Você está na página 1de 55

SKIN TUBERCULOSIS

INTRODUCTION
• Tuberculosis usually affects the lung, but virtually all other
system may be involved : intestine, kidney, lymph node,
bones, joints, epididymis, skin ( called EXTRA
PULOMONARY TUBERCULOSIS).
• Tb of the skin is a relatively rare, with a wide spectrum of
clinical finding depending on the source of infection & the
immune status of the host.
• The most prevalent in Indonesia : scrofuloderma, tb verucosa
cutis
1
EPIDEMIOLOGY
• First recognized in 1826 by Laennec
• IT NOW OCCURS MOSTLY IN THE TROPICS
• IN THE TROPICS (INDONESIA), THE MOST
FREQUENT FORMS OF SKIN TB ARE
SCROFULODERMA & TB VERUCOSA CUTIS.
• IN EUROPEAN & AMERICAN COUNTRIES,
LUPUS VULGARIS & SCROFULODERMA ARE
MORE FREQUENT.
• LV IS MORE THAN TWISE IN WOMEN
• TB VERUCOSA CUTIS IS MORE COMMON IN
MEN

2
CLASSIFICATION
OF SKIN TUBERCULOSIS
1. Exogenous infection :
a. Primary inoculation tuberculosis
b. Tuberculosis verucosa cutis

2. Endogenous spread :
a. Lupus vulgaris
b. Scrofuloderma
c. Acute miliary tuberculosis
d. Orificial tuberculosis
e. Tubereculous gumma (Metastatic tuberculous abs
cess.
3. Tuberculid
3
ANOTHER CLASSIFICATION
PILLSBURRY CLASSIFICATION :

A. TRUE TUBERCULOSIS
1. Primary skin tuberculosis :
a. Tuberculous chancre/ Primary
inoculation tuberculosis/ Tuber-
culous primary complex.
b. Tuberculosis cutis milliaris

2. Secondary skin tuberculosis :


a. Scrofuloderma
b. Tuberculosis verucosa cutis
c. Tuberculous gumma/ Metastatic tuberculous
abscess.
d. Orificial tuberculosis/ Tuberculosis ulcerosa cutis et muco-
sae.
e. Lupus vulgaris
B. TUBERCULID

4
Other classification:
A. Multibacillary form:
1. Direct inculation:
- Primary inoculation tuberculosis (chancre)
- Skrofuloderma
- Perioral tuberculosis
2. Hematogenous spread:
- Acute milliary tuberculosis
- Metastatic abscess (gumma)
B. Paucibacillary form:
1. Direct inoculation:
- Tuberculosis verrucosa cutis (warty tuberculosis)
- Lupus vulgaris
2. Hematogenous spread:
- Lupus vulgaris
- Tuberculid papulonecrotic, erythema induratum, lichen scrofulosorum

5
ETIOLOGY
All forms of skin tuberculosis are caused by

• M. tuberculosis
• M. bovis
• The attenuated BCG organism

6
PATHOGENESIS
THERE ARE 5 ROUTES OF SKIN TB :

• Continuous extension of tb process in the


skin overlying another site of infection (e.g.
tb lymphadenitis, tb of bones and joints or
tb epididymis) --- > scrofuloderma.
• Auto-inoculation --- > orificial tb/ tb
ulcerosa cutis et mucosae.
7
Pathogenesis (continued)
• Hematogenous --- > tb cutis miliaris, LV
• Lymphogen --- > lupus vulgaris (LV)
• Exogenous inoculation ---- > tb verucosa
cutis or tuberculous chancre depending
on the immunologic state of the host.

8
TUBERCULIN REACTION
• This reaction is a delayed type, induced by
mycobacteria during primary infection.
• The “old tuberculin” has now been
replaced by PPD (Purified Protein
Derivative)
• The method most widely used is ID
injection --- > leads to local tuberculin
reaction --- > erytheme & induration > 10
mm (+).
9
SCROFULODERMA
(tuberculosis colliquativa cutis)
• Scrofuloderma is subcutaneous tb leading to
cold abscess formation & a secondary
breakdown of the overlying skin.
• The underlying infections could be : lymph node,
bones, joints, testis or epididymis.
• The infections on lymph nodes, bones, joints,
testis and epididymis could be caused by
hematogenous spreads of tb infection from the
lung, kidney or other tb process in the body.
• The most common of skin tb in Indonesia & India

10
Scrofuloderma (continued)
• It first presents as a firm, sc nodule, usually well
defined, freely movable, and asymptomatic.
• As the lesion enlarges it softens.
• After months, liquefaction with perforation
occurs, causing ulcers and sinuses.
• The ulcers are linear, undermined, bluish edges
and soft (livide), granulating floors, without
indurations, and no painful.
• Skin bridge developed.
• Tuberculin sensitivity is usually pronounced.
11
12
Scrofuloderma (continued)
Hitopathology :
- Massive necrosis & abscess formation in
the centre of lesion are non spesific.
- The periphery of the abscesses or margins
of the sinuses contain tuberculoid
granuloma.

13
Scrofuloderma (continued)
Diagnosis :
- Clinical manifestation (anamnesis, physical
examination). If there is an underlying tuberculous
lymphadenitis/ bones/ joints disease/testis, the diagnosis
usually presents no difficulty.
- Tb process in another site of the body (e.g. pulmonary/
kidney tb or others)
- PPD test is strongly positive.
- Laboratoric examinations (Ziehl Neelsen), culture on
Lowenstein media. Positive results on culture confirm the
diagnosis.

14
Differential dignosis of
scrofuloderma
• Syphilitic gumma
• Sporotrichosis
• Actinomycosis
• Hydradenitis suppurativa
• Atypical mycobacterial infections

15
TUBERCULOSIS VERRUCOSA
CUTIS (warty tuberculosis)
Pathogenesis :
- Tb verrucosa cutis caused by exogenous
re-infection (inoculation) in previously
sensitized individuals with high immunity.
- Inoculation occurs at sites of minor
wounds or rarely from own patient sputum.
- Children may become infected playing on
contaminated ground.
16
Tb verrucosa cutis (continued)
Epidemiology :
- The second most frequent form of skin tb
in Indonesia.
- More often found in men.
- In adults, these tend to be occupational
lesions of pathologists: prosectors warts or
butcher’s warts.

17
Clinical manifestations :
- Lesions usually occur on the hands or in children on the lower
extremities as a small asymptomatic papule or papulo- pustule with
a purple inflammatory halo.
- They become hyperkeratotic and are often mistaken for a common
wart.
- Slow growth and peripheral expansion lead to the development of a
verrucous plaque with an irregular border.
- The lesion usually is solitary, but multiple lesions may occur.
- Regional lymphnodes are rarely affected.
- Spontaneous involution eventually occurs, leaving an atrophic scar.

18
19
Differential diagnosis :

- Wart or keratosis
- Chromomycosis
- Hypertrophic lichen planus
- Squamous cell carcinoma

20
ORIFICIAL TUBERCULOSIS
(tb ulcerosa cutis et mucosae)
Pathogenesis :
- Orificial tb is a rare form of tb of the mucous
membranes and orifices that is caused by auto-
inoculation of mycobacteria from progressive tb
of internal organs (e.g pulmonary tb/ intestine tb/
kidney tb and others).
- Mycobacteria shed from these foci in large
numbers are inoculated into the mucous
membranes.

21
Clinical manifestations :
- In patient with pulmonary tb, the lesion can develop
around the anus or lip.
- A small yellowish/ reddish nodule appears on the
mucosa and breaks down to form a soft ulcer with a
typical punched-out appearance, undermined edges,
and circular, irregular border.
- The ulcer floor bleed easily.
- The surrounding mucosa is edematous and inflamed.
- Lesion may be single/ mutiple, extremely painful
resulting dysphagia.

22
23
• The tongue is most frequently affected,
particularly the tip and the lateral margins.
• Soft and hard palate are also common site
• In advanced cases the lip are involved and oral
condition often represents an extension of
ulcerative tb of the pharynx and larynx.
• In patients with intestinal tb, lesion develop
around the anus, and in females with active
genitourinary disease, the vulva is involved.

24
• Histopathology

- there is a massive non-spesific inflamma-


tory infiltrate and necrosis, but tubercles
with caseation may be found deep in the
dermis.
- Mycobacteria are easily demonstrated.

25
• Course :

* Orificial tb is a symptom of advanced


internal disease and usually portends a
fatal outcome.

* The result of tuberculin test is negative


(false negative --- > anergy)
26
TUBERCULOUS CHANCRE
(primary inoculation tb, tb primary
complex)
• Tuberculous chancre & affected regional lymph
nodes --- > constitute the tb primary complex in
the skin.
• It is rare, but in some regions with a high
prevalence of tb & poor living conditions, the
disease is not un
• usual.
• Children are the most affected.
• Sites of predilection are the face, including the
conjunctivae and oral cavity, as well as the
hands & lower extremities.
27
28
• Pathogenesis :
* tubercle bacilli are introduced into the
tissue at the site of minor wounds.

* oral lesions may be caused by bovine


bacilli in non-pasteurized milk and oc-
cur after mucosal trauma or tooth ex-
traction.
29
• Clinical manifestation

- The chancre initially appears 2-4 weeks after inoculation and


presents as a small papule, crust, or erosion with little tendency to
heal.
- A painless ulcer develop, the diameter can reach > 5 cm.
- The ulcer is undermined and of reddish blue hue, with granular or
hemmorrhagic base with miliary abscesses or covered by necrotic
tissue.
- They become indurated with thick adherent crusts.
- Mucosal infections result in painless ulcers or fungating granuloma.
- Inoculation tb of the finger may present as a painless paronychia.

30
• Inoculation of punture wounds may result in
subcutaneous abscesses.
• Slowly progressive regional lymphadenopathy
develops 3-4 weeks after the infection.
• After weeks or months, cold abscess may
develop that perforate to the surface of the skin
and form sinuses.
• The regional lymphnode may also be involved.

31
• Body temperature may be slightly elevated
• In half the patients, fever, pain and swelling
simulate a pyogenic infection.

Histopathology :
- Early, there is an acute non spesific inflam
matory reaction.
- Mycobacteria are easily detected
- After 3-6 weeks the infiltrate and regional
lymphnodes acquire a tuberculoid appearance
and caseation may occur.
32
• Course :

- Untreated, the condition may last up to 12 months.

- Rarely, LV develop at the site of a healed tb chancre.

- Hematogenous spread may give rise to tb of other


organs, particularly of the bones and joints. It may also
lead to miliary disease with a fatal outcome.

- Erythema nodosum occurs in approximately 10 % of


cases.

33
• Differential diagnosis :

- Syphilis
- Sporotrichosis
- Pyogenic infection

34
• Diagnosis

- Any ulcer with little or no tendency to heal & unilateral


regional lymphadenopathy in a child --- > should arouse
suspicion.

- Mycobacterium tb are found

- The d/ is confirmed by bacterial culture

- Initially, PPD reaction is negative, but latter convert to


positive as immunity develops.

35
LUPUS VULGARIS
• LV is an extremely chronic progressive
form of cutaneous tb.
• It occur on individuals with moderate
immunity & a high degree of tuberculin
sensitivity.
• Females appear to affected 2-3 than
males.
• All age groups are affected equally.
36
LUPUS VULGARIS (continued)
PATHOGENESIS

• LV IS A POSTPRIMARY TB
• THE ROUTE OF INFECTIONS COULD BE
HAEMATOGENOUS (from pulmonary tb or others),
LYMPHATIC, OR CONTIGUOUS SPREAD FROM
ELSEWHERE IN THE BODY
• SPONTANEOUS INVOLUTION MAY OCCUR & NEW
LESIONS MAY ARISE WITHIN OLD SCAR.
• COMPLETE HEALING RARELY OCCURS WITHOUT
THERAPY.

37
• Clinical manifestation

- Usually solitary lesion, but 2 or more sites may be


involved simultaneously.
- Location : > 90 % on the head and neck
- LV usually starts on the cheek, nouse and earlobe, than
slowly extends onto adjacent regions.
- The initial lesion is a brownish red, soft or friable macule
or papule with smooth or hyperkeratotic surface. On
diascopy the infiltrate exibits a typical apple jelly color.
- Progression is characterized by elevation, a deeper
brownish color and formation of a plaque.
38
39
• Involution in one ares with expansion in
another often results in a gyrate outline
border.
• Involvement of the nasal or auricular
cartilage may result in extensive
destruction & disfigurement
• Atrophic scarring, with/ without prior
ulceration, is characteristic.
• Fibrosis may be pronounced.
40
• The mucosae may primarily involved/
become affected by the extension of skin
lesions.
• Dry rhinitis is often the only symptom of
early LV, but lesions may also destroy the
cartilage of the nasal septum.

41
• Diagnosis

- Clinical manifestation : typical lesion may be


recognized by the softness of the lesions,
brownish red color, and slow evolution.
- The apple jelly nodules revealed by diascopy
are highly characteristic
- Tuberculin test is strongly (+)
- Bacterial culture results may be negative.
42
• Differential diagnosis

1. Discoid lupus erythematosus


2. Leprosy
3. Deep mycotic infection

43
• Course

- LV is very long-term disorder


- May lead to the development of carcinoma
such as SCC or BCC.
- In 40 % of patients there is associated tb
lymphadenitis, and 10-20 % have active
pulmonary tb or tb on the bones and joints.
44
Treatment of skin tuberculosis
• In general, the management of skin tb is
similar to that of tb of other organs.

45
Treatment of skin tuberculosis
• In general, the management of skin tb is
similar to that of tb of other organs.
• Chemotherapy is the treatment of choice.
• Rifampicin 10 mg/kg ---- bactericidal
• Isoniazid 5 mg/kg ---- bactericidal
• Pyrazinamide 30 mg/kg ---- bactericidal
• Ethambutol 15 mg/kg ---- bacteriostatic
• Streptomycin 15 mg/kg ---- bacteriostatic

46
TUBERCULID
• TUBERCULIDS : condition in which M. tb/ M.
bovis appears to playa significant role 9lichen
scrofulosorum, papulonecrotic tuberculid.
• FACULTATIVE TUBERCULIDS : condition in
which M. tb/ M. bovis may be one of several
pathogenic factors (erythema induratum of
Bazin, EN).
• NON-TUBERCULIDS : condition formerly
designated as tuberculids, there is no
relationship to tb (lupus miliaris disseminata
fasciei, Rosacea-like tuberculid, lichenoid
tuberculid).
47
Lichen scrofulosorum
• Is an uncommon lichenoid eruption
ascribed to hematogenous spread of
mycobacteria in an individual strongly
sensitive to M. tb
• Usually associated with chronic tb of the
lymph nodes, bones, or pleura.

48
• Clinical manifestation

- Lesions are usually confined to the trunk


- Occur most often in children and adolescents with active
tb.
- The lesions are asymptomatic, firm, follicular or
perifollicular flat-topped yellowish or pink papules,
sometimes with fine scale.
- Lichenoid grouping is pronounced, and lesion may
coalesce to form rough, discoid plaques.
- Treatment : anti tb may results in complete resolution
within weeks.
49
• Histopathology :
- superficial tuberculoid granuloma around hair
follicle.
- Mycobacterium are not seen in the section
- Mycobacterium can not be culture from biopsy

• Differential diagnosis : lichen planus, lichen


nitidus, lichenoid secondary syphilis.

50
Papulonecrotic tuberculid
• PT is a symmetric eruption of necrotizing
papules
• Appearing in crops & healing with scar
formation
• It preferentially in children or young adults
• It is rare, but not uncommon in populations
with a high prevalence of tb.

51
• Pathogenesis
- Associated pulmonary or extrapulmonary tb is
common.
- Lesions are reported to respond promptly to anti
tb drugs, wether or not a tb focus is identified.
- In studies of skin lesions , M. tb DNA was
detected in approximately 50 % of patients.
- Some cases of PT have been associated with
DLE, arthritis, or EN and may therefore be
trigerred by antigen unrelated to M. tb

52
• Clinical manifestation

- Sites of predilection : extensor aspect of the


extremities, buttock, lower trunk, but the eruption
may become widespread.
- Distribution is symmetric and consist of
disseminated crops of livid or dusky red papules
with a central depression and adherent crust
over a crater-like ulcer.
- There is spontaneous involution, which leaves
pitted scars.

53
54
• Differential diagnosis

1. Prurigo
2. Pleva (pityriasis lichenoides et variolifor
mis acuta.
3. Secondary syphilis

55

Você também pode gostar