INT J TUBERC LUNG DIS 3(6):494–500 © 1999 IUATLD

Cutaneous : a twenty-year prospective study

B. Kumar, S. Muralidhar Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

SUMMARY

SETTING: A tertiary care hospital in northern India. the spectrum of cutaneous tuberculosis (22.1%), but OBJECTIVE: To study the patterns of clinical presenta- was seen more often in the presence of gumma and tion of cutaneous tuberculosis, to correlate them with . There were more unvaccinated individ- Mantoux reactivity and BCG vaccination status, and to uals in the group with disseminated disease (80.3%) suggest a clinical classification based on these factors. than in those with localised disease (65.5%). DESIGN: Analysis of the records of patients with cuta- CONCLUSIONS: was the most common neous tuberculosis who attended the hospital between clinical presentation, followed by scrofuloderma, tuber- 1975 and 1995. culids, tuberculosis verrucosa cutis and tuberculous RESULTS: A total of 0.1% of dermatology patients had gumma. Some patients presented more than one clinical cutaneous tuberculosis. Lupus vulgaris was the com- form of the disease. Classification of cutaneous tuber- monest form, seen in 154 (55%) of these patients, fol- culosis needs to be modified to include smear-positive lowed by scrofuloderma in 75 (26.8%), tuberculosis ver- and smear-negative scrofuloderma apart from the inclu- rucosa cutis in 17 (6%), tuberculous gumma(s) in 15 sion of disseminated disease. The presence of regional (5.4%) and tuberculids in 19 (6.8%). No correlation serves as a clinical indicator of dis- was found between Mantoux reactivity and the extent of seminated disease. Patients with disseminated disease disease (localised disease 63.6%, disseminated disease were less likely to have been BCG-vaccinated than those 67.9%). The presence of regional lymphadenopathy with localised disease. was an indication of dissemination of the disease (loca- KEY WORDS: cutaneous tuberculosis; disseminated tuber- lised disease 34.7%, disseminated disease 71.7%). Dis- culosis; Mantoux reactivity; BCG vaccination; treatment semination of the disease was observed in the whole of protocol

TUBERCULOSIS, which is known to have existed We present a clinical analysis of patients with since 3000 BC, continues to pose a significant public cutaneous tuberculosis seen during the last twenty health problem even today, and kills around 3 million years. An attempt has also been made to extrapolate people annually.1 The emergence of the human immuno- its clinical spectrum to reach a more practical clinical deficiency virus (HIV) has led to a 20% increase in the classification. incidence of extra-pulmonary tuberculosis in the US.2 As cutaneous tuberculosis constitutes 1.5% of all MATERIALS AND METHODS cases of extra-pulmonary tuberculosis,3 it is natural that its incidence will increase proportionately. Clas- Patients with cutaneous tuberculosis seen in the Der- sification of a disease such as tuberculosis should matology Department of the Postgraduate Institute of reflect its immunopathogenesis, and should be able to Medical Education and Research (PGIMER), Chan- convey information on prognosis and aid the clinician digarh, India, between 1975 and 1995 were included in selecting an appropriate drug schedule. in the study. All the patients were also examined by Since 1896, when Darier4 classified cutaneous the senior author. The relevant details were recorded tuberculosis into true tuberculosis and tuberculids, on a predesigned proforma. Apart from a complete several attempts have been made by different workers physical examination, the haematological, hepatic to classify the disease based on the mode of spread of and renal functional profiles were analysed, in addi- the infection3 or on the rate of healing.5 Although tion to screening for evidence of concomitant tuber- each has its own merit, they do not fulfil all the needs culosis elsewhere in the body. Other investigations of the clinician. included chest X-ray, sputum examination, deposit of

Correspondence to: Professor B Kumar, Head, Department of Dermatology, Venereology and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh 160-012, India. Tel: (91) 172 747 610 24. Fax: (91) 172 744 401/745 078. e-mail: [email protected] Article submitted 17 November 1997. Final version accepted 6 January 1999. Cutaneous tuberculosis: a 20-year prospective study 495

24 hour urine, and fine needle aspirate (FNAC) of Of the 19 patients who had tuberculids, respec- lymph nodes for acid-fast bacilli (AFB) by smear tively six, 10 and three had papulo-necrotic tubercu- and culture. Wherever indicated, barium meal follow- lids, erythema nodosum and . A through or enema, endometrial curettage or cerebrospi- small proportion of patients had more than one form nal fluid (CSF) examination were also undertaken. of the disease: lupus vulgaris and scrofuloderma were Biopsy was taken from the most prominent lesion seen in eight patients, lupus vulgaris and tuberculosis and stained with haematoxylin and eosin and for verrucosa cutis in two, and scrofuloderma and tuber- demonstration of AFB. Mantoux testing was done in culous gumma in one patient. all patients using 1 TU (0.02 mg) of PPD and read at There were 157 (56.1%) male and 123 (43.9%) 72 hours. Induration 10 mm was taken as sugges- female patients, with a male:female ratio of 1.27:1. tive of infection with tuberculosis. Cor- Tuberculous gumma(s) were seen more often in females, relation between various parameters such as lympha- but all other types were more common in male denopathy and the dissemination of disease was done patients. TVC and tuberculids were equally distrib- by the 2 test. uted over the ages 20–60. Miliary cutaneous tuber- Patients were classified according to the morphol- culosis was seen in two women aged 50 and 17 years, ogy of lesions described in the standard texts.3 Wher- respectively. The mean age of male patients with ever any systemic organ (lungs, liver, spleen, central lupus vulgaris was 31.7 15.8 years, scrofuloderma nervous system [CNS], bone, etc.) was involved, the 26.5 15.02 years, tuberculous verrucosa cutis 27.8 disease was classified as disseminated. 19.2 years, tuberculous gumma 18.8 2.9 and tuber- culids 33.4 18.6 years. The corresponding mean ages for female patients were 31.2 20.63, 23.4 RESULTS 13.7, 31.5 23.3, 37.2 18.29 and 36.1 13.2, Of the 267 420 patients who attended the Dermatol- respectively. Most of the patients with scrofuloderma ogy Out-Patient Department (OPD) between 1975 and (98.6%), tuberculous gumma (92.8%) and tubercu- 1995, 280 had cutaneous tuberculosis, giving a preva- lids (72.2%) had sought medical attention within 5 lence rate of 0.1% among dermatology patients. years of onset. However, nearly one third of the With the exception of tuberculous , all patients with lupus vulgaris (33.6%) and TVC forms of cutaneous tuberculosis were seen. Lupus (28.6%) had had the disease for more than 5 years vulgaris was the commonest form, seen in 154 patients before presenting for treatment. (55%), followed by scrofuloderma (SFD) in 75 In the investigation the erythrocyte sedimentation (26.8%), tuberculosis verrucosa cutis (TVC) in 17 rate (ESR) was elevated (30 mm in the first hour by (6.%), tuberculous gumma(s) in 15 (5.4%) and tuber- the Westergren method) in 61 (21.8%) patients, and culids in 19 (6.8%) (Table 1). 14 (5%) patients were anaemic (HB 10 gms%). Four patients developed lupus vulgaris following The Mantoux test was positive (10 mm) in 170 bacille Calmette Guérin (BCG) vaccination, two pa- patients (66.7%) and negative in 85 (33.3%) for tients with scrofuloderma had dacrocystitis and one whom information was available. There was no sig- had dactylitis. Two laboratory workers handling tu- nificant difference in the incidence of Mantoux reac- bercle bacilli developed TVC on the palms after acci- tivity between those with localised or disseminated dental inoculation. Of the 15 patients with tubercu- disease (63.6% and 67.9%, respectively, Table 2). lous gumma, two had and one Among the 272 patients for whom there was clin- orificial tuberculosis. Apart from the 15 patients with ical information on BCG vaccination status, 86 tuberculous gumma, 47 other patients had systemic patients had been BCG vaccinated and the remaining involvement; these 62 patients were classified as hav- 186 had not (Table 3). There were relatively more ing disseminated tuberculosis. unvaccinated patients with disseminated tuberculosis

Table 1 Age distribution of patients with cutaneous tuberculosis

Tuberculosis Age group Lupus verrucosa Tuberculous (years) vulgaris Scrofuloderma cutis gumma(s) Tuberculids 10 13 24 0 0 0 11–20 36 20 6 7 3 21–30 44 16 2 4 6 31–40 23 5 4 1 3 41–50 19 7 4 1 4 51–60 10 2 1 0 0 60 9 1 — 2 3 Total 154 75 17 15 19 (%) (55) (26.8) (6) (5.4) (6.8) 496 The International Journal of Tuberculosis and Lung Disease

Table 2 Mantoux reactivity

Tuberculosis Lupus verrocosa Tuberculous Disease spectrum vulgaris Scrofuloderma cutis gumma Tuberculids Total Localised disease Positive 78 30 11 — 15 134 Negative 48 20 0 — 0 68 Disseminated disease Positive 14 15 1 6 0 36 Negative 6 7 0 4 0 17

Positive 10 mm; Negative 10 mm.

(80.3%) compared to those with localised disease has hovered at 0.1–0.5% over the last few decades.6,7 (65.6%, P 0.05, Table 3). Although the prevalence of cutaneous tuberculosis has Histopathology reports were available from the remained mostly constant, the recent upsurge in prev- records of 224 patients: 119 with lupus vulgaris, 67 alence of HIV infection would lead one to expect an with scrofuloderma, 17 with TVC, 12 with tubercu- increase in its incidence akin to that seen in the US, lous gumma and nine with tuberculids. Of these, 92 where an increase of 20% in the incidence of extra- patients with lupus vulgaris, 42 with scrofuloderma, pulmonary tuberculosis has been reported.2 15 with TVC, nine with tuberculous gumma and seven Lupus vulgaris is the commonest form of cutane- with tuberculids had histopathological findings consis- ous tuberculosis seen in most countries, except in tent with tuberculosis. In the remaining patients the Mexico where scrofuloderma is commonly encoun- findings were non-specific, and were in the form of tered.8 Scrofuloderma was reported to be the common- chronic inflammatory infiltrate. In only five patients est form in only one local study, from Delhi, India.9 (1/27 with LV, 3/25 with SFD and 1/3 with tubercu- Tuberculids have recently emerged as the com- lous gumma) could AFB be demonstrated in the his- monest form of cutaneous tuberculosis seen in Hong tological section. For four sections agreement about Kong.10 Cutaneous tuberculosis is more commonly the presence of AFB was not unanimous. seen in young adults, because of their propensity to Of the 620 sputum smears examined, AFB were sustain injuries at work and the inoculation of tuber- seen in only four, of which three were positive on cul- cle bacilli.6 This is reflected in the frequent observa- ture. AFB were found in two of the 270 deposits of tion of cutaneous tuberculosis, especially lupus vul- urine; only one yielded a positive culture. In the 18/ garis and TVC, occurring in the extremities of young 330 FNAC smears positive for AFB, positive cultures adults.7 Scrofuloderma is more frequent in children were obtained in eight. Systemic organ involvement in India, whereas in Europe, middle-aged or elderly was seen in 62 patients (22.1%), and various organs in- persons are affected more often.11,12 This may be due cluding lungs (45), bones (15), abdominal organs to differences in the source of infection. Consump- (13), CNS (5) and heart (1) were affected (Table 4). tion of unpasteurized milk is a common phenome- Regional lymphadenopathy was more common in pa- non in India. This leads to infection of cervical lymph tients with disseminated tuberculosis (71%) than in nodes by M. bovis via the tonsils, and subsequent those with localised disease (34.7%, P 0.05, Table development of scrofuloderma, whereas in Europe- 5). A family history of tuberculosis was available in ans and Indian adults it usually results from endoge- only nine (3.2%) patients. nous reactivation. As scrofuloderma is highly visible, patients sought treatment earlier compared to those with lupus vul- DISCUSSION garis or TVC. In Hong Kong, nearly 40% of patients The prevalence of cutaneous tuberculosis among with TVC developed the disease before the age of 10 patients attending various dermatology OPDs in India years,13 whereas in the present study none of the

Table 3 BCG vaccination status in patients and controls

Tuberculosis Lupus vulgaris Scrofuloderma verrucosa cutis Tuberculous Vaccinal status Localised Dissem. Localised Dissem. Localised Dissem.gumma Tuberculids Total BCG-vaccinated 41 4 22 4 3 1 3 8 86 Non BCG vaccinated 84 18 31 18 11 1 12 11 186

BCG bacille Calmette Guérin; Dissem Disseminated. Cutaneous tuberculosis: a 20-year prospective study 497

Table 4 Systemic organ involvement in various types of cutaneous tuberculosis

Tuberculosis Lupus verrucosa Tuberculous vulgaris Scrofuloderma cutis gumma Total Orificial (genital) 0 0 0 1 1 Lungs 19 16 2 8 45 Abdominal* 2 3 0 8 13 Bone(s) 1 9 1 4 15 CNS 2 3 0 0 5 Heart 0 0 0 1 1 Total patients 22 23 2 15 62

The discrepancy in total is due to the involvement of more than one organ in some patients. * Liver, spleen, mesenteric lymph nodes, tuberculous ascites, etc. CNS central nervous system. patients developed the disease before 10 years of age. Classification of cutaneous tuberculosis Concurring with the popular perception that TVC is An ideal classification of the disease should enable the mainly acquired by inoculation, most of our patients clinician to make a rough assessment of the immuno- (80%) had lesions in the extremities. logical status and prognosis, and should aid in the Tuberculous gumma is considered to be common selection of the therapeutic regimen. Such a classifica- in malnourished children,3 whereas in this study it tion of cutaneous tuberculosis is, however, elusive. In was young adults and adolescents, but not children, 1896, Darier classified the disease into true tuberculo- who were found to be commonly affected. sis and tuberculids.4 Michelson and Laymon classi- fied cutaneous tuberculosis based on the rate of heal- Disseminated tuberculosis ing, and included sarcoidosis in their classification, Disseminated forms of tuberculosis have not been given which is clearly no longer valid.5 Beyt et al. classified due importance in the classification of cutaneous tuber- the disease into 1) inoculation tuberculosis, 2) sec- culosis.3 We defined disseminated disease as one in ondary tuberculosis, 3) haematogenous tuberculosis, which there is concurrent systemic organ involvement; and 4) eruptive tuberculosis,15 and Grange classified 22.1% of our patients (62/280) had dissemination of the disease in a fairly similar fashion.16 Tappeiner and the disease according to these criteria, irrespective of Wolf classified the disease into 1) exogenous infection the number of lesions. Ramesh et al.14 described wide- and 2) tuberculosis due to BCG vaccination and spread disease as multiple lesions involving more than tuberculids.17 In most of these observations an one site, and reported it in 18.8% of their patients. attempt was made to base the classification on a Although dissemination was seen in all the clinical mode of spread that is not always possible to identify, variants, it was more frequent in patients with scrof- and more often than not there is a combination of uloderma and tuberculous gumma, compared to more than one mode of spread, i.e., haematogenous those with lupus vulgaris or TVC. Similarly, involve- and lymphatic. ment of the abdominal organs and bone was common It is also known that the most common variants of in patients with scrofuloderma and gumma. the disease, i.e., lupus vulgaris and tuberculosis verru- Regional lymphadenopathy served as an indicator cosa cutis, can result both from inoculation and from of dissemination of disease. Patients with lymph node endogenous spread.3,11 It may be difficult to deter- enlargement were more likely to have disseminated mine the mode of endogenous spread, i.e., lymphatic disease than those without (Table 5). or haematogenous, in a given patient. It is also known Mantoux reactivity did not correlate with localised for a patient to have a combination of disease pat- or disseminated form of disease. Patients with a dissem- terns, e.g., lupus vulgaris and TVC, or lupus vulgaris inated form of the disease were less likely to have been and scrofuloderma. Beyt et al.15 have classified lupus vaccinated with BCG than those with localised disease. vulgaris under both inoculation and haematogenous

Table 5 Regional lymphadenopathy

Tuberculosis Lupus verrucosa Tuberculous vulgaris Scrofuloderma cutis gumma Total Disseminated disease Present 14 — 1 13 28 Absent 8 — 1 2 11 Localised disease Present 47 — 4 — 51 Absent 85 — 11 — 96 498 The International Journal of Tuberculosis and Lung Disease

Figure 1 Lupus vulgaris on the buttock, extending Figure 6 Tuberculous dactylitis. from orificial tuberculosis of the anal region.

Figure 2 Lupus vulgaris sporotrichoid pattern. Figure 7 Lichen scrofulosorum (trunk).

Figure 8 Papulo necrotic tuberculid (papules) Figure 3 Lupus vulgaris multiple lesions. glans penis.

Figure 4 Tuberculosis verrucosa cutis (palm). Figure 9 Papulo necrotic tuberculid (nodules and scars) glans penis.

Figure 5 Tuberculosis verrucosa cutis (sole). Figure 10 Scrofuloderma with facial nerve palsy. Cutaneous tuberculosis: a 20-year prospective study 499 tuberculosis; again, they have overlooked lymphatic tuberculosis in the classification of the disease is spread. Grange’s classification suffers from similar essential for therapeutic purposes. Regional lymph- flaws.16 adenopathy is more likely to be associated with dis- These classifications do not reflect the immunolog- semination of the disease. Mantoux reactivity does ical spectrum of the disease, nor do they take into not correlate with the extent of the disease. Patients in consideration systemic organ involvement, and so are India with disseminated disease are less likely to have not of much help in aiding the physician to select an been vaccinated with BCG. appropriate chemotherapy regimen. For practical management, it is only necessary to know the extent of the disease and whether or not the tubercle bacilli References can be detected from the lesion(s). 1 Rodrigues L C, Smith P G. Tuberculosis in developing coun- Therefore, based on our clinical experience and tries and methods for its control. Trans Roy Soc Trop Med Hyg keeping in mind the above objective, we propose the 1990; 84: 739–744. 2 Barnes P F, Bloch A B, Davidson P T, Snider D E. Tuberculosis following modifications in the classification of cutane- in patients with human immunodeficency virus infection. New ous tuberculosis. Engl J Med 1991; 324: 1644–1650. 3 Gawkrodger D J. Mycobacterial infections. In: Champion 1 Localised disease: primary tuberculous chancre, R H, Burton J L. Ebling F J G, eds. Text Book of Dermatology. tuberculosis verrucosa cutis, lupus vulgaris, smear- 6th ed. London; Blackwell Scientific Publications. 1998; Vol 2: negative scrofuloderma.* 1181–1214. 4 Satyanaraydana B V. Tuberculoderma—a brief review together 2 Disseminated disease: disseminated tuberculosis, with statistical analysis and observations. Indian J Dermatol tuberculous gumma, orificial tuberculosis, miliary Venereol 1963; 29: 25–42. cutaneous tuberculosis 5 Michelson H E, Laymon C W. Classification of tuberculosis of skin. Arch Dermatol Syphilol 1945; 52: 108–113. 3 Tuberculids: papulo-necrotic tuberculids, Erythema 6 Ramesh V, Misra R S, Jain R K. Secondary tuberculosis of the nodosum, Lichen scrofulosorum. skin. Clinical features and problems in laboratory diagnosis. Int J Dermatol 1987; 26: 578–581. We stress the importance of disseminated tuberculo- 7 Kumar B, Kaur S. Pattern of cutaneous tuberculosis in North sis, by which we mean involvement of any organ in India. Indian J Dermatol Venereol Leprol 1986; 52: 203– addition to the presence of cutaneous lesions. Classi- 207. 8 Amezquita R. Tuberculosis cutánea, aspectos clínocos epide- fication in the above mentioned spectrum is impor- miológicos en México. Thesis, Acta Leprol, Vol 16. Abstract in tant, particularly in the Indian subcontinent, from the Excerpta Medica 1965; 19: 674. point of view of treatment. If concomitant systemic 9 Seghal V N, Manoj K J, Srivastava G. Changing pattern of involvement is present and a three-drug regimen is rec- cutaneous tuberculosis: a prospective study. Int J Dermatol ommended without awareness of systemic involve- 1989; 28: 231–236. ment, it is likely to fail because of the high prevalence 10 Chong L Y, Kong K L O. Cutaneous tuberculosis in Hong Kong: a 10 year retrospective study. Int J Dermatol 1995; 34: 18 of drug-resistant organisms (25%). We therefore 26–29. recommend the standard three-drug regimen that is 11 Seghal V N, Wagh A. Cutaneous tuberculosis: current con- used for smear-negative tuberculosis19 for the disease cepts. Int J Dermatol 1990; 29: 237–251. pattern comprised of tuberculids, TVC, lupus vul- 12 Yates V M, Ormerod L P. Cutaneous tuberculosis in Blackburn garis and smear-negative scrofuloderma. For those district (UK): a 15 year prospective series, 1981–1995. Brit J Dermatol 1997; 136: 483–489. with the other disease patterns, the standard four-drug 13 Wong K O, Lee K P, Chiu S F. Tuberculosis of the skin in regimen used in treatment of smear-positive tuberculo- Hong Kong: a review of 160 cases. Brit J Dermatol 1968; 80: sis should be used.19 Patients with a combination of 424–442. clinical variants but without systemic involvement 14 Ramesh V, Misra RS, Saxena U, Mukherjee A. Comparative should be treated according to the morphology of the efficacy of drug regimens in skin tuberculosis. Clin Exp Derma- tol 1991; 16: 106–109. lesions at the lower end of the activity spectrum. 15 Beyt B E Jr, Ortbals D W, Santa Cruz D J, Kobayashi G S, Eisen A Z, Medoff G. Cutaneous tuberculosis: analysis of 34 cases with a new classification of the disease. Medicine (Baltimore) CONCLUSIONS 1981; 60: 95–109. In each part of the clinical spectrum of cutaneous 16 Grange J M. Mycobacteria and the skin. Int J Dermatol 1982; 21: 497–503. tuberculosis there is a proportion of patients with dis- 17 Tappeiner G, Wolff K D. Tuberculosis and other mycobacterial semination (systemic involvement) which is of great infections. In: Fitzpatrick T B, Eisen A Z, Wolff K D et al, eds. significance both epidemiologically and in the man- Dermatology in General Medicine. McGraw Hill, Inc, New agement of the disease. Inclusion of disseminated York, 4th ed, 1993: 2370–2394. 18 Nagpaul D R. Multidrug resistance in tuberculosis. Indian J Tuberc 1994; 1: 1–2. 19 Harries A, Maher D, Uplekar M. A clinical manual of tuber- * Patients with scrofuloderma who are smear-positive for AFB culosis for South East Asia. Geneva: World Health Organisa- should be treated as for open pulmonary tuberculosis. tion, 1997. 500 The International Journal of Tuberculosis and Lung Disease

RÉSUMÉ

CADRE : Hôpital de soins tertiaire dans le Nord de ladie généralisée 71,7%). La dissémination de la maladie l’Inde. a été observée dans l’ensemble du spectre des tuberculo- OBJECTIF : Etude du type de présentation clinique de la ses cutanées (22,1%), mais elle fut plus fréquente en tuberculose cutanée, corrélation de celui-ci avec la réac- présence de gommes et d’écrouelles. Il y a eu plus d’indi- tion de Mantoux et l’état vaccinal BCG, et suggestion vidus non vaccinés par le BCG dans le groupe avec ma- d’une classification clinique fondée sur ces facteurs. ladie disséminée (80,3%) que dans celui avec maladie SCHÉMA : Analyse des dossiers des patients atteints de localisée (65,5%). tuberculose cutanée qui ont fréquenté l’hôpital entre CONCLUSIONS : Lupus vulgaris fut la forme clinique la 1975 et 1995. plus courante, suivi par les écrouelles, les tuberculides, RÉSULTATS : La tuberculose cutanée a été diagnostiquée la tuberculose cutanée verruqueuse et la gomme. Chez chez 0,1% des patients dermatologiques. Les formes les certains patients on a observé plus d’une forme clinique plus courantes furent dans l’ordre : lupus vulgaris chez de la maladie. La classification de la tuberculose cutanée 154 patients (55%), les écrouelles chez 75 (26,8%), la doit être modifiée pour y introduire les écrouelles à tuberculose cutanée verruqueuse chez 17 (6%), les gom- bacilloscopie positive ou négative en dehors de l’inclu- mes chez 15 (5,4%) et les tuberculides chez 19 (6,8%). sion des maladies disséminées. La présence d’une adéno- L’on n’a pas trouvé de corrélation entre la réactivité au pathie régionale peut servir d’indicateur clinique de dis- test de Mantoux et l’étendue de la maladie (maladie sémination de la maladie. Les patients atteints d’une localisée 63,6%, maladie disséminée 67,9%). La présence maladie disséminée sont moins susceptibles d’avoir été d’une adénopathie régionale fut une indication de dis- vaccinés par le BCG que ceux atteints d’une maladie sémination de la maladie (maladie localisée 34,7%, ma- localisée.

RESUMEN

MARCO DE REFERENCIA : Un hospital de atención ter- medad (enfermedad localizada 34,7%, diseminada en el ciaria en el norte de la India. 71,7%). La diseminación de la enfermedad se observó OBJETIVO : Estudiar los tipos de presentación clínica de en todo el espectro de la tuberculosis cutánea (22,1%), la tuberculosis cutánea, relacionarla con la reacción pero con más frecuencia en el goma y en la escrófuloder- de Mantoux y la vacunación BCG y sugerir una clasifi- mia. Habían más individuos no vacunados con BCG en cación clínica basada en estos factores. el grupo con enfermedad diseminada (80,3%) que en MÉTODO : Análisis de las historias clínicas de los pacientes aquellos con enfermedad localizada (65,5%). con tuberculosis cutánea atendidos en el hospital entre CONCLUSIONES : El lupus vulgaris fue la presentación 1975 y 1995. clínica más frecuente, seguida por escrófulodermia, RESULTADOS : El 0,1% de los pacientes dermatológicos tuberculides, tuberculosis verrugosa y el goma. En algunos tenían una tuberculosis cutánea. Las formas más común- enfermos había más de una forma clínica. La clasifi- mente observadas fueron el lupus vulgaris en 154 (55%) cación de la tuberculosis cutánea debe ser modificada de los pacientes, la escrófulodermia en 75 casos para incluir la escrófulodermia con esputo positivo y (26,8%), la tuberculosis verrugosa en 17 (6%), gomas negativo y la inclusión de la enfermedad diseminada. La en 15 (5,4%) y tuberculides en 19 (6,8%). No existía presencia de adenopatías regionales sirve como indica- correlación entre la reacción de Mantoux y la extensión dor clínico de enfermedad diseminada. Los pacientes de la enfermedad (enfermedad localizada en el 63,6% y con enfermedad diseminada tenían menos probabi- diseminada en el 67,9%). La presencia de adenopatías lidades de haber sido vacunados con BCG que aquellos regionales era un índice de diseminación de la enfer- con enfermedad localizada.