Clinico-epidemiological Profile of Cutaneous Tuberculosis in

Dr. M. Djamil Hospital Padang Period of 2015 – 2017

Indah Indria Sari and Tutty Ariani

Dermato-Venereology Department of Dr. M. Djamil Hospital, Padang, Indonesia

Keywords: Cutaneous tuberculosis, epidemiology, clinical profile

Abstract: Cutaneous tuberculosis (CTB) is a relatively rare manifestation with a wide spectrum of clinical profiles

depending on the source of infection and the immune status of the host that is influenced by co morbidity

diseases. The study was conducted to assess the epidemiology and clinical profile of patient with CTB in Dr.

M. Djamil Hospital Padang. A retrospective study had been done by collecting data from the medical records

of patients with diagnosis of CTB at Dr. M. Djamil Hospital Padang between January 2015 and December

2017. A total of 17 cases are included in the final analysis. There were 9 males and 8 females with ratio males

: females was 1.3:1 and generally occurs in young adults (64.7%). All of patients had no family history of

tuberculosis infection. Among these patients, 76.48% was scrofuloderma, 11.76% was lupus vulgaris and

11.76% was tuberculosis verrucosa cutis. Neck was the most common site of involvement. Regional

lymphadenopathy was found in 82.35%. Pulmonary tuberculosis was found in 76.47% patients. There were

3 patients had acquired immune deficiency syndrome (AIDS), 2 patients had diabetes mellitus, 1 patient had

chronic kidney disease and 1 patient had malnutrition. Combination of scrofuloderma and morbus hansen was

noted in one patient. CTB had wide variation with most of cases having co morbidity diseases. More multi-

department studies should be carried out to obtain clinic-epidemiological profile of cutaneous tuberculosis in

Dr. M. Djamil Hospital, Padang, Indonesia.

1 INTRODUCTION

Globally in 2016 there were an estimated 10,4 million

incident cases of TB (range 8.8 million to 12.2

million), equivalent to 140 cases per 100 000

population. The 30 high TB burden countries

accounted for 87% of all estimated incident cases

worldwide. The five countries that stood out as

having the largest number of incident cases in 2016

were India, Indonesia, China, the Philippines and

Pakistan, which together accounted for 56% of the

global total. Of these, China, India and Indonesia

alone accounted for 45% of global cases in 2016.

Nigeria and South Africa each accounted for 4% of

the global total (WHO, 2017).

CTB is relatively

uncommon and not a well-defined disease,

comprising only 1-1.5% of all extra-pulmonary

manifestations (Zyl et al., 2015). The problem is now

further complicated by relentless spread of HIV

which causes AIDS pandemic and the emergence of

multidrug resistant strains (Verma and Mahajan,

2007).

Infection can occur through exogenous routes,

i.e., cutaneous inoculation takes place directly on the

skin (tuberculous chancre, tuberculosis verrucosa

cutis and some cases of lupus vulgaris) or endogenous

ones, with cutaneous involvement occurring

secondarily, through hematogenous route from a

distant tuberculosis focus or by contiguity from an

already established focus (most cases of lupus

vulgaris, scrofuloderma, miliary tuberculosis and

orificial tuberculosis) (Dias et al., 2014).

The development of clinical manifestations in

CTB should be understood as the outcome of

interactions between the environment, the agent and

the host. The factors are infected person’s cellular

immunity state, infection route, bacilli resistance,

virulence factors, individual’s inherent factors (age,

sex, race), factors that lead to immunosuppression

such as malnutrition, alcoholism, silicosis, diabetes

mellitus, gastrectomy, and immunosuppressive

conditions caused by disease or drugs are also

important and environmental factors (Santos et al.,

2014).

This study was conducted to assess the

epidemiology and clinical profile of patient with CTB

Sari, I. and Ariani, T.

Clinico-epidemiological Proﬁle of Cutaneous Tuberculosis in Dr. M. Djamil Hospital Padang Period of 2015 - 2017.

DOI: 10.5220/0008155402670271

In Proceedings of the 23rd Regional Conference of Dermatology (RCD 2018), pages 267-271

ISBN: 978-989-758-494-7

267

in Dr. M. Djamil Hospital Padang period between

January 2015 and December 2017.

2 METHODS

The present study is retrospective study using medical

records patients with CTB in Dr. M. Djamil Hospital

Padang between January 2015 and December 2017,

which were diagnosed on the basis of clinical

presentation and histopathology finding. These cases

were classified by year. The medical records consist

of age, sex, family history of tuberculosis infection,

duration of disease, distribution of lesions, regional

lymphadenopathy, x-ray chest, co-morbidity disease

and type of cutaneous tuberculosis.

3 RESULT

A total of 17 patients with CTB were identified during

the period, which represents 0.48% of the total 3508

cases of tuberculosis. Of the various patterns of CTB

seen. The most common was scrofuloderma seen in

76.48% patient. Followed by tuberculosis cutis

verrucosa and lupus vulgaris in 11.76% patient. There

were 9 males and 8 females with ratio males : females

was 1.3:1. The age of the patients ranged from 7 to 67

years. The most commonly affected was young adult

with the age group was 18-40 years (64.7%).

Followed by adult, the age group 41-65 years was

23.5%, childhood the age group 2-10 years and

elderly the age group more than 65 years were 5.9%.

The duration of the lesion ranged from 1 month to 24

months with a mean 5.31 months. There were 70.59%

patient had CTB for less than 6 months duration. All

of patient had no family history of pulmonary

tuberculosis.

Neck was the most common site of involvement

seen in 64.71% cases. The others site was face, back,

arm, hand, inguinal and leg. There were 82.35%

patients had lymphadenopathy and the most common

was cervical region. Pulmonary tuberculosis was

found in 13 patients. Beside that, there were 3 patients

had acquired immune deficiency syndrome (AIDS), 2

patients had diabetes mellitus, 1 patient had chronic

kidney injury and 1 patient had malnutrition. Five

patients had more than 1 co-morbidity disease.

Combination of scrofuloderma and morbus hansen

was noted in one patient.

4 DISCUSSION

CTB is relatively uncommon comprising only 1-1.5%

of all extra-pulmonary manifestations.

During the

period, a total of 17 patients with CTB were

identified, which represents 0.48% of the total 3508

cases of tuberculosis in Dr. M. Djamil Hospital. There

is an increase in cases of CTB each year during this

period. Compare with study from Nepal by Mathur M

et al in 2014 reported incidence of cutaneous

tuberculosis in Nepal was 0,1% (Mathur and Pandey

et al., 2014). Thus, the incidence of CTB in Dr. M.

Djamil Hospital is still higher than other area.

Of the 17 patients, there were 9 males and 8

females. It means ratio males : females was 1.3:1. The

most commonly affected was young adult with the

age group was 18-40 years (64.7%). Punia RS et al

reported in 2015, 54% of patients were in 2

and 3

decade of life (Punia et al., 2015). Preponderance for

the younger age has also been in the other studies

from India. Males : females ratio was almost equal.

Young adult is productive periods, which allows

frequent contact with tuberculosis-infected patients

thus increasing the risk of transmission. Beside that,

skin trauma due to increased physical activity during

younger age as well as contact with active

tuberculosis cases at an early age may be the

underlying factors for younger age predilection

(Gopinathan et al., 2001).

All of patient had no family

history of tuberculosis infection.

Scrofuloderma was the commonest type of CTB

in this study. Followed by tuberculosis verrucosa

cutis, lupus vulgaris and tuberculosis caseosa cutis.

Similar with cases in Cipto Mangunkusumo hospital

Jakarta at 2010, scrofuloderma was the most common

type of CTB, followed by tuberculosis verrocusa

cutis. Scrofuloderma and tuberculosis verrucosa cutis

commonly found in developing countries, especially

low socioeconomic groups and generally in children

and young adult (Djuanda, 2016).

The duration of the lesion ranged from 1 month to

24 months with a mean 5.31 months. There were

70.59% patient had CTB for less than 6 months

duration. It means that most of patients can be

diagnosed and treated at an early stage. Neck was the

most common site of involvement observed (64.6%)

in comparison to other sites such as arm, back, axilla,

hand and leg, which is similar to other studies

reported. Sharma S et al reported in 2015, neck and

axilla being the most common in scrofuloderma

(Sharma et al., 2015).

Regional lymphadenopathy was seen in 13

patients (82.35%) and cervical lymph nodes were

commonly affected in scrofuloderma. The similar

RCD 2018 - The 23rd Regional Conference of Dermatology 2018

268

Figure 1. Incidence of cutaneous tuberculosis in Dr. M. Djamil Hospital Padang (2015-2017)

Table 1. Clinico-epidemiological profile of cutaneous tuberculosis at Dr. M. Djamil Hospital Padang period of 2015-2017

No. Epidemiology and Clinical Profile

Case Number

(n=16)

Percentage of Total

Cases (%)

1. Sex

Male

Female

52.94

47.06

2. Age (year)

Infant : 0 – <2

Childhood : 2 – 10

Adolescence : 11 – 17

Young adult : 18 – 40

Adult : 41 – 65

Elderly : >65

5.9

64.7

23.5

5.9

3. Duration of disease

< 6 months

≥ 6 months

70.59

29.41

4. Distribution of lesions

Face

Neck

Axilla

Trunk

Inguinal

Arm

Leg

Other

5.9

64.6

5.9

4. Family history

Yes

100

5. Regional lymphadenopaty

Yes

82.35

17.65

6. X-ray chest : Pulmonary tuberculosis

Clinico-epidemiological Proﬁle of Cutaneous Tuberculosis in Dr. M. Djamil Hospital Padang Period of 2015 - 2017

269

Yes

76,47

23.53

7. Co-morbidity

No co-morbidity

AIDS

Diabetes mellitus

Chronic kidney injury

Malnutrition

23.53

17.65

11.76

5.9

8. Clinical diagnosis

Scrofuloderma

Lupus vulgaris

Tuberculosis verrucosa cutis

76.48

11.76

case had been reported by Shresta SB et al in 2015

(Shrestha et al., 2015).

The pulmonary tuberculosis

was found in 12 patients (75%). Based on theory,

infection of CTB can occur through exogenous

routes, i.e., cutaneous inoculation takes place directly

on the skin (tuberculous chancre, tuberculosis

verrucosa cutis and some cases of lupus vulgaris) or

endogenous ones, with cutaneous involvement

occurring secondarily, through hematogenous route

from a distant tuberculosis focus or by contiguity

from an already established focus (most cases of

lupus vulgaris, scrofuloderma, miliary tuberculosis

and orificial tuberculosis) (Dias et al., 2014; Santos et

al., 2014).

There are many other co-morbidity for CTB such

as HIV infection (AIDS), transplantation,

malnutrition, diabetes, renal failure, liver failure,

cancers, immunosuppressive drugs and

corticosteroids (Shrestha et al., 2015). There were 3

patients had acquired immune deficiency syndrome

(AIDS). In recent years, the epidemiology of

tuberculosis has been adversely affected by the

human immunodeficiency virus (HIV) pandemic. In

fact, HIV infection is now the most important

predisposing factor to the development of active

tuberculosis. Moreover, tuberculosis and HIV

infection pose the two greatest global public health

threats owing to their high morbidity and mortality

rates (Bonamonte et al., 2017). There were 2 patients

had diabetes mellitus, 1 patient had chronic kidney

injury and 1 patient had malnutrition. Four patients

had more than 1 co morbidity disease. All these

condition play an important role in CTB.

Combination of scrofuloderma and morbus

hansen was noted in one patient. Tuberculosis (TB)

and leprosy, the 2 major mycobacterial infections of

humans, are classic granulomatous diseases that still

affect millions of people. Both infections are now

curable, but no highly effective vaccine is yet

available for either of them. Both are ancient scourges

with a wide range of cutaneous manifestations, and

both are infamous for their ability to mimic other

diseases and sometimes fool even the most skilled

diagnostician (Scollard et al., 2015).

5 CONCLUSION

The incidence of CTB in Dr. M. Djamil Hospital

increased during the period and the most commonly

affected was young adult. Scrofuloderma was the

most common type. Majority of patients were

accompanied by pulmonary tuberculosis and others

disease like acquired immune deficiency syndrome

(AIDS), diabetes mellitus, chronic kidney disease and

malnutrition. More multi-centered studies should be

carried out to obtain epidemiological data of

cutaneous tuberculosis in Dr. M. Djamil Hospital,

Padang, Indonesia.

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