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Background: Even though remarkable progress for diagnostics of pulmonary TB has been made, it is still a challenge to establish a definitive diagnosis for extrapulmonary TB (EPTB) in clinical practice. Among all the presentations of EPTB, cold abscesses are unusual and deceptive, which are often reported in the chest wall and spine. Subcutaneous abscess in the connective tissue of limbs is extremely rare., Case Presentation: A 48-year-old man with dermatomyositis was hospitalized because of multiple subcutaneous tuberculous abscesses in his limbs, but without pulmonary tuberculosis. Particularly, one insidious abscess appeared during anti-TB treatment due to "paradoxical reaction". After routine anti-TB therapy, local puncture drainage and surgical resection, the patient was cured and discharged., Conclusions: Tuberculous infection should be kept in mind for the subcutaneous abscess of immunocompromised patients, even without previous TB history. Treatment strategy depends on the suppurating progress of abscess lesions. Meanwhile, complication of newly-developed insidious abscess during treatment should be vigilant.

Tuberculous gummas are an unusual form of tuberculosis (TB) accounting for 1%-2% of all cutaneous TB cases. The aim of this article was to describe the epidemiological, clinical, bacteriological, immunological, and therapeutic features of this form upon a case report and a literature review. Forty-eight case reports were identified through a PubMed and Google Scholar search using the following keywords: "tuberculous gumma" and "metastatic tuberculous abscesse." Tuberculous gumma can occur at any age. Immunodepression is not a sine qua non condition to the development of the disease. Limbs are the most frequent site for gummas. Tuberculous gummas are associated to another location in only 73% of cases. The most frequent associated locations are lung, nodes, and musculoskeletal apparatus. Mantoux test is negative in 38% of cases. Skin stain is positive in 45% of cases and culture in 85% of cases. Giant epithelioid cell granuloma is present in 82.4% of cases. There is no universally accepted chemotherapy regimen for metastatic tuberculous abscesses. The classic 2RHZE/4RH is highly effective., Competing Interests: There are no conflicts of interest

Tropical skin diseases are infectious conditions influenced by factors such as nutrition, housing, and the environment. Migration patterns have caused these conditions to be seen all around the world, not only in developing countries. Many of these diseases have a different presentation in childhood, which changes the diagnostic approach and management options. In this article, we review some of the most common tropical mycobacterial, protozoan, parasitic, and viral dermatologic conditions in children, including their epidemiologic, clinical, diagnostic, and therapeutic aspects., (© 2016 Wiley Periodicals, Inc.)

Background: Although cutaneous tuberculosis (CTB) is well described, it is wise to periodically revisit the prevailing clinical and epidemiological features, of this somewhat uncommon entity in developed nations that is also usually neglected in national tuberculosis control programs in countries where tuberculosis is a major health problem, to maintain heightened awareness as the HIV pandemic runs its course., Methods: Medical records of 165 cases of CTB, diagnosed from 2007 to 2010, were studied. The diagnosis in each was made on the basis of well-conceived and described criteria. All patients had earlier been immunized with Bacillus Calmette-Guérin soon after birth. Patients were evaluated by routine hematology, Mantoux test, screening for HIV status in addition to fine-needle aspiration cytology, and/or histopathology of the lesion., Results: Of the 165 cases (94 males and 71 females, male:female ratio of 1.32:1; age range, 1-64), 85 were lupus vulgaris, 11 tuberculosis verrucosa cutis (paucibacillary), and 39 scrofuloderma (multibacillary). The remaining 17 were tuberculids comprising 24 lichen scrofulosorum, 3 papulonecrotic tuberculid, 2 erythema induratum, and 1 erythema nodosum, afflicting children and young adults (age range, 0-10; 21-30). Fine-needle aspiration cytology was diagnostic in 39 cases, histopathology in 117, and their combination in 9. Clinicopathologic correlation and response to antituberculosis treatment were additional diagnostic adjuncts., Conclusions: CTB has a varied clinical and morphological spectrum. Cytology and histopathology play a key role in its diagnosis. An additional adjunct is the clinical response to antituberculosis treatment.

Primary inoculation tuberculosis (TB) is a rare form of cutaneous TB resulting from direct introduction of Mycobacterium tuberculosis into the skin or mucosa of a previously uninfected, nonimmune person. We herein report the first case, to our knowledge, of primary inoculation TB to be seen after varicella; this case explains the possible mechanism of varicella-zoster virus-mediated transient cellular immune suppression that predisposed the patient to cutaneous TB. In this case, we believe that varicella-zoster virus (VZV) infection predisposed the patient to primary inoculation TB by leading to direct inoculation of tuberculosis bacilli through vesicles or by suppressing cellular immunity.

Background: Tropical dermatoses and ulcers, although essentially unique to tropical and subtropical areas, are occasionally seen in Australian general practice on returning travellers and migrants from endemic countries., Objective: This article will discuss important causes of tropical and exotic ulcers occasionally seen in Australia., Discussion: As tropical ulcers may mimic many other causes of skin ulceration and nodules, a history of recent travel should arouse clinical suspicion. The time frame since exposure to the causative organism is an important feature in the diagnostic process. For example, pyodermas and cutaneous larva migrans present a few days after contact with the causative agents, whereas leishmaniasis, cutaneous tuberculosis, atypical mycobacterial diseases (swimming pool granulomas) and tropical mycosis take weeks to months to appear.

History and Clinical Findings: After a trivial injury, a male patient from India presented with a non-healing minor injury. A necrotic lesion at the right medial ankle was evident., Examinations: Mycobacterium tuberculosis complex was detected from tissue material both in cultures and by molecular markers. Sonography of the abdomen indicated a retroperitoneal abcess formation., Diagnosis, Treatment and Course: Cutaneous tuberculosis with involvement of the spine and an abscess of the psoas muscle was diagnosed. After initiation of antituberculotic treatment elevation of liver enzymes was noted. The initially observed skin lesion in the area of the right ankle healed quickly; however, the abscess of the psoas muscle did not. The abscess was drained by puncture. During follow up no fistula formation was observed., Conclusion: Tuberculosis should be considered as differential diagnosis in cases of poorly healing skin lesions caused by trauma, especially in patients from tuberculosis high incidence regions., (© Georg Thieme Verlag KG Stuttgart · New York.)

Interferon-γ receptor-1 (IFNγR1) deficiency is caused by mutations in the IFNγR1 gene and is characterized mainly by susceptibility to mycobacterial disease. Herein, we report an 8-month-old boy with complete recessive IFNγR1 deficiency, afflicted by recurrent mycobacterial diseases with Mycobacterium bovis, Mycobacterium tuberculosis, Mycobacterium avium intracellulare and Mycobacterium fortuitum. Genetic analysis showed a homozygous mutation (106insT) in the IFNγR1 gene leading to complete IFNγR1 deficiency. In addition, he had atypical mycobacterial skin lesions caused by M. avium intracellulare and developed scrotal and lower limb lymphedema secondary to compression of large and fixed inguinal lymphadenopathies. Hematopoietic stem cell transplantation was performed from a matched unrelated donor at 5 years of age; however, he died at 9 months post-transplant. To our knowledge, the patient is the first case with IL-12/IFN-γ pathway defect and severe lymphedema. We have also reviewed and summarized the literature related with IFNγR1 deficiency.

Cutaneous tuberculosis is the rarest presentation of all the forms of tuberculosis. Scrofuloderma is a frequent manifestation of cutaneous tuberculosis in Indian scenario. Males are affected one and half times more than females. The most common affected age group showing clinical infection is within the first three decades of life. A series of cases mostly malnourished children attending a tertiary care centre in a rural area of central India is being reported. They have presented with a wide spectrum of clinical features, forcing us to establish the final diagnosis by Mantoux test, fine needle aspiration cytology and histopathological examination. The mainstay of treatment remains medical therapy but the underlying cause for severe immunosuppression needs to be ruled out and treated.

Introduction: At the turn of the twentieth century, ultraviolet light was successfully used to treat tuberculosis of the skin. Upper respiratory tract infections had been inversely associated with sun exposure. During the last decade, basic scientific research demonstrated that vitamin D has an important anti-infective role., Method: Review of the relevant literature on the influence of vitamin D on innate immunity and respiratory tract infection., Results: Vitamin D is involved in the production of defensins and cathelicidin - antimicrobial peptides that provide a natural defence against potential microbiological pathogens. Vitamin D supplementation increases cathelicidin production. Low vitamin D levels are associated with an increased incidence of upper respiratory tract infections., Conclusions: Vitamin D appears to play an important role in the regulation of innate immunity in the upper respiratory tract. Optimal vitamin D levels and appropriate dosing schedules have yet to be determined.

We present a case of inoculation of the first dorsal web space by a nurse practitioner who accidentally stuck herself while preparing Bacilli Calmette-Guérin vaccine for treatment of bladder tumor. We report the evolution and management of this resistant chronic Mycobacterium infection that ultimately required use of a vacuum wound management system followed by a microvascular free tissue transfer.

A rare case of tuberculous deep palmar abscess of the hand was treated with radical excisional debridement, resulting in a large palmar skin and soft tissue defect that was successfully closed with a vacuum dressing followed by split skin grafting. Vacuum dressings are useful adjuncts to treat large soft tissue defects in patients who are unsuitable for complex reconstruction. The moist wound environment prevents desiccation of exposed vital structures and decreases pain, allowing early mobilisation in the hand. The wound granulates and contracts rapidly, allowing earlier skin grafting or faster healing by secondary intention. The closed system vacuum dressing is particularly useful in managing debrided tuberculous soft tissue infections. The dressing is perfectly sealed and requires less frequent changing, decreasing contamination and transmission of tuberculosis to other patients and health care staff, while minimising the risk of secondary nosocomial bacterial infection of the wound.

Background: Tuberculosis is a major public health problem in Ethiopia but cutaneous tuberculosis (CT) has not been documented., Objective: This study was conducted to determine its existence and its clinical pattern in Tigray, a northern region of Ethiopia., Methods: We report 202 cases of CT who attended the Italian Dermatological Centre in the 34-month period between January 2005 and October 2007. The diagnosis was made on a clinical, cytological and histological basis., Results: Clinically, 143 cases of scrofuloderma, 22 of lupus vulgaris, 18 of gumma, 11 of lichen scrofulosorum, 6 of tuberculosis verrucosa cutis and 2 of erythema induratum of Bazin were observed in our department. All patients were aged between 18 months and 69 years, and 49 were paediatric cases. Forty-five were HIV positive., Conclusion: The number of CT cases observed in the period of 34 months indicates a high incidence of the disease in the region also in the paediatric age. CT is still underdiagnosed due to the low number of dermatologists as well as the poor life conditions of the population and the traditional belief in magic medicine. The current study may therefore provide some indication about the epidemiology of CT in Ethiopia., (Copyright 2008 S. Karger AG, Basel.)

Cutaneous tuberculosis continues to be one of the most elusive and more difficult diagnoses to make for dermatologists practicing in developing countries. Not only because they have to consider a wider differential diagnosis (leishmaniasis, leprosy, actinomycosis, deep fungal infections, etc) but also because of the difficulty in obtaining a microbiological confirmation. Despite all the advances in microbiology, including sophisticated techniques such as polymerase chain reaction, the sensitivity of new methods are no better than the gold standard, that is, the isolation of Mycobacterium tuberculosum in culture. Even now, in the 21st century, we rely on methods as old as the intradermal reaction purified protein derivative (PPD) standard test and therapeutic trials, as diagnostic tools. In this situation, it is important to recognize the many clinical faces of cutaneous tuberculosis to prevent missed or delayed diagnoses.

Lupus erythematosus and lupus valgaris, i.e., cutaneous tuberculosis, are confusing skin lesions in the history. Here, we reported on a Chinese lupus patient manifested with multiple nodular erythematous rashes on both upper extremities, which turned out to be cutaneous mycobacterial infection.

Mycobacterium abscessus is the most pathogenic and chemotherapy-resistant rapid-growing mycobacterium. It is commonly associated with contaminated traumatic skin wounds and with post-surgical soft tissue infections. It is also one of the mycobacteria that are most often isolated from cystic fibrosis patients. It is essential to differentiate this species from the formerly indistinct "M. chelonae-complex", as chemotherapy is especially difficult in M. abscessussenso strictu. Clarithromycin or azithromycin are the only regular oral antimycobacterial agents with an effect on M. abscessus, and should preferably be supplemented with other drugs since long-term monotherapy may cause resistance. Amikacin is a major parenteral drug against M. abscessus that should also be given in combination with another drug. The recently introduced drug tigecycline may prove to be an important addition to chemotherapy, but has yet to be fully clinically evaluated as an antimycobacterial agent. Surgery can be curative, or at least helpful, in the healing of M. abscessus infection, and if conducted, it should include the removal of all foreign or necrotic material. There is increasing awareness of M. abscessus as an emerging pathogen.

Objective: To explore the etiological factors of hand special chronic infections and their relationship with tuberculosis, and to give evidence for clinical diagnosis as well as treatments., Methods: From 2002 to 2004 pathologic inspection, acid-fast stain, bacterial cultication, mycobacterial cultivation were performed in all 29 cases of hand special chronic infections., Results: All cases showed granulomatous lesions in pathological appearance, 2 positive in acid-fast stain, 12 positive in bacteria cultivation, and 1 nocardiosis, 1 staphylococcus epidermidis, 7 M.marinum, 1 M.tuberculosis, 1 M.fortuitum, 1 M.kansasii., Conclusions: Non-tuberculo-mycobacterium (NTM) especially M.marinum are far more important as the major factor than tuberculosis and other bacterial in hand special chronic infections. Bacteria cultivation should be routine examined for all cases.

Tuberculosis (TB) of the ribs is extremely rare and its diagnosis is often delayed due to the late appearance of radiologic signs. Although antituberculous drugs are the mainstay of treatment, surgery has a definite therapeutic role in recalcitrant or recurrent cases. A 5-year-old boy with scrofuloderma of the chest wall due to underlying TB of the rib, who responded partially to antituberculous treatment is reported. Surgical resection of the affected rib led to complete resolution. Early diagnosis of TB of this rare site and the role of surgical intervention in such cases is emphasized.

As we move into the 21st century, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary tuberculosis. Mycobacterium tuberculosis, Mycobacterium bovis, and the BCG vaccine cause tuberculosis involving the skin. True cutaneous tuberculosis lesions can be acquired either exogenously or endogenously, show a wide spectrum of morphology and M. tuberculosis can be diagnosed by acid-fast bacilli (AFB) stains, culture or polymerase chain reaction (PCR). These lesions include tuberculous chancre, tuberculosis verrucosa cutis, lupus vulgaris, scrofuloderma, orificial tuberculosis, miliary tuberculosis, metastatic tuberculosis abscess and most cases of papulonecrotic tuberculid. The tuberculids, like cutaneous tuberculosis, show a wide spectrum of morphology but M. tuberculosis is not identified by AFB stains, culture or PCR. These lesions include lichen scrofulosorum, nodular tuberculid, most cases of nodular granulomatous phlebitis, most cases of erythema induratum of Bazin and some cases of papulonecrotic tuberculid. Diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with diagnostic testing; in addition to traditional AFB smears and cultures, there has been increased utilization of PCR because of its rapidity, sensitivity and specificity. Since most cases of cutaneous tuberculosis are a manifestation of systemic involvement, and the bacillary load in cutaneous tuberculosis is usually less than in pulmonary tuberculosis, treatment regimens are similar to that of tuberculosis in general. In the immunocompromised, such as an HIV infected patient with disseminated miliary tuberculosis, rapid diagnosis and prompt initiation of treatment are paramount. Unfortunately, despite even the most aggressive efforts, the prognosis in these individuals is poor when multi-drug resistant mycobacterium are present. An increased awareness of the re-emergence of cutaneous tuberculosis will allow for the proper diagnosis and management of this increasingly common skin disorder.

Despite the many advances in technology, research and educational initiatives in tissue viability, wound management remains a complex and challenging area for healthcare professionals. This article describes the management of an unusual groin wound that developed as a result of tissue breakdown secondary to tuberculosis.

Setting: A tertiary care hospital in northern India., Objective: To study the patterns of clinical presentation of cutaneous tuberculosis, to correlate them with Mantoux reactivity and BCG vaccination status, and to suggest a clinical classification based on these factors., Design: Analysis of the records of patients with cutaneous tuberculosis who attended the hospital between 1975 and 1995., Results: A total of 0.1% of dermatology patients had cutaneous tuberculosis. Lupus vulgaris was the commonest form, seen in 154 (55%) of these patients, followed by scrofuloderma in 75 (26.8%), tuberculosis verrucosa cutis in 17 (6%), tuberculous gumma(s) in 15 (5.4%) and tuberculids in 19 (6.8%). No correlation was found between Mantoux reactivity and the extent of disease (localised disease 63.6%, disseminated disease 67.9%). The presence of regional lymphadenopathy was an indication of dissemination of the disease (localised disease 34.7%, disseminated disease 71.7%). Dissemination of the disease was observed in the whole of the spectrum of cutaneous tuberculosis (22.1%), but was seen more often in the presence of gumma and scrofuloderma. There were more unvaccinated individuals in the group with disseminated disease (80.3%) than in those with localised disease (65.5%)., Conclusions: Lupus vulgaris was the most common clinical presentation, followed by scrofuloderma, tuberculids, tuberculosis verrucosa cutis and tuberculous gumma. Some patients presented more than one clinical form of the disease. Classification of cutaneous tuberculosis needs to be modified to include smear-positive and smear-negative scrofuloderma apart from the inclusion of disseminated disease. The presence of regional lymphadenopathy serves as a clinical indicator of disseminated disease. Patients with disseminated disease were less likely to have been BCG-vaccinated than those with localised disease.

A localised subcutaneous swelling developed on the nasal bridge of a cat receiving chemotherapy for alimentary tract lymphosarcoma. Cytological and histological examination of representative samples of the lesion demonstrated pyogranulomatous inflammation and abundant acid-fast bacilli. A Mycobacterium sp was cultured from tissue excised from the lesion. Extensive testing at three reference laboratories indicated the strain was a member of the Mycobacterium avium complex. The infection was treated successfully by cytoreductive surgery and a 6 weeks course of orally administered clofazimine.

A patient with skin infection due to Mycobacterium avium is reported. A 9-year-old female had 10 subcutaneous nodules and two ulcers on the abdomen and legs. She had no medical history of systemic disease, skin disease or immunosuppressive therapy. Cultures of a biopsy specimen and of aspirated seropurulent fluid in nodules showed acid-fast bacteria, identified as M. avium by the DNA-DNA hybridization method. We treated her with a combination of surgery and the antibiotics, cycloserine, isoniazid and clarithromycin.

We report a 26-year-old housemaid whose partner was an intravenous drug abuser with undiagnosed pulmonary tuberculosis. The patient presented with a painless chin ulcer with an elevated irregular border and a firm, nontender submandibular adenopathy. The lesion had been present for 2 months and did not respond to antibiotic therapy. The tuberculin test was positive, and a biopsy and Löwenstein culture confirmed the diagnosis of cutaneous chancre. The patient was treated with rifampicin, isoniazid and pyrazinamide and, after 6 months of treatment, she developed scrofuloderma which had to be surgically removed. After 1 year of follow-up, the lesions had totally cleared.

In an 82-year-old female diabetic tuberculosis involved the maxilla, zygomatic region, maxillary sinus and facial skin. No other foci of tuberculosis were found in the organism. The diagnosis and treatment are described stressing the extreme rarity of this involvement by tuberculosis.

We report a case of disseminated Mycobacterium fortuitum in a 76-yr-old male with no identifiable predisposing factors except chronic interstitial lung disease. Recurrent, progressive pulmonary symptoms and radiographic findings were followed by the development of multiple, culture-positive peripheral lesions. The patient responded rapidly and completely to combination therapy consisting primarily of ciprofloxacin, minocycline, and surgical drainage. Our experience supports the cautious use and further study of fluorinated quinolones for M. fortuitum infections caused by susceptible isolates.

A case of penis tuberculid (papulonecrotic tuberculid of the glans penis) and its treatment with combination of oral rifampicin (RFP) and injection of an extract from tubercle bacilli (T.B. vaccine) were reported. We also examined the literature and discovered 37 cases of this disease in Japan in the last 10 years (between 1978 and 1987).