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CUTANEOUS TUBERKULOSIS

DEFINITION:
Tuberkulosis is an chronic infectious granulomatous disease. It is caused by the basil of mycobacterium tuberkulosis. The transmission of the bacteria are by: -inhalation -unpasteurized milk

EPIDEMIOLOGY

PREDISPOSITION FACTOR : low social status, malnutrition, intravenous drugs, immunodeficiency skrofuloderma : most common(84%), tuberkulosis cutis verucosa : (13%), Lupus vulgaris : rarely found

ETIOLOGY

*M. tuberculosis (M tb) *M.bovis *Vaccine : Bacillus Calmette-Guerin (BCG)

BACTERIOLOGY
Mycobacterium tuberculosis: Aerobic, nonspore-forming, non-motile, facultative. Curved intracellular rods measuring 0.2-0.5 m by 2-4 m. Their cell walls contain mycolic, acid-rich, long-chain glycolipids and phospholipoglycans (mycocides) that protect mycobacteria from cell lysosomal attack and also retain red basic fuchsin dye after acid rinsing (acid-fast stain). BACTERIOLOGIC TEST: MICROSCOPIC(Ziehl Neelsen staining) CULTURE (Lowenstein Jensen Media)

CLASSIFICATION:
1. TRUE CUTANEOUS TB : -THE BACTERIA CAN BE FOUND ON THE SURFACE OF THE SKIN. PRIMARY CUTANEOUS TB: - Inoculation of primary TB / Tuberculosis chancre - Miliary Tuberkulosis SECONDARY CUTANEOUS TB : - Scrofuloderma - Tuberkulosis verucosa cutis - Tuberkulosis gumosa cutis - Tuberkulosis cutis orifacialis - Lupus vulgaris

2. Tuberculid Generalised exanthem in patients with moderate or high degree of immunity to TB because of previous infection. Usually in good health with no identifiable focus of active TB in skin or elsewhere
PAPULE SHAPED: - Necrotic papule Tuberkulosis - Liken sklofulosorum GRANULOMATOUS AND ULSERONODULUS SHAPED: - Erytema nodosum - Erythema induratum (bazin disease)

TB CHANCRE (primary complex)


Exogen : patient have not been infected before. *children>>adults Predilection : face, hand, low extremity

CLINICAL MANIFESTATIONS

innoculation (2-4 weeks) brownish-red papules, pain (-) nodule/plaque ulceration (Tuberculous chancre), 3-8 weeks after being infected lyphadenopathy regions(Primary tuberculous complex)

Incubation period : 2-3 weeks Can be cured spontaneously in approximately < 1 year, scar (+)
INCUBATION

MILIARY TUBERCULOSIS CUTIS


TRANSMISSION
FROM FOCAL POINT TO THE SKIN ERITHEMA, PAPULE, VESICLE, PUSTULE, SQUAMA, NEGATIVE

TUBERKULIN TEST

PROGNOSIS

MALAM

SKOFLURODERMA
TRANSMISSION
From the organ that had already being infected with TB

LOCATION

NECK: tonsil, lungs ARMPIT: apex pleura LOWER EXTREMITY : lower thighs

Ununiformed soft mass (cold abses) eruption fistule livid, closed, ununiform seropurulent pus. cicatrix skin bridge

LUPUS VULGARIS
Predilection : face, body(lower extremity). A group of red nodules that change to yellow in color in time. If pressured is applied they will turn to apple jelly color. Confluence: form destructive plaque ulcus Involution: cicatrix (scar) Serpiginosa (+)

SCLOFULOSORUM LICHEN
FOUND MOSTLY IN CHILDREN. Miliar papule, skin like tone, erythema. Fairly alligned: sirsinar, fine squama Predilection: chest, abdomen, sacral area, buttocks Chronic residual Heals without cicatrix (scar)

ERYTHEMA INDURATUM (BAZIN DISEASE)


Erythema and indolence nodes Predilection: flexor Suppurative lession form ulcus without suppurative lessions regression hipotrophy chronic residual

TREATMENT:
Regular medication is crucial in avoiding bacterial resistancy of against antibiotics. Combination of drugs, minimum 2 bacterocides are used. INH + 2 - 3 (bactericidal)

Treatment plan depends on: economy status of the patient, severity of the disease, contraindication.

STANDARD REGIMENT (6MONTHS) 1. INITIAL PHASE (3/4 TABS PERDAY FOR 2 MONTHS)
ADULTS A. isoniazide 300 mg CHILDREN 5-8 mg/w

B. Rifampicin >50kg
<50kg C. Pirazinamid >50kg <50kg Ethambutol or >60kg

600 mg
450 mg 2g 1.5g 15 mg/KgBB 25 mg/KgBB 3-4 gr IM

10-12 mg/w

20-35 mg/W

Not recommended 15-20 mg/KgBB

<60kg

Streptomycine

2. CONTINUOUS PHASE:

(2 types for 4 months) Isoniazide + Rifampicin (dosage is based on the previous table)

Phase 1. Intensive (initial) Kills active bacterias

Phase 2. (continous) Sterilisation Kills slow growth bacterias.

The combination of HRZ is very potent. Before choosing this type of treatment, check the patients kidney function (SGOT, SGPT, ALK. PHOSPHATASE). The level of SGOT, SGPT, ALK. PHOSPHATASE usually rise after 2 weeks of treatment. The treatment is still ongoing even after the increment is detected. INH (EVERYDAY) + rifampicin (2x/week)