Mamagement and Diagnosis of cutaneous TB.pptx

Dermatology

1. Cutaneous Tuberculosis DR. M OMER ALTAF PGR DERMATOLOGY LAHORE GENERAL HOSPITAL

2. Tuberculosis Mycobacterium tuberculosis Most often affects the lungs

3. Epidemiology Incidence 10 million people per year 1.5 million deaths per year Prevalence : Pakistan: 5 th Number in TB cases 562,000 TB cases in Pakistan in 2018

4. Cutaneous Tuberculosis Tuberculosis of the skin caused by Mycobacterium tuberculosis,Mycobacterium bovis and Bacillus Calmette-Guerin Depends on : Route of infection Immune status of the patient Previous sensitization with tuberculosis

5. Pathogenesis of Tuberculosis

6. Classification of Cutaneous Tuberculosis

7. Primary Inoculation Tuberculosis Inoculation of M. tuberculosis into skin of an individual No natural or artificially acquired immunity to organism

8. Differential Diagnosis Cutaneous leishmaniasis Buruli ulcer Other causes of ulceration Malignancies sporotrichosis

9. Scrofuloderma Direct invasion of tubercle bacillus into skin from an underlying contiguous tuberculous focus Commonest form of cutaneous tuberculosis

10. Clinical Variant Extensive ulcerative lesions

11. Differential Diagnosis Actinomycosis Bacterial abscess Sporotrichosis Mycobacterium avium complex lymphadenitis

12. Orificial Tuberculosis Painful ulcerated lesions due to tuberculous infection of mucosa or skin adjoining orifices Patient usually have advanced internal tuberculosis

13. Differential Diagnosis Crohn disease Mucocutaneous leishmaniasis Oral paracoccidiomycosis Herpes simplex infectio n

14. Acute cutaneous miliary tuberculosis Haematogenous spread of tubercle bacilli into skin Seen in advanced pulmonary or meningeal and disseminated tuberculosis

15. Metastatic Tuberculous Abscess Disseminated haematogenous spread of mycobacteria Single or multiple dermal subcutaneous nodules Lesions break down to form ulcers

16. Differential Diagnosis Pyogenic bacterial infections Syphilis Non-tuberculous mycobacterial infections Pyoderma gangrenosum

17. Warty Tuberculosis Indolent,warty,plaque -like form of tuberculosis Exogenous inoculation of M.tuberculosis into skin through open wounds or abrasion Common in Asia

18. Differential Diagnosis Warts Blastomycosis Actinomycosis Leishmaniasis Chromoblastomycosis

19. Lupus Vulgaris Chronic,progressive,paucibacillary form of cutaneous tuberculosis Hematogenous spread from an underlying tuberculin focus or by direct inoculation Most prevalent form of cutaneous tuberculosis More common in women

20. Plaque form

21. Ulcerative and Mutilating forms

22. Vegetating Forms

23. Tumor like form

24. Papular and Nodular form

25. Mucosal Involvement

26. Differential diagnosis Sarcoidosis Lupus erythematosus Deep mycosis Lichen simplex chronicus Leprosy

27. Complications and co-morbidities Scarring,contractures,tissue destruction Invasive squamous cell carcinoma Basal cell carcinoma

28. Histopathology

29. Diagnostic tests for Cutaneous tuberculosis Mycobacterial DNA by PCR T-SPOT test Tuberculin test

30. Diagnostic Criteria for cutaneous tuberculosis Mycobacterium tuberculosis in either tissue culture from skin biopsy or cytological smear Mycobacterial DNA by PCR The presence of active, proven tuberculosis elsewhere in the body

31. The presence of acid‐fast bacilli in the lesion itself A positive reaction to tuberculin Positive IFN‐γ release assay The effect of specific therapy

32. Tuberculids Cutaneous hypersensitivity reactions to haematogenous dissemination of Mycobacterium tuberculosis Antigen from a primary source in an individual with strong antituberculosis cell-mediated immunity.

33. Diagnostic Criteria Tuberculoid histology on skin biopsy Strong positive Mantoux reaction Absence of M.tuberculosis in the smear Negative culture Resolution of skin lesions with anti-tuberculous therapy.

34. Classification Micropapular : lichen scrofulosorum Papular : papulonecrotic tuberculid Nodular: erythema induratum of Bazin or nodular tuberculid

35. Lichen scrofulosorum Causative Organisms : Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium avium Mycobacterium szulgai

36. Clinical Variants Lichenoid Psoriasiform Granuloma annulare

37. Differential Diagnosis Lichen nitidus Keratosis spinulosa Keratosis pilaris Papular sarcoidosis Secondary syphilis

38. Papulonecrotic Tuberculid Causative Organisms : Mycobacterium tuberculosis Mycobacterium kanassi Mycobacterium avium Mycobacterium bovis

39. Differential Diagosis Pityriasis lichenoides Leukocytoclastic vasculitis Nodular prurigo

40. Erythema induratum of Bazin Most common form of tuberculid Causative Organisms : Mycobacterium tuberculosis Mycobacterium bovis Mycobacterium chelonae

41. Differential Diagnosis Erythema nodosum Pancreatic panniculitis Lupus profundus Subcutaneous sarcoid Cutaneous T-cell lymphoma

42. Histopathology

43. Treatment First-Line Second-Line Isoniazid Rifampicin Ethambutol Pyrazinamide Cycloserine Ethionamide Levofloxacin Moxifloxacin p- Aminosalicylic acid Streptomycin Amikacin/kanamycin Capreomycin

44. Atypical Mycobacteria Environmental organisms in soil and water Disease in immunocompromised hosts Causative organisms : Mycobacterium Marinum Mycobacterium Ulcerans Mycoabcterium avium complex Mycobacterium fortuitum complex

45. Mycobacterium Marinum Infection Disease in fish species Human infection due to contact with contaminated water or fish

46. Differential Diagnosis Leishmaniasis Sporotrichosis Other atypical mycobacterial infections i.e. mycobacterial kanasii Complications and Co-morbidities : Tenosynovitis Myelitis bursitis Septic arthritis

47. Treatment Preventive measures Chlorination of swimming pools Clarithromycin Combination drugs in case of deeper structure infection Azithromycin Amikacin Surgical debridement of lesions Photodynamic therapy

48. Mycobacteria Ulcerans Infections

49. Differential Diagnosis Ulcerated tuberculous lesions Cellulitis Pyoderma gangrenosum Foreign body granuloma Deep fungal infections Complication and Co-morbidities : Bone involvement contractures

50. Treatment First line : Oral Rifampicin(10mg/kg) and intramuscular streptomycin(15mg/kg) for 8 weeks Surgery Second line : Rifampicin 10mg/kg and amikacin 15mg/kg for 8 weeks Third line : Rifampicin and clarithromycin for 8 weeks

51. References World Health Organization. Use of high burden country lists for TB by WHO in the post-2015 era (discussion paper). Geneva: World Health Organization; 2015 (https://www.who.int/tb/publications/global_report/high_tb_ burdencountrylists2016-2020.pdf, accessed 28 July 2020)   Brasil . Ministério da Saúde . Secretaria de Vigilância em Saúde . Departamento de Vigilância Epidemiológica . Manual de Recomendações para o Controle da Tuberculose no Brasil .  Ministério da Saúde ; Brasília: 2011. 284 p. (Série A. Normas e Manuais Técnicos - Series A. Standards and Technical Manuals). [ Google Scholar ] Ramam M, Malhotra A, Tejasvi T, Manchanda Y, Sharma S, Mittal R, et al. How useful is the Mantoux test in the diagnosis of doubtful cases of cutaneous tuberculosis? Int J Dermatol. 2011;50:1379–1382. [ PubMed ] [ Google Scholar ]