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Lewandowsky's Rosaceiform Eruption: a Form of Cutaneous Tuberculosis Confirmed by PCR in Two Patients.

Conlledo R, Guglielmetti A, Sobarzo M, Woolvett F, Bravo F, González S, Fich F, Vial V - Dermatol Ther (Heidelb) (2014)

Bottom Line: The current problem with diagnosis is the demonstration of bacillus in the skin, especially paucibacillar forms, where sources like polymerase chain reaction (PCR) have improved diagnostic capacity.In paucibacillar forms, when culture and staining are negative and TBC is still suspected, it is recommended to use DNA amplification by PCR for an accurate diagnosis.Both cases bring up the concern about once again bringing Lewandowsky's rosaceiform eruption into the spectrum of cutaneous TBC, and the discussion about the current definition of tuberculid.

View Article: PubMed Central - PubMed

Affiliation: Department of Dermatology, School of Medicine, University of Valparaíso, Hontaneda 2653, Valparaíso, Chile, rodrigoconlledo@hotmail.com.

ABSTRACT

Introduction: Cutaneous tuberculosis (TBC) is a chronic disease caused by Mycobacterium tuberculosis, and is present in less than 1-2% of all TBC cases. The current problem with diagnosis is the demonstration of bacillus in the skin, especially paucibacillar forms, where sources like polymerase chain reaction (PCR) have improved diagnostic capacity.

Case presentation: Two cases of cutaneous TBC are reported. The first patient was 52-year-old woman with facial erythematous papulo-nodular lesions which had been developing for 4 months, and had previously been treated as acne rosacea, with partial response. Histopathological studies showed chronic granulomatous inflammation. TBC was suspected, so PCR was performed, which showed positive for M. tuberculosis. The second case was a 43-year-old woman with a facial rosaceiform plaque which began 6 months previously, and was treated as rosacea without any change for 5 months. Skin biopsy and PCR were positive for TBC. Both cases were treated using primary schedule for TBC, and both presented a favorable response.

Discussion: A clinical profile called Lewandowsky's rosacea-like eruption has been previously described. The condition has been questioned for years and was later removed from the spectrum of tuberculids and cutaneous TBC for not being able to isolate microorganisms in skin samples, a situation that might now change. In paucibacillar forms, when culture and staining are negative and TBC is still suspected, it is recommended to use DNA amplification by PCR for an accurate diagnosis. Both cases bring up the concern about once again bringing Lewandowsky's rosaceiform eruption into the spectrum of cutaneous TBC, and the discussion about the current definition of tuberculid.

No MeSH data available.


Related in: MedlinePlus

Medical control at 6 months of treatment using primary schedule for tuberculosis, with significant improvement and atrophic scars as sequels
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Related In: Results  -  Collection


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Fig4: Medical control at 6 months of treatment using primary schedule for tuberculosis, with significant improvement and atrophic scars as sequels

Mentions: A 52-year-old Chilean woman presented with facial erythematous papulo-nodular and pruriginous lesions which first occurred 4 months previously in both glabellar regions. These legions extended progressively to the rest of the face, with confluence zones and an association with scratching (Fig. 1). She had no relevant medical history or contact with patients with known TBC, and had been vaccinated with Bacillus Calmette–Guérin (BCG) after birth. She had been previously treated for 3 months for acne rosacea using different drug therapies (oral doxycycline 100 mg every 12 h, followed by oral isotretinoin 20 mg per day, and topical treatment with alpha-bisabolol 1% and metronidazole gel 1%) with partial response. Laboratory examinations [C-reactive protein, C3, C4, anti-neutrophil cytoplasmic antibodies (ANCA), anti-proteinase 3 (anti-PR3), anti-myeloperoxidase (anti-MPO), lupus erythematosus (LE) cells in peripheral blood sample] were either negative or in the normal range, but an antinuclear antibody (ANA) test was positive in 1:640 dilution with NuMA-1 pattern. Lupus erythematosus was suspected, so skin biopsy and direct immunofluorescence assay (IFD) were performed. Histopathological study showed chronic histiocitary and lymphoplasmocitary inflammatory process, with numerous granulomas with central caseificant necrosis and giant multinucleated Langerhans cells (Fig. 2) (cytology and histopathology laboratory, Catholic University Health Network), while IFD was negative for C3, immunoglobulin A (IgA), IgG, IgM and fibrin. Because of these findings, cutaneous TBC was suspected, and so PCR for M. tuberculosis was requested. PCR technique was done using amplification in duplicate for sequence IS6110 [specific for Mycobacterium tuberculosis complex (MTC)] [12]. Evaluation of DNA’s integrity from the sample was performed by amplification of human beta-globin gene (positive internal control) and a water-only sample (H2O), to discard the possibility of contamination (negative external control) [13] (cytology and histopathology laboratory, Catholic University health network). PCR result was positive for TBC (Fig. 3). Tuberculin test with Mantoux technique [purified protein derivative (PPD)] was requested to determine her sensitivity to the bacillus (injection of 2 tuberculin units per 0.1 mL volume, using PPD RT-23) [14], and resulted in positive erythema and 5 mm of induration 72 h later (assessed at Medical Specialties Center, Carlos Van Buren Hospital, Valparaiso). A chest radiograph (X-ray) and computed tomography (CT) scan of thorax, abdomen and pelvis, urine exams and serum chemistry panel were all negative. Treatment was started with a primary schedule of 6 months (using isoniazid 300 mg + rifampicin 600 mg + pyrazinamide 1,500 mg + ethambutol 1,200 mg daily for the first 2 months; and isoniazid 800 mg + rifampicin 600 mg for the subsequent 4 months). The patient responded positively to treatment, evident after 30 days of treatment, with complete clearance of lesions at the end of the treatment (Fig. 4).Fig. 1


Lewandowsky's Rosaceiform Eruption: a Form of Cutaneous Tuberculosis Confirmed by PCR in Two Patients.

Conlledo R, Guglielmetti A, Sobarzo M, Woolvett F, Bravo F, González S, Fich F, Vial V - Dermatol Ther (Heidelb) (2014)

Medical control at 6 months of treatment using primary schedule for tuberculosis, with significant improvement and atrophic scars as sequels
© Copyright Policy
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4374068&req=5

Fig4: Medical control at 6 months of treatment using primary schedule for tuberculosis, with significant improvement and atrophic scars as sequels
Mentions: A 52-year-old Chilean woman presented with facial erythematous papulo-nodular and pruriginous lesions which first occurred 4 months previously in both glabellar regions. These legions extended progressively to the rest of the face, with confluence zones and an association with scratching (Fig. 1). She had no relevant medical history or contact with patients with known TBC, and had been vaccinated with Bacillus Calmette–Guérin (BCG) after birth. She had been previously treated for 3 months for acne rosacea using different drug therapies (oral doxycycline 100 mg every 12 h, followed by oral isotretinoin 20 mg per day, and topical treatment with alpha-bisabolol 1% and metronidazole gel 1%) with partial response. Laboratory examinations [C-reactive protein, C3, C4, anti-neutrophil cytoplasmic antibodies (ANCA), anti-proteinase 3 (anti-PR3), anti-myeloperoxidase (anti-MPO), lupus erythematosus (LE) cells in peripheral blood sample] were either negative or in the normal range, but an antinuclear antibody (ANA) test was positive in 1:640 dilution with NuMA-1 pattern. Lupus erythematosus was suspected, so skin biopsy and direct immunofluorescence assay (IFD) were performed. Histopathological study showed chronic histiocitary and lymphoplasmocitary inflammatory process, with numerous granulomas with central caseificant necrosis and giant multinucleated Langerhans cells (Fig. 2) (cytology and histopathology laboratory, Catholic University Health Network), while IFD was negative for C3, immunoglobulin A (IgA), IgG, IgM and fibrin. Because of these findings, cutaneous TBC was suspected, and so PCR for M. tuberculosis was requested. PCR technique was done using amplification in duplicate for sequence IS6110 [specific for Mycobacterium tuberculosis complex (MTC)] [12]. Evaluation of DNA’s integrity from the sample was performed by amplification of human beta-globin gene (positive internal control) and a water-only sample (H2O), to discard the possibility of contamination (negative external control) [13] (cytology and histopathology laboratory, Catholic University health network). PCR result was positive for TBC (Fig. 3). Tuberculin test with Mantoux technique [purified protein derivative (PPD)] was requested to determine her sensitivity to the bacillus (injection of 2 tuberculin units per 0.1 mL volume, using PPD RT-23) [14], and resulted in positive erythema and 5 mm of induration 72 h later (assessed at Medical Specialties Center, Carlos Van Buren Hospital, Valparaiso). A chest radiograph (X-ray) and computed tomography (CT) scan of thorax, abdomen and pelvis, urine exams and serum chemistry panel were all negative. Treatment was started with a primary schedule of 6 months (using isoniazid 300 mg + rifampicin 600 mg + pyrazinamide 1,500 mg + ethambutol 1,200 mg daily for the first 2 months; and isoniazid 800 mg + rifampicin 600 mg for the subsequent 4 months). The patient responded positively to treatment, evident after 30 days of treatment, with complete clearance of lesions at the end of the treatment (Fig. 4).Fig. 1

Bottom Line: The current problem with diagnosis is the demonstration of bacillus in the skin, especially paucibacillar forms, where sources like polymerase chain reaction (PCR) have improved diagnostic capacity.In paucibacillar forms, when culture and staining are negative and TBC is still suspected, it is recommended to use DNA amplification by PCR for an accurate diagnosis.Both cases bring up the concern about once again bringing Lewandowsky's rosaceiform eruption into the spectrum of cutaneous TBC, and the discussion about the current definition of tuberculid.

View Article: PubMed Central - PubMed

Affiliation: Department of Dermatology, School of Medicine, University of Valparaíso, Hontaneda 2653, Valparaíso, Chile, rodrigoconlledo@hotmail.com.

ABSTRACT

Introduction: Cutaneous tuberculosis (TBC) is a chronic disease caused by Mycobacterium tuberculosis, and is present in less than 1-2% of all TBC cases. The current problem with diagnosis is the demonstration of bacillus in the skin, especially paucibacillar forms, where sources like polymerase chain reaction (PCR) have improved diagnostic capacity.

Case presentation: Two cases of cutaneous TBC are reported. The first patient was 52-year-old woman with facial erythematous papulo-nodular lesions which had been developing for 4 months, and had previously been treated as acne rosacea, with partial response. Histopathological studies showed chronic granulomatous inflammation. TBC was suspected, so PCR was performed, which showed positive for M. tuberculosis. The second case was a 43-year-old woman with a facial rosaceiform plaque which began 6 months previously, and was treated as rosacea without any change for 5 months. Skin biopsy and PCR were positive for TBC. Both cases were treated using primary schedule for TBC, and both presented a favorable response.

Discussion: A clinical profile called Lewandowsky's rosacea-like eruption has been previously described. The condition has been questioned for years and was later removed from the spectrum of tuberculids and cutaneous TBC for not being able to isolate microorganisms in skin samples, a situation that might now change. In paucibacillar forms, when culture and staining are negative and TBC is still suspected, it is recommended to use DNA amplification by PCR for an accurate diagnosis. Both cases bring up the concern about once again bringing Lewandowsky's rosaceiform eruption into the spectrum of cutaneous TBC, and the discussion about the current definition of tuberculid.

No MeSH data available.


Related in: MedlinePlus