Lichen planus is a very common dermatosis of unknown etiology characterized by the appearance of pruritic polygonal papules, with a purplish color and shiny surface, preferentially located in the distal areas of the extremities. Characteristically these papules show a symmetrical distribution and are preferentially located on the anterior aspect of the wrists (Figure 1) and ankles. Oral mucosal involvement is very frequent, and approximately 75% of patients with lichen planus show an asymptomatic whitish reticulation affecting the jugal or lingual mucosa.

The patient presents since 2 weeks ago a pruritic eruption consisting of multiple polygonal erythematous-violaceous papules, with flattened surface, preferentially located on the anterior aspect of the wrists, pretibial area and lumbar area. She also presents whitish reticulated lesions in the jugal mucosa. What is the most probable diagnosis?

DERMATOLOGY, VENEREOLOGY AND PLASTIC SURGERY

Segmental lesions in pityriasis rosea: a rare presentation.

A 34-year-old nonpregnant woman noted a mildly pruritic skin lesion on her right breast for 1 week following an episode of coryza, malaise, and low-grade fever of 3 days' duration. The latter symptoms subsided without any treatment. Ketoconazole cream prescribed by her family physician did not resolve the breast eruption after 1 week, so was stopped. A week later, multiple skin lesions erupted suddenly on her right chest wall starting near the herald patch in midaxillary line and spread distally until the midback. She then consulted the authors. She denied a history of abrasion or trauma to the affected areas. Travel, contact, sexual, and drug histories were unremarkable. She categorically denied past or family history of eczema, psoriasis, contact dermatitis, and drug eruptions. On examination, the initial lesion was an annular and well-demarcated erythematous plaque on her right breast in the upper outer quadrant. Multiple small oval scaly plaques were noted, extending distally along the ribs to the midline on her back, not crossing the midline, predominantly over the distribution of right T4 dermatome (Figure 1). Peripheral collarette scaling was noted (Figure 2). A few scattered small lesions were also noted in the vicinity of this dermatome. Three isolated small plaques were also present on the trunk, one in the supramammary area and the other two on the abdomen and back, respectively. Palmoplantar and mucosal surfaces were uninvolved. The rest of the skin and systemic examination revealed no abnormalities. Complete blood cell counts, fasting glucose, and urinalysis were normal. Venereal Disease Research Laboratory (VDRL) results were nonreactive and human immunodeficiency virus (HIV) antibodies were negative. Repeat testing ofVDRL in serial dilutions and HIV antibodies after 3 months were also nonreactive and negative, respectively. Scrapings from the initial large lesion and subsequent smaller eruptions did not show any evidence of fungal infection on potassium hydroxide smear examination. The patient declined skin biopsy; however, we thought that the most diagnostic label for this condition was pityriasis rosea. Hence, we treated her with triamcinolone acetonide ointment 0.025% to be applied twice daily and desloratadine tablet 5 mg daily for 10 days. The patient demonstrated complete resolution, leaving postinflammatory hypopigmentation. There was no recurrence until 1 year after complete remission.

Hyperkeratotic Palmoplantar Lichen Planus in a child.

Lichen planus (LP) is a common idiopathic inflammatory disorder that affects the flexor aspect of the wrists, the legs, and the oral and genital mucosa. Depending upon the site of involvement, LP can be divided into mucosal, nail, scalp, or palmoplantar types. Palmoplantar LP can pose a diagnostic problem to the clinician as it resembles common dermatoses like psoriasis, verruca, corn, calluses, lichenoid drug eruption, and papular syphilide of secondary syphilis. In this case report, we describe a 4-year-old male child who presented with highly pruritic erythematous to violaceous hyperkeratotic papules and plaques on his palms and soles. Typical LP papules were noted on the upper back. Histopathology of the papular lesion showed features of LP. Dermatoscopy of a papule from the back showed the characteristic Wickham striae. We report this rare involvement of palm and soles in a case of childhood LP.

Dermoscopy of Gottron's papules and other inflammatory dermatoses involving the dorsa of the hands.

Several inflammatory dermatoses, including dermatomyositis (DM), may present as erythematous papules or plaques on the dorsal aspects of the hands over the joints. Limited skin involvement in these entities may pose a diagnostic challenge. (Video)dermoscopy is being utilized more frequently to aid in the differential diagnosis of inflammatory skin conditions. To describe the dermoscopic findings in Gottron's papules and compare them with dermoscopic features of other dermatoses involving the dorsal aspects of the hands. Videodermoscopic images from patients presenting with erythematous papules or plaques on the dorsal surface of the hands were retrospectively analysed for the presence of standardized dermoscopic parameters. Dermoscopic images from patients with DM (n = 12), psoriasis (n = 19), chronic dermatitis (n = 16), mycosis fungoides (n = 7), lichen planus (n = 5) and pityriasis rubra pilaris (n = 3) were included. Gottron's papules were characterized by pleomorphic vessels (dotted vessels accompanied by thick or thin linear vessels with branches or linear curved vessels) in 66.7% of cases, arranged in an unspecified pattern (91.7%), and accompanied by white or pink structureless areas (75.0%). Psoriatic plaques were characterized by dotted vessels arranged in a uniform pattern (94.7%). Vessels arranged in a ring pattern were nearly exclusively observed in psoriasis, while yellow structureless areas and erosions were more frequently present in chronic dermatitis. White lines, corresponding to Wickham striae, were specific for lichen planus. Videodermoscopy might be of value in differentiating Gottron's papules from other dermatoses involving dorsa of the hands.

[Follicular psoriasis with cicatricial alopecia. Piccardi-Lassueur-Graham Little syndrome of a psoriatic nature].

The case of a 21 years old female patient is reported who has had scaly lesions on the scalp since the age of 3, alopecia (later scarring alopecia) since the age of 5, and erythematous and squamous lesions on the trunk and limbs since the age of 14. More recently she developed grouped follicular papules on the trunk, back of the neck and upper limbs. Seven biopsies from the scalp, trunk and sole of foot were performed which showed typical psoriatic changes in all but one, from the scalp, where only scarring alopecia changes could be found. In one lesion from the trunk pseudogranulomatous features were observed in some papillae which were probably due to ectasia, tortuosity and endothelial proliferation of papillary blood vessels. The oral administration of RO 10-9359 was followed by a good remission of the lesions with exception of the scalp alopecia. The differential diagnosis, particularly with pityriasis rubra pilaris and lichen planus, is discussed and the similarities of our case with the Piccardi-Lassueur-Graham Little syndrome emphasised. If one accepts multiple diseases as the cause of the syndrome psoriasis could be admitted as one of them.

Annular Lesions: Diagnosis and Treatment.

Annular lesions can present in a variety of diseases. Knowledge of the physical appearance and history of presentation of these skin findings can help in the diagnosis. A pruritic, annular, erythematous patch that grows centrifugally should prompt evaluation for tinea corporis. Tinea corporis may be diagnosed through potassium hydroxide examination of scrapings. Recognizing erythema migrans is important in making the diagnosis of Lyme disease so that antibiotics can be initiated promptly. Plaque psoriasis generally presents with sharply demarcated, erythematous silver plaques. Erythema multiforme, which is due to a hypersensitivity reaction, presents with annular, raised lesions with central clearing. Lichen planus characteristically appears as planar, purple, polygonal, pruritic papules and plaques. Nummular eczema presents as a rash composed of coin-shaped papulovesicular erythematous lesions. Treatment is aimed at reducing skin dryness. Pityriasis rosea presents with multiple erythematous lesions with raised, scaly borders, and is generally self-limited. Urticaria results from the release of histamines and appears as well-circumscribed, erythematous lesions with raised borders and blanched centers. Annular lesions occur less commonly in persons with fixed drug eruptions, leprosy, immunoglobulin A vasculitis, secondary syphilis, sarcoidosis, subacute cutaneous lupus erythematosus, and granuloma annulare.

Dermoscopy in differential diagnosis of inflammatory dermatoses and mycosis fungoides.

The use of dermoscopy for the evaluation of various inflammatory dermatoses has witnessed a gradual increase in recent years. The present study describes and highlights the importance of dermoscopic findings in the differential diagnosis of plaque psoriasis (PP), lichen planus (LP), mycosis fungoides (MF), pityriasis rosea (PR), and nummular dermatitis (ND) that mostly involve the trunk. The study included 150 cases (PP:50, LP:30, MF:20, PR:30, ND:20). The lesions were inspected using a polarized dermoscope. The dermoscopic findings of each lesion were evaluated for background color, type, and distribution of vessels, color and distribution of scales, and other additional findings. When the patient groups were evaluated for background color, yellow color was prominent in PR, and light and dull red color was prominent in other groups. Dotted vessels were prominent in PP, PR, and ND, and dotted + linear vessels were significantly more prominent in MF and LP. In the evaluation of the distribution pattern of vessels, PP showed regular, LP showed peripheral, and PR, MF, and ND showed patchy distribution patterns. White scales were prominent in PP, PR, and MF, and yellow-white scales were prominent in LP and ND. Only PR had a predominant peripheral distribution of scales, while other groups had a patchy distribution. In conclusion, it was observed that PP, LP, MF, PR, and ND exhibited specific dermoscopic patterns that might be useful in clinical diagnosis.

Accuracy of dermoscopic criteria for the diagnosis of psoriasis, dermatitis, lichen planus and pityriasis rosea.

Dermoscopy is useful in evaluating skin tumours, but its applicability extends also to the field of inflammatory skin disorders. Plaque psoriasis (PP), dermatitis, lichen planus (LP) and pityriasis rosea (PR) are common inflammatory skin diseases, but little is currently known about their dermoscopic features. To determine and compare the dermoscopic patterns associated with PP, dermatitis, LP and PR and to assess the validity of certain dermoscopic criteria in the diagnosis of PP. Patients with PP, dermatitis, LP and PR were prospectively enrolled. The single most recently developed lesion was examined dermoscopically and histopathologically. Variables included vascular morphology, vascular arrangement, background colour, scale colour, scale distribution and presence of Wickham striae. Univariate and adjusted odds ratios were calculated. Discriminant functions were used to plot receiver-operator characteristic curves. Eighty-three patients with PP and 86 patients with either dermatitis, LP or PR were included in the study. Dotted vessels in a regular arrangement over a light red background and white scales were highly predictive for the diagnosis of PP, whereas dermatitis more commonly showed yellow scales and dotted vessels in a patchy arrangement. PR was characterized by yellowish background, dotted vessels and peripheral scales; whitish lines (Wickham striae) were seen exclusively in LP. PP, LP, PR and dermatitis show specific dermoscopic patterns that may aid their clinical diagnosis. Certain combinations of dermoscopic features can reliably predict the diagnosis of PP.

The practical usefulness of dermoscopy in general dermatology.

Beside to traditional use, dermoscopy is more and more used in the assessment of other "general" dermatologic conditions, namely scalp and hair disorders (trichoscopy), nails abnormalities (onychoscopy), skin infections and infestations (entomodermoscopy), and cutaneous inflammatory diseases (inflammoscopy). Among the list of new applications of dermoscopy, the study of inflammatory dermatoses is probably the most promising topic in terms of development and usefulness, considering the large number of such disorders and the frequent problems in their differential diagnosis which the dermatologist encounters in own daily clinical practice. In this paper, we report selected relatively common clinical differential diagnosis issues concerning inflammatory dermatoses (and some clinically related noninflammatory conditions), analysing them by a dermoscopic point of view in order to assist their noninvasive resolution according to the available literature data and our personal experience, including papulosquamous dermatoses (guttate psoriasis, pityriasis lichenoides chronica, pityriasis rosea, lichen planus, lymphomatoid papulosis, classic pityriasis rubra pilaris, papulosquamous sarcoidosis, disseminated forms of porokeratosis and papulosquamous chronic GVHD), dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides, subacute cutaneous lupus erythematosus), palmar psoriasis vs. chronic hand eczema, scalp psoriasis vs. seborrheic dermatitis, erythematous-desquamative disorders typically involving the elbows (psoriasis vulgaris, circumscribed juvenile pityriasis rubra pilaris, dermatomyositis/Gottron's sign), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), common facial inflammatory skin diseases (rosacea, seborrheic dermatitis and demodicidosis), lichen sclerosus vs. morphea, urticaria vs. urticarial vasculitis and common inflammatory cicatricial alopecia (discoid lupus erythematosus, lichen planopilaris and folliculitis decalvans).

Dermoscopy in General Dermatology: A Practical Overview.

Over the last few years, dermoscopy has been shown to be a useful tool in assisting the noninvasive diagnosis of various general dermatological disorders. In this article, we sought to provide an up-to-date practical overview on the use of dermoscopy in general dermatology by analysing the dermoscopic differential diagnosis of relatively common dermatological disorders grouped according to their clinical presentation, i.e. dermatoses presenting with erythematous-desquamative patches/plaques (plaque psoriasis, eczematous dermatitis, pityriasis rosea, mycosis fungoides and subacute cutaneous lupus erythematosus), papulosquamous/papulokeratotic dermatoses (lichen planus, pityriasis rosea, papulosquamous sarcoidosis, guttate psoriasis, pityriasis lichenoides chronica, classical pityriasis rubra pilaris, porokeratosis, lymphomatoid papulosis, papulosquamous chronic GVHD, parakeratosis variegata, Grover disease, Darier disease and BRAF-inhibitor-induced acantholytic dyskeratosis), facial inflammatory skin diseases (rosacea, seborrheic dermatitis, discoid lupus erythematosus, sarcoidosis, cutaneous leishmaniasis, lupus vulgaris, granuloma faciale and demodicidosis), acquired keratodermas (chronic hand eczema, palmar psoriasis, keratoderma due to mycosis fungoides, keratoderma resulting from pityriasis rubra pilaris, tinea manuum, palmar lichen planus and aquagenic palmar keratoderma), sclero-atrophic dermatoses (necrobiosis lipoidica, morphea and cutaneous lichen sclerosus), hypopigmented macular diseases (extragenital guttate lichen sclerosus, achromic pityriasis versicolor, guttate vitiligo, idiopathic guttate hypomelanosis, progressive macular hypomelanosis and postinflammatory hypopigmentations), hyperpigmented maculopapular diseases (pityriasis versicolor, lichen planus pigmentosus, Gougerot-Carteaud syndrome, Dowling-Degos disease, erythema ab igne, macular amyloidosis, lichen amyloidosus, friction melanosis, terra firma-forme dermatosis, urticaria pigmentosa and telangiectasia macularis eruptiva perstans), itchy papulonodular dermatoses (hypertrophic lichen planus, prurigo nodularis, nodular scabies and acquired perforating dermatosis), erythrodermas (due to psoriasis, atopic dermatitis, mycosis fungoides, pityriasis rubra pilaris and scabies), noninfectious balanitis (Zoon's plasma cell balanitis, psoriatic balanitis, seborrheic dermatitis and non-specific balanitis) and erythroplasia of Queyrat, inflammatory cicatricial alopecias (scalp discoid lupus erythematosus, lichen planopilaris, frontal fibrosing alopecia and folliculitis decalvans), nonscarring alopecias (alopecia areata, trichotillomania, androgenetic alopecia and telogen effluvium) and scaling disorders of the scalp (tinea capitis, scalp psoriasis, seborrheic dermatitis and pityriasis amiantacea).

Clinicopathological Study of Non-Infectious Erythaematous Papulosquamous Skin Diseases.

Papulosquamous diseases are characterized by scaly papules and plaques with similar clinical picture which amounts to confusion and hence, a definitive histopathological diagnosis goes a long way in treatment of such diseases. The aim of the study was to study the histomorphology of non-infectious, erythaematous, papulosquamous lesions of skin with clinicopathological correlation. Skin biopsies from 150 clinically diagnosed/suspected non-infectious erythaematous, papulosquamous skin diseases were received in the Department of Pathology. The specimens obtained were subjected to formalin fixation and paraffin embedding, stained with haematoxylin and eosin and studied. The lesions were classified as psoriasis, lichen planus, lichen nitidus, lichen striatus, pityriasis rosea and pityriasis rubra pilaris and clinicopathological correlation was done. Papulosquamous lesions were common in the elderly. Males were commonly affected except in pityriasis rosea. Among the 150 cases studied, 72 cases (48%) were histopathologically confirmed to be papulosquamous lesions. Psoriasis was the most common lesion. Key histopathological features and clinicopathological correlation gives a conclusive diagnosis. The importance of specific histomorphological diagnosis lies in distinguishing these lesions as the treatment and prognosis varies widely.

Lichen Planus -- History and Physical

Lichen planus can display a variety of lesion types, but the most common presentation is an area of polygon-shaped, itchy, violaceous, flat-topped papules a few millimeters wide. This classic presentation is known as The Six Ps of LP: purple, polygonal, planar, pruritic papules, and plaques. The lesions have a shiny surface covered in fine white lines known as Wickham striae and are firm on palpation. They may be seen as a few individual lesions, found scattered widely, grouped in plaques, or arranged in annular, linear, or actinic (sun-exposed) patterns. The isomorphic response (i.e., Koebner phenomenon) can be seen in LP wherein new lesions arise in lines where scratching occurs, just as is seen in psoriasis. The most common areas of involvement include the flexor wrists, dorsal hands, lower back, ankles, and shins. Frequently a grayish-brown hyperpigmentation can be found after lesions resolve due to deposition of melanin in the superficial dermis. [5] [10]

Pityriasis rosea

Diagnosis Experienced practitioners may make the diagnosis clinically. Classical symptoms are usually straightforward to recognize, but the wide range of atypical forms may cause difficulty for the clinician in diagnosing some cases. Misdiagnosis by nondermatologists is not uncommon. If the diagnosis is in doubt, tests may be performed to rule out similar conditions such as Lyme disease, ringworm, guttate psoriasis, nummular or discoid eczema, drug eruptions, other viral exanthems. The clinical appearance of pityriasis rosea in some cases is similar to that of secondary syphilis, and rapid plasma reagin testing should be performed if there is any clinical concern for syphilis. A biopsy of the lesions will show extravasated erythrocytes within dermal papillae and dyskeratotic cells within the dermis. A set of validated diagnostic criteria for pityriasis rosea is as follows: A patient is diagnosed as having pityriasis rosea if:

Profile of lichen planus in Bangladesh.

Lichen planus is one of the common inflammatory disorders of skin, mucous membrane, nail and hair characterized by violaceous, polish, pruritic, polygonal, flat-topped papules usually distributed bilaterally symmetrically over the extremities. Our objectives in this study were to explore the prevalence of lichen planus in large area of Dhaka in Bangladesh and to establish the clinical characteristics of lichen planus. This descriptive type of cross sectional study was carried out from September 2006 to August 2008 in the Department of Dermatology and Venereology of Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka Medical College Hospital (DMCH) and Combined Military Hospital (CMH) in Dhaka. Patients suffering from lichen planus were selected as study population. By face to face interview and clinical observations, data were collected from sample. A total 120 patients of lichen planus were selected, on the basis of age, 30(25%) were 10-30 years of age, 75(62.56%) were 30-50 years and 16(13.33%) were over 50 years of age. The mean age of the patient was 40+/-4 years. Out of 120 patients, 80(66.66%) were male and 60(33.33%) were female and eight patients (6.67%) had positive family history among highest age group (30 to 50 years). In case of duration of disease, highest percentage (68%) of cases was 15 days to 6 months and considering clinical sign, koebnerization was present 45(37.5%) cases and Wickhams striae 22(18.33%) cases. Regarding site of onset of lesion, lesions were highest 100(83.33%) in upper limbs, next lower limbs, trunk, oral mucosa etc. The distribution of clinical pattern of lichen planus showing classic pattern (68.33%) was the most common type, followed by hypertrophic, actinic, ashy dermatoses, lichen plano-pilaris, erosive or ulcerative etc. This clinico-epidemiological study of lichen planus attending in the different hospital in Dhaka, Bangladesh has shown that lichen planus is usually associated with 30 to 50 years of age group, with higher male prevalence than female, 15 days to 6 months are mainly duration of disease, koebnerization and Wickhams striae are common clinical signs, upper limbs is mainly the site of onset of lesion, and classic pattern is the most common clinical type in lichen planus.

Histopathologic diagnosis of dermatitis

Interface dermatitis with lichenoid inflammation Interface dermatitis with lichenoid inflammation, not otherwise specified, can be caused by lichen planus-like keratosis, lichenoid actinic keratosis, lichenoid lupus erythematosus, lichenoid GVHD (chronic GVHD), pigmented purpuric dermatosis, pityriasis rosea, and pityriasis lichenoides chronica. Unusual conditions that can be associated with a lichenoid inflammatory cell infiltrate are HIV dermatitis, syphilis, mycosis fungoides, urticaria pigmentosa, and post-inflammatory hyperpigmentation. In cases of post-inflammatory hyperpigmentation, it is important to exclude potentially harmful mimics such as a regressed melanocytic lesion or lichenoid pigmented actinic keratosis. Psoriaform dermatitis Examining multiple deeper levels is recommended if initial cuts do not correlate well with the clinical history.

Papule

Papules with scale on the palms and soles may occur in secondary syphilis, psoriasis, eczema, tinea manuum, mycosis fungoides. In lichen planus papules may be itchy, flat-topped, polygonal, purplish with white streaks, and can be solitary, or occur in clusters or in a line. See also List of cutaneous conditions References External links Dermatologic terminology

Seborrheic Dermatitis -- Differential Diagnosis -- Trunk

Psoriasis - sharply-defined red plaques with a loose, silvery lamella scale Pityriasis rosea - herald spot; collarette scale; Christmas tree distribution Pityriasis versicolor - not symmetrical; hypo/hyperpigmentation Subacute lupus erythematosus - photosensitive distribution Eczema (nummular) - intense pruritus Tinea corporis - raised leading edges and central clearing; uncommon in infants Erythema annulare centrifugum - recurrent polycyclic lesions that slowly expand and disappear Darier disease - Greasy wart-like papules and plaques Grover disease (transient acantholytic dermatosis) - acanthosis Drug reaction - drug history (neuroleptic; immunosuppressant; PUVA; lithium) Parapsoriasis - elderly; very slow growing; resistant to treatment Pemphigus foliaceus - fragile, painful blisters - Nikolsky sign is positive Secondary syphilis - lesions on the palms and soles; a history of chancre

Palmar lichen planus mimicking tinea nigra.

Lichen planus (LP) is a chronic inflammatory skin disease characterized by polygonal, violaceous papules commonly involving flexural areas of the wrists, legs, and oral and genital mucous membranes. This report describes a patient who presented with asymptomatic black colored patches on both palms simulating Tinea nigra, a superficial fungal infection. She was previously diagnosed as allergic contact dermatitis and was being treated with potent topical steroid i.e. clobetasol propionate 0.05% and white soft paraffin. Dermatoscopy of the lesion showed brownish pigmentation along ridges of the dermatoglyphics. A biopsy from the lesional skin showed findings of lichen planus. Our case highlights the potential diagnostic confusion that can occur with unusual variants of palmoplantar lichen planus and importance of histopathology in diagnosis of such unusual lesions.

[Papular mycosis fungoides].

Mycosis fungoides (MF) is the most common type of cutaneous T-cell lymphoma. A new form of incipient MF has recently been described: papular MF. Herein, we report a case and propose a literature review. A 63-year-old man presented with erythematous and non-pruritic papular lesions of the trunk. The general examination was unremarkable. A skin biopsy showed moderately dense epidermotropic lymphocytic infiltration consistent with MF. Screening for CD30 was negative. Treatment with an extremely potent corticosteroid (clobetasol, one application per day) seemed effective, with almost complete disappearance of the lesions. Many clinical variants of the initial stages of MF have been described, one of the most recent of which is papular mycosis fungoides (PMF), of which 10 cases are reported in the literature. PMF begins clinically with an erythematous, non-pruritic and chronic papular rash that is not associated with the classic erythematous-squamous lesions of incipient MF. There appears to be no predominance of gender, and the age of onset ranges from 31 to 63 years. Histological examination of the PMF lesions revealed an epidermotropic subepidermal infiltrate composed predominantly of CD4+T-cells. The prognosis appeared good with the treatments conventionally used for incipient MF. PMF is likened to a form of incipient MF with a good prognosis. Associated classic MF lesions comprising erythematous-squamous plaques have been described as the condition progresses. Differential diagnoses include pilotropic MF, pityriasis lichenoides chronica, pityriasis lichenoides varioliformis acuta, and especially type B lymphomatoid papulosis, the histopathological findings of which may be close to PMF. Papular MF would appear to be a papular variant of incipient MF with a good prognosis. However, it is necessary to obtain clinical and disease progression data for a greater number of patients in order to better characterize this entity.

Papulosquamous disorder

A papulosquamous disorder is a condition which presents with both papules and scales, or both scaly papules and plaques. Examples include psoriasis, lichen planus, and pityriasis rosea. See also List of cutaneous conditions References Further reading http://www.emedicine.com/derm/index.shtml#papulosquamous External links Dermatologic terminology Papulosquamous disorders

Lichen planus

Signs and symptoms Although lichen planus can present with a variety of lesions, the most common presentation is as a well defined area of purple-coloured, itchy, flat-topped papules with interspersed lacy white lines (Wickham's striae). This description is known as the characteristic "6 Ps" of lichen planus: planar (flat-topped), purple, polygonal, pruritic, papules, and plaques. This rash, after regressing, is likely to leave an area of hyperpigmentation that slowly fades. That said, a variety of other lesions can also occur. Skin

Malassezia Furfur -- Differential Diagnosis

Several dermatologic disorders may mimic PV. SD may occur on the trunk as PV does, but lesions are more erythematous with thicker scaling, and other locations, including the scalp, are usually involved. Pityriasis rosea may be differentiated from PV by the appearance of a herald patch before the onset of symptoms, "Christmas tree" distribution, and erythematous, scaling macules and patches. Whereas PV causes hypopigmented skin lesions, those seen in vitiligo are depigmented. The eczematous lesions of pityriasis alba also may appear as hypopigmented macules and patches; however, the face is primarily affected, and affected children typically have a history of atopy. Secondary syphilis must be ruled out in a patient with generalized hyperpigmented macules involving the palms and soles. Mycosis fungoides may present as hypopigmented lesions on the trunk and extremities, but scaling, erythema, and plaques are more characteristic. [17]

Vesicular palmoplantar pityriasis rosea.

A 16-year-old young man presented with intensely itchy erythematous dermatitis on the body for 1 week and vesicular lesions on the palms and soles for 4 to 5 days. Lesions on the palms and soles were accompanied by severe burning and itching. The patient gave a history of sore throat and fever, 1 week prior to the onset of lesions. A general physical examination was normal, and cutaneous examination revealed multiple, well-defined erythematous scaly plaques with collaret scaling on the trunk and extremities (Figure 1). Vesicular lesions were seen on the palms and soles (Figure 2). The differential diagnoses we considered were pityriasis rosea and secondary syphilis. The possibility of dermatophytid, vesicular pityriasis rosea, and pompholyx was limited to the palms and sole lesions. Complete blood cell count was within normal limits. Results from antistreptolysin O titer, potassium hydroxide mount, and venereal disease research laboratory were negative. Skin biopsies were taken from the back and left palm. The biopsy specimen from the back revealed focal spongiosis, lymphocyte exocytosis, vacuolar changes in the basal layer, and perivascular lymphocytic infiltrate in the dermis (Figure 3). The biopsy obtained from the vesicular lesion on the left palm revealed an intraepidermal vesicle with no evidence of acantolytic process (Figure 4). A diagnosis of pityriasis rosea was made and the patient was started on clarithromycin 500 mg once a day for 7 days, along with antihistamines and emollients. The lesions faded dramatically in a very short period, and there was significant involution of almost all of the lesions after 7 days of clarithromycin. During the 6 months of follow-up, no recurrence was observed.

Psoriasis

Diagnosis A diagnosis of psoriasis is usually based on the appearance of the skin. Skin characteristics typical for psoriasis are scaly, erythematous plaques, papules, or patches of skin that may be painful and itch. No special blood tests or diagnostic procedures are usually required to make the diagnosis. The differential diagnosis of psoriasis includes dermatological conditions similar in appearance such as discoid eczema, seborrheic eczema, pityriasis rosea (may be confused with guttate psoriasis), nail fungus (may be confused with nail psoriasis) or cutaneous T cell lymphoma (50% of individuals with this cancer are initially misdiagnosed with psoriasis). Dermatologic manifestations of systemic illnesses such as the rash of secondary syphilis may also be confused with psoriasis.

Lichen Nitidus -- History and Physical

Lichen nitidus usually presents as asymptomatic, shiny, flat-topped, fleshy pink to dark brown papules. They are typically 1 to 2 mm in diameter. In patients with darker skin lesions can appear as light spots. Lesions commonly present on the neck, trunk, limbs, abdomen, and penile shaft. The involvement of mucous membranes, palms, soles, and nails are rare, but there are reports. [2] [3] [4] If lichen nitidus is symptomatic, the patient mainly complains of mild sporadic pruritus. [3] Koebner phenomenon is a hallmark of lichen nitidus, as seen in lichen planus, but is not present in all cases. [3] [4] Rarely lichen nitidus will present only on the palms and soles and will usually present with lichen nitidus lesions in other locations. [11] If lesions present in the oral mucosa, they will be flat, greyish papules. [3] [12]

Pityriasis amiantacea

Diagnosis Pityriasis amiantacea can easily be misdiagnosed due to its close resemblance to other scalp diseases such as psoriasis, seborrhoeic dermatitis or lichen planus. However, in pityriasis amiantacea the scales are attached to both the hair shaft and the scalp. Pityriasis amiantacea may be present with other inflammatory conditions such as atopic dermatitis or seborrhoeic dermatitis and sebaceous scales and alopecia can occur. According to Bolognia's textbook "Dermatology," this rare condition is most often combined with psoriasis, but it may also develop as secondarily infected atopic dermatitis, seborrheic dermatitis, and/or tinea capitis. Treatment

InternalMed_Harrison

CHAPTER 71 Eczema, Psoriasis, Cutaneous Infections, Acne, and Other Common Skin Disorders Psoriasis Sharply demarcated, erythematous plaques with mica-like scale; predominantly on elbows, knees, and scalp; atypical forms may localize to intertriginous areas; eruptive forms may be associated with infection Lichen planus Purple polygonal papules marked by severe pruritus; lacy white markings, especially associated with mucous membrane lesions Pityriasis rosea Rash often preceded by herald patch; oval to round plaques with trailing scale; most often affects trunk; eruption lines up in skinfolds giving a “fir tree–like” appearance; generally spares palms and soles Dermatophytosis Polymorphous appearance depending on dermatophyte, body site, and host response; sharply defined to ill-demarcated scaly plaques with or without inflammation; may be associated with hair loss May be aggravated by certain drugs, infection; severe forms seen in association with HIV

Epidermodysplasia verruciformis

Signs and symptoms Clinical diagnostic features are lifelong eruptions of pityriasis versicolor-like macules, flat wart-like papules, one to many cutaneous horn-like lesions, and development of cutaneous carcinomas. Patients present with flat, slightly scaly, red-brown macules on the face, neck, and body, recurring especially around the penial area, or verruca-like papillomatous lesions, seborrheic keratosis-like lesions, and pinkish-red plane papules on the hands, upper and lower extremities, and face. The initial form of EV presents with only flat, wart-like lesions over the body, whereas the malignant form shows a higher rate of polymorphic skin lesions and development of multiple cutaneous tumors. Generally, cutaneous lesions are spread over the body, but some cases have only a few lesions which are limited to one extremity.

Lichen planus

Lichen planus (LP) is a chronic inflammatory and immune-mediated disease that affects the skin, nails, hair, and mucous membranes. It is not an actual lichen, and is only named that because it looks like one. It is characterized by polygonal, flat-topped, violaceous papules and plaques with overlying, reticulated, fine white scale (Wickham's striae), commonly affecting dorsal hands, flexural wrists and forearms, trunk, anterior lower legs and oral mucosa. Although there is a broad clinical range of LP manifestations, the skin and oral cavity remain as the major sites of involvement. The cause is unknown, but it is thought to be the result of an autoimmune process with an unknown initial trigger. There is no cure, but many different medications and procedures have been used in efforts to control the symptoms.

Pemphigoid

Presentation Primary lesions of small and large blisters, known as vesicles and bullae, are found on the skin and sometimes on the mucous membranes. Non-bullous pemphigoid In some patients, pemphigoid starts off with cutaneous manifestations of BP without bullae, as the only sign of the disease. Pruritic eczematous, papular, or urticaria-like skin lesions may also persist for weeks to months. Bullous phase The bullous stage of BP shows vesicles and bulla, appearing on apparently normal or erythematous skin, predominantly at the flexural aspects of the extremities and the lower trunk. Mucosal lesions, which typically are erosions of the oral mucosa, are present in 10 to 30 percent of patients. Occasionally, the blister fluid becomes blood-tinged. The blisters are tense, about 1–4 cm in diameter, leaving eroded and crusted areas, together with urticarial and infiltrated papules and plaques in an annular or figurate pattern.

Pityriasis Rosea -- History and Physical

The rashes of pityriasis rosea usually last for five weeks and resolve by 8 weeks in more than 80% of patients. Pityriasis rosea needs to be differentiated from secondary syphilis, dermatophytosis, guttate psoriasis, nummular eczema, pityriasis lichenoid chronic, cutaneous T-cell lymphoma, erythema annular centrifugal and erythema chronic migrans.

Psoriasis of the Nails -- Differential Diagnosis

Onychomycosis: The changes of onychomycosis resemble nail psoriasis, and sometimes it is difficult to distinguish between the two. Nail pitting, onycholysis, and oil drop sign are the main features of nail psoriasis. Onychomycosis can be diagnosed by fungal culture, nail clipping with periodic acid Schiff( PAS)and potassium hydroxide (KOH) preparations. [1] Alopecia areata: It usually appears as linear ridging, nail pitting, longitudinal nail fissuring, and some other nail abnormalities along with non-scarring patchy alopecia of the scalp or other body areas. Lichen planus: Nail involvement presents as thinning of nails with ridges and grooves of the nail plate sometimes scarring of cuticle occur leading to pterygium formation. Lichen planus also involves the mucosa or skin. The skin manifestations of lichen planus are itchy, purple, polygonal papules or plaques. [13]

InternalMed_Harrison

Lichen planus (LP) is a papulosquamous disorder that may affect the skin, scalp, nails, and mucous membranes. The primary cutaneous lesions are pruritic, polygonal, flat-topped, violaceous papules. Close examination of the surface of these papules often reveals a network of gray lines (Wickham’s striae). The skin lesions may occur anywhere but have a predilection for the wrists, shins, lower back, and genitalia (Fig. 71-5). Involvement of the scalp (lichen planopilaris) may lead to scarring alopecia, and nail involvement may lead to permanent deformity or loss of fingernails and toenails. LP commonly involves mucous membranes, particularly the buccal mucosa, where it can present on a spectrum ranging from a mild, white, reticulate eruption of the mucosa to a severe, erosive stomatitis. Erosive stomatitis may persist for years and may be linked to an increased risk of oral squamous cell carcinoma. Cutaneous eruptions clinically resembling LP have been observed after administration of


In young contacts, chemoprophylaxis should be started even if the mantoux test is negative and repeated after 2-3 months to decide whether to continue treatment for 6 months (if it turns positive) or to stop it.

A 14-year-old asymptomatic boy whose father has just been diagnosed with pulmonary TB undergoes a Mantoux test, with a negative result. What is the appropriate course of action?

Start chemoprophylaxis and repeat skin test after 3 months.

A sputum study should be performed before starting chemoprophylaxis with Isoniazid for 1 year.

Decision analysis, public health policy, and isoniazid chemoprophylaxis for young adult tuberculin skin reactors.

As part of a plan to eliminate tuberculosis in America, tuberculin skin testing was advised for all US citizens, with isoniazid chemopreventive therapy administered to appropriate positive reactors. Implementation of this plan, however, may be limited by concerns over which skin test reactors should receive isoniazid therapy. Recent decision analyses suggest that, contrary to American Thoracic Society guidelines, asymptomatic skin test reactors under age 35 years with normal chest roentgenograms and no predisposing conditions to tuberculosis reactivation will not benefit from isoniazid chemopreventive therapy. Repeated analysis of these studies reveals that calculated life expectancy depends on estimates of the probability of certain chance outcomes. If the isoniazid-related hepatitis case-fatality rate is below 1%, isoniazid chemopreventive therapy appears to be beneficial. A literature review suggests that this rate is indeed this low. If the tuberculosis case-fatality rate is above 6.7%, also supported by the literature, the advantages of isoniazid therapy are further increased. This repeated analysis should reassure physicians that isoniazid chemoprophylaxis for tuberculin skin test reactors is beneficial to the individual and consonant with public health policies.

[Outbreak of pulmonary tuberculosis in which tuberculosis developed from QuantiFERON-TB second generation (QFT-2G) test negative persons].

To clarify the points to be considered when QFT-2G tests are used in the contacts examination by public health center. We analyzed the results of contacts examination on 43 workplace colleagues (39 y/o and younger) of a pulmonary tuberculosis patient (bII2, Gaffky 9, cough for 1.5 months). After two months of the last contact with the index case, tuberculin skin tests, QFT-2G tests and chest X-rays were undertaken. After 6 months, chest X-rays were taken, and after 9 months, QFT-2G tests and chest CT scans were also undertaken. The tuberculin skin tests after two months showed a bimodal distribution, and 10 were QFT-2G positive and 2 showed doubtful reaction. The latter 12 persons underwent chemoprophylaxis. After 6 months, however, out of 31 QFT-2G negative persons, 2 developed pulmonary tuberculosis. Moreover, after 9 months, chest CT scans revealed 5 pulmonary tuberculosis patients. Three out of 7 new patients showed positive or doubtful reactions in QFT-2G tests undertaken after 9 months. The sensitivity of QFT-2G tests is reported to be 80 to 90%, and the possibility of false negative is not negligible. We propose measures for public health center to conduct the contacts examination as follows; In case of high QFT-2G positive (including doubtful reaction) rate and/or a bimodal distribution of tuberculin skin test result, many infected persons are likely to be included in the group; and the following measures are recommended; 1) Necessity of chemoprophylaxis should be judged considering both tuberculin skin test results and the situation of contact with the index case, and not only by QFT-2G test results. 2) QFT-2G negative persons also need to be followed with chest X-rays.

Detection of pulmonary tuberculosis in patients with a normal chest radiograph.

To describe the early symptoms of pulmonary tuberculosis (TB) when the chest radiograph (CXR) is normal. Centralized, provincial TB control program. Twenty-five patients with culture-positive pulmonary TB and a normal CXR were identified from a review of 518 consecutive patients with culture-positive pulmonary TB in the province of Saskatchewan from January 1, 1988 to March 31, 1997. Patients with abnormal CXRs at the time of diagnosis were excluded from the analysis. Twenty-three of the 25 patients (92%) were symptomatic at the time of diagnosis, with cough/sputum (76%) being reported most commonly. Eleven patients were identified because of contact tracing from cases of infectious pulmonary TB, while the other 14 patients were identified because of an investigation of symptoms. Twenty-four patients (96%) exhibited one or more symptoms of cough for > 1 month, fever for > 1 week, or skin-test conversion after contact with infectious TB. The sputum smear of only one patient was positive. Two patients were pregnant at the time of diagnosis, one patient was HIV-positive, and one patient demonstrated isoniazid-resistant organisms on sensitivity testing. Five patients were diagnosed as having primary TB associated with Mantoux skin-test conversion. The incidence of culture-positive pulmonary TB with a normal chest radiograph was < 1% in the period from 1988 to 1989 and steadily increased to 10% in the period from 1996 to 1997. Culture-positive pulmonary TB with a normal CXR is not uncommon, and the incidence of this presentation is increasing. Patients with this presentation of TB are typically symptomatic and/or are detected by contact tracing to infectious cases of pulmonary TB. The results suggest that patients presenting with a cough for > 1 month, with a fever for > 1 week, or with documented skin-test conversion < 2 years after known exposure to infectious TB should have sputum submitted for a Mycobacterium tuberculosis smear and culture despite a normal CXR.

Underutilization of isoniazid chemoprophylaxis in tuberculosis contacts 50 years of age and older. A prospective analysis.

To examine the utilization of chemoprophylaxis for tuberculosis in certain high-risk groups, ie, infected contacts 50 years and older, and to study the safety of isoniazid (INH) preventive therapy in such persons. From 1987 to 1992, two-part questionnaires were sent to each of the regional health offices within the 95 counties of Tennessee to document cases of purified protein derivative skin test conversion or reaction among close contacts of new patients with active tuberculosis. Infected contacts 50 years and older were included in the study. Data collected from these questionnaires were grouped according to age, sex, race, liver functions test (LFT), and whether chemotherapy was completed. Reasons for early discontinuation were also recorded. High values of LFTs were classified in the various groups as either twofold elevation or greater than threefold elevation. Of the 829 responses for persons fitting the criteria for INH chemoprophylaxis, 415 began treatment; 249 (60%) of those completed the full course (9 months) and 166 stopped prematurely. Of the 414 persons (50%) who did not start preventive therapy, 233 (56.5%) respondents listed age as the reason. No patients started on a regimen of therapy developed hepatitis. Of those completing therapy, 6.9% had a rise in liver enzyme values but remained asymptomatic for hepatitis. Liver enzyme level elevation was significantly higher among patients who discontinued therapy, particularly white women, than those who completed the full course. Asymptomatic liver enzyme level elevation (> or = 3 times normal value), private practitioners' preferences, and patients arbitrarily stopping therapy were the leading reasons for incomplete INH preventive therapy. We conclude that 30% of tuberculosis-infected contacts deserving chemoprophylaxis were actually provided the full benefit of INH preventive therapy, indicating underutilization of this prevention strategy, particularly in contacts older than 50 years.

[A case of isoniazid-resistant tuberculosis diagnosed during chemoprophylaxis with isoniazid].

A 15-year-old man, who was a classmate with the index case of a large outbreak of tuberculosis in a junior high school in Kochi city, showed strongly positive reaction to tuberculin skin test in March 1999. After taking a chest X-ray film, which showed no abnormal finding, chemoprophylaxis with isoniazid was started in April 1999. He was compliant with therapy, and had no symptom until July 1999, when he was checked again by chest X-ray and abnormal finding was suspected. He visited a hospital for further examinations, and chest X-ray revealed cavitary lesion and sputum smears showed acid-fast baccili. Cultures of the sputum was positive for Mycobacterium tuberculosis, and drug susceptibility tests revealed that the organism was resistant to isoniazid (5 micrograms/ml) and sensitive to RFP, SM, and EB. RFLP analysis of Mycobacterium tuberculosis isolated from the index-case patient and the present patient demonstrated an identical pattern, although the organism obtained from the index-case patient was sensitive to isoniazid, RFP, SM, and EB. Mycobacterium tuberculosis isolated from other 7 patients in the same outbreak showed an identical pattern in RFLP analysis and were also sensitive to isoniazid. The present patient was a close contact with the highly infectious index-case patient. The patient was estimated to be infected around September to October, 1998, and chemoprophylaxis with isoniazid was started in April 1999, when the tubercle baccili had grown considerably, but not enough to show radiographic abnormality. These two factors might be attributable to rarely seen development of isoniazid resistance in this case.

[The current situation and treatment of childhood tuberculosis].

We performed a retrospective analysis of 394 patients who were treated for active tuberculosis (TB) at our hospital from 1976 to 1997. The diagnosis criteria for establishing TB were history of direct contact with TB patients, tuberculin skin test reactivity, positive bacteriology and radiographic findings compatible with TB. There were 192 males and 202 females (age range 1 month to 18 years of age, mean 6.3 years of age). Fifty-four percent of the cases were under 5 years of age. Primary pulmonary TB was presented in 200, post primary pulmonary TB in 97, pleural effusion in 53, endbronchial TB in 4, TB meningitis (TBM) in 28, miliary TB in 28 and other extra-pulmonary TB in 31. A history of contact with the patients was obtained in 72.8% of cases. Two hundred and thirty (58.4%) had received BCG, 134 (34%) no BCG, 30 (7.6%) were unclear. Especially, under 5 years of age, only 29 (13.6%) had received BCG. TBM is not disappeared in Japan and there were 28 cases with TBM. Fifteen patients out of them recovered completely, 8 patients recovered with severe neurological sequelae which included mental retardation, motor weakness, seizures and hydrocephalus and 5 patients died. Twenty-six had no BCG. Particularly in 1990s, we had experienced 4 dead TBM cases, 1 multi-drug resistant (MDR) TBM case and 1 TBM case due to nosocomial infection. Children with TBM should received 12-month regimen using initial daily treatment with isoniazid, rifampin, pyrazinamide, and streptmycin, followed by isoniazid and rifampin administered daily. Pulmonary TB in children is successfully treated with 6-month standard chemotherapy using isoniazid, rifampin, and pyrazinamide daily for 2 months, followed by isoniazid and rifampin daily for 4 months. In order to promote TB control and eliminate childhood TB, especially in infants, the following is necessary; 1) early detection and treatment of adult TB patients, source of infection, 2) prompt and appropriate contact examination and chemoprophylaxis, 3) BCG vaccination during early infancy, 4) protection from MDR TB are most important in Japan.

[Study on familial attacks of pulmonary tuberculosis in Sapporo City].

We studied familial attacks of pulmonary tuberculosis in Sapporo City from 1987 to 1990. There were 146 sources of infection. Two hundred twenty three were infected secondly. Chemotherapy was given to the 75 out of 223 patients. Chemoprophylaxis was given to the total of 148 children. The average ages of the sources, those who were infected secondly and those who had given chemoprophylaxis were 44.8, 32.2 and 7.7 years of age respectively. The ratio of male vs female was 1:0.4 among the sources. The main routes of transmission of this disease were from husbands to wives, from fathers to children, and from grandfathers to grandchildren. The patients who did not have health examination in the preceding one year of their present diagnoses had more severe state of disease as well as higher Gaffky degrees and were treated for more than one year. The infectious patients accounted for more than 50% of the active pulmonary tuberculosis in Sapporo City in 1990. Tuberculin skin test has been performed in almost cases of family examination and the period of chemoprophylaxis has been standardized along the guideline for the chemoprophylaxis by Japan Tuberculosis Association and the Ministry of Health and Welfare. Family and relatives of the patient who expectorates tuberculosis bacilli should take at least one examination annually. Younger people should take it more frequently and chemoprophylaxis should be given to the child whose reaction of Tuberculin skin test is strongly positive.

Heaf test

The reading of the Heaf test was defined by a scale: Negative - No induration, maybe six minute puncture scars Grade 1 - four to six papules (also considered negative) Grade 2 - Confluent papules form indurated ring (positive) Grade 3 - Central filling to form disc (positive) Grade 4 - Disc >10 mm with or without blistering (strongly positive) Grades 1 and 2 could result from previous BCG or avian tuberculosis, rather than human TB infection. Children who were found to have a grade 3 or 4 reaction were referred for X-ray and follow-up. For interpretation of the test, see Tuberculosis diagnosis. Other tests The equivalent Mantoux test positive levels done with 10 TU (0.1 mL 100 TU/mL, 1:1000) are 0–4 mm induration (Heaf 0-1) 5–14 mm induration (Heaf 2) >15 mm induration (Heaf 3-4) The Mantoux test is preferred in the United States for the diagnosis of tuberculosis; multiple puncture tests, such as the Heaf test and Tine test, are not recommended. References

Tuberculosis diagnosis

Tuberculin skin test Two tests are available: the Mantoux and Heaf tests. Mantoux skin test The Mantoux skin test is used in the United States and is endorsed by the American Thoracic Society and Centers for Disease Control and Prevention (CDC). If a person has had a history of a positive tuberculin skin test, another skin test is not needed. Heaf test The Heaf test was used in the United Kingdom until 2005, and is graded on a four-point scale. The Mantoux test is now used. The equivalent Mantoux test positive levels done with 10 TU (0.1 ml 100 TU/ml, 1:1000) are 0–4 mm induration (Heaf 0 to 1) 5–14 mm induration (Heaf 2) Greater than 15 mm induration (Heaf 3 to 5)

Latent tuberculosis

The results of both tests are roughly equivalent as follows: Heaf grade 0 & 1 ~ Mantoux less than 5 mm; Heaf grade 2 ~ Mantoux 5–14 mm; Heaf grade 3 & 4 ~ Mantoux 15 or greater Tuberculin conversion Tuberculin conversion is said to occur if a patient who has previously had a negative tuberculin skin test develops a positive tuberculin skin test at a later test. It indicates a change from negative to positive, and usually signifies a new infection.

Mantoux test

Use of two-step testing is recommended for initial skin testing of adults who will be retested periodically (e.g., health care workers). This ensures any future positive tests can be interpreted as being caused by a new infection, rather than simply a reaction to an old infection. The first test is read 48–72 hours after injection. If the first test is positive, consider the person infected. If the first test is negative, give a second test one to three weeks after the first injection. The second test is read 48–72 hours after injection. If the second test is positive, consider the person infected in the distant past If the second test is negative, consider the person uninfected. A person who is diagnosed as "infected in the distant past" on two-step testing is called a "tuberculin reactor". The US recommendation that prior BCG vaccination be ignored results in almost universal false diagnosis of tuberculosis infection in people who have had BCG (mostly foreign nationals).

InternalMed_Harrison

It is estimated that about 2 billion people, or nearly one-third of the human population, have been infected with M. tuberculosis. Although only a small fraction of these infections will progress toward active disease, new active cases will continue to emerge from this pool of “latently” infected individuals. Unfortunately, there is no diagnostic test at present that can predict which individuals with LTBI will develop active TB. Treatment of selected persons with LTBI aims at preventing active disease. This intervention (also called preventive chemotherapy or chemoprophylaxis) is based on the results of a large number of randomized, placebo-controlled clinical trials demonstrating that a 6to 9-month course of isoniazid reduces the risk of active TB in infected people by up to 90%. Analysis of available data indicates that the optimal duration of treatment is ~9 months. In the absence of reinfection, the protective effect is believed to be lifelong. Clinical trials have shown that

Health professional

Recommended testing procedures The CDC recommends either a blood test, also known as an interferon-gamma release assay (IGRA), or a skin test, also known as a Mantoux tuberculin skin test (TST). It is not the intention of this article to explore the protocol of carrying out a proper TB test. A TB blood test for baseline testing does not require two-step testing. If the skin test method is used to test HCP upon hire, then two-step testing should be used. A one-step test is not recommended. Two-step testing The CDC has outlined further specifics on recommended testing for several scenarios. In summary: Previous documented positive skin test (TST) then a further TST is not recommended Previous documented negative TST within 12 months before employment OR at least two documented negative TSTs ever then a single TST is recommended All other scenarios, with the exception of programs using blood tests, the recommended testing is a two-step TST

Randomised trial of thiacetazone and rifampicin-containing regimens for pulmonary tuberculosis in HIV-infected Ugandans. The Makerere University-Case Western University Research Collaboration.

Among HIV-positive patients who received treatment for active tuberculosis, thiacetazone has been associated with cutaneous hypersensitivity and recurrent tuberculosis. No controlled trials have investigated the safety and efficacy of thiacetazone-containing regimens compared with alternative regimens among patients with HIV. In a randomised clinical trial of 191 HIV-positive patients with active pulmonary tuberculosis, we examined the safety and short-term efficacy of isoniazid, rifampicin, and pyrazinamide for two months followed by isoniazid and rifampicin for seven months (RHZ) compared with streptomycin, thiacetazone, and isoniazid for two months followed by thiacetazone and isoniazid for ten months (STH). Between May, 1990, and September, 1991, 191 HIV-positive adult Ugandan patients with acid-fast bacilli sputum smear-positive pulmonary tuberculosis (93% confirmed by culture) received either STH or RHZ. Subjects had a standard evaluation that included Mantoux skin test, complete blood count with differential white blood cell count, and chest radiography. After starting therapy, subjects were followed-up over one year for three outcomes: complications of anti-tuberculosis therapy, early sterilisation of cultures, and survival. Of 191 eligible subjects, 90 received STH and 101 received RHZ. The overall one-year survival was similar for STH and RHZ (65% vs 72%), but when controlled for baseline differences in Mantoux reaction size and absolute lymphocyte count, the relative risk of death for STH compared with RHZ was 1.57 (95% CI 1.0-2.48). Overall, 12 adverse drug reactions occurred in the STH arm (18.2 reactions per 100 person years [PYO]) compared with one in the RHZ arm (1.6 reactions per 100 PYO) for a relative risk of 11.7 (95% CI 1.52-90.0). 10 cutaneous reactions occurred in the STH arm (15.2 events per 100 PYO) compared with one event in the RHZ arm (1.6 events per 100 PYO) for a relative risk of 9.7 (95% CI: 1.24, 75.8). A greater proportion of RHZ patients compared with STH patients had sterilised their sputum within two months (74% vs 37%, p < 0.001). In developing countries, rifampicin-containing regimens should be given, when possible, to HIV-positive patients to reduce drug toxicity and to prolong survival.

Latent tuberculosis

The UK guidelines are formulated according to the Heaf test: In patients who have had BCG previously, latent TB is diagnosed if the Heaf test is grade 3 or 4 and have no signs or symptoms of active TB; if the Heaf test is grade 0 or 1, then the test is repeated. In patients who have not had BCG previously, latent TB is diagnosed if the Heaf test is grade 2, 3 or 4, and have no signs or symptoms of active TB. Repeat Heaf testing is not done in patients who have had BCG (because of the phenomenon of boosting). For details of tuberculin skin test interpretation, please refer to the BTS guidelines (references given below).

Low uptake of isoniazid window prophylaxis in patients exposed to a health-care worker with pulmonary tuberculosis in a paediatric ward.

A nurse on a paediatric multidisciplinary ward was diagnosed with smear-positive pulmonary tuberculosis. Children <2 years old, immunocompromised, or >40 h of contact (n = 173) were contact-traced. Children received clinical review, chest X-ray, tuberculin skin test (TST; <5 years old) and/or an interferon-gamma release assay (Quantiferon TB-Gold, ≥5 years old). Infants <6 months old or children <5 years old screened <2 months from exposure were recommended isoniazid window prophylaxis (WP) until a repeat TST at 6 months old or 8-10 weeks after the last exposure to the index case, respectively. Empiric treatment for latent tuberculosis infection (LTBI) was individually considered for immunocompromised patients. Of 173 children (135 immunocompetent, 38 immunocompromised), two were uncontactable, seven refused screening and two immunocompromised children excluded. Eight of 126 immunocompetent children were diagnosed with LTBI (initial TST positive n = 7, TST conversion n = 1); seven started isoniazid. Thirty-two of 36 immunocompetent children were recommended WP; 15 accepted (one non-compliant after 1 month). Six of seven immunocompromised children accepted empiric LTBI treatment due to severe immunosuppression/initial indeterminate Quantiferon TB-Gold result. Of 15 immunocompromised children offered WP, only five accepted. There was high acceptance of screening but low uptake of isoniazid WP in high-risk children exposed to pulmonary tuberculosis. Perception of exposure risk and chemoprophylaxis should be explored further.

Variability in the intradermal and in vitro lymphocyte responses to PPD in patients receiving isoniazid chemoprophylaxis.

Much attention has been focused on problems related to the interpretation of the tuberculin (Tb) skin test in terms of the "booster" phenomenon observed with repeated skin testing. However, relatively little attention has been given to the problem of the interpretation of repeat Tb skin tests in patients who have been given isoniazid (INH) chemoprophylaxis. Sixteen female hospital workers who were receiving INH for asymptomatic recent conversion of their Tb skin test, and 1 male physician under treatment with INH and rifampin for active tuberculosis as a result of a patient exposure, were studied over a 1-yr period. Intradermal skin tests with 5 tuberculin units purified protein derivative (PPD) and assessment of in vitro lymphocyte proliferation and production of leukocyte inhibitory factor on exposure to PPD were performed on 4 occasions at 3-month intervals-3 during therapy and 1 after completion of therapy. Four of 10 patients tested on all occasions showed at least 1 negative Tb skin test. In 2 of 4, the reversions were not stable. Considerable variability was observed between results of skin tests and in vitro lymphocyte responses, and no one in vitro lymphocyte response to PPD was adequate to identify the presence of delayed hypersensitivity to PPD. On the basis of these data, it is concluded that the presence of a single negative PPD skin test during or shortly after the completion of INH chemoprophylaxis does not constitute sufficient evidence to conclude that a patient has had a stable skin test reversion. Confirmation of the loss of tuberculin reactivity requires the in vitro assessment of lymphocyte responses to PPD both in terms of proliferation and the production of a lymphokine(s).

The use of repeat skin tests to eliminate the booster phenomenon in serial tuberculin testing.

During the early years of our annual tuberculosis skin testing program for hospital employees, we experienced conversion rates that were inordinately high. In an effort to eliminate the booster phenomenon in serial tuberculin testing as a contributing factor, a program of repeat skin testing performed within 7 to 28 days in new employees with less than 10-mm induration on initial skin testing was begun in 1978. Employees demonstrating a 6-mm increase in reaction size to a total induration of 10 mm or greater on repeat testing were classified as boosters. The booster rate for 1978 was 8.3%, and elimination of these employees from subsequent annual testing resulted in a decrease in the conversion rate from 8.7% in 1978 to 2.9% in 1979 (p less than 0.01). The rate of conversion was age-dependent in 1978, but this effect was absent in 1979 when the boosters were eliminated. On the basis of the results for the first 2 yr of our program, we concluded that repeat tuberculin skin testing is a practical approach to reduce falsely elevated conversion rates and can potentially reduce the number of persons exposed to the risk of isoniazid toxicity.

Tuberculosis in neonates and infants: epidemiology, pathogenesis, clinical manifestations, diagnosis, and management issues.

Tuberculosis is one of the leading infectious causes of death and as such represents a major global health problem. Infants may develop congenital tuberculosis from an infectious mother or, most commonly, they may acquire postnatal disease by contact with an infectious adult source. Important epidemiologic, pathogenetic, and clinical data regarding the management of infantile disease are reviewed. Diagnostic evaluation includes tuberculin skin tests, chest radiography and other imaging studies, smears and cultures, examination of the cerebrospinal fluid, and polymerase chain reaction, as well as the more recent interferon-gamma assay. Pregnant women with a positive Mantoux skin test but normal chest x-ray should either start chemoprophylaxis during gestation or after delivery depending on the likelihood of being recently infected, their risk of progression to disease, as well as their clinical evidence of disease. Pregnant women with a positive Mantoux skin test and chest x-ray or symptoms indicative of active disease should be treated with non-teratogenic agents during gestation; all household contacts should also be screened. When tuberculosis is suspected around delivery, the mother should be assessed by chest x-ray and sputum smear; separation of mother and offspring is indicated only if the mother is non-adherent to medical treatment, needs to be hospitalized, or when drug-resistant tuberculosis is involved. According to the American Academy of Pediatrics, treatment of latent infection is highly effective with isoniazid administration for 9 months. This regimen may be extended to 12 months for immunocompromised patients. When drug resistance is suspected, combination therapies, which usually consist of isoniazid with rifampin (rifampicin), are administered until the results of susceptibility tests become available. Organisms resistant to isoniazid only may be treated with rifampin alone for a total of 6-9 months. All infants with tuberculosis disease should be started on four agents (isoniazid, rifampin, pyrazinamide, and ethambutol or streptomycin) until drug susceptibility is assessed. For susceptible intrathoracic tuberculosis, isoniazid, rifampin, and pyrazinamide are administered for a total of 2 months, at which point pyrazinamide is withdrawn and the other two agents are continued for another 4-10 months depending on the severity of the disease. The same regimen may be applied in extrapulmonary tuberculosis with the exception of skeletal, miliary, and CNS disease, which require daily administration of isoniazid, rifampin, pyrazinamide, and streptomycin for 1-2 months, followed by isoniazid and rifampin daily or twice weekly for another 10 months. When drug-resistant tuberculosis is suspected, a regimen of isoniazid, rifampin, and pyrazinamide plus either streptomycin or ethambutol should be initially prescribed, until the results of susceptibility tests become available. HIV-seropositive infants with pulmonary tuberculosis should receive isoniazid, rifampin, pyrazinamide, and ethambutol or an aminoglycoside for 2 months, followed by isoniazid and rifampin for a total of at least 12 months. Apart from conventional antimycobacterial agents, novel therapeutic modalities, which stimulate the host immune system such as interleukin-2 (IL-2), IL-12, interferon-gamma, and tumor necrosis factor antagonists have been tested with promising results.

Ineffectiveness of annual chest roentgenograms in tuberculin skin test-positive hospital employees.

Annual routine chest x-ray examinations have been recommended for many years for tuberculin skin test-positive hospital employees who have not received chemoprophylaxis. To examine the case-finding effectiveness of this policy in a university teaching hospital, employee health records covering an 18-year period were reviewed. Pulmonary tuberculosis was diagnosed in four employees during that time period. None of the patients were identified through the routine annual chest x-ray examination. In the study institution the policy requiring routine annual chest x-ray examinations for tuberculin-positive hospital employees who had not received preventive therapy was rescinded. Currently, the first chest x-ray examination is required at the time of skin test conversion, the second 1 year after conversion, and the third 2 years after conversion. Health teaching and counseling regarding the symptoms of tuberculosis have been initiated for tuberculin-positive hospital employees.

[Minor outbreak of Tuberculosis infection in a junior high school--infection from a preventable case].

A second-year junior high school student (14 years old) was diagnosed as pulmonary tuberculosis. She was a member of the volleyball club in the school. She complained a high fever of 39 degrees at first on September 13, 2001. She visited a local physician and was administered medicine for a cold. On September 18, she was seen again for cough and fever, and informed the physician that her father was under treatment for pulmonary tuberculosis since June 2000. As a result, she was examined by chest X-ray, and was diagnosed as pulmonary tuberculosis with moderately positive smear and she was referred to hospital "N" where she was admitted on the next day. Three days after admission, a smear specimen of her sputum was heavily positive for tuberculosis bacilli. She had not been given any preventive chemotherapy when her father was diagnosed with TB because the results of her tuberculin skin test performed two months after her father's onset did not meet the criteria for preventive chemotherapy. Restriction fragment length polymorphism (RFLP) was carried out with 2 strains of tuberculosis bacillus isolated from her and her father, and the RFLP pattern of both strains was same. Thus, it can be concluded that the patient was infected from her father and developed pulmonary tuberculosis. A contact survey was subsequently carried out on October 4, 2001 for 107 students and 20 teachers at the school. None of the subjects examined showed any abnormalities on their chest X-ray. A tuberculin skin test survey of 105 students and one teacher was also carried out on November 12, 2001, about 2 months after the final contact. The diameter of skin reactions revealed a monomodal distribution pattern in subjects. The results of the present tuberculin skin test were verified with respect to the degree of contact and last tuberculin test in routine health examination at the school. Four students who had close contact with the patient evidently and showed a strong positive skin reaction of more than 30 mm in diameter in the present tuberculin skin test, accompanied by enhanced reaction of more than 20 mm compared with the last tuberculin skin test, were administered preventive chemotherapy.

Should we take a history of prior treatment, and check sputum status at 2-3 months when treating patients for tuberculosis?

Pinetown, South Africa (1975-1983). To determine the value of previous treatment history and sputum smear examination at 2-3 months in predicting treatment failure and relapse in tuberculosis patients treated with four drugs given twice weekly for six months under direct observation. Four cohort studies among 562 ambulant adults with culture positive pulmonary tuberculosis, designed to test the effectiveness of isoniazid 600-900 mg, rifampicin 600 mg, pyrazinamide 2-3 g, and streptomycin 1-2 g, given twice weekly. The same drug regimen was given to all patients irrespective of previous treatment history. Therapy was not changed if smears remained positive at 2-3 months. Positive predictive values of a history of previous treatment for a positive smear at 2-3 months (18.3%), treatment failure (5.2%), and relapse (9.4%) were poor. Although patients with positive smears at 2-3 months were more likely to fail therapy than patients with negative smears (relative risk=4.5, 95% Confidence Interval [CI]: 1.6-12.8), positive predictive value for treatment failure was only 12.5%. Although relapse was more frequent in patients with positive smears than those with negative smears (9.7% vs 6.2%; P=0.4), most patients who relapsed had been smear negative at 2-3 months (18/21). A four-drug rifampicin-containing regimen can safely be given twice weekly under direct observation to both new and retreatment cases, and the 2-3 month smear examination can safely be omitted.

[The significance of tuberculin skin test in the investigation of mass outbreak of tuberculosis in schools].

A high school teacher was diagnosed as pulmonary tuberculosis. He was 27 years old and taught bookkeeping to the 1st year grade students in classes 3 and 6, the 2nd year grade students in classes 4 and 5. He was also the assistant teacher in charge of class 1 of the 3rd year grade students and the adviser of the badminton club in the school. He first noticed a slight cough in November 1999, and visited his physician. On December 24, he visited again for a moderate cough, fever and chill and was administered medicine and drip infusion for a cold. In the middle of January 2000, he visited another physician for a severe cough. He was referred to hospital N and was admitted due to an abnormal shadow on chest X-ray films. The result of sputum smear examination was positive for AFB, Gaffky 8. Subsequent contacts examination was conducted for 153 students and 63 teachers of the school. A tuberculin skin test survey of 153 students was also carried out, in February 2000. The diameter of erythema revealed a monomodal distribution pattern in students, however, one student was diagnosed as pulmonary tuberculosis by the chest X-ray examination, and 27 (18%) showed erythema 40 mm and larger. They were indicated chemoprophylaxis as they were most likely newly infected in this epidemic. After 2 months, a second contact examination was conducted for the students (excluding those who underwent chemoprophylaxis or had tuberculosis) and all teachers. Based on chest X-ray examination, two new students and one teacher were diagnosed as pulmonary tuberculosis, and another one student was diagnosed as tuberculous pleurisy. Comparing the erythema size distribution in the first and second tuberculin tests, the distribution of the latter markedly shifted to right, namely became much larger than the former. It was assumed that students in whom the difference in erythema diameter was larger than 17 mm between the first and second examinations had been newly infected in this epidemic. Chemoprophylaxis was indicated for 45 students and 3 teachers. After 6 months, a third contact examination was conducted for the students and teachers (excluding those who underwent chemoprophylaxis or had tuberculosis). After a year, one teacher was diagnosed as pulmonary tuberculosis by the fourth contact examination (chest X-ray). Restriction fragment length polymorphism (RFLP) analysis was carried out with 2 strains of M. tuberculosis isolated from these patients (the index case and the second teacher patient), and the RFLP pattern of 2 patients was same.

[Chemotherapy of the source and the risk of infection in home contacts].

An attack treatment with 3 drugs during 4-6 months and a consolidation treatment with 2 drugs then INH was applied in 595 cases detected between July 1, 1968 and June 30, 1972, i.e. 264 group A (positive), 200 group B (negative cultures) and 131 group C (pleuretics). The contacts had been in close contact with the source for at least three months before establishing the diagnosis; 549 had been vaccinated at birth with BCG and 209 revaccinated; 413 had undergone chemoprophylaxis with INH.  The control group comprised 1008 subjects, the mean age of the groups being very close; they were followed up for 2 years and 1 month and 2 years and 7 months.  Testing was done every year with 1 u PPD IC 65. The contacts were controlled annually by radiophotography and X-ray and the controls only in case of shifting of the test. Among the contacts there were 44 conversions in the subjects with an initial tuberculin reaction of 0-5 mm and 4 in those with an initial tuberculin reaction of 6-9 mm, representing 15.1% (group A 27.7%, group B 9,8%, group C 10.5%). Three months after the initiation of chemotherapy the proportion of conversions in the three groups (group A 12.3%, group B 5.9%, group C 10.5%) was equal to that of the controls (8.8%). The next year there were 11.2% conversions among the contracts (group A 11.4%, group B 9.6% and C 17.7%) as against 11.9% among the controls. In the first year 8.3% of the contacts contracted tuberculosis (A 15.6%, B 2.4%, C 4.0%) and 0.32% of the controls. The next year 2.8% of the  contacts fell ill (A 4.3%, B 2%, C 0%) and 0.5% of the controls. Among group A contacts aged 0 to 6 years there were 31.7% conversions and 30.7% cases of tuberculosis in the first year, and 7.1% and 1.8% respectively in the following year. Group B and C presented 10.9% conversions and 6% cases of disease in the first year, and no case of tuberculosis in the second year. Chemotherapy reduced conversions and sickness in this group three months after the diagnosis was established.

Erythema induratum in a Kenyan child.

A 10-year-old Kenyan girl presented with a 9-month history of a persistent, painful eruption of multiple, tender, non-ulcerated, pigmented nodules involving the calves, shins and soles of the feet. She had recurring fevers particularly at night, lethargy, weight loss and a persistent non-productive cough. The Mantoux test was positive. Chest X-ray revealed mild peribronchial thickening in the hilar region but no evidence of hilar lymphadenopathy, consolidation and/or cavitation suggestive of tuberculosis. Sputum and gastric washings were negative for acid-fast bacilli. Histology on a skin biopsy showed a granulomatous panniculitis with no histological evidence of Mycobacterium tuberculosis, consistent with erythema induratum. In view of her constitutional symptoms, chronic non-productive cough and positive Mantoux test, she was diagnosed with pulmonary tuberculosis despite the non-specific chest X-ray and negative bacteriology. Anti-tuberculous therapy was initiated with pyrazinamide, isoniazid and rifampicin for 2 months followed by dual therapy with isoniazid and rifampicin for a further 4 months. Her constitutional and respiratory symptoms and skin eruption cleared within 6 months with treatment.

Tuberculin screening: cost-effectiveness analysis of various testing schedules.

Because there is no tuberculin screening schedule currently recommended for adults, we used a Markov process in a cost-effectiveness analysis to determine an optimal strategy. We simulated the prognosis of a cohort of black 20-year-olds to evaluate the effects of various screening schedules with intradermal tuberculin and administration of isoniazid prophylaxis to those with positive results. The schedule with the lowest cost-effectiveness ratio is a single screening at 50 years of age, which costs $41,672 per quality-adjusted life year (QALY) gained. The cost-effectiveness ratio is nearly the same for all schedules involving a single screening between 30 and 70 years of age. Repeated screening strategies are less cost effective. Sensitivity analysis shows that the range of acceptable screening strategies changes significantly under alternate assumptions about the mortality from isoniazid hepatitis. However, screening at 50 years of age remains nearly optimal under the alternatives considered. Altering the values of other parameters generally produced only small changes. Tuberculin screening at 50 years of age should be added to primary care preventive practices because the strategy is as cost effective as standard health interventions and is robust to alternative assumptions. If further research confirms the base case assumptions about isoniazid toxicity, consideration should be given to increasing screening to every 10 years, which would produce a larger health benefit, albeit at substantially higher cost.

[Development of cervical tuberculous lymphadenitis in a patient with Crohn's disease receiving infliximab despite of chemoprophylaxis with isoniazid].

We herein report a case of a 41-year-old female with a 14-year history of Crohn's disease who had been treated with diet and mesalazine. Because of inadequate control, therapy with infliximab was planned. She had a positive result on the interferon-gamma release assay (QuantiFERON TB). After active tuberculosis was ruled out by chest x-ray and computed tomography, she was started on a six-month course of isoniazid 7 weeks prior to starting infliximab. After 10 doses of infliximab (15 months of therapy), she presented with pain of cervical lymphadenopathy. A biopsy of the lymph nodes revealed Langhans giant cells from granulomas and a positive result of polylmerase chain reaction for Mycobacterium tuberculosis. The treatment with infliximab was discontinued and anti-tuberculosis therapy was started. Although treatment for latent tuberculosis infection lowers the risk of reactivation of tuberculosis due to tumor necrosis factor alpha-blockers, it cannot completely inactivate tuberculosis. Despite the completion of chemoprophylaxis, patients receiving such agents should be instructed to watch out for any symptoms associated with pulmonary and extrapulmonary tuberculosis such as fever, cough, malaise, body weight loss, night sweating and lymphadenopathy, and they should also be closely followed up.

How soon does cutaneous tuberculosis respond to treatment? Implications for a therapeutic test of diagnosis.

It is difficult to demonstrate Mycobacterium tuberculosis in smears or biopsies and to grow it in culture in cutaneous tuberculosis because most cases are paucibacillary. A therapeutic trial of antitubercular drugs is frequently used to confirm the diagnosis in difficult cases. Information is lacking on the response to antitubercular therapy in cutaneous tuberculosis; consequently there are no clear guidelines on when to expect a response and also when to abandon a therapeutic trial. We studied the records of 60 patients treated for cutaneous tuberculosis at our hospital to study the time course of the therapeutic response. All patients were treated with a short-course antitubercular regimen consisting of isoniazid 300 mg daily, rifampicin 450 mg daily, ethambutol 800 mg daily and pyrazinamide 1500 mg daily for 2 months followed by isoniazid and rifampicin in the same doses for 4 months. At follow-up visits, each patient was assessed by a dermatologist who recorded the presence or absence of clinical improvement in the skin lesions. Of the 60 patients seen, eight patients did not follow up after the initial consultation, 48 patients improved with treatment and four patients were classified as treatment failures. The timing of the first visit varied from 3 days to 15 months (median 27.5 days, mean 58.96 +/- 94.50) after initiation of treatment. Twenty-one patients were recorded to have improved within the first month of therapy. Twenty-seven patients who first reported more than 30 days after initiation of treatment were found to have improved. Four patients failed to respond during follow up ranging from 3 to 17 months. When a therapeutic trial is undertaken in cutaneous tuberculosis, 6 weeks of therapy with four drugs appears adequate to prove (or disprove) the diagnosis.

Disseminated Tuberculosis in a Psoriasis Patient under Adalimumab Treatment despite the Chemoprophylaxis of Latent Tuberculosis: A Case Report.

Recently, biologic therapy has become a major advance in the management of moderate-to-severe psoriasis. Although the overall safety profile of biologics is favorable, primary infection or reactivation of latent tuberculosis (TB) is the major concern in the setting of tumor necrosis factor-alpha inhibitor therapy. Therefore, the treatment of latent tuberculosis infection (LTBI) before starting biologics is mandatory to prevent the reactivation of LTBI. A 27-year-old female was treated with adalimumab due to psoriasis. As latent TB was detected by the interferon-γ release assay, we started isoniazid treatment (300 mg/day) 3 weeks before starting adalimumab and maintained this for 6 months. Although the patient's psoriatic skin lesions improved, after 45 weeks of adalimumab therapy, she visited the emergency department because of fever and back pain for 2 weeks. Abdominopelvic computed tomography (CT) and chest CT revealed multiple nodular lesions on both lungs, peritoneal wall, mesentery, and spleen, along with ascites. In the ascitic fluid, adenosine deaminase was increased to 96.4 U/L, and <iMycobacterium tuberculosis</i grew in an acid-fast bacilli culture. The patient was diagnosed with disseminated TB and treated with conventional TB medication with discontinuation of adalimumab. Five months after the completion of TB treatment, the ustekinumab, an interleukin (IL)-12/IL-23 inhibitor, was administered. Until now, her skin lesions are under excellent control without reactivation of TB for 9 months after starting ustekinumab.

Does a positive Heaf test reaction in Asian schoolchildren predict later breakdown of tuberculosis?

Some authorities advise giving prophylactic antituberculosis treatment to those with a grade 3 or 4 reaction to Heaf tests performed as part of the schools' BCG programme. This is not done in Leicestershire, which because of its large Asian population would require considerable resources to do so. A calculation of the "breakdown" rate, and thus the potential value of chemoprophylaxis, in these children would therefore be valuable. Lists of names of Asian children who had a grade 3 or 4 Heaf test reaction in 1982 and 1983 were compared with lists of notifications for the five years 1983 to 1987. Those who were on both lists were considered to have tuberculosis that had "broken down." Of the 760 children with positive Heaf test reactions, only four were on the subsequent notification lists. The chest radiograph obtained because of the Heaf test result showed evidence of active tuberculosis in only three of these. Only one child had infection that "broke down" later. The benefit of chemoprophylaxis seems likely to be limited in these Asian children, most of whom had received BCG early in life.

[Evaluation of screening for tuberculosis in a population of apprentices and high school children].

Taking into account the present epidemiological situation the health authorities of the Canton of Vaud, Switzerland, have decided to modify the strategy of tuberculosis prevention in children and adolescents by abandoning routine chest radiophotography while maintaining the tuberculin skin test. The present study focuses on the detection and follow-up of adolescents presenting with a positive tuberculin reaction at the first routine school health visit. As part of routine prophylactic school health measures, 753 boys and 1043 girls, aged 16 to 20, received 2 units of Danish tuberculin intradermally. 48 to 72 hours later, 100 subjects (5.6%) exhibited a pathological reaction and were sent to their doctors for further evaluation. 10% did not attend. Among the 90 remaining, the positive reaction to tuberculin test was not confirmed by the private physician in 48 (predictive value of the test: 47%). Among the 42 subjects for whom the reaction was confirmed, 39 had post-BCG vaccinal conversion and 3 spontaneous conversion. The prevalence of tuberculous infection was thus 2.3% (42/1796). Among the 42 positive subjects, only 18 (43%) were given preventive isoniazide treatment as recommended by the Association Suisse contre la Tuberculose et les Maladies Pulmonaires. Instruction on tuberculin testing and its interpretation must be improved, as must information regarding the prophylaxis and treatment of tuberculosis infection.

An outbreak of pulmonary tuberculosis and a follow-up investigation of latent tuberculosis in a high school in an eastern city in China, 2016-2019.

In October 2016, a senior high school student was diagnosed with sputum-smear positive [SS(+)] pulmonary tuberculosis (TB). We conducted an investigation of an outbreak in the school, including among students and teachers diagnosed with latent TB, who we followed until July 2019. We defined latent TB infection (LTBI) as a tuberculin skin test (TST) induration of 15mm or larger; probable TB as a chest radiograph indicative of TB plus productive cough/hemoptysis for at least 2 weeks, or TST induration of 15mm or larger; and confirmed TB as two or more positive sputum smears or one positive sputum smear plus a chest radiograph indicative of TB or culture positive with M. tuberculosis. We conducted mycobacterial interspersed repetitive unit-variable number tandem repeat (MIRU-VNTR) typing based on 24 loci in the isolates. Between October 2016 and July 2019, we identified 52 cases, including nine probable, six confirmed, and 37 LTBI cases. The index case-student had attended school continuously despite having TB symptoms for almost three months before being diagnosed with TB. We obtained three isolates from classmates of the index case in 2016; all had identical MIRU-VNTR alleles with the index case. The LTBI rate was lower among students (7.41%, 30/405) than among teachers (26.92%, 7/26) (rate ratio [RR] = 0.28, 95% confidential interval [CI]: 0.13-0.57). Among the 17 students who had latent TB and refused prophylaxis in October 2016, 23.53% (4/17) became probable/confirmed cases by July 2019. None of the six teachers who also refused prophylaxis became probable or confirmed cases. Of the 176 students who were TST(-) in October 2016, 1.70% (3/176) became probable/confirmed cases, and among the 20 teachers who were TST(-), 1 became a probable case. Delayed diagnosis of TB in the index patient may have contributed to the start of this outbreak; lack of post-exposure chemoprophylaxis facilitated spread of the outbreak. Post-exposure prophylaxis is strongly recommended for all TST-positive students; TST-negative students exposed to an SS(+) case should be followed up regularly so that prophylaxis can be started if LTBI is detected.