Cutaneous tuberculosis in China - A multicentre retrospective study of cases diagnosed between 1957 and 2013.

BACKGROUND: China has one of the largest populations with tuberculosis worldwide. Cutaneous tuberculosis (CTB) is a rare manifestation of mycobacterial infection. Although CTB is well described, it is important to periodically revisit the prevailing clinical and epidemiological features in most populated countries such as China, India, and Indonesia, where tuberculosis is still a major health problem. OBJECTIVE: This retrospective study aimed to re-evaluate the CTB cases in China in the past 50 years to obtain a comprehensive insight into this multiplex entity. METHODS: Cases of diagnosed CTB with confirmed histology from four large medical centres in central China between 1957 and 2013 were collected and analysed, including demographic data, clinical manifestations and pathological findings. RESULTS: Of the 1194 cases enrolled, there were 666 (55.78%) and 528 cases (44.22%) of true CTB and tuberculids, respectively. Erythema induratum of Bazin (EIB) was the most common CTB (35.8%), followed by lupus vulgaris (LV, 32.7%), tuberculosis verrucosa cutis (18.9%), papulonecrotic tuberculid (8.0%), scrofuloderma (2.8%), tuberculosis cutis ulcerosa (1.3%), penile tuberculids (0.4%), and lichen scrofulosorum (0.1%). EIB was the predominant tuberculid (80.87%), while LV the predominant true CTB (58.7%). The number of diagnosed CTB showed a decreasing trend in the 1960s and 1970s, then increased again, and peaked in the 1990s. CONCLUSIONS: Cutaneous tuberculosis is still a common problem in China. Chronologic changes in CTB cases reported in China over the past 50 years may reflect the prevalence transition of overall tuberculosis. CTB has diverse clinical presentations, and each subtype is characterized by specific gender predilection, duration, age, clinic and pathological findings.

Orofacial tuberculosis--a 16-year experience with 46 cases.

PURPOSE: The aim of this study was to evaluate clinical signs and symptoms of orofacial tuberculosis, with an emphasis on the importance of histologic diagnosis. Based on an evaluation of 46 patients, Andrade's classification is presented with a novel 10-point protocol for the management of orofacial tuberculosis. MATERIALS AND METHODS: Forty-six patients were evaluated for orofacial tuberculosis over 16 years (1996 through 2011). All 46 patients were managed with a 10-point protocol for the care of orofacial tuberculosis. RESULTS: Forty-six cases with a positive diagnosis of orofacial tuberculosis were confirmed by histopathologic and other investigations specified in the 10-point protocol for the management of orofacial tuberculosis. The male:female ratio was 0.917, with no gender predilection. Most cases were seen in the second and third decades of life. A large number of patients (n = 22) presented with a lesion in relation to the angle of the mandible. CONCLUSIONS: In a tuberculosis-prevalent country such as India, it is very important to be aware of tubercular lesions involving the orofacial region. Andrade's classification of orofacial tuberculosis helped classify different forms of tubercular lesions that may involve the orofacial region. The 10-point protocol formulated and applied to all 46 cases proved successful in the management of these cases.

Cutaneous tuberculosis: a diagnostic dilemma.

Cutaneous tuberculosis continues to be one of the most difficult conditions to diagnose. It is a challenge particularly in developing countries due to the lack of resources. The authors define the classification and clinical manifestations considered predictive of its diagnosis.

[Cutaneous tuberculosis: two case reports and review]. / Tuberculosis cutánea: reporte de dos casos y revisión de la literatura.

Cutaneous tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis. It is uncommon (1% of all cases of tuberculosis), but has increased due to the human immunodeficiency virus epidemic and to pharmacologic immunosuppression. It presents a wide variety of clinical forms depending on how bacteria reach the skin and on the immune status of the patient. We present two cases of cutaneous tuberculosis diagnosed in the Hospital Clínico de la Pontificia Universidad Católica de Chile. We emphasize the difficulty in diagnosis and classification of this disease and briefly discuss on the different diagnostic and therapeutic approaches.

Tuberculous verrucosa cutis with a sporotrichoid distribution.

Tuberculosis verrucosa cutis (TBVC) is a common paucibacillary form of cutaneous tuberculosis caused by exogenous reinfection in previously sensitized individuals. The typical morphology is usually observed as a single verrucous plaque with inflammatory borders mostly on the hands, knees, ankle, and buttocks; however, several atypical morphologies of the lesions have also been described. TBVC occurring in sporotrichoid pattern is relatively rare. We report a case of a rare sporotrichoid presentation of TBVC in a 38-year-old male patient in the absence of any primary tuberculous focus.

Cutaneous tuberculosis.

Cutaneous tuberculosis continues to be one of the most elusive and more difficult diagnoses to make for dermatologists practicing in developing countries. Not only because they have to consider a wider differential diagnosis (leishmaniasis, leprosy, actinomycosis, deep fungal infections, etc) but also because of the difficulty in obtaining a microbiological confirmation. Despite all the advances in microbiology, including sophisticated techniques such as polymerase chain reaction, the sensitivity of new methods are no better than the gold standard, that is, the isolation of Mycobacterium tuberculosum in culture. Even now, in the 21st century, we rely on methods as old as the intradermal reaction purified protein derivative (PPD) standard test and therapeutic trials, as diagnostic tools. In this situation, it is important to recognize the many clinical faces of cutaneous tuberculosis to prevent missed or delayed diagnoses.

Cutaneous tuberculosis--a study of 400 cases.

A prospective study was conducted on 400 cases having clinical manifestation of cutaneous tuberculosis from 1992 to 2001 in the department of Dermatology and Venereology, Dhaka Medical College Hospital (DMCH) and Bangabandhu Sheikh Mujib Medical University (BSMMU), formerly Institute of Postgraduate Medicine and Research, Dhaka, Bangladesh. The clinical diagnosis was confirmed by histopathological examination. Among 400 cases, 260 (65%) were males and 140 (35%) were females with a male to female ratio 1.86:1. Age ranged from 10 to 70 years. Majority of the cases 200 (50%) were diagnosed as Tuberculosis verucosa cuties, 160 cases (40%) and 40 cases (10%) were diagnosed as Lupus vulgaris and Scrofuloderma respectively. All patients received combined antitubercular therapy.

Escrofuloderma, una manifestación extrapulmonar de tuberculosis: a propósito de un caso y actualización de esquema de tratamiento en Chile / Scrofuloderma, a manifestation extrapulmonary tuberculosis: about a case and treatment scheme update in Chile

La tuberculosis (TBC) es una enfermedad infecciosa causada por organismos del complejo Mycobacterium tuberculosis. Las presentaciones extrapulmonares constituyen hasta el 25% de los casos de TBC reportados en nuestro país. La TBC cutánea es una manifestación extrapulmonar rara que representa el 1-2% de los casos, siendo el escrofuloderma y el lupus vulgar las formas clínicas más comunes. El escrofuloderma es una manifestación endógena de la infección, como resultado de la extensión contigua a la piel suprayacente desde estructuras adyacentes. La biopsia de piel asociada a técnicas moleculares y cultivo de micobacterias constituyen el gold standard diagnóstico de la TBC cutánea. El tratamiento de la TBC cutánea sigue las mismas recomendaciones que para otras formas de TBC. Presentamos el caso de un paciente con escrofuloderma.

Tuberculosis (TB) is an infectious disease caused by organisms of the Mycobacterium tuberculosis complex. Extrapulmonary presentations may constitutes up to 25% of TB cases. Reported in our country Cutaneous tuberculosis is a rare extrapulmonary manifestation that represents 1-2% of cases, with scrofuloderma and lupus vulgaris being the most common clinical forms. Scrofuloderma is an endogenous manifestation of the infection, because of contiguous extension to the overlying skin from adjacent structures. Skin biopsy associated with molecular techniques and mycobacterial culture constitute the gold standard for diagnosis of cutaneous TB. The treatment of cutaneous TB follows the same recommendations as for other forms of TB. We present the case of a patient with scrofuloderma.

Cutaneous tuberculosis overview and current treatment regimens.

Tuberculosis is one of the oldest diseases known to humankind and it is currently a worldwide threat with 8-9 million new active disease being reported every year. Among patients with co-infection of the human immunodeficiency virus (HIV), tuberculosis is ultimately responsible for the most deaths. Cutaneous tuberculosis (CTB) is uncommon, comprising 1-1.5% of all extra-pulmonary tuberculosis manifestations, which manifests only in 8.4-13.7% of all tuberculosis cases. A more accurate classification of CTB includes inoculation tuberculosis, tuberculosis from an endogenous source and haematogenous tuberculosis. There is furthermore a definite distinction between true CTB caused by Mycobacterium tuberculosis and CTB caused by atypical mycobacterium species. The lesions caused by mycobacterium species vary from small papules (e.g. primary inoculation tuberculosis) and warty lesions (e.g. tuberculosis verrucosa cutis) to massive ulcers (e.g. Buruli ulcer) and plaques (e.g. lupus vulgaris) that can be highly deformative. Treatment options for CTB are currently limited to conventional oral therapy and occasional surgical intervention in cases that require it. True CTB is treated with a combination of rifampicin, ethambutol, pyrazinamide, isoniazid and streptomycin that is tailored to individual needs. Atypical mycobacterium infections are mostly resistant to anti-tuberculous drugs and only respond to certain antibiotics. As in the case of pulmonary TB, various and relatively wide-ranging treatment regimens are available, although patient compliance is poor. The development of multi-drug and extremely drug-resistant strains has also threatened treatment outcomes. To date, no topical therapy for CTB has been identified and although conventional therapy has mostly shown positive results, there is a lack of other treatment regimens.

Cutaneous mycobacteriosis: analysis of 34 cases with a new classification of the disease.

Several points can be made from analysis of the published cases of cutaneous mycobacteriosis and those in our series: 1) mycobacterial cutaneous infections are probably more common than is reported-we collected 34 cases over a 10-year period; 2) most patients with cutaneous infections caused by nontuberculous mycobacteria have significant underlying disease; 3) there is a relative lack of classic histologic features in patients with cutaneous mycobacteriosis, and there appear to be diverse forms of clinical presentation; 4) a high index of suspicion is needed in evaluating patients with possible cutaneous mycobacteriosis, and appropriate cultures must be done to establish the diagnosis. In attempting to provide a practical classification of cutaneous mycobacteriosis which includes infection by nontuberculous mycobacteria, we propose the following grouping, which uses simple terms, avoids confusing nomenclature, and incorporates pathophysiologic descriptions and prognostic information: 1) Mycobacteriosis caused by inoculation from an exogenous source. 2) Cutaneous mycobacteriosis caused by spread from an endogenous source. Contiguous spread originates most often with osteomyelitis, but also occurs through autoinoculation of the perirectal, oral, or vaginal skin as organisms are passed or expectorated from pulmonary or genitourinary tuberculosis. 3) Cutaneous mycobacteriosis caused by hematogenous spread. This group includes lupus vulgaris, nodules and abscesses, and acute disease with hemorrhagic pustules. Some mycobacterioses will be difficult to classify when inoculation or hematogenous spread cannot be ruled out. However, the system of classification we have proposed should help clinicians understand and diagnose the diverse forms of cutaneous mycobacterial infections.

Cutaneous tuberculosis: diagnosis and treatment.

As we move into the 21st century, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary tuberculosis. Mycobacterium tuberculosis, Mycobacterium bovis, and the BCG vaccine cause tuberculosis involving the skin. True cutaneous tuberculosis lesions can be acquired either exogenously or endogenously, show a wide spectrum of morphology and M. tuberculosis can be diagnosed by acid-fast bacilli (AFB) stains, culture or polymerase chain reaction (PCR). These lesions include tuberculous chancre, tuberculosis verrucosa cutis, lupus vulgaris, scrofuloderma, orificial tuberculosis, miliary tuberculosis, metastatic tuberculosis abscess and most cases of papulonecrotic tuberculid. The tuberculids, like cutaneous tuberculosis, show a wide spectrum of morphology but M. tuberculosis is not identified by AFB stains, culture or PCR. These lesions include lichen scrofulosorum, nodular tuberculid, most cases of nodular granulomatous phlebitis, most cases of erythema induratum of Bazin and some cases of papulonecrotic tuberculid. Diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with diagnostic testing; in addition to traditional AFB smears and cultures, there has been increased utilization of PCR because of its rapidity, sensitivity and specificity. Since most cases of cutaneous tuberculosis are a manifestation of systemic involvement, and the bacillary load in cutaneous tuberculosis is usually less than in pulmonary tuberculosis, treatment regimens are similar to that of tuberculosis in general. In the immunocompromised, such as an HIV infected patient with disseminated miliary tuberculosis, rapid diagnosis and prompt initiation of treatment are paramount. Unfortunately, despite even the most aggressive efforts, the prognosis in these individuals is poor when multi-drug resistant mycobacterium are present. An increased awareness of the re-emergence of cutaneous tuberculosis will allow for the proper diagnosis and management of this increasingly common skin disorder.

Atypical mycobacterial infections of the skin.

The term nontuberculosis mycobacteria or environmental mycobacteria should now be used rather than atypical mycobacteria. This article reviews the epidemiology and prevalence of the infections in humans as well as classifies them into four groups.

[Clinical forms of the cutaneous tuberculosis]. / Formes cliniques de la tuberculose cutanée.

Since Laennec's description of the "prosector's wart" in 1826, science has made great strides forward. The cutaneous forms of the infection with Mycobacterium tuberculosis are various. The most common clinical forms of cutaneous tuberculosis are lupus vulgaris and scrofuloderma. The clinical forms of cutaneous tuberculosis are usually classified according to the patient's immune status, and the way through which the skin has been infected. Nonetheless, as in leprosy, a classification based on the importance of the bacterial inoculum in situ is possible. Subsequently the diagnosis should be considered as easy in the multibacillary forms and much more difficult in the paucibacillary forms. In the former, the diagnosis should rely on bacteriological data. In the latter, the diagnosis will rely on the association of epidemiological, clinical and histological data whereas genomic amplification with PCR may be of potential interest.

[Anatomo-clinical forms of skin tuberculosis. (Dermatology service-Regional Hospital Center of Bouake, Ivory Coast)]. / Les formes anatomo-cliniques de la tuberculose cutanée. (Service de Dermatologie-Centre Hospitalier Régional de Bouaké-Côte d'Ivoire).

Tuberculosis of the skin is not exceptional in Africa South of the Sahara. The different ways of contamination of the skin by the tubercular bacillus and the level of immunologic reaction of the host account for the clinical polymorphisms. The bacillus is detected with difficulty, and the classical anatomo-pathological feature of tuberculoid granuloma is rarely complete: A classification based on physiopathological, clinical, bacteriological and histological criteria is an help to diagnosis.

[Cutaneous tuberculosis: a case of difficult classification]. / Tubercolosi cutanea: un caso di difficile classificazione.

We describe a case of cutaneous tuberculosis in a 25-year-old Philippine man. Erythematous papulo-nodular lesions, measuring 0.5 to 1 cm, were present on lower limbs; a 2 cm nodule was located on the left flank. The examination of the skin biopsy showed the presence of a superficial and deep perivascular dermatitis with histiocytes, lymphocytes and plasma cells. Ziehl-Nielsen stain for mycobacterium were negative, while the cultural examination led to the isolation of M. tuberculosis. Direct smear and cultural examination of sputum for M. tuberculosis were negative; chest and skeletal roentgenograms, syphilis and HIV infection serology, haematological and hematochemical examinations and urinalysis were negative. Specific treatment with isoniazid, rifampin and ofloxacin led to a rapid remission of cutaneous lesions. This case was particularly difficult to classify, but the Authors think it would be considered a tuberculid.

[Cutaneous manifestations of tuberculosis]. / Manifestations cutanées de la tuberculose.

Tuberculous lesions of the skin occur rarely nowadays. We therefore have mostly lost the knowledge to recognize this entity. Furthermore, the great variability of the clinical and particularly dermatologic manifestations of the disease can tax the most astute clinician. The challenge is even greater, when the patient has an intercurrent condition such as a malignancy or AIDS. In order to make understanding easier, we replace all descriptive terms, some carried over from the last century, by a useful pathogenetic and clinical, algorithmic classification. Finally the necessity of biopsy and specific cultures for proper diagnosis and treatment of any skin lesion consistent with skin tuberculosis is emphasized.

[Cutaneous mycobacteriosis]. / Mycobactérioses cutanées.

Tuberculosis is reappearing, due to diminished surveillance, illegal immigration, the HIV epidemic and certainly also due to emerging resistance. The clinical expression of cutaneous tuberculosis depends on the stage of development, the clinical background and the virulence of the germ. Diagnosis is predominantly clinical, but laboratory results also play a role. Treatment involves the quadruple antibiotic treatment prescribed for any tubercular infection. Atypical mycobacteria are widespread throughout the environment and are pathogenic, but also saprophytic, comensal and opportunistic, figure a favourable setting in the immunodeficient individual. Following entry by penetrance, the early lesion is papulonodulary, nodulary, keratoid, crusted, ulcerated, sporotrichoid, generally without peripheral adenopathy. Histological examination discloses a granulomatous reaction limiting the development of the infection; such development is absent in the immunodeficient patient, thus explaining the spread. The most common mycobacterial infection in France, generally in the immunocompetent individual, is "aquarium disease" which follows a benign course; the most common in tropical areas is Mycobacterium ulcerans; whereas Mycobacterium avium intracellulare, fortuitum and chelonae cause, in the immunodeficient patient, severe and extensive infection. Treatment should start as soon as diagnosis is made and the germ identified.

[Cutaneous tuberculosis yesterday and today]. / Las tuberculosis cutáneas ayer y hoy.

Cutaneous tuberculosis were very frequent in Europe until the middle of the 20th. Century in which their incidence decreased drastically as a consequence of the specific treatments. On the other hand, the M. bovis caused infections which were previously very common have also been disappearing due to control of milk and the livestock produced for eating purposes. Cutaneous tuberculosis have classically been divided into two groups: typical tuberculosis, with follicular structure and demonstrated bacillus by culture or inoculation and atypical tuberculosis (tuberculids), in which there are no follicular structure and the bacillus is not isolated. Its relationship with tuberculosis is principally based on the personal and/or familial background and on the strong positivity of the Mantoux reaction. The concept of tuberculide has always been under debate. Above all in the second half of the 20th. Century, most of the authors were skeptical in regards to its tuberculous etiology. However, since the 1990's, determinations of bacillary DNA in the lesions by the PCR technique has made it possible to demonstrate the M. tuberculosis in them. At present, due to the probably re-emergence of tuberculosis in general as consequence of the immunodeficiency (AIDS), of the M. tuberculosis strains resistant to treatment, and of the cases imported by immigration, some increase in the incidence of cutaneous tuberculosis can be predicted in the future, although it need be feared that this will reach the amounts of other periods. On the other hand, immunodeficiences have made the anergic forms, such as tuberculosis cutis miliaris diseminata or tuberculous gumma, which were previously rare, less rare al present.

[Apropos of cutaneous tuberculosis]. / A propósito de las tuberculosis cutáneas.

A revision of in and out patients' cases of cutaneous tuberculosis is made, joining them in typical forms and tuberculids. From a total of 70 patients, 49 corresponded to typical forms and the rest to tuberculids. They are joining by sex, middle age and nationality remarking if there was any association or no to another envolvement sides and at last, 9 cases with some peculiar characteristics are mentioned.