Download MBBS Dermatology PPT 4 Cutaneous Tuberculosis Lecture Notes

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CUTANEOUS

TUBERCULOSIS

ETIOLOGY- Mycobacterium Tuberculosis

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PATHOGENESIS- manifestations of lesions depend

on

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1.Immunity of the host
Specific immunity to M. Tuberculosis ? depending

on whether exposure to the bacteria is primary or

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secondary

General immunity of the host

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2. Route of entry


3. Bacterial load

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CLASSIFICATION

1.Exogeneous source

Tuberculous chancre

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Warty tuberculosis/ TVC

Lupus vulgaris

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2.Endogenous source

a. contiguous source ? Scrofuloderma

b. auto-inoculation ? Oroficial T.B.

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c. hematogenous - Lupus vulgaris,

Tuberculous gumma

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3.Tuberculides ?

a. Micropapular ? Lichen scrofulosorum

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b. Papular, Papulo-necrotic

c. Nodular? Erythema nodosum

Erythema induratum(Bazin)

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Tuberculous Chancre
No prior immunity to M. tuberculosis

( Primary complex in the skin)

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Entry?cuts, abrasion, insect bites, wounds
Site- exposed areas of limbs, face
Age - children

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Clinical feature

Nodule ulcerates

producing tuberculous

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chancre

Crusts form and edges

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become indurated

Regional

lymphadenopathy in

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few weeks

Dev. Of immunity

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lesion heal to produce

a scar

Warty Tuberculosis/ Tuberculosis Verrucosa

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Cutis

Exogenous source
Moderate to high immunity to M.

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tuberculosis

Occupational- who handle tuberculous

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tissue eg. butcher, pathologist,

veterinarians (anatomist wart)

Site ? hands, feet

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Single indolent

verrucous nodule or

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plaque with a

serpenginous border,

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indurated base, centre

may show scarring.

Heals in several

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months leaving thin

atrophic scar

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Lymphadenopathy rare

Scrofuloderma/ Tuberculosis Cutis

Colliquativa

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Develops as an extension of an underlying

focus ? lymph node or bone

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Site ? cervical region common with

infected cervical lymph nodes breaking

down into the skin

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Infected lymph nodes

become inflamed,

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swollen, get fixed to

overlying bluish skin

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Breakdown of lymph

nodes formation of

ulcers with undermined

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edge

AFB can be

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demonstrated

Orificial Tuberculosis/ Tuberculosis Cutis

Orificialis

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Develops from auto inoculation around the

muco cutaneous junctions in patients with

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internal tuberculosis

Site- lips, mouth in pulmonary T.B.

anal region in intestinal T.B

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external genitalia in genitourinary T.B

Host immunity poor with active internal

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disease.

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Small erythematous

nodules break

down, form round,

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shallow, granulating

ulcers covered by

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thin crust.

Painful
No tendency to heal

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without effective

treatment

Tuberculin test may

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be -ve

Lupus Vulgaris
most common form of cut. TB

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Usually acquired from an external source;

rarely from haematogenous dissemination

Site ? around nose (nasal mucosa and

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lips) and face in western countries

buttocks, thighs, legs in India

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Initial lesion is a soft erythematous nodule

Slowly several such nodules coaslesce to

form a soft plaque which slowly extends

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Presence of APPLE JELLY nodules at edge

of plaques- in diascopy( uncommon in

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Indian skin)

MATCH STICK sign ? soft nodules can be

probed or pierced with a match skick

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Diseases relentlessly progresses with

irregular extension of the plaque

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Healing occurs with SCARRING

Occasional ulceration, crusting and

scarring with destruction of underlying

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tissues and cartilage- ULCERATIVE and

MUTILATING form

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Tuberculous Gumma
Results hematogenous dissemination from

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a tubercular focus

Usual in malnourished children

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The lesion is initially a subcutaneous

nodule which breaks into the skin to form

an ulcer with an undermined edges.

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TUBERCULIDES
Symmetrical eruptions

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Result of internal focus of tuberculosis,

though internal disease may not be active.

Patient health is good.

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Prob. Cause hematogenous dissemination of

bacilli in a person with high degree of

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immunity

Tuberculin test always +ve

Cured by ATT

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Lichen Scrofulosorum

Tiny<5mm,

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perifollicular,

lichenoid papules
Asymptomatic

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Site ? trunk

Involute after many

months without scars

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Tuberculin test ?

strongly +ve

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Papulonecrotic Tuberculides
Crops of deep seated papules and nodules
Lesions are capped by pustules; ulcerate

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forming crusts

Heal in a few months with scar
New crops keep developing

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Asymptomatic
Tuberculin test strongly +ve


Erythema Nodosum

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Crops of indurated very tender,

erythematous deep seated nodules,

which evolve from red to violaceous to

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yellow

Inspection ? bruise, palpation nodule
Never ulcerates; heal without scarring

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Site ? bilateral shins
Constitutional- fever, malaise

Tuberculin test +ve
Course-

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spontaneous

resolution in 6

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weeks

Histology ? septal

pannicullitis no

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vasculitis


Erythema Induratum

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Site- calves in young adult females
Bilaterally symmetrical
Initial develop in cold weather
Subcutaneous nodules and plaques

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with gradually involve the overlying

skin with ulceration

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Tuberculin test

+ve

Ulcers heal

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leaving atrophic

scars

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Chronic ,

recurrrent

Histological ?

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nodular vasculitis


Investigations

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To confirm tuberculosis
A. Biopsy ? caseating granuloma
B. Isolation of M.tuberculosis ?

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1.culture of AFB from pus, skin

biopsy specimen

2. PCR

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C. Mantoux test

To rule out concomittant tuberculosis

in other organs

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1. CXR
2. X-ray joint, bones
3. FNAC ? of enlarged lymph nodes

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Differential diagnosis

lupus vulgaris- leishmaniasis, sarcoidosis,

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systemic fungal infection, SCC

tuberculosis verrucosa cutis - warts

TREATMENT

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Standard ATT
Intensive phase ? isoniazid 5mg/kg

For 2 months rifampicin 10mg/ kg

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ethambutol 15mg/ kg

pyrazinamide 20mg/kg
Continuous phase - isoniazid 5mg/kg

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For 4 months rifampicin 10mg/ kg

Extension ? max. 8 months

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