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SHORT COMMUNICATION
Year : 2012  |  Volume : 57  |  Issue : 1  |  Page : 63-65
A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam


1 Department of Dermatology, Sikkim Manipal Institute of Medical Sciences, Gangtok, India
2 Department of Dermatology, Gauhati Medical College and Hospital, Guwahati, Assam, India

Date of Web Publication10-Mar-2012

Correspondence Address:
Binod Kumar Thakur
Department of Dermatology, Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5154.92685

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   Abstract 

Background: Cutaneous tuberculosis forms a small subset of extra pulmonary tuberculosis and has a worldwide distribution. Aims: The present study is an attempt to find out the incidence, clinical spectrum, and histopathological features of cutaneous tuberculosis. Materials and Methods: A total of 42 cases of newly diagnosed patients of cutaneous tuberculosis attending dermatology out patient department over a period of 1 year were included in the study. A detailed clinical examination and investigations including histopathological examination were carried out. Results: Scrofuloderma was the most common form seen in 50% cases followed by lupus vulgaris in 42.86%, tuberculosis verrucosa cutis in 4.76%, and lichen scrofulosorum in 2.38% cases. The Mantoux test was positive in 83.33% cases. Characteristic tuberculoid granulomas were seen in 72.22% cases of lupus vulgaris, 42.86% cases of scrofuloderma and all cases of tuberculosis verrucosa cutis and lichen scrofulosorum. Conclusion: Cutaneous tuberculosis is still highly prevalent in upper Assam. Early diagnosis and treatment are essential to prevent its complications.


Keywords: Cutaneous tuberculosis, histopathology, granuloma


How to cite this article:
Thakur BK, Verma S, Hazarika D. A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam. Indian J Dermatol 2012;57:63-5

How to cite this URL:
Thakur BK, Verma S, Hazarika D. A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam. Indian J Dermatol [serial online] 2012 [cited 2019 Dec 8];57:63-5. Available from: http://www.e-ijd.org/text.asp?2012/57/1/63/92685



   Introduction Top


Cutaneous tuberculosis is a form of extra pulmonary tuberculosis with varied clinical presentation determined by the route of infection as well as status of cellular immunity of the host. Most of the cases of cutaneous tuberculosis can be diagnosed clinically but some cases really pose diagnostic challenges. Histopathological features are not pathognomonic but play a corroborative role in diagnosis. The present study is a keen effort to find out the incidence, clinical profile, and histopathological features of cutaneous tuberculosis.


   Materials and Methods Top


The patients of newly diagnosed cutaneous tuberculosis attending Dermatology Out-patient Department of a tertiary care hospital over a period of 1 year were included in the study. A detailed history was taken with particular reference to occupation, trauma, bacillus calmette-guerin (BCG) vaccination, and family history of tuberculosis. A thorough general physical, systemic and cutaneous examination was carried out. All cases were subjected to hemogram, hepatic and renal function tests, enzyme linked immuno sorbent assay (ELISA) for human immunodeficiency virus (HIV), and chest X-ray. Sputum smear examination for acid fast bacilli (AFB) and other radiological investigations were done in relevant cases. A skin biopsy and the Mantoux test were performed in all the cases.


   Results and Observations Top


A total of 42 cases of cutaneous tuberculosis were observed in a patient population of 16,864, the incidence of cutaneous tuberculosis being 0.25%. The study comprised of 23 (54.76%) males and 19 (45.24%) females. The age varied from 3 to 65 years, majority of patients, 25 (59.52%) were in their second and third decades of life. Maximum number of patients, 31 (73.8%), were from tea garden laborers' families.

The most common clinical type of cutaneous tuberculosis was scrofuloderma seen in 21 patients (50%), followed by lupus vulgaris in 18 (42.86%), tuberculosis verrucosa cutis in 2 (4.76%), and lichen scrofulosorum in 1 patient (2.38%) [Figure 1], [Figure 2], [Figure 3] and [Figure 4]. Most of the patients had single site involvement but 10 (47.6%) scrofuloderma cases had multiple sites of involvement. Head and neck was the most common involved site both in scrofuloderma (13 cases) and lupus vulgaris (7 cases). A family history of tuberculosis was obtained in 16 (38.1%) cases. BCG scar was present in 15 (35.71%) patients which failed to protect from cutaneous tuberculosis. Cutaneous tuberculosis with multiple site of involvement was mostly seen in nonvaccinated patients. Tuberculosis of internal organs was seen in 22 (52.38%) patients of cutaneous tuberculosis, the most common being tubercular lymphadenopathy in 19 (45.24%) cases followed by bone tuberculosis in 3 (7.14%) cases, pulmonary tuberculosis in 2 (4.76%) cases, and tubercular meningitis in 1 case (2.38%). No case was on corticosteroid or anticancer therapy.
Figure 1: Plaque of lupus vulgaris involving left cheek, neck and chest

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Figure 2: Scrofuloderma with multiple sites of involvement

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Figure 3: Tuberculosis verrucosa cutis: Warty plaque on root of thumb

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Figure 4: Lichen scrofulosorum: lichenoid papules on trunk and proximal limbs

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All patients were subjected to the Mantoux test. Thirty-five cases (83.33%) showed Mantoux positivity which included 14 (66.67%) cases of scrofuloderma and all patients of lupus vulgaris, tuberculosis verrucosa cutis, and lichen scrofulosorum. The patients of scrofuloderma with the negative Mantoux test had multiple sites of involvement. Acid fast bacilli were observed in exudates of two cases (9.52%) of scrofuloderma. All the patients were negative for HIV.

On histopathological examination epidermal hyperplasia was observed in 10 (55.56%) cases of lupus vulgaris and both cases of tuberculosis verrucosa cutis. Well-defined tuberculoid granulomas [Figure 5] were observed in 9 (42.86%) cases of scrofuloderma, 13 (72.22%) cases of lupus vulgaris, and all cases of tuberculosis verrucosa cutis and lichen scrofulosorum. In other cases, a diffuse infiltrate of epithelioid cells and Langhan's giant cells was seen. Caseation necrosis was found in all cases of scrofuloderma, 2 (11.11%) cases of lupus vulgaris, and 1 case (50%) of tuberculosis verrucosa cutis. Acid fast bacilli were not seen in histopathological examination of any case.
Figure 5: Well defined tuberculoid granulomas with Langhan's giant cells (H and E, 450×)

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   Discussion Top


Cutaneous tuberculosis represents 1.5% of all cases of extra pulmonary tuberculosis. [1] It presents with diverse clinical and histopathological features. The incidence of cutaneous tuberculosis has been reported from 0.15% to 0.26% in various studies. [2],[3],[4],[5] In our study, incidence was quite high (0.25%). Males outnumbered females in a ratio of 1.2: 1 as in other studies. [2, 4, 5] Most of the patients were in their second and third decades of life, similarly observed in other Indian studies. [4],[5]

The most common type of cutaneous tuberculosis was scrofuloderma (50%) which was also noticed in some studies. [3],[6] However, other studies [4],[5] from India found lupus vulgaris as the most common type. Head and neck as most commonly involved site was also noticed by others authors. [1],[4] The positivity of the Mantoux test has been reported from 68% to 100% in various studies [3],[4],[7] and our study compared well with their findings.

In one study, [3] epidermal hyperplasia was observed in 41.2% cases of lupus vulgaris and all cases of tuberculosis verrucosa cutis. Our study exceeded its incidence in lupus vulgaris. Tuberculoid granulomas in dermis were reported in 70.6% cases of lupus vulgaris, 39.1% cases of scrofuloderma, and all cases of tuberculosis verrucosa cutis [3] which were comparable to our study. Caseation necrosis was reported in 59% sections of lupus vulgaris and 87% sections of scrofuloderma in a study. [3] However, in another study, [6] caseation necrosis was observed in 8.3% cases of lupus vulgaris.

Cutaneous tuberculosis is an important health problem in this part of the country especially in lower socioeconomic group. Parents should be encouraged for routine BCG vaccination as well as proper nutrition of their children. In many occasions, the varied clinical presentation makes the diagnosis of the disease difficult. Clinicopathological correlation is essentially useful in those cases where clinical presentation poses diagnostic difficulties.

 
   References Top

1.Kumar B, Rai R, Kaur I, Sahoo B, Muralidhar S, Radotra BD. Childhood cutaneous tuberculosis: A study over 25 years from northern India. Int J Dermatol 2001;40:26-32.  Back to cited text no. 1
[PUBMED]  [FULLTEXT]  
2.Kumar B, Kaur S. Pattern of cutaneous tuberculosis in North India. Indian J Dermatol Venereol Leprol 1986;52:203-7.  Back to cited text no. 2
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3.Sehgal VN, Srivastava G, Khurana VK, Sharma VK, Bhalla P, Beohar PC. An appraisal of epidemiologic, clinical, bacteriologic, histopathologic and immunologic parameters in cutaneous tuberculosis. Int J Dermatol 1987;26:521-6.  Back to cited text no. 3
[PUBMED]    
4.Acharya KM, Ranpara H, Dutta R, Mehta B. A clinicopathological study of 50 cases of cutaneous tuberculosis in Jamnagar district. Indian J Dermatol Venereol Leprol 1997;63:301-3.   Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.Patra AC, Gharami RC, Banerjee PK. A profile of cutaneous tuberculosis. Indian J Dermatol 2006;51:105-7.   Back to cited text no. 5
  Medknow Journal  
6.Gopinathan R, Pandit D, Joshi J, Jerajani H, Mathur M. Clinical and morphological variants of cutaneous tuberculosis and its relation to mycobacterium species. Indian J Med Microbiol 2001;19:193-6.   Back to cited text no. 6
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7.Arya L, Koranne RV, Deb M. Cutaneous tuberculosis in children: A clinicomicrobiological study. Indian J Dermatol Venereol Leprol 1999;65:137-9.  Back to cited text no. 7
[PUBMED]  Medknow Journal  


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]

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