? Classification of cutaneous TB
? Description of various clinical presentations
? Diagnostic principles
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? Treatment and other related factorsEpidemiology
? Cutaneous tuberculosis occurs worldwide; incidence
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of different forms varying global y? A form of extrapulmonary TB
? < 1% of al TB cases and about 15% of
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extrapulmonary? Cutaneous tuberculosis- Usual y not a marker of
immunosuppression and, rarely, associated with HIV
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infection/AIDS? In India, scrofuloderma is common in children; lupus
vulgaris commoner in adults
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Aetiology
? Term `mycobacterium' in 1896, group of bacteria
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producing mouldlike pel icles when grown on liquidmedia
? Caused by M. tuberculosis
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? Spectrum of cutaneous changes induced by M.
tuberculosis depend upon:
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?Route of infection?Immunological state of the host
?Size of inoculum
?Mere presence of Mycobacteria in the skin does not
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lead to the clinical diseaseRoutes of infection
? Exogenous
? From an external source, through breach in the
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skin at the site of trauma
? Endogenous
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? Through contiguous involvement of skin? Through lymphatic spread
? Through haematogenous dissemination
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? Auto-inoculation
? Eruptive
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Classification? Inoculation tuberculosis (exogenous source)
? Secondary and haematogenous tuberculosis
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(endogenous source)
? Eruptive tuberculosis (tuberculids)
Classification
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? Exogenous source? Tuberculosis chancre (occasional y)
? Warty tuberculosis (Tuberculosis verrucosa cutis)
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? Lupus vulgaris (some cases)
Classification
? Secondary tuberculosis (endogenous source)
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? Contiguous spread: Scrofuloderma
? Auto-inoculation: Orificial tuberculosis
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? Haematogenous tuberculosis? Acute miliary tuberculosis
? Lupus vulgaris (some)
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? Tuberculous gumma
Classification
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? Eruptive tuberculosis (tuberculids)? Micropapular
? Lichen scrofulosorum
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? Papular
? Papulonecrotic tuberculid
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? Nodular? Erythema induratum (Bazin)
? Erythema nodosum
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Tuberculous chancre? Occurs fol owing M. tuberculosis inoculation through
breach in the skin of a previously non-infected
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individual (a na?ve host)
? Initial y, a smal papule, scab, nodule or a poorly
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healing wound? Gradual y - a painless ulcer with a shal ow, granular
or haemorrhagic base and undermined edges
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? Spontaneous healing within 3 to 12 months, with
atrophic scar
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Tuberculosis verrucosa cutis(Warty tuberculosis)
Pathogenesis
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? Previously infected individual with moderate to high
immunity
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? Accidental superinfection from exogenous sources:butchers, anatomists (anatomists' wart)
? Common sites
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? Adults - fingers and hands
? Children - ankles and buttocks
Tuberculosis verrucosa cutis
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?Clinical features?Smal , solitary, indurated, red or brown, papule or
nodule
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?Verrucous plaque (finger-like projections; fissuredsurface)
?Regional lymph nodes may enlarge due to secondary
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bacterial infection
Tuberculosis verrucosa cutis
Course
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? Verrucous lesions persist; but seldom ulcerate
? Usual y chronic course
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? Lesions may involute spontaneously, resulting insunken, atrophic scars
Lupus vulgaris
Pathogenesis
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? Most common form of cutaneous tuberculosis
? Occurs in sensitized individuals with moderate to
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high immunity? Affects al age groups
Lupus vulgaris
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Clinical features?Smal , solitary reddish-brown nodule
?Plaque: Elevated, infiltrated, deep brown in colour
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?Slowly expands at one end; heals with scarring atthe other end
?Asymptomatic lesions, commonly affects the
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buttocks and trunk
Lupus vulgaris
Clinical presentations
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? Plaque? Ulcerative and mutilating
? Vegetating
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? Tumor-like lesions
Lupus vulgaris
Course
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? Untreated lesions- Chronic, indolent, over years
? Lesions undergo ulceration and superficial scarring
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? Characteristical y thin, white, smooth scars; maybreak down or become keloidal
? Complications- contractures, tissue destruction,
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development of squamous cel carcinoma in the
scars (8%) ? may take up to 25-30 years; rarely basal
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cel carcinomaScrofuloderma
(Tuberculosis col iquativa cutis)
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Pathogenesis? Contiguous involvement of the skin overlying a
tuberculous focus, usual y a lymph node, an infected
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bone or joint
? Common in children, adolescents and aged; may
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affect al age groups? Sites - Usual y affects the face and neck, often
bilateral y
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? Commonly involves the cervical, parotid,
submandibular and supraclavicular lymph nodes;
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less commonly, axil ary and inguinalScrofuloderma
Clinical features
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?Initial y, a firm, subcutaneous nodule, fixed to theoverlying skin
?`Cold' abscess formation [lacks the intense
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inflammation]
?Secondary ulceration, sinus tract formation
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?Ulcer - undermined edges with granulationScrofuloderma
Course
? Numerous sinus tracts and fistulae develop over a
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period of several months
? Spontaneous healing may occur, with puckered and
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cord-like scars? Scar tracts - bridge the areas of ulceration or even
normal skin
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Orificial tuberculosis
? A rare form of tuberculosis of the mucous
membrane and skin adjoining the orifices
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? Presents as a nodule which ulcerates with
undermined edges
Orificial tuberculosis
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? Site affected depends on the site of internaltuberculosis:
? Pulmonary tuberculosis: mouth
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? Tuberculosis of pharynx, larynx: lips
? Intestinal tuberculosis: external genitalia; anus;
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perianal? Genitourinary tuberculosis in women: vulva
? Prognosis: poor due to internal disease
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Acute miliary tuberculosis of the skin
? Rare fulminating form due to haematogenous
dissemination of Mycobacteria into the skin
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? Focus - from a meningeal or pulmonary source
? Crops of numerous, minute, erythematous to bluish,
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macules, papules, vesicles, pustules or purpuriclesions
? Occur on al parts of the body, especial y the trunk
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? Usual y occurs in infants, young children, or
fol owing viral infections e.g. measles
Tuberculous gumma (Metastatic tuberculous
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abscess)
? Haematogenous dissemination of mycobacteria
from a primary tuberculous focus, during periods of
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lowered resistance
? Commonly involves the trunk, extremities or head
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? Lesions arise as a single or multiple, firmsubcutaneous nodule or fluctuant abscess
? Ulcers with undermined edges, sinuses and fistulae
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may occur
? Healing occurs with cord-like and puckered scarring
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Tuberculids (eruptive)? Occur as a hypersensitivity reaction M. tuberculosis or
its products in a patient with moderate to high
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immunity
? Main features:
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? A positive tuberculin test? Evidence of current or past tuberculosis
? A positive response to anti-tuberculous therapy
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TuberculidsTypes
Micropapular
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? Lichen scrofulosorumPapular
? Papulonecrotic tuberculid
Nodular
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? Erythema induratum (Bazin)
? Erythema nodosum
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Erythema induratum of Bazin(Nodular tuberculid)
? A chronic, recurrent, nodular and ulcerative disorder
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? Commonly affects young, or middle-aged, obese
women; men affected occasional y
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? Predominantly affects calves; may also occur on upperlimbs, thighs, buttocks and trunk
? The nodules run an indolent course and form ulcers
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? Ulcers are ragged, irregular and shal ow, with bluish
edge
Diagnosis of cutaneous TB
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? Chronicity of lesions
? Characteristic morphology
? Pathologic feature - caseating granuloma
? Other investigations
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Treatment
? Same as TB of other organs
? Rifampin, Isoniazid, Pyrazinamide, Ethambutol x 2 months
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? Rifampin, Isoniazid, Ethambutol x 4 months? Given daily
? Drug resistance in cutaneous ? relatively rare
? Response ? 6 weeks
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