Cutaneous Tuberculosis

Digital Lecture Series : Chapter 09

Dr. (Prof.) Archana Singal

University College of Medical Sciences
& GTB Hospital,
New Delhi
 CONTENTS
 Introduction  Management
 Epidemiology • General Principles
 Etiopathogenesis- • Investigations
• Etiological agent • Treatment
• Host-Pathogen interaction • Resistance
• Presdisposing factors  MCQs
 Clinical classification  Photoquiz
• Exogenous/inoculation
• Endogenous
• Tuberculide
 Differential diagnosis
 Introduction
 Tuberculosis (TB), one of the oldest infectious disorders
 Organism identified 130 yrs back by Robert Koch(1882)
 Intradermal Skin test developed 100 yrs back by Charles Mantoux
 TB vaccine in use for 80 yrs (1928)
 Chemotherapy in use for 50 yrs (1963)

STILL

 2nd most common infectious cause of death after HIV/AIDS worldwide

 Pulmonary TB remains to be the most common form of TB
 TB of extra-pulmonary sites such as lymph nodes, bone, skin, abdomen
and pelvis is on a steady rise.
 Epidemiology

Globally -
 Cutaneous TB (CTB) is less common clinical forms of TB
 About 1% to 2% of total extrapulmonary cases
 Incidence of 0.07% has been reported in a 10-year survey from Hong
Kong.

India -
 CTB constitutes 10% cases of all extrapulmonary TB
 And 0.1% - 2% of total skin OPD patients
 Lupus vulgaris is considered the commonest form of CTB in adults and
Scrofuloderma in children
 Tuberculides especially lichen scrofulosorum (LS) has emerged as the
commonest variant in many regions including India
 HIV Infection & TB

 Life time risk with HIV – 50%

 In developing world 50% are co-infected

 World over 4 million people are co-infected

 5% develop disseminated infection which is the cause of death
 Etiology

 M. Tuberculosis major etiological agent

 M. bovis 1 – 1.5%

WITH HIV

 M. avium complex 2 / 3 cases

 M. tuberculosis 10% cases
 M. kansasii
 M. scrofulaceum
 Pathogenesis

 No known endotoxin
 Tissue destruction mediated by host immune response

 Skin manifestation depends on

• Sensitization status of the patient
• Cellular immunity
• Route of infection

contd.
 Pathogenesis

EXPOSURE (BCG/Pri. Pulm. Infection/Skin Inoculation)

Mycobacteria engulfed by macrophages

Antigen presented to CD4+ TH1 cell

(In 2-3 weeks)

Hypersensitivity / Granuloma Formn / Caseous Necrosis

Disease Arrested Latent Infection Progressive Disease (5-10%)

 Predisposing factors

 HIV pandemic leading to resurgence in TB & drug resistant strains of M.

tuberculosis,
 Use of immunosuppressive therapy,
 Ease of global travel and migration,
 Poverty and malnutrition

Factors affecting host-pathogen interaction

 Virulence of the infecting mycobacteria
 Route of infection
 Prior contact with the bacilli
 Host’s immune response
 Environmental factors
 Routes of infection

Exogenous
 Direct inoculation of TB bacilli from an infected person to susceptible one,
through breach in the skin at the site of trauma

Endogenous
 Through contiguous involvement of skin
 Through lymphatic spread
 Through haematogenous dissemination

Autoinoculation
 Classification of Cut TB (Beyt et al)

Exogenous cutaneous tuberculosis

Tuberculous chancre
Tuberculosis verrucosa cutis (TBVC)

Endogenous cutaneous tuberculosis

By contiguity or autoinoculation
 Scrofuloderma (SFD)
 Orificial tuberculosis
 Lupus vulgaris (some cases) LV

contd.
 Classification of Cut TB (Beyt et al)

By hematogenic dissemination
 Lupus vulgaris (LV)
 Tuberculous gumma
 Acute miliary tuberculosis

Tuberculids
 Papulonecrotic tuberculid (PNT)
 Erythema induratum of Bazin (EIB)
 Lichen scrofulosorum (LS)
 Phlebitic tuberculid*

*Phlebitic’ or ‘nodular granulomatous phlebitis’ has been recently proposed as a new

tuberculid
 Tuberculous chancre (Primary Inoculation TB)

 Rare form of CTB, develop in adults without previous sensitization to

Mycobacterium Tuberculosis; natural or artificial

 Usually follows
• Abrasion, cuts and ulcers
• Circumcision
• Tattooing and Ear piercing with unsterilized needles
• Contact with infected sputum

 Localized form
 Site - Face and extremities
 After 2-4 weeks of inoculation

Firm, painless and brownish papule

2-3 weeks 3-8 weeks

Firm, non-tender ulcer Regional LAP
with undermined bluish margins (Primary Complex)

- Slow healing in up to Subsides with calcification

- 12 months with scars Rarely cold abscess
- Rarely progression to & sinuses develop
- LV or SFD in untreated
Post Tattoo inoculation TB in two brothers that progressed to LV.
 Tuberculosis verrucosa cutis (TBVC)
Syn: warty tuberculosis
 Exogenous inoculation at trauma prone sites in pre-sensitized hosts with
moderate to high degree of immunity
• Accidental – physicians, pathologists, post mortem attendants
• Autoinoculation by sputum in active pulmonary TB patients
• Accidental inoculation from infected sputum
Clinically - Wart like papule & verrucous plaque
 Regresses or heals with a thin scar
 Lymphadenitis is rare
Sites- Finger, hands & feet, ankle
Warty lesions of TBVC in adults with
good immunity on extremities
(trauma prone sites) Left foot, left
palm and sole of the left foot.
 Differential Diagnosis of TBVC

 Hypertrophic lichen planus

 Verruca vulgaris
 Chromoblastomycosis

 Leishmaniasis
 Scrofuloderma (SFD)

 SFD occurs as a result of contiguous spread from an underlying primary

tubercular focus like
• Lymph nodes or
• Bone
• Joints or
• Testicles
 Age - More common in children but affects all age groups
 Lymph nodes - Cervical lymph nodes most common followed by axillary,
pre and post auricular, submandibular, Inguinal
 Clinical features of Scrofuloderma

Firm, subcutaneous nodule, fixed to the

overlying skin

Cold abscess formation overlying LN/ Bone/ Joint

Secondary ulceration, sinus tract formation

Ulcer has undermined edges and

bluish boggy margin
Clockwise:
1. Tubercular abscess overlying rib cage
with impending rupture. Pus smear from
aspirate on ZN staining showed numerous
AFB i.e M. tb
2. Scrofuloderma overlying cervical and
supraclavicular TB lymphnodes
3. Scrofuloderma overlying TB focus in
the bone i.e 2nd metacarpal bone which
shows a lytic lesion on x-ray
Young girl with SFD with underlying TB focus in cervical Lymph nodes
 Course

 Scrofuloderma runs a very protracted course

 It tends to heal spontaneously over months and years

 Leave behind cerebriform or bridging scars and pockets of retraction

 Underlying focus of TB in bone/ joint, may reveal osteolytic lesions in

bone
 Differential Diagnosis

 Bacterial abscesses / Bacterial osteomyelitis

 Hidradenitis suppurativa

 Atypical mycobacterial infection ([Link] and M. scrofulaceum)

 Sporotrichosis

 Actinomycosis
 Tumor metastasis
 Orificial TB (Syn Tuberculosis cutis orificialis)

 Rare form that affects middle-aged / elderly man with impaired CMI .
 Follow autoinoculation of Mycobacterium Tuberculosis into skin/ mucosa
of the adjoining orifices in patients with advanced
• intestinal or
• Genitourinary
• pulmonary TB
 Site -
• Around mouth
• Perianal region
• Ext genitalia
 Orificial Tuberculosis

 Small, edematous reddish nodule

Breaks down
 Painful, non-healing, shallow ulcers with undermined bluish edges

 Course – Prognosis : is poor due to

• Advanced internal disease and
• Compromised immunity
 Lupus vulgaris (LV)
 Most common type of Cut TB
 Paucibacillary disease in pts. with moderate to high immunity
 Affects all age group
 Sites - Head & neck, Gluteal region

The infection is acquired by

 Lymphatic spread or
 Hematogenous spread or
 Direct extension from a tuberculous focus
 At site of inoculation
 Clinical Features
 Reddish brown, flat plaque
 Extends slowly, peripherally with central atrophy and scarring. May result
in contractures
 Apple jelly nodules at the advancing edges
 May lead to destruction of underlying cartilage
 Regional lymphadenopathy present
 SCC may develop in scar or chronic ulcer
 Clinical Variants

 Plaque

 Ulcerative & mutilating

 Hypertrophic

 Vegetating & tumor like

 Atrophic and plantar
Clockwise: Lupus vulgaris ( LV)
1. LV of nose in a young girl child leading
to destruction and mutilation of nose
(cartilage and bone both)
2. Multi focal LV with characteristic
central clearing and advancing margins in
a young boy
3. Lesion of LV on buttock in an adult
male
 LUPUS VULGARIS

Classic lesions of LV with central clearing and advancing margin on

the elbow and face of young boys
 Differential Diagnosis of Lupus Vulgaris

 Sarcoidosis

 Hansen’s disease
 Lupus erythematosus

 Granuloma faciale
 Leishmaniasis

 Squamous cell carcinoma

 Tuberculous gumma (Syn. Metastatic Tuberculous Abscess)
 Hematogenous dissemination of Mycobacterium Tuberculosis from a
primary TB focus during lowered resistance/decreased immunity
 Undernourished children, immunocompromised patient
 Single/multiple firm, nontender,erythematous nodule

Breakdown to form undermined ulcers & sinuses

 Subsequent course similar to scrofuloderma
 Pus may be positive for AFB
Tuberculosis Gumma
 Acute miliary tuberculosis

 Rare and severe form of TB seen in very ill patients

 Massive hematogenous dissemination of Mycobacterium Tuberculosis into skin
 Affects young children, immunosuppressed, HIV co-infected and following
measles or other exanthems

Clinically
 Profuse crops of minute bluish papules, vesicles, pustules
 May become necrotic to form ulcers
 Poor prognosis but occasionally may respond to Rx.

Differential Diagnosis
 Varicella, enteroviral exanthem, Pityriasis lichenoides et varioliformis acuta
(PLEVA)
 Tuberculides: Definition and diagnostic criteria

 Tuberculides represent cutaneous immunologic reaction to the presence

of Mycobacterium Tuberculosis or their products in a patient with
significant immunity

Diagnostic Criteria
 Tuberculoid histology on skin biopsy
 Absence of organism in smears
 Negative mycobacterial culture
 Evidence of tubercular focus elsewhere; Active or healed
 Strongly positive tuberculin test and
 Swift resolution of the lesions with ATT
 Classic Tuberculide

 Micropapular- Lichen scrofulosorum (LS)

 Papular- Papulonecrotic tuberculid (PNT)
 Nodular- Erythema induratum of Bazin (EIB)

 The recently described ‘phlebitic tuberculid’, ‘nodular granulomatous

phlebitis’ or ‘superficial thrombophlebitic tuberculid’ may necessitate its
inclusion as the fourth member of the tuberculide spectrum
 Lichen Scrofulosorum (LS)

 LS is one of the most common presentations in children.

 Asymptomatic, 0.5-3mm, closely grouped, skin coloured to erythematous,
follicular or perifollicular, flat-topped to spinous papules on truck, back
and proximal limbs
 LS confined to the vulva; genital tuberculid
 Underlying focus of TB include
• TB LAP
• Pulmonary TB
• Skin TB
• Rarely Abdominal, intracranial and endometrial foci
 A systemic focus of TB is detected in a majority of LS cases
Grouped, skin colored, mildly scaly follicular papular lesions of LS in a patient with
strongly positive Mantoux and Pulm focus of TB
Positive Mantoux test with blistering
after 48 hrs

Pulmonary Kochs
 Papulonecrotic Tuberculide
 Recurrent crops of
 Symmetrically distributed
 Firm, dusky red necrotizing papules and pustules
 Predominantly over the extremities
 Isolated lesions involving male genitalia (genital tuberculid) in children
as well as adults
 Lymphadenopathy may be present
 Associated pulmonary TB
 Constitutional symptoms such as fever and asthenia may precede
cutaneous manifestations
Differential diagnosis: Varicella and PLEVA
Multiple extensive PNT lesions in a severely malnourished and febrile young girl
with Pulmonary Koch’s
Erythema Induratum of Bazins

Indolent and recurrent nodular lesions

 Site: calves; may occur on upper
limbs, thighs, buttocks and trunk
 Affects young or middle-aged obese
women
 Tend to ulcerate during winters
forming ragged, irregular & shallow
ulcers with a bluish edge
 Resolution is slow even with
adequate ATT
 Management of Cutaneous Tuberculosis
General Principles

 Notification

 Identification and treatment of the underlying tuberculous focus which is

identifiable in ½ to 1/3rd of cases
 Identification and treatment of co-existent infections such as HIV
 Specific chemotherapy

 Family screening
 Ancillary measures
 Investigations

Hematological
 CBC with ESR
 LFT
 RFT

Mantoux test

Sputum for AFB

Radiological
 X-ray chest
 Radiograph of the affected region- bone
 USG Abdomen
 CECT – chest And MRI – selected cases
 Investigations
 FNAC
 Skin Biopsy
 Mycobacterial culture-
• LJ medium (Lowenstein Jensen)
• BACTEC 460 liquid medium
 PCR
 Antigen detection
 Biochemical characteristics
 Histology of Cutaneous TB
 Hall mark is presence of characteristic granuloma composed of epitheloid
cells, lymphocytes and Langhan’s giant cells

 Based on host immune response, histology of CTB may be grouped into

three groups_
• Well-formed granulomas with absence of caseous necrosis: Lupus
Vulgaris and Lichen Scrofulosorum.
• Granulomas with caseous necrosis: TBVC, tubercular chancre, acute
military tuberculosis, tuberculosis orificialis and Papulonecrotic
tuberculide.
• Presence of poorly formed granulomas with intense caseous necrosis:
Scrofuloderma and TB gumma
Compact epithelioid cell granuloma in mid and upper dermis in LV
 Diagnosis

Absolute criteria
 Positive culture from lesion
• LJ (Lowenstein Jensen) medium
• BACTEC Culture
 Successful guinea-pig inoculation
 Identification of mycobacterial DNA by PCR

Other indicators
 Characteristic histopathology
 Positive tuberculin test
 Presence of active proven TB elsewhere
 Presence of AFB in the lesion
 Response to ATT
 Drug Regimen

The standard regimens comprise of:

 Initial intensive phase (Phase I)

Rapidly destroys large populations of multiplying mycobacteria.

 Continuation phase (Phase II)

Eliminates persistent dormant organisms.
 Treatment
 Duration6 months
 Category I
 Regimen2 (HRZE) + 4 (HR) Daily or
 DOTS Thrice weekly
Drug Daily Tx DOTS
mg/kg/d (Total) mg/kg/d (Total)
Isoniazid 5 (300) 10 (600)

Rifampicin 10 (450) 10 (450)

Pyrazinamide 25 (1500) 25 (1500)

Ethambutol 15 (800) 20 (1200)

 Special Considerations

 Surgical intervention may be required along with ATT

 Plastic Surgery in cases of disfigurement due to Lupus Vulgaris, to release
contractures
 HIV-positive- Standard regimen is effective
 HIV-infected individuals: higher drug reaction and infection rates
 Drug Resistance in Cut TB

 Multidrug-resistant tubercle bacilli (MDR-TB) are isolates showing

resistance to Rifampicin & INH , with or without resistance to other drugs
 Extensively drug-resistant TB (XDR-TB) as tubercular infections caused by
Mycobacterium Tuberculosis resistant to both INH and Rifampicin as well
as a fluoroquinolone, and at least one second-line injectable agent
(capreomycin, amikacin,or kanamycin)
 Recently few cases of MDR Cut TB have been reported from India.
 MDR TB should be thought of when reasons such as poor Rx compliance,
inadequate doses and wrong diagnosis have been carefully excluded
 MCQ’S

Q.1) What is the classification system used for Cutaneous Mycobacterial

infection?
A. Schobinger's classification
B. Freidrikson's classification
C. Beyt's classification
D. Luxar and Zulian classification

Q.2) Which of these precludes a diagnosis of Tuberculid?

E. Positive tuberculin test
F. Partial response to Antituberculous therapy
G. Negative Mycobacterial Culture
H. Past history of Pulmonary Tuberculosis
 MCQ’S

Q.3) Which of the following malignancies are known to occur in long standing
case of lupus vulgaris?
A. Squamous cell carcinoma
B. Basal cell carcinoma
C. Sarcoma
D. Malignant melanoma

Q.4) Which of the lymph nodes are commonly involved in cutaneous

tuberculosis ?
E. Axillary
F. Cervical
G. Inguinal
H. Epitrochlear
 MCQ’S

Q.5) A 25 year old male presented with an asymptomatic plaque on the right
side buttock with active spreading edge at one end and scarring at the
other end since 1 year. What is the likely diagnosis?
A. Scar sarcoid
B. Lupus vulgaris
C. Hypertrophic lichen planus
D. Tuberculosis verrucosa cutis
 Photo-Quiz

Q. Identify the type of tuberculosis and describe evolution of

lesion ?
 Photo-Quiz

Q. Identify the type of Cut TB?

 Photo-Quiz

Q. Identify the type of Cut TB ?

Thank You!