Papulonecrotic Tuberculid Research Articles

Clinico-Laboratory Profile of Tuberculides: An Experience at a Tertiary Care Centre from Chandigarh, India.

Tuberculides are characterised by delayed-type of immunologic reactions to Mycobacterium tuberculosis or its products in immuno-competent individuals. We herein describe clinico-epidemiological features and response to treatment in patients with tuberculides from a tertiary care centre from North India. This was a retrospective analysis of the clinical records of all the cutaneous tuberculosis (TB) patients (year 2000-2019) enrolled in the TB clinic. The patient records fulfilling the diagnostic criteria of tuberculides were considered for analysis. A total of 225 patients attended the tuberculosis clinic; out of this, 34 were diagnosed as tuberculides. Out of these 34 cases, 21 were identified as LS, 2 erythema induratum of Bazin, 1 papulonecrotic tuberculide, and 10 erythema nodosum. History of contact to open cases of TB was present in 15/34 (44.1%) patients. History of BCG vaccination was found in 15/34 (44.1%) patients. The focus of underlying TB could be identified in 20/34 (58.8%) patients. Skin biopsy was performed in all patients. In all patients, the diagnosis was confirmed by clinico-pathological correlation, positive TST, and the underlying focus of TB. All patients received 6 months regimen of anti-tubercular therapy with first-line drugs. In this study, we demonstrated various forms of tuberculides; lichen scrofulosorum was the most common form. We also included erythema nodosum cases also, which responded well to ATT. Observation from our study showed that tuberculides are important cutaneous markers for underlying tuberculosis infection, which helps in early detection of occult tuberculosis and timely management.

Metastatic Tuberculous Abscess and Papulonecrotic Tuberculid Developing During Chemotherapy in a Post-Surgical Case of Carcinoma of Breast.

Metastatic Tuberculous Abscess and Papulonecrotic Tuberculid Developing During Chemotherapy in a Post-Surgical Case of Carcinoma of Breast.

A cross sectional descriptive study of dermoscopic features of clinical variants of cutaneous tuberculosis

Tuberculosis continues to be a major public health concern worldwide with almost 20–40% of the world's population being affected yearly. Cutaneous Tuberculosis (TB) is a rare and underdiagnosed entity that manifests in about 1–1.5% of extrapulmonary tuberculosis cases worldwide. Dermoscopy is a non-invasive tool which will be a useful aid to histopathology in the confirmation of the diagnosis alongside culture, and molecular techniques. This is a cross-sectional descriptive study that was conducted at a tertiary care center in Mumbai, India. A total of 31 patients were enrolled in this study; 14 males and 17 females. The mean duration of disease was 4.3 months and the average age was 31 years. There were 10 cases of lupus vulgaris, 7 scrofuloderma, 5 papulonecrotic tuberculid (PNT), 3 tuberculosis verrucosa cutis (TBVC), and 2 cases each of erythema induratum of Bazin, lichen scrofulosorum and resolved lupus vulgaris. All the lesions demonstrated orange yellow background suggestive of dermal granuloma. Other key dermoscopic features noted include yellowish-white scales, patulous follicles, white structureless areas, milia-like cysts, white streaks, pigment globules, hairpin and linear vessels. Newer findings such as the crown of vessels and perifollicular pallor in lichen scrofulosorum, and radiating white streaks in PNT were also noted. Dermoscopy of infective granulomas such as cutaneous tuberculosis is a less explored field of dermatology. Newer dermoscopic features of each clinical variant of cutaneous TB have been described.

Tuberculids: A Narrative Review.

Tuberculids are a group of dermatoses with tuberculoid histology and the absence of tubercle bacilli. They are considered to be hypersensitivity reactions to circulating Mycobacterium tuberculosis (M. tb) or its antigens in individuals with good immunity. The objective of the review is to provide a detailed literature review of all available articles on tuberculids in the past 10 years and provide an update on epidemiology, etiopathogenetic mechanisms, clinical manifestations, and treatment. A search was performed on PubMed using the keywords lichen scrofulosorum, papulonecrotic tuberculid, erythema induratum, and erythema nodosum tuberculosis for all articles, with no restrictions on age, gender, or nationalities. An update on tuberculids, including some new concepts in pathogenesis, atypical presentations, new investigative modalities, and treatments are reviewed.

Dermoscopy of the Diverse Spectrum of Cutaneous Tuberculosis in the Skin of Color.

Cutaneous tuberculosis is an uncommon form of tuberculosis, accounting for 1%-2% of all forms of extra-pulmonary tuberculosis. Knowledge of the dermoscopic characteristics of different clinical types of cutaneous tuberculosis can help timely diagnosis resulting in better outcomes. To characterize the Dermoscopy findings in different clinical types of cutaneous tuberculosis in dark skin phototypes. All clinically suspected and biopsy confirmed cases of cutaneous tuberculosis seen from July 2019 through December 2021 were retrospectively recruited. Information including age, gender, disease duration, site and morphology of lesions, and presence of concomitant tuberculosis elsewhere was noted. Two investigators retrospectively reviewed the dermoscopic characteristics of these cases. Twenty-two patients comprised of 12 women and 10 men met the inclusion criteria. Lupus vulgaris was the commonest presentation of cutaneous tuberculosis seen in 13 patients. Five had scrofuloderma, 2 had tuberculosis verrucosa cutis and 1 patient each had lichen scrofulosorum and papulo-necrotic tuberculid. Yellow-orange structureless areas (100%), linear/dot vessels (100%), white scales (92.3%), and white structureless areas (84.6%) were the predominant dermoscopy findings in lupus vulgaris. In scrofuloderma, linear vessels and white structureless areas were visible in all cases. Dirty white scales with a papillated surface were characteristically seen in tuberculosis verrucosa cutis, with 1 of the 2 patients each showing vessels and yellow-orange structureless areas. White globules with surrounding erythema were seen in lichen scrofulosorum and yellow-orange structureless areas with keratin plugs in papulo-necrotic tuberculid. A thorough understanding of the characteristic dermoscopy of cutaneous tuberculosis can help suspect the diagnosis early resulting in better management opportunity.

Diagnosis of Papulonecrotic Tuberculid with Chronic Kidney Disease- A Rare Case Report.

A 56-year old male with pulmonary tuberculosis and non-compliant to anti-tuberculosis therapy presented with multiple skin eruptions over the shins and hands for 2 months. Clinical features and skin biopsy were indicative of Papulonecrotic tuberculid, hence, he was put on renal adjusted ATT due to his worsening serum creatinine.

Atypical presentations of cutaneous tuberculosis: Series of 10 cases

Cutaneous tuberculosis classically presents as Lupus vulgaris, scrofuloderma, tuberculosis verrucose cutis and tubercular abscess. Hypersensitivity reaction to the bacilli leads to Lichen scrofulosorum and papulonecrotic tuberculids. At the same time, it can have myriad of clinical presentations, many of which are still undescribed. It is important to regularly update ourselves with these unusual manifestations so as to ensure early treatment and reduction of overall morbidity. In this case series tuberculosis manifesting as rapidly progressing diffuse facial granulomas, sporotrichoid tuberculosis, tuberculosis mimicking squamous cell carcinoma, scrofuloderma as tubercular ulcer, lupus vulgaris with nasal septal perforation, lupus vulgaris resembling furuncle, psoriasis, dermatitis and BT Hansen are described in immunocompetent individuals. These cases highlight the importance of recognition of atypical forms of cutaneous tuberculosis to minimize scarring and dissemination of bacilli.

Clinical Images: Papulonecrotic tuberculid and Poncet disease.

Clinical Images: Papulonecrotic tuberculid and Poncet disease.

Lichen scrofulosorum coexisting with phlyctenular keratoconjuctivitis: Dermoscopy and ocular findings

Lichen scrofulosorum is the most common tuberculid and its incidence in India is 2.38%. Tuberculosis is responsible for 77% of cases of phlyctenular keratoconjunctivitis (PKC). Both lichen scrofulosorum and PKC represent delayed hypersensitivity responses to Mycobacterium tuberculosis in skin and eyes, respectively. Previously PKC had been described in patients with underlying lichen scrofulosorum, papulonecrotic tuberculids, and in a single case of lupus vulgaris, with primary focus being pulmonary tuberculosis.[1234] To the best of our knowledge, ocular examination (through dermoscope) has not been described in these cases, while dermoscopy of lichen scrofulosorum have been described in 2 cases only.[5] Our case is demonstrating this rare association along with their dermoscopy and ocular findings. Ten-year-old girl complained of redness, watering, and photophobia in both eyes and multiple asymptomatic lesions on the trunk for past 1 week and 2 weeks, respectively. She gave history of weight loss, poor appetite, evening rise of temperature for past 2 months. The lesions were multiple, discrete to loosely aggregated at places, skin-colored to slightly erythematous pinhead-sized papules with fine white scaling, present on trunk and upper limbs [Figure 1] long with upper deep cervical lymphadenopathy. Examination by Ophthalmologist revealed bilateral conjunctival congestion along with phlycten at the 7o'clock limbus in the right eye. Rest of the systemic examination was normal.Figure 1: Clinical image of lichen scrofulosorum: multiple, discrete as well as loosely aggregated, skin-colored to slightly erythematous pinhead-sized papules with fine white scalingDermoscopy [AM7013MZTS (4S) Dino-Lite Premier, AnMo corporation, Taiwan] showed follicular and extrafollicular lesions with central cluster of brown clods along with halo of pallor with telangiectasias and marginal rim of white fine scales [Figure 2]. On eye dermoscopy, phlycten was seen at the right limbus as a structureless white area surrounded by dilated irregular conjunctival vessels of varying widths [Figure 3].Figure 2: Dermoscopy of papules on back shows follicular as well as extrafollicular lesions with central cluster of brown clods (yellow arrow) along with halo of pallor with telangiectasias (black arrow) and rim of fine white scales (170× magnification, Polarized mode)Figure 3: Eye dermoscopy reveals phlycten at 7o'clock right limbus as a structureless white area (black arrow) surrounded by dilated irregular conjunctival vessels (yellow arrow) of varying widths (70× magnification, Polarized mode)Mantoux test showed ulceration and induration (20 × 20 mm). FNAC from the lymph nodes showed tubercular lymphadenitis and Ziehl-Neelsen stain was positive for acid fast bacilli. Skin biopsy from a papule on the back showed hyperkeratosis and perifollicular giant cell granulomas [Figure 4]. Chest X-ray did not reveal any abnormality. Based on above findings, we diagnosed lichen scrofulosorum secondary to tubercular lymphadenitis with PKC. Skin lesions responded within 1 month of the institution of ATT and phlycten responded to topical steroid eye drops.Figure 4: Skin biopsy from a papule on the back showed hyperkeratosis and perifollicular giant cell granulomas (400× magnification, H and E stain)Lichen scrofulosorum is the most common tuberculid in Indian children. PKC has been described previously in conjunction with papulonecrotic tuberculids, lichen scrofulosorum, scrofuloderma and lupus vulgaris [Table 1].[1234] The primary focus being pulmonary tuberculosis or tubercular lymphadenitis [Table 1].[1234] Jassi et al. had reported pale round monomorphic grouped perifollicular large dots with central black follicular opening topped with a crust and marginal rim of fine white scaling and marginal hyperpigmentation (in one of the case) as dermoscopic findings of lichen scrofulosorum; however, we noticed follicular as well as extrafollicular lesions with central cluster of brown clods (instead of black follicular opening) and telangiectasia in addition to their findings.[5] Ocular findings of PKC on dermoscopy require further validation by more studies.Table 1: Various studies shows association of tuberculid with phlyctenular conjunctivitis, along with tuberculosis focusLastly, PKC should be actively looked for, especially in the patients of cutaneous tuberculosis, as this association may be more common than described. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Papulonecrotic tuberculid caused by Bacille Calmette-Guerin vaccination requiring no antitubercular agents.

This paper describes a case of papulonecrotic tuberculid after Bacille Calmette-Guerin (BCG) vaccination. A 6-month-old boy was seen in our emergency room with a fever and erythematous papular. He received BCG vaccination at the age of 5 months and there were no systemic problems after the vaccination. There were no abnormal physical findings except for skin lesions and fever. Histopathologically, the lesion was associated with pyogenic granulomatous inflammation and fibrosis, with multiple instances of vascularization and infiltration of various inflammatory cells. Acid-fast stain, culture,and polymerase chain reaction for tuberculous bacillus DNA of the papulonecrotic skin lesions were negative. He was diagnosed papulonecrotic tuberculid caused by BCG vaccination. The fever lasted 10 days, and all lesions healed spontaneously in 2 months. Papulonecrotic tuberculid is a vasculitis caused by an allergic reaction to an internal focus of Mycobacterium tuberculosis or its metabolites. The appearance of an unexplained skin rash may cause parental anxiety, nevertheless the disease may require no treatment unless the patient is immunocompromised. It is necessary to improve awareness regarding the disease as a side effect of BCG vaccination.

Recurrent Genital Ulcers

Papulonecrotic tuberculid represents a hypersensitivity reaction toMycobacterium tuberculosisor its products that disseminate through hematogenous route to the skin from an internal tuberculous focus. It is characterized by recurrent eruptions of asymptomatic, dusky red papules, which undergo ulceration and crusting, and eventually heal after a few weeks with varioliform scarring. Although it most commonly involves extragenital sites, isolated glans penis involvement has been reported very rarely.

Tubercúlide papulonecrótica

As tubercúlides são reações de hipersensibilidade cutânea aos antígenos do Mycobacterium tuberculosis. Este é o caso de uma mulher de 45 anos que procurou a Unidade Básica de Saúde (UBS) com um quadro de eritema nodoso com mais de 10 anos de evolução, de etiologia desconhecida, e que evoluía como nódulos em pescoço e membros, que se tornavam úlceras necróticas, cicatrizavam e recidivavam periodicamente. Biópsias das lesões evidenciavam um processo inflamatório granulomatoso com extensa necrose, sugestivo de tuberculose, mas sem a presença do bacilo. Após anos sem tratamento adequado, finalmente levantou-se a hipótese de tubercúlide papulonecrótica. A paciente iniciou tratamento com o esquema básico (2RHZE/4RH) e dessensibilização vacinal, recebendo alta por cura.

Simultaneous Occurence of Papulonecrotic Tuberculid and Erythema Induratum in a Child: A Case Report

Hypersensitivity reactions to Mycobacterium tuberculosis (tuberculids) include papulonecrotic tuberculid (PNT), erythema induratum (EI), and lichen scrofulosorum. . These rarely coexist in a child. We, therefore, report coexistence of papulonecrotic tuberculid and erythema induratum in a four-year old male. He presented with two-week history of skin eruptions involving the arm, abdomen and ears. Reddish bumps later appeared on the legs. Examination revealed erythematous papules, with central necrosis, on the lateral aspect of the left upper arm, ear helices and trunk. There were also several symmetrically distributed non-tender erythematous nodules, some with necrosis, on the shins and calves. Histology of the biopsied papules (PNT) revealed intense wedge-shaped necrosis with perivascular inflammation.and of the leg nodule (EI), extensive dermal fat necrosis with granulomatous lymphocytic infiltration. These findings are compatible with TB. Chest-xray revealed hilar and paratracheal adenopathy. Sputum was positive for Mycobacterium tuberculosis DNA using polymerase chain reaction (PCR). He did well on anti-tuberculosis medications. erythema induratum (EI), and lichen scrofulosorum. . These rarely coexist in a child. We therefore report coexistence of papulonecrotic tuberculid and erythema induratum in a four-year old male. He presented with two-week history of skin eruptions involving the arm, abdomen and ears. Reddish bumps later appeared on the legs. Examination revealed erythematous papules, with central necrosis, on the lateral aspect of the left upper arm, ear helices and trunk. There were also several symmetrically distributed non-tender erythematous nodules, some with necrosis, on the shins and calves. Histology of the biopsied papules (PNT) revealed intense wedge-shaped necrosis with perivascular inflammation.and of leg nodule (EI) extensive dermal fat necrosis with granulomatous lymphocytic infiltration. These findings are compatible with TB. Chest-xray revealed hilar and paratracheal adenopathy. Sputum was positive for Mycobacterium tuberculosis DNA using polymerase chain reaction (PCR). He did well on anti-tuberculosis medications.

Where in the World Did You Get That Rash?

1. Panteha Eshtiaghi, HBSc* 2. Miriam Weinstein, MD, FRCPC† 1. *Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada 2. †Hospital for Sick Children, Toronto, Ontario, Canada * Abbreviations: ACD: : allergic contact dermatitis CD: : cercarial dermatitis CL: : cutaneous leishmaniasis CLM: : cutaneous larva migrans DF: : dengue fever HFMD: : hand, foot, and mouth disease HSV: : herpes simplex virus KD: : Kawasaki disease PCR: : polymerase chain reaction PR: : pityriasis rosea RT-PCR: : reverse transcriptase polymerase chain reaction The challenge to diagnose cutaneous eruptions and lesions in patients who have spent time in foreign countries is increasingly common. With the advent of increased global travel, foreign adoptions, immigration, and refugee seekers, rashes that were once relegated to the realm of the exotic and likely to show up in a tropical diseases clinic may now present to a general pediatrician. Furthermore, the pediatric traveler is at increased risk for dermatoses. (1) It behooves the practitioner to be aware of these skin findings, to be able to recognize them and distinguish them from other skin conditions. After completing this article, readers should be able to: 1. Identify and classify rashes by main morphologic patterns. 2. Develop a broad differential diagnosis and diagnostic approach for a rash in a returned pediatric traveler based on initial morphology, history, epidemiology, and other clinical features. 3. Consider both infectious and noninfectious causes of skin disorders presenting in a patient with a travel history. 4. Outline the basic investigations and principles of management for travel-acquired and non–travel-acquired dermatologic illnesses. 5. Discuss …

Papulonecrotic tuberculid: a case report

Introduction: Papulonecrotic tuberculid (PNT) is a chronic, recurrent, and symmetric eruption of necrotising skin papules in crops involving the arms and legs, and healing with scar formation. PNT is an uncommon disorder, occurring in less than 5 % of cases of active TB. The pathophysiology of this disease has remained controversial.Case: A 31 years old Balinese woman, visited Outpatient Clinic Department of Dermatology and Venereology Sanglah Hospital Denpasar in 8th September 2003, she has complained of recurrent ulcer for 14 years ago. The clinical feature showed papules, multiple ulcer, and scars, symmetrically on her arms, legs and trunk. Mantoux skin test was strongly positive with 13 mm induration. Lymphohystiocytic vasculitis was found on cell pathology examination, there is no evidence of microbial growth in culture, Ziehl-Neelsen staining and PCR was negative. She was given anti-tuberculosis with a rapid improvement after therapy for 6 months with no significant adverse event.Conclusion: Treatment for six months using anti-tuberculosis drugs provides satisfactory results with clinical improvement in patients with PNT.

Koebner phenomenon induced by Mantoux testing in a case of papulonecrotic tuberculid.

The present report illustrates a case of Mantoux testing induced Koebner phenomenon in papulonecrotic tuberculid.

Simultaneous Occurrence of Papulonecrotic Tuberculid and Erythema Induratum in a Patient Without a Previous History of Tuberculosis Infection: A Case Report and Review of Literature

: Papulonecrotic tuberculid (PNT) is a relatively rare subtype of cutaneous tuberculosis believed to represent a hypersensitivity reaction to tuberculosis antigens. Yet, the simultaneous occurrence of PNT and Erythema Induratum (EI) is even more uncommon. Here, we present a case of concomitant PNT and EI in a 53-year-old woman without any previous history of Mycobacterium tuberculosis infection who was successfully treated with anti-tuberculosis agents without recurrence in a subsequent follow-up

Simultaneous occurrance of papulonecrotic tuberculid and extra pulmonary tuberculosis (cervical lymphadenopathy) in an adult man. A Case report

Simultaneous occurrance of papulonecrotic tuberculid and extra pulmonary tuberculosis (cervical lymphadenopathy) in an adult man. A Case report

Infectious granulomatous dermatoses: Clinico-histopathological correlation in punch biopsy specimens

Infectious granulomatous dermatoses: Clinico-histopathological correlation in punch biopsy specimens - JDPO- Print ISSN No: - 2581-3714 Online ISSN No:- 2581-3706 Article DOI No:- 10.18231/2581-3706.2019.0011, IP Journal of Diagnostic Pathology and Oncology-IP J Diagn Pathol Oncol

Cutaneous tuberculosis and HIV infection at a referral centre in Rio de Janeiro, Brazil.

BACKGROUNDCutaneous tuberculosis (CTB) is a rare extrapulmonary form of tuberculosis (TB). Despite the increase in the number of cases of TB and HIV, few cases of CTB have been reported.OBJECTIVE To describe CTB cases among patients with HIV infection from a cohort with tuberculosis.METHODS We describe a series of 15 CTB and HIV cases, based on secondary data from 2000 to 2016. Diagnosis was based on isolation of Mycobacterium tuberculosis in culture or clinical response to anti-tuberculous treatment associated with positive smear or histopathologic findings from affected skin or an adjacent lymph node.FINDINGS Scrofuloderma was present in 12 (80%) patients and solitary gumma in three (20%) patients. One case of scrofuloderma was associated with papulonecrotic tuberculid. Seven (46.6%) patients had pulmonary TB. Diagnosis was based on culture in nine patients (60%). The median CD4 cell count was 262 cells/µL. All patients were cured at the end of treatment (median time 6 months). Three patients presented with immune reconstitution inflammatory syndrome.CONCLUSIONS In this study, CTB associated with HIV infection presented as localised forms or in association with pulmonary TB. In patients with HIV who have subacute and chronic skin lesions, CTB should be considered in differential diagnosis, which may represent a good opportunity for early diagnosis of active TB.