Tuberculosis verruca cutis is a chronic infection of the skin that occurs as a result of human contact with pathogen–infected material or with patients suffering from open forms of tuberculosis. The main symptom of the disease is the formation of a rounded purple-tinged granuloma on the back of the hands, which tends to grow, with the outcome in a dense large papule covered with warty growths. Such a “tuberculous tubercle” is allowed by scarring. Subjectively, the patient’s well-being is not disturbed. Tuberculosis verruca cutis is diagnosed by setting tuberculin samples. The treatment is pathogenetic with the use of anti-tuberculosis drugs.
A18.4 Tuberculosis verruca cutis
Tuberculosis verruca cutis is a local form of specific skin superinfection. It is included in a small group of diseases related to skin pathology in tuberculosis, and accounts for about 5% of the total number of such diseases. There are no accurate statistics on the prevalence of this pathology, since the clinically warty form of tuberculosis of the skin has similarities with other dermatological diseases, does not meet due alertness in diagnosis by general practitioners. People who are in contact with tuberculosis-infected material (forensic experts, veterinarians, meat choppers) and medical specialists (doctors, middle and junior medical personnel) are mostly ill.
Tuberculosis has been known since the time of Hippocrates. The first mention of the skin manifestations of a specific respiratory disease in artisans dates back to 1700 (B. Ramadzini). The discovery of Koch’s wand in 1882 and X-rays in 1895 turned out to be revolutionary, because it gave doctors the keys to the diagnosis of all manifestations of tuberculosis infection, including tuberculosis verruca cutis. The relevance of the study is determined by the steady growth of tuberculosis infection everywhere, since the late 1990s. This is due to the epidemic of HIV infection, migration processes, the development of resistance to anti-tuberculosis drugs.
Infection with Koch mycobacteria most often occurs endogenously, through reactivation of already existing foci of infection, when mycobacteria penetrate into the dermis with blood flow, lymph. The primary contact of the pathogen with the skin after contact with the infected material is possible. Autoinoculation, “self-vaccination”, unintentional transfer of the pathogen from the primary focus of infection to other areas of the skin and mucous membranes is not excluded.
The pathogenesis of the disease has not been fully studied. Normally, the skin is not susceptible to mycobacteria. Additional reasons are needed for the development of the pathogenic process: decreased immunity, stress, hypovitaminosis, metabolic disorders, antisocial lifestyle. At the site of the entrance gate of infection, a papule the size of a pea forms, lymph nodes increase, a tuberculosis symptom complex develops. The process is disseminated with the formation of tuberculids – angiovasculitis as a result of allergic, immune inflammation or ends with local healing of a tissue defect. It all depends on how immunocompromising the patient is.
Children and men are more likely to suffer from this form of pathology. The main clinical symptom is the appearance of small, up to 10 mm in diameter, rounded nodules of bluish color, painless, dense consistency, with clear boundaries and typical localization on the back of the hands, less often – feet, lower legs. The tubercles tend to grow peripherally, transforming into flat plaques with horny layers on the surface. The process of scar formation is allowed. Plaques form a local focus, in which three zones are visible during its maturation: atrophy with a lumpy bottom – in the center; infiltrate with scales, cracks, crusts – in the middle; purple shiny canvas – on the periphery. Microabsesses form under the skin, when pressed, “splashing” purulent contents onto the surface of the skin.
Lymph nodes, lymphatic and blood vessels react to the development of infection. Along the periphery of the “plaque island”, fresh primary elements tend to merge. The general condition of the patients is not disturbed. Mycobacteria of Koch are not always found in the focus, but tuberculin tests are positive in 99% of cases. Hair and nails are never affected by tuberculosis, because Mycobacterium cannot live without air. Histology is specific: acanthosis of the epidermis in combination with papillomatosis and tuberculoid structure in the dermis.
If you suspect tuberculosis verruca cutis, you need to consult a dermatologist and a phthisiologist with a full diagnosis. One method of research cannot be limited. Primary diagnosis consists of anamnesis data, clinic, histological examination, radiography of the alleged primary lesion. Next, bacterioscopy is used (examination of the separated focus or punctate of the lymph node in a smear under a microscope). Bacteriological diagnostics are used (back-sowing of the separated focus on nutrient media), biological methods (animal experiments are an absolute confirmation of tuberculosis).
Positive tuberculin tests are important for detecting the sensitization of the body to Koch’s bacillus (Pirke skin test and intradermal Mantoux). The most modern method of diagnosing warty tuberculosis is serological testing – T-SPOT.TB and its analogue is the quantiferon test.
Tuberculosis verruca cutis is histologically differentiated with common warts that do not have an inflammatory component in the formation of papules; vegetative pyoderma, with bullous purulent rashes that occur against the background of secondary infection; spinocellular cancer, demonstrating asymmetry in the rash of primary elements when localized along the perimeter of physiological openings, rapidly degenerating into ulcers; dermatomycosis, tuberculous lupus, verrucous red flat lichen. Serological differential diagnosis is performed with leishmaniasis and tubercular syphilis.
Therapy is carried out by a phthisiologist. First, the patient is treated inpatient. Anti-tuberculosis drugs (ftivazid, rifampicin, kanamycin) are used in various combinations, the duration of treatment is 1 year. The combination of drugs must be constantly changed in order not to cause addiction, resistance to the treatment. In severe cases, chemotherapy is prescribed. After discharge from the hospital, rehabilitation is carried out on the basis of the sanatorium. Then, for 5 years (the period of dispensary observation), two two-month courses of specific therapy are prescribed annually in order to prevent relapse and dissemination of the process.
Immunomodulators (echinacea juice, interferon alpha, sodium deoxyribonucleate), multivitamins, therapeutic nutrition are used in complex treatment. To strengthen the body’s defenses, a high-calorie diet with a high content of proteins (meat, fish, nuts), carbohydrates (fruits, vegetables, honey), fats (natural creamy meat, dairy products) is recommended. Iron preparations, angio- and hepatoprotectors that improve blood microcirculation are shown. Outside of the active phase of tuberculosis verruca cutis, physiotherapy is used: electrophoresis with anti-tuberculosis drugs.
Surgical intervention is used exclusively according to indications, removing seals and affected lymph nodes that have formed into cosmetic defects that worsen the patient’s quality of life. Scars (up to 5 cm) are removed after consultation with a cosmetologist and plastic surgeon using excision, laser cosmetology methods, cryotherapy.
Prevention and prognosis
Prevention aimed at preventing the development of tuberculosis of any form is carried out from birth: vaccination of newborns, revaccination of children aged 7, 14 years. In accordance with the laws of the Russian Federation, every patient hospitalized in a round-the-clock and day hospital is subject to mandatory fluorographic examination. An important method of prevention is the general medical examination of the population, preventive examinations, including when applying for a job (FLG). The prognosis of tuberculosis verruca cutis, despite the duration of therapy, is favorable for life – complete recovery.