DERMATOLOGY EXIMIUS

MYCOBACTERIAL DISEASES OF THE SKIN 2021

Dr. Hera

4 MAJOR CATEGORIES OF CUTANEOUS TUBERCULOSIS TUBERCULIN TESTING

• Designed to detect a memory cell-mediated immune response to M. tuberculosis
A. Inoculation from an exogenous source • Test becomes positive between 2 and 10 weeks following infection and remains
• Primary inoculation tuberculosis positive for many years although it may wane with age
• Tuberculosis verrucosa cutis • Mantoux test is the standard offering highest degree of consistency and reliability
o Test is read 48-72 hrs after ID injection
B. Endogenous cutaneous spread contiguously or by auto-inoculation o 5 mm or more induration is considered positive
• Scrofuloderma
• Tuberculosis cutis orificialis

C. Hematogenous spread to the skin

• Lupus vulgaris
• Acute military tuberculosis
• Tuberculosis ulcer, gumma, abscess

D. Tuberculids
• Erythema induratum [Bazin’s disease],
• Papulonecrotic tuberculid,
• Lichen scrofulosorum

EPIDEMIOLOGY
• Mid-1980’s 3 phenomena
1. Large number of immigrants from high-prevalence countries
2. AIDS/HIV epidemic
3. Increasing number of persons in congregative facilities
• Asians, Hispanics, Americans and Africans have the greatest risk for developing
TB in the US
• Africa- 29% TB cases worldwide
• TB is still very, very common with 1.8 Million new cases diagnosed every year
• Cutaneous TB is an uncommon complication of tuberculous infections (2% cases)
• Multiple Host Factors:
1. Age
• 25% occur in children (Scrofuloderma, Lichen Scrofulosorum)
2. Gender
• Women- 10 times more likely to develop Erythema induratum
• Men- 2-3 times more likely to have other forms of cutaneous TB
3. Anatomic Location
• Lupus vulgaris occurs on the face and extremities
• TB verrucosa cutis occurs on the sole and foot
4. Nutritional Status
• Tuberculous abscesses and scrofuloderma are associated with malnutrition

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 DERMATOLOGY EXIMIUS
MYCOBACTERIAL DISEASES OF THE SKIN 2021
Dr. Hera

A. INOCULATION CUTANEOUS TUBERCULOSIS FROM EXOGENOUS SOURCE

I. Primary Inoculation Tuberculosis Histological findings Differential diagnosis
• Develops at the site of inoculation of tubercle bacilli into • 1st 2 weeks – marked inflammatory response with many PMN Differential diagnosis
a tuberculous free individual leukocytes and tubercle bacilli 1. Sporotrichosis
• Primary tuberculous complex • Next 2 weeks- Lymphocytes and epithelioid cells appear and 2. Blastomycosis
o There is presence of regional lymphadenopathy replace the PMNls. 3. Histoplasmosis
• Occurs chiefly in children affecting the face and o Development of distinct tubercles at the site of 4. Atypical Mycobacterial Diseases
extremities inoculation including regional lymph nodes at 3-4 weeks 5. Coccidioidomycosis
• May occur after trauma such as tattooing, medical after inoculation 6. Pyogenic Granuloma
injections, nose piercing and external traumas o Number of tubercle bacilli decreases rapidly with 7. Nocardiosis
increasing number of epithelioid cells 8. Cat Scratch Disease
9. Syphilis
• Tuberculous chancre 10. Leishmaniasis
o Earliest lesion occurs 2-4 weeks 11. Yaws
after inoculation 12. Tularemia
o Painless brown-red papule which
develops into an indurated
nodule or plaque that may
ulcerate
o Prominent regional
lymphadenopathy at 3-8 weeks
after infection
o Cold, suppurative, and draining
lesions may appear over involved
nodules
• May occur after BCG vaccination in tuberculin-negative children.
• Spontaneous healing may occur within a year or less

II. Tuberculosis Verrucosa Cutis

• Begins as small papule which becomes • (+) pseudoepitheliomatous hyperplasia of the epidermis and 1. Atypical mycobacteriosis caused by
hyperkeratotic, resembling a wart hyperkeratosis Mycobacterium marinum
• Enlarges by peripheral expansion, with or • (+) Suppurative and granulomatous inflammation is seen in the 2. North American blastomycosis
without central clearing upper and mid-dermis, sometimes perforating through the 3. Chromoblastomycosis
• (+) fissuring of surface and may discharge epidermis 4. Verrucous epidermal nevus
purulent exudates • Caseation is rare 5. Hypertrophic lichen planus
• Solitary with regional adenopathy if with • The number of acid-fast bacilli (AFB) is usually scant, and failure 6. Halogenoderma
secondary bacterial infection to find AFB should not be used to exclude the diagnosis 7. Verruca vulgaris
• Culture will be positive in slightly more than 50% of cases
• Frequent locations: DIAGNOSIS
o Dorsa of the fingers and hands in adults • Confirmatory: skin biopsy and (+) AFB
Ankles and buttocks in children culture.
• Seldom ulcerates and heals spontaneously • PPD test may also result positive.

TREATMENT
• 4-drug regimen: RIPE/S

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 DERMATOLOGY EXIMIUS
MYCOBACTERIAL DISEASES OF THE SKIN 2021
Dr. Hera

B. CUTANEOUS TUBERCULOSIS FROM ENDOGENOUS SOURCE BY DIRECT EXTENSION (SCROFULODERMA AND PERIORIFICIAL TB)
I. Scrofuloderma Histological findings Differential Diagnosis
• Aka Tuberculosis cutis colliquativa • The tuberculous process begins in the underlying lymph node or 1. Atypical mycobacterial infection
• Tuberculous involvement of the skin by direct extension from an bone and extends through the deep dermis 2. Sporotrichosis
underlying focus of infection • Necrosis occurs with formation of a cavity filled with liquefied 3. Actinomycosis
• Occurs most frequently over the cervical lymph nodes but also may debris and polymorphonuclear leukocytes 4. Coccidioidomycosis
occur over bone or around joints • At the periphery, more typical granulomatous inflammation is 5. Hidradenitis suppurativa
• Clinically, the lesions begin as subcutaneous masses, which enlarge to seen, along with AFB observed in slightly less than half of cases.
6. Lymphogranuloma venereum (LGV)
form nodules
favors the inguinal and perineal
• Suppuration occurs centrally
areas, and has positive serologic
• They may be erythematous or skin-colored, and usually the skin
temperature is not increased over the mass tests for LGV.
• Lesions may drain, forming sinuses, or they may ulcerate with reddish
granulation at the base
• Heals by characteristically cordlike scars

II. Perianal Tb (Tuberculosis Fistulosa Subcutanea)

• Characterized by a chronic anal fistula characteristically in men between

• 30 and 60 years of age
• Involvement of the intestinal tract, especially the rectum, is present in
most of these cases
• Anal strictures and involvement of the scrotum may occur if disease is
untreated
III. Tuberculosis Cutis Orificialis

• Occurs at the mucocutaneous borders of the nose, mouth, anus, urinary • The ulcer base is usually composed largely of granulation tissue
meatus, and vagina, and on the mucous membrane of the mouth or infiltrated with polymorphonuclear leukocytes
tongue • Deep and lateral to the ulcer, granulomatous inflammation may
• It is caused by autoinoculation from underlying active visceral TB, be found and AFB are numerous
particularly of the larynx, lungs, intestines, and genitourinary tract
indicating failing resistance to the disease
• Consequently, tuberculin positivity is variable but usually positive
• Lesions ulcerate from the beginning and extend rapidly, with no
tendency to spontaneous healing.
• The ulcers are usually soft and punched out, and have undermined edges

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 DERMATOLOGY EXIMIUS
MYCOBACTERIAL DISEASES OF THE SKIN 2021
Dr. Hera

C. CUTANEOUS TUBERCULOSIS FROM HEMATOGENOUS SPREAD

I. Lupus Vulgaris Histologic findings Differential Diagnosis
• May appear at sites of inoculation, in • Classic tubercles - hallmark 1. Colloid milia
scrofuloderma scars, or most commonly at • Caseation within the tubercles is seen in about half the cases and 2. Acne vulgaris
distant sites from the initial infectious focus, is rarely marked 3. Sarcoidosis
probably by hematogenous dissemination • Sarcoidosis may be simulated 4. Rosacea
• Approximately half of such cases will have • The epidermis is affected secondarily, sometimes flattened and 5. Tertiary syphilis
evidence of TB elsewhere, so a complete at other times hypertrophic. AFB are found in 10% or less of cases 6. Chronic discoid lupus
evaluation is mandatory with standard acid-fast stains erythematosus
• Associated with moderately high immunity to TB, most patients will have • PCR still lacks the sensitivity and specificity to diagnose 7. Hansen’s disease
a positive tuberculin test paucibacillary forms of cutaneous TB reproducibly, and will be 8. Systemic mycoses
positive in about one quarter of cases or less 9. Leishmaniasis
• Cultures of the skin lesions grow M. tuberculosis in about half the
cases.

• Typically a single plaque composed of grouped red–

brown papules, which, when blanched by diascopic
pressure, have a pale brownish yellow or
“apple-jelly”color
• The papules (called lupomes) tend to heal slowly in one
and progress in another
• They are minute, translucent, and embedded deeply and diffusely in the
infiltrated dermis, expanding by the development of new papules at the
periphery, which coalesce with the main plaque
• The plaques are slightly elevated
• The disease is destructive frequently causes
ulceration, and on involution leaves deforming scars
as it slowly spreads peripherally over the years
• Lupus vulgaris lesions of the head and neck can at
times be associated with lymphangitis or
lymphadenitis
• If lesions involve the nose or the lobes of the ears, these structures are
shrunken and scarred, as if nibbled away
• Atrophy is prominent, and ectropion and eclabion may occur
• The tip of the nose may be sharply pointed and beaklike, or
the whole nose may be destroyed, and only the orifices and
the posterior parts of the septum and turbinates visible
• The rate of progression of lupus vulgaris is slow, and a lesion
may remain limited to a small area for several decades
• The onset may be in childhood and persist throughout a lifetime
• It may slowly spread, and new lesions may develop in other regions
• In some instances, the lesions become papillomatous, vegetative, or
thickly crusted, so that they have a rupioid appearance
• Squamous cell carcinoma may develop in long-standing lesions

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 DERMATOLOGY EXIMIUS
MYCOBACTERIAL DISEASES OF THE SKIN 2021
Dr. Hera

I.a. Lupus Vulgaris Postexanthematicus II. Miliary (Disseminated) Tuberculosis III. Metastatic Tuberculous Abscess,
Ulceration, Or Cellulitis
• An unusual form of lupus vulgaris • Appears in the setting of • The hematogenous dissemination of
may follow measles or another fulminant TB of the lung or mycobacteria from a primary focus may
significant febrile illness meninges result in firm, nontender erythematous
• The window of immune deficiency • Generally, patients have other plaques (resembling cellulitis) or nodules
caused by the acute illness results in unmistakable signs of severe • The nodules can evolve to form abscesses,
dissemination of the TB disseminated TB ulcers, or draining sinus tracts
hematogenously from a single focus • Most common in children but
• This form of cutaneous TB is usually seen in
of lupus vulgaris may occur in adults
children, and most patients have decreased
• Multiple erythematous papules in a • Most reported instances of
generalized distribution appear a month or more after the illness cutaneous TB seen in patients immunity from malnutrition, intercurrent
• These lesions evolve to small papules and plaques clinically and with AIDS are of this type. infection, or an immunodeficiency state
histologically resembling lupus vulgaris • Miliary TB may also follow infectious illnesses that reduce • Patients presenting with tuberculous skin
• The TST is negative during the immediate period following the febrile immunity, especially measles. Because this represents ulcers may or may not have other foci of TB
illness, and then rapidly reverts to strongly positive uncontrolled hematogenous infection, the tuberculin test is identified
• Classically considered a scarring and atrophying process, lesions of the negative • Aerosolization of mycobacteria may occur
lips and ears may be quite hyperplastic • Lesions are generalized and may appear as erythematous during incision and drainage and during
• The lips may resemble cheilitis granulomatosis clinically and macules or papules, pustules, subcutaneous nodules, and dressing changes, leading to secondary cases
histologically purpuric “vasculitic” lesions among surgical and nursing staff treating
• Uniform hyperplasia of the ear pinna and lobe may closely mimic “turkey • Ulceration may occur, and the pain in the infarctive lesions may these ulcers
ear,” as described in sarcoidosis be substantial. The prognosis is guarded
• Histologically, abscess formation and
• When the mucous membranes are involved, the lesions become • Skin biopsies show diffuse suppurative inflammation of the
numerous AFB are seen
papillomatous or ulcerative dermis or subcutis with predominantly polymorphonuclear
• They may appear as circumscribed, grayish, macerated, or granulating leukocytes, at times forming abscesses
plaques • Caseating granulomas may be seen. AFB are abundant
• On the tongue, irregular, deep, painful fissures occur, sometimes
associated with microglossia to the degree that nutrition is compromised
IV. Sporotrichoid Tuberculosis V. Tuberculous Mastitis
• 3% of cases of cutaneous TB in a sporotrichoid pattern, suggesting • Rare and will present as subcutaneous nodules on the breast
lymphatic spread • The lesions can suppurate, forming abscesses, or break down,
• Classically, this begins with a distal lesion, and new lesions appearing forming sinus tracts
more proximally • Favors women of child-bearing age, it can also affect men
• Less commonly, a proximal lesion is present initially, and new lesions • Biopsies are frequently carried out
appear distally(retrograde lymphatic spread)
• Abscesses may be incised and drained
• The draining proximal lymphnnodes may be enlarged
• TST is positive
• A string of lupus vulgaris-like lesions is most common
• Histology shows granulomatous inflammation with negative AFB
• Less often, there is a string of deep nodules that may become fluctuant,
drain to the surface, or ulcerate, forming linear scrofuloderma-like lesion stains
• The TST is positive • Culture is usually negative
• Underlying foci of systemic TB are often not found
• Biopsy of the lesions (and affected lymph nodes) typically shows
granulomatous
• inflammation, but AFB stains are usually negative.
• Culture may be positive.

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 DERMATOLOGY EXIMIUS
MYCOBACTERIAL DISEASES OF THE SKIN 2021
Dr. Hera

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