Tuberculosis fungosa serpiginosa

Rare cutaneous form of tuberculosis with "fungal" skin lesions.

• Very rare cutaneous tuberculosis
• V.a. in the elderly

Both by exogenous and endogenous inoculation.

• Localisation
  • Forearms and back of the hand
• Papillomatous, fistulous, perforating growths through which a turbid or purulent secretion may be discharged

• Travel history
• clinic
• Tuberculin test is negative
• Quantiferone test
• Microscopic detection of the pathogen is possible, however
• Biopsy (both dermatopathological and microbiological examination)
• Thoracic X-ray or CT chest
• 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)

Forearms and back of the hands.

Tuberculoid granulomas with inflammatory infiltrate.

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. Antituberculous therapy should be continued for at least 2 months after the skin is 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 case of additional therapy with NNRTIs
• Moist, antiseptic compresses
• Surgical ablation if necessary

1. 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
2. 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