Tuberculous lupus, or lupus vulgaris, develops against the background of developing immunity in the post-primary or early secondary period with a benign course of tuberculosis. The occurrence of tuberculous lupus occurs endogenously, lympho- or hematogenously (tuberculosis of the lungs, lymph nodes, osteoarticular apparatus).

Clinical manifestations . The main morphological element of lupus is lupoma - a tubercle of yellowish-red or yellowish-brown color, in most cases, of a soft consistency. When pressed with a button probe, the latter easily penetrates into the depths of the infiltrate, which is due to the destruction of collagen and elastic fibers of the skin. When pressed with a glass spatula (diaskopia), the skin is drained of blood and the lupoma appears in the form of a spot the color of burnt sugar or apple jelly (apple jelly phenomenon). There are two main forms of lupus - flat and ulcerative, which, in turn, have a number of varieties, characterized by clinical features.

With a flat form of lupus, lupomas and plaques almost do not rise or protrude slightly above the level of the surrounding normal skin. Lupus tubercles develop slowly over months long time may remain unchanged. They are rarely located in the form of single elements, usually increasing through peripheral growth and merging with each other, forming plaques of different sizes and shapes. The tumor-like type of lupus is represented by soft tumor-like formations of a yellow-brown color. Most often, this type of lupus is localized on the tip of the nose, ears, but can be located on the chin and other parts of the body. Lumpy and tumor-like variants of lupus can exist independently, but often at the same time there are elements of flat lupus in the form of lumps and plaques.

The development of ulcerative lupus is always preceded by the formation of lupomas, which slowly, but sometimes relatively quickly, undergo ulceration. On the surface of the lesions, as a result of the disintegration of the lupous infiltrate, ulcerations are formed, which can occupy part of the lesion or the entire lesion area. Ulcers in lupus are superficial, with soft edges, painful, and often bleed easily.

The same patient often experiences different clinical manifestations of lupus: for example, lupus planus in combination with ulcerative, warty or other varieties, while the outcome of lupus is always the same - scarring. Scars are usually thin, smooth, superficial, pigmented, later depigmented, and easily gather into folds, but deep fibrous scars, similar to keloid scars, can also form. The favorite localization of lupus is the face (nose, upper lip, neck, submandibular region). Hypertrophic-ulcerative forms in children and adolescents relatively quickly cause destruction of the soft parts and cartilaginous septum

Tuberculous (vulgar) lupus. Treatment of tuberculous lupus

The disease is characterized by a chronic, slow course and a tendency to melt tissue. More often it begins in childhood and continues for years and decades. Recently, cases of lupus in adults have become more frequent. Infection by hemato- and lymphogenous route.

Lumps (lupomas) of a red-brown color, of different sizes, doughy consistency with a smooth shiny surface appear on the skin. Along the periphery of the lesions there is a stagnant red zone. Tuberculosis lupus most often appears on the face and ears. There are 2 pathogmonic symptoms:

symptom of “apple jelly” - when pressing on the tubercle with a glass slide, blood is squeezed out from the dilated and paralyzed vessels, and the tubercle becomes brownish-yellow in color.

symptom of “probe failure” (Professor Pospelov) - when pressing on the tubercle with a button-shaped probe, a dent forms on its surface, which straightens out very slowly. This phenomenon can be compared with the picture observed when pressing a finger on yeast dough. This is due to the destruction of collagen and elastic fibers in the lesion.

Lupomas resolve with scarring or cicatricial atrophy. New lupomas may form at the site of scarring.

Clinical forms.

Flat - represented by flat tubercles with silvery peeling and may resemble psoriasis.

Tumor-like - the infiltrate hypertrophies and rises sharply above the skin level. All are saved characteristic features lupomas.

Ulcerative – occurs due to injury to the focus and the addition of a secondary pyococcal infection. Lupus ulcers have a scalloped outline with a fine-grained bottom, which is covered with scanty discharge and bleeds easily.

Collicative tuberculosis of the skin (scrofuloderma).

The name of the disease shows that it is based on tissue softening.

Primary – skin lesions in any area due to hematogenous spread of infection from the affected organs. More often this is a single skin lesion.

Secondary - the infection spreads from the affected areas through a continuum lymph nodes.

Clinical manifestations.

One or more dense, painless limited nodes are noted in the subcutaneous tissue. Gradually, the node increases, reaching the size of a chicken egg, fuses with the surrounding tissues and protrudes sharply above the skin level. The skin over the node becomes red and then bluish. Fluctuation (cold abscess) gradually appears. The skin becomes thinner, the infiltrate breaks through, and serous-purulent-hemorrhagic fluid is released through the fistula.

Healing is very slow with the formation of characteristic scars. They are uneven, keloid-like, in some places they have bridges and jumpers, between which there are areas of healthy skin (“bridge-like” scars). New nodes may form under the scars.

Ulcerative tuberculosis of the skin and mucous membranes.

Observed in patients with active tuberculosis internal organs. Caused by autoinactivation. Localized around the mouth, nasal passages, anus, genitals.

Small yellow-red nodules are formed, which are prone to pustulation and ulceration. At the bottom of these ulcers there are caseously degenerated tuberculous tubercles - “Trel grains”. Pain, difficulty in eating, urinating, and defecating develop.

Diagnostic principles.

characteristic clinical picture;

medical history data (history of tuberculosis, contacts with tuberculosis patients, unfavorable social status);

tuberculin tests;

histological studies;

culture of pathological discharge on nutrient media(Levenshtein-Jensen or Finn II);

the presence of concomitant lesions of tuberculosis etiology.

Principles of treatment.

N.B.! Treatment must be comprehensive and long-term!

Etiotropic therapy:

GINK preparations: isoniazid, ftivazid, tubazid;

rifampicin;

streptomycin, kanamycin;

Pathogenetic therapy:

desensitizing therapy;

vitamin therapy;

hormone therapy;

physiotherapeutic procedures;

climatotherapy;

therapeutic nutrition rich in proteins, carbohydrates, vitamins.

LEPROSY

This is a chronic infectious disease primarily affecting the skin, mucous membranes and peripheral nervous system. Historical names: leprosy, sorrowful disease, black sickness, lazy death.

Etiology.

Pathogen: Mycobacterium leprae (G. Hansen, 1871) – Hanson’s bacillus.

Alcohol-resistant.

Acid-resistant.

Does not have a capsule.

Does not form a dispute.

Not cultivated.

Microscopy and Ziehl-Neelsen staining (curved rods arranged in bunches in the form of a “bunch of bananas”).

The source of infection is a sick person.

Routes of infection.

Through the mucous membrane of the upper respiratory tract.

Through damaged skin.

By consuming contaminated food and water.

The incubation period is from 6 months to 20 years (on average 5-7 years).

Epidemiology.

The main source of the disease is the countries of Africa and Southeast Asia. The largest number of leprosy patients is in Brazil (for this “achievement” the country is listed in the Guinness Book of Records). Every year, 500-800 thousand patients are diagnosed worldwide. In total, according to WHO data, there are about 12-15 million patients in the world, but according to modern approaches For medical examination, after a 2-year course of therapy, patients are removed from the register. The total number of registered people is 1 million.

In the Russian Federation (2001), 711 patients with leprosy were registered. Main foci: Astrakhan region, North Caucasus, Yakutia, Far East. There are 2 leper colonies on the territory of the Russian Federation: in Zagorsk (Moscow region) and Astrakhan (Leprosy Research Institute).

In the Omsk region, no patients have been registered for many years.

Classification(after Ridley-Jopling, Bergen, 1973).

The essence of the classification is that there are 2 forms of leprosy: lepromatous (benign) and tuberculoid (malignant).

lepromatous polar;

lepromatous subpolar;

lepromatous borderline;

border;

tuberculoid borderline;

tuberculoid subborderline;

tuberculoid polar;

undifferentiated.

LEPROMATOUS LEPROSIS.

Reddish spots with a bluish tint appear on the skin. Gradually they transform into a dense, powerful infiltrate. The process involves subcutaneous fatty tissue– nodes (lepromas) form. Localization is most often on the extensor surfaces of the forearms, on the face, in the forehead, brow ridges, cheeks, nose. The face takes on a ferocious expression - facies lionica (lion's muzzle). The lesions ulcerate and then scar.

Often the nasal mucosa of the cartilaginous part of the septum is involved in the process with the development of chronic lepromatous ulcerative rhinitis. Infiltrates form in the area of the tongue, hard and soft palate, which spread to the mucous membrane of the larynx and vocal cords, as a result, hoarseness of the voice occurs, and then aphonia. Characteristic is the disappearance of sensitivity in the lesions.

Lepramotosis type.

It is characterized by a complete lack of body resistance to the pathogen, the development of macrophage granulomas with a tendency to limitless intracellular proliferation of mycobacterium leprosy. Desimination of the process and negative lepromin test.

Tuberculoid type.

It is characterized by pronounced body resistance to Mycobacterium leprosy and the development of tuberculoid granuloma. There is a tendency to limit the process, with low bacilli and a positive lepromin test.

Undifferentiated form.

Assumes an uncertain immune response from the body. Morphological nonspecific lymphocytic infiltrate, small bacilli, positive-negative lepromin test.

Diagnostic principles.

Typical clinical picture.

Medical history (stay in leprosy-endemic areas, prolonged contact with a leprosy patient).

Collection of material (scraping from the mucous cartilaginous part of the nasal septum, tissue juice from biopsied tissue from lesions).

Microscopy with Ziehl-Neelsen staining.

PCR diagnostics.

Diagnosis by infecting mice in the flesh of their footpads. Armadillos are also used as experimental animals. certain types monkeys

Principles of treatment.

Etiotropic combination therapy(destruction of mycobacteria).

Prevention and treatment of reactive conditions.

Prevention and treatment of neurological complications.

Teaching the patient the rules of behavior in the absence of sensitivity.

Social adaptation.

Anti-leprosy drugs: dapsone, diucifon, dimocyphon; rifampicin; lampren (clofazimine).

Prevention of leprosy(determined by the national leprosy control program).

According to the Zagorsk leper colony, patients with the lepromatous type are treated in a hospital for 3 to 5 years, and then treated in a hospital for the rest of their lives. outpatient setting. For tuberculosis type – 1 year inpatient treatment, all my life - under dispensary observation. Persons who were in contact with patients - preventive treatment for 6 months at the place of residence.

regular preventive examinations in endemic regions;

vaccination (BCG) of the population of endemic regions;

isolation of identified patients in the leper colony;

determining the circle of people to whom the patient could transmit the infection;

preventive treatment of family members aged 2-60 years;

sanitary educational work.

A disease like tuberculous lupus, develops rather slowly, but carries with it many negative consequences. It often develops into chronic form. Treatment can last for years. At risk for this disease are adults with weak immune systems and children. The disease affects the epidermis layer. On skin appears severe irritation, which, as the disease progresses, quickly grows over the entire area of the body. Infected cells impair blood flow and tissue regeneration. Stop development pathological process possible by starting treatment of the disease on time.

In most cases, cutaneous tuberculosis or lupus does not have a pronounced character during development.

Symptoms of the disease in which you need to see a doctor and undergo an examination:

The appearance of a rash or irritation on the skin of the face, limbs, back, etc. Initially, it may look like a simple heat rash. But then they appear on the skin small bumps(lupoms) round shape. The location of irritation gradually expands. The skin exhibits severe dryness and the appearance of ulcers and scars.
Deterioration of general condition. The patient complains of fatigue, malaise, bad dream, decreased concentration and attention, headaches, etc.
The appearance of new lupomas on previously formed scars. There are cases when ulcers appear on the affected tissues.

According to qualifications, tuberculous lupus is divided into 2 types - flat and tuberous. In the first stage, the neoplasms do not protrude above the surface of the epidermis. In the second case, the lupomas have a convex shape.

Tuberous lupus has a pronounced character. In patients, it immediately causes concern. It is especially frightening when the infection grows on the skin of the face. If incorrect or untimely treatment the resulting scars can disfigure the patient.

Initially cutaneous lupus may be confused with dermatitis. For any rash on the body that does not go away for several days, you should seek help from a doctor. Early diagnosis the disease gives a greater chance of successful treatment.

Symptoms of tuberculous lupus are:

The rashes become more and more sensitive. New purulent formations appear on the tubercles. All this causes itching and unpleasant painful sensations. Damaged areas of the epidermis ooze, the wounds do not heal.
The resulting ulcers grow in size and merge into one large one. This does not give peace to the patient. The skin becomes more than sensitive, there is negative reaction to any contact mechanical impact.
The ulcers gradually mature and then become keratinized. Severe peeling appears on the damaged skin and may even peel off top layer epidermis.
In places where lupus has affected the mucous membrane, the development of a necrotic process is noted. The tissue dies and the ulcers turn into holes.

The main thing is not to ignore the symptoms of cutaneous tuberculous lupus, especially if the disease affects the tissues of the nose, ears, cheeks and forehead. Modern medicinal methods make it possible to fight this disease at the proper level.

Unfortunately, in most cases, tuberculous lupus is diagnosed late. Only 20% of patients who applied for medical care on early stage development of the disease. The treatment is long and difficult.

The causes of the disease may be:

severe mechanical injuries. The impetus for the development of lupus may be deep cut, laceration, dissection other. Infections hidden in the skin are activated when provoking factors are created and immunity is reduced and become the cause of the development of tuberculosis;
hormonal imbalance. Patients who have chronic diseases are at risk endocrine system. Also greater danger people with overweight. Often a provoking factor in the development of cutaneous tuberculosis is a malfunction of the nervous system;
long-term treatment of other diseases with the use of corticosteroids. By using medical supplies on this basis they fight such ailments as rheumatism, allergic dermatitis, colitis, inflammation genitourinary system, pancreatitis, etc. Corticosteroids – hormonal agents, therefore, with prolonged use, other troubles may arise;
chemotherapy. Another reason for the appearance of cutaneous tuberculosis. Cancer treatment using this method helps fight malignant tumors. But chemotherapy negatively affects the immune system. When a patient encounters an infection, the body cannot resist it.

It is also important what kind of life a person leads. Also at risk for tuberculous lupus are people who healthy image life. Bad habits (drinking alcohol, drugs, smoking), unhealthy diet, constant stress and lack of sleep sooner or later give impetus not only to the development of skin diseases, but also other serious ailments.

If any signs of illness appear, you should immediately consult a doctor. Initially, you need to see a dermatologist. Tuberculous lupus and its diagnosis require special attention infectious disease specialist That is, the treatment of this disease is prescribed not by one doctor, but by several. Skin tuberculosis is often accompanied by formations malignant tumors all over the body. In such cases, the help of an oncologist is required. Final diagnosis It is also placed after the consultation.

A complete examination of the patient includes the following steps:

Conducting a visual inspection and interview. Initially, the dermatologist externally evaluates the appearance of spots on the skin. Asks the patient what worries him besides the tumors. Based on the first appointment, the doctor prescribes other tests for further diagnosis.
Laboratory research. These include donating blood, urine, scrapings, samples, etc. Differential diagnosis makes it possible to exclude other diseases, such as lupus erythematosus, actinomycosis, etc.

It is almost impossible to determine skin tuberculosis by eye. To make a diagnosis, you need to undergo a series of tests. Therefore, you should not make hasty conclusions when spots appear on the skin. Any rash is only a sign that you need to see a doctor.

The fight against skin tuberculosis involves the use of comprehensive drug therapy. Treatment can take quite a long time. It all depends on the individual capabilities of the patient’s body, the stage of development of the disease, accompanying unfavorable factors, reactions to drugs.

Treatment of lupus tuberculosis includes:

Direct impact on the infectious agent. For this purpose, the patient is prescribed drugs, active substances which kill mycobacteria or slow down the process of their spread throughout the body.
Increasing general immunity. The better they work protective functions body, the better it fights any disease. Patients with lupus are prescribed additional immunostimulating drugs. This makes it possible to improve the well-being of patients on several levels, as well as consolidate the results of previous anti-infective therapy.
Symptomatic treatment. Doctors also prescribe medications that help fight the discomfort that the disease provokes - antipyretics, painkillers, antihistamines and other drugs.
Local therapy. This includes the use various ointments, creams, lotions, etc., which help with itching, as well as other unpleasant sensations, resist the spread of mycobacteria, and other infections entering wounds and ulcers.

Treatment of patients is carried out only in tuberculosis dispensaries. Getting rid of the disease at home is almost impossible and risky for people who live with infected person.

If treated irrationally, the patient's disease may worsen significantly. general condition up to coma or death.

Late diagnosis, ignoring the symptoms of the disease, incorrectly prescribed medications lead to the following complications:

distortion of facial features, erysipelas, deformity. This applies to those patients in whom lupus manifests itself on the skin of the forehead, cheeks, nose, and ears. The necrological process of tissue develops rapidly and is irreversible. The person is left with large scars on their face for the rest of their life. Just the photos of such patients with complications after the disease are already frightening;
depression severe form. Patients with lupus often get worse emotional state. Every third patient suffers from a mental disorder. This is due to loss of attractiveness, constant lack of sleep and irritation. All this suppresses the patient so much that he ceases to adequately assess the surrounding situation and withdraws;
oncology. There are quite a few cases where lupus develops into worst disease– cancer. Its development gives metastases and brings the patient closer to death. IN modern medicine There are adequate methods of treating both the disease itself and its complications, so in no case should you give up.

To prevent complications, you should always monitor your health. At hereditary predisposition medical examinations must be done 2 times a year, in other cases - 1.

It's not much, but it's so important. Also, do not be shy or afraid to ask questions to specialists during routine examinations. If there is at least some suspicion of the development of the disease, you need to talk to your doctor about it.

Prevention

No one can give a 100% guarantee to a person that he will never become infected with tuberculous lupus. But this does not mean that you can ignore the recommendations of doctors.

Everyone should adhere to the following simple rules to maintain your health and protect yourself from contracting this disease:

Conducting vaccinations. When to do this, the patient decides together with his leading doctor. The first vaccination is usually carried out in early infancy, and then according to the calendar or doctor’s prescription.
Avoiding contact with infectious patients. This applies to those who have signs of developing the disease on the face, that is, visible to the naked eye. You should limit any contact with such people, especially children under 10 years of age.
Compliance with personal hygiene rules. After trips to public transport When going to a store, clinic or other crowded places, you must wash your hands with soap.
Healthy lifestyle. To strengthen your overall immunity, you should get rid of bad habits, learn self-control, follow recommendations proper nutrition, work and rest schedule, playing sports.

Lupus is scary and dangerous. Characteristic sign its manifestations are the formation of red spots all over the body, which quickly grow in size.

To protect your health, you can learn more about disease prevention from a specialist. Similar lectures are also held for children and students in educational institutions, production workers, etc.

The main causative agent of lupus is currently M. tuberculosis. Tuberculin reactions are usually positive. In approximately half of patients, lupus vulgaris occurs against the background of benign tuberculosis of internal organs, most often pulmonary tuberculosis.

Infection can occur due to hematogenous or lymphogenous spread of pathogens from internal organs, less commonly through exogenous inoculation of mycobacteria. Infection of the skin with subsequent development of the lupus process is sometimes observed with perforation of scrofuloderma abscesses. In these cases, the scrofuloderma lesions resolve over time, and the lupus continues to progress.

The disease can occur at any age. Women get sick twice as often as men. Lesions in lupus tend to be extremely long lasting (years) with very slow peripheral growth. Unfavorable living conditions, intercurrent diseases, especially acute infections, worsen the course of lupus.

Primary morphological element skin rash with lupus there is a tubercle (lupoma), which is a formation slightly elevated above the level of the skin or embedded in its depths, the size of a pinhead to a lentil. The tubercles have a brownish-red color and a soft consistency. During diascopy, a translucent yellowish-brown (“rusty”) spot remains at the site of the tubercles, the so-called “symptom” apple jelly". The presence of this symptom is explained a large number lipids present in epithelioid cells of tuberculoid granulomas. When pressing on the tubercles with a blunt probe, a hole is formed and they are easily pierced. When the probe is removed, a drop of blood appears from the hole it creates. The reason for this so-called probe symptom is a sharp thinning of the epidermis and destruction of the middle part of the dermis by tuberculous infiltrate. There are several forms of lupus vulgaris.

1. Lupus planus(l. v. planus). The most common and typical shape a disease characterized by the appearance of the lupoma described above. Initially, they are located in a group, and then merge into a continuous infiltrate, which slowly increases through peripheral growth due to the addition of new tubercles. After many months, the tubercles resolve with the formation of scar atrophy white, gathering into a fold like crumpled tissue paper. A feature of lupus is the appearance of new tubercles in areas of scar atrophy. Lupus flatus primarily affects the skin of the face, especially the nose, ears, cheeks, scalp, and less commonly, the buttocks, upper and lower extremities.

2. Spotted lupus(lupus spot) is characterized by small spots, 2–10 mm in size, resembling. The spots grow slowly with peripheral growth, and on diascopy they give the symptom of “apple jelly” in the form of separate points, closely adjacent to each other. Over many years, lupus spots transform into more severe forms of the disease.

3. Psoriasiform lupus(l. v. psoriasiformis) is distinguished by the accumulation of silvery-white scales on the surface of the lupus infiltrate, resulting in a resemblance to.

4. Verrucous lupus(l. v. verrucosus) is characterized by the appearance of warty growths on the surface of lupus infiltrates.

5. Ulcerative form (l. v. ulcerosus) occurs due to injury to the lupus focus and complications with pyogenic infection. Lupus ulcers are superficial, have uneven, scalloped edges, their bottom is fine-grained, covered with scanty purulent discharge, and bleeds easily. Located on open areas of the skin, they are easily covered with lumpy purulent-bloody crusts.

6. Lupus mutilans(l. v. mutilans). Occurs when there is a lesion tuberculosis process skin and underlying tissues (periosteum, bones) of the fingers, which leads to destruction and rejection of the latter.

7. Tumorous lupus(l. v. tumidus) is characterized by the fact that the lupus infiltrate, like a tumor, protrudes above the skin level, while retaining all the signs characteristic of lupus tubercles. This form of lupus usually occurs in ears.

Lupus vulgaris can affect the mucous membranes of the nose and mouth (isolated or together with the skin). The nasal lesion is characteristic symptom lupus The disease in this case, as a rule, occurs simultaneously in the skin and mucous membrane, which leads to the destruction of the cartilage of the wings of the nose and the nasal septum. As a result, the nose shortens and sharpens, taking on the appearance of a bird's beak. With an isolated lesion of the mucous membrane, a soft, lumpy, bluish infiltrate is formed in it, which bleeds easily and disintegrates to form an ulcer. When the process is localized on the mucous membrane of the nasal septum, it cartilaginous part collapses and perforation occurs. In advanced cases, lupus can significantly destroy soft fabrics face and lead to disfigurement of the patient.

In the oral cavity, lupus is most often localized on the mucous membrane of the gums and hard palate; it is characterized by the formation of closely grouped small tubercles of a bluish-red color. Subsequently, an ulcer forms, having irregular finely scalloped outlines, granular, covered yellow coating bottom. Separate bumps form around the ulcer.

Complications of lupus are recurrent erysipelas, elephantiasis, as well as the development of skin cancer (lupus-carcinoma) against the background of atrophic lupus scars.

Lupus vulgaris should be differentiated from tubercular syphilide, leprosy and.

Tuberculous (ordinary) lupus

Differential diagnosis

"Differential diagnosis of skin diseases"
Guide for doctors
edited by B. A. Berenbeina, A. A. Studnitsina

The causative agent of skin tuberculosis (tuberculosis cutis) is mycobacterium tuberculosis (Mucobacterium tuberculosis). Skin lesions develop, as a rule, against the background of a general tuberculosis infection (tuberculosis damage to the lungs, lymph nodes, bones) as a result of the penetration of Mycobacterium tuberculosis into the skin by the lymphatic or hematogenous route. Manifestations of tuberculosis skin lesions are varied and depend on the type of mycobacteria, their virulence, body resistance, as well as environmental conditions.

Tuberculous (ordinary) lupus(Lupus vulgaris) is the most common type of skin tuberculosis. In most cases, the disease occurs in childhood or adolescence, the rash is localized mainly on the face, much less often on the extremities, in the perianal area, in in rare cases on the body. Rashes most often appear first on the skin, and often on the nasal mucosa, then the process spreads to neighboring areas of the face.

Due to the fact that tuberculous tubercles, or lupomas, are located deeply, at the beginning of the disease they look like yellowish-red or reddish-brown spots with a diameter of 2-5 mm with relatively clear boundaries. Over the course of several months, the infiltration increases and the tubercles become more noticeable, but in most cases they still rise slightly above the skin (lupus vulgaris planus). Only in rare cases do the lesions noticeably stand above the skin level (lupus vulgaris tumidus).npH diascopy, the color of the elements changes to yellowish-brown (apple jelly symptom). The tubercles are characterized by a soft consistency, and therefore, when pressed with a probe, a persistent depression occurs, and with more vigorous pressure, the element ruptures, severe pain and bleeding are noted (a symptom of the probe failing).

Lupomas are prone to peripheral growth and fusion with the formation of solid foci of various sizes and shapes. Initially, the surface of the lesions is smooth, then peeling appears, sometimes significant (lupus vulgaris pityriasiformis), layering of crusts, sometimes warty growths (lupus vulgaris verrucosus), ulceration often occurs (lupus vulgaris exulcerans). The ulcers are superficial, with soft, undermined, jagged edges, a light brown infiltrate remains around them. The bottom of the ulcers is covered with pus, granular due to the formation of granulations. Ulcerative lesions can spread along the periphery (lupus vulgaris serpiginosus) or in depth, resulting in the destruction of subcutaneous fatty tissue, the cartilaginous part of the nose and ears, which can lead to significant disfigurement (lupus vulgaris mutilans).

The course of tuberculous lupus is long, without treatment it can last for many years. Scars remain at the site of ulcerative lesions. If the tubercles do not ulcerate, then they leave behind a gentle cicatricial atrophy. The presence of typical lupoma in the area of scar or atrophy is typical. With long-term existence of lupus (somewhat more often in men), lupus-carcinoma can develop, mainly against the background of an ulcerative process.

Histological examination reveals tubercles of epitheoid cells surrounded by lymphocytes. The presence of Langhans giant cells and, as a rule, caseous necrosis in the center of the tubercle is also characteristic. Mycobacterium tuberculosis may be detected.

Differential diagnosis

Tuberculous lupus must be differentiated from tubercular syphilide, small nodular sarcoidosis, lymphocytoma, discoid lupus erythematosus, squamous cell carcinoma, lupoid sycosis, tuberculoid leprosy, tuberculoid form of leishmaniasis.

Tuberculous lupus differs from tubercular syphilide in that it occurs in early childhood(tertiary tubercular syphilis is observed, as a rule, in adults), it affects the cartilaginous, and not the bone (as in syphilis) part of the nose, the lesions slowly develop and spread (with lupus, they often only take a few years to acquire the size that with syphilis reach within a few weeks from the moment the tubercles erupt), the process lasts a long time (with syphilis, months, with tuberculosis, decades).

The tuberculate elements in syphilis have a dense elastic consistency, while in tuberculosis they are soft. Syphilides have a rich dark red color, lupomas are pale red with a yellowish tint. The tubercles in syphilis are located, as a rule, isolated, and in tuberculous lupus they merge into continuous lesions. It also matters different character ulcers and scars. With tubercular syphilis, the ulcers are deeper, have steeply cut edges, are surrounded by a dense ridge of infiltration, and their bottom is covered with necrotic decay. In tuberculosis, the ulcers are superficial, have undermined, soft, overhanging edges, a red bottom, covered with a yellow-gray coating and easily bleeding granular granulations. With syphilis, the scars are unevenly pigmented, not smooth, and there are no new rashes on them. In tuberculous lupus, the scars are smooth, discolored, and are characterized by the presence of old or newly appeared lupomas in their area. The phenomena of apple jelly and probe failure in syphilis are negative. Important have positive serological reactions for syphilis in tertiary tubercular syphilis.

If clinical signs quite enough to carry out in most cases differential diagnosis tubercular syphilide and tuberculous lupus, it is difficult to distinguish these diseases histologically, since in both diseases a chronic inflammatory process such as infectious granuloma is detected. The diagnosis of syphilis may be supported by such signs as the predominance of plasma cells in the infiltrate rather than epithelioid ones, as in tuberculous lupus, significant proliferative changes in the vessels, more frequent detection of giant cells of the type foreign bodies, and not white process epidermocytes, as in tuberculous lupus.

Tuberculous lupus differs from small nodular sarcoid in that sarcoidosis affects mainly adults; Tuberculous lupus is characterized by a lower density of tubercles, a yellowish rather than bluish tint of their color, positive phenomena of probe failure and apple jelly (it should be emphasized that in the case of sarcoidosis, diascopy reveals a yellowish-brown color of the lesion, similar to that of lupus tuberculosis of the skin, but it is not solid, but dust-like, dotted). With tuberculous lupus, the tubercles are more prone to ulceration; it is characterized by the presence of typical lupomas in the scar area and a slow long-term course. It is difficult to differentiate these diseases histologically. However, infiltrates in tuberculous lupus tend to be more superficial than in sarcoidosis. Their composition is more polymorphic (in sarcoidosis, the tubercle contains exclusively epithelioid cells and a small number of lymphocytes and giant cells). Caseous necrosis in the lesion may be absent even in tuberculous lupus, but if it is present, this indicates in favor of the diagnosis of tuberculous lupus.

Tuberculous lupus differs from lymphocytoma in that it occurs in at a young age, its course is long, lupomas are prone to fusion and ulceration, tubercles develop on the scars, positive phenomena of probe failure and apple jelly are determined. Histologically, tuberculous lupus reveals granulomas consisting of epithelioid cells surrounded by a ridge of lymphocytes, among which giant white branched epidermocytes are identified.

It is usually not difficult to distinguish tuberculous lupus from discoid lupus erythematosus. It is taken into account that tuberculous lupus develops in children, and lupus erythematosus, as a rule, in adults. With tuberculous lupus, there is no follicular hyperkeratosis, the color of the rashes is less bright, there is no such tendency, as with lupus erythematosus, to a symmetrical arrangement of lesions (butterfly-shaped). In contrast to lupus erythematosus, ulceration is often observed in the lesions; the presence of lupoma is characteristic not only on healthy skin, but also within the scar. The presence of increased photosensitivity in lupus erythematosus should also be taken into account, while the course of skin lupus tuberculosis may improve somewhat in the summer. If you have difficulty installing correct diagnosis helps histological examination, because the differences histological structure in these diseases are significant. Thus, with discoid lupus erythematosus there are no tubercles (dermal disorders manifest themselves in the form of focal, predominantly lymphocytic perivascular infiltrates located around the appendages of the dermis). At the same time, from the very beginning of the disease, pronounced changes in the epidermis are determined (hyperkeratosis, atrophy of the germ layer, vacuolar degeneration of basal cells), which in tuberculous lupus can be observed with a sufficient duration of the disease.

Differential diagnosis of tuberculous lupus with squamous cell carcinoma is carried out on the basis that the latter usually develops in adults, is a single tumor, has a much more rapid course than tuberculous lupus, and metastasizes already in early period development, deep ulceration, density of ulcer edges, absence of lupomas, tendency to scarring, apple jelly phenomena and probe failure, other histological picture(deeply penetrating proliferations cancer cells in the dermis with eosinophilic protoplasm, resembling cells of the spinous layer, karyokinesis, cancerous “pearls” of layered spinous cells with keratinization). However, it must be taken into account that spinocellular epithelioma can develop against the background of long-term tuberculous lupus, especially after radiotherapy. Signs of beginning malignancy of the focus of tuberculous lupus can be resistance ulcerative lesion to treatment, a rapid increase in the diameter and depth of the ulcer, thickening of its edges, and the crater-like nature of the ulcer.

Lupoid sycosis differs from tuberculous lupus in that the disease develops in middle-aged and elderly men, primary element is not a lupoma, but a follicular pustule; the lesions are usually single, located not in the central part of the face, but on areas of the skin covered with hair ( hairy part head, mustache, beard, pubic areas). With lupoid sycosis, a more rapid evolution of individual elements is observed (with a long-term course of the process due to the appearance of new pustules), ending with scarring and death of hair follicles.