Primary Inoculation Tuberculosis Research Articles

167 Unusual case of tuberculous chancre at the exact site of application of the Mantoux test

We report an unusual case of cutaneous tuberculosis that developed at the exact site where a Mantoux test (also known as PPD test) was performed. A 25 year old male patient, recently diagnosed with HIV infection and acquired immunodeficiency syndrome (AIDS), in use of lamivudine, efavirenz and dolutegravir for two months, reported cough, night sweats and weight loss. Mantoux test was performed, ordered by his general practitioner, however, the patient presented an intense inflammatory response at the test site with subsequent ulcer formation within four weeks.

Tuberculous chancre in a foot leading to a disseminated tuberculosis infection.

article: Tuberculous chancre in a foot leading to a disseminated tuberculosis infection - Italian Journal of Dermatology and Venereology 2021 December;156(Suppl. 1 to No. 6):89-91 - Minerva Medica - Journals

Hand Tuberculous Chancre with Secondary Pulmonary Tuberculosis.

Hand Tuberculous Chancre with Secondary Pulmonary Tuberculosis.

TUBERCULOUS GUMMA AN UNUSUAL EXTRAPULMONARY TB IN A 17-YEAR-OLD MALE: A CASE REPORT

TOPIC: Chest Infections TYPE: Fellow Case Reports INTRODUCTION: Extrapulmonary TB (EPTB) is estimated at 15% of the global burden and 1.5% of these cases are cutaneous TB. Tuberculous gummas, are unusual forms of cutaneous TB, with an incidence of 1%–2% of all cutaneous TB cases. Local data shows a total 139 tuberculosis of skin and subcutaneous among pediatric population as reported by the accredited hospitals of the Philippine Pediatric Society. CASE PRESENTATION: This is a case of a 17-year-old male, Filipino, from Metro Manila with a history of chest pain, aggravated by exertion, relieved by rest and a lumbar mass a year prior to consult. He was seen at outpatient clinic with a lumbar mass measuring 16cm x 17cm, on the right and 9cm x 7cm on the left, both were soft and non-tender. (Figure 1) His chest CT scan showed opacities in the mediastinum, reticulonodular opacities in the left upper lobe and pericardial thickening with a large, well-circumscribed, non-enhancing hypodense mass in the right posterior chest wall underneath the right trapezius muscle. Ultrasound of his lumbar mass revealed subcutaneous anechoic masses and greenish purulent fluid was evacuated. The collected specimen was positive for reverse transcriptase PCR for M. tuberculosis DNA. DISCUSSION: Tuberculosis (TB) is primarily transmitted via airborne. Cutaneous TB a rare form is acquired via 4 routes: (1) direct inoculation from an exogenous source such as in tuberculous chancre and verrucosa cutis; (2) direct extension from a primary focus such as in scrofuloderma; (3) hematogenous spread such as in miliary tuberculosis and tuberculous gumma and (4) lymphatic spread such as in lupus vulgaris. Metastatic tuberculous abscess known as tuberculous gumma presents as non-tender and fluctuant subcutaneous abscess, solitary or multiple on the trunk, extremities and often invade the skin. Similarly, our patient had a lumbar mass which was soft and non-tender. The National Tuberculosis Control Program recommends treatment of newly diagnosed tuberculosis involving the skin with 2 months intensive therapy with Isoniazid (10 mkd), Rifampicin (15 mkd), Pyrazinamide (30 mkd) and Ethambutol (20 mkd), followed by 4 months maintenance therapy of isoniazid and rifampicin whether bacteriologically confirmed or clinically diagnosed. In this patient, there was a significant decrease in the mass after 1-month intensive therapy with resolution of chest pain. CONCLUSIONS: Tuberculosis mimics various disease condition. This report presents a case of a patient with a rare form of extrapulmonary TB. Extrapulmonary TB should be a part of the differential diagnosis among individuals with baffling presentation, in our case a mass skin lesion. Adherence to government mandated preventive measures must be strictly implemented to further decrease the transmission of TB. It is likewise important to upskill health care personnel to identify possible cases of extrapulmonary TB and prevent its' dreaded outcomes. REFERENCE #1: Global Tuberculosis Report, Executive Summary 2020, Available, https://www.who.int/tb/publications/global_report/TB20_Exec_Sum_20201014.pdf REFERENCE #2: Machan A, Hanafi T, Hjira N, Boui M. Tuberculous gummas: Epidemiological, clinical, bacteriological, immunological, and therapeutic features. Int J Mycobacteriol 2018;7:203-11 REFERENCE #3: Philippine Pediatric Society ICD10 Registry. Philippine Pediatric Society. [cited 2021 April 24]. Available from https://pps.org.ph/icd-10-registry DISCLOSURES: No relevant relationships by Edmund Anthony Sumayod, source=Web Response

Coexistence of tuberculous chancre on a chronic nonhealing wound and bilateral submandibular scrofuloderma

Cutaneous tuberculosis is caused by Mycobacterium tuberculosis with varied clinical features depending on the dissemination route and host immune status. Scrofuloderma is a type of cutaneous tuberculosis that often occurs in locations where there is an infected lymph node or bone underneath, whereas tuberculous chancre often appears in sites that are prone to trauma. Although several cases have been reported, the coexistence of more than one type of cutaneous tuberculosis is very rare. We report a 21-year-old immunocompetent male with a chronic nonhealing lesion on the left tibia followed by bilateral purulent ulcers on the submandibular area. Acid-fast bacilli examination was positive for M. tuberculosis, and the patient was diagnosed with tuberculous chancre and scrofuloderma, respectively. This case showed the importance of high clinical suspicion of cutaneous tuberculosis and the possibility of the coexistence of more than one type of cutaneous tuberculosis in order to avoid misdiagnosis and delay in treatment.

Tuberculous chancre in a foot leading to a disseminated tuberculosis infection

Tuberculous chancre in a foot leading to a disseminated tuberculosis infection

Cutaneous tuberculosis: A great imitator

Tuberculosis (TB) is still prevalent in many developing countries and can pose a new potential threat to global health due to international migration. As an uncommon form of extrapulmonary TB, cutaneous TB is complicated in its clinical manifestation, pathogenesis, and classification. Cutaneous TB can be divided into two major categories, true cutaneous TB and tuberculid, depending on the source of infection, the route of transmission, the amount of bacteria, and the immune state of the host. Clinical manifestations may include patches and plaques (lupus vulgaris, TB verrucosa cutis), macules and papules (acute miliary TB, papulonecrotid tuberculid, lichen scrofulosorum), nodules, and abscesses (erythema induratum of Bazin, tuberculous gumma), erosions, and ulcers (tuberculous chancre, orificial TB, scrofuloderma), mimicking diverse skin diseases. Uncommon localizations such as external genitalia, unusual presentations such as nodular granulomatous phlebitis, and coexistence with other morbidities such as Behçet disease and acne inversa or hidradenitis suppurativa deserve special attention. Treatment of both true and tuberculid cutaneous TB follows the same drug regimens of the World Health Organization’s recommendation for treatment of new cases of pulmonary TB. Erythema induratum of Bazin may need longer treatment duration and adjuvants such as dapsone, potassium iodide, doxycycline, and corticosteroids to tackle inflammation. Misdiagnosis and undertreatment in daily practice are likely, and contemplation of this classic great imitator in dermatology is warranted.

Analysis of 30 patients with acupuncture-induced primary inoculation tuberculosis.

Primary inoculation tuberculosis is a skin condition that develops at the site of inoculation of Mycobacterium tuberculosis in tuberculosis-free individuals. This report describes the diagnosis, treatment and >1 year follow-up of 30 patients presenting with acupuncture-induced primary inoculation tuberculosis. Our data provide a deeper insight into this rare route of infection of tuberculosis. We also review effective treatment options.

Primary inoculation tuberculosis after an accidental scalpel injury

Tuberculosis (TB) infection in healthcare personnel occurs mostly by mycobacteria inhalation and contact with infected material. Here, we report a case of primary inoculation TB in a surgeon resulting from an accidental scalpel injury. Standard anti-TB treatment produced a good result, and no relapses occurred in the 18-month follow-up period. Given the increased incidence of TB and the use of surgery to treat multidrug-resistant (MDR) strains, this report underscores the need to take special precautions during lesion excision in TB patients.

Lichen Scrofulosorum and Immune Thrombocytopenic Purpura in a Child With Tuberculosis

To the Editors: Lichen scrofulosorum is a rare manifestation of cutaneous tuberculosis (TB) characterized by closely grouped reddish-brown minute papules, often perifollicular and is believed to be due to hematogenous spread of mycobacteria.1 Thrombocytopenia is also an uncommon feature in patients with tuberculosis.2 We report a 12-year-old girl with lichen scrofulosorum over her trunk, immune thrombocytopenia induced petechiae over the body with mediastinal lymphadenopathy, who responded to methylprednisolone and antitubercular therapy. A 12-year-old girl was admitted for high grade fever and diffuse papular rash of 15 days duration. The rash was limited to her chest, abdomen, and back and was associated with mild itching. Five days after the onset of fever she developed epistaxis which worsened over a period of 2 days and necessitated nasal packing. On the same day, the patient noticed a new rash, reddish in color, nonelevated, nontender, and pin point on her limbs and gradually involving the whole body. There was no history of hematologic or liver disease and the patient did not report any chronic drug intake. Clinical examination was significant for multiple grouped reddish brown follicular and extrafollicular lichenoid papules involving the front and back of the trunk suggestive of lichen scrofulosorum (Fig., Supplemental Digital Content 1, https://links.lww.com/INF/A501). She also had multiple petechiae predominantly over her limbs. Initial laboratory investigations revealed hemoglobin of 9.2 g/dL, total leukocyte count (TLC) 11.8 × 109/L with polymorphs 68% and lymphocytes 31%. Initial platelet count was 20 × 109/L with paucity of platelets in the peripheral smear. Prothrombin time and activated partial thromboplastin time were normal. The liver and renal function tests were normal. Tests for antinuclear antibody, Coombs test and serologies for HIV, hepatitis-B, hepatitis-C, Ebstein-Barr virus, cytomegalovirus, and varicella zoster and dengue were negative. Blood cultures were sterile. Tuberculin skin test (5TU, purified protein derivative) was positive producing a 22-mm induration. Chest radiograph was significant for superior mediastinal widening, which on computed tomography, revealed multiple lymph nodes in the mediastinum with areas of necrosis and calcification. Sputum for acid fast bacilli was negative. Bone marrow aspiration showed increase in size and number of megakaryocytes with normal myeloid and erythroid precursors without any evidence of acid fast bacilli or granuloma. Skin biopsy showed dermal granulomatous inflammation with negative Ziehl-Neelsen staining. Ultrasonography of abdomen was normal. Two days after admission, her platelet count fell to 5 × 109/L which necessitated 2 units platelet transfusion. She was treated with intravenous methyl-prednisolone (1000 mg) for 3 days and followed by oral prednisolone (1 mg/kg). Antitubercular therapy consisting of isoniazid, rifampin, ethambutol, and pyrazinamide was started. The child responded to treatment, her platelet count started rising reaching 112 × 109/L on day 7 of therapy. Fever and petechiae subsided completely and the papular lesions started decreasing gradually. Prednisolone was continued at 1 mg/kg for 6 weeks and then subsequently tapered. After 2 months of antitubercular therapy, she was changed to a maintenance regimen of isoniazid and rifampicin for 4 months. Last evaluated 4 months after the onset of therapy, the patient was asymptomatic and doing well. Cutaneous tuberculosis is an uncommon presentation of tuberculosis and can be often missed.3,4 It is also highly varied and range from lupus vulgaris, scrofuloderma, or tuberculosis verrucosa cutis in a previously sensitized individual, to military tuberculosis of skin and tuberculous chancre is a previously nonexposed individual.5 There are also a group of less well understood lesions (tuberculids) which are believed to result from hypersensitivity.1 Lupus scrofulosorum is a rare form of tuberculid, first recognized by Hebra in 1868, usually seen in children and young adults.6 It consists of small firm follicular and parafollicular lichenoid papules covered by fine scales confined mainly to the trunk. The lesion may persist for months and may resolve spontaneously.1,7 The cutaneous manifestion of our patient were consistent with lichen scrofulosorum and was confirmed by skin biopsy. In addition our patient subsequently developed petechiae which on evaluation was found to be due to immune thrombocytic purpura (ITP). Thrombocytopenia is an uncommon manifestation in TB and currently there have been only 4 reports of ITP in children with tuberculosis.8–11 To our knowledge, this is the first report of 2 extremely rare manifestations of tuberculosis occurring in a patient, ie, lichen scrofulosorum and ITP. Aberrant immune response may be the underlying pathophysiology for the occurrence of both these manifestations, hypersensitivity for lichen scrofulosorum and cytotoxic antibodies directed against platelets for ITP. Vineet K. Surana, MB BS Ankur Singh, MD Seema Kapoor, MD Department of Pediatrics Maulana Azad Medical College and associated Lok Nayak Hospital New Delhi, India Kabeer Sardana, MD Department of Dermatology Maulana Azad Medical College New Delhi, India

Cutaneous tuberculosis: A diagnostic and therapeutic study of 20 cases

Cutaneous tuberculosis is showing a resurgence. It continues to be one of the most elusive and difficult diseases to diagnose in dermatological practice. We sought to describe the clinical manifestations, laboratory features, and antituberculous therapy in cases of cutaneous tuberculosis. Twenty cases of cutaneous tuberculosis were observed in this study. Of the 20 cases, seven were in women (35%) and 13 were in men (65%). There were eight (40%) cases of lupus vulgaris, four (20%) cases of orificial tuberculosis, four (20%) cases of tuberculosis verrucosa cutis, two (10%) cases of scrofuloderma, and two (10%) cases of primary inoculation tuberculosis. In total, 20 strains of acid-fast bacilli were isolated by culture in Löwenstein-Jensen medium at 37°C. Mycobacterial species identification by polymerase chain reaction (PCR) assay showed that all strains were Mycobacterium tuberculosis. In vitro susceptibility testing by use of absolute concentration method showed that the 20 strains were sensitive to rifampin, ethambutol, and isoniazid; however, two strains were resistant to streptomycin. All of the patients responded favourably to antituberculous treatment. Cutaneous tuberculosis is a skin disease that should still be thought much of in mainland China, and in this study lupus vulgaris is the most common clinical presentation.

Three Cases of Primary Inoculation Tuberculosis as a Result of Illegal Acupuncture

Primary inoculation tuberculosis results from the direct inoculation of Mycobacterium tuberculosis into the skin of a person who has no natural or artificially acquired immunity to the organism. The pathogenesis requires a break in the skin from an abrasion or injury that allows entry of the tubercle bacilli. We report 3 cases of primary inoculation tuberculosis resulting from illegal acupuncture. Three patients over 70 years old presented with erythematous, ulcerative, indurated plaques on the back. Skin lesions had developed at the acupuncture sites 1 or 2 weeks after a session of acupuncture, which was intended to relieve back pain. An unlicensed, non-medically trained person conducted each session. The patients' past medical and family histories were unremarkable. Granulomatous inflammatory infiltration and acid-fast bacilli were observed histologically. M. tuberculosis was identified by mycobacterial culture and polymerase chain reaction. Nine months after the initiation of antituberculosis medication, skin lesions improved, and no evidence of recurrence or other organ involvement was observed at the 1-year follow-up visit.

Primary cutaneous inoculation tuberculosis in a healthcare worker as a result of a surgical accident

In May 2004, a 48-year-old male surgeon, resident in Bucaramanga, Colombia, suffered a superficial cut with a scalpel to the lateral aspect of the mid-phalanx of the second finger of the left hand while performing a pulmonary decortication surgical procedure for tuberculous empyema with pulmonary entrapment. The injury healed normally but, approximately 2 weeks after the event, an erythematous, nonpainful papule of approximately 3 mm in diameter developed, and increased progressively to 7 mm 3 days after its initial appearance. At this time, the papule showed spontaneous secretion of a clear liquid and superficial ulceration (Fig. 1). Approximately 3 weeks after the injury, a Gram stain of the liquid was performed; it showed no bacteria but a moderate leukocyte reaction. Because of the high suspicion of possible tuberculous infection, bacilloscopy of the liquid was performed, and was positive (++) for acid-fast bacteria (Fig. 2). The liquid was cultured and grew Mycobacterium tuberculosis. The culture was sent to the Laboratory of Mycobacteria at the National Institute of Health, Bogota, Colombia for drug resistance testing. Susceptibility was demonstrated against streptomycin, isoniazid, rifampicin, and ethambutol. During this time, the patient presented an ipsilateral painful axillary adenopathy of about 2.5 cm in diameter. The patient consulted with an infectologist, who initiated a Directly Observed Therapy Short Course (DOTS) regimen [first phase (8 weeks): daily, except Sundays, streptomycin 1 g intramuscularly, pyrazinamide 1500 mg orally, isoniazid 300 mg, and rifampicin 600 mg; second phase (18 weeks): twice weekly rifampicin 600 mg and isoniazid 500 mg], accompanied by daily pyridoxine to prevent secondary effects from isoniazid. After 3 weeks of treatment, the finger lesion had disappeared. Treatment was undertaken as described above, with the patient reporting symptoms of vertigo, nausea, epigastralgia, and mild myalgia as the adverse effects of medication. A chest x-ray was taken and reported to be normal. The axillary adenopathy disappeared approximately 6 months after the injury. Nearly 3.5 years after the incident, the patient has not presented any type of symptomatology.

Lichen scrofulosorum in a Saudi adolescent with multifocal tuberculosis

Lichen scrofulosorum in a Saudi adolescent with multifocal tuberculosis

Lupus vulgaris with squamous cell carcinoma

Tuberculosis is still a significant problem in developing countries. Cutaneous forms of tuberculosis account for approximately 10% of all cases of extrapulmonary tuberculosis. Cutaneous tuberculosis may be because of true infection with Mycobacterium tuberculosis or because of tuberculids. Tuberculids are immunological reactions to haematogenously spread antigenic components of M. tuberculosis. True cutaneous tuberculosis may be because of inoculation or haematogenous spread of M. tuberculosis to the skin. Lupus vulgaris is the commonest form of true cutaneous tuberculosis. Other forms of true cutaneous tuberculosis are tuberculous chancre, tuberculosis verrucosa cutis, scrofuloderma, periorificial tuberculosis and miliary tuberculosis of the skin. Lupus vulgaris is usually chronic and progressive. It occurs in patients with moderate to high immunity against M. tuberculosis as evidenced by strongly positive tuberculin test. Long-standing cases of lupus vulgaris may be complicated by squamous cell carcinoma (SCC). We describe a patient who had undiagnosed lupus vulgaris for 35 years until she developed SCC on the lesion of lupus vulgaris.

Fatal case of tuberculous chancre in a patient with AIDS

Mycobacterium bovis is an unusual cause of tuberculosis. A fatal case of disseminated tuberculosis due to M. bovis with a chancre as a primary portal of entry and lymph node, pulmonary and renal involvement is presented in a patient with AIDS.

Cutaneous tuberculosis in Morocco

To describe the salient epidemiologic, clinical, histopathologic, and bacteriologic aspects of cutaneous tuberculosis in Morocco. A retrospective review of all cases of cutaneous tuberculosis at our hospital from January 1981 through December 2004. Two-hundred and sixteen cases of cutaneous tuberculosis were identified and included. Men and women were equally affected. The mean patient age was 29 years. Major clinical types of cutaneous tuberculosis were scrofuloderma and gumma (72%), lupus vulgaris (12%), tuberculosis verrucosa cutis (7%), tuberculids (6%), orificial tuberculosis (1%), and tuberculous chancre (1%). Systemic involvement was seen in 35%. Where performed (66%), 81% of subjects had positive Mantoux skin tests. Lesion biopsy for histopathologic study was performed in 81% of patients and showed classical tuberculous findings in 57%. Mycobacterium tuberculosis was isolated in culture from 9% of patients. Cutaneous tuberculosis is still a common disease in Morocco, and scrofuloderma and gumma are the most common clinical presentations.

Papular eruption on a tattoo: A case of primary inoculation tuberculosis

The pathogenesis of inoculation cutaneous tuberculosis requires a break in the skin, through minor abrasions or injury, allowing the entry of tubercle bacilli. We report a 33-year-old man who presented with erythematous papules over a tattoo on the right upper arm, 1 month after undergoing a tattoo procedure. Histology and cultures revealed infection with Mycobacterium tuberculosis. He was started on a 9-month course of antituberculous medication and 3 months after initiation of the drugs all the papules had subsided. He has since completed the course of therapy and there has been no recurrence 1 year after treatment was started.

Cutaneous tuberculosis: diagnosis and treatment.

As we move into the 21st century, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary tuberculosis. Mycobacterium tuberculosis, Mycobacterium bovis, and the BCG vaccine cause tuberculosis involving the skin. True cutaneous tuberculosis lesions can be acquired either exogenously or endogenously, show a wide spectrum of morphology and M. tuberculosis can be diagnosed by acid-fast bacilli (AFB) stains, culture or polymerase chain reaction (PCR). These lesions include tuberculous chancre, tuberculosis verrucosa cutis, lupus vulgaris, scrofuloderma, orificial tuberculosis, miliary tuberculosis, metastatic tuberculosis abscess and most cases of papulonecrotic tuberculid. The tuberculids, like cutaneous tuberculosis, show a wide spectrum of morphology but M. tuberculosis is not identified by AFB stains, culture or PCR. These lesions include lichen scrofulosorum, nodular tuberculid, most cases of nodular granulomatous phlebitis, most cases of erythema induratum of Bazin and some cases of papulonecrotic tuberculid. Diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with diagnostic testing; in addition to traditional AFB smears and cultures, there has been increased utilization of PCR because of its rapidity, sensitivity and specificity. Since most cases of cutaneous tuberculosis are a manifestation of systemic involvement, and the bacillary load in cutaneous tuberculosis is usually less than in pulmonary tuberculosis, treatment regimens are similar to that of tuberculosis in general. In the immunocompromised, such as an HIV infected patient with disseminated miliary tuberculosis, rapid diagnosis and prompt initiation of treatment are paramount. Unfortunately, despite even the most aggressive efforts, the prognosis in these individuals is poor when multi-drug resistant mycobacterium are present. An increased awareness of the re-emergence of cutaneous tuberculosis will allow for the proper diagnosis and management of this increasingly common skin disorder.

Primary tuberculous chancre caused by Mycobacterium bovis after goring with a bull's horn

A 14-year-old boy was gored by a bull during festival celebrations. The horn of the bull caused a wound on his left hand and after 3 months it was a accompanied by an ulcerated nodule on the left upper arm and an axillary adenopathy. The tuberculin test was positive and a culture of the aspiration biopsy specimen of the axillary lymph node yielded Mycombacterium bovis. (J Am Acad Dermatol 2000;43:535–7.)