Tuberculosis ulcerosa mucosae et cutis

Tuberculosis orificialis.

In cases of pronounced immunosuppression, tuberculous infestation of the mucous membranes.

Men from middle age onwards are preferentially affected.

The disease occurs in the case of an unfavourable immune situation.

• Localisations: Enoral, perioral
• The term staphylococcal tuberculosis refers to the infection of the localisations through which secretions rich in tubercle bacilli are excreted (anus, rectum, kidney, lungs)
• Enoral (from the larynx to the lips) and perioral stool-like ulcerative papules and pustules
• CAVE: Contagiousness is particularly high due to the high number of tubercle bacilli in the skin lesions!

• Travel history
• Clinical
• Tuberculin test is often false negative (due to usually poor immune status)
• Quantiferone test
• Biopsy

• To exclude systemic involvement:
  • Thoracic X-ray or CT- thorax
  • Sonography of the abdomen and kidneys
  • In the morning (fasting up to 4h) on 3 consecutive days, sputum must be collected
  • Pass urine in the morning on 3 consecutive days (fluid restriction the evening before!)
• Bronchoalveolar lavage (BAL)

• Enoral
• Perioral

Nonspecific, cellular proliferating, partly necrotising inflammation, tuberculoid granulomas.

Most often, disseminated organ infestation occurs.

Therapy regimen:

• The initial phase should last for 8 weeks/2 months. During this time, the majority of the bacteria are killed. In the subsequent phase of therapy (lasting for months), attempts are made to eliminate the remaining bacteria. The antituberculous therapy should be continued for at least 2 months after the skin has become free of symptoms.
• The therapy should last individually between 12-24, but at least 6 months!

Induction phase (2 months):

• Rifampicin p.o. 10 mg/kg bw/d
• Isoniazide p.o. 5 mg/kg bw. (with Vit B 6)
• Pyrazinamide p.o. 35 mg/ bw/ d if necessary combination with allopurinol!
• Ethambutol p.o. 15 mg/kg bw/ d
• A clear improvement can be seen in the vast majority of cases after 1 ½ months.

Consolidation phase:

• Rifampicin p.o. 10 mg/kg bw/d
• Isoniazide p.o. 5 mg/kg bw. (with Vit B 6)
• Ethambutol p.o. 15 mg/kg bw/d (can also be omitted if isoniazid resistance has been ruled out)
• HIV patients: therapy must be given for ≥ 7 months. Ethambutol should be replaced by streptomycin p.o. 15-20 mg/kg bw/d (from > 60 y. max 750 mg) in the case of additional therapy with NNRTI.

• Analgesic local therapeutics e.g.:
  • Lidocaine
    • Mouth gel
    • Smoothies
    • Patches

1. Barbagallo J, Tager P, Ingleton R, Hirsch RJ , Weinberg JM. Cutaneous Tuberculosis. American Journal of Clinical Dermatology 2002;3:319-28.
2. Barbagallo J, Tager P, Ingleton R, Hirsch RJ , Weinberg JM. Cutaneous tuberculosis: diagnosis and treatment. Am J Clin Dermatol 2002;3:319-28.
3. Rietbroek RC, Dahlmans RP, Smedts F, Frantzen PJ, Koopman RJ , van der Meer JW. Tuberculosis cutis miliaris disseminata as a manifestation of miliary tuberculosis: literature review and report of a case of recurrent skin lesions. Rev Infect Dis 1991;13:265-9.
4. Sehgal VN, Bhattacharya SN, Jain S , Logani K. CUTANEOUS TUBERCULOSIS: THE EVOLVING SCENARIO. International Journal of Dermatology 1994;33:97-105.
5. Handog, E. (2016). Cutaneous manifestations of tuberculosis. Uptodate.com. Retrieved 24 May 2016, from http://www.uptodate.com/contents/cutaneous-manifestations-of-tuberculosis?source=search_result&search=tuberkulosis+skin&selectedTitle=1~16
6. Haas, W. (2016). RKI - RKI-Ratgeber für Ärzte - Tuberkulose. Rki.de. Retrieved 24 May 2016, from https://www.rki.de/DE/Content/Infekt/EpidBull/Merkblaetter/Ratgeber_Tuberkulose.html#doc2374486bodyText3