Facial cutaneous tuberculosis infected by non-tuberculous mycobacteria.

BACKGROUND: Cutaneous infections caused by non-tuberculous mycobacteria (NTM) are extremely rare, particularly when they are localized to the facial area. This condition presents significant diagnostic challenges due to its unusual presentation and the need for precise microbiological identification. CASE PRESENTATION: A two-year-old male patient presented with a progressively enlarging reddish-brown mass on the left side of his face. Despite the absence of systemic symptoms, the lesion's growth warranted investigation due to its growth. Ultrasonography showed a hypoechoic mass in the dermis, indicating an underlying abscess. The subsequent aspiration resulted in pale yellow pus, which upon testing and culture, confirmed the presence of Mycobacterium avium complex infection, a species of NTM. This case exemplifies the synergy between imaging modalities and microbiological analysis, highlighting the crucial role of both in achieving favorable clinical outcomes in patients with suspected cutaneous NTM infections. Ultrasound can expedite diagnosis, improve treatment planning, and enhance patient care by enabling targeted interventions and monitoring response to therapy in these scenarios. However, it is the combination of pathogen-specific diagnostics that ensures accurate etiological attribution and appropriate antimicrobial stewardship. CONCLUSION: Although rare, facial cutaneous infections caused by NTM still deserve thorough investigation to determine the exact cause. Ultrasound is used to identify cutaneous lesions, measure their extent, and guide surgical procedures. The ultimate diagnosis is based on microbiological confirmation.

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.

Diagnostic Utility of Biplex/Multiplex Polymerase Chain Reaction in Infectious Granulomatous Dermatitis in North Indian Population.

BACKGROUND: A definite diagnosis of infectious granulomatous dermatitis (IGD) is difficult for both practicing dermatologists and dermatopathologists due to overlapping clinical and histomorphological features. We aimed to explore the role of multiplex polymerase chain reaction (PCR) for identifying a definite etiological agent for diagnosis and appropriate treatment in IGD in formalin-fixed paraffin-embedded tissue. MATERIALS AND METHODS: Sixty-two cases of IGD were included, excluding leprosy. The histochemical stains including Ziehl-Neelsen, periodic acid-Schiff, and Giemsa were performed in all cases. A multiplex PCR was designed for detection of tuberculosis (TB) (IS6110 and mpt64), fungal infections (ITS1, ITS2; ZM1, and ZM3), and leishmaniasis (kDNA). The results of histomorphology, histochemical stains, and multiplex PCR were compared. RESULTS: Among 62 cases, the sensitivity rate of PCR detection for organisms was 16.7%, 0%, 100%, 72%, 75%, and 66.7% in patients with TB, suggestive of TB, leishmaniasis, fungal infections, and granulomatous dermatitis not otherwise specified and granulomatous dermatitis suggestive of fungus, respectively. The TB PCR using IS6110 primers was negative in all cases; however, PCR using mpt64 primers was positive in 33.33% cases of scrofuloderma. The histochemical stains including Ziehl-Neelsen for acid-fast bacilli, periodic acid-Schiff for fungus, and Giemsa for Leishman-Donovan bodies showed positivity in 11.3%, 43.5%, and 3.2%, respectively. CONCLUSION: A multiplex PCR (Mycobacterium tuberculosis, Leishmania, and panfungal) is highly recommended in all cases of IGD where an etiological agent is difficult to establish by skin biopsy and histochemical stains along with a clinicopathological correlation. This will augment in appropriate treatment and will reduce empirical treatment and morbidity in such patients.

Lichenoid granulomatous dermatitis as a tuberculid in association with spondylitis due to Mycobacterium tuberculosis.

Lichenoid granulomatous dermatitis (LGD) is a histopathologic pattern with a band-like lymphocytic infiltrate, typical of lichenoid dermatitis, combined with dermal histiocytes and granulomatous inflammation. Prior reports have described cases of LGD caused by non-tuberculous mycobacteria, with evidence of intralesional acid-fast bacilli or mycobacterial DNA. Herein, we report a patient with pulmonary and extrapulmonary Mycobacterium tuberculosis infection who developed LGD. No evidence of M. tuberculosis was detected within the cutaneous lesions, suggesting a potential delayed-type hypersensitivity reaction to tuberculosis.

Cutaneous Tuberculosis and Nontuberculous Mycobacterial Infections at a National Specialized Hospital in China.

To identify the microorganism distribution clinical characteristics and management of cutaneous Mycobacterium tuberculosis and nontuberculous mycobacterial infectious diseases in the past 10 years we collected and analyzed the patient records of all cutaneous M. tuberculosis and nontuberculous mycobacterial infection cases diagnosed by culture and/or PCR from 2008 to 2017 in the Hospital of Dermatology Chinese Academy of Medical Sciences. Among 203 cases including 89 M. tuberculosis infections and 114 nontuberculous mycobacterial infections M. tuberculosis was the most common species in all patients and M. marinum predominated among the nontuberculous mycobacterial followed by M. abscessus. Cases of cutaneous mycobacterial infection especially nontuberculous mycobacterial infection increased in the past 10 years and infection with rapidly growing mycobacteria significantly increased in the last 5 years in this national hospital in Southeast China. Injuries were common causative factors. Approximately 91.3% of patients responded well to longstanding antibiotic therapy.

Nested Polymerase Chain Reaction and Cutaneous Tuberculosis.

The role of Mycobacterium tuberculosis in the etiology and pathogenesis of cutaneous tuberculosis is controversial because of the difficulties associated with demonstrating the presence of these mycobacteria in tuberculid cutaneous lesions by routinely available microbiological and histological techniques. In this study, we aimed to demonstrate the presence of M. tuberculosis in cutaneous tuberculosis. Multiple polymerase chain reaction (PCR) followed by nested PCR was used to amplify genomic fragments from 3 different mycobacteria species. DNA was isolated from 30 paraffin-embedded skin biopsies. Samples were selected randomly from patients with a clinical and histopathological diagnosis of the most frequent groups of cutaneous tuberculosis in Mexico as follows: 5 cases of scrofuloderma tuberculosis; 2 cases of lupus vulgaris tuberculosis; and 5 cases of tuberculosis verrucosa cutis. The other cases denominated tuberculids in some countries such as Mexico and included the following: 7 cases of rosacea-like tuberculosis; one case of papulonecrotic tuberculosis; and 10 cases of erythema induratum of Bazin. Four normal skin biopsies were included as controls. M. tuberculosis DNA was amplified successfully by nested PCR in 80% of the samples (24 of the 30 samples) assayed. Mycobacterial DNA was not detected in the normal skin biopsies used as controls. Detection of M. tuberculosis DNA in 80% of cutaneous tuberculosis analyzed implicates this mycobacterium in the pathogenesis of multiple clinical forms of cutaneous tuberculosis.

Mycobacterium decipiens sp. nov., a new species closely related to the Mycobacterium tuberculosis complex.

Two mycobacterial strains with close similarity to the Mycobacterium tuberculosis complex (MTBC) were isolated from cutaneous lesions of patients in the USA and Italy. At the phenotypic level, similarities to the MTBC included slow growth rate, rough morphotype of the unpigmented colonies and nearly identical high-performance liquid chromatography profiles of mycolic acids. In contrast to the MTBC, the strains were niacin- and nitrate-negative, and catalase-positive both at 68 °C and in semi-quantitative tests. The clinical isolates were more closely related to M. tuberculosis than to any other known mycobacterium and scored positive with commercial DNA probes (Hologic AccuProbe M. tuberculosis). Both average nucleotide identity and genome-to-genome distance suggested the strains are different from the MTBC. Therefore, given the distinguishing phenotypic and genomic-scale differences, we submit that the strains belong to a new species we have named Mycobacteriumdecipiens with type strain TBL 1200985T (=ATCC TSD-117T=DSM 105360T).

Unlocking the mystery of persistent skin ulcers in a young man and successful treatment with a simple regimen.

Despite the high prevalence of pulmonary tuberculosis worldwide, extrapulmonary tuberculosis especially cutaneous and osteoarticular tuberculosis occurs rarely, both of which are often difficult to be recognized since their symptoms mimic those of many other cutaneous and osteoarticular diseases. Here, we present a rare case of cutaneous tuberculosis potentially accompanied by osteroarticular tuberculosis in a 36-year-old Chinese man who presented with multiple persistent skin ulcers for one year and were nonresponsive to multiple therapeutic approaches. A single anti-tuberculous regimen with rifampicin resulted in healing of all skin lesions and excellent recovery of the general condition.

New onset erythematous nodules in an elderly woman.

An 86-year- old woman with a history of recurrent bronchitis and giant cell arteritis presented for new onset, cyclic and migratory erythematous nodules associated with fatigue and weight loss. Although a systemic vasculitis was initially suspected, elevated inflammatory markers and symptoms persisted despite aggressive corticosteroid therapy. Excisional biopsy of one nodule showed dense suppurative and granulomatous inflammation that was rife with acid-fast bacilli. The patient was urgently admitted for empiric treatment of disseminated mycobacterial infection. Although T-SPOT Tuberculosis testing and direct mycobacterial PCR were negative, mass spectrometry demonstrated Mycobacterium chelonae. The patient was treated with a macrolide and quinolone combination regimen and then discharged to a rehabilitation facility.

Molecular Characteristics of Mycobacterium tuberculosis Strains Isolated from Cutaneous Tuberculosis Patients in China.

Cutaneous tuberculosis (CTB) is probably underreported due to difficulties in detection and diagnosis. To address this issue, genotypes of Mycobacterium tuberculosis strains isolated from 30 patients with CTB were mapped at multiple loci, namely, RD105 deletions, spacer oligonucleotides, and Mycobacterial Interspersed Repetitive Unit-Variable Number Tandem Repeats (MIRU-VNTRs). Fifty-eight strains of pulmonary tuberculosis (PTB) were mapped as experimental controls. Drug resistance-associated gene mutations were determined by amplicon sequencing of target regions within 7 genes. Beijing family isolates were the most prevalent strains in CTB and PTB. MIRU-VNTR typing separated the Beijing strains from the non-Beijing strains, and the majority of CTB could be separated from PTB counterparts. Drug resistance determining regions showed only one CTB strain expressing isomazid resistance. Thus, while the CTB strains belonged to the same phylogenetic lineages and sub-lineages as the PTB strains, they differed at the level of several MIRU-VNTRs and in the proportion of drug resistance.

Perianal Ulcer in an Asian Man.

A 79-year-old Chinese man presented with a 2-month history of pruritic, tender ulceration covering his perianal region. He was initially treated with oral amoxicillin/clavulanic acid and vancyclovir, with no improvement. His history included hypertension. On physical examination, there was a 1.5-cm solitary, pink shallow ulcer with a tender erythematous base on the right side of the buttock cleft (Figure 1).

Effects of MBL-associated serine protease-2 (MASP-2) on liquefaction and ulceration in rabbit skin model of tuberculosis.

Tuberculosis is a chronic infectious disease, which caused by Mycobacterium tuberculosis. It typically affects the functions of the lung and causes high morbidity and mortality rates worldwide. The lectin pathway, one of the complement cascade systems, provides the primary line of defense against invading pathogens. However, what is the specific effection between tuberculosis and complement is unknown. Mannose-binding lectin (MBL), a recognition subunit, binds to arrays of carbohydrates on the surfaces of pathogens, which results in the activation of MBL-associated serine protease-2 to trigger a downstream reaction cascade of complement system. The effects of human MBL-associated serine protease-2 (hMASP-2) were assessed in a rabbit-skin model by intradermal injection of 5 × 106 viable BCG bacilli. The rAd-hMASP-2 accelerated the formation of liquefaction and healing of the granuloma lesions, reduced the bacteria loads of the skin nodules. The serum levels of IL-2 and IFN-γ were significantly increasing during the granuloma and liquefaction phases in the rAd-hMASP-2 group. This study suggests that hMASP-2 can induce a protective efficacy in BCG-infected rabbit skin models, which affects both the progress of lesions and the survival of the mycobacteria within them.

Cutaneous Granulomas Associated With Interferon Therapy.

Treatment with interferon (IFN) could be associated with variable cutaneous adverse reactions. The aim of this study was to describe the clinicopathological spectrum of cutaneous granulomas associated with IFN therapy and identify the causal relation between IFN therapy and granulomatous reactions. The study included 18 patients (16 males and 2 females) with an average age of 48 years. Clinically, most of the lesions were solitary (83.3%) and located on the face (44.4%) and/or trunk (38.9%). The lesions were commonly presented as nodules (33.3%) or plaques (27.8%) with a common size of 5-10 cm. Granulomatous reactions were localized to the injection site in 4 cases, distributed on other body areas (remote granuloma) in 11 cases, and associated with lung involvement (systemic granuloma) in 3 cases. Histologically, injection site granuloma showed suppurative reaction in 75% and sarcoidal reaction in 25%. Remote granuloma showed tuberculoid reaction in 27.3%, interstitial in 27.3%, and sarcoidal in 45.4%. Systemic granuloma showed sarcoidal reaction in all cases. After withdrawal of IFN, only 3 lesions showed spontaneous complete clearance, whereas most of the lesions (83.3%) showed only partial improvement. Our results suggested that IFN is not a causal agent of all associated cutaneous granulomas but it mostly provokes the appearance of granulomatous reactions in susceptible individuals. Findings that prove this concept include the formation of granuloma in body sites away from the injection site, the heterogeneous pattern of granuloma both clinically and histologically, and incomplete clearance of most of the lesions after withdrawal of IFN.

Tuberculids: cutaneous indicator diseases of Mycobacterium tuberculosis infection in young patients.

BACKGROUND: In the past years the incidence of tuberculosis has dropped significantly in most parts of Europe and the presentation of symptomatic tuberculosis cases have become increasingly rare. With the recent influx of refugees in Europe coming from tuberculosis endemic areas like the Middle East and Africa, it is expected that the incidence of tuberculosis will increase. OBJECTIVES: Cutaneous symptoms are important hallmarks that can be of aid for the correct diagnosis of an underlying disease, like tuberculosis. METHODS: We describe 2 young patients with tuberculids, respectively lichen scrofulosorum and papulonecrotic tuberculids, caused by a systemic Mycobacterium tuberculosis infection. RESULTS: Tuberculids are cutaneous immunological reactions triggered by a Mycobacterium tuberculosis infection elsewhere in the body. The three main manifestations of cutaneous tuberculids are: lichen scrofulosorum, papulonecrotic tuberculids and erythema induratum of Bazin. Whereas the latter is more common, the first two presentations are rare. CONCLUSION: It is of importance that clinicians, including dermatologists, are aware of the spectrum of clinical presentations of tuberculosis to halt this destructive and highly contagious disease early in its course.

Cutaneous Tuberculosis: An Update.

Among extra pulmonary tuberculosis cutaneous tuberculosis occurs rarely, despite a high and increasing prevalence of tuberculosis worldwide particularly in developing countries. Cutaneous tuberculosis can be acquired exogenously or endogenously and present as a diverse of differing clinical morphologies. Diagnosis of these lesions can be difficult, as they resemble many other dermatological conditions that are often primarily considered. Moreover, microbiological confirmation is poor, despite scientific advances, such as the more frequent use of polymerase chain reaction. Furthermore, treatment of cutaneous tuberculosis is also challenging in many cases.

[Cutaneous tuberculosis of the ear due to Mycobacterium bovis]. / Tuberculose cutanée de l'oreille à Mycobacterium bovis.

INTRODUCTION: Isolated cutaneous tuberculosis is uncommon, accounting for only 0.14 to 5% of Mycobacterium tuberculosis infections. We report a rare case of ear cutaneous tuberculosis due to Mycobacterium bovis in an immunocompetent woman. CASE REPORT: A 59-year-old woman presented an erythematous and scaly lesion of the ear present for two years. The histological findings were compatible with a diagnosis of sarcoidosis, with non-necrotic granuloma. After failure of dermal corticosteroid therapy, a further biopsy identified M. bovis; the patient was cured following anti-tubercular treatment. DISCUSSION: Ear lesions are predominantly associated with tumors, fungal infections, chondritis, lupus and sarcoidosis. The ear, like the face in general, is a classic localization of lupus vulgaris, a chronic form of confined tuberculosis infection with progressive evolution. The paucibacillary nature of these lesions is the reason why their diagnosis is based in some cases on clinical, histological and immunological findings without bacteriological evidence. However, given the potential therapeutic implications, it is important to push the microbiological analysis as far as possible. In our case, culture and identification provided evidence of M. bovis infection, enabling suitable and effective therapy to be given.

[A CASE OF MILIARY TUBERCULOSIS ORIGINATED FROM CUTANEOUS INFECTION].

An 86-year-old woman with severe dementia had been treated with oral prednisolone at 2 mg/day for autoimmune bullous dermatosis for several years. One year ago, she referred to our hospital due to an ulcerative skin lesion over the right tibial tuberosity. The lesion was treated by an iodine-containing ointment, but did not heal. Subsequently, a new skin lesion appeared in the right popliteal fossa. One month ago, the patient had increased sputum production that was accompanied by fever, anorexia, and dyspnea; consequently, she visited our department. Chest computed tomography revealed diffuse micronodules with ground-glass attenuation. Acid-fast bacteria staining of the sputum was positive and the polymerase chain reaction detected Mycobacterium tuberculosis. In addition, the bacilli were also found in the skin lesions of the right limb. Therefore, a diagnosis of cutaneous, and miliary tuberculosis was made. Although the anti-tuberculous combination chemotherapy consisting of isoniazid, rifampicin, and ethambutol was immediately initiated, her condition did not improve. She died on day 19 of hospitalization. Drug susceptibility testing revealed no resistance to all the three drugs; hence, it was concluded that the time-delay in diagnosis of cutaneous tuberculosis lead to the progression to miliary tuberculosis and subsequent death.