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CPD • Dermatology doi: 10.1111/j.1365-2230.2007.02352.x
(a)
(b)
particularly at trauma-prone sites in previously sensiti- immunity. This leads to the destruction of the bacilli; it
zed individuals on a background of moderate to high then becomes difficult to demonstrate their presence.22
immunity. In the past, certain professionals such as The various forms of tuberculids include erythema
anatomists and physicians were prone to this form of induratum of Bazin (EIB), lichen scrofulosorum, papulo-
cutaneous TB as a result of direct inoculation of the necrotic tuberculid, and a newly described form called
tubercles through broken skin. In the tropics, TVC is nodular tuberculid.23 All the tuberculids show a dra-
seen more often in children, caused by walking barefoot matic response to antituberculous chemotherapy.
on soil contaminated with tuberculous sputum.20 TVC EIB is characterized by the presence of multiple,
develops as a small papule surrounded by a purple chronic, painful, indurated, often ulcerated nodules that
inflammatory halo and progresses into an asympto- predominantly affect the lower limbs (Fig. 3a,b), usually
matic warty lesion. Other manifestations of exogenous in women. This condition is associated with a strong
inoculation include tuberculous chancre and rarely LV. tuberculin hypersensitivity reaction, but clinically overt
Tuberculous chancre, also known as primary inocu- TB is rare. The search for M. tuberculosis in EIB has
lation TB, occurs as a result of trauma, often unre- yielded conflicting results even with the use of
ported, to the skin, which facilitates the entry of polymerase chain reaction (PCR). Ziehl–Nielsen stain
M. tuberculosis in previously non-sensitized patients. for acid-fast bacilli (AFB), tissue culture and PCR for M.
Within a month, a nodular lesion develops, rapidly tuberculosis are often negative. A recent study carried
enlarges and forms a painless ulcer.1 Tissue culture is out in northwest Spain showed that about 10% of cases
often positive for M. tuberculosis, and histologically, a of EIB were positive for M. tuberculosis by PCR.24 Other
necrotizing inflammatory infiltrate with the presence of organisms such as M. bovis25 and Mycobacterium
tubercle bacilli is seen early in the course of the marinum may also be implicated.26 Histologically, EIB
infection. As the disease progresses, a granulomatous is characterized by lobular panniculitis associated with
inflammation is noted, with a concomitant reduction in vasculitis (Fig. 4). The main differential diagnosis is
the number of bacilli.21 erythema nodosum (EN), which can be triggered by a
range of infectious and noninfectious agents, and can
occur in association with systemic diseases such as
Immune-mediated mechanisms: the
sarcoidosis. Among the infectious agents, streptococcal
tuberculids
infection and primary TB are the commonest aetiologi-
The tuberculids are a group of cutaneous TB resulting cal factors. Several reports have suggested that EN is
from a hypersensitivity reaction to an extracutaneous seen only in primary tuberculous infection.27,28 Similar
source of M. tuberculosis, usually in individuals with high to EIB, EN occurs more frequently in women, and may
(a) (b)
in treatment. Cutaneous TB is still a relatively rare lung tuberculosis: a case report. J Cutan Pathol 2005; 32:
entity in the developed world. However, in an era of 629–33.
high population migration and the emergence of HIV 5 Yates VM, Ormerod LP. Cutaneous tuberculosis in Black-
and AIDS, it is becoming increasingly prevalent, and burn district (U.K.): a 15-year prospective series, 1981–
95. Br J Dermatol 1997; 136: 483–9.
hence requires early recognition.
6 Sehgal VN, Bhattacharya SN, Jain S et al. Cutaneous
tuberculosis: the evolving scenario. Int J Dermatol 1994;
33: 97–104.
Learning points 7 Tappeiner G, Wolff K. Tuberculosis and other mycobac-
terial infections. In: Dermatology in General Medicine (Fit-
• The incidence of tuberculosis (TB) in the UK is zpatrick TB, Eisen AZ, Wolff K et al. eds), 5th edn. New
rising, owing to the emergence of HIV and AIDS York: McGraw-Hill, 1999: 2274–92.
and to mass immigration from developing coun- 8 Barbagallo J, Tager P, Ingleton R et al. Cutaneous tuber-
tries. culosis: diagnosis and treatment. Am J Clin Dermatol 2002;
• While pulmonary TB is common, cutaneous TB 3: 319–28.
9 Ramesh V, Misra RS, Jain RK. Secondary tuberculosis of
is rare, with an incidence range of 1–4.4%.
the skin. Clinical features and problems in laboratory
• Endogenous and exogenous inoculation and
diagnosis. Int J Dermatol 1987; 26: 578–81.
immune-mediated mechanisms are important in 10 Sehgal VN, Wagh SA. Cutaneous tuberculosis. Current
the pathophysiology of cutaneous TB. concepts. Int J Dermatol 1990; 29: 237–52.
• Endogenous inoculation gives rise to scrofulo- 11 Connolly B, Pitcher JD Jr, Roth B et al. Scrofuloderma of
derma, miliary TB, metastatic abscesses, orificial the lower extremity treated with wide resection: a case
TB and lupus vulgaris. report and review of the literature. Am J Orthop 1999; 28:
• Tuberculosis verrucosa cutis and tuberculous 417–20.
chancre develop as a result of exogenous inocula- 12 Pandhi D, Reddy BS, Chowdhary S et al. Cutaneous
tion. tuberculosis in Indian children: the importance of
• The tuberculids are a group of cutaneous TB screening for involvement of internal organs. J Eur Acad
Dermatol Venereol 2004; 18: 546–51.
that develops as a result of a hypersensitivity
13 Visser AJ, Heyl T. Skin tuberculosis as seen at Ga-Rank-
reaction to tuberculous antigen. They comprise
uwa Hospital. Clin Exp Dermatol 1993; 18: 507–15.
erythema induratum of Bazin, lichen scrofuloso- 14 Almagro M, Del Pozo J, Rodriguez-Lozano J et al. Meta-
rum, papulonecrotic tuberculid and a newly des- static tuberculous abscesses in an immunocompetent pa-
cribed entity called nodular tuberculid. tient. Clin Exp Dermatol 2005; 30: 247–9.
• A high index of suspicion is required for reach- 15 Premalatha S, Rao NR, Somasundaram V et al. Tubercu-
ing a diagnosis of cutaneous TB as Ziehl–Nielsen lous gumma in sporotrichoid pattern. Int J Dermatol 1987;
stain, mycobacterial culture and PCR for myco- 26: 600–1.
bacterial TB may all be negative. 16 Sehgal VN, Srivastava G, Bajaj P, Sengal R. Re-infection
• TB is a notifiable disease. The consultant in (secondary) inoculation cutaneous tuberculosis. Int J
communicable disease control must be informed Dermatol 2001; 40: 205–9.
17 Wozniacka A, Schwartz RA, Sysa-Jedrzejowska A et al.
once a clinical diagnosis of TB is made.
Lupus vulgaris: report of two cases. Int J Dermatol 2005;
44: 299–301.
18 Ekmekci TR, Koslu A, Sakiz D et al. Squamous cell carci-
noma arising from lupus vulgaris. J Eur Acad Dermatol
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