Year : 2006 | Volume
: 51 | Issue : 2 | Page : 105--107
A profile of cutaneous tuberculosis
Apares Chandra Patra, Ramesh Chandra Gharami, Paritosh K Banerjee
Department of Dermatology and STDs, Medical College, Kolkata and B. S. Medical College, Bankura, West Bengal, India
Ramesh Chandra Gharami
114/North Bireshpally, Ashoke Vihar Apartment, Madhyamgram, Kolkata - 700129
About 39330, new patients were examined over a period of two years and it was revealed that 104 patients (0.26%) had cutaneous tuberculosis. Most of the tuberculosis patients (61.52%) were between the age of 5 to 25 years. Lupus vulgaris was the commonest variant (57.69%), followed by scrofuloderma (21.15%). Males suffered more than females (2.25:1) and all patients belonged to lower socio-economic class. 62 cases (59.61%) showed evidence of BCG vaccination that failed to protect cutaneous tuberculosis. Mantoux test was positive in all cases except 4. Bacteriological examination was negative in all cases. Response to antitubercular therapy was very good except in two cases which required addition of an extra drug and also took more time.
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Patra AC, Gharami RC, Banerjee PK. A profile of cutaneous tuberculosis.Indian J Dermatol 2006;51:105-107
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Patra AC, Gharami RC, Banerjee PK. A profile of cutaneous tuberculosis. Indian J Dermatol [serial online] 2006 [cited 2020 Mar 30 ];51:105-107
Available from: http://www.e-ijd.org/text.asp?2006/51/2/105/26929
The disease tuberculosis is perhaps as old as mankind, with evidences of the disease being found in the vertebrae of the Neolithic man in Europe and Egyptian mummies. But it was not until 1882 that Robert Koch discovered the causative agent as Mycobacterium tuberculosis. It has been estimated that the genus mycobacterium probably causes more suffering for humans than all other bacterial genera combined.
Improved hygiene and living standards, introduction of BCG and effective chemotherapy have greatly reduced the prevalence and incidence of tuberculosis in developed countries but it is still very common in developing countries.
In India tuberculosis continues to be the biggest public health problem and cutaneous tuberculosis remains a common diagnosis at the Dermatology OPD. Thus despite the discovery of effective antitubercular drugs and a National programme to check it, the disease is still a headache because of unusual manifestations as well as failure of diagnosing even typical manifestations of the disease due to lack of experience of physicians and concerned lack of awareness of the patients. Histopathology is also varied viz., necrotizing granuloma, poorly formed granuloma, non-specific inflammatory infiltrate etc.
In the HIV era, the impact of HIV on tuberculosis has gained importance. Also in recent years, due to the increasing use of immunosuppressants (anticancer and corticosteroid) and emergence of immunocompromised host, it remains to be seen how the position of cutaneous tuberculosis is altered.
So, cutaneous tuberculous with its wide range of variations in morphology, histopathology, immunology and treatment response, compelled us to study the subject further.
Materials and Methods
All new patients attending the Dermatology OPD of Medical College, Kolkata and B.S. Medical College, Bankura between July 2001 to June 2002, and December 2002 to November 2003 respectively, were thoroughly examined. The demographic details, history, clinical features, results of investigation like routine blood, urine and stool tests, Mantoux test, Chest X-ray, biopsy HIV (Elisa) test, smear for AFB and culture of AFB of all suspected patients with cutaneous tueberculosis were recorded in the proforma.
A total of 39,330 patients were examined and only 104 patients (0.26%), comprising 72 males and 32 females (ratio 2.25:1), had cutaneous tuberculosis. Age of the patients varied from 6 to 65 years and the most common age groups were 5-15 and 16-25 years (30.76% each group - [Table 1]). Only four morphological variants of cutaneous tuberculosis were seen of which lupus vulgaris (LV) was the commonest (57.69%), followed by scrofuloderma (SFD) (about 21.15%) [Table 2].
Lupus vulgaris was distributed among all age group but was commonest in 16-25 years (18 cases) but scrofuloderma was the commonest in 5-15 years group (10 cases) [Table 1]. Most of the patients were having single lesion but 20 cases (19.23%) had multiple lesions. It was noticed that SFD cases attend earlier than tuberculosis verrucosa cutis (TVC) and LV [Table 3]. Most patients (84.61%) were from families with number of members ranging from 5 to 10 and poor socio economic back ground. No case was found to be in close contact with an open case of pulmonary tubeculosis. Lymphadenopathy was more significant in cases of SFD than other cases.
Unexplained weight loss, prolonged fever or diarrhea were not found in any of the cases. No case was on corticosteroid or anticancer therapy. X-ray chest showed no abnormality in any of the cases except in one lichen scrofulosorum (LS) case where hilar lymphadenopathy was prominent. Hemoglobin was lower than 10 mg/dl in 76 patients (73.07%) and ESR was more than 20 mm in 1st hour in all cases. Mantoux test was significantly positive [Table 4] as more than 15 mm induration in 62 cases (59.61%) and 10-15 mm in 40 cases (38.46%), but negative in two cases. ELISA test for HIV was negative in all cases. No morphological abnormality was seen except multiple lesions in 20 cases (19.23%), Histopathology found granuloma in all except 4 cases of TVC. Smear showed no AFB (Mycobacterium tuberculosis). Culture for AFB was also negative in all cases.
With 4 standard drugs (rifampicin, isoniazid (INH), ethambutol, pyrazinamide for 1st two months and rifampicin-INH for next four months) all cases responded very well except 4 cases of LV where ciprofloxacin had to be added with rifampicin INH for additional 3 months to cure the cases. Response was found after 4 weeks of therapy in most cases and lesions healed 1-3 months before the completion of antitubercular therapy. Residual scarring was seen in all cases except LS cases.
The prevalence of cutaneous tuebrculosis was 0.26% which was similar to findings in other studies like 0.24% by Satyanarayan, 0.28% by Pandhi et al but differed to an extent from some reports like 0.5% by Banerjee BN and 0.59% by G Singh.
The commonest type of cutaneous tuberculosis was lupus vulgaris in our study (57.69%) which was also noticed by Gurmohan singh (74%) and Bhusan Kumar et al (81.8%). The second most common type was scrofuloderma (21.2%) followed by tuberculosis verrucosa cutis (19.23%). But Pandhi et al found LV more common (44%) and Wong et al found TVC as the commonest type. Tuberculide (lichen scrofulosorum) was rarest in our study (1.92%). It was also noticed to be negligible by Gurmohan Singh and BV Satyanarayan. Most of the cases were below the age of 25 years (61.52%) in our study, corroborating Satyanarayan and Wong. Males outnumbered the females in a ratio of 2.25:1 as in other studies., The commonest site of cutaneous tuberculosis varied from study to study, viz., lower limbs in our study but face in a study from West and also one from north India, Single lesion of a particular type of cutaneous tuberculosis was seen in most cases without immuno-compromise. It is remarkable to notice that all patients (100%) were from low-socioeconomic condition.
Duration of the disease was variable. More than 5 years, duration was noticed in 30% cases by Pandhi et al while the same was 17.3% in our study. HIV seropositivity was not seen in any case. X-ray of chest showed hilar lymphadenopathy which completely disappeared following antitubercular treatment in a case of lichen scrofulosorum. In all other cases it was normal. But BN Banerjee noticed association of pulmonary tuberculosis in 45% cases and Wong noticed it in 10%. It might be due to introduction of effective antitubercular therapy and increased awareness. Mantoux test was positive in all cases except two in our study but Bhusan Kumar et al noticed negative result in 27.7% cases.
BCG vaccination scar of was found in 59.62% cases which reflected the incapability of the vaccine to protect tuberculosis completely.
Histopathology was well correlated with clinical findings except 4 cases where therapeutic response confirmed the diagnosis. Though Lever stated that AFB (acid fast bacilli) were numerous in histologic section of scrofuloderma and also demonstrable in tuberculosis verrucosa cutis, we could not find any such instance.
Therapeutic response was good in all the cases except four where addition of ciprofloxacin after 6 months of therapy along with rifampicin and INH for extra 3 months were needed to cure the patients. The cause could not be explained. Responses to therapy started after 1st month of therapy in most of cases and lesions were healed with scarring 2-3 months before the completion of therapy.
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