Cutaneous T B and Leprosy : 1 M.Yousry TB&leprosy Cutaneous T B and Leprosy BY
M.Yousry M.Abdel-Mawla Cutaneous T B : M.Yousry TB&leprosy 2 Cutaneous T B Mycobacterium tuberculosis is the causative agent of tuberculosis (TB).
Aerobic, nonsporeforming, nonmotile, facultative, intracellular, curved rods measuring 0.2-0.5 by 2.0-4.0 mm.
Stained with acid-fast stain. The variants of cutaneous TB : M.Yousry TB&leprosy 3 The variants of cutaneous TB Primary-inoculation TB (tuberculous chancre)
TB verrucosa cutis
TB cutis orificialis
Miliary TB of the skin
Tuberculids Slide 4: M.Yousry TB&leprosy 4 Classification:
Tuberculous chancre (primary complex).
Warty tuberculosis (tuberculosis verrucosa cutis).
Lupus vulgaris (some).
2-Secondary tuberculosis (endogenous source)
Orificial tuberculosis. Slide 5: M.Yousry TB&leprosy 5 3-Hematogenous tuberculosis
Acute miliary tuberculosis.
Lupus vulgaris (some).
4- Eruptive tuberculosis (tuberculides)
Micropapular, papular and nodular. Tuberculous Chancre : M.Yousry TB&leprosy 6 Tuberculous Chancre Results from direct introduction of mycobacteria into the skin or mucosa of an individual who was not previously infected with TB.
. An inflammatory papule develops in 2-4 weeks at the inoculation site that breaks down into a firm, nonhealing, shallow, nontender, undermined ulcer with a granulomatous base. Painless regional lymphadenopathy is evident at 3-8 weeks. TB verrucosa cutis : M.Yousry TB&leprosy 7 TB verrucosa cutis Occurs after direct inoculation of TB into the skin in someone who has been previously infected with mycobacteria
Presents as a purplish or brownish-red warty growth
Lesions most often occur on the knees, elbows, hands, feet and buttocks
Lesions may persist for years but can clear up even without treatment Lupus vulgaris : M.Yousry TB&leprosy 8 Lupus vulgaris Persistent and progressive form of cutaneous TB
Small sharply defined reddish-brown lesions with a gelatinous consistency (called apple-jelly nodules)
Lesions persist for years, leading to disfigurement and sometimes skin cancer Slide 9: M.Yousry TB&leprosy 9 Diascopy test:
If the lesion is pressed by a glass slide to diminish the vascular component of inflammation, individual nodules appear as yellow brown spots (apple jelly color), so the nodules are named “apple jelly nodules”. Slide 10: M.Yousry TB&leprosy 10 Slide 11: M.Yousry TB&leprosy 11 Slide 12: M.Yousry TB&leprosy 12 Slide 13: M.Yousry TB&leprosy 13 Scrofuloderma : M.Yousry TB&leprosy 14 Scrofuloderma Results from direct extension of underlying TB infection of lymph nodes, bone or joints
Often associated with TB of the lungs
Firm, painless lesions that eventually ulcerate with a granular base
May heal even without treatment but this takes years and leaves unsightly scars Slide 15: M.Yousry TB&leprosy 15 The process usually begins with a deep purplish induration of the skin overlying diseased lymphatic glands, which have been matted together.
The glands break down and the resultant purulent and caseous exudates stretch the superimposed skin and form fistulae in it. Slide 16: M.Yousry TB&leprosy 16 Slide 17: M.Yousry TB&leprosy 17 Chronic discharging sinuses, ulcerations, granulations, crusts, hypertrophic scars and cicatricial bands result, and these combined conditions compose scrofuloderma Slide 18: M.Yousry TB&leprosy 18 TB cutis orificialis : M.Yousry TB&leprosy 19 TB cutis orificialis Results from autoinoculation of mycobacteria into the periorificial skin and mucous membranes in patients with advanced TB
Tuberculin sensitivity is strong. The site of the periorificial lesion often is determined by trauma.
Red papules that evolve into painful, soft, punched-out, shallow ulcers. Slide 20: M.Yousry TB&leprosy 20 Orificial tuberculosis (Tuberculosis cutis orificialis)
Orificial tuberculosis occurs at the mucocutaneous borders of the nose, mouth, anus and urinary meatus in addition to the mucous membranes of the mouth and tongue. Slide 21: M.Yousry TB&leprosy 21 It is found usually in young adults with severe visceral tuberculosis, particularly of the lungs, intestines and genitourinary tract.
The lesion presents as painful small shallow ulcers with undermined edges and no tendency to spontaneous healing. Miliary TB : M.Yousry TB&leprosy 22 Miliary TB Chronic TB infection that has spread from the primary infection (usually in the lungs) to other organs and tissues via the bloodstream
Skin lesions are small (millet-sized) red spots that develop into ulcers and abscesses
In immunocompromised patients, e.g. HIV, AIDS, cancer
The patient is generally sick
Prognosis is poor (many patients die even if diagnosed and treated) Tuberculid : M.Yousry TB&leprosy 23 Tuberculid Generalised exanthem in patients with moderate or high degree of immunity to TB
Usually in good health
Erythema induratum (Bazin disease) :recurring lumps on the back of the legs (mostly women) that may ulcerate and scar.
Papulonecrotic tuberculid :crops of recurrent crusted skin papules on knees, elbows, buttocks or lower trunk that heal with scarring after about 6 weeks.
Lichen scrofulosorum : an extending eruption of small follicular papules T B Patient Work Up : M.Yousry TB&leprosy 24 T B Patient Work Up Medical history Perform a physical examination.
Tuberculin skin test
Posteroanterior chest radiograph
Specimens for bacteriologic examination: 3 sputum specimens on each of 3 consecutive days.
Skin biopsies THERAPY of T B : M.Yousry TB&leprosy 25 THERAPY of T B Isoniazid: 5 mg/kg/d in adults; 10-20 mg/kg/d in children, not to exceed 300 mg qd
Rifampin: 10 mg/kg/d in adults; 10-20 mg/kg/d in children, not to exceed 600 mg qd
Pyrazinamide: 15-30 mg/kg/d in adults and children, not to exceed 2000 mg qd
Ethambutol: 15-25 mg/kg/d in adults and children or streptomycin: 15 mg/kg/d in adults; 20-40 mg/kg/d in children, not to exceed 1000 mg qd Cutaneous leprosy : M.Yousry TB&leprosy 26 Cutaneous leprosy Leprosy is a chronic granulomatous disease, caused by Mycobacterium leprae, which affects principally the skin and peripheral nervous system
Animal reservoirs of leprosy : 9-banded armadillos & chimpanzees Pathophysiology: : M.Yousry TB&leprosy 27 Pathophysiology: The areas most commonly affected by leprosy are the superficial peripheral nerves, skin, mucous membranes of the upper respiratory tract, anterior chamber of the eyes, and testes. These areas tend to be cooler parts of the body.
Tissue damage is caused by the degree to which cell-mediated immunity is expressed, the extent of bacillary spread and multiplication, the immunologic complications (ie, lepra reactions), and the nerve damage and its sequelae Slide 28: M.Yousry TB&leprosy 28 M leprae is an obligate intracellular acid-fast bacillus with a unique ability to enter nerves.
The incubation period ranges from 6 months to 40 years or longer. The average incubation period is 2-3 years. Medical Diagnosis of Leprosy : M.Yousry TB&leprosy 29 Medical Diagnosis of Leprosy The disease is usually diagnosed on the basis of : anesthesia of a skin lesion, thickened nerves, and typical skin lesions.
Prodromal symptoms are generally so slight that the disease is not recognized until a cutaneous eruption is present.
Temperature is the first sensation that is lost
The next sensation lost is light touch, then pain, and finally deep pressure.
A hypopigmented macule :the first cutaneous lesion. From this stage, most lesions evolve into the lepromatous, tuberculoid or borderline types. Indeterminate leprosy (IL) : M.Yousry TB&leprosy 30 Indeterminate leprosy (IL) This early form causes one to a few hypopigmented, or sometimes erythematous, macules. Sensory loss is unusual.
Most cases evolve from this state into one of the other forms, depending on the patient's immunity to the disease.
Those with strong immunity may become cured of disease.
May persist in this indeterminate form.
In those with weaker immunity, the disease progresses to one of the other forms. Slide 31: M.Yousry TB&leprosy 31 Indeterminate leprosy
This early and transitory stage of leprosy occurs in those whose immunological state has not yet been determined and usually evolves into tuberculoid, lepromatous or borderline types. Slide 32: M.Yousry TB&leprosy 32 The classical lesions consist of one or more hypo-pigmented or erythematous macules, a few centimeters in diameter, with poorly defined margins.
Hair growth, sensation and sweating are normal. Indeterminate Leprosy : M.Yousry TB&leprosy 33 Indeterminate Leprosy Slide 34: M.Yousry TB&leprosy 34 The histopathology is non-specific.
Nerve involvement is absent.
Bacilli are usually absent but may be few in slit- skin smears.
Lepromin test is variable. Slide 35: M.Yousry TB&leprosy 35 Slide 36: M.Yousry TB&leprosy 36 Slide 37: M.Yousry TB&leprosy 37 Slide 38: M.Yousry TB&leprosy 38 Slide 39: M.Yousry TB&leprosy 39 Classification
Based on the clinical, bacteriologic, immunologic and histopathologic features, leprosy is classified into 6 types:
Tuberculoid leprosy (TT).
Borderline tuberculoid leprosy (BT).
Borderline leprosy (BB).
Borderline lepromatous leprosy (BL).
Lepromatous leprosy (LL).
The ‘indeterminate’ leprosy. Tuberculoid leprosy (TT) : M.Yousry TB&leprosy 40 Tuberculoid leprosy (TT) Skin lesions :few in number. Usually, one erythematous large plaque is present, with well-defined borders that are elevated and slope down into an atrophic center.
Another presentation involves a large asymmetric hypopigmented macule.
Neural involvement is common in TT; it leads to tender, thickened nerves Slide 41: M.Yousry TB&leprosy 41 Tuberculoid leprosy
This type affects only nerves and skin, and may be purely neural (neural leprosy).
Cutaneous lesions are few, often solitary, with asymmetrical distribution and occur on the face, limbs or anywhere. Slide 42: M.Yousry TB&leprosy 42 The typical lesion is an erythematous plaque with raised and clear-cut edge sloping towards a flattened and hypo-pigmented centre.
The surface of the lesion is usually dry (anhydrotic), hairless and anesthetic.
Nerve involvement is usually marked and in a few nerves. Tuberculoid Leprosy : M.Yousry TB&leprosy 43 Tuberculoid Leprosy Slide 44: M.Yousry TB&leprosy 44 Slide 45: M.Yousry TB&leprosy 45 Slide 46: M.Yousry TB&leprosy 46 Slide 47: M.Yousry TB&leprosy 47 The bacilli are usually absent in slit-skin smears.
The histopathology shows tuberculoid granulomas composed of epithelioid cells surrounded by a zone of lymphocytes.
Lepromin test is strongly positive. Slide 48: M.Yousry TB&leprosy 48 Slide 49: M.Yousry TB&leprosy 49 Borderline leprosy
Skin lesions are intermediate in number between those of the two previous polar types.
They may take the form of macules, plaques and annular lesions.
Plaques with a “punched-out appearance” are characteristic of the mid-borderline type. Borderline Leprosy : M.Yousry TB&leprosy 50 Borderline Leprosy Slide 51: M.Yousry TB&leprosy 51 Nerve involvement is early, affects several nerves and asymmetrical.
Bacilli are present in slit-skin smears but less than in lepromatous leprosy.
Histopathology shows mixed tuberculoid & lepromatous features.
Lepromin test is weakly positive in BT, negative in BB and BL. Borderline tuberculoid leprosy (BT) : M.Yousry TB&leprosy 52 Borderline tuberculoid leprosy (BT) Lesions in this form are similar to those in the tuberculoid form, but they are smaller and more numerous. The nerves are less enlarged,
Disease can remain in this stage, convert back to the tuberculoid form, or progress. Borderline borderline leprosy (BB) : M.Yousry TB&leprosy 53 Borderline borderline leprosy (BB) Cutaneous : numerous, red, irregularly shaped plaques that are less well defined. Their distribution may mimic those of the lepromatous type, but they are more asymmetric.
Anesthesia : moderate.
Regional adenopathy may be present.
Disease may remain in this stage, improve or worsen. Borderline lepromatous leprosy (BL) : M.Yousry TB&leprosy 54 Borderline lepromatous leprosy (BL) Lesions : numerous and consist of macules, papules, plaques, and nodules.
. Anesthesia : often absent.
As with the other forms of borderline leprosy, the disease may remain in this stage, improve, or regress. Lepromatous leprosy (LL) : M.Yousry TB&leprosy 55 Lepromatous leprosy (LL) Early cutaneous lesions :pale macules. Later, infiltrations are present, with numerous bacilli. Macular lesions : small, diffuse, and symmetric.
The lateral eyebrows are affected by alopecia
Lepromatous infiltrations : diffuse, nodules (called lepromas), or plaques. The diffuse type results in the appearance of a leonine facies.
Lymphadenopathy ,hepatomegaly Stridor ,hoarseness ,osteomyelitis &Brawny edema . Slide 56: M.Yousry TB&leprosy 56 Lepromatous leprosy
In this type, skin, nerves, mucous membranes, eyes, bones and internal organs are involved. Slide 57: M.Yousry TB&leprosy 57 Cutaneous lesions consist of macules, papules, infiltration or nodules (lepromas).
They are numerous, bilateral, symmetrical, ill-defined with shiny surface.
The sites commonly affected are the face, arms, legs and buttocks, but may be anywhere. Slide 58: M.Yousry TB&leprosy 58 Slide 59: M.Yousry TB&leprosy 59 Lepromatous Leprosy : M.Yousry TB&leprosy 60 Lepromatous Leprosy Lepromatous Leprosy : M.Yousry TB&leprosy 61 Lepromatous Leprosy Slide 62: M.Yousry TB&leprosy 62 Hair growth, sweating and sensation are not initially impaired over the lesions.
Infiltration and deepening of the lines of the forehead lead to the characteristic “leonine facies” . Slide 63: M.Yousry TB&leprosy 63 The ear lobes may be infiltrated and thickened.
A slow progressive loss of hair takes place from the outer third of the eyebrows, then the eyelashes and, finally, the body . Slide 64: M.Yousry TB&leprosy 64 Slide 65: M.Yousry TB&leprosy 65 Skin Biopsy : M.Yousry TB&leprosy 66 Skin Biopsy Epidermis
Collections of Foamy macrophages in the upper dermis.
Around adnexa Slide 67: M.Yousry TB&leprosy 67 Characteristics of the two polar types of leprosy Lab. Studies: : M.Yousry TB&leprosy 68 Lab. Studies: Tissue smear test:An incision is made in the skin, to obtain fluid from a lesion. The fluid is placed on a glass slide and stained by using the Ziehl-Neelson acid-fast method to look for organisms.The bacterial index (BI) is then determined
Skin biopsy: for morphologic features and the presence of acid-fast bacilli.
Sensory testing :Tactile and temperature sensations should be tested. Lab. Studies: : M.Yousry TB&leprosy 69 Lab. Studies: Lepromin testing
It indicates host resistance to M leprae. and does not not confirm the diagnosis, but they are useful in determining the type of leprosy. It is a prognostic rather than a diagnostic test
A positive finding indicates cell-mediated immunity,. A negative finding suggests a lack of resistance to disease.
To perform this test, bacillary suspension is injected into the forearm. When the reaction is assessed at 48 hours, it is called the Fernandez reaction When the reaction is read at 3-4 weeks, it is called the Mitsuda reaction. Slide 70: M.Yousry TB&leprosy 70 Effect of Cell-Mediated Immunity on Leprosy Clinical Outcome Reactions in Leprosy : M.Yousry TB&leprosy 71 Reactions in Leprosy Slide 72: M.Yousry TB&leprosy 72 Reactions in Leprosy
During the chronic course of leprosy, acute episodes (reactions) may occur.
There are 2 main types of reactions, type 1 and type 2. Slide 73: M.Yousry TB&leprosy 73 Type 1 reaction
It occurs in borderline leprosy.
It is due to the rapid change in cell - mediated immunity.
Nerves become swollen and tender with loss of sensory and motor functions.
Serious complications as facial palsy and dropped foot may occur.
Existing skin lesions become erythematous, edematous and may ulcerate. Type 1 Reaction : M.Yousry TB&leprosy 74 Type 1 Reaction Slide 75: M.Yousry TB&leprosy 75 Slide 76: M.Yousry TB&leprosy 76 Type 2 reaction
erythema nodosum leprosum (ENL)
It occurs in patients with LL and BL.
It is an immune - complex disorder.
ENL manifests as painful, red nodules on the face and extensor surfaces of limbs, and fading over several days. Type 2 Reaction : M.Yousry TB&leprosy 77 Type 2 Reaction Slide 78: M.Yousry TB&leprosy 78 Fever and malaise are common and may be accompanied by uveitis, arthritis, lymphadenitis, myositis and orchitis.
Nerve involvement is less than that of type 1 reaction. Slide 79: M.Yousry TB&leprosy 79 Slide 80: M.Yousry TB&leprosy 80 Slide 81: M.Yousry TB&leprosy 81 Slide 82: M.Yousry TB&leprosy 82 Medical Classification of leprosy : M.Yousry TB&leprosy 83 Medical Classification of leprosy Paucibacillary or PB leprosy.: patients can be cured by
treating the patient with two drugs for six months.
Multibacillary or MB leprosy :patients can be cured by treating the patient with three drugs for twelve months.
How to tell if someone has PB or MB leprosy?
Count the skin patches
• If you find five patches or less, classify the patient as PB.
• If you find more than five patches, classify the patient as MB.
When a skin smear is taken
• If the skin smear is negative and the patient has five patches or less, classify the patient as PB.
• If the skin smear is positive, classify the patient as MB, whatever the number of skin patches. Slide 84: M.Yousry TB&leprosy 84 Therapy of LeprosyMultiple Drug Therapy (MDT) : M.Yousry TB&leprosy 85 Therapy of LeprosyMultiple Drug Therapy (MDT) Slide 86: M.Yousry TB&leprosy 86 Slide 87: M.Yousry TB&leprosy 87 Therapy for lepra reactions : M.Yousry TB&leprosy 88 Therapy for lepra reactions Early diagnosis and the timely initiation of anti-inflammatory measures.
The possible precipitating factor should be removed MDT should be continued in full dosage without interruption.
The principles of treatment : Rest, both physical and mental, with appropriate sedation.
Analgesics and anti-inflammatory drugs:
Aspirin (acetylsalicylic acid) and corticosteroids Therapy with corticosteroids : M.Yousry TB&leprosy 89 Therapy with corticosteroids Type 1 lepra reaction: Prednisolone should be started with a single daily dose of 40–60 mg (maximum 1mg/kg body weight) according to severity.
In severe Type 2 lepra reaction: prednisolone should be started at a dose of 20–40 mg/day.
Clofazimine :given in doses up to 300 mg daily for one month, and then gradually reduced. Slide 90: M.Yousry TB&leprosy 90 Treatment of reactions
The anti-leprosy drugs should be continued without interruption.
Rest, analgesics and anti-inflammatory drugs.
Clofazimine in large doses (300 mg / day).
Corticosteroids, used in moderate and severe cases.
Thalidomide has a dramatic effect in controlling ENL but is teratogenic in early pregnancy. THANK YOU : M.Yousry TB&leprosy 91 THANK YOU