Study on association of cutaneous tuberculosis with pulmonary tuberculosis.

Abstract

Tuberculosis continues to be a health problem in many countries. There may be simultaneous multiple organ involvement. Diagnosis of one organ disease may lead to missing off diagnosis of other organ involvement.
The present study was done to analyze the association of cutaneous tuberculosis with pulmonary tuberculosis.
Through purposive sampling a total of 23 patients of suspected cutaneous tuberculosis were primarily enrolled in this cross sectional study. History was taken and examinations were done to find out types of cutaneous lesions and to explore a pulmonary involvement. Investigations including CBC with ESR, Mantoux test and skin biopsy were done for each and every patient. Those who had cutaneous tuberculosis on histopathology chest x-ray were done to detect pulmonary lesions. After investigations 2 patients were excluded due to absence of tubercular infection. Finally 21 patients were included in this study. Data were collected in a predesigned structured questionnaire.
Out of 21 patients 16 (76.19%) were male and 5 (23.81%) were female with a male to female ratio of 3.2:1. Age range varies from 5-70 years with a mean of 29.76 +/- 1 8.2 years. MT was positive in 76.20% of patients. CXR showed 23.81% of the patients with cutaneous TB had simultaneous pulmonary involvement. The association is statistically significant (p < 0.05).
Patients with cutaneous tuberculosis may have pulmonary involvement in a statistically significant number. In any patient with cutaneous TB, meticulous systemic examinations and relevant investigations have to be done to explore pulmonary involvement.

Full text

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Bangladesh Med Res Counc Bull 2010; 36: 57-60

Study on association of cutaneous tuberculosis with
pulmonary tuberculosis


TAK Mahmud1, HK Paul2, ASM Zakaria2, MA Rahman3, MAJ Chowdhury1

1Dept of Medicine, 2Dept of Dermatology & Venereology; 3Dept of Respiratory Medicine,
Bangabandhu Sheikh Mujib Medical University, Dhaka


Abstract

Background: Tuberculosis continues to be a health problem in many countries. There may be
simultaneous multiple organ involvement. Diagnosis of one organ disease may lead to missing off
diagnosis of other organ involvement. Objectives: The present study was done to analyze the
association of cutaneous tuberculosis with pulmonary tuberculosis. Material and methods: Through
purposive sampling a total of 23 patients of suspected cutaneous tuberculosis were primarily enrolled
in this cross sectional study. History was taken and examinations were done to find out types of
cutaneous lesions and to explore a pulmonary involvement. Investigations including CBC with ESR,
Mantoux test and Skin biopsy were done for each and every patient. Those who had cutaneous
tuberculosis on histopathology chest x-ray were done to detect pulmonary lesions. After investigations
2 patients were excluded due to absence of tubercular infection. Finally 21 patients were included in
this study. Data were collected in a predesigned structured questionnaire. Results: Out of 21 patients
16 (76.19%) were male and 5(23.81%) were female with a male to female ratio of 3.2:1. Age range
varies from 5-70 years with a mean of 29.76±18.2 years. MT was positive in 76.20% of patients. CXR
showed 23.81% of the patients with cutaneous TB had simultaneous pulmonary involvement. The
association is statistically significant (p<0.05). Conclusions: Patients with Cutaneous tuberculosis may
have pulmonary involvement in a statistically significant number. In any patient with cutaneous TB,
meticulous systemic examinations and relevant investigations have to be done to explore pulmonary
involvement.



Introduction

Tuberculosis (TB) is one of the world’s most
widespread and deadly illnesses. M. tuberculosis,
the organism that causes tuberculous infection and
disease (TB), infects an estimated 20-43% of the
world’s population. Worldwide 3 million people
die of the disease in each year. It is estimated that
15 million people are infected with M. tuberculosis
in United states1. Humans are the only known
reservoir for Mycobacterium tuberculosis. TB is
transmitted by airborne droplet nuclei, which may
contain fewer than 10 bacilli. Exposure to TB
occurs by sharing common airspace with a patient
who is infectious2. The portal of entry is often the
lung but may also be the tonsils or intestine or
rarely the skin or mucous membrane3. When
inhaled, droplet nuclei are deposited within the
terminal airspaces of the lung. Upon encountering
the bacilli, macrophages ingest and transport the
bacteria via the lymphatics to regional lymph nodes
and then via the blood stream2,3.
The bacilli have 4 potential fates: (1) they may be
killed by the immune system, (2) they may multiply
and cause primary TB, (3) they may become
dormant and remain asymptomatic, or (4) they may
proliferate after a latent period (reactivation
disease). Reactivation disease may occur following
either (2) or (3) above2.

Tuberculosis occurs disproportionately among
disadvantaged population
malnourished, homeless and those living in over
crowed and substandard housing. There is an
increased occurrence of tuberculosis among HIV-
positive individuals1. Despite prevention programs,
tuberculosis is still endemic in many developing
countries4.

such as the
Over 300,000 people develop the disease each year
of whom 70,000 die5. Extra-pulmonary tuberculosis
constitutes about 10 percent of all cases of
tuberculosis. Cutaneous tuberculosis represents
1.5% of all cases of extra pulmonary tuberculosis4,

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2.96% with parenchymal tuberculosis and 3.51%
of all cases of tuberculosis6. The development of
resistance to antitubercular drugs and the increase
in diseases and conditions associated with
immunodeficiency such
chemotherapy have caused tuberculosis to increase
recently6.

0.5% of the population have been found to have
smear positive pulmonary tuberculosis who if left
untreated infect on an average of 10-15 persons
every year7.

Though cutaneous tuberculosis is one of the less
common extra-pulmonary tuberculosis, resurgence
of skin tuberculosis especially with drug-resistant
strains has been well documented in recent years8.
Bangladesh is listed among the countries where the
prevalence of tuberculosis is the highest.2 Patient
with cutaneous TB simultaneously may have
pulmonary involvement. So to decrease the
transmission of tuberculous infection and to treat
tuberculosis patient adequately, any patient with
cutaneous TB should properly be investigated to
find out pulmonary involvement. Patients with only
cutaneous involvement require treatment with 3
drugs regimen but pulmonary
necessitate 4 drugs therapy. In case of pulmonary
involvement therapy with 3 drugs regimen is
mostly inadequate and may increases the chance of
emergence of drug resistance tuberculosis. Hence,
the present study was done to analyze the
association of cutaneous
pulmonary tuberculosis (PTB).


Materials and Methods

This cross sectional study was conducted in the
dept. of Medicine and dept. of Dermatology &
Venereology, Bangabandhu Sheikh Mujib Medical
University, Dhaka, Bangladesh from January 2008
to August 2008. Purposive sampling was done. All
the patients attending the out patient departments
on two consecutive days in a week were examined
with a view to find out patients with suspected
cutaneous tuberculosis. Among the patients 23
were suspected as having cutaneous tuberculosis
and were primarily enrolled after taking due
consent. A detailed history was taken. Age, sex,
occupation, socioeconomic status, duration of the
disease, personal past and family history of
tuberculosis, history of BCG vaccination, close
contact with tuberculosis and history suggestive of
pulmonary involvement were recorded. Meticulous
cutaneous examinations to find out types of
cutaneous lesions and systemic examinations to
as AIDS and
involvement
tuberculosis with

explore a pulmonary involvement were done.
Investigations including CBC with ESR, Mantoux
test and skin biopsy were done to each and every
patient. MT ≥10 mm was considered s positive.
Biopsy specimens were examined after staining
with hematoxylin and eosin. All of those patients
who had cutaneous TB on histopathology
underwent chest x-ray P/A view to detect
pulmonary lesions. Sputum-smear examinations for
acid-fast bacilli (AFB) on 3-consecutive days were
done in selected cases. After investigations 2
patients were excluded due to absence of tubercular
infection. One of them had lichenoid drug reaction
and the other had chronic non-specific dermatitis.
Finally 21 patients were included in this study.
Data were collected in a predesigned structured
questionnaire.

All the data were checked and edited after
collection and were analyzed. Z-test was done as a
test of significance. P-value < 0.05 was considered
as statistically significant.


Results


Out of 21 patients 16 (76.19%) were male and
5(23.81%) were female with a male to female ratio
of 3.2:1. Age varies from 5-70 years with a mean of
29.76±18.2 years. Most of the patients (61.90%)
were in the age group of 21-50 years. 5 (23.80%)
patients were student followed by house-wife 4
(19.04%), service holder 4 (19.04%), cultivator 2
(9.52%), Businessman 4(19.05%) other professions
constitute 2 (9.52%) of the patients. 12 (57.15%)
patients were poor, 5 (23.81%) lower middle class,
3 (14.28%) upper middle class and 1 (4.76%)
patient was rich (Table-I).

Fever, weight loss, loss of appetite and night sweats
were there in 8(38.09%), 6 (28.57%), 4 (19.04%)
and 3 (14.28%) of cases respectively. Chest pain
and cough were in 1 (4.76%) and 3 (14.28%) cases.
None had shortness of breath (SOB) or
haemoptysis. Past history of TB and Family history
of TB were present in 1 (4.76%) and 3 (14.28%)
patients. History of vaccination was present in 13
(61.90%) cases (Table-II).

CBC was normal in 20 (95.23%), leucocytosis in 1
(4.76%); ESR raised (>10-90mm) in 18 (85.71%),
normal in 3 (14.29%); MT raised (≥10-27mm) in
16 (76.20%) and normal in 5 (23.80%) of patients.
Mycobacterial culture and sensitivity (MB C/S)
from tissue done in 2 (5.52%) patients and were
negative. Among 4 (19.05%) patients with PTB,
Sputum for AFB was positive in 1 patient (Table-
III).

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CXR showed active PTB in 4 (19.05%), healed
PTB in 1 (4.76%) and pleural effusion in 1 (4.76%)
patient (Fig-1).

Table-I: Socio-demographic variables

Variables
Age (Range 5-70 years)
≤20
21-30
31-40
41-50
51-60
61-70
Sex (M:F=3.2:1)
Male
Female
Occupation
Student
House-wife
Service
Cultivator
Business
Others
Socio-economic status
Poor
Lower middle class
Upper middle class
Rich


Table-II: Clinical variables

Variables
Present
General symptoms
Fever
Wt. loss
Loss of appetite
Night sweets
Respiratory symptoms
SOB
Chest pain
Cough
Haemoptysis

Past history of TB
Family history of TB

H/O BCG vaccination 13 (61.90%)


Table-III: Laboratory variables

Investigation
CBC
Count normal (3-11×109/L)
Leukocytosis
ESR (Range 10-90mm)
Normal (≤10mm)
Raised (>10mm)
MT(Range 02-27mm)
<10
≥10
Other tests
MB C/S done in 2 patients
Sputum for AFB done in 1 pt
No (Percentage)

5 (23.80%)
7 (33.33%)
4 (19.05%)
2 (9.52%)
0 (00%)
3 (14.28%)

16 (76.20%)
5 (23.80%)

5 (23.80%)
4 (19.05%)
4 (19.05%)
2 (9.52%)
4 (19.05%)
2 (9.52%)

12 (57.15%)
5 (23.81%)
3 (14.28%)
1 (4.76%)
No (Percentage)
Absent

8 (38.09%)
6 (28.57%)
4 (19.04%)
3 (14.28)

0 (00%)
1 (4.76%)
3 (14.28%)
0 (00%)

1 (4.76%)
3 (14.28%)


13 (61.91%)
15 (71.43%)
17 (80.96%)
18 (85.72%)

21 (100%)
20 (95.24%)
18 (85.72%)
21 (100%)

20 (95.24%)
18 (85.72%)

8 (38.09%)
Result
(number& percentage)
20 (95.24%)
1 (4.76%)

3 (14.29%)
18 (85.71%)

5 (23.80%)
16 (76.20%)

Negative
Positive
Figure-1: Bar diagram showing chest X-ray findings.



Discussions

Virtually all of the organ systems may be infected
with tuberculosis. Approximately 80-85% of the
tuberculosis are limited to the lungs, only 15-20%
involve extra-pulmonary or both pulmonary and
extra-pulmonary sites. The extra-pulmonary sites
commonly involved
genitourinary, CNS, abdomen, skeletal, pleura,
upper airways and pericardial. Less common extra-
pulmonary sites are- skin, uveal tract, ears, adrenal
glands, mammary glands9.

In this study majority of the cases (61.90%) were in
the age group of 21-50 years. These are the patients
who are in their active years of life. The World
Health Organization had reported highest incidence
of tuberculosis in this age group10 Study done by
Rahim AM et al revealed almost similar results11.
Male to female ratio was 3.2:1 in our study. Rahim
MA et al11 and Choudhury AM et al12 reported
male to female ratio of 2.1:1.2 and 1.86:1
respectively, which were inconsistent to that of the
present study.

Tuberculosis occurs disproportionately among the
disadvantaged population
malnourished, homeless and those living in over
crowed and substandard housing1. Our observation
was also similar. In the present study Poor and
lower middle class constitute 81% of cases,
followed by upper middle class 14.28% and only
4.76% were rich.

Only 4.76% cases had past history of TB and
14.28% had family history of TB. Weir and
Thornton13 in their series reported 31.57% of the
patients had good history of prior exposure.

61.90% patients were vaccinated with BCG and
38.09% were not vaccinated. This reflects that
BCG vaccination could
development of cutaneous tuberculosis in all cases.
ESR was increased and MT was positive in 85.71%
and 76.20% cases. Increased ESR is a common
accompaniment in all types of tuberculosis.
are lymph nodes,
such as the
not prevent the

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Choudhury AM et al12 reported MT positive in
80% of cases with skin TB.

We observed active PTB in 19.05%, healed PTB in
1(4.76%) and pleural effusion in 1(4.76%) patients.
Here it is evident that 23.81% patients with
cutaneous TB had simultaneous pulmonary
involvement. The association is statistically
significant (p<0.05). In one patient there was
healed pulmonary lesions, he had history of anti
tubercular therapy earlier but later on developed
cutaneous TB. One patient with lupus vulgaris
received 4 drugs regimen for 6 months, clinically
lesions healed up. He developed lupus vulgaris
again 2 months after discontinuation of therapy.
These might be due
mycobacterium. In a series Pandhi D et al. detected
pulmonary involvement in 20.6% cases of
cutaneous TB in children8. This is quite similar to
our findings. But our findings are in sharp contrast
to the study by Kivanc-Altunay I et al.6 They
reported 61.5% patients with cutaneous TB also
had pulmonary involvement.

Conclusion: Patients
simultaneously may have pulmonary involvement
in a statistically significant number. As drug
therapy is different in cutaneous TB with or
without pulmonary involvement, to decrease the
transmission of tuberculous infection, to treat
tubercular patient adequately and to reduce the
chance of emergence
tuberculosis, any patient with cutaneous TB should
properly be investigated to find out pulmonary
involvement.

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