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.

Gummatous cutaneous tuberculosis associated with the use of infliximab for Crohn's disease

Abstract As the treatment of infectious and parasitic diseases improved, the prevalence of these conditions declined. However, with the expansion of the use of immunobiologicals, opportunistic infections have emerged, especially under atypical presentations. The present study reports the case of a patient treated with infliximab for Crohn's disease, who presented diarrhea, weight loss, abdominal pain, fever, and subcutaneous erythematous nodules that evolved with spontaneous fluctuation and ulceration. With the finding of alcohol-resistant bacilli and Mycobacterium tuberculosis DNA in a cutaneous fragment, through polymerase chain reaction, the diagnosis of gummatous tuberculosis was confirmed, probably secondary to hematogenous dissemination from an intestinal focus.

Diagnosis of cutaneous tuberculosis (lymph node scrofuloderma) using the Xpert MTB/RIF® method

Abstract Cutaneous tuberculosis is a rare infection that is difficult to diagnose, because it shows less sensitivity and specificity in classic complementary exams when compared with the pulmonary form. The Xpert MTB/RIF® method offers an early diagnosis that identifies the DNA of Mycobacterium tuberculosis and the main mutations that give the bacterium resistance to rifampicin. The authors present a case of scrofuloderma whose diagnosis was quickly obtained through the secretion of a cervical lesion, allowing an early diagnosis and the initiation of appropriate treatment.

Escrofuloderma, una manifestación extrapulmonar de tuberculosis: a propósito de un caso y actualización de esquema de tratamiento en Chile / Scrofuloderma, a manifestation extrapulmonary tuberculosis: about a case and treatment scheme update in Chile

La tuberculosis (TBC) es una enfermedad infecciosa causada por organismos del complejo Mycobacterium tuberculosis. Las presentaciones extrapulmonares constituyen hasta el 25% de los casos de TBC reportados en nuestro país. La TBC cutánea es una manifestación extrapulmonar rara que representa el 1-2% de los casos, siendo el escrofuloderma y el lupus vulgar las formas clínicas más comunes. El escrofuloderma es una manifestación endógena de la infección, como resultado de la extensión contigua a la piel suprayacente desde estructuras adyacentes. La biopsia de piel asociada a técnicas moleculares y cultivo de micobacterias constituyen el gold standard diagnóstico de la TBC cutánea. El tratamiento de la TBC cutánea sigue las mismas recomendaciones que para otras formas de TBC. Presentamos el caso de un paciente con escrofuloderma.

Tuberculosis (TB) is an infectious disease caused by organisms of the Mycobacterium tuberculosis complex. Extrapulmonary presentations may constitutes up to 25% of TB cases. Reported in our country Cutaneous tuberculosis is a rare extrapulmonary manifestation that represents 1-2% of cases, with scrofuloderma and lupus vulgaris being the most common clinical forms. Scrofuloderma is an endogenous manifestation of the infection, because of contiguous extension to the overlying skin from adjacent structures. Skin biopsy associated with molecular techniques and mycobacterial culture constitute the gold standard for diagnosis of cutaneous TB. The treatment of cutaneous TB follows the same recommendations as for other forms of TB. We present the case of a patient with scrofuloderma.

A case of tuberculosis verrucosa cutis in Brazil undiagnosed for 15 years

ABSTRACT Tuberculosis verrucosa cutis is a rare medical condition that is caused by the inoculation of Mycobacterium tuberculosis into the skin of a previously sensitized individual. This clinical form of tuberculosis corresponds to 1-2% of all cases of tuberculosis and due to the paucibacillary characteristic of the lesions, patients can be misdiagnosed, accounting for the chronification of the skin infection. Herein, we report the case of a 26-year-old male farmer, presenting plaques with verrucosa and hyperkeratosis features in the left thigh and buttocks during 15 years. M. tuberculosis was identified by PCR and the patient was treated with standard anti-tuberculosis drugs, with subsequent improvement of the skin lesions.

Disseminated tuberculosis associated with reactive arthritis of Poncet in an immunocompetent patient

Abstract Cutaneous tuberculosis is a rare extrapulmonary manifestation of tuberculosis which, like disseminated tuberculosis, commonly occurs in immunocompromised patients. Poncet reactive arthritis is a seronegative arthritis affecting patients with extrapulmonary tuberculosis, which is uncommon even in endemic countries. We report a previously healthy 23-year-old male patient with watery diarrhea associated with erythematous ulcers on the lower limbs and oligoarthritis of the hands. Histopathological examination of the skin showed epithelioid granulomatous process with palisade granulomas and central caseous necrosis. AFB screening by Ziehl-Neelsen staining showed intact bacilli, the culture was positive for Mycobacterium tuberculosis, and colonoscopy revealed multiple shallow ulcers. Disseminated tuberculosis associated with reactive Poncet arthritis was diagnosed, with an improvement of the clinical and skin condition after appropriate treatment.

Tuberculosis cutánea en pabellón auricular: reporte de un caso / Cutaneous tuberculosis in ear auricle: a case report

RESUMEN La tuberculosis cutánea representa menos del 2% de todos los casos de la infección por Mycobacterium tuberculosis. Su baja prevalencia, asociada a la amplia variedad en la presentación clínica de las lesiones, dificulta y retrasa el diagnóstico y, por tanto, el inicio del tratamiento. El siguiente es el caso de una paciente de 80 años, con una lesión ulcerada, crónica, en pabellón auricular izquierdo, con evolución tórpida y pobre respuesta al manejo farmacológico instaurado; con biopsia de piel que mostró reacción inflamatoria crónica y presencia de bacilos ácido-alcohol resistentes.

ABSTRACT Cutaneous tuberculosis represents less than 2% of all cases of infection with Mycobacterium tuberculosis. Its low prevalence, associated with a wide variety in clinical presentation of the lesions, hinders and delays the diagnosis and, thus, treatment initiation. The following is the case of an 80-years old, female patient with an ulcerated, chronic lesion in the left ear auricle, with a torpid evolution and poor response to established pharmacological management; with a skin biopsy that showed chronic inflammatory reaction and the presence of acid-fast bacilli.

Reação em cadeia da polimerase como determinante para o diagnóstico de tuberculose cutânea / Polymerase chain reaction as a cutaneous tuberculosis diagnostic determinant

Relatamos um caso de tuberculose cutânea do tipo eritema indurado de Bazin em paciente do sexo feminino, 26 anos de idade, com presença de úlceras e nódulos infiltrados, eritêmato- ferruginosos, com áreas de supuração e de aspecto endurecido em região de membro inferior esquerdo. O diagnóstico foi feito por meio da detecção de DNA micobacteriano nas lesões cutâneas por meio do método de reação em cadeia da polimerase. Realizou-se tratamento com pirazinamida, rifampicina, isoniazida e etambutol, obtendo-se melhora clínica e resolução das lesões cutâneas da paciente.(AU)

We report a clinical case of Erythema Induratum of Bazin cutaneous tuberculosis on a 26-year-old female patient that presented with ulcers and erythematous-ferruginous infiltrated nodules, with hardened suppuration areas on left lower limb. Diagnosis was made through mycobacterian DNA detection on cutaneous lesions using the chain polymerase reaction method. The treatment was carried out with Pyrazinamide, Rifampicin, Isoniazid and ethambutol, which provided clinical improvement and resolution of the patient's cutaneous lesions.(AU)

Tuberculides tuberculosas en población adulta de la Región Metropolitana, Chile: serie de casos 2006-2010 / Tuberculids in the adult population of the Region Metropolitan, Chile: case series 2006-2010

Introducción: Las tuberculides tuberculosas (TLTB) se subdividen en verdaderas de etiología atribuible al Mycobacterium tuberculosis y facultativas causadas por múltiples condiciones, entre ellas la tuberculosis. En Chile representan el 75% de las tuberculosis cutáneas en la región metropolitana (RM). Objetivo: caracterizar las TLTB de la RM de acuerdo a epidemiología, clínica, estudio y manejo terapéutico. Material y método: Estudio descriptivo retrospectivo del total de TLTB diagnosticadas por biopsia en los servicios de anatomía patológica de 4 hospitales públicos de la RM y un hospital privado de la RM en el quinquenio 2006-2010. Resultados: 83 casos de TLTB, 59% aportados por el sistema público, 84% de los pacientes fueron mujeres, 18% fueron tuberculides verdaderas y 82% tuberculides facultativas. A pesar de ser el tratamiento antituberculoso la elección en las tuberculides verdaderas, sólo se indicó en el 65% de los casos y de estos, 45% realmente lo realizó. Sólo el 4,5% de las tuberculides facultativas de esta serie tuvieron indicación de tratamiento antituberculoso, realizándose en el 100% de los casos. Conclusión: Existe seguimiento insuficiente a través del tiempo en estos pacientes, dificultando dimensionar el éxito real de los tratamientos indicados. Se evidencia una falla en la coordinación al momento de derivar los pacientes al programa de control de la tuberculosis.

Introduction: Tuberculids are subdivided in true tuberculids, which are associated to mycobacterium tuberculosis, and facultative tuberculids which can be caused by several conditions, including tuberculosis. In Chile tuberculids represent 75% of cutaneous tuberculosis in the metropolitan region (MR). Objective: to characterize tuberculids according to epidemiology, clinical, study and therapeutic management. Methods: Descriptive study of the total tuberculids diagnosed by biopsy in the pathology services of 4 public hospitals of the MRI and a private hospital of the MRI in the five-year period 2006- 2010. Results: 83 cases of tuberculids, 59% where provided by the public system, 84% of the patients were women, 18% were true tuberculids and 82% facultative tuberculids. Despite being antitubercular therapy the first line treatment for true tuberculids, this treatment was prescribed in 65% of cases and only 45% of these were actually treated. Only 4.5% of the facultative tuberculids in this series had indication of antitubercular therapy, performed in 100% of cases. Conclusions: There is insufficient follow up in these patients, making it difficult to assess the real success of the treatment. Is evident the lack of coordination when referring patients to the tuberculosis control program.

Cutaneous tuberculosis due to multidrug-resistant tubercle bacilli and difficulties in clinical diagnosis.

This report describes 6 HIV-negative patients including 5 children with scrofuloderma and an adult with lupus vulgaris, out of a total of 303 cases of cutaneous tuberculosis seen during a 4½-year period, who showed a positive tuberculin test and granulomatous histopathology, but failed to respond to fi rst-line antitubercular therapy. They were suspected to have multidrug-resistant infection as no other cause could be ascertained. Tissue aspirate or biopsy was sent for histopathology and culture. Mycobacterium tuberculosis was isolated from the aspirate in three patients and sputum in one with associated pulmonary tuberculosis. Drug susceptibility tests showed that all isolates were resistant to rifampicin and isoniazid, and one each additionally to streptomycin and ethambutol, respectively. In two, culture was unsuccessful. All were administered second-line antitubercular drugs. Clinical improvement was appreciable within 2 months as weight gain, and regression of ulcers, swellings and plaques. Two completed the recommended 24 months of therapy. Multidrug-resistant cutaneous tuberculosis should be suspected in patients with no response to fi rst-line drugs, with clinical deterioration, and where other causes of treatment failure are not forthcoming. Owing to poor isolation rates on culture and low sensitivity of molecular tests, in such cases, a trial of second-line anti-tubercular drugs may be justifi ed for a reasonable period of 2 months. Where facilities permit, culture and drug sensitivity tests should be done before starting treatment. Culture positivity is better from aspirated material.

Cutaneous tuberculosis with nonreactive PPD skin test: a diagnostic challenge

The authors report a case of cutaneous tuberculosis in a 63-year-old female patient, who had an infiltrated, erythematous-ferruginous plaque of indurated aspect on her right leg and a nonreactive PPD skin test. Diagnosis was made by tissue culture and PCR of skin biopsy material. The treatment was performed with pyrazinamide, rifampicin, isoniazid and ethambutol, with good response.

Update on cutaneous tuberculosis

Tuberculosis continues to draw special attention from health care professionals and society in general. Cutaneous tuberculosis is an infection caused by M. tuberculosis complex, M. bovis and bacillus Calmette-Guérin. Depending on individual immunity, environmental factors and the type of inoculum, it may present varied clinical and evolutionary aspects. Patients with HIV and those using immunobiological drugs are more prone to infection, which is a great concern in centers where the disease is considered endemic. This paper aims to review the current situation of cutaneous tuberculosis in light of this new scenario, highlighting the emergence of new and more specific methods of diagnosis, and the molecular and cellular mechanisms that regulate the parasite-host interaction.

Cutaneous tuberculosis: diagnosis, histopathology and treatment - Part II

The evolution in the knowledge of tuberculosis' physiopathology allowed not only a better understanding of the immunological factors involved in the disease process, but also the development of new laboratory tests, as well as the establishment of a histological classification that reflects the host's ability to contain the infectious agent. At the same time, the increasing bacilli resistance led to alterations in the basic tuberculosis treatment scheme in 2009. This article critically examines laboratory and histological investigations, treatment regimens for tuberculosis and possible adverse reactions to the most frequently used drugs.

Tuberculosis cutánea: reporte de un caso / Cutaneous tuberculosis: case report

Se denomina tuberculosis cutánea a la enfermedad cutánea infecciosa crónica ocasionada por el Mycobacterium tuberculosis. Es poco frecuente y particularmente difícil de diagnosticar. Su incidencia, según la bibliografía, oscila entre el 1,5 y el 4% de todas las formas de tuberculosis extrapulmonares. Las formas clínicas dependen de la vía de llegada del bacilo a la piel, del estado inmunológico del paciente y del medio ambiente. Se presenta un caso de tuberculosis cutánea en un niño con lesiones dermatológicas crónicas, de evolución tórpida, sin respuesta a los tratamientos instituidos, la biopsia de piel mostró granulomas caseosos. El objetivo es describir un paciente con una presentación clínica infrecuente de esta enfermedad, destacar la importancia de su reconocimiento y tratamiento precoz, y evitar así la aparición de complicaciones y secuelas.

Cutaneous tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis. It is not very frequent and particularly difficult to diagnose. It incidence ranges between 1.5 and 4% of all extrapulmonary tuberculosis, according to bibliography. The clinic presentations depend on the arrival via of the bacillus to the skin, the patient's immune state and the environment. We show a cutaneous tuberculosis on a child with chronic dermatologic lesions, with torpid evolution, without response to treatments; the skinbiopsy showed caseous granulomas. The aim is to show a patient with an infrequent clinic presentation of this disease, to emphasize the importance of an early recognition and treatment, avoiding the appearance of complications and sequels.

Escrofuloderma: la tuberculosis olvidada / Scrofuloderma: the forgotten tuberculosis

INTRODUCCIÓN: La escrofuloderma es una manifestación extrapulmonar de la tuberculosis, siendo su incidencia menor al 1 por ciento de los casos de tuberculosis no pulmonar. Actualmente, la escrofuloderma se presenta con mayor frecuencia en personas inmunocomprometidas o en pacientes que viven en condición de hacinamiento, recintos tales como hogares de ancianos, cárceles o en viviendas de estratos socioeconómicos más bajos. PRESENTACIÓN DEL CASO: A continuación, se presenta el caso de un paciente de 29 años que vive en condiciones de hacinamiento en un recinto penitenciario. Es derivado a policlínico de Medicina Broncopulmonar para estudio con fibrobroncoscopía ante la sospecha de tuberculosis pulmonar. Se pesquisa lesión nodular subcutánea supurativa, asociada a placas cicatriciales rojo-violáceas que, según contexto del paciente, características de las lesiones y resultado de biopsia se diagnosticaron como escrofuloderma. Se inició tratamiento antituberculoso con buena respuesta clínica de las lesiones cutáneas. DISCUSIÓN: Debido al proceso de eliminación que está sufriendo la tuberculosis en Chile, las manifestaciones extrapulmonares de la tuberculosis, entre ellas las cutáneas, representan hoy en día un desafío diagnóstico principalmente por el bajo índice de sospecha que se tiene sobre ellas.

INTRODUCTION: Scrofuloderma is a manifestation of extrapulmonary tuberculosis, being its incidence less than 1 percent of the non-pulmonary cases. Nowadays, scrofuloderma is presented more frequently in immunosuppressed people or in patients living in overcrowded conditions, in enclosures such as nursing homes, prisons or houses from the lowest socioeconomic status. CASE REPORT: We present a clinical case of a 29-year-old patient living in overcrowded conditions in a penitentiary facility. The patient is referred to the neumology Outpatients Unit for study with fibrobronchoscopy for suspected pulmonary tuberculosis. A nodular subcutaneous suppurative lesion is found, associated to purpurish red cicatricial plaques that according to the clinical context of the patient, characteristics of the lesions and biopsy results, were diagnosed as scrofuloderma. Antituberculosis treatment was initiated, with a positive clinical response of the skin lesions. DISCUSSION: Due to the process of elimination that tuberculosis is suffering in Chile, the extrapulmonary manifestations, being the cutaneous manifestations among them, represent a diagnosis challenge principally because of the low index of suspicion.

Tuberculosis por inoculación / Inoculation tuberculosis

Una bacterióloga sufrió un accidente por punción con una aguja con jeringa que contenía una cepa de Mycobacterium tuberculosis en un dedo de la mano. La zona de la punción se inflamó y la expresión del dedo 15 días después del accidente arrojó una gota de pus que puesta al microscopio permitió observar 3 bacilos ácido-alcohol resistentes con la técnica de Ziehl-Neelsen. Se diagnosticó tuberculosis por inoculación accidental y fue tratada como tal. Se discuten las características de este caso encuadrado como tuberculosis cutánea, cuando se produce como infección exógena por inoculación directa.

A bacteriologist suffered a puncture accident while manipulating a Mycobacterium tuberculosis strain, affecting a finger. The involved area swelled and a drop of pus came out after pressure on the finger 15 days afterwards. This was stained by Ziehl-Neelsen technique, and three acid-fast bacilli were observed. Tuberculosis was diagnosed, and proper treatment was started. We discuss the case, classified as cutaneous tuberculosis produced by exogenous infection through accidental direct inoculation.