CUTANEOUS TUBERKULOSIS

DEFINITION:

Tuberkulosis is an chronic infectious granulomatous disease. It is caused by

the basil of mycobacterium tuberkulosis.

The transmission of the bacteria are by:

-inhalation

-unpasteurized milk

 

EPIDEMIOLO

GY

•PREDISPOSITION FACTOR : low social status, malnutrition, intravenous drugs, immunodeficiency•skrofuloderma : most common(84%),•tuberkulosis cutis verucosa : (13%), •Lupus vulgaris : rarely found

ETIOLOGY

• *M. tuberculosis (M tb)• *M.bovis• *Vaccine : Bacillus Calmette-

Guerin (BCG)

BACTERIOLOGYMycobacterium tuberculosis:

• Aerobic, non–spore-forming, non-motile, facultative.• Curved intracellular rods measuring 0.2-0.5 μm by 2-4 μm. • Their cell walls contain mycolic, acid-rich, long-chain

glycolipids and phospholipoglycans (mycocides) that protect mycobacteria from cell lysosomal attack and also retain red basic fuchsin dye after acid rinsing (acid-fast stain).

BACTERIOLOGIC TEST:

– MICROSCOPIC(Ziehl Neelsen staining)

– CULTURE (Lowenstein Jensen Media)

CLASSIFICATION:

1. TRUE CUTANEOUS TB :

-THE BACTERIA CAN BE FOUND ON THE SURFACE OF THE SKIN.

– PRIMARY CUTANEOUS TB:

- Inoculation of primary TB / Tuberculosis chancre

- Miliary Tuberkulosis

– SECONDARY CUTANEOUS TB :

- Scrofuloderma

- Tuberkulosis verucosa cutis

- Tuberkulosis gumosa cutis

- Tuberkulosis cutis orifacialis

- Lupus vulgaris

2. Tuberculid• Generalised exanthem in patients with moderate or high

degree of immunity to TB because of previous infection.• Usually in good health with no identifiable focus of active

TB in skin or elsewhere

PAPULE SHAPED:

- Necrotic papule Tuberkulosis

- Liken sklofulosorum

GRANULOMATOUS AND ULSERONODULUS SHAPED:

- Erytema nodosum

- Erythema induratum (bazin disease)

TB CHANCRE (primary complex)•Exogen : patient have not been infected before.•*children>>adults•Predilection : face, hand, low extremity

CLINICAL MANIFESTATIONS •innoculation (2-4 weeks) →brownish-red papules, pain (-) → nodule/plaque → ulceration (Tuberculous chancre), 3-8 weeks after being infected→ lyphadenopathy regions(Primary tuberculous complex)

INCUBATION •Incubation period : 2-3 weeks•Can be cured spontaneously in approximately < 1 year, scar (+)

MILIARY TUBERCULOSIS CUTIS

•FROM FOCAL POINT TO THE SKIN•ERITHEMA, PAPULE, VESICLE, PUSTULE, SQUAMA,

TRANSMISSION

•NEGATIVETUBERKULIN TEST

•MALAMPROGNOSIS

SKOFLURODERMA

•From the organ that had already being infected with TB

TRANSMISSION

•NECK: tonsil, lungs•ARMPIT: apex pleura•LOWER EXTREMITY : lower thighs

LOCATION

•Ununiformed soft mass → (cold abses)→ eruption→ fistule → livid, closed, ununiform seropurulent pus. → cicatrix → skin bridge

LUPUS VULGARIS

• Predilection : face, body(lower extremity).

• A group of red nodules that change to yellow in color in time. If pressured is applied they will turn to apple jelly color.

• Confluence: form destructive plaque →ulcus

• Involution: cicatrix (scar)

• Serpiginosa (+)

SCLOFULOSORUM LICHEN

FOUND MOSTLY IN CHILDREN.

• Miliar papule, skin like tone, erythema.

• Fairly alligned: sirsinar, fine squama

• Predilection: chest, abdomen, sacral area, buttocks

• Chronic residual

• Heals without cicatrix (scar)

ERYTHEMA INDURATUM (BAZIN DISEASE)

• Erythema and indolence nodes

• Predilection: flexor

• Suppurative lession form ulcus

• without suppurative lessions→ regression → hipotrophy

• chronic residual

TREATMENT:

Regular medication is crucial in avoiding bacterial resistancy of against antibiotics.

• Combination of drugs, minimum 2 bacterocides are used.

INH + 2 - 3 (bactericidal)

• Treatment plan depends on: economy status of the patient, severity of the disease, contraindication.

STANDARD REGIMENT (6MONTHS)1. INITIAL PHASE (3/4 TABS PERDAY FOR 2 MONTHS)

ADULTS CHILDREN

A. isoniazide 300 mg 5-8 mg/w

B. Rifampicin >50kg 600 mg 10-12 mg/w

<50kg 450 mg

C. Pirazinamid >50kg 2g 20-35 mg/W

<50kg 1.5g

Ethambutol >60kg 15 mg/KgBB Not recommended

or <60kg 25 mg/KgBB 15-20 mg/KgBB

Streptomycine 3-4 gr IM

2. CONTINUOUS PHASE:

(2 types for 4 months)

Isoniazide + Rifampicin

(dosage is based on the previous table)

• Phase 1. Intensive (initial)Kills active bacterias

• Phase 2. (continous)Sterilisation Kills slow growth bacterias.

• The combination of HRZ is very potent. Before choosing this type of treatment, check the patients kidney function (SGOT, SGPT, ALK. PHOSPHATASE).

• The level of SGOT, SGPT, ALK. PHOSPHATASE usually rise after 2 weeks of treatment.

• The treatment is still ongoing even after the increment is detected.

• INH (EVERYDAY) + rifampicin (2x/week)