I-DEFINITION:
- tuberculosis is all dermatological manifestations due to the presence of TB in the body and especially in the skin.
II– EPIDEMIOLOGY:
1– FREQUENCY:
– rare in Europe and industrial countries, this is due to:
– Improving living conditions, hygiene, and nutrition.
– Vaccination and TB chemotherapy.
– in Algeria, tb is a public health problem that is endemic.
2- PATHOGEN:
– Koch bacillus (BK) is a mycobacteria, immobile, very sensitive to heat but resistant to cold and desiccation,
– coloured red by fuchsin, not discoloured by nitric acid or alcohol (acid-alcoholic-resistant bacillus[BAAR]).
– It is grown in strict aerobics between 35 and 37 degrees Celsius on enriched environments "Lewenstein Jensen" – One distinguishes:
– Mycobacterium tuberculosis hominis or Koch bacillus,
– Mycobacterium tuberculosis bovis, an agent of bovine tuberculosis (involved in 1 to 5% of human TB cases).
III– CLASSIFICATION:
BeYT classification of skin tuberculosis: based on pathophysiological criteria
I- Inoculation tuberculosis (exogenous):
– Tubering chancre
– Wartuted tuberculosis
II- Secondary tuberculosis (endogenous):
– By contiguity: Scrofuloderm
– Self-inoculation: Orificial tuberculosis
III- Blood-borne tuberculosis:
– Vulgar Lupus
– Acute military tuberculosis
– Tuberc plastic gum
IV- Eruptive tuberculosis:
– Lichen scrofulosorum
– Papulous or papulo-necrotic tubercides
– Bazin's indated erythema
– Nodular Vascularitis
I- Inoculation tuberculosis (exogenous):
1- Tubercle Chancre; mutibacillary form
- Secondary to direct skin-mucous inoculation of the bacillus in an unimmunized subject:
- Especially in infants and young children
- After a direct infectious injury: circumcision, traditional surgery, ear piercing, it is rarely a contaminated wound (bites, spitting)
- predominates in the lower limbs, face and orogenetal mucous membranes.
- Incubation:1 to 3 weeks
- a firm erythematovolac nodule, which ulcerates with detachment of the edges and is complicated, in 1 to 2 months, by lymphangitis with satellite poly adenopathy of fistulized evolution
- No general signs
- Evolution: Spontaneous healing sometimes extension of TBC to other organs
- Negative IDR
- Ex direct and cultures allow to find the BK
- Histology finds a nonspecific inflammatory infiltrate rich in PNN , presence of BAAR, granulomatous evolution is only after lymph node damage.
2- Wartish tuberculosis: pauci bacillary form, infrequent
- it results in either:
- the recurrence of The Koch Bacillus in a previously sensitized subject,
- Inoculation is accidental often professional: cattle farmers, slaughterhouse employees, paramedic medical personnel.
- Hard horned nodule that gradually spreads out to form a very limited wart closet surrounded by an inflammatory areola from which deaf pus
- Siege: hands (radial edge), dorsal face of fingers / wrist, peri region and at the buttocks and at the point of inoculation.
- Associated signs: satellite adenopathy, tubercular lymphangitis, damage to the tendons, bones and underlying joints.
- Slow and torpedo evolution
- Untreated: swarming in the vicinity and at a distance
- IDR is positive
- Direct review and often negative cultures
- Histology
– tuberuloid granuloma with casey necrosis
– papillomatosis and acanthosis
– orthokeratosic hyperkeratosis
- Differential diagnosis: skin leishmaniasis, pyodermites, fungi, warts.
Ii. Secondary tuberculosis (endogenous):
1- The scrofuloderm: F .multibacillary
- Makes up more than 50% of all skin TBCs
- Secondary to the extension to the skin of an adenite or osteoarthritis of tuberculosis origin
- Seat: neck, trunk, limbs, spine
- These are dermo-hypodermic nodules, evolving towards softening, fistulization to the skin and ulceration, then healing
- IDR :positive
- The BK is found in the cultivation of the abscess puncture liquid because the ex direct is generally unprofitable
- Radiological and biological explorations allow us to find the original focus.
- Characteristic Histology: Koester tuberuloid follicle with caseous necrosis is re-established at the nodule and softening stage
2- Orificial tuberculosis: F paucibacillary
- Secondary to self-inoculation from pulmonary, laryngeal, digestive and urinary tract.
- Mainly touches the man with evolutionary visceral focus
- subacute periorificial ulcerations (tongue, lips, nostrils, anus, urethra)
- Typical tuber ulcer of the tongue: Unique superficial ulcer, undurable and not infiltrated with irregular edges, the bottom is purulent fibrino, painful.
- associated signs: homolateral inflammatory polyADP.
- evolution: No spontaneous tendency to heal, often with the appearance of small coalescent peripheral exulcerations.
- IDR :positive
- :psositive cultures
- Histology initially a non-specific inflammatory infiltrate with the presence of B.A.A.R., then a pseudo-epitheliomatous hyperplasia forms.
- Differential diagnosis: with sores, mucous plaques of secondary syphilis, sleocellular epithelioma.
III– Hematogenic tuberculosis:
a)– tuber lupus:
- Frequent bacillary pauci form
- Female predominance
- Related to reactivation of visceral TB that is central or rarely progressive
- seat: 80% face, neck, ears, rare on limbs
- Reddish or yellowish placard, soft squamous in relief that slowly spreads with jagged contours, formed by the confluence of lupomes – dermal micronodules – having a yellowish appearance to the so-called "apple jelly" vitropression
- Evolution is slow with ulcerations, atrophic and fibrous scars with evolutionary purple edges
- In the long term, extension can lead to mutilation or even s spinocellular degeneration
- Positive IDR
- Histology agglomeration of tuberculoid granulomas
- Direct examination and culture are often negative
- Differential diagnosis: with sarcoidosis, skin leishmaniasis, tertiary syphilis
b)– Acute military tuberculosis:
- it results in either:
- blood-borne spread from a visceral focus, most often pulmonary or
- Occurs during severe first infection on immunosuppressed terrain
- Malnourished child, elderly
- Bluish papules, scattered necrotic hemorrhagic vesicles
- Alteration of the general state
- Frequently associated with pulmonary miliary, meningeal
- Eye background: Bouchut retinal tubers
- Negative IDR
- Ex direct finds the BK
- Evolution is often fatal
c)– Tuberculosis gum:
Tuberculosis gums:
- immunosuppressed, malnourished.
- seat: especially the lower limbs.
- appearance: cold abscesses or firm dermohypodermal nodules that soften and then ulcerate.
- The progression is slow (several months) towards a fibrous scar
- bacteriological examinations (Ziehl-Neelsen and culture) can objectify the BK.
- histology: the tuberculoid follicle of Koster is found before the stage of ulceration.
IV- Eruptive tuberculosis:
Skin manifestations involving immunological phenomena
1- Lichen scrofulosum
- Rare, child
- Micro pink papules, firm, shiny cluster in granite cupboards
- Trunk, limbs, upper lips
- IDR
2- Tuberculides papulo necrotic
- Dark, hard, sometimes pustular red papules in places or necrotic.
- Faces of extension of the limbs, dorsal face of the hands, feet, buttocks, lumbar region.
- IDRT always positive.
- Histology: tuberuloid granuloma with case necrosis.
- Bacteriology always negative.
- Differential diagnosis: with necrotic acne, necrotic syphilids, prurigo, boils.
3- Bazin's indated erythema
- Predominant asymmetric hypodermitis flare-ups to lower limbs
- Predominates in obese women with venous insufficiency
- Purple and painful inflammatory nodules or closets with chronic evolution
- IDR
4- knotty rash
- Manifestation of the first TB infection
- Acute nodular hypodermitis, performing painful hot red inflammatory nodos
- Leg extension faces
- Fever, arthralgia and altered general condition
V- skin manifestations of BCG:
On the BCG website you can have
- Ulceration not only scarring several months of evolution
- Pustular reaction
- Nodule under skin evolving towards absedation
- Rarely diffuse manifestations:papulonecrotic tuberculides,EN,nodular vascularitis
IV- POSITIVE DIAGNOSTIC ELEMENTS:
– it is held on a bundle of arguments.
1/ Presumption elements:
'Anamnesis':
– Tb screening.
– history or coexistence of visceral TB lesions.
Biology:
– FNS: hyperleucocytosis with hyper lymphocytosis.
– IDR: tubercina, uses purified tubercina
– Injection of 10 IU of tubercle intradermal, on the ant side of the forearm.
– Play after 72 hours, measuring the diameter of the induration
2/ Elements of certainty:
A– bacteriological:
– this is the highlighting of the BK.
– the sample: on a skin caseous fireplace, puncture of an adenopathy, biopsy part, serouss.
1- DIRECT EXAMEN: after coloring ZIEL NELSEN, looking for BAAR
2- CULTURE on the middle of lovenstein
– For the identification of the species and the development of the antibiotic:
– the multiplication of Koch bacillus (division time – 20 hours) requiring an average growing time of 28 days, and 42 days.
B- histology:
– The characteristic but non-specific histological element of tuberculosis is the Koester follicle
C- "PCR" genetic amplification methods:
– their interest is in paucibacillary forms such as vulgar lupus, or reactionary states (erythema, indurated BAZIN), but however it lacks specificity and sensitivity,
VI– TREATMENT:
Anti-TB chemotherapy (Rifampicin,Isoniaside,Ethambutol,Pyrazinamide)
- Triple for 2 months
- Double for 4 months
- Depends on the clinical form
- Oral ANTI-TB should be administered in a single morning dose on an empty date 1/2 hour before breakfast.
- Patients who have had a major side effect to one of the products may use separate molecules.
- Rimifon alone has a dose of 5 mg/kg/J for 6 months may be sufficient in the treatment of BCG complications
VII- PROPHYLAXIS:
- It is based on vaccination with BCG, a vaccine made up of live attenuated bacillus,
- early detection and treatment of multibacillary forms to prevent contagion,
- raising the overall socio-economic level, allowing for better hygiene and nutrition conditions.
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