MYCOBACTERIAL INFECTION

Mycobacteria of dermatological interest

A. Slow growers I. Photochromogens

M. marinum M. kansasii M. Scrofulaceum M. szulgai M. tuberculosis M. avium M. ulcerans

II. Scotochromogens

III.Non chromogens

B. Rapid growers IV M. smegmatis M. fortuitum M. chelonae

C. Non culturable

M. leprae

ANDREW'S DISEASES OF THE SKIN CLINICAL DERMATOLOGY

CLASSIFICATION OF CUTANEOUS TUBERCULOSIS

Localized forms Primary inoculation complex Lupus vulgaris Tuberculosis verrucosa cutis Scrofuloderma Tuberculosis cutis orificialis Hematogenous form Tuberculosis miliaris Lupus miliaris disseminatus faciei Papulonecrotic tuberculid Lichen scrofulosorum Erythema induratum

The result of infection by M. tuberculosis

- number - virulence - route of infection - resistance of the individual

Tuberculin testing
- indicates hypersensitivity to tuberculosis - purified protein derivative ( PPD ) - injecting 0,1 ml I.c. ( volar aspect of the forearm )

PRIMARY TUBERCULOUS COMPLEX

= Tuberculous chancre - initial cutaneous infection excoriation / ulcer - previously free of tuberculosis - children face, extremities - brownish red papule indurated nodule / plaque ulcerate - prominent regional lymphadenopathy - healing in several weeks

LUPUS VULGARIS = Tuberculosis luposa

- most common type - reddish-brown patches of nodules (apple-jelly color) - forming plaque by coalescence - slightly elevated, covered by scales - destructive, ulcerations scars - exposed parts ( face ) - course : slow - Diff. Diagnosis : - rosacea - acne vulgaris - tertiary syphilis - lupus erythematosus - treatment : - INH + Rifampicin - surgical excition

TUBERCULOSIS VERUCOSA CUTIS

=anatomist's wart ( prosector's wart ) - single hyperkeratotic - dorsa of the fingers, the hand, ankle - discoid, circumscribed large plaques - Diff. Diagnosis : - blastomycosis - verrucous epidermal nevus - verruca vulgaris - treatment : INH + Rifampicin

TUBERCULOSIS CUTIS ORIFICIALIS

- localized, mucocutaneous borders ( nose, mouth, anus, urinary meatus, vagina ) - young adult with severe visceral tbc - ulcer : oval, shallow, covered by crusts - Diff diagnosis : - chancroid - LGV - Syphilitic gumma TUBERCULOSIS MILIARIS DISSEMINATA - rare - acute generalized eruption - ulcer : small, circular dull red border seropurulent exudate - Tubercle bacilli + in this lesion

SCROFULODERMA
( TUBERCULOSIS CUTIS COLLIQUATIVA )

- originating from tbc. beneath the skin - relatively frequent - most often occurs in the parotidal, submandibular, supraclavicular regions, lateral aspect of the neck - clinical manifestation : first present as firm, subcutaneous nodules asymptomatic infiltrate, initially freely movable - perforation - ulcers and sinuses developed - linear, undermined, inverted, blursh color - cord like scars

PAPULO NECROTIC TUBERCULID

- cutaneous reaction ------ immune respons - clinical features : - succesive crops - extensor surface - vary in size - association with : - erythema induratum - lichen scrofulosorum - acne vulgaris - treatment : anti tuberculous therapy
LICHEN SCROFULOSORUM = tuberculosis cutis lichenoides - groups of indolent, minute, keratotic - scattered over the trunk or extrimities - no pruritus, no pain

ERYTHEMA INDURATUM
( = tuberculosis induratum, Bazin's disease ) - chronic benign vasculitis - unrelated to tuberculosis infection - larger than papulonecrotic tuberculid - symmetrical , indolent - usually in young women who have tbc. - Prefered site : calf - Persist three or four months - Diff. diagnosis : - erythema nodosum - nodular vasculitis - gummatous syphilid

LUPUS VULGARIS

Questions ????

LEPROSY = Hansen's disease = Hanseniosis=Lepra

Definition - chronic, systemic, infectious - caused by M.leprae - specific granulomatous / neurotrophic skin, mucous membrane, nerves, anterior segment of the eye, bones, viscera. Classification of leprosy - clinical : cutaneous lesion neurologic sign - bacteriologic - immunologic - histopathologic

Klasifikasi kusta menurut WHO (1980) & modifikasi WHO (1988)

Pausibasiler (PB) TT BT BB

Multibasiler (MB) LL BL BB

Ridley & Jopling ( 1966 )

Tuberculoid leprosy ( TT ) - erythematous plaque - sharply define - elevated border - anesthetic - neural involvement Border Tuberculoid Leprosy ( BT ) - cutaneous smaller, more numerous - nerve slightly enlarge

Borderline Leprosy
* skin and nerve * becteriologic exam. + * lesion : numerous irregular plaques small satelite asymetric moderate anesthesia

Borderline Lepromatous Leprosy - lesion : numerous

macules, papules, nodules, punched out - nerve lesion appear late - no lepromatous feature - anesthesia is often absent

Lepromatous Leprosy ( LL )
* lepromatous infiltrations * numerous bacilli * lepromatous macules small and numerous * tendency become progressive * lepromatous characteristic diffuse plaque nodular type * diffuse leprosy of lucio * histoid leproma * eye involvement * mucous membrane - nerve involvement

Etiology
- m. leprae - intracellular habitat - by Hansen 1869 - acid fast bacilli - 2 to 7 um 0,3 to 0,4 um - waxy capsule identification Hunter 1982, phenolic glycolipid I

Hubungan inang parasit pd spektrum penyakit kusta

Epidemiology
- 15 million people - highest Central Africa - transmitted person to person - latent period 2 - 5 years - greatest prevalence : - low economic status - inadequate housing - insuitable sanitation - poor nutrition - lack of education - male : female = 2 : 1

Immune response * leprosy is a spectrum disease dependent of the hosts specific cellular immune response * antibody response abnormal * reversal reaction

Differential Diagnosis
* great immitator

* TT : - tinea corporis - granuloma anulare - syphilis - drug eruptions - erythema nodosum

* BB : - p. alba - T. versicolor - Seborrhoeic dermatitis

Lepromatosus leprosy
* Mycosis fungoides * Neuro dermatitis * Urticaria * Lupus vulgaris Lepra reaction * reversal reactions : upgrading - downgrading * acute exacerbation : in lepromatous patients * ENL : leucoclastic vasculitis About 6 months after treatment Untreatment Erythematous nodules in crops Produce severe clinical expression Visceral manifestation

Diagnostic procedure
* History taking * Clinical lesion * Skin sensory test * Slit skin smear

TANDA KARDINAL KUSTA : 1. Kelainan kulit berupa hipopigmentasi, atau eritem, yg an/hipestesi 2. Penebalan saraf tepi dengan kelainan sensoris 3. BTA (+)

Treatment * Rifampicin * Dapsone * Clofacimine 12-18 months * Lepra reactions : corticosteroid PROGNOSIS Depend on early diagnosis and treatment

Pengobatan PB dewasa

Pengobatan MB dewasa

Pengobatan PB anak

Pengobatan MB anak

REAKSI KUSTA

PEWARNAAN ZIEHL NEELSEN

HISTOPATOLOGIS KUSTA

KUSTA TIPE TT

KUSTA TIPE LL