberculosis (tuberculosis cutis) is one of the extrapulmonary forms of tuberculosis, which may affect the skin only or co-exist with tuberculosis of other organs, particularly the lungs. We describe a case of lupus vulgaris in a 72-year-old male patient with a single lesion localized on his lower extremity, developing for 30 years before correct diagnosis and previously treated with topical steroids. Bacillus infection in other organs was not detected. Diagnosis of tuberculosis was made based on personal history, clinical picture, hypersensitivity to tuberculin, histopathology and polymerase chain reaction. A multidrug therapy with rifampicin, isoniazid and pyrazinamide resulted in regression of the lesion. The common lack of knowledge about the clinical picture of cutaneous tuberculosis causes its late diagnosis and treatment.

Lichen scrofulosorum: an important marker of occult tuberculosis

Lichen scrofulosorum is a tuberculid that is usually seen in children or young adults. Although a rare occurrence, this tuberculid is an important marker of occult tuberculosis, which may not be detected otherwise. We report here a case of lichen scrofulosorum in a ten year-old boy with typical grouped lichenoid papules on the trunk associated with axillary tuberculous lymphadenitis.

Erythema induratum of Bazin in a child: evidence for a cell-mediated hyper-response to Mycobacterium tuberculosis

Tuberculids are chronic nodular skin eruptions believed to be a systemic reaction to Mycobacterium tuberculosis. We report on a 6-year-old boy with tender subcutaneous lesions on his legs. A tuberculin skin test resulted in 2.5 cm of induration and an interferon-gamma releasing assay was also markedly positive. A diagnosis of erythema induratum of Bazin was confirmed on skin biopsy. The patient was successfully treated with multi-drug antituberculosis therapy.

Cutaneous tuberculosis in Morocco

OBJECTIVE

To describe the salient epidemiologic, clinical, histopathologic, and bacteriologic aspects of cutaneous tuberculosis in Morocco.

METHODS

A retrospective review of all cases of cutaneous tuberculosis at our hospital from January 1981 through December 2004.

RESULTS

Two-hundred and sixteen cases of cutaneous tuberculosis were identified and included. Men and women were equally affected. The mean patient age was 29 years. Major clinical types of cutaneous tuberculosis were scrofuloderma and gumma (72%), lupus vulgaris (12%), tuberculosis verrucosa cutis (7%), tuberculids (6%), orificial tuberculosis (1%), and tuberculous chancre (1%). Systemic involvement was seen in 35%. Where performed (66%), 81% of subjects had positive Mantoux skin tests. Lesion biopsy for histopathologic study was performed in 81% of patients and showed classical tuberculous findings in 57%. Mycobacterium tuberculosis was isolated in culture from 9% of patients.

CONCLUSION

Cutaneous tuberculosis is still a common disease in Morocco, and scrofuloderma and gumma are the most common clinical presentations.

Cutaneous tuberculosis in children and adolescents: a clinicohistological study

BACKGROUND AND OBJECTIVES

Resurgence of tuberculosis (TB) in the era of human immunodeficiency virus (HIV) has rejuvenated the interest in this global health problem. Cutaneous TB, an important extra-pulmonary form in children, is commonly seen in our dermatological practice. As detection of acid-fast bacillus (AFB) on smear or culture is not always positive, histopathology is necessary to help in diagnosing and classifying the variants of skin TB. The current study was conducted to analyse the clinicopathological characteristics of cutaneous TB in children and adolescents.

MATERIALS AND METHODS

This prospective study included 103 patients (age<19 years). A detailed history and clinical examination was followed by complete investigative work up including fine needle aspiration cytology and culture. Histopathological evaluation was performed specifically noting the epidermal and dermal features. The patients were followed up regularly for one year after the start of treatment.

RESULTS

The different patterns of cutaneous TB seen were, scrofuloderma 38 (36.9%), lichen scrofulosorum 34 (33%), lupus vulgaris 22 (21.3%), TB verrucosa cutis 4 (3.9%), papulonecrotic tuberculid 4 (3.9%) and erythema nodosum 3 (2.9%). Systemic associations were seen in 55 (53.4%) patients, namely TB lymphadenitis in 30 (29.2%), pulmonary TB in 13 (12.6%), abdominal TB in 6 (5.8%) and TB arthritis in 6 (5.8%). The histopathological corroboration of clinical diagnosis was seen in 65.7% of cases of scrofulodermas, 72.7% of cases of lupus vulgaris and 67.6% of cases of lichen scrofulosorum.

CONCLUSIONS

A large spectrum of clinical patterns and histological characteristics of cutaneous TB exists in children. Lichen scrofulosorum is more commonly seen in comparison to adults. Systemic involvement was a feature in a major proportion of our patients.

Tuberculosis verrucosa cutis in a patient with long-standing generalized lichen planus: improvement of lichen after antitubercular polychemotherapy

Tuberculosis verrucosa cutis (TBVC) is a rare form of skin tuberculosis in Western communities, and is generally seen in certain risk groups. A 52-year-old housewife with recalcitrant generalized cutaneous and mucosal lichen planus (LP) of more than a 20-year duration presented with an erythematous-edematous plaque with a warty surface containing deep hemorrhagic fissures and numerous orifices draining purulent material on the back of her left hand. On the basis of clinical, histological and bacteriological findings, TBVC was diagnosed. The patient was successfully treated with isoniazid, rifampicin, ethambutol and pyrazinamide. Interestingly, all lichen lesions improved completely with this therapy. To the best of our knowledge, this is the first documented case of TBVC associated with LP, which was cured by antitubercular polychemotherapy. The case is presented because it reflects a possible reciprocal causal relationship between two cutaneous conditions of different natures.

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

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

PATIENTS AND METHODS

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

RESULTS

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

DISCUSSION

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

Atypisches Erythema induratum Bazin bei tuberkulöser Osteomyelitis

Diagnosis of all types of cutaneous tuberculosis is challenging because the clinical picture of these diseases is highly variable. We describe the case of a 79-year old woman with an atypical presentation of Erythema induratum Bazin (EIB) on the chest and left arm in association with a tuberculous osteomyelitis of the left olecranon. Surprisingly, M. tuberculosis grew also from biopsies of the EIB-lesions. This contradicts the conventional view that considers EIB (a tuberculid) to be caused by a hypersensitivity reaction to mycobacteria. The presented case supports the hypothesis that EIB may also be caused by hematogenous or lymphatic spread of viable M. tuberculosis.

Multifocal scrofuloderma with disseminated tuberculosis in a severely malnourished child

Tuberculosis and malnutrition continue to be significant health problems in developing countries. Moderate to severe malnutrition can cause immunosuppression and predispose children to various infections. We report disseminated tuberculosis in a severely malnourished Indian child who presented primarily with cutaneous involvement.

Epidemiology of cutaneous tuberculosis in Japan: a retrospective study from 1906 to 2002

BACKGROUND

Interest in tuberculosis has recently been revived, especially in association with the onset of acquired immunodeficiency syndrome (AIDS). In Japan, the incidence of tuberculosis has declined since the 1950s, but has shown a tendency to increase in the past 10 years.

METHODS

To determine the patterns of prevalence of cutaneous tuberculosis in Japan, data for cutaneous tuberculosis cases recorded between 1906 and 2002 were obtained from the dermatologic clinic of Kyushu University Hospital. The population of tuberculosis-infected patients was stratified into groups encompassing 10-year periods. Each patient group was then classified as having true tuberculosis or tuberculid, as well as being classified by gender. The total number of patients with cutaneous tuberculosis analyzed was 1324.

RESULTS

The incidence of cutaneous tuberculosis, both true tuberculosis and tuberculid, decreased between 1906 and 1935, increased between 1936 and 1955, and decreased again from 1955. The incidence of true tuberculosis was higher than that of tuberculid between 1906 and 1925. The incidence rates of true tuberculosis and tuberculid were equal from 1926 to 1945, and since 1946 the incidence of tuberculid has been higher than that of true tuberculosis. The incidence of tuberculid decreased between 1986 and 1995, but showed a dramatic increase between 1996 and 2000. The frequency of cutaneous tuberculosis was highest in the 10-49 year age group before 1980, but since 1981 has been highest in groups over 40 years of age.

CONCLUSIONS

The incidence of cutaneous tuberculosis in Japan is decreasing and shows a shift towards older generations. However, there is an increase in the incidence of tuberculid, especially in elderly female patients.

A case of multifocal lupus vulgaris that preceded pulmonary tuberculosis in an immune compromised patient

We describe the rare case of a Japanese male with multifocal lupus vulgaris that preceded asymptomatic pulmonary tuberculosis and adult T-cell leukemia/lymphoma (ATL). He visited our hospital with multiple reddish plaques and erythema of 4-12 months duration. A skin biopsy revealed non-caseating epithelioid granulomas. Mycobacterium tuberculosis was detected by polymerase chain reaction (PCR)-hybridization from a skin biopsy specimen and was also isolated from a culture of the skin biopsy sample. The result of chest roentogenography was compatible with pulmonary tuberculosis. In addition, the diagnosis of ATL was based upon the presence of atypical lymphocytes with convoluted nuclei in his peripheral blood and a positive anti-ATL antibody reaction. Cases of cutaneous tuberculosis presenting with unusual clinical features may be on the increase, accompanying the spread of tuberculosis in immunosuppressed patients, including those with ATL and acquired immunodeficiency syndrome (AIDS).

Polymerase chain reaction based detection of Mycobacterium tuberculosis in tissues showing granulomatous inflammation without demonstrable acid-fast bacilli

BACKGROUND

Cutaneous tuberculosis is especially difficult to distinguish from other granulomatous dermatoses. We used polymerase chain reaction (PCR) to evaluate the incidence of cutaneous tuberculosis and atypical mycobacterial infection in formalin-fixed, paraffin-embedded tissues with unspecified granulomatous inflammation and negative results for acid-fast bacilli (AFB), and analyzed the pattern of cutaneous tuberculosis in this group of patients.

METHODS

A total of 38 specimens which had been collected from 36 patients and fulfilled the criteria for tissues described above were used in this study. Two different primer pairs targeting the gene encoding for 16S ribosomal RNA (common to all mycobacteria) and the insertion sequence IS6110 (specific for M. tuberculosis complex) were used in the PCR assays. The clinical characteristics, histopathologic findings, and culture results of the patients were also analyzed.

RESULTS

Four specimens were excluded from the analysis due to the lack of internal control testing. Of the remaining 34 specimens, 22 were PCR positive for the 16S rRNA gene. Among them, 18 specimens were PCR positive for both the 16S rRNA gene and IS6110. Cutaneous tuberculosis could be diagnosed in these 18 cases (56.2%). Out of the 18 cases, there were 8 women and 10 men. The age range was 15-77 years (mean: 44.2 years). After reviewing their clinical presentation, 11 cases were considered as tuberculosis verrucosa cutis, 6 cases as lupus vulgaris, and 1 case as erythema induratum. The remaining 4 cases (12.5%) positive only for 16S rRNA gene were considered as possible atypical mycobacteria infection.

CONCLUSIONS

These results show that in paucibacillary form of cutaneous tuberculosis with unclassical clinical and histological presentation, this PCR system provides rapid and sensitive detection of M. tuberculosis DNA in formalin-fixed, paraffin-embedded specimens. Cutaneous tuberculosis represents a significant proportion in specimens showing granulomatous inflammation. In areas like Taiwan, where prevalence of pulmonary tuberculosis is still high, tuberculosis verrucosa cutis and lupus vulgaris are common forms of cutaneous tuberculosis and are seen more frequently than atypical mycobacterial infection.

Incidence of cutaneous tuberculosis in patients with organ tuberculosis

BACKGROUND

Tuberculosis continues to be a health problem in some countries. The development of resistance to antituberculitic drugs and the increase in diseases and conditions associated with immunodeficiency such as AIDS and chemotherapy have caused tuberculosis to increase recently. As a result, the incidence of cutaneous tuberculosis has been increasing as well.

AIM

To detect cutaneous tuberculosis in patients with organ tuberculosis and to establish some characteristics of the relation between organ and cutaneous TB.

MATERIAL AND METHODS

A total of 370 patients (145 females and 225 males), aged 2-76 years (mean age 27.5), enrolled for this screening study. These patients were hospitalized patients who already had pulmonary or extrapulmonary tuberculosis diagnosed before admission. All patients underwent a general skin examination, and, if needed, cutaneous biopsies were taken from involved skin areas.

RESULTS

Three hundred and forty-seven (93.78%) out of 370 patients had pulmonary tuberculosis only or in association with one of other organ tuberculoses. Twenty-three patients had extrapulmonary TB: nine were TB adenitis, six were TB peritonitis, three were bone tuberculosis, and five were TB meningitides. Of 370 patients, only 13 (3.51%) had cutaneous TB: seven scrofuloderma (SCD; 2.16%), four lupus vulgaris (LV; 1.35%), one LV and SCD, and one Bacille Calmette-Guerin (BCG) adenitis (0.027%). Cutaneous tuberculosis was observed in seven out of 260 patients with parenchymal tuberculosis (2.96%). Four out of nine patients with TB adenitis (44.4%), one out of 12 pulmopleuretic (8.3%), and one out of 67 pleuresic patients (1.40%) had cutaneous TB as well. Mean age of the 13 patients was 32.46 years: mean age of SCD and LV was 24.8 and 48 years, respectively. The one patient with BCG adenitis was 7 months old. Five (62.5%) out of eight patients with SCD, and only one (20%) out of five patients with LV were new cases. Four patients with SCD had a positive family history, while LV patients did not.

CONCLUSIONS

Organ tuberculosis is rarely associated with cutaneous tuberculosis. Scrofuloderma and LV are the most frequent forms of skin TB associated with organ TB in this population. Tuberculosis adenitis is the organ TB that causes cutaneous TB most often among other organ tuberculoses. More than one form of cutaneous TB affected only one patient with pulmonary TB; therefore, it is very rare. Tuberculids were not observed in any of the patients.

Cutaneous tuberculosis: diagnosis and treatment

As we move into the 21st century, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary tuberculosis. Mycobacterium tuberculosis, Mycobacterium bovis, and the BCG vaccine cause tuberculosis involving the skin. True cutaneous tuberculosis lesions can be acquired either exogenously or endogenously, show a wide spectrum of morphology and M. tuberculosis can be diagnosed by acid-fast bacilli (AFB) stains, culture or polymerase chain reaction (PCR). These lesions include tuberculous chancre, tuberculosis verrucosa cutis, lupus vulgaris, scrofuloderma, orificial tuberculosis, miliary tuberculosis, metastatic tuberculosis abscess and most cases of papulonecrotic tuberculid. The tuberculids, like cutaneous tuberculosis, show a wide spectrum of morphology but M. tuberculosis is not identified by AFB stains, culture or PCR. These lesions include lichen scrofulosorum, nodular tuberculid, most cases of nodular granulomatous phlebitis, most cases of erythema induratum of Bazin and some cases of papulonecrotic tuberculid. Diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with diagnostic testing; in addition to traditional AFB smears and cultures, there has been increased utilization of PCR because of its rapidity, sensitivity and specificity. Since most cases of cutaneous tuberculosis are a manifestation of systemic involvement, and the bacillary load in cutaneous tuberculosis is usually less than in pulmonary tuberculosis, treatment regimens are similar to that of tuberculosis in general. In the immunocompromised, such as an HIV infected patient with disseminated miliary tuberculosis, rapid diagnosis and prompt initiation of treatment are paramount. Unfortunately, despite even the most aggressive efforts, the prognosis in these individuals is poor when multi-drug resistant mycobacterium are present. An increased awareness of the re-emergence of cutaneous tuberculosis will allow for the proper diagnosis and management of this increasingly common skin disorder.

Perianal ulceration in a "healthy" Chinese man with disseminated tuberculosis

Orificial tuberculosis (OTB) is a rare form of cutaneous Mycobacterium tuberculosis infection affecting the mucosa and skin around orifices in patients with advanced internal tuberculosis and poor general health. We report a 72-year-old Chinese man who had a 10-year history of OTB with disseminated tuberculosis infection of the lungs and urinary tract. He appeared surprisingly healthy and had been free from systemic symptoms all along despite widespread tuberculosis. The diagnosis of OTB was established by the microscopic presence of acid-fast bacilli (AFB) in the tissue section and was rapidly confirmed by polymerase chain reaction (PCR) to be Mycobacterium tuberculosis. PCR shortens the time of diagnosing rare presentations of cutaneous tuberculosis and prevents delays in treatment. Conventional culture is still important in confirming the diagnosis and screening for drug resistance.

Clinical and epidemiological observations of cutaneous tuberculosis in Larkana, Pakistan

BACKGROUND

Cutaneous tuberculosis is widespread in Pakistan but has not been fully documented. This study was conducted to determine the clinical pattern, nature and existence of the disease in Larkana, Sindh province, Pakistan.

METHODS

We are reporting 153 cases of patients with cutaneous tuberculosis who visited our department from 1996 to 1999. All cases were diagnosed at the clinic, and the biopsies were examined for histopathological evidence. The patients received three antituberculous treatments during a 9 month course.

RESULTS

Clinically, 63 (41.2%) cases of lupus vulgaris, 54 (35.3%) of scrofuloderma, 29 (19.59%) of lupus verrucosa cutis, six (3.92%) of tuberculosis cutis orificialis and one (0.64%) case of disseminated cutaneous tuberculosis were observed in our department from 1996 to 1999. All patients were aged between 3 and 50 years and had experienced the present complaints for 1 to 12 years. Sixty-nine (45.1%) cases were children aged under 10 years, 50 cases (37.25%) were aged between 10 and 20 years, and 27 cases (17.65%) were aged over 20 years. There was no considerable ratio difference of the disease between male and female patients. Histopathologically, all the specimens showed chronic granulomatous changes; the majority was infiltrated with epitheloid cells, langhans giant cells, plasma cells and other inflammatory cells, such as lymphocytes, eosinophils and neutrophils in ulcerated lesions. Increased numbers of mast cells were seen in upper and lower dermis in two-thirds of the specimens. Caseating necrosis was visible in half of the specimens while Ziehl-Neelsen stain was negative in all the sections.

CONCLUSIONS

The observed number of patients was moderately large, thus indicating a high incidence of cutaneous tuberculosis in Larkana. Lupus vulgaris, a form of cutaneous tuberculosis, was widespread in this area and prevalent in adults, while scrofuloderma was prevalent in children. Moreover, the existing rate of the disease was higher in children aged under 10 years and lower in adults. This indicates that children are more prone to this disease than adults.

Scrofuloderma and Sweet's syndrome

BACKGROUND

In recent years, the rare association of Sweet's syndrome with nontuberculous mycobacterial lymphadenitis has been reported.

OBJECTIVE

To report the clinical, demographic, and bacteriologic data and association with Sweet's syndrome of 18 patients with scrofuloderma and scrofuloderma-like condition caused by nontuberculous mycobacterial infections seen during the past 7 years (1994-2000).

METHODS

In all patients, a biopsy specimen was obtained for histopathologic and microbiologic studies. Patients from whom Mycobacterium tuberculosis and nontuberculous mycobacteria were isolated from the culture of skin biopsy specimens were included. Deep fungal infection was excluded by the lack of a fungal element in histologic section and cultural methods. The patients were treated with antimicrobials or antituberculous drugs according to the causative species.

RESULTS

Eighteen cases of scrofuloderma (nine male, nine female; mean age, 36.9 years) were found among 104 patients with cutaneous tuberculosis and nontuberculous mycobacterial cutaneous infections. Sixteen of the 18 cases had lymphadenitis as the underlying focus of scrofuloderma: 15 cases occurred in the cervical group and one case in the inguinal area. One case drained from the soft tissue and one from the paranasal air sinus. Five cases had multiple episodes of Sweet' s syndrome during the course of treatment. Most cases in this group (four of the five) were middle-aged women with cervical lymphadenitis, and the most common species were rapid growers.

CONCLUSIONS

Age, sex, and the site of infection may have some influence on the association with Sweet's syndrome in nontuberculous mycobacterial infections.

Scrofuloderma with multiple organ involvement in a 5-year-old child

Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis seen in children in developing countries. We report a 5-year-old child with cutaneous tuberculosis with involvement of lymph nodes, lungs, and the musculoskeletal and central nervous systems, which was not clinically obvious. Antituberculous treatment led to marked clinical improvement. The importance of a thorough search for internal organ involvement in patients presenting with cutaneous tuberculosis is emphasized.

Childhood cutaneous tuberculosis: a study over 25 years from northern India

AIMS

We undertook this study to analyse the pattern of childhood cutaneous tuberculosis prevailing in northern India over the past 25 years and to highlight differences from and similarities to adult tuberculosis.

MATERIALS AND METHODS

Clinical records of children with cutaneous tuberculosis who attended the Nehru Hospital attached to the Postgraduate Institute of Medical Education and Research, Chandigarh, India, between January 1975 to December 1999 were analysed.

RESULTS

Four hundred and two patients with cutaneous tuberculosis were examined during the 25-year period of observation. These patients formed 0.1% of the total dermatology outpatients. Seventy-five (18.7%) of these 402 cases were children (</= 16 years). There were 32 (42.7%) boys and 43 (57.3%) girls with a boy : girl ratio of 0.74 : 1. The majority of the children, 41 (54.7%) were in the 10-14 years age group. There was no significant boy or girl preponderance in any group other than in scrofuloderma (SFD), where girls significantly outnumbered boys at all ages. Of the various patterns of cutaneous tuberculosis seen, 40 (53.3%) had SFD, 30 (40.0%) had lupus vulgaris (LV), 3 (4.0%) had tuberculosis verrucosa cutis (TVC), 1 (1.3%) child each had tuberculids and tubercular gumma. No child had a tubercular chancre or acute miliary cutaneous tuberculosis. The neck was the commonest site afflicted with SFD and the face was the commonest site affected with LV. No child had generalized lymphadenopathy. Eighteen (60.0%) of the 30 children with LV had regional lymphadenopathy of which 15 (83.3%) had localized disease and 3 (16.7%) had disseminated disease. Of the 16 children with systemic organ involvement, 12 (75.0%) had regional lymphadenopathy. Of the 62 children in whom the data regarding vaccination status was available, 31 (50.0%) had been vaccinated and 31 (50.0%) had not. Among the vaccinated group no child had disseminated disease. Three (9.7%) children in the nonvaccinated group had disseminated disease. Information regarding Mantoux reactivity was available in 71 (94.7%) children, 61 (86.0%) with localized disease and 10 (14.1%) with disseminated disease. Of the 61 children with localized disease, 56 (91.8%) were Mantoux positive and of the 10 children with disseminated disease, only 5 (50.0%) were Mantoux positive (> 10 mm). Histopathologic reports were available for evaluation in all 75 children. Out of 30 cases of LV, 24 (80%) showed classical tuberculous histology. In contrast, out of 40 cases with SFD, only 19 (47.5%) showed classical histology. Classical tuberculous histology was noted in all 3 (100%) cases of TVC and 1 (100%) case each with tuberculids and gumma. Tubercle bacilli could be demonstrated in 4/30 (13.3%) cases with LV and 9/40 (22.5%) cases with SFD. Systemic involvement was seen in 16 (21.3%) children, of whom 3 (18.8%) had LV and 13 (81.3%) SFD. The lungs were the most common organs involved in 8 (50.0%) children followed by bone(s) in 4 (25.0%), abdomen in 2 (12.5%), and both lung and bone in 1 (6.3%) child. In contrast to adults, girls outnumbered boys in the childhood series; SFD was a common form of presentation in contrast to LV and TVC, tuberculous gumma and tuberculids were noted less often. In both children and adults, Mantoux reactivity did not correlate with the extent of the disease; patients with disseminated disease were found to be less often vaccinated with BCG and regional lymphadenopathy was noted more often in patients with disseminated disease.

CONCLUSIONS

In the whole spectrum of cutaneous tuberculosis, there is a proportion of patients with dissemination (systemic involvement) who are of great epidemiological significance as they require a change in the standard therapeutic regimens recommended for cutaneous tuberculosis.

A study of cutaneous tuberculosis in children

Sixty-three children out of a total of 199 patients seen with cutaneous tuberculosis during a 7-year period were included in this study. Culture was positive in only four, and the diagnosis was based on clinical examination, tuberculin reaction, histopathology, and response to antitubercular therapy. Forty had lupus vulgaris (LV) and 23 scrofuloderma (SD). The lower half of the body was predominantly affected in those with LV, and keratotic and hypertrophic forms were frequently encountered. LV planus mainly affected the face. Ulcerative and atrophic types of LV were infrequent. Extensive lesions in three children led to disfiguring scars and contractures. Scrofuloderma often involved the cervical group of lymph nodes followed by the inguinal, submandibular, and axillary groups. As compared to skin tuberculosis in adults, regional lymph node involvement in LV was more common, and a combination of both LV and SD was less frequent in children. No difference in clinical presentation could be detected between the BCG vaccinated and unvaccinated children. Tuberculous infection either in the lungs or the bones was present in eight children. An HIV test done in five patients with widespread lesions was negative. Irregular therapy or late diagnosis leading to serious complications, inadequate parental or community support, and lack of awareness among practitioners are the problems to be remedied.

Cutaneous tuberculosis: a rare presentation in an immigrant

The increased incidence of tubercular diseases in industrialized countries appears to be due to several factors, including development of resistance to the most commonly used specific chemotherapeutic substances, unsuitable control programmes, HIV infection, the increased influx of immigrants, and homelessness. Different forms of cutaneous tuberculosis are caused by different species of mycobacteria (e.g., Mycobacterium tuberculosis, M. bovis, M. avium). Determining the species of mycobacteria is relevant when disease is suspected to be linked to the type of employment of the patient, mainly because the clinical features do not always indicate which species is the cause of the infection. Mycobacterium tuberculosis (MT) usually infects through the lung, but in rare cases can penetrate the skin or mucous membranes. Skin transmission can be exogenous by inoculation, or endogenous by diffusion (lymphatic or hematic) or by contiguity. The immunologic status of the patient is a crucial factor which influences the clinical variants and the course of disease itself. Here we report a case of an illegal immigrant who presented with a bilateral, symmetrical ulcer on the neck.

The histopathologic spectrum of erythema induratum of Bazin

Erythema induratum of Bazin is a tuberculid that is strongly associated with tuberculosis. Clinically, erythema induratum of Bazin show recurrent tender subcutaneous nodules that occur mainly on the calves of women with tuberculin hypersensitivity. Previous studies have not documented the histopathologic spectrum of erythema induratum of Bazin in detail. We identified two major histopathologic groups in 19 of 20 skin biopsies obtained from 20 patients with well-documented erythema induratum of Bazin. Six cases (group I) showed focal septolobular panniculitis in close association with a single muscular artery or small vessel with primary neutrophilic vasculitis. Thirteen cases (group II) revealed diffuse septolobular panniculitis with primary neutrophilic vasculitis of either large or smaller vessels. Both groups showed varying combinations and degrees of acute and chronic inflammation, coagulative and caseation-like necrosis, and granulomatous inflammation. Poorly developed granulomas predominated, but mixed, palisading, and lipophagic granulomas also occurred. Inflammation and necrosis were more extensive in group II. Erythema induratum of Bazin may show predominantly acute suppurative or granulomatous panniculitis. Immunostaining showed S100+ antigen-presenting cells, macrophages, and T-lymphocytes. B-lymphocytes were rare. The presence of primary vasculitis and granulomas suggests that types III and IV hypersensitivity reactions play a role in the pathogenesis or erythema induratum of Bazin. The latter remains a clinicopathologic diagnosis, but awareness of the heterogeneous histopathologic spectrum of EIB will ensure a timely diagnosis and institution of antituberculous treatment.

Lupus vulgaris in a patient with systemic lupus erythematosus and persistent IgG deficiency

We present the case of a patient with juvenile onset systemic lupus erythematosus (SLE) who developed a persistent, acquired hypogammaglobulinaemia with IgG deficiency. The hypogammaglobulinaemia was probably a complication of high dose corticosteroid treatment. The serum IgG level remained subnormal despite intravenous immunoglobulin therapy. Lupus vulgaris, which developed on the nasal cartilage in this patient with SLE, is not an expected finding. This patient is probably the first reported case of SLE associated with lupus vulgaris.