Cutaneous tuberculosis in Rio de Janeiro, Brazil: description of a series of 75 cases
巴西里约热内卢的皮肤结核病：75例病例的系列描述。
BACKGROUND:Brazil is one of the highest tuberculosis (TB) burden countries of the world. Cutaneous tuberculosis (CTB) is a rare form of extrapulmonary manifestation of tuberculosis. This study aimed to describe the clinico-evolutive, laboratory and therapeutic aspects of CTB cases among patients from a cohort with TB in Rio de Janeiro, Brazil. 背景：巴西是世界上结核病负担最高的国家之一。皮肤结核（CTB）是结核病肺外表现的一种罕见形式。这项研究旨在描述巴西里约热内卢某结核病队列患者中CTB的临床演变，实验室和治疗方面的情况。 METHODS:Cases of diagnosed CTB with microbiologic confirmation or clinical response to anti-tuberculous treatment associated with positive smear or histopathological findings between the years 2000 and 2016 were selected. 方法：经微生物学确诊的CTB病例选取2000年至2016年间对结核性涂片阳性或组织病理学检查结果阳性的抗结核治疗的临床反应或临床反应。 RESULTS:Seventy-five patients with CTB were included, most were women (58.7%) with a median age of 42 years. CTB diagnosis was based on culture in only 42.7% of the cases. Scrofuloderma represented 50.7% of the cases, followed by erythema induratum of Bazin (EIB) (18.7%), tuberculous gumma (13.3%), lupus vulgaris (8%), TB verrucosa cutis (4%), orificial TB (2.7%) and associated forms (2.7%). Other TB presentations were pulmonary (22.7%), mammary (6.6%) and osteoarticular (4%). All patients who completed the treatment (97.3%) had their lesions healed. Only two patients (2.6%) needed to change the therapy due to adverse reactions. Fifty percent of EIB patients presented recurrence. 结果：纳入了75例CTB患者，大多数为女性（58.7 ％）的平均年龄为42岁。CTB诊断仅基于培养的病例占42.7％。阴囊皮肤病占病例的50.7％，其次是巴赞硬红斑（EIB）（18.7％），结核性胶瘤（13.3％），寻常型狼疮（8％），结核性疣状皮肤（4％），原发性结核（2.7％）及相关表现（2.7％）。其他结核病表现为肺部（22.7％），乳腺（6.6％）和骨关节（4％）。所有完成治疗的患者（97.3％）的病灶均已治愈。由于不良反应，只有两名患者（2.6％）需要改变治疗方法。 50％的EIB患者出现复发。 CONCLUSIONS:These data highlight the diversity of CTB presentations and the importance of the skin to assist in early identification and treatment of TB. More studies are necessary to improve the knowledge on EIB for a better approach towards these patients, mainly in cases of recurrence. 结论：这些数据强调了CTB表现的多样性以及皮肤在早期识别和治疗结核病中的重要性。有必要进行更多的研究以提高对EIB的了解，从而更好地针对这些患者，尤其是在复发病例中。
1.结核性初疮 即原发性结核综合征。发生于从未感染结核分枝杆菌的人群,儿童好发。主要见于面部和四肢,皮损多发生于受损皮肤。皮损于接种后2～4周出现,为一处无痛性、坚实的棕红色丘疹、结节,缓慢增大成斑块,最终破溃形成边界清楚的侵蚀性溃疡。皮损通常在一年或一年内自行愈合,遗留萎缩性瘢痕。常伴局部淋巴结肿大,受累淋巴结偶可破溃排脓,随后淋巴结或持续肿大或钙化。 2.疣状皮肤结核 为最常见的皮肤结核。发生于已致敏、对结核分枝杆菌有一定免疫力的个体。系直接接触病原菌所致,极大部分为成人。常见于暴露部位,以手背及手指背部最为多见,其次为足、臀、小腿等处。损害大多为单个,少数可为2～3个。初起为黄豆大小呈紫红色丘疹,质硬,丘疹逐渐扩大成斑块,表面呈疣状增生,角化粗糙,加压时常有波动感,可见脓液从裂隙中流出。疣状增生的外围呈暗紫色,再外围为平滑红晕区。病程极端慢性,数年后皮损可自愈,留下光滑柔软而表浅的瘢痕。结核菌素试验强阳性。 3.瘰疬性皮肤结核由结核病灶直接扩散而累及皮肤。常由淋巴结核、骨结核或关节结核蔓延而来。好发于颈部,其次为腋下、腹股沟及上胸等处。皮损初起为深在的皮下结节,可为红色或皮色,表面皮温正常,无显著压痛,被称为“冷脓肿”。结节逐渐增大、增多,继而破溃形成溃疡及瘘管,有干酪样物质和稀薄脓液排出,溃疡愈合后形成特征性索状瘢痕。病程缓慢,可多年不愈。结核菌素试验阳性。 4.腔口皮肤结核 发生于鼻、口、肛门、尿道和阴道等腔口处皮肤黏膜结核。通常有活动性内脏结核,特别是喉、肺、肠道和泌尿生殖道结核,杆菌由自然腔道蔓延至皮肤黏膜。皮损为针头大黄色丘疹,很快溃破形成溃疡,边缘呈潜行性,周围绕以红晕,疼痛显著。没有自愈倾向。可伴有局部淋巴结肿大。病程慢性。本病患者内脏结核大多严重,故常伴发热及中毒症状,预后不佳。结核菌素试验多变,通常阴性。 5.寻常狼疮 血行传播所致,也可继发于卡介苗接种、疣状皮肤结核和瘰疬性皮肤结核。患者对结核分枝杆菌有中度的免疫力。多见于青壮年。好侵犯颈部、面部、臀部及四肢,亦可累及黏膜。皮损最常发生于远离最初感染病灶的部位。基本损害为由一群针头至黄豆大小、半透明的丘疹、结节融合成的斑块,质地柔软,呈棕黄色,用玻片按压时呈“苹果酱”颜色,称之为苹果酱现象。斑块向周围扩展,中央趋向于缓慢吸收,遗下菲薄、光滑的萎缩性瘢痕,边缘有新的结节产生。瘢痕收缩可导致组织破坏,功能障碍。 常见累及黏膜为上呼吸道及口腔。损害为局限性、灰色、浸润性或颗粒状乳头瘤样结节、斑块,极易破溃形成溃疡。鼻腔狼疮患者常诉“长期感冒”,鼻中多痂,易出血,久之黏膜因浸润而肥厚,鼻腔受阻,导致呼吸困难,患者多用口呼吸。口腔黏膜病变最常见于牙龈,其次为硬软腭,再次为腭垂。 病程缓慢,大多数患者结核菌素试验强阳性。 6.急性粟粒性皮肤结核 少见。常见于婴幼儿、机体抵抗力下降者、艾滋病患者。由于大量结核分枝杆菌侵入血液后引起的菌血症表现。皮损泛发,为针头大小紫红色丘疹,上有水疱,水疱中央有脐凹,继之结痂,遗留边缘褐色的白色瘢痕。也可出现红斑、丘疹、脓疱、皮下结节和紫癜等“血管炎”损害,梗死性皮损可有疼痛。全身中毒症状严重。结核菌素试验阴性。 7.皮肤结核性脓肿或溃疡 血液播散所致。表现为坚实、无痛性红斑结节,然后结节软化、形成溃疡、窦道或瘘管。本病常见于营养不良、细胞免疫低下、疾病后的儿童。 8.丘疹坏死性结核疹 为最常见的结核疹。多见于儿童和青少年。皮损好发于四肢伸面,也可见于臀部。典型皮损为针头至绿豆大的坚实小结节,呈青红色或紫色,可变成脓疱,中央坏死、形成溃疡,但很快干涸结痂,留下萎缩性瘢痕。损害常成群分批发出,一般无自觉症状,偶有瘙痒。 9.瘰疬性苔藓 常发生在有淋巴结、骨或关节结核的儿童和青少年。损害毛囊周围淡红色或黄褐色的针头大小粟粒形丘疹,质坚实,上覆薄鳞屑。簇状分布于躯干,无任何症状。可持续多月后消失或无变化,不留痕迹,可复发。 10.硬红斑多见于中年女性。常伴有周围循环不良,如肢端发绀等。皮损先后或成批出现,惯发于小腿屈面、中下部位。多个、对称分布。为樱桃大或更大的红色、紫罗兰色皮下结节,位置较深。有酸痛、烧灼等症状,有压痛。结节可/或不破溃,破溃后形成溃疡,可自愈,遗留略萎缩性瘢痕,伴色素沉着。病程慢性,易复发。 实例病例 Figure 1 (a) Scrofuloderma associated with cervical lymph node tuberculosis. (b) Acidfast bacillus in lymph node fragment (Histopathology, Wade, 91000) Figure 2 (a) Gumma (red arrow) on the left forearm. (b) Ulcerated gumma on the right forearm in a male patient. (c) Gumma on the right arm in a female patient. (d)Histopathology of skin fragment with an ulcer area and diffuse dermal inflammation that was categorized as granulomatous with caseous necrosis (hematoxylin & eosin,940) Figure 3 (a) Scrofuloderma associated with breast tuberculosis at the beginning of the treatment. (b) At the end of the treatment Figure 4 (a) Orificial tuberculosis in the oral mucosa and lips at the beginning of the treatment. (b) At the end of the treatment Figure 5 (a) Lupus vulgaris plaque in the posterior thorax of a male patient with 25 years of evolution. (b) Ulcerated lupus vulgaris in the inguinal region of a female patient. (c) Histopathology of skin fragment with irregular acanthosis, superficial inflammatory infiltrate categorized as granulomatous, and deeper fibrosis (hematoxylin & eosin, 940) Figure 6 (a) Verrucous tuberculosis. (b)Associated with gumma on the left limb in the same male patient. (c) Histopathology of skin fragment presenting hyperkeratosis,acanthosis, papillomatosis, chronic dermal inflammatory infiltrate categorized as granulomatous, and fibrosis (hematoxylin & eosin, 940) Figure 7 (a) Patient with erythema induratum presenting nodules and ulcers on the calves. (b, c) Histopathology of skin fragment with lobular panniculitis and necrotic area surrounded by palisade of epithelioid cells, forming a chronic granulomatous process (hematoxylin & eosin, 940 and 9100, respectively). (d) Vessel with lumen obstructed by thrombus (hematoxylin & eosin, 9100) 参考文献：Cutaneous tuberculosis in Rio de Janeiro, Brazil: description of a series of 75 cases.International Journal of Dermatology 2019.DOI：10.1111/ijd.14617