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.

Cutaneous tuberculosis due to multidrug-resistant tubercle bacilli and difficulties in clinical diagnosis.

This report describes 6 HIV-negative patients including 5 children with scrofuloderma and an adult with lupus vulgaris, out of a total of 303 cases of cutaneous tuberculosis seen during a 4½-year period, who showed a positive tuberculin test and granulomatous histopathology, but failed to respond to first-line antitubercular therapy. They were suspected to have multidrug-resistant infection as no other cause could be ascertained. Tissue aspirate or biopsy was sent for histopathology and culture. Mycobacterium tuberculosis was isolated from the aspirate in three patients and sputum in one with associated pulmonary tuberculosis. Drug susceptibility tests showed that all isolates were resistant to rifampicin and isoniazid, and one each additionally to streptomycin and ethambutol, respectively. In two, culture was unsuccessful. All were administered second-line antitubercular drugs. Clinical improvement was appreciable within 2 months as weight gain, and regression of ulcers, swellings and plaques. Two completed the recommended 24 months of therapy. Multidrug-resistant cutaneous tuberculosis should be suspected in patients with no response to first-line drugs, with clinical deterioration, and where other causes of treatment failure are not forthcoming. Owing to poor isolation rates on culture and low sensitivity of molecular tests, in such cases, a trial of second-line anti-tubercular drugs may be justified for a reasonable period of 2 months. Where facilities permit, culture and drug sensitivity tests should be done before starting treatment. Culture positivity is better from aspirated material.

Lichen scrofulosorum caused by Mycobacterium leprae: first report.

BACKGROUND: Tuberculides are skin lesions caused by the hematogeneous dissemination of Mycobacterium tuberculosis. Bacilli are rapidly destroyed in the skin and are thus neither visible histologically nor identifiable by culture. Diagnosis depends on previous knowledge of systemic and/or cutaneous tuberculosis. Lichen scrofulosorum (LS), the most uncommon variant of tuberculid, is usually associated with M. tuberculosis infection of lymph nodes or bone but was also reported in association with other mycobacterioses. OBJECTIVES: We report a case of LS in a patient with M. leprae infection. METHODS: In 2008, a 51-year-old woman from the Philippines was diagnosed with tuberculoid leprosy and treated. In 2010 the leprosy was considered to have been cured, and treatment was stopped. In 2011 the patient presented with lesions on the trunk and legs. Biopsy specimens were obtained for histopathologic examination and DNA detection for polymerase chain reaction (PCR). RESULTS: Histopathology in the biopsy from the trunk revealed the dermis to be diffusely occupied by granulomas with perineural and periadnexal disposition. Granulomas were composed of epithelioid cells and lymphocytes. Fite-Faraco staining revealed a few solid acid-fast bacilli within nerve fascicles. Reinfection or the re-reactivation of multibacillary borderline tuberculoid leprosy was diagnosed. Histopathology in the biopsy taken from the leg showed superficial, well-formed granulomas in the vicinity of hair follicles and sweat ducts. No acid-fast bacilli were seen. Analysis by PCR revealed M. leprae DNA in specimens from both the leg and trunk. The clinical features of the papular eruption and the histopathologic findings and concomitant mycobacterial infection with M. leprae led to a diagnosis of LS. Treatment was commenced with dapsone 100 mg/day, clofazimine 50 mg/day and 300 mg/month, and rifampicin 600 mg/day. The lichenoid eruption on the legs disappeared at one month of therapy, whereas the other skin lesions resolved in one year leaving residual hypochromic macules. CONCLUSIONS: Infection with M. leprae may cause LS. The use of PCR in skin biopsies from granulomatous dermatitis of unknown origin can help to identify the responsible agents.

Polymerase chain reaction-based molecular diagnosis of cutaneous infections in dermatopathology.

Conventional methods, including microscopy, culture, and serologic studies, are a mainstay in the diagnosis of cutaneous infection. However, owing to limitations associated with these techniques, such as low sensitivity for standard microscopy and in the case of culture delay in diagnosis, polymerase chain-reaction based molecular techniques have taken on an expanding role in the diagnosis of infectious processes in dermatopathology. In particular, these assays are a useful adjunct in the diagnosis of cutaneous tuberculosis, atypical mycobacterial infection, leprosy, Lyme disease, syphilis, rickettsioses, leishmaniasis, and some fungal and viral infections. Already in the case of tuberculosis and atypical mycobacterial infection, standardized polymerase chain-reaction assays are commonly used for diagnostic purposes. With time, additional molecular-based techniques will decrease in cost and gain increased standardization, thus delivering rapid diagnostic confirmation for many difficult-to-diagnose cutaneous infections from standard formalin-fixed paraffin-embedded tissue specimens.

[Tubercular inflammation of cervical lymph nodes with a colliquative tuberculosis focus--a case study]. / Gruzlica wezlów chlonnych szyi z ogniskiem gruzlicy rozplywnej--opis przypadku.

Cutaneous tuberculosis is a specific form of tuberculosis, with various clinical pictures and resulting from either endo- or exogenous way of infection, immunological mechanisms and unfavourable conditions for mycobacterium development. The atypical course and symptoms of the disease may cause difficulties in obtaining proper diagnosis and, in consequence, result in delayed onset of appropriate treatment. When diagnosing cutaneous tuberculosis, a broad spectrum of differential diagnoses should be applied, taking into account other diseases, such as, among others, leishmaniasis, actinomycosis, leprosy or deep mycoses. In this report, a case of lymph node tuberculosis and of colliquative tuberculosis of the skin, at first erroneously diagnosed as actinomycosis, complicated by multiform erythema. In the reported case, no tuberculous bacilli were identified in bacteriological evaluations of bioptates, collected from the skin changes. The final diagnosis of the disease was determined by the presence of specific granulation tissue in the last of performed histopathological studies, as well as by hypersensitivity to tuberculin and the presence of mycobacterial DNA in PCR evaluation. According to the authors, in case of clinically suspected cutaneous tuberculosis, repeated (several) histopathological studies of samples from observed changes seem to be fairly justified. The results of histopathological studies should be completed by one of the methods of oligomycobacterial material evaluation, e.g. by identification of mycobacterial genetic material by means of nucleic acid amplification in the PCR method.

Mycobacterial skin disease: approaches to therapy.

Many mycobacteria, including M tuberculosis, M leprae, and several atypical organisms, produce skin disease. Chemotherapy is necessary for most infections. Surgery may be helpful for some atypical infections.

Relationships between titers of antibodies immunoreacting against glycolipid antigens from Mycobacterium leprae and M. tuberculosis, the Mitsuda and Mantoux reactions, and bacteriological loads: implications in the pathogenesis, epidemiology and serodiagnosis of leprosy and tuberculosis.

Analysis of cell-mediated immunity [(CMI) as judged from the Mantoux, Fernandez, and Mitsuda reactions and the presence of granulomas in biopsy material] against humoral immunity (measurements of anti-PGL-I, PGL-Tb1, and SL-IV IgG and IgM antibody titers by ELISA) were performed in selected human populations. The investigations yielded data indicating that humoral (B-cell) responses preceded protective CMI in both tuberculosis and leprosy. The B-cell responses were unrelated to (unfavorable) cell-mediated delayed-type hypersensitivity (DTH). Notwithstanding the difficulty in inferring sequential events from studies in humans, it was shown that in humoral responses there was an initial rise of specific IgM immunoglobulins that switched afterward to IgG production during subclinical tuberculosis and leprosy infections. In patent tuberculosis disease the IgM-to-IgG switch was observed in the majority of patients; in patent leprosy disease the switch was impaired in the majority of patients. The clinical, immunological, and laboratory data indicated that the B-cell responses were suppressed as protective CMI was re-established in the patients during the protracted subclinical infection. According to the data, the diagnosis of subclinical tuberculosis and leprosy may be accomplished using ELISA. The yearly risk of tuberculosis in apparently healthy persons but with significant antibody titers was estimated at 44%; the yearly risk for leprosy has not yet been established. The clinical, epidemiologic, and diagnostic implications of these findings are discussed.

[Cutaneous tuberculosis with multifocal visceral involvement]. / Tubercolosi cutanea con coinvolgimento viscerale multifocale.

The case of a young Senegalese man who developed a form of cutaneous tuberculosis associated with a disseminated disease, successfully treated with appropriate antitubercular chemotherapy is reported. We found Mycobacterium Microti in the cutaneous ulcers, the only organism isolated after many cultural and microscopical examinations of different exudates and tissues. This mycobacterium was considered up to now to be pathogenic to rodents, but not man. Its possible pathogenicity to man (under certain situations) is also suggested, and it is expected that this possibility will be supported by other reports in the near future. In addition, stress is laid on the problems of diagnosis and classification of the cutaneous tuberculosis, so uncommon in the Western Hemisphere, and its possible association with leprosy.

The cutaneous infiltrates of leprosy. A transmission electron microscopy study.

The dermal lesions of 18 patients with leprosy have been examined by transmission electron microscopy. The patients exhibited a spectrum of disease from polar lepromatous to polar tuberculoid with intermediate stages in various states of therapy and relapse. The nature and quantities of inflammatory cells and bacteria have been determined by electron microscopy to supplement previous light and fluorescence microscopy studies. Lepromatous leprosy was characterized by many parasitized foam cells containing large, multibacillary vacuoles with intact, osmiophilic Mycobacterium leprae: Bacteria were embedded in an electron-lucent matrix. No extracellular bacteria were evident. Only small numbers of scattered lymphocytes were found. As one approached the borderline state, smaller numbers of bacilli were present as singlets and doublets in small vacuoles of macrophages. The more reactive forms showed increasing bacillary fragmentation, larger numbers of lymphoid cells, and an occasional epithelioid cell. At the tuberculoid end of the spectrum, clear evidence of an exuberant lymphocyte response was evident. Large numbers of T cells with extremely long and complex filipodia were closely associated with epithelioid and multinucleated giant cells. Many of the mononuclear phagocytes appeared nonviable, and areas of necrosis were evident. Bacillary remnants were scarce and the cytoplasm of the epithelioid cells contained occasional dense bodies and many stacks of endoplasmic reticulum and mitochondria. These results suggest that Leu 3a/OKT4 helper cells may be capable of driving the effector function of mononuclear phagocytes. This would lead to a significant microbicidal effect on M. leprae, perhaps through the production of toxic oxygen intermediates.