A cross sectional descriptive study of dermoscopic features of clinical variants of cutaneous tuberculosis.

Tuberculosis continues to be a major public health concern worldwide with almost 20-40% of the world's population being affected yearly. Cutaneous Tuberculosis (TB) is a rare and underdiagnosed entity that manifests in about 1-1.5% of extrapulmonary tuberculosis cases worldwide. Dermoscopy is a non-invasive tool which will be a useful aid to histopathology in the confirmation of the diagnosis alongside culture, and molecular techniques. This is a cross-sectional descriptive study that was conducted at a tertiary care center in Mumbai, India. A total of 31 patients were enrolled in this study; 14 males and 17 females. The mean duration of disease was 4.3 months and the average age was 31 years. There were 10 cases of lupus vulgaris, 7 scrofuloderma, 5 papulonecrotic tuberculid (PNT), 3 tuberculosis verrucosa cutis (TBVC), and 2 cases each of erythema induratum of Bazin, lichen scrofulosorum and resolved lupus vulgaris. All the lesions demonstrated orange yellow background suggestive of dermal granuloma. Other key dermoscopic features noted include yellowish-white scales, patulous follicles, white structureless areas, milia-like cysts, white streaks, pigment globules, hairpin and linear vessels. Newer findings such as the crown of vessels and perifollicular pallor in lichen scrofulosorum, and radiating white streaks in PNT were also noted. Dermoscopy of infective granulomas such as cutaneous tuberculosis is a less explored field of dermatology. Newer dermoscopic features of each clinical variant of cutaneous TB have been described.

Multifocal Tuberculosis Verrucosa Cutis: Case Report and Review of the Literature.

Cutaneous tuberculosis (TB) is still a major public health problem worldwide. Tuberculosis verrucosa cutis (TBVC) is a cutaneous form of exogenous TB caused by exogenous reinfection in previously sensitized individuals. TBVC typically presents as a unifocal condition. Multifocal cutaneous lesions without any other tubercular foci are extremely rare in exogenous TB and few cases are reported in the literature. We describe the first case of multifocal TBVC in an 81-year-old Greek man. In total, 14 cases of multifocal TBVC have been reported in the literature (8 males and 6 females), with mean age 47.64 years (SD = 20.75) and mean time to diagnosis of 9.69 years (SD = 15.31). Most cases (11/12) responded rapidly to treatment, implying the accuracy of diagnosis, while no one was reported to be immunocompromised. Finally, in 10 cases (71.4%), history of skin microtrauma was reported (related either to daily life habits or to professional praxis), confirming it as the main risk factor. The tuberculin skin test was positive in 10 cases and tissue culture for mycobacteria was negative in all cases. TBVC can present with multiple lesions, even in countries where TB prevalence is not high, especially in patients with history of skin abrasions. Prompt specialist assessment can expedite the establishment of diagnosis.

Cutaneous tuberculosis as a manifestation of Pott's Disease: A diagnostic challenge in patients with Non-HIV immunosuppression.

Tuberculosis (TB) is one of the most important public health issues in developing countries. The World Health Organization estimates that approximately 20%-40% of the world's population is infected. Pulmonary forms account for the majority of cases; however, it can manifest as extrapulmonary disease in 8.4%-13.7% of cases. Of these extrapulmonary forms of TB, only 1%-2% may have skin manifestations. Cutaneous tuberculosis (CTB) is relatively uncommon and is not a well-defined disease, which complicates diagnosis. We present two patients with Pott's disease that manifested as CTB, one with tuberculous gumma and the other with scrofuloderma. Both patients with non-HIV immunosuppression. The diagnosis of CTB was made by detecting Mycobacterium tuberculosis in skin samples by real-time polymerase chain reaction (Xpert MTB/RIF test) and Ziehl-Neelsen staining. The histologic findings described in these two forms of TB may vary or be absent in immunosuppressed patients, making diagnosis difficult.

Undermined Skin Lesion Emerged as Tubercular Meningitis: A Case Report.

Cutaneous tuberculosis is a rare type of extrapulmonary tuberculosis and it is uncommon even in places where tuberculosis is widespread. A 32-year-old female presented with fever and headache along with prior history of an ulcer in her leg which was treated as cellulitis at another centre. The neck rigidity, and the Kernig and Budzinski sign were also positive. There were also features of increased intracranial pressure. The non-contrast computed tomography showed bilateral hydrocephalus and hypodense areas. She was managed for increased intracranial pressure and anti-tubercular therapy for disseminated tuberculosis. Biopsy of non-healing wounds should be checked for lupus vulgaris. Keywords: case reports; lupus vulgaris; meningitis; skin; tuberculosis.

Acral involvement in lichen scrofulosorum: A diagnostic oddity with distinctive features on dermoscopy.

A commonly underdiagnosed harbinger of visceral tuberculosis, lichen scrofulosorum classically manifests as centripetally located erythematous to violaceous cutaneous papules. Perifollicular and perieccrine tuberculoid granulomas constitute the histologic hallmark. We report a case of lichen scrofulosorum with involvement of the acral areas which is unusual. Also, dermoscopy, which has not yet been widely utilized in this condition gave a novel insights into histopathology in this case.

Cutaneous tuberculosis. Part II: Complications, diagnostic workup, histopathologic features, and treatment.

Despite the availability of effective treatment regimens for cutaneous tuberculosis, challenges to disease control result from delayed diagnosis, infection with multidrug-resistant mycobacterial strains, and coinfection with HIV. Delayed diagnosis can be mitigated when dermatologists are sensitized to the clinical signs and symptoms of infection and by the incorporation of appropriate diagnostic tests. All cases of cutaneous tuberculosis should be confirmed with histopathology and culture with or without molecular testing. In each case, a thorough evaluation for systemic involvement is necessary. Mycobacteria may not be isolated from cutaneous tuberculosis lesions and therefore, a trial of antituberculosis treatment may be required to confirm the diagnosis. The second article in this 2-part continuing medical education series describes the sequelae, histopathology, and treatment of tuberculosis.

Tuberculosis cutánea esporotricoide en la Amazonía peruana: reporte de caso / Sporotrichoid cutaneous tuberculosis in the peruvian amazon: case report

RESUMEN La tuberculosis cutánea es una presentación rara de la infección por Mycobacterium tuberculosis. Se presenta el caso de una mujer sin antecedentes médicos de importancia, con un tiempo de enfermedad de año y medio, caracterizado por lesiones tipo esporotricoide, con diseminación linfocutánea en miembro superior derecho, de evolución lentamente progresiva. Se realizó un estudio histopatológico encontrándose células gigantes tipo Langhans y escasa necrosis. El paciente recibió terapia de esquema sensible antituberculoso, con evolución favorable.

ABSTRACT Cutaneous tuberculosis is a rare presentation of Mycobacterium tuberculosis infection. We present the case of a woman without important medical history, with a disease period of one year and a half, characterized by sporotrichoid-like lesions, with lymphocutaneous dissemination in the right upper limb, and with slowly progressive evolution. The histopathological tests revealed Langhans type giant cells and scarce necrosis. The patient received therapy with a sensitive antituberculous scheme, and evolved favorably.

Successful treatment of tuberculosis verrucosa cutis with fester as primary manifestation with photodynamic therapy and anti-tubercular drugs.

Tuberculosis verrucosa cutis (TBVC) is a rare type of cutaneous tuberculosis, which often occurs in the body with good immunity to tuberculosis bacilli. It usually presents as a hyperkeratotic verrucous plaque with polygonal boarders but can mimic or evolved into other dermatosis such as verruca vulgaris, chromoblastomycosis, hyperkeratotic lupus vulgaris, hypertrophic lichen planus, or squamous cell carcinoma, leading to delayed diagnosis. Here, we reported that a 62-year-old patient diagnosed by TBVC with fester as primary manifestation. Photodynamic therapy combined with anti-tuberculosis drugs is an effective method to treat TBVC lesions with fester, and it may shorten the treatment cycle of anti-tuberculosis drugs.

Case Report: A Case of Tuberculosis with Psoriasiform Lichen Scrofulosorum Exhibiting Koebner's Phenomenon followed by Scrofuloderma.

Lichen scrofulosorum is the most common tuberculid in the Indian population and the second most common form of cutaneous tuberculosis. We discuss an uncommon presentation of lichen scrofulosorum, with psoriasiform morphology and koebnerization at tuberculin test site, associated with cervical lymphadenitis in a 17-year-old girl. Although the cutaneous lesions resolved completely after 3 months of antitubercular treatment (ATT), she developed scrofuloderma in the left cervical region at 4 months. In the absence of rifampicin resistance, ATT was continued for another 6 months, with no further evidence of disease activity. This case represents an infrequent occurrence of lichen scrofulosorum followed by scrofuloderma, which necessitated a prolonged course of first-line ATT.

Recurrent Genital Ulcers.

Papulonecrotic tuberculid represents a hypersensitivity reaction to Mycobacterium tuberculosis or its products that disseminate through hematogenous route to the skin from an internal tuberculous focus. It is characterized by recurrent eruptions of asymptomatic, dusky red papules, which undergo ulceration and crusting, and eventually heal after a few weeks with varioliform scarring. Although it most commonly involves extragenital sites, isolated glans penis involvement has been reported very rarely.

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.

Multi-targeted loop mediated amplification PCR for diagnosis of extrapulmonary tuberculosis.

AIMS: The present study was conceived to evaluate multi-targeted loop mediated amplification (MLAMP) for the rapid diagnosis of extrapulmonary tuberculosis (EPTB). METHODS AND RESULTS: A total of 700 patients were included who were classified into 2 groups: Group 1 (n = 400) included a 100 culture confirmed EPTB patients and 300 culture negative, suspected EPTB patients. Group 2 (n = 300) included negative controls from non-tubercular patients. All samples were subjected to Ziehl-Neelsen microscopy, solid culture on Lowenstein Jensen media, Polymerase chain reaction (PCR) targeting IS6110 gene and LAMP targeting both IS6110 and MPB64 individually and as MLAMP. The overall sensitivity of microscopy, culture, IS6110 PCR, IS6110 LAMP, MPB64 LAMP and the MLAMP assay were 12%, 25%, 72.5%, 80% and 86.6% respectively and the specificity of all the tests was 100%. CONCLUSION: MLAMP is a rapid robust tool for the diagnosis of EPTB and utilizing two targets for M. tuberculosis can improve the overall sensitivity and increase the yield of detection from extrapulmonary samples. The rapidity, ease of performance and low cost make MLAMP an excellent alternative in low-income, resource limited settings.

An evolving presentation of cutaneous tuberculosis.

Tuberculosis is a fairly common disease in the United States and around the world, newly infecting ten million people throughout the world per year. Despite the pervasiveness of tuberculosis, cutaneous tuberculosis (CTB) rarely manifests worldwide. Tuberculous infections of the skin arise in several distinct variants that can be classified as either multibacillary or paucibacillary; each subtype within these categories presents with its own morphological and histological findings. The diagnosis of CTB can prove clinically challenging as its variants mimic many conditions dermatologist encounter on a daily basis. Additionally, tissue confirmation is difficult. We report a case of CTB which evolved from a lupus vulgaris presentation to the metastatic tuberculous abscess variant.

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.

Multiple subcutaneous tuberculous abscesses in a dermatomyositis patient without pulmonary tuberculosis: a case report and literature review.

BACKGROUND: Even though remarkable progress for diagnostics of pulmonary TB has been made, it is still a challenge to establish a definitive diagnosis for extrapulmonary TB (EPTB) in clinical practice. Among all the presentations of EPTB, cold abscesses are unusual and deceptive, which are often reported in the chest wall and spine. Subcutaneous abscess in the connective tissue of limbs is extremely rare. CASE PRESENTATION: A 48-year-old man with dermatomyositis was hospitalized because of multiple subcutaneous tuberculous abscesses in his limbs, but without pulmonary tuberculosis. Particularly, one insidious abscess appeared during anti-TB treatment due to "paradoxical reaction". After routine anti-TB therapy, local puncture drainage and surgical resection, the patient was cured and discharged. CONCLUSIONS: Tuberculous infection should be kept in mind for the subcutaneous abscess of immunocompromised patients, even without previous TB history. Treatment strategy depends on the suppurating progress of abscess lesions. Meanwhile, complication of newly-developed insidious abscess during treatment should be vigilant.

Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient

Abstract Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl-Neelsen staining showed intact bacilli, the culture was positive for Mycobacterium tuberculosis, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.

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.

Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient.

Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl-Neelsen staining showed intact bacilli, the culture was positive for Mycobacterium tuberculosis, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.

Disseminated tuberculosis presenting as medium-vessel vasculitis in an immunocompromised host.

Cutaneous tuberculosis is an uncommon entity with several clinical forms recognized. Histopathologically, most cases are characterized by granulomatous inflammation and caseating necrosis, although less common findings, including vasculitis, have also been described. We report a 55-year-old male with a history of recently diagnosed dermatomyositis receiving immunosuppression with mycophenolate mofetil and prednisone, who developed multifocal soft tissue abscesses and an indurated erythematous plaque on the back. Skin biopsy of the back revealed a necrotizing medium-vessel vasculitis. Mycobacterium tuberculosis was detected in the skin via acid-fast bacilli stain and confirmed by tissue culture and polymerase chain reaction. Cutaneous findings improved rapidly with antituberculosis therapy. This case illustrates an uncommon clinical and histopathologic presentation of disseminated tuberculosis.