A Case of Scrofuloderma in a Patient on JAK Inhibitor Treatment for Rheumatoid Arthritis.

A 78-year-old woman with rheumatoid arthritis, who was started on baricitinib five or six months earlier, was referred to our hospital due to a subcutaneous abscess in her right axilla. Contrast-enhanced chest, abdomen, and pelvis computed tomography showed subcutaneous abscesses in her right axilla and lymphadenopathy with calcification. Cultures from the subcutaneous abscess and skin biopsy specimens were positive for Mycobacterium tuberculosis. These findings led to the diagnosis of scrofuloderma associated with tuberculous lymphadenitis. She was started on an antitubercular regimen of isoniazid, rifampicin, pyrazinamide, and ethambutol as the initial phase treatment (first 2 months), followed by isoniazid and rifampicin for 4 months (total 6 months). After 6 months of antitubercular treatment, the abscesses and lymphadenitis disappeared. Although cases of tuberculosis during JAK inhibitor treatment are rare, they are serious adverse events that require caution.

Tuberculous Mastitis.

This case report describes induration of the right breast with multiple painful ulcers, draining nodules, and fistulae.

Disseminated tuberculosis in an immunocompetent 15-year-old adolescent.

Tuberculosis is one of the oldest known diseases and it remains one of the main causes of morbidity and mortality, especially in developing countries. It is associated with social inequalities and affects different age groups. Tuberculosis in children and adolescents should be considered a sentinel event, since it is linked to a recent infection through contact with bacilliferous adults. We report an immunocompetent 15-year-old adolescent with tuberculosis, exhibiting pulmonary, osteoarticular, and cutaneous involvement. Conventional treatment with tuberculostatic drugs for a year had satisfactory results without sequelae.

Case Report: Clinical and Pathological Findings of Tuberculous Gumma: A Case Report and Literature Review.

Tuberculous gumma (TG) is a rare type of cutaneous tuberculosis thought to occur as a result of the hematogenous spread of Mycobacterium tuberculosis, which is more common in immunosuppressed individuals. An 8-year-old boy presented with a 2-month history of multiple indolent enlarging ulcerated nodules on his left upper extremity. He had a past medical history of bacille Calmette-Guerin vaccine induced lupus vulgaris. Skin biopsy of the nodules showed granulomas and neutrophil-dominated purulent inflammation. Ziehl-Neelsen staining was negative, and the cultures were positive for M. tuberculosis. Furthermore, the M. tuberculosis complex was identified using metagenomic next-generation sequencing. Standard antitubercular therapy was started at full doses, and the skin lesions had significantly improved 3 months later. Here we review the literature since 2000 and describe the clinical and pathological features of TG.

Should antituberculosis treatment be prescribed in erythema induratum? A case-control and incidence correlation study in Taiwan, 2001-2020.

BACKGROUND: Erythema induratum (EI) is a tuberculid associated with Mycobacterium tuberculosis infection. Using polymerase chain reaction (PCR), M. tuberculosis has been identified in Taiwan with a high percentage of EI. However, this pathogen is now rarely detected in Taiwan. OBJECTIVES: To explore the association between EI, the annual incidence of tuberculosis (TB) in Taiwan and treatment outcomes over the last two decades. METHODS: Patients diagnosed with EI between 2001 and 2020 were enrolled based on histopathology, tissue culture and positive M. tuberculosis PCR tests. Other cases of panniculitis with positive M. tuberculosis PCR results were used as controls. The clinical information of participants was obtained. The results were correlated with the annual incidence of TB and compared between groups. RESULTS: Fifty-five biopsy specimens from patients with EI met the inclusion criteria; three (5%) had positive M. tuberculosis PCR results. One patient diagnosed with erythema nodosum in the control group had a positive M. tuberculosis PCR (n = 1/27; 4%). There was no significant relationship between M. tuberculosis and EI (odds ratio 1.5, 95% confidence interval -0.964 to 3.964). The correlation between the incidence of M. tuberculosis and the number of EI cases was not statistically significant (r = -0.185, P = 0.45). Only four patients received anti-TB treatment; they all showed clinical improvement without recurrence. One patient with M. tuberculosis PCR-positive EI was not treated with anti-TB therapy; however, the skin lesion improved after 3 months. No other patients in the EI group were diagnosed with M. tuberculosis infection over a follow-up period of 508 person-years. CONCLUSIONS: Most cases of EI in Taiwan are nodular vasculitis and not tuberculid, owing to well-controlled TB. This condition can be alleviated without anti-TB treatment.

Rare concurrence of lepromatous leprosy and cutaneous tuberculosis.

The coinfection of leprosy and tuberculosis has been rarely reported in literature. A middle-aged man who was a known case of hepatitis B infection had presented with ichthyosis with claw hand deformity and submandibular swelling, which were diagnosed with lepromatous leprosy and scrofuloderma, respectively.

Cutaneous Tuberculosis among Patients Presenting to Dermatology Outpatient Department of a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Cutaneous tuberculosis is an uncommon form of extrapulmonary tuberculosis. It can present in various morphological presentations leading to a late diagnosis in many cases. It is mainly associated with significant scarring and morbidity. It is classified as paucibacillary or multibacillary depending on the bacillary load. Similarly, it can be acquired through either an endogenous or an exogenous source. The mainstay of treatment is anti-tubercular medications. The objective of the study was to find out the prevalence of cutaneous tuberculosis among patients presenting to the dermatology outpatient department of a tertiary care centre. Methods: A descriptive cross-sectional study was done among the patient presenting to the outpatient department of dermatology and venerology in a tertiary care centre where all patients data from medical records were taken from April 2016 to March 2021 after taking ethical approval from the Institutional Review Committee (Reference number: 503/2078/79). Demographic details of the patients including age, sex, site and duration of the lesion were recorded. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 1,30,924 cases, 40 (0.03%) (0.02-0.04, at 95% Confidence Interval) cutaneous tuberculosis was seen. Conclusions: The prevalence of cutaneous tuberculosis was similar to the studies done in similar settings. Keywords: cutaneous; extrapulmonary tuberculosis; tuberculid.

Undermined Skin Lesion Emerged as Tubercular Meningitis: A Case Report.

Cutaneous tuberculosis is a rare type of extrapulmonary tuberculosis and it is uncommon even in places where tuberculosis is widespread. A 32-year-old female presented with fever and headache along with prior history of an ulcer in her leg which was treated as cellulitis at another centre. The neck rigidity, and the Kernig and Budzinski sign were also positive. There were also features of increased intracranial pressure. The non-contrast computed tomography showed bilateral hydrocephalus and hypodense areas. She was managed for increased intracranial pressure and anti-tubercular therapy for disseminated tuberculosis. Biopsy of non-healing wounds should be checked for lupus vulgaris. Keywords: case reports; lupus vulgaris; meningitis; skin; tuberculosis.

Cutaneous Tuberculosis in Heart Transplant.

Tuberculosis is a disease with a significant global burden in terms of morbidity and mortality. It usually presents as a pulmonary disease but can occasionally have extrapulmonary presentations. Immunosuppressed people are at an increased risk of tuberculosis and more frequently have atypical manifestations of the disease. Cutaneous involvement is estimated to occur in only 2% of extrapulmonary presentations. We report a case of a heart transplant recipient with disseminated tuberculosis who initially presented with cutaneous manifestations in the form of multiple abscesses that were mistaken for a community-acquired bacterial infection. The diagnosis was made after positive nucleic acid amplification testing and cultures for Mycobacterium tuberculosis from the drainage of the abscesses. After initiating antituberculous treatment, the patient had 2 instances of immune reconstitution inflammatory syndrome. A combination of diminished immunosuppression due to discontinuation of mycophenolate mofetil in the setting of acute infection, rifampin drug interactions with cyclosporine, and the beginning of treatment of tuberculosis all contributed to this paradoxical worsening. The patient responded favorably to increased glucocorticoid therapy and showed no signs of treatment failure after 6 months of antituberculous therapy.

Atypical cutaneous tuberculosis with an unusual course.

Cutaneous tuberculosis represents the fifth extrapulmonary form in Morocco after pleural, lymph node, urogenital, and intestinal tuberculosis. It is recognized to form a continuous immunopathologic spectrum, ranging from a high intensity to a low intensity of cell-mediated immunity, which explains the multiplicity and heterogeneity of anatomo-clinical forms. Association of multiple forms in the same patient is really rare. In this regard, we report a case of scrofuloderma on axillary tuberculosis adenitis associated to a lupus vulgaris in an immunocompetent patient, which was confirmed by histology, QuantiFERON-TB Gold test, and polymerase chain reaction. He received an antituberculous therapy with clinical regression of the lesions. In conclusion, cutaneous tuberculosis is still endemic in developing countries.The diagnosis is difficult because of its clinical polymorphism. That's why it's should be suspected clinically in the presence of any destructive or verrucous skin lesion evolving without healing for a long period and confirmed by bacteriological examinations and histology.

Multiple diagnostic examinations are effective for the early diagnosis of scrofuloderma.

Although scrofuloderma is the most common subtype of cutaneous tuberculosis, its diagnosis is often delayed. In this case, ciprofloxacin was first administered as only Pseudomonas aeruginosa was detected by initial culture tests. Mycobacterium tuberculosis is usually susceptible to quinolone antibiotics, hence the partial improvement in inflammatory symptoms and subsequent delay in diagnosis. Our case serves as a reminder that we should always be aware of the possibility of cutaneous tuberculosis being the cause of an abscess, especially when the abscess is not completely resolved by antibiotics. Moreover, our case reminds us that it is necessary to conduct repeated culture tests, rather than relying purely on polymerase chain reaction (PCR) results, given that cases of PCR-negative acid-fast bacilli (AFB) culture-positive scrofuloderma have been reported. Fine needle aspiration is a less invasive and useful way to collect culture samples.