Cutaneous tuberculosis
 
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Ira Shah
Medical Sciences Department, Pediatric Oncall, Mumbai, India

Address for Correspondence: Dr Ira Shah, 1, B Saguna, 271, B St Francis Road, Vile Parle {W}, Mumbai 400056


Clinical Problem :
A 3 years old boy presented in December 2014 with reddish patch of 1 cm diameter over left cheek for the past 1½ years. He had been to various dermatologists for the same but had no relief. A biopsy done in October 2014 showed patchy nodular tuberculoid granulomatous infiltrate made up of lymphocytes, plasma cells, histiocytes and epithelioid cells with occasional langerhans giant cells suggestive of tuberculosis. There was no contact with a patient having TB. He was started on antituberculous therapy {ATT} and referred for further management. On presentation, weight was 12.7 kg, height was 90 cm. He had chancre over left cheek. Other systems were normal. On enquiry, mother gave history of taking bath from bore well water prior to onset of rash. His mantoux test was 1.7 cm and chest X-Ray was normal. He was continued on ATT and clarithromycin was added to cover atypical organisms.


Question :
How to manage cutaneous TB_?

Expert Opinion :
Cutaneous tuberculosis {TB} is skin TB that can be caused by Mycobacterium tuberculosis {MTB}, Mycobacterium bovis, non-tuberculous mycobacteria {NTM} and the Bacille Calmette-Guérin {BCG} vaccine. {1,2} Nearly every pathogenic species of NTM may cause skin and soft tissue infections. It is quite rare and difficult to diagnose. TB is an airborne transmissible disease with skin manifestations presenting as a result of hematogenous spread or direct extension from a latent or active foci of infection. However, primary inoculation may occur as a direct introduction of the mycobacterium into the skin or mucosa of a susceptible individual by trauma or injury with water or other contaminated products {1,3} Through direct inoculation, it can cause tuberculous chancre, tuberculosis verrocosa cutis and lupus vulgaris. Through hematogenous spread, it can cause acute miliary TB, metastatic TB abscess {gummatous TB}, papulonecrotic tuberculid and lupus vulgaris. Spread from contiguous area can cause scrofuloderma, orificial TB. {4} Tuberculous chancre typically follows a penetrating injury that results in the direct introduction of mycobacterium into the skin or mucosa of an individual with no previous TB infection. Within 2 to 4 weeks, an inflammatory papule develops at the inoculation site and evolves into a firm, shallow, non-tender, non-healing, undermined ulcer with a granulomatous base {1} Diagnosis is based on histopathology, culture from the skin lesion. However yield is poor and PCR may be a more useful test which also helps in identification of the species. Screening for internal organ assessment should be done to rule out endogenous TB. The treatment of cutaneous TB is the same as that for systemic TB. NTM are resistant to conventional antituberculous drugs and macrolides form the mainstay of therapy. In our patient, we were unable to do PCR test on the chancre. In view of exposure to bore well water, and isolated cutaneous TB, he was suspected to have inoculation as direct exposure and thus cover for NTM was also added.

References
1. Frankel A, Penrose C, Emer J. Cutaneous Tuberculosis. J Clin Aesthet Dermatol. Oct 2009` 2: 19–27.
2. Wentworth AB, Drage LA, Wengenack NL, Wilson JW, Lohse CM. Increased incidence of cutaneous nontuberculous mycobacterial infection, 1980 to 2009: a population-based study.
3. Alcaide F, Esteban J. Cutaneous and soft skin infections due to non-tuberculous mycobacteria. Enferm Infecc Microbiol Clin. 2010`28 Suppl 1:46-50
4. Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM. Cutaneous tuberculosis: diagnosis and treatment. Am J Clin Dermatol. 2002` 3:319-328. Mayo Clin Proc. 2013` 88:38-45


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