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.

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.

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.

The history of lupus throughout the ages.

The word lupus (Latin term for the wolf) was used indistinctively since the Middle Ages for several types of diseases characterized by ulcerous lesions, mainly in the lower limbs. In the middle of the 18th century, the French dermatologist Cazenave mentioned for the first time the term "lupus érythémateux," while Kaposi reported discoid lupus as a separate entity. The true turning point in the history of lupus occurred at the beginning of the 19th century, when the distinction between lupus vulgaris and cutaneous lupus in its modern sense emerged slowly. Major subsequent contributions from Kaposi, Sequiera and Balean, and Osler enabled the recognition of the systemic nature of the disease, with its modern history being marked by the recognition of DNA as the main target of antinuclear antibodies and the central role of interferons. Although many nonpharmacologic treatments have been used throughout the ages, glucocorticoids, hydroxychloroquine, and immunosuppressive agents mainly appeared in the second half of the 20th century. The beginning of the 21st century is now characterized by an in-depth understanding of the pathogenesis of the disease and the appearance of biologic and targeted treatments, paving the way for a better care of lupus patients.

[A case of cutaneous tuberculosis evolving for 50 years]. / Un cas de tuberculose cutanée évoluant depuis plus de 50 ans.

INTRODUCTION: Tuberculosis is an infection caused by Mycobacterium (M.) tuberculosis. It is rare in France. Clinical presentations vary, making demonstration of the cause of M. Tuberculosis difficult and rendering diagnosis and management difficult. PATIENTS AND METHODS: A 58-year-old man, born in Morocco, consulted for ulceration of the right forefoot that had been present since the age of 3 years. He had previously consulted at several dermatology departments. He had undergone numerous skin biopsies and bacteriological and mycobacteriological cultures but these did not contribute to the diagnosis. Slow extension and oozing were observed over time and resulted in functional disability. Given the evocative clinical aspect and despite further negative screening for mycobacteria, anti-TB quadrotherapy was prescribed and resulted in complete cure of the lesion. DISCUSSION: This case underscores the difficulty of diagnosing cutaneous tuberculosis. Such a diagnosis must be clinically suspected in the presence of long lasting destructive or verrucous skin lesions that fail to heal, even where cultures are negative, and anti-TB therapy should be putatively prescribed.

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.

[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.

Paradoxical reaction to antituberculosis therapy in a patient with lupus vulgaris.

Patients receiving treatment for tuberculosis may experience an unexpected deterioration of their disease; this is known as a paradoxical reaction. We present the case of a 59-year-old man with lupus vulgaris who experienced a paradoxical deterioration of cutaneous lesions after starting antituberculosis therapy. The reaction was self-limiting; the lesions gradually improved, and the final outcome was very good. Paradoxical reactions are well-known in patients with human immunodeficiency virus (HIV) infection who start antiretroviral therapy, but they can also occur in non-HIV-infected patients with tuberculosis who start antituberculosis therapy. In the literature reviewed, paradoxical reactions involving skin lesions were described in patients with miliary tuberculosis. The case we report is the first of a paradoxical reaction in lupus vulgaris. The increasing frequency of tuberculosis in Spain could lead to a rise in the number of paradoxical reactions.

Surgical Excision Combined with Photodynamic Therapy for Squamous Cell Carcinoma Arising in Lupus Vulgaris.

Cutaneous squamous cell carcinoma (SCC) is a common non-melanoma skin cancer (NMSC). Although most cutaneous SCC in people with lighter skin pigmentation as a result of sun damage, patients with underlying conditions such as skin ulcers and chronic inflammation-including conditions such as lupus vulgaris (LV) and chronic discoid lupus erythematosus-are also predisposed to developing SCC. Here we report a case of secondary SCC diagnosed in a 54-year-old patient with 20 years of lupus vulgaris without prior formal systemic treatment, a rarity in clinical practice. Two months ago, the patient developed papules on the right cheek that ulcerated and discharged purulent fluid. Laboratory tests revealed a positive TSPOT result and histopathological examination confirmed granulomatous lesions, supporting the diagnosis of SLE. However, a tissue biopsy unexpectedly revealed a moderately differentiated SCC of the keratinizing type. In this case, we performed surgical excision of the lesion followed by cosmetic closure and adjuvant photodynamic therapy (PDT). Concurrently, the patient underwent systemic anti-tuberculosis treatment. At 6 months post-treatment, no tumour recurrence was observed and the rash associated with lupus erythematosus had also resolved. The patient was satisfied with the treatment outcome.

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.

Cutaneous tuberculosis, different clinical spectrum of the same disease: the importance of pre-test probability.

This report presents three cases of cutaneous tuberculosis that were identified at the Calderon Hospital in Quito, Ecuador. The first case involved a 44-year-old man who had tuberculosis verrucosa cutis, characterized by circinate erythematous areas, ulcerated nodules, and verruciform plaques extending from the right lower limb to the hip. In the second case a 50-year-old woman with a 1-year history of pruritic dermatosis in the left ciliary area was diagnosed with lupus vulgaris. In the third case, a 23-year-old man with erythematous nodules draining caseous material at the neck, thorax, and axillary region was diagnosed with scrofuloderma. It was discovered that nearly every laboratory test that was accessible had drawbacks as a diagnostic technique. Correlating clinical and epidemiological features with the pretest probability is crucial for optimizing indicators and confirming or ruling out the diagnosis in immunocompromised and high-risk individuals with atypical lesions.

A Verrucous Plaque Healing with Cribriform Scarring.

Lupus vulgaris manifests with diverse clinical presentations, although the typical pattern involves a plaque that extends at one end and heals at the other, leaving behind characteristic atrophic scarring. Cribriform scarring is classically described after the healing of ulcerative pyoderma gangrenosum. In this case report, we present a noteworthy instance of lupus vulgaris that exhibited healing accompanied by cribriform scarring.

Lupus Vulgaris Plaque Type on the Face Without Pulmonary Involvement: A Rare Case.

Cutaneous tuberculosis is a rare finding with a difficult diagnosis. This is mainly due to the low sensitivity and specificity of almost all diagnostic tests, accompanied by ambiguity in clinical presentations and non-specific clinical features. A 25-year-old Indian male is presented who reported having a thick, scaly lesion on the left side of his face. A definite diagnosis was achieved after a detailed clinical examination and a detailed diagnostic workup that involved a biopsy. He was put on antituberculous chemotherapy for six months.

A Clinico-Histopathological Study of Lupus Vulgaris at a Tertiary Care Centre.

Background and objectives Lupus vulgaris is a chronic, progressive, paucibacillary form of cutaneous tuberculosis that occurs in persons with moderate to high immunity. Due to its varied clinical presentation, it can masquerade as different dermatological conditions. This study describes the demographic patterns and varieties of clinical manifestations that can be possible in this curable illness. Methods This study was conducted over two years and included 19 patients with histopathologically confirmed lupus vulgaris in Odisha, India. Demographic data, clinical features, and response to treatment are presented. Results Thirteen cases (68.4%) were seen in adults and six (31.6%) in pediatric patients. The lower limbs were the more affected (n=10), followed by the upper limb (6), the face (2), and the chest (1). All but one patient had plaque-type lesions. On histopathology, all showed a tuberculoid granuloma with no demonstration of acid-fast bacilli with Ziehl-Neelsen staining. Conclusion In the present study, the incidence was mostly observed in the young and higher activity age groups (5-40 years). Plaque-type lesions were most commonly encountered. In histopathology, all the cases had tubercular granuloma-type lesions without any incidence of malignant transformations. All the patients responded well to conventional multi-drug anti-tubercular chemotherapeutic regimens.

Multifocal Lupus Vulgaris: A Rare Presentation.

Lupus vulgaris (LV) is a common type of cutaneous tuberculosis and commonly presents as a single erythematous plaque either on the face or buttocks with scarring and an active spreading edge. Multiple lesions of LV are sparingly reported in the literature. We hereby report a case of LV in a male presenting with multiple lesions over the buttock, thigh, and trunk. The diagnosis was done on the basis of clinical findings, histopathology, positive tuberculin test, and response to a standard anti-tubercular regimen.

Atypical cutaneous tuberculosis with an unusual course.

Cutaneous tuberculosis represents the fifth extrapulmonary form in Morocco after pleural, lymph node, urogenital, and intestinal tuberculosis. It is recognized to form a continuous immunopathologic spectrum, ranging from a high intensity to a low intensity of cell-mediated immunity, which explains the multiplicity and heterogeneity of anatomo-clinical forms. Association of multiple forms in the same patient is really rare. In this regard, we report a case of scrofuloderma on axillary tuberculosis adenitis associated to a lupus vulgaris in an immunocompetent patient, which was confirmed by histology, QuantiFERON-TB Gold test, and polymerase chain reaction. He received an antituberculous therapy with clinical regression of the lesions. In conclusion, cutaneous tuberculosis is still endemic in developing countries.The diagnosis is difficult because of its clinical polymorphism. That's why it's should be suspected clinically in the presence of any destructive or verrucous skin lesion evolving without healing for a long period and confirmed by bacteriological examinations and histology.

Primary cutaneous large B cell lymphoma masquerading as lupus vulgaris.

Primary cutaneous large B cell lymphoma, leg type is a rare and aggressive variant of cutaneous B cell lymphoma. It predominantly affects elderly women, with the lower limb being the most common site of presentation. The overall prognosis is poor, compared to other cutaneous B cell lymphomas. A 47-year-old man presented with a progressively enlarging nodule over the medial aspect of the left foot since 2 months. Clinical examination revealed a nodular plaque-like lesion with central ulceration that measured 7 × 7 cm, firm in consistency, and with ill-defined margins. The initial clinical diagnosis was lupus vulgaris. An incision biopsy was done, which on histopathology and immunohistochemistry revealed a rare diagnosis of primary cutaneous B cell lymphoma, leg type. The patient was started on chemotherapy; however, he succumbed to his illness about 1 year after the initial presentation. It is a rare type of cutaneous lymphoma, which may masquerade infectious disorders such as lupus vulgaris. A detailed histopathological and immunohistochemical analysis is essential for its correct diagnosis and management. Only a handful of cases of this rare condition are reported to date. This case has been reported in view of its rarity and unusual clinical presentation.

"Lichenoid Granulomatous Pattern" in a Case of Lupus Vulgaris.

Lupus vulgaris is a one of the most common skin infections in the Indian subcontinent. Even today, it often creates a diagnostic dilemma for both clinicians and histopathologists. We describe a case of lupus vulgaris that showed lichenoid granulomatous inflammation in the dermis. This pattern is not uncommon, but is rarely described in the literature as newer modalities currently take precedence in diagnosis. Our aim is to make clinicians and dermatopathologists aware of this pattern of inflammation seen in this common infection.

Giant Lupus Vulgaris with Negative T-SPOT.TB, a Case Report and Literature Review.

Lupus vulgaris is a paucibacillary form of cutaneous tuberculosis (CTB) which is accounting for 1-2% of all tuberculosis cases. Here, we report a rare huge lupus vulgaris misdiagnosed as sarcoidosis for 11 years. A 65-year-old man presented to dermatology outpatient with a large asymptomatic erythematous plaque and erosions on his neck. Sarcoidosis was initially diagnosed on the basis of negative interferon-gamma release tests and biopsies of lymph nodes and lesions. The patient was treated with long-term oral steroid and immunosuppressive agents, but the lesions expanded gradually. Lupus vulgaris was finally diagnosed by combining molecular detection and mycobacterial culture. The skin lesions were resolved after six months of standard antituberculosis therapy. We report this case to analyze the reasons for the misdiagnosis and review-related literature to further provide experience for the diagnosis and treatment of cutaneous tuberculosis with negative T-SPOT.TB.