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 Table of Contents  
ORIGINAL ARTICLE
Year : 2020  |  Volume : 9  |  Issue : 4  |  Page : 429-434

A clinicopathological pattern of cutaneous tuberculosis and HIV concurrence in western Rajasthan


1 Consultant Dermatologist, Jodhpur, Rajasthan, India
2 Department of Dermatology, Dr. Sampurnanand Medical College, Jodhpur, Rajasthan, India

Date of Submission30-Sep-2020
Date of Decision30-Oct-2020
Date of Acceptance31-Oct-2020
Date of Web Publication15-Dec-2020

Correspondence Address:
Paras Choudhary
Department of Dermatology, Dr. Sampurnanand Medical College, Jodhpur, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_183_20

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  Abstract 


Background: Cutaneous tuberculosis (TB) forms a small subset of extrapulmonary TB and continues to be a significant diagnostic dilemma in routine practice. The present study is an attempt to find the incidence, clinical spectrum, and histopathological features of cutaneous TB in western Rajasthan. The relation of cutaneous TB with the human immunodeficiency virus (HIV) was also assessed. Method: A total of 40 cases of newly diagnosed patients of cutaneous TB attending the dermatology outpatient department over a period of 1 year were included in the study. A detailed clinical examination and investigations including histopathological examination were carried out. Results: The overall incidence of cutaneous TB was 0.025% (40 of 160,000 outpatients). HIV concurrence was 5% (2 cases) of all cutaneous TB cases. The most common variants were scrofuloderma (40%), lupus vulgaris (30%), TB verrucosa cutis (8%), orificial TB (2%), and lichen scrofulosorum (2%). Males suffered more than females (2.07:1) and all patients belonged to lower socioeconomic class. The Mantoux test was positive in 65% of cases. Extracutaneous involvement occurred in 17 (42.50%) cases. Characteristic well-defined tuberculoid granulomas were seen in 60% of cases, whereas 40% of cases showed nonspecific changes. Conclusion: This study provides the epidemiological data of cutaneous TB in western Rajasthan, identifies the clinicohistopathological pattern, and calls the attention of the health-care professionals that they should improve the propaedeutics of neglected and underdiagnosed cases of cutaneous TB that is prevalent in the lower socioeconomic group. Due to the varied clinical presentations, physician awareness and a high index of suspicion are necessary to diagnose cutaneous forms of TB.

Keywords: Cutaneous tuberculosis, human immunodeficiency virus, lupus vulgaris, scrofuloderma


How to cite this article:
Maghwal N, Jain VK, Chouhan C, Rao P, Choudhary P. A clinicopathological pattern of cutaneous tuberculosis and HIV concurrence in western Rajasthan. Int J Mycobacteriol 2020;9:429-34

How to cite this URL:
Maghwal N, Jain VK, Chouhan C, Rao P, Choudhary P. A clinicopathological pattern of cutaneous tuberculosis and HIV concurrence in western Rajasthan. Int J Mycobacteriol [serial online] 2020 [cited 2021 Jan 15];9:429-34. Available from: https://www.ijmyco.org/text.asp?2020/9/4/429/303453




  Introduction Top


Cutaneous tuberculosis (TB) is not a well-defined uniform disease entity but comprises a multitude of skin changes, classified according to the primary source of infection and immune status of an individual. Despite the discovery of effective antitubercular drugs and a National program to check it, the disease still poses diagnostic challenges because of the lack of experience of physicians and concerned lack of awareness of the patients. Clinical presentations of cutaneous TB are various (e.g., ulcers, verrucous plaques, discharging sinuses, and suppurative nodules) and mimic a wide differential diagnosis (deep fungal infections, leprosy, vasculitis, syphilis, and chronic granulomatous disease).[1],[2],[3] Histopathological features are also varied and not pathognomonic but play a corroborative role in diagnosis.

TB of the skin remains a relatively common dermatological problem in India, although the incidence has fallen from 2% to 0.15%, and recently, it has fallen to 0.1%.[4] This decline in incidence may be attributed to the availability of effective antitubercular drugs, elimination of milk herds, and general improvement in the living standards and Bacille Calmette–Guérin (BCG) vaccination. However, in this scenario, the disease is fast reappearing due to the human immunodeficiency virus (HIV) pandemic and due to the emerging resistance to the conventional treatment.[5] Furthermore, in recent years, due to the increasing use of immunosuppressants and the emergence of immunocompromised host, the impact on cutaneous TB is altered.[6]

The present study has been undertaken to observe the clinical and histopathological patterns of cutaneous TB, in western Rajasthan, and also to observe its relation to the HIV status of the individual cases.


  Method Top


This hospital-based, observational study was done in a tertiary level teaching center over a period of 1 year. Clinically and histopathologically diagnosed cases of cutaneous TB attending the dermatology outpatient department were included in the study.

Ethical permission was duly obtained from the institutional ethics and research board. After informed consent from the patient, a detailed history was taken including age, sex, occupation, socioeconomic status, site and duration of the lesion, nature of spread, present and past history of TB of other organs, family members and close relatives as well as the history of BCG vaccination. A thorough clinical examination was made in every case noting in detail the morphology, site, duration, mode of onset, condition of draining lymph nodes, and concomitant tubercular lesion in any other organs. A thorough general physical and systemic examination was also carried out. All cases were subjected to hemogram, hepatic and renal function tests, erythrocyte sedimentation rate, smear examination, enzyme-linked immunosorbent assay (ELISA) for HIV, and chest X-ray. Sputum smear examination for acid-fast bacilli (AFB) and other radiological investigations were done in relevant cases. A skin biopsy and the Mantoux test were performed in all the cases.

Variables were analyzed using the Statistical Package for Social Sciences (SPSS) software, version 25.0 (IBM Corp., Armonk, New York, USA), determining the absolute and relative frequencies for nominal, ordinals, and dichotomous variables, as well as central index and dispersion measures for the dimensional variables.


  Results Top


A total of 40 cases of cutaneous TB were observed in a patient population of 1,60,000 constituting the incidence of 0.025% among the general skin patients. The study comprised 27 (67.50%) males and 13 (32.50%) females. The majority of patients, 17 (42.5%) were in their second and third decades of life, while the lowest incidence of 10% was seen in the age group of under 10 years [Table 1]. Most of the cases of cutaneous TB were farmer (27.5%) by occupation, followed by students (22.50%), laborers (20%), and housewives (17.5%). Most patients were of lower socioeconomic status.
Table 1: Age incidence of cutaneous tuberculosis

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The clinical presentations of cutaneous TB were in the form of chronic ulcers, discharging sinuses, suppurative nodules, verrucous plaques, and lichenoid eruptions. The most common clinical type of cutaneous TB was scrofuloderma [Figure 1] and [Figure 2], seen in 16 (40%) cases, followed by lupus vulgaris [Figure 3] in 12, TB verrucosa cutis [Figure 4] in 8, orificial TB in 2, and lichen scrofulosorum [Figure 5] in 2 cases. The most common site affected was the neck and trunk in 7 patients, each followed by the hand in 6 patients and lower limb in 5 patients. Scrofuloderma affected the neck most commonly in 43.75% cases, lupus vulgaris affected extremities in 50%, and TB verrucosa cutis affected the extremities in 100% of cases. Orificial TB exclusively noted on the face and lichen scrofulosorum on the trunk [Table 2].
Figure 1: Scrofuloderma: nodular lesion in right axilla

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Figure 2: Multiple nodular lesions on neck in case of scrofuloderma

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Figure 3: Plaque with central crusting presents over the lower lip

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Figure 4: Tuberculosis verrucosa cutis: warty plaque on dorsum of the hand and index finger

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Figure 5: Lichenoid papules of lichen scrofulosorum on the abdomen

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Table 2: Site distribution in clinical type

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Elevated ESR was noted in 29 patients. Twenty-six patients (65%) showed Mantoux positivity which included 75% of cases of scrofuloderma, 66.66% of lupus vulgaris, and 50% of TB verrucosa cutis. Mantoux was negative in all cases of orificial TB. Of 26, 16 cases showed a result between 10 and 20 mm, while 10 cases showed a reading higher than 20 mm [Table 3].
Table 3: Mantoux test

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Three patients (7.5%) showed pathological changes on chest X-ray, which were inadequately treated old case of pulmonary TB. Of 20 smears done from discharge, eight smears showed positive results, whereas of 12 smears done from tissue extract, none was positive. The strains of TB are unknown since culture was not done to determine the strain.

Extracutaneous TB was observed in 17 (42.50%) cases. Lymph node (64.7%) was the most common organ affected, followed by the lung (17.76%) and bone (17.76%). ELISA for HIV positivity was seen in 2 cases (5%) of scrofuloderma and orificial TB [Table 4]. No case was on corticosteroid or anticancer therapy. No case was found to be in close contact with an open case of pulmonary TB.
Table 4: Enzyme-linked immune-sorbent assay for human immunodeficiency virus in cutaneous tuberculosis

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On histopathological examination, epidermal hyperplasia was observed in 6 (%) cases of lupus vulgaris and all 8 cases of TB verrucosa cutis. Epidermal thinning and atrophy were noted in 4 cases. Of 40, 24 cases showed well-defined tuberculoid granuloma [Figure 6], whereas 16 cases showed nonspecific changes. Tuberculoid granulomas were reported in 8 cases of lupus vulgaris, 11 cases of scrofuloderma, 3 cases of TB verrucosa cutis, 1 case of lichen scrofulosorum [Figure 7], and 1 case of orificial TB. In other cases, a diffuse infiltrate of epithelioid cells, Langhan's giant cells, and lymphocytes was seen. Caseation necrosis was found in all cases of scrofuloderma, 4 (%) cases of lupus vulgaris, and 4 cases (%) of TB verrucosa cutis and 1 case of orificial TB. Dermal fibrosis was noted in 3 cases of lupus vulgaris [Table 5]. AFB were seen in histopathological examination of 5 cases, of which 3 were scrofuloderma, 1 was lupus vulgaris, and 1 was TB verrucosa cutis.
Figure 6: Well-defined tuberculoid granuloma with Langhans giant cell (H and E, ×100)

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Figure 7: Well-defined tuberculoid granuloma in papillary dermis suggestive of licgen scrofulosorum (H and E, ×40)

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Table 5: Histopathological changes in cutaneous tuberculosis

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  Discussion Top


Cutaneous TB represents 1.5% of all cases of extrapulmonary TB.[4] It is frequently misleading and challenging as it presents with diverse clinical and histopathological features. Chronic discharging ulcers, oozing skin lesions, and resistant skin lesions should always be a high index of suspicion of cutaneous TB, as reported previously.[7],[8]

The incidence of cutaneous TB has been reported from 0.15% to 0.26% in various studies.[4],[6],[9],[10],[11] Males outnumbered females in a ratio of 2.07:1 as in other studies. [6,9-11] Most of the patients were in their second and third decades of life, similarly observed in other Indian studies.[6],[10],[11]

The most common type of cutaneous TB in our study was scrofuloderma (40%), which was also noticed by other authors.[1],[4],[11],[12] However, other studies from India found lupus vulgaris as the most common type.[6],[9],[10],[13] Lupus vulgaris was the second most common type in our study, seen in 30% of patients. Lichen scrofulosorum and orificial TB were rarest (5%) in our study. Patra et al. noticed the incidence of lichen scrofulosorum (1.92%) and it was noticed negligible by G Singh and BV Satyanarayana, whereas Varshney et al. noticed an incidence of 11.92% which was higher than the present sudy.[6],[13],[14],15] Wang et al. reported a higher (20%) incidence of orofacial TB.[16]

Our study showed that laborers and farmers were most commonly affected similarly to other studies.[11] This could be due to fact that they are frequently traumatized with higher chances of exposure to the organism. Malnutrition, overcrowding, and poor hygiene may be contributory for their higher incidence.

In the present study, the most common site of scrofuloderma was the neck, seen in 7 patients, followed by the axilla (4 patients), trunk (3 patients), and inguinal region in 2 patients. The neck as the most commonly affected site was also noticed by other authors.[10],[11],[17]

Scrofuloderma showed varied morphology, for example, fluctuating swelling, subcutaneous nodules, ulcers with undermined edges, and discharging sinuses with or without puckered scarring.

The most common site for lupus vulgaris was extremities (6 patients), in our study, followed by the face, whereas the most common presentation was asymptomatic plaque showing healing at one end and activity at other ends. Kumar et al., Patra et al., Varshney et al., Pandhi et al., and Vashisht et al. have reported lower extremities and buttocks as the most common site of lupus vulgaris,[6],[15],[17],[18],[19] whereas few authors reported the face and neck region as the most common site for lupus vulgaris.[10],[20] Warty TB was reported on extremities (100%) in our study, similar to other studies.[6],[15]

The positivity of the Mantoux test has been reported from 68% to 100% in various studies[3],[4],[7] and our study compared well with their findings.[4],[6],[10]

In the present study, tuberculoid granulomas were reported in 8 cases of lupus vulgaris, 11 cases of scrofuloderma, 3 cases of TB verrucosa cutis, 1 case of lichen scrofulosorum, and 1 case of orificial TB; which were comparable to other studies.[6],[11],[15] Caseation necrosis was noted in 62.5% cases of our study, whereas Shegal et al. and Thakur et al. showed in 83.33% and 57.14% of cases, respectively.[4],[11]

Of 40, 17 were (40.4%) associated with systemic TB. Of these, 3 cases had associated pulmonary TB, 11 cases had lymph node TB, and 3 had associated bone TB. All cases of tuberculous lymphadenitis were associated with scrofuloderma. The frequency of clinically active systemic TB varied widely in different studies.[10],[15] Acharya et al. reported in 32% of cutaneous TB cases.[10] Amraoui et al. reported 7 cases of multifocal TB including cutaneous involvement in immunocompetent patients explaining the endemic nature of cutaneous TB.[21]

We encountered 2 cases (5%) in our study that were found to be HIV reactive by the ELISA technique. They were confirmed by rapid tests. Varshney et al. and Viswanathan et al. reported an HIV incidence of 9.1% and 13.7% in their respective studies of cutaneous TB.[15],[22]

HIV is the most important known risk factor that promotes progression to active TB in people with Mycobacterium tuberculosis infection, the number of cases of both pulmonary and extrapulmonary TB is expected to rise. Although the number of such cases was small and no statistical correlation could be observed, we have tried to bring attention to the importance of such lesions in diagnosing underlying immunosuppressed states and for the appropriate management of such patients.


  Conclusion Top


Cutaneous TB is an important health problem in this part of the country, especially in the lower socioeconomic group. On many occasions, the varied clinical presentation makes the diagnosis of the disease difficult. Clinicopathological correlation is useful in those cases where clinical presentation poses diagnostic difficulties.

Meanwhile, physician awareness in terms of varied presentations and strong clinical suspicion is a must in diagnosing these diseases. We thus conclude that in all patients with cutaneous TB, HIV testing should be done routinely to rule out concomitant HIV and TB.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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