Singh and Gupta: Clinical pattern of cutaneous tuberculosis in paediatric age group


Introduction

The World Health 0rganization 2020 report estimates that there are about 9.96 million new cases of tuberculosis (TB) each year and the deaths due to TB is estimated to be 1.4 million each year.1 It is an ancient disease and for more than 4,000 years has affected mankind. In developing countries it is one of the leading cause of morbidity and mortality, about 7% of all deaths are attributed to TB.2 A group of closely related bacterial species termed Mycobacterium tuberculosis complex causes TB and the principal cause of human tuberculosis is Mycobacterium tuberculosis. Other members of this complex are M. bovis, M. microti and M. africanum.3

Among the extra-pulmonary tuberculosis which is about 8.4-13.7% of all tuberculosis cases cutaneous tuberculosis is relatively uncommon and comprises of 1-1.5%. The prevalence of cutaneous TB in Indian children varies from 18 to 54%.4 Cutaneous TB manifestations are varied and typical dermatologic lesions are rarely seen. Cutaneous tuberculosis can present with unusual histopathological features and the bacteria is seldom identified by stain or culture causing difficulty in diagnosis. So cases are diagnosed based on strong clinical suspicion, family history of pulmonary/extrapulmonary TB, a positive Mantoux test and typical histopathological features. 5 The current study was aimed to describe various clinical pattern of cutaneous tuberculosis in children of paediatric age group attending a tertiary health centre.

Materials and Methods

Study design

It was a cross sectional observational study.

Setting

The study was carried out in the Department of Dermatology at Silchar Medical College and Hospital, Assam.

Inclusion criteria

  1. All children 1year to 13 years (male and female with cutaneous tuberculosis

  2. Diagnosed at our hospital

Exclusion criteria

  1. Participants whose parents are not willing to give consent for the study

  2. Patient with MDR-TB and XDR-TB

  3. Children less than 1year

  4. Children with HIV infection

Sample size

Total 11 diagnosed cases of cutaneous tuberculosis are included in study attending Silchar Medical and Hospital during study period.

Study period

1st August 2019 to 31st July 2020 (one year study duration)

Study Procedure

Cutaneous TB patients of age 1year to up to 13 year, satisfying the inclusion and exclusion criteria were included in the study. Their parents were informed about the purpose and nature of study and after obtaining written informed consent from them, demographic data, a detailed clinical history, family history of contact with TB disease, and physical examination for each child was recorded in a standardized format. Complete blood count, Mantoux test, Chest X-ray, histopathological examination and Ultrasound whole abdomen were done for all the cases. In Mantoux test induration of more than 10 mm was taken as suggestive of infection with Mycobacterium tuberculosis in non-vaccinated patients and 15 mm and above was taken in vaccinated child. All diagnosed patient of Cutaneous TB were put on directly observed treatment short course (DOTS) of anti-tuberculosis treatment under RNTCP (Revised National Tuberculosis Control Program).

Results

In the current study, 11 children with cutaneous tuberculosis were analysed to explore the clinical pattern of cutaneous TB. Out of them maximum 45.45% patients were within 11-13 years age followed by 6-10 years 36.35% and least 1-5 years 18.18%. The mean age of the patients was 9.63 years. The male is to female ratio was found to be 4.5:1. Commonest type of Cutaneous TB in the study population was scrofuloderma (54.55%), followed by lupus vulgaris (36.36%), and tuberculosis verrucosa cutis (9.09%). Lower limb involvement was commonest followed by involvement of neck.

Table 1

Cutaneous TB; Types and sites of presentation

Cutaneous TB type

Site

Number of cases

Total cases

Scrofuloderma

Neck

3

6

Axillae

3

Lupus Vulgaris

Lower Limb

3

4

Upper Limb

1

TBVC

Lower Limb

1

1

Figure 1

Scrofuloderma in the neck

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Figure 2

Scrofuloderma in the axillary region.

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Figure 3

Lupus vulgaris; nodulo-plaque type on the upper limb

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Figure 4

Lupus vulgaris; plaque type on lower limb

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Figure 5

Tuberculosis verrucosa cutis (TBVC) on the lower limb

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Majority of the patient presented with single lesion (72.73%) and the rest (27.27%) had involvement of multiple sites. All of the patient were from poor social strata. Lymph node involvement was seen in all 6 cases of scrofuloderma (54.55%) cases. Histopathology was consistent with cutaneous tuberculosis in all of the cases. Mantoux test was positive in 9 of the cases (81.82%). BCG vaccination was done in 8(72.72%) of the cases. 2 cases had positive family history of TB. None of the cases had systemic involvement of other organs.

Figure 6
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Figure 7

Histopathology ofScrofuloderma having granuloma with epitheloid cells

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Figure 8

Histopathology of Lupus Vulgaris showing epithelioid granulomas in the upper dermis with lymphocytes and Langhans giant cells

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Figure 9

Histopathology of TBVC showing hypertrophic changes such as pseudoepitheliomatous hyperplasia, tuberculoid granulomas with caseous necrosis in the mid‑dermis, and the presence of acute infiltrate in the upper dermis.

https://s3-us-west-2.amazonaws.com/typeset-prod-media-server/fab754c9-db7a-418c-8a1d-298d8150d34fimage9.png

Discussion

In this study the total number of patients included were 11.The male to female ratio was found to be 4.5:1 and the preponderance of infection in male is in accordance to study done by Muley P et al where the M:F ratio was 1.53:1. This could be because of the fact that male child are more ambulatory and in a developing country like India more attention paid to male child could also be the reason.6

Most of the cases belong to the age group 11 to 13 years (45.45%) which was also seen in study done by Sultana A et al where 46.7% patient were in age group 11-15 years.7 The most common cutaneous TB was scrofuloderma (54.55%), followed by lupus vulgaris (36.36%), and tuberculosis verrucosa cutis (9.09%). Scrofuloderma is the direct extension from an underlying tubercular focus, most commonly tubercular lymphadenitis or skeletal tuberculosis into the skin. They clinically presents as ulcerated lesions in the neck with discharging ‘cheesy’ material Scrofuloderma is found to be the most common and lupus vulgaris the second most common cutaneous TB in children in studies done by Singal A et al, Vashisth P et al and Sethuraman G.8, 9, 10

Study showed that all the patients 100% were from low socio-economic condition.11 A positive family history of tuberculosis was associated in 2 of the cases (18.18%) in our study as similar to study done by Panda M et al where it was13.64%.12 The most common site of cutaneous tuberculosis was lower limb in our study this was also seen in study done by Panda M et al.12

Conclusion

Cutaneous TB has varied clinical presentations and generally occurs due to direct inoculation into skin or sometimes due to underlying focus of infection. Therefore, high clinical suspicion is required to diagnose the case. Since children especially male child are more ambulatory they have greater incidence of cutaneous TB compared to adults and also the immune status of children is not well-developed. A rising incidence of cutaneous tuberculosis is a marker of active infection in the community. Early diagnosis based on strong clinical suspicion will help initiate early diagnosis and successful treatment. Thus to accomplish this the present study was undertaken.

Source of Funding

No financial support was received for the work within this manuscript.

Conflict of Interest

The authors declare they have no conflict of interest.

References

1 

World Health Organization. Global Tuberculosis Report 2020. Geneva, Switzerland: World Health Organization2020

2 

K Zaman Tuberculosis: A Global Health ProblemJ Health, Popul Nutr2010282111310.3329/jhpn.v28i2.4879

3 

G K Sandhu Tuberculosis: Current Situation, Challenges and Overview of its Control Programs in IndiaJ Global Infect Dis20113214350

4 

P K Saha K S Prakash Clinical profile of cutaneous tuberculosis in a tertiary care teaching hospital in Eastern BiharInt J Contemp Med Res20207413

5 

T Kaur A Thakur K Pandey S K Malhotra K P Singh Cutaneous TB profile in North West Punjab, India: a retrospective data analysisOur Dermatol Online2013444586110.7241/ourd.20134.117

6 

P Muley T Odedara R Memon A Sethi D Gandhi Clinical Profile of Childhood Tuberculosis in a Tertiary Care Rural HospitalIAIM20174610924

7 

A Sultana MSI Bhuiyan A Haque A Bashar MT Islam MM Rahman Pattern of cutaneous tuberculosis among children and adolescentBangladesh Med Res Counc Bull201338394710.3329/bmrcb.v38i3.14335

8 

A Singal S Sonthalia Cutaneous tuberculosis in children: The Indian perspectiveIndian J Dermatol, Venereol, Leprol201076549450310.4103/0378-6323.69060

9 

P Vashisht B Sahoo N Khurana BSN Reddy Cutaneous tuberculosis in children and adolescents: a clinicohistological studyJ Eur Acad Dermatol Venereol200721140710.1111/j.1468-3083.2006.01858.x

10 

G Sethuraman V Ramesh Cutaneous Tuberculosis in ChildrenPediatr Dermatol201330171610.1111/j.1525-1470.2012.01794.x

11 

B Kumar S Kaur Patternof Cutaneous Tuberculosis in North IndiaIndian J Dermatol201052203207

12 

M Panda N Patroa M Dashb S Mohapatroc M Jenad Clinical profile of childhood cutaneous tuberculosis in eastern India - A prospective studyPediatr Infect Dis201574926



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