40 JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 51NUMBER 1 [January 2010 ARTICLES: Cutaneous tuberculosis among children and adolescents; a study in a rural teaching hospital L. Padmavathy' ,L. Lakshmana Rao’ ,K. Chockalingam’ ,‘T. Pari’ [Abstract] study on the incidence of cutaneous tuberculosis Cutaneous tuberculosis constitutes a minor proportion of the clinical manifestations of tuberculosis. A in children and adolescents was conducted at Rajah Muthiah Medi- cal College and Hospital (RMMCH) , Annamalai Nagar, between 1992 and 1998. A total of 54 patients were en- countered during the period of study of which lupus vulgaris (LV) constituted 25 cases, (46. 2% ) ,scrofuloderma (s ) contributed to 12 cases ( 22.2% ) ,and the rest i. €,17 cases, (31.6 % ) were tuberculosis verrucosa ct (TBYC). The various clinical features and other investigational parameters are discussed, [Key words] INTRODUCTION ‘Tuberculosis continues to be a major health problem in India and other developing countries. With the advent of Human Immunodeficiency Virus (HIV) infection it has re-emerged as an important cause of morbi the developed countries also, Cutaneous tuberculosis constitutes a very small number of extra pulmonary type of tuberculosis patients. ‘The present study was undertaken to assess the in- cidence of cutaneous tuberculosis among children and adolescents attending the Out-patient Department of Rajah Muthiah Medical College and Hospital (RM- MCH) , between 1992 and 1998. MATERIALS AND METHODS. Fifty four children and adolescents with cutaneous tu- herculosis, attending Rajah Muthiah Medical College Hospital, ( RMMCH) , Annamalai University ,2 tertiary 1 Division of Community Medicine, RMMC Annamalai University India sion of Pathology MMC, Annamalai) University nda SRMMLC® Annan Universi Lia 4 Comultant Deematlogst Chennai India Correspondence to Dr. Padivathy,MBES,D.D,Ph. D, (Desmatology) ,PC Dip, Health Sciences (Acupuncture), Derm rmatlogy,Depastent of C E-mail; padinavathy. lanka® grail. com ninunity Medicine, Rajah Muthish Medical College, Anam lupus vulgaris; scrofuloderma ;tuberculosis verrucosa cutis cutaneous tuberculosis sacid fast bacilli care hospital catering to the rural population of Cudda- lore district of Tamil Nadu, South India were included in the study, which was conducted from 1992 ~ 1998. The patients were grouped into different clinical types and were subjected to routine hematological and bio- chemical investigations. Family history of tuberculosis and previous history of BCG vaceination were also re- corded. Mantoux test and X-ray chest to rule out pul- monary tuberculosis were undertaken. Fine needle aspi- tation cytology of affected lymph nodes and biopsy of skin and lymph nodes were carried out as found neces- sary. The data is analyzed and compared with reports of other workers. Observations F berculos iy four patients with various types of cutaneous tu- were encountered during the period of study. y were lupus vulgaris (LV) (25 cases 46.2% ) Major logis! & Lectaee in Der University, Annamalai Nagar-60002, Tamil Nad, IndiaJOURNAL of CHINESE CLINICAL MEI = VOLUME 51NUMBER 1 [January 2010 4 [Figure 1] followed in decreasing order of frequency by 17 cases, (31.6% ) , tuberculosis verrucosa. cutis (TBVC) [Figure 2] and 12 cases ( 22. 2% ) of serof- uloderma (SCF) [ Figure 3]. The youngest patient in the series was 2 years old while the oldest was 18 years age. The mean age of the patients in the study group and 13.8 for was 11 years, for LV 11.1 years for SCI TRV M,F ratio of 1, 25. However, incidence of TBVC there was an overall male preponderance with higher among females (Figure 4,5) Majority of patients presented with single lesion, while multiple lesions were more common among. pa- tients with LV (10 cases 40% ). Concomitant pulmona- ry tuberculosis was seen in 10 patients (40% ) of LV ,3 patients (25% ) of SCI and one patient (5.8% ) of TBVC. Positive family history of tuberculosis 4 patients (16.7%) of LV, 4 patients (33.3% ) of scrofuloderma and § eases (41. 1%) of TBVC. Figure 1 Figure 3 Scrofuloderma-lesionsover neck Lupus vulgaris-lesions on thigh Figure 2 ‘Tuberculosis verucosa cutis-lesion on dorsum of foot 20 Is Number 0 1 Scrofhloderma Figure 4 1B Lypas Vulgaris eTavc neous tuberculosis in children and adolescents-age incidence42 JOURNAL of CHINESE CLI INICAL MEDICINE VOLUME 51NUMBER 1 [January 2010 Mantoux test was positive in all 17 (100% ) pa- tients of TBVC,18 patients (81.8% ) of LV and 6 pa- (0%) (51.75% ) of serofuloderma, 13. patients (52% ) pa- tients of LV and & patients (47% ) of TRVC had BCG vaccination, ‘The duration of ill ness varied from a mini- tients with scrofuloderma. Five _ patients the series. Involvement of neck was the more common in SCF followed by axillae, while involvement of lower limbs and feet was more common in LV and TBVC. Skin biopsy was carried out in all cases and lymph node aspiration and biopsy also were performed in rele- vant cases for histopathological evaluation (Table 1, mum of one month to 15 years among the patients in Figure 6). 16 “ n 0 8 Number 6 ‘ Male Female sex BW Siofuoderma pos Velgwis__ OOTBVC Figure § Cutaneous tuberculosis in children and adolescents-sex incidence 2 20 Numb ofcacs 10 Seofuoderma Laps Vlas TaVe Type of CTH Dsanpesve Bupa Genie tN Dania IN ‘inguinal LN [Sub Mandibular LN {Pr auricular LN {BUper Limb Mowertimb Neck ‘@Abiomen ‘BPalmonaryEmvotvement mare mca @Mroux any Cyl colton Figure 6 Cutancous tubete slosis in children and adolescentsJOURNAL of CHINI E VOLUME $1NUMBER 1 January 2010 43 Table 1 Cutaneous tuberculosis in childhood and adolescence — a clinical histopathological and epidemiological study Serofuloderma Lupus vulgaris rBve le size 2 25 7 Multiple sites 3 ical =7 ,Aaillary =3, Sites of involvement Inguinal & Submandibular 2 each pre-auticula 1 Pulmonary involvement 2 Lymph node involvement 2 Other systems NIL. Other associated conditions 5 Duration of illness Family history 4 Cytological / Histologic correlation — 6 AFB sil Bee 5 Manu reactivity HIV 10 1 UL =4,LL=18, Neck = 1 ab- Multiple sites (9 omen LL=13;UL=4 sites) =1 1 1 7 9 1 NIL. ‘Tender hepatomegaly and splenomegaly 7 1 One month to 15 years One month to 10 years 3 8 2s ” Nil ail 2 8 ” Nil Nil Abbreviations; UL = Upper limb. LL = Lower Limb DISCUSSION Serofuloderma; Tuberculous lymphadenitis of the neck is also known as scrofula'' . It is probably derived from the latin word Serofa-a brood sow from the likeness of the cluster of nodes to piglets feeding from the sow. Others believe that it reflects the somewhat sow like features imparted to the victims by the swelling of the face and neck. SCF is also known to occur secondary to ‘| “The other syno- infection of bone, joints and testi nyms for SCF are tuberculosis colliquativa cutis and tu- berculosis cutis colliquativa® SCF results from direct extension of tubercle ba- cilli into skin from underlying tuberculosis which most often is a lymph node. The lesions are usually unilateral and cervical group of lymph nodes are commonly in- volved followed by axillary, inguinal , para-stemal ,epi- trochlear, pre and post auricular,submandibular, oce ital and supraclavicular ymphnodes. SCF is the most common form of cutaneous tuberculosis in dren“. The severity of the disease is more in el dren in comparison to adults. However in the present 22. 2% ) was second to LV (47% ). Simi- lar findings were reported by workers from North Indi- a” Ina study from Tunis out of seven cases of cuta- neous tuberculos and LV accounted for 3 eases each (42.9% ) while one patient had a perianal ul- cer”), Involvement of cervical lymphnodes was most common in the present series akin to the reports by oth- er authors LV was first described by Erasmas Wilson in 1865. LV is the most common form of cutaneous tuber- culosis in India and Europe “''’ ,occurring in a previ- ously sensitized individual. The ulcer tear ig into the flesh like ravages of a wolf probably fitted the clinical = The condi- description and hence the name “Lupus tion was common in earlier times and the adjective44 JOURNAL of CHINESE CLINICAL MEDICINE VOLUME 51NUMBER 1 [January 2010 “Vulgaris” in LV is given "''. Healing with sear in one area and ai vity in another area is the hall mark of this lesion. Tuberculosis Iuposa and tuberculosis Iuposa eu- tis are other synonyms for this condition’? Involvement of face is more common among west- em population "while lower extremities were common- ly affected in children in the present study as reported by other Indian workers °°") ‘TBVC was originally named verruca necrogenica hy Wilks and Poland in 1862. The other synonyms for this condition are Prosector’s wart, post-mortem wart anatomical tubercle cadaver wart jand warty tuberculo- sis, Butcher's wart, lupus verrucosus, and tubercul cutis verrucosa "', TBVG occurs as a result of exoge- nous inoculation in previously sensitized individuals with involvement of lower extremities.” . especially ac- ral areas, The disease may be unilateral or bilateral. In the present study group, lower extremities were more commonly involved as reported in other Indian stud- Systemic involvement in cases of cutaneous tuber- culosis was reported varying from 12. 7% to 53.4% by various workers ""*', Pulmonary tuberculosis was seen in 2 patients (16.7% ) of SCF,7 patients (28% ) of LV and 1 patient (5.9% ) of TRVC in the present se- ies. However in the present study, systemic involve- ment was observed in 14 eases (26.7% ) similar to the findings reported from Delhi”. Mantoux test or tuberculin test is a useful sereen- ing tool for presence or absence of tuberculous infec~ tion, Mantoux test reportedly can be positive in 80% of the cases“. In the present study, Mantoux test was positive in all cases (100% ) of TBVC,60% cases of SCF and 88.9% cases of LV with an overall 83. 3% Mantoux positivity, which is similar to fir Chandigarh'* . Higher positivity (66% to 100% ) was reported by other workers °°". In the present study, lings from all patients tested for HIV were negative ,similar to oth- er reports", However ,no correlation was observed hetween the Mantoux positivity, extent of the disease and previous BCG vaccination akin to earlier re- ports ". Histopathological correlation varying from 64% to 100% was reported by different work- ers" In the present series 100% histopathological correlation was seen similar to the findings of Lathika eal”. Bacillary load in secondary tuberculosis is low due to greater degree of immuni «Hence , demonstra- tion of AFB on cytology ,histology or culture in skin le- sions is difficult as observed in the present series. Since only a small percentage of cases of cutaneous tubercu- losis have positive smear or culture , histopathological diagnosis and clinical correlation are considered more important”, BCG vaccine is protective against disseminated tu- berculosis '’. It is described to offer moderate protec- tion against cutaneous tuberculosis" while others did not find any significant differences hetween the vacci- nated and unvaccinated groups". In our study, there ‘was no correlation between the type, extent or severity of the disease with BCG vaccination. Our patients were treated with the standard antitu- herculous therapy as used for pulmonary tuberculosis, i.e, initial 2 months intensive phase with four drugs (ifamp ‘in, isoniazide, pyrazinamide and ethambutol and later 2 drugs (isoniazide and rifampicin) for 4 months. Ethambutol was used with eaution in children substituted as and in some patients streptomycin wa needed. Since tuberculosis is an easily treatable condition , proper diagnosis and correct therapy go a long way the control and eradication of this disease-aptly, termed-“captain of these men of death” or “King of diseases” |" REFERENCES 1. Ram, Cato tubercloniska: Shanna SK, Mahan itn Tubereulosis. 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