Cutaneous Tuberculosis
Dr. (Prof.) Archana SingalUniversity College of Medical Sciences
& GTB Hospital, New Delhi
Digital Lecture Series : Chapter 09
CONTENTS
Introduction Epidemiology Etiopathogenesis-
• Etiological agent• Host-Pathogen interaction• Presdisposing factors
Clinical classification• Exogenous/inoculation• Endogenous• Tuberculide
Differential diagnosis
Management• General Principles• Investigations• Treatment• Resistance
MCQs Photoquiz
Introduction
Tuberculosis (TB), one of the oldest infectious disorders Organism identified 130 yrs back by Robert Koch(1882) Intradermal Skin test developed 100 yrs back by Charles Mantoux TB vaccine in use for 80 yrs (1928) Chemotherapy in use for 50 yrs (1963)
STILL
2nd most common infectious cause of death after HIV/AIDS worldwide Pulmonary TB remains to be the most common form of TB TB of extra-pulmonary sites such as lymph nodes, bone, skin, abdomen
and pelvis is on a steady rise.
Globally - Cutaneous TB (CTB) is less common clinical forms of TB About 1% to 2% of total extrapulmonary cases Incidence of 0.07% has been reported in a 10-year survey from
Hong Kong.
India - CTB constitutes 10% cases of all extrapulmonary TB And 0.1% - 2% of total skin OPD patients Lupus vulgaris is considered the commonest form of CTB in adults
and Scrofuloderma in children Tuberculides especially lichen scrofulosorum (LS) has emerged as
the commonest variant in many regions including India
Epidemiology
Life time risk with HIV – 50%
In developing world 50% are co-infected
World over 4 million people are co-infected
5% develop disseminated infection which is the cause of death
HIV Infection & TB
M. Tuberculosis major etiological agent M. bovis 1 – 1.5%
WITH HIV
M. avium complex 2 / 3 cases M. tuberculosis 10% cases M. kansasii M. scrofulaceum
Etiology
No known endotoxin Tissue destruction mediated by host immune response
Skin manifestation depends on• Sensitization status of the patient• Cellular immunity• Route of infection
Pathogenesis
contd.
EXPOSURE (BCG/Pri. Pulm. Infection/Skin Inoculation)
Mycobacteria engulfed by macrophages
Antigen presented to CD4+ TH1 cell
(In 2-3 weeks)
Hypersensitivity / Granuloma Formn / Caseous Necrosis
Disease Arrested Latent Infection Progressive Disease (5-10%)
Pathogenesis
HIV pandemic leading to resurgence in TB & drug resistant strains of M. tuberculosis,
Use of immunosuppressive therapy, Ease of global travel and migration, Poverty and malnutrition
Factors affecting host-pathogen interaction Virulence of the infecting mycobacteria Route of infection Prior contact with the bacilli Host’s immune response Environmental factors
Predisposing factors
Exogenous Direct inoculation of TB bacilli from an infected person to susceptible one,
through breach in the skin at the site of trauma
Endogenous Through contiguous involvement of skin Through lymphatic spread Through haematogenous dissemination
Autoinoculation
Routes of infection
Exogenous cutaneous tuberculosisTuberculous chancreTuberculosis verrucosa cutis (TBVC)
Endogenous cutaneous tuberculosisBy contiguity or autoinoculation Scrofuloderma (SFD) Orificial tuberculosis Lupus vulgaris (some cases) LV
Classification of Cut TB (Beyt et al)
contd.
By hematogenic dissemination Lupus vulgaris (LV) Tuberculous gumma Acute miliary tuberculosis
Tuberculids Papulonecrotic tuberculid (PNT) Erythema induratum of Bazin (EIB) Lichen scrofulosorum (LS) Phlebitic tuberculid*
Classification of Cut TB (Beyt et al)
*Phlebitic’ or ‘nodular granulomatous phlebitis’ has been recently proposed as a new tuberculid
Rare form of CTB, develop in adults without previous sensitization to Mycobacterium Tuberculosis; natural or artificial
Usually follows• Abrasion, cuts and ulcers• Circumcision• Tattooing and Ear piercing with unsterilized needles• Contact with infected sputum
Localized form Site - Face and extremities
Tuberculous chancre (Primary Inoculation TB)
Firm, painless and brownish papule
2-3 weeks 3-8 weeks Firm, non-tender ulcer Regional LAPwith undermined bluish margins (Primary Complex)
- Slow healing in up to Subsides with calcification - 12 months with scars Rarely cold abscess
- Rarely progression to & sinuses develop - LV or SFD in untreated
After 2-4 weeks of inoculation
Post Tattoo inoculation TB in two brothers that progressed to LV.
Exogenous inoculation at trauma prone sites in pre-sensitized hosts with moderate to high degree of immunity• Accidental – physicians, pathologists, post mortem attendants• Autoinoculation by sputum in active pulmonary TB patients• Accidental inoculation from infected sputum
Clinically - Wart like papule & verrucous plaque Regresses or heals with a thin scar Lymphadenitis is rare
Sites- Finger, hands & feet, ankle
Tuberculosis verrucosa cutis (TBVC)Syn: warty tuberculosis
Warty lesions of TBVC in adults with good immunity on extremities
(trauma prone sites) Left foot, left palm and sole of the left foot.
Hypertrophic lichen planus
Verruca vulgaris
Chromoblastomycosis
Leishmaniasis
Differential Diagnosis of TBVC
SFD occurs as a result of contiguous spread from an underlying primary tubercular focus like• Lymph nodes or• Bone• Joints or• Testicles
Age - More common in children but affects all age groups Lymph nodes - Cervical lymph nodes most common followed by
axillary, pre and post auricular, submandibular, Inguinal
Scrofuloderma (SFD)
Firm, subcutaneous nodule, fixed to theoverlying skin
Cold abscess formation overlying LN/ Bone/ Joint
Secondary ulceration, sinus tract formation
Ulcer has undermined edges and bluish boggy margin
Clinical features of Scrofuloderma
Clockwise:1. Tubercular abscess overlying rib cage with impending rupture. Pus smear from aspirate on ZN staining showed numerous AFB i.e M. tb2. Scrofuloderma overlying cervical and supraclavicular TB lymphnodes3. Scrofuloderma overlying TB focus in the bone i.e 2nd metacarpal bone which shows a lytic lesion on x-ray
Young girl with SFD with underlying TB focus in cervical Lymph nodes
Scrofuloderma runs a very protracted course.
It tends to heal spontaneously over months and years.
Leave behind cerebriform or bridging scars and pockets of
retraction.
Underlying focus of TB in bone/ joint, may reveal osteolytic
lesions in bone
Course
Bacterial abscesses / Bacterial osteomyelitis
Hidradenitis suppurativa
Atypical mycobacterial infection (M.avium and M. scrofulaceum)
Sporotrichosis
Actinomycosis
Tumor metastasis
Differential Diagnosis
Rare form that affects middle-aged / elderly man with impaired CMI .
Follow autoinoculation of Mycobacterium Tuberculosis into skin/ mucosa of the adjoining orifices in patients with advanced
• intestinal or • Genitourinary• pulmonary TB
Site -• Around mouth• Perianal region• Ext genitalia
Orificial TB (Syn Tuberculosis cutis orificialis)
Small, edematous reddish nodule Breaks down Painful, non-healing, shallow ulcers with undermined bluish edges
Course – Prognosis : is poor due to• Advanced internal disease and• Compromised immunity
Orificial Tuberculosis
Most common type of Cut TB Paucibacillary disease in pts. with moderate to high immunity Affects all age group Sites - Head & neck, Gluteal region
The infection is acquired by Lymphatic spread or Hematogenous spread or Direct extension from a tuberculous focus At site of inoculation
Lupus vulgaris (LV)
Reddish brown, flat plaque Extends slowly, peripherally with central atrophy and scarring. May
result in contractures Apple jelly nodules at the advancing edges May lead to destruction of underlying cartilage Regional lymphadenopathy present SCC may develop in scar or chronic ulcer
Clinical Features
Plaque
Ulcerative & mutilating
Hypertrophic
Vegetating & tumor like
Atrophic and plantar
Clinical Variants
Clockwise: Lupus vulgaris ( LV)1. LV of nose in a young girl child leading to destruction and mutilation of nose (cartilage and bone both)2. Multi focal LV with characteristic central clearing and advancing margins in a young boy3. Lesion of LV on buttock in an adult male
Classic lesions of LV with central clearing and advancing margin on the elbow and face of young boys
LUPUS VULGARIS
Sarcoidosis
Hansen’s disease
Lupus erythematosus
Granuloma faciale
Leishmaniasis
Squamous cell carcinoma
Differential Diagnosis of Lupus Vulgaris
Hematogenous dissemination of Mycobacterium Tuberculosis from a primary TB focus during lowered resistance/decreased immunity
Undernourished children, immunocompromised patient Single/multiple firm, nontender,erythematous nodule
Breakdown to form undermined ulcers & sinuses Subsequent course similar to scrofuloderma Pus may be positive for AFB
Tuberculous gumma (Syn. Metastatic Tuberculous Abscess)
Tuberculosis Gumma
Rare and severe form of TB seen in very ill patients Massive hematogenous dissemination of Mycobacterium Tuberculosis into skin Affects young children, immunosuppressed, HIV co-infected and following
measles or other exanthems
Clinically Profuse crops of minute bluish papules, vesicles, pustules May become necrotic to form ulcers Poor prognosis but occasionally may respond to Rx.
Differential Diagnosis Varicella, enteroviral exanthem, Pityriasis lichenoides et varioliformis acuta
(PLEVA)
Acute miliary tuberculosis
Tuberculides represent cutaneous immunologic reaction to the presence of Mycobacterium Tuberculosis or their products in a patient with significant immunity.
Diagnostic Criteria Tuberculoid histology on skin biopsy Absence of organism in smears Negative mycobacterial culture Evidence of tubercular focus elsewhere; Active or healed Strongly positive tuberculin test and Swift resolution of the lesions with ATT
Tuberculides: Definition and diagnostic criteria
Micropapular- Lichen scrofulosorum (LS) Papular- Papulonecrotic tuberculid (PNT) Nodular- Erythema induratum of Bazin (EIB)
The recently described ‘phlebitic tuberculid’, ‘nodular granulomatous phlebitis’ or ‘superficial thrombophlebitic tuberculid’ may necessitate its inclusion as the fourth member of the tuberculide spectrum
Classic Tuberculide
LS is one of the most common presentations in children. Asymptomatic, 0.5-3mm, closely grouped, skin coloured to
erythematous, follicular or perifollicular, flat-topped to spinous papules on truck, back and proximal limbs
LS confined to the vulva; genital tuberculid Underlying focus of TB include
• TB LAP• Pulmonary TB• Skin TB• Rarely Abdominal, intracranial and endometrial foci
A systemic focus of TB is detected in a majority of LS cases
Lichen Scrofulosorum (LS)
Grouped, skin colored, mildly scaly follicular papular lesions of LS in a patient with strongly positive Mantoux and Pulm focus of TB
Positive Mantoux test with blistering after 48 hrs
Pulmonary Kochs
Recurrent crops of Symmetrically distributed Firm, dusky red necrotizing papules and pustules Predominantly over the extremities Isolated lesions involving male genitalia (genital tuberculid) in
children as well as adults Lymphadenopathy may be present Associated pulmonary TB Constitutional symptoms such as fever and asthenia may precede
cutaneous manifestationsDifferential diagnosis: Varicella and PLEVA
Papulonecrotic Tuberculide
Multiple extensive PNT lesions in a severely malnourished and febrile young girl with Pulmonary Koch’s
Erythema Induratum of Bazins
Indolent and recurrent nodular lesions Site: calves; may occur on upper
limbs, thighs, buttocks and trunk Affects young or middle-aged obese
women Tend to ulcerate during winters
forming ragged, irregular & shallow ulcers with a bluish edge
Resolution is slow even with adequate ATT
Notification
Identification and treatment of the underlying tuberculous focus
which is identifiable in ½ to 1/3rd of cases
Identification and treatment of co-existent infections such as HIV
Specific chemotherapy
Family screening
Ancillary measures
Management of Cutaneous TuberculosisGeneral Principles
Hematological CBC with ESR LFT RFT
Mantoux testSputum for AFBRadiological
X-ray chest Radiograph of the affected region- bone USG Abdomen CECT – chest And MRI – selected cases
Investigations
FNAC Skin Biopsy Mycobacterial culture-
• LJ medium (Lowenstein Jensen)• BACTEC 460 liquid medium
PCR Antigen detection Biochemical characteristics
Investigations
Hall mark is presence of characteristic granuloma composed of epitheloid cells, lymphocytes and Langhan’s giant cells.
Based on host immune response, histology of CTB may be grouped into three groups_ • Well-formed granulomas with absence of caseous necrosis:
Lupus Vulgaris and Lichen Scrofulosorum.• Granulomas with caseous necrosis: TBVC, tubercular chancre,
acute military tuberculosis, tuberculosis orificialis and Papulonecrotic tuberculide.
• Presence of poorly formed granulomas with intense caseous necrosis: Scrofuloderma and TB gumma
Histology of Cutaneous TB
Compact epithelioid cell granuloma in mid and upper dermis in LV
Absolute criteria Positive culture from lesion
• LJ (Lowenstein Jensen) medium• BACTEC Culture
Successful guinea-pig inoculation Identification of mycobacterial DNA by PCR
Other indicators Characteristic histopathology Positive tuberculin test Presence of active proven TB elsewhere Presence of AFB in the lesion Response to ATT
Diagnosis
The standard regimens comprise of:
Initial intensive phase (Phase I) Rapidly destroys large populations of multiplying mycobacteria.
Continuation phase (Phase II) Eliminates persistent dormant organisms.
Drug Regimen
Duration6 months Category I Regimen2 (HRZE) + 4 (HR) Daily or DOTS Thrice weekly
Treatment
Drug Daily Txmg/kg/d (Total)
DOTSmg/kg/d (Total)
Isoniazid 5 (300) 10 (600)
Rifampicin 10 (450) 10 (450)
Pyrazinamide 25 (1500) 25 (1500)
Ethambutol 15 (800) 20 (1200)
Surgical intervention may be required along with ATT Plastic Surgery in cases of disfigurement due to Lupus Vulgaris, to
release contractures HIV-positive- Standard regimen is effective HIV-infected individuals: higher drug reaction and infection rates
Special Considerations
Multidrug-resistant tubercle bacilli (MDR-TB) are isolates showing resistance to Rifampicin & INH , with or without resistance to other drugs
Extensively drug-resistant TB (XDR-TB) as tubercular infections caused by Mycobacterium Tuberculosis resistant to both INH and Rifampicin as well as a fluoroquinolone, and at least one second-line injectable agent (capreomycin, amikacin,or kanamycin)
Recently few cases of MDR Cut TB have been reported from India. MDR TB should be thought of when reasons such as poor Rx
compliance, inadequate doses and wrong diagnosis have been carefully excluded
Drug Resistance in Cut TB
Q.1) What is the classification system used for Cutaneous Mycobacterial infection?
A. Schobinger's classificationB. Freidrikson's classificationC. Beyt's classification D. Luxar and Zulian classification
Q.2) Which of these precludes a diagnosis of Tuberculid?E. Positive tuberculin testF. Partial response to Antituberculous therapyG. Negative Mycobacterial CultureH. Past history of Pulmonary Tuberculosis
MCQ’s
Q.3) Which of the following malignancies are known to occur in long standing case of lupus vulgaris?
A. Squamous cell carcinomaB. Basal cell carcinomaC. SarcomaD. Malignant melanoma
Q.4) Which of the lymph nodes are commonly involved in cutaneous tuberculosis ?
E. AxillaryF. CervicalG. InguinalH. Epitrochlear
MCQ’s
Q.5) A 25 year old male presented with an asymptomatic plaque on the right side buttock with active spreading edge at one end and scarring at the other end since 1 year. What is the likely diagnosis?
A. Scar sarcoidB. Lupus vulgarisC. Hypertrophic lichen planusD. Tuberculosis verrucosa cutis
MCQ’s
Q. Identify the type of tuberculosis and describe evolution of lesion ?
Photo Quiz
Q. Identify the type of Cut TB?
Photo Quiz
Q. Identify the type of Cut TB ?
Photo Quiz
Thank You!