Skin tuberculosis

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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 & quot; Lewenstein Jensen" – One distinguishes:

– Tuberculosis is 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 canker

– Wartuted tuberculosis

II- Secondary tuberculosis (endogenous):

– By contiguity: Scrofuloderm

– Self-inoculation: Orificial tuberculosis

III- Blood-borne tuberculosis:

– Lupus vulgaris

– 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
  • The expansionn: Spontaneous healing sometimes extension of TBC to other organs
  • Negactivate 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
  • victorye: hands (outdial 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

  • Differentito diagnosiss: 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, ourthey, 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.
  • evolvedOn: 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)– youber 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
  • The expansionn 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 culyoure are often negative
  • Differentito diagnosiss: with sarcoidosis, skin leishmaniasis, tertiary syphilis

b) Acout Militarand Tubercprophecys:

  • 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,IN,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 EXAMINATION: 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,

WE– 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.