Lupus

I- DEFINITION :

• Tuberculosis is’all dermatologic manifestations due to the presence of TB bacteria in’body including the skin level.

II- EPIDEMIOLOGY :

1- FREQUENCY :

– rare in Europe and the industrialized countries, this is due to :

– L’improvement of living conditions, Hygiene, and nutrition.

– Immunization and tuberculosis chemotherapy.

– in Algeria, TB is a public health problem, which Sevie to’endemic.

2- PATHOGEN :

– Koch's bacillus (BK) is a mycobacterium, immobile, very heat sensitive but resistant to cold and desiccation,

– colored red by the fuchsin, not decolorized by nitric acid or alcohol (acid-fast bacillus [BAAR]).

– It is cultivated in strict aerobic between 35 ° C and 37 C on enriched media " Lowenstein Jensen » – On distingue:

– Tuberculosis is on bacille de Koch,

– Mycobacterium tuberculosis bovis, agent of bovine tuberculosis (involved in 1 at 5% cases of human tuberculosis).

III- CLASSIFICATION :

Classification of cutaneous tuberculosis according beyt :based on pathophysiological criteria

I- TB inoculation (exogenously) :

– canker tuberculosis

– warty tuberculosis

II- secondary tuberculosis (endogenous) :

– Par contiguïté : Scrofuloderme

– Auto-inoculation: orificial tuberculosis

III- hematogenous tuberculosis :

– lupus vulgaris

– Acute miliary tuberculosis

– TB gum

IV- eruptive tuberculosis :

– Lichen scrofulosorum

– Tuberculides papular or papulopustular necrotic

– Erythema induratum

– nodular vasculitis

I- TB inoculation (exogenously) :

1- canker tuberculosis ; mutibacillaire form

• Secondary inoculation mucocutaneous bacillus directly in a non-immunized subject :
• Especially in infants and young children
• After infecting a direct injury: circumcision, traditional surgery, pierced ear, there is rarely a dirty wound (bites,coughing)
• predominates in the lower limbs,  face and mucous orogenital.
• Incubation :1at 3 weeks
• érythématoviolacé a firm nodule, that ulcer with peeling edges and complicated, and 1à 2 month, lymphangitis lymphadenopathy with poly satellite fistulized evolution
• No general signs
• Evolution :Sometimes extension spontaneous cure TB to other organs
• IDR negative
• Ex Direct and cultures allow to find the BK
• histology found a nonspecific inflammatory infiltrate rich in neutrophils , AFB, granulomatous evolution occurs only after lymph node involvement.

2- The warty tuberculosis : pauci bacillary form,infrequent

• it results either :
• re-inoculation of Mycobacterium tuberculosis in a previously sensitized subject,
• Inoculation is often accidental professional : cattle breeders, slaughterhouse workers, paramedic medical staff.
• Horny hard nodule which gradually spread to form a warty very limited closet surrounded by an inflammatory areola where deaf pus
• Siege : hands (bord radial)++,dorsal side of the fingers / wrist ,peri region anal and the buttocks and the point of inoculation.
• signs Related :adénopathies satellites , tuberculous lymphangitis,achievement of tendons, bones and joints underlying.
• Evolution slow and torpid
• In the absence of treatment : swarming near and distance
• IDR is positive
• Exam Direct and cultures often negative
• histology

– tuberculoid granuloma with caseating

– acanthosis and papillomatosis

– hyperkératose orthokératosique

• Diagnostic differential :cutaneous leishmaniasis, pyodermites, mycoses,verrues.

II. secondary tuberculosis (endogenous) :

1- Le scrofuloderme : F .multibacillaire

• Is over 50% of all cutaneous TBC
• Secondary to the extension to the skin of adenitis or osteo arthritis to tuberculosis
• Seat : cou, trunk, members, rachis
• These are nodules dermo-hypodermic, progressing to softening, fistula to the skin and’ulceration, and healing
• IDR :positive
• We find the BK culture of the aspirate of the abscess because the former is generally unprofitable Direct
• The radiological and biological explorations allow to find the initial focus.
• histology  feature : follicle tuberculoïde Koester with caseating retouve is at the stage of nodule and softening

2- The orificial tuberculosis : F paucibacillaire

• Secondary to self-inoculation from pulmonary homes, laryngeal, digestive and urinary.
• Touche especially the man with fireplace evolutionary visceral
• periorificial ulcerations subacute (the language , the lips, nostrils, anus, urethra)
• Ulcer typical TB language : single superficial ulceration , not hardened and not infiltrated with irregular edges ,the bottom is fibrin purulent ,painful ++.
• signs Related : polyADP inflammatory ipsilateral.
• evolution : No spontaneous tendency to healing, often with appearance small abrasions coalescing devices.
• IDR :positive
• Cultures :positives
• Histology initially nonspecific inflammatory infiltrate with presence B.A.A.R., then form a pseudo-epitheliomatous hyperplasia.
• Diagnostic differential : with sores, plates mucosa of secondary syphilis, squamous cell carcinoma.

III- TB bloodborne :

a)- lupus tubercular :

• Pauci bacillary form common
• female
• Liée to a reactivation of a quiescent or tuberculose viscérale rare évolutive
• seat : 80% face,cou,ears,rare on members
• Built reddish or yellowish, soft embossed squamous which slowly spreads with rugged , formed by the confluence of lupomes- micronodules dermal- having a yellowish aspect vitropression the so-called "apple jelly"
• The evolution is slow with ulcerations,atrophic scarring and fibrous with scalable purplish edges
• A long-term extension can give mutilation or squamous cell degeneration
• IDR positive
• histology agglomeration of tuberculoid granulomas
• examination direct and the culture  are often negative
• Diagnostic differential :with sarcoidosis, cutaneous leishmaniasis, tertiary syphilis

b)- The tuberculosis miliary acute :

• it results either:
• a spread through blood from a visceral focus mostly pulmonary or
• Occurs during a primary infection in immunocompromised patients severe
• children malnourished, elderly people
• papules bluish ,hemorrhagic vesicles scattered necrotic
• Impaired general condition
• Frequently associated with pulmonary miliary, meningeal
• Fundus :retinal tubers Bouchut
• IDR negative
• Ex Direct found BK
• The evolution is often fatal

c)- The tires tubercular :

gums tubercular :

• terrain : immunodéprimé, malnourished.
• seat : especially the lower limbs.
• aspect : cold abscess or nodules dermohypodermiques farms which soften, then ulcerate.
• Evolution is slow(several months) to a fibrous scar
• bacteriological tests(Ziehl-Neelsen et culture) BK may objectify.
• histology : tuberculoïde the follicle Koëster is found before the stage of ulceration.

IV- eruptive tuberculosis :

Cutaneous manifestations involving immunological phenomena

1-  Lichen scrofulosum

• Rare, child
• Micro pink papules, farms, shiny granites fall into closets
• Trunk, members, upper lips
• IDR +++

2-  Tuberculides papulo nécrotique

• Dark red papules, dures, sometimes pustules or necrotic places.
• Faces extension members, dorsal hands, feet, buttocks, the lumbar region.
• always positive IDRT.
• histology : tuberculoid granuloma with caseating.
• always negative bacteriology.
• Differential diagnosis : with necrotic acne, syphilides necrotic, prurigo, furoncles.

3- Erythema induratum

• Pushed asymmetric predominant hypodermitis the lower limbs
• Predominates in obese women with venous insufficiency
• Inflammatory nodules or cupboards purplish and painful with a chronic course
• IDR ++++

4- erythema nodosum

• Manifestation of primary TB infection
• Hypodermitis acute nodular, performing hot red painful inflammatory nodules
• Faces of leg extensions
• Fever, arthralgia and impaired general condition

V- cutaneous manifestations of BCG :

On the BCG website can be

• Ulceration not healing after several months of evolution
• pustular reaction
• Nodule subcutaneous abscess progressing to
• Rarely diffuse protests :tuberculides papulonecrotiques,IN,vascularite nodulaires

IV- POSITIVE ELEMENTS OF DIAGNOSIS :

– it is retained on a beam of’arguments.

1/ elements presumption :

*anamnesis :

– Concept with tuberculosis.

– history or coexistence visceral tubercular lesions.

* biology :

– FNS : leukocytosis with hyper lymphocytosis.

– IDR : tuberculin, uses of the purified tuberculin

– injection 10 IU intradermal tuberculin, ant on the front of the’forearm.

– after reading 72 h, by measuring the diameter of the’induration

2/ items certainties :

A- bacteriological :

– c’is the highlight of the BK.

– sampling : on skin cheesy home, puncture of’lymphadenopathy, biopsy specimen , serosities.

1- DIRECT EXAMINATION : after staining ZIEL NELSEN, the AFB

2- CULTURE on the middle of Lovenstein

– For the identification of the species and the development of antibiotic susceptibility :

– the multiplication of tubercle bacilli (time division = 20 hours) imposing a culture of delay means 28 days, and 42 days.

B- histology :

– The characteristic histological element but not specific for tuberculosis is the follicle Koester

C- methods’genetic amplifications » PCR » :

– their interest is in paucibacillary forms as lupus vulgaris, or the reaction conditions (erythema, endure pools), but however it lacks specificity and sensitivity,

WE- THE TREATMENT :

Chemotherapy anti tuberculous (Rifampicine,Isoniaside,Ethambutol,Pyrazinamide)

• Triple for 2 month
• Double for 4 month
• Depends on the clinical form
• Oral TB must be given as a single morning dose on an empty stomach 1 / 2heure before breakfast.
• Patients who have a major side effect of one of the products may use separate molecules.
• The Rimifon only one dose 5 mg / kg / day for 6 months may be sufficient in the treatment of complications of BCG

VII- PROPHYLAXIE :

• It is based on the BCG vaccination, vaccine consisting of live attenuated bacilli,
• the early detection and treatment forms Multibacillary to prevent contagion,
• raising the socioeconomic globally for better conditions of hygiene and nutrition.