Unmasking the enigma: Investigating the clinicoepidemiological and histopathological dimensions of cutaneous tuberculosis in a Western Indian tertiary care hospital.

BACKGROUND AND AIM: Cutaneous Tuberculosis constitutes 1-1.5 % of extrapulmonary tuberculosis with a wide clinical spectrum which relies upon the portal of entry of mycobacteria and patient's immunity. Complications of cutaneous tuberculosis if treatment is delayed includes hazardous sequel like dissemination and disfigurement. Early diagnosis and cure is the ultimate way to prevent such complications. This has motivated us to study clinicoepidemiological, histopathological profile and outcome post treatment of cutaneous tuberculosis patients of our region in detail. METHODS: Total 78 patients were studied during the period of August 2018-2022, who were suspicious to have cutaneous tuberculosis clinically of which 54 were confirmed with histopathology. Patient related clinicoepidemiological data such as age, gender, past history of tuberculosis or contact history, chest-x ray, tuberculin test positivity was analysed in a retrospective manner. RESULTS: Among the 54 biopsy proven cases (33 women, 21 men) ranging from 6 to 76 years, 27 patients have been found to have Lupus Vulgaris followed by 15 cases of scrofuloderma. Acid fast bacilli were seen in 9 patients with majority in scrofuloderma. Histopathology revealed epithelioid cell granuloma without necrosis in 34 cases and caseation necrosis in 20 patients. 48 patients showed complete recovery with 6 months of Anti-Koch Treatment and some complications were observed in remaining. Limitation of this research was that long term follow up was not possible. CONCLUSION: Lack of familiarity might lead to overlooking of a standard presentation or misdiagnosis. So, an eagle eye with high degree of suspicion is crucial for control and prevention of morbidity and for improving socio-economic burden of cutaneous tuberculosis.

Lupus vulgaris: a narrative review.

Lupus vulgaris (LV) is a type of paucibacillary cutaneous tuberculosis that can occur due to inoculation, lymphatic, or hematogenous route. It occurs in a previously sensitized individual with high immunity to tuberculosis. LV can have different morphology of presentation, which can lead to difficulty in diagnosis. The Tuberculin test is strongly positive. Histopathology will show epithelioid granulomas in the superficial dermis and acid-fast bacilli rarely demonstrable within the granulomas. Dermoscopy will show focused linear vessels on a yellow to orange background. Culture is the gold standard for diagnosis, but its positivity rate is low. Mycobacterium tuberculosis bacilli can be detected using polymerase chain reaction from the lesions. Histopathology, tuberculin test, dermoscopy, molecular test, and culture would help diagnose LV. This review discusses the introduction, pathogenesis, clinical features, differential diagnosis, investigations, complications, and treatment of lupus vulgaris in detail. This review can help the dermatologist understand the condition better with appropriate diagnosis and therapy.

Co-existence of atypical tuberculid with lupus vulgaris.

Cutaneous tuberculosis (CTB) is an uncommon form of extra-pulmonary tuberculosis accounting for ≤2% of mycobacterium tuberculosis cases and is more often reported from developing countries. Tuberculid, a cutaneous hypersensitivity reaction to mycobacteria or its fragments, is a another rare cutaneous manifestation seen in association with tuberculosis of other organ systems including tuberculous lymphadenitis, pulmonary tuberculosis, etc. Co-occurrence of a tuberculid with CTB is extremely rare. Herein we report a childhood case of lupus vulgaris, a type of CTB, associated with an atypical presentation of tuberculid.

Atypical presentations of cutaneous tuberculosis: Series of 10 cases.

Cutaneous tuberculosis classically presents as Lupus vulgaris, scrofuloderma, tuberculosis verrucose cutis and tubercular abscess. Hypersensitivity reaction to the bacilli leads to Lichen scrofulosorum and papulonecrotic tuberculids. At the same time, it can have myriad of clinical presentations, many of which are still undescribed. It is important to regularly update ourselves with these unusual manifestations so as to ensure early treatment and reduction of overall morbidity. In this case series tuberculosis manifesting as rapidly progressing diffuse facial granulomas, sporotrichoid tuberculosis, tuberculosis mimicking squamous cell carcinoma, scrofuloderma as tubercular ulcer, lupus vulgaris with nasal septal perforation, lupus vulgaris resembling furuncle, psoriasis, dermatitis and BT Hansen are described in immunocompetent individuals. These cases highlight the importance of recognition of atypical forms of cutaneous tuberculosis to minimize scarring and dissemination of bacilli.

Lupus miliaris disseminatus faciei: when a rare skin disease involves the eyelid / Lupus miliaris disseminatus faciei: quando uma rara dermatose acomete a pálpebra

ABSTRACT The authors present a case of lupus miliaris disseminatus faciei , a rare skin disease of unknown etiology, which may cause unaesthetic scarring due to its difficult treatment. The histopathological examination of epithelioid granulomas with caseating necrosis, together with the clinical features, are important for diagnosis and early treatment with better results. Despite difficult and unsatisfactory treatment, there are ongoing studies on therapy to improve aesthetic and social impairment. This case report describes an initial misdiagnosis delaying appropriate treatment, and highlights the value of physical examination and clinical judgment for another pathological examination, whenever necessary, aiming at better treatment outcomes in daily practice.

RESUMO Os autores apresentam um caso de lupus miliaris disseminatus faciei , uma dermatose rara, de etiologia desconhecida, que pode deixar cicatrizes não estéticas, pela dificuldade de tratamento. O exame histopatológico de granulomas compostos por células epitelioides, com necrose caseosa, e as características clínicas, são importantes para o diagnóstico e tratamento precoce, com melhores resultados. Apesar do tratamento difícil e insatisfatório, há estudos em andamento sobre terapias para melhorar o comprometimento estético e social. Este relato de caso descreve um diagnóstico inicial errôneo, que atrasou o tratamento adequado, e destaca o valor do exame físico e raciocínio clínico para solicitar outro exame anatomopatológico, quando necessário, de forma a obter melhores desfechos com o tratamento, na prática diária.

Unusual presentations of cutaneous tuberculosis.

Cutaneous tuberculosis occurs in 1-2% of world cases of tuberculosis and more common in tropical countries. It presents with different clinical forms. Unusual clinical presentations are not uncommon and awareness of these will help in suspecting and managing these patients successfully. Lupus pernio like lupus vulgaris, tuberculosis of glans penis and lichen scrofulosorum on the distal parts of limbs are presented here because of their unusual clinical presentation.

Sporotrichoid presentation of lupus vulgaris mimicking mycetoma.

Most common form of cutaneous tuberculosis (TB) is lupus vulgaris (LV). Atypical presentation of LV is rare and may lead to delay in diagnosis and hence increase in morbidity. Here, we report a case of sporotrichoid form of LV in a 38 year old male who presented as cutaneous lesions mimicking mycetoma. High index of clinical suspicion and relevant investigations play a vital role in confirmation of diagnosis wherever atypical form of cutaneous TB is suspected.

Relevant diagnostic implications of the therapeutic challenge with antitubercular therapy in an unusual case of sarcoidosis mimicking lupus vulgaris.

Cutaneous manifestations in sarcoidosis are seen in 25-35% of patients with systemic disease and may be the sole manifestation in few patients. It is known that isolated cutaneous sarcoidosis is a great mimicker and can be easily misdiagnosed as other granulomatous conditions especially lupus vulgaris in regions with high burden of tuberculosis (TB). Here we present a case with cutaneous sarcoidosis who was initially misdiagnosed and treated as bifocal lupus vulgaris with antitubercular therapy (ATT) for 6 months. This nonresponsiveness to therapy prompted us to investigate the patient further for other differentials, failing which a diagnosis of cutaneous sarcoidosis was made and the patient was treated with oral steroids and methotrexate with complete clearance of lesions after 14 weeks of therapy. Our case reemphasizes the value of therapeutic trial of ATT in diagnosis of cutaneous TB and highlights the remarkable clinical mimic of sarcoidosis with lupus vulgaris.