cutaenous tuberculosis in india!!!!!!!!!

Cutaenous tuberculosis.. types and classification

1. Cutaneous tuberculosis Dr richa jain jr2

2. Introduction- Cutaneous tb caused by mycobacterium tuberculosis, M. bovis,and the bcg can cause tuberculosis involving skin. Cuta tb is 1.5% of extra pulmonary TB. Diagnosis of these lesions can be difficult, as they resemble many other dermatological condition. Cuta . TB can be acquired exogenously or endogenously and present as a multitude of differing clinical morphologies. Skin manifestations present as a result of heamatogenous spread or direct extension from a latent or active foci of infection.

3. Primary cut TB – intial infection of m.tb in previously non sensitized individual ,where portal of entry through skin manifest as tubercular chancre. Secondary cut tb - it is more common. Occur in individual who is previously sensitized with tubercular antigen. Exogenous reinfection and endogeneous dormal bacilli reactivation is responsible for this type of disease.

4. Classification of cut. TB

5. Beyt et al. classification Inoculation tuberculosis Secondary tuberculosis Haematogenous tuberculosis Eruptive tuberculosis

7. Classification based on bacterial load and immunity MULTIBACILLARY – abundant mycobacteria with low immunity I.e. scrofuloderma , tubercular chancre ,acute military tb PAUCIBACILLARY – where m.tb difficult to isolate with high immunity Lupus vulgaris, tuberculosis verrucosa cutis and tuberculid

8. PATHOGENESIS The mycobacteria are 0.2 to 0.5 × 2 μm sized nonmotile , noncapsulated , and nonsporing grampositive bacilli. Acid fast bacilli (AFB ).on Ziehl-Neelsen staining , mycobacteria appear as pink stained rods lying singly or in groups on blue background. slow-growing organisms . cultured on solid Lowenstein-Jensen (L-J) medium and the growth appears in 2–8 weeks. BACTEC is a newer liquid medium with a radiometric growthdetection system yielding quicker results within 10–20 days.

9. Tuberculous chancre/ primary inoculation tuberculosis Tuberculous chancre occurs in an individual who has never been exposed to tubercle bacilli in the past. occur in children and involves mainly the exposed sites such as extremities and face. The portal of entry is usually a minor injury such as puncture wound, abrasion, circumcision, ear piercing, venepuncture , tattooing,needle stick injury, or vaccinations. 30–34 After about 2 to 3 weeks of inoculation , a skin colored or erythematous papule/nodule or an impetiginous patch appears at the site that progress to chancriform ulcer . ulcer is about 0.5–2 cm, shallow , tender/ nontender , firm or indurated with undermined edges, and necrotic tissue at the floor.

10. The primary lesion heals with scarring over 1–3 months . regional lymph nodes also get involved. Conjunctiva and eyelids can also develop tuberculous chancre . For diagnosis in any nonhealing ulcer with or without lymphadenopathy, especially in a child, with or without history of injury. differential diagnosis include syphilis , foreign body granuloma, cutaneous leishmaniasis , sporotrichosis , nontuberculous mycobacterial infections, tularemia, and cat-scratch disease.

11. Miliary CT active primary tubercular focus usually, the hematogenous dissemination of the mycobacteria to almost all parts of the body results in miliary tuberculosis. child with less resistance to the organism,immunosuppression and malnutrition. child appears sick having fever, malaise, headache. disease is more of eruptive nature and may manifest after a recente pisode of a viral exanthema. crops of erythematous or bluish macules, papules, vesicles, or pustules over the trunk and extremities. the presence of necrotic and hemorrhagic lesions with tuberculosis elsewhere in the body.

12. oral mucosa may be affected. Eye examination should always be done as that may show characteristic choroid tubercles. usually seen in immunocompetent individuals and responds very well to tt . differential diagnosis include pityriasis lichenoides varioliformis et acuta , secondary syphilis , drug reactions, lymphomatoid papulosis, papulo -necrotic tuberculids .

13. Lupus Vulgaris Lupus Vulgaris (LV) is most commonly seen in individuals with a previous history of infection or immunization providing a high degree of immunity . Mc seen in adults. acquired by exogenous inoculation or by hematogenous or lymphatic spread in the presence of internal organ involvement . most common sites involved are the face,extremities , and buttocks. starts as a skin colored or erythematous, asymptomatic, soft plaque with a smooth surface that later becomes infiltrated and enlarges slowly. The lesion progresses peripherally with center in the form of atrophy or scarring

14. on diascopy apple-jelly nodules regional lymph nodes may be enlarged. Nasal and oral mucosae are the most common sites for mucous membrane LV . morphological variants include nodular, ulcerative, keloidal , verrucous, and hypertrophic. Longstanding LV lesion may evolve into a squamous cell carcinoma differential diagnosis include lupoid leishmaniasis , sporotrichosis , pseudolymphoma,tuberculoid leprosy, Bowen’s disease, sarcoidosis, and lupoid rosacea.

15. Lupus vulgaris presenting as erythematous soft plaque with progression at one end and atrophy and scarring at another end.

16. Lupus vulgaris presenting as large disfiguring erythematous plaque with involvement of lower conjunctivas.

17. Hypertrophic lupus vulgaris presenting as hyperkeratotic verrucous plaque with peripheral erythematous margin over the buttock

18. Tuberculosis Verrucosa Cutis (Warty CT, Anatomist’s Wart ) TBVC most chronic forms of CT. one or more asymptomatic firm papulonodular lesions on the exposed part. They gradually enlarge and coalesce to form verrucous plaques that may continue to extend peripherally over many years with a polycyclic or serpiginous border. neglected course of the disease can lead to large verrucous masses with scarring and deformities. Dd - chromoblastomycosis,blastomycosis , viral verrucae, hypertrophic lichen planus, lichen simplex chronicus, cutaneous leishmaniasis , and tertiary syphilis

19. Tuberculosis verrucosa cutis presenting as thick verrucous hyperkeratotic plaque on the sole.

20. Scrofuloderma (Tuberculosis Cutis Colliquativa ) Condition caused by tuberculous involvement of the skin by direct extension, usually from underlying tuberculous lymphadenitis. Asymptomatic reddish discoloration which breaks down to form sinuses,fistulate or tuberculous ulcers. Mc site- neck and chest. long-drawn disease, the scarring can strangulate the lymphatics with thedevelopment of lymphedema the inguinal lymph nodes.

21. differential diagnosis include nonspecific pyodermicsuppurations of lymph nodes and soft tissues, nontuberculous mycobacteriosis , osteomyelitis, hidradenitis suppurativa , actinomycosis , syphilitic gummas , lymphogranuloma venereum , and nonspecific anal fistulae

22. Scrofuloderma presenting as ulcer with undermined edge and pus discharge. The underlying focus is lymph node tuberculosis.

23. Tuberculosis Cutis Orificialis among patients who have an advanced tubercular disease in the body . infection of oral tissues from pulmonary tuberculosis, perianal/perineal CT from intestinal tuberculosis and penile/ vulval CT from genitourinary tuberculosis. reddish or yellowish nodule that soon ruptures to form painful, tender,and punched-out ulcers . The commonest site is the lateral margin of the tongue followed by the palate . These ulcers do not heal spontaneously . differential diagnosis - Aphthosis , glossitis, syphilitic chancre, and local malignancy.

24. Tuberculous Gumma uncommon form of CT. immunosuppressed or malnourished individuals. hematogenous spread single or multiple subcutaneous firm nodules progress to abscess ,ulcer and sinuses. The commonest sites of involvement are the trunk or extremities. an internal focus of tuberculosis is detected involving lungs, lymph nodes , or musculoskeletal system .

25. Multiple tubercular gumma in a young girl with non- Hodgkin lymphoma

26. Tuberculous gumma presenting as multiple discharging ulcers with undermined edges.

27. DIAGNOSIS OF CT high prevalence in india . Cut tb considered as dd with nonhealing ulcer, single or multiple abscesses,and any other forms of cutaneous lesion in the presence of evident tuberculosis elsewhere in the body.

28. Tuberculin Skin Test Interferon Gamma Release Assay Two types of IGRAs : QuantiFERON TB Gold In-Tube (QFN-GIT) and T-SPOT.TB (T-Spot ). ZN Staining used to demonstrate AFB. Culture of M.tb is gold standard. PCR

29. Histopathology Scrofuloderma (H&E, 400×) showing mixed granulomatous inflammatory infiltrate composed of histiocytes , lymphocytes, epitheloid cells, Langerhans giant cells, neutrophils, and plasma cells

30. Lupus vulgaris (H&E, 40×): Epidermal acanthosis, confluent lichenoid granulomatous infiltrate in the upper dermis with a deep, discrete granuloma

31. Tuberculosis verrucosa cutis (H&E, 40x): Hyperkeratosis, marked acanthosis with pseudoepitheliomatous hyperplasia and papillomatosis along with a lichenoid granulomatous infiltrate.

32. Therapeutic Trial with Antituberculous Drugs skin lesions are highly suspicious of tuberculous etiology but the histologicaland bacteriological studies are inconclusive. strong tuberculin reactivity daily dose regimen of ATT for 5-6wks.

33. TUBERCULIDS noninfectious cutaneous eruptions associated with a focus of tuberculosis elsewhere in the body. 1. Typical clinico -histopathological features. 2. No demonstrable bacilli in the lesions. 3. Strongly positive TST or IGRA tests. 4. Regression with the intake of antituberculosis Medications. 5. Evidence of present/past tuberculosis ( may not be evident

34. treatment

35. Isoniazid- 5mg/kg ADR peripheral neuritis ,hepatitis ,fever, Rifampicin 10mg /kg Ethambutol 15mg/kg Pyrizinamide 25mg/kg Streptomycin 15mg/kg

36. Thank you…………………