Dermatovenerology. Skin tuberculosis (most important)

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Dermatovenerology. Skin tuberculosis (most important)

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LECTURE No. 11. Tuberculosis of the skin

Tuberculosis of the skin is a group of diseases that differ in clinical and morphological manifestations and outcome, caused by mycobacteria of human tuberculosis, less often of bovine type.

Etiology. Mycobacterium tuberculosis is a short, straight or slightly curved, acid-fast bacilli about 2,5 microns in length. Mycobacteria are characterized by polymorphism, do not form spores, and their virulence varies significantly.

Etiology and pathogenesis. Infection most often occurs aerogenously, but it is also possible through the gastrointestinal tract. It is extremely rare that Mycobacterium tuberculosis initially enters directly into the skin. At the site of introduction of mycobacteria, a primary affect is formed, then the lymph nodes are affected, and a primary tuberculosis complex is formed. In the future, dissemination of mycobacteria or, with a favorable outcome, local spread with subsequent encapsulation and petrification, leading to persistent healing, is possible.

Mycobacterium tuberculosis enters the skin more often secondarily (endogenously), rarely - primarily (exogenously).

Most forms of skin tuberculosis are the result of hematogenous spread (in pulmonary or extrapulmonary tuberculosis) from primary or secondary foci. Both dissemination of Mycobacterium tuberculosis throughout the body (including from skin to skin) and metastatic spread are possible.

The result of the dissemination of the pathogenic beginning is the so-called tuberculides (in which the intensity of immunity is very high and mycobacteria quickly die, having time to cause a reaction).

It is practically impossible to detect the causative agent of tuberculosis in the skin in such cases. Tuberculin tests are sharply positive. Lesions do not tend to grow peripherally and are relatively easy to treat.

With a metastatic entry of the pathogen into a specific area of \uXNUMXb\uXNUMXbthe skin (tuberculous lupus, some cases of scrofuloderma), single lesions develop (focal, localized forms). An important feature of these variants of tuberculous skin lesions is the tendency to peripheral growth.

With exogenous contact of the pathogen with the skin, the following forms of skin tuberculosis may develop:

1) tuberculous chancre (primary tuberculosis of the skin). Currently almost never found. Observed in newborns who were not infected (i.e., immunity and infectious allergies were absent) and became infected during ritual circumcision or piercing of the earlobes;

2) verrucous (warty) tuberculosis. It develops as a result of the introduction of mycobacteria into the damaged skin of pathologists or butchers in the presence of formed infectious immunity and allergies (the primary focus is called the "tubercle of pathologists" or "cadaveric tubercle").

In patients with bacillary tuberculosis of various internal organs (lungs, kidneys, gastrointestinal tract), mycobacteria can get on the skin. In such cases, the following forms may develop:

1) verrucous (warty) tuberculosis. The most common cause of skin lesions is sputum on the back of the hands. Occurs in immunocompromised patients;

2) ulcerative tuberculosis (tuberculosis of the skin and mucous membranes). With cavernous tuberculosis or a primary focus in the lungs, mycobacteria with sputum enter the oral mucosa. In people with tuberculosis of the genitourinary organs, mycobacteria get on the genitals, and in patients with the gastrointestinal tract - on the skin of the perianal region. In these cases, the pathogen is easily detected on the surface of the ulcers (in smears and cultures).

Clinic. The following forms of skin tuberculosis are distinguished: tuberculous lupus, colliquative tuberculosis of the skin, warty tuberculosis of the skin, ulcerative tuberculosis of the skin and mucous membranes, papulo-necrotic tuberculosis, indurative tuberculosis, lichenoid tuberculosis. The first four diseases are focal (localized) forms, and the remaining three are disseminated.

Tuberculous lupus (lupus vulgaris, lupus tuberculosis of the skin). The most common form of localized skin tuberculosis.

The most commonly affected skin is the face, especially the wings and tip of the nose, cheeks, upper lip, auricles and neck. The skin of the extremities and trunk is affected much less frequently. Foci are single or few. The primary element is a tubercle (lupoma) of a brownish-yellow color. Similar lupomas are quickly formed around, located very close. After a few weeks or months, a plaque of various sizes with scalloped edges forms. A smooth white superficial scar gradually forms in the center, resembling crumpled tissue paper.

Tuberculous lupus is characterized by a symptom of the probe: when pressed with a blunt probe on the affected surface, a persistent retraction is formed.

Collicative tuberculosis, scrofuloderma - the result of hematogenous or lymphogenous spread. Allocate secondary and primary scrofuloderma. Secondary is the result of Mycobacterium tuberculosis entering the subcutaneous lymph nodes, and only then into the skin. The most common localization is in the region of the collarbones, sternum, and neck. Primary scrofuloderma occurs as a result of metastatic hematogenous entry of Mycobacterium tuberculosis directly into the subcutaneous tissue.

The primary element is a node in the subcutaneous tissue, the skin over which is not changed at first, and then acquires a red-yellow translucent color. Caseous necrosis is formed in the center. The knot softens and opens. Discharge is copious, crumbly-purulent. The resulting ulcer has soft undermined edges and is covered with yellowish-white caseous masses that adhere very tightly. Along the periphery, similar rashes appear, ulcers merge. The process ends with a characteristic scarring: bridge-like scars are formed.

Warty tuberculosis. May be the result of autoinoculation. The lesions are exclusively on the back of the hands. The primary element is the papule. Lesions of various sizes, with a clear boundary. Three zones are distinguished: in the central part there are warty growths up to 0,5-1 cm high, cracks, crusts, possible scarring, along the periphery there is a swollen purple shiny zone in the form of a border.

Ulcerative tuberculosis of the skin and mucous membranes. Manifestations are localized on the oral mucosa, genital organs, in the perianal region. Painful ulcers are formed with scalloped outlines, undermined edges and a bottom dotted with yellowish nodules. Ulcers are painful when eating, defecation, urination. Mycobacterium tuberculosis is easily detected in the discharge of ulcers.

Papulo-necrotic tuberculosis. Clinically very close to papulo-necrotic vasculitis, but flows for years. Exacerbates in cold weather. Papules the size of lentils are covered with crusts that fall off. Exodus - stamped scars. Typical localization - extensor surfaces of the limbs, buttocks, face.

Indurative tuberculosis, indurative erythema of Bazin. Vasculitis of deep vessels of tuberculous etiology. Usually happens in women. Nodules are formed with the capture of subcutaneous tissue and dermis. The skin above them is not changed at first, then it becomes reddish-bluish. Knots are dense, painless. Between them, you can feel the strands (endo- and periphlebitis). The most common localization is the lower third of the posterior surface of the legs. The nodes sometimes ulcerate, leaving a smooth retracted scar after resolution.

Lichenoid tuberculosis, lichen scrofula. It develops in children and adolescents with active tuberculosis of the internal organs. Small, often grouped, sometimes merging nodules are formed. Localization - chest, back.

Diagnostics. In addition to clinical manifestations and medical history, a histological examination of the affected skin, a bacterioscopic method, detection of foci of tuberculosis in internal organs, and serological tests (tuberculin tests) help establish a final diagnosis.

In some cases, it is possible to obtain a culture of the pathogen and positive results of infection of guinea pigs, which is an absolute confirmation of the diagnosis.

Treatment. Treatment of patients with skin tuberculosis begins in a specialized hospital after a thorough examination. After the diagnosis is established, combination treatment with anti-tuberculosis drugs (isoniazid with rifampicin, ftivazide with rifampicin) is prescribed. Duration of treatment is 9-12 months. Subsequently, two two-month courses of therapy are carried out annually for 5 years. An important component of complex therapy is nutritional therapy. Additionally, vitamins, iron supplements, hepato- and angioprotectors, and drugs that improve blood microcirculation are prescribed.

In senile patients with a variety of comorbidities, poor tolerance to anti-tuberculosis drugs, a good result can be achieved with long-term monotherapy with one of the derivatives of GINK - (for example, ftivazid) in medium doses. With a formed cosmetic defect, a corrective operation is indicated.

Author: Sitkalieva E.V.

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