Eritema indurado de Bazin como una reactivación de una tuberculosis latente en una paciente con tratamiento biológico anti-factor de necrosis tumoral / Erythema induratum of Bazin as a reactivation of latent tuberculosis infection in a patient receiving anti-tumor necrosis factor treatment

Resumen El eritema indurado de Bazin es una tuberculosis cutánea rara, considerada una tuberculide o reacción de hipersensibilidad a Mycobacterium tuberculosis. El tratamiento con agentes biológicos es un factor de riesgo conocido para la reactivación de tuberculosis, especialmente en áreas de alta incidencia como Latinoamérica, por lo que existen protocolos de búsqueda y tratamiento antes del inicio de este tipo de terapias. Se presenta un caso clínico de eritema indurado de Bazin como reactivación de una infección tuberculosa latente en una paciente con artritis reumatoide que recibía tratamiento con golimumab.

Abstract Erythema induratum of Bazin is a rare form of cutaneous tuberculosis, considered as part of the spectrum of tuberculids or hipersensitivity reactions to Mycobacterium tuberculosis. Treatment with biologic agents is a known risk factor for tuberculosis reactivation, especially in areas of high incidence like Latin America, which is why screening and treatment protocols must be followed before these therapies are initiated. We present a case of erythema induratum of Bazin as a reactivation of latent tuberculosis infection in a patient with rheumatoid arthritis treated with golimumab.

Relato da ocorrência simultânea de escrofuloderma, eritema indurado de Bazin e tuberculide pápulo-necrótica em paciente imunocompetente / Report of simultaneous occurrence of scrofuloderma, Bazin's indurated erythema and papulonecrotic tuberculid on an immunocompetent patient

Modelo do estudo: relato de caso Importância do problema: A tuberculose é um grave problema de saúde no nosso país, no entanto poucos profissionais sabem identificar as formas extrapulmonares da doença, que são responsáveis por 23,3% dos óbitos por tuberculose no Brasil. Das formas extra-pulmonares, apenas 1-2% representam formas cutâneas. É importante que o médico generalista conheça as formas cutâneas de tuberculose, uma vez que pode ser a única manifestação da doença. O seu diagnóstico é um desafio, pois os exames tradicionais têm menor sensibilidade e especificidade para a apresentação cutânea em relação à forma pulmonar. No entanto, novos exames vêm sendo implantados como o GeneXpert. Comentários: Relatamos um caso raro de tuberculose cutânea em paciente imunocompetente, com a manifestação de três formas clínicas simultaneamente ­ escrofuloderma, tubercúlide papulonecrótica e eritema indurado de Bazin. A ocorrência de duas formas simultâneas é descrita na literatura mas a ocorrência de três formas simultâneas é inédita. Essa manifestação atípica foi de difícil diagnóstico clínico por simular outras doenças e os exames tradicionais como o RX de tórax, baciloscopia e cultura não evidenciaram o diagnóstico. A identificação do Mycobacterium tuberculosis só foi possível por meio da pesquisa de PCR com o GeneXpert, que mostrou positividade no escarro pulmonar e no exsudato do escrofuloderma, possibilitando iniciar o tratamento precocemente. Este novo exame de alta sensibilidade e especificidade no diagnóstico da tuberculose pulmonar mostrou-se de grande utilidade no diagnóstico deste caso atípico de tuberculose cutânea onde os exames tradicionais não definiram o diagnóstico. (AU)

Study: Case Report Importance: Tuberculosis is a serious health problem in Brazil. Nevertheless, only few physicians know how to identify the non-pulmonary cases of this disease, which can represent up to 23,3% of deaths caused by tuberculosis in Brazil. Among the non-pulmonary cases, only 1-2% affect the skin. It is important for the general physician to understand the cutaneous presentations of tuberculosis, once it can be the only symptom that the patient presents. Diagnosing cutaneous tuberculosis is a challenge, because traditional laboratory tests have smaller sensitivity and specificity for the cutaneous form in contrast to pulmonary tuberculosis. However, implementation of new exams such as GeneXpert may come in hand. Comments: We report a rare case of cutaneous tuberculosis on an immunocompetent patient, with three different simultaneous presentations - scrofuloderma, papulonecrotic tuberculids and Bazin's indurated erythema. Occurrence of two simultaneous presentations has been reported, however, three simultaneous forms have not. Diagnosing this atypical manifestation was very hard because the clinical presentation often mimics other dermatological conditions, and traditional laboratory testing such as chest X-ray, bacilloscopy and culture did not evidence infection. Identification of Mycobacterium tuberculosis was only possible due to positive PCR testing through GeneXpert on pulmonary and scrofuloderma fluids, allowing rapid treatment initiation. This new high sensitivity and specificity exam proved to be of great value when diagnosing this atypical cutaneous tuberculosis case, in which diagnose was not possible through traditional laboratory testing. (AU)

Tuberculosis cutánea: revisión del tema a propósito de dos casos / Cutaneous tuberculosis: two cases and literature review

La Tuberculosis Cutánea es una enfermedad infecciosa crónica causada por el Mycobacterium tuberculosis. Pese a ser una forma poco frecuente de presentación de la Tuberculosis, representa un gran desafío para los clínicos que se enfrentan a estos casos, debido principalmente a la gran diversidad de formas clínicas existentes. A continuación presentamos 2 casos clínicos de Tuberculosis Cutánea diagnosticados en el Hospital Regional de Talca y una revisión del tema basada en la clasificación, diagnóstico y tratamiento de la enfermedad.

Cutaneous Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis. Despite being a rare presentation of the disease, Cutaneous Tuberculosis is a major challenge for clinicians who face these cases, mainly due to the great diversity of clinical forms. We present 2 cases of Cutaneous Tuberculosis diagnosed in Hospital Regional de Talca and a review of the topic based in classification, diagnosis and treatment of the disease.

Eritema Indurado de Bazin / Erythema Induratum of Bazin

El eritema indurado de Bazin, es una enfermedad nodular crónica, recurrente asociada a una hipersensibilidad al bacilo tuberculoso, que típicamente se localiza en la cara posterior de las piernas de mujeres de edad media, y cuyo patrón histopatológico es una paniculitis lobular con vasculitis y presencia de granuloma tuberculoide. Presentamos el caso de una paciente de 18 años que acudió a la consulta por presentar placas eritematovioláceas en la cara interna y posterior de las piernas, de un mes de evolución. Se hace una breve revisión de ésta entidad y se recalca la importancia del diagnóstico diferencias con patologías que se presentan como nódulos o placas inflamatorias en las piernas.

The erythema induratum of Bazin is a recurrent chronic nodular disease associated to a hypersensibility to tuberculosis bacillus, that typically localizes in posterior aspects of legs of middle age women and with a histopathology pattern of lobular panniculitis with vasculitis and tuberculoid granuloma. A female patient 18 years old is presented with erythematous violaceous plaques at posterior and inner side of legs of one month of evolution. A brief revue of this entity is made whit especial emphasis on differential diagnoses.

Vasculitis nodular (enfermedad de Bazin) / Nodular vasculitis (Bazin's disease)

Presentamos el caso de una paciente de 56 años con Vasculitis Nodular o Eritema Indurado de Bazin, localizada en ambas piernas, que durante 12 años de evolución no fue diagnosticada, coincidiendo con Tuberculosis Pulmonar. Con terapéutica tuberculostática presentó buena evolución luego de 30 días de tratamiento.

Erythema nodosum or erythema induratum: an important distinction for appropriate treatment

Objective and Importance: The objective of this case report is to draw the attention of the readers to a commonly seen disorder, namely panniculitis. Clinically, the condition resembles cellulitis, that often causes a diagnostic problem. The report hightlights the importance of accurate diagnosis of panniculitis and its subtypes for its proper management. Clinical Presentation: Two patients with clinically typical lesions of panniculitis on their lower extremities are described. The lesions in these 2 patients had marked clinical resemblance to cellulitis. However, with the help of biopsy and histopathological examination it was possible to accurately diagnose the distinct forms of panniculitis in these patients. It helped in the correct management of the patients with satisfactory outcome. It is concluded that in patients with lesions resembling cellulitis, especially on the shin, the possibility of panniculitis must be considered. The experience with these 2 patients highlights the need for accurate histological characterization as an essential step in the diagnosis and proper management of different forms of panniculitides

Tuberculosis nodular profunda / Deep nodular tuberculosis

La tuberculosis nodular profunda o eritema indurado de Bazin es la forma de tubercúlide más común. Se reporta un caso en una mujer de 25 años de edad, por lo poco frecuente que se observan estos casos en la actualidad