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 lupus erythematosus 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 bellied probe, the latter easily passes into the depths of the infiltrate, which is due to the destruction of the collagen and elastic fibers of the skin. When pressed with a glass spatula (diascopy), the skin is bled and the lupoma appears as a spot of 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 unsharply above the level of the surrounding normal skin. Lupous tubercles develop slowly over months, may remain unchanged for a long time. They are rarely located in the form of single elements, usually increasing by peripheral growth and merging with each other, forming plaques of various sizes and shapes. The tumor-like variety 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, auricles, but can be located on the chin and other parts of the body. The tuberous and tumor-like variants of lupus can exist independently, but often there are elements of lupus flatus in the form of lupus and plaques at the same time.

The development of lupus ulcer is always preceded by the formation of a lupoma, slowly, but sometimes relatively quickly, undergoing ulceration. On the surface of the lesion, as a result of the collapse of the lupus infiltrate, ulcerations are formed, which can occupy part of the lesion or the entire area of the lesion. Ulcers in lupus are superficial, soft-edged, painful, and often bleed easily.

The same patient often has different clinical manifestations of lupus: for example, flat lupus 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, easily folded, but deep fibrous scars can also form, resembling keloid scars. The favorite localization of lupus is the face (nose, upper lip, neck, submandibular region). Hypertrophic-ulcerative forms in children and adolescents relatively quickly cause the destruction of the soft parts and the cartilaginous septum.

Tuberculous (vulgar) lupus. Treatment of lupus erythematosus

The disease is characterized by a chronic slow course and a tendency to tissue melting. It often starts in childhood and lasts for years and decades. Recently, cases of lupus in adults have become more frequent. Infection by the hemato- and lymphogenous route.

Tubercles (lupoma) appear on the skin, red-brown in color, of different sizes, doughy consistency with a smooth shiny surface. On the periphery of the foci there is a stagnant red zone. Most often, lupus erythematosus appears on the face, auricles. 2 pathogmonic symptoms are characteristic:

a symptom of "apple jelly" - when pressing on the tubercle with a glass slide, blood is squeezed out of the dilated and paralyzed vessels, and the tubercle acquires a brownish-yellow color.

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

Lupomas resolve with a scar or cicatricial atrophy. At the site of scarring, new lupomas may form.

Clinical forms.

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

Tumor-like - the infiltrate hypertrophies and rises sharply above the level of the skin. All characteristic features of lupoma are preserved.

Ulcerative - occurs due to trauma 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 infection from the affected organs. Most often it is a single skin lesion.

Secondary - in a continuum way, the infection passes from the affected 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, soldered to the surrounding tissues and sharply protrudes above the level of the skin. The skin over the knot becomes red and then bluish. Gradually there is a fluctuation (cold abscess). 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, sometimes have bridges and bridges, between which there are areas of healthy skin (“bridge-like” scars). Under the scars, the formation of new nodes is possible.

Ulcerative tuberculosis of the skin and mucous membranes.

It is observed in patients with active tuberculosis of the internal organs. due to autoinactivation. Localized around the mouth, nasal passages, anus, genitals.

Small nodules of yellow-red color are formed, which are prone to pustulation and ulceration. At the bottom of these ulcers there are caseously degenerated tubercles - “Trela grains”. Soreness, difficulty in eating, urinating, defecation develops.

Diagnostic principles.

characteristic clinical picture;

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

tuberculin tests;

histological studies;

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

the presence of a concomitant lesion of tuberculous etiology.

Principles of treatment.

NB! Treatment should be comprehensive and long!

Etiotropic therapy:

GINK preparations: isoniazid, ftivazid, tubazid;

rifampicin;

streptomycin, kanamycin;

Pathogenetic therapy:

desensitizing therapy;

vitamin therapy;

hormone therapy;

physiotherapy procedures;

climatotherapy;

health food rich in proteins, carbohydrates, vitamins.

LEPROSY

This is a chronic infectious disease with a primary lesion of the skin, mucous membranes and peripheral nervous system. Historical names: leprosy, mournful disease, black infirmity, 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 staining according to Ziehl-Neelsen (curved sticks arranged in bunches in the form of a "bunch of bananas").

The source of infection is a sick person.

Ways of infection.

through the mucosa of the upper respiratory tract.

Through broken skin.

By ingesting contaminated food and water.

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

Epidemiology.

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

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

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 subborder;

tuberculoid polar;

undifferentiated.

LEPROMATOUS LEPROMA.

Reddish spots with a bluish tinge appear on the skin. Gradually, they transform into a dense powerful infiltrate. Subcutaneous fat is involved in the process - nodes (lepromas) are formed. Localization is more often on the extensor surfaces of the forearms, on the face, in the forehead, superciliary arches, cheeks, nose. The face takes on a ferocious expression - facies lionica (lion's face). 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. In the region of the tongue, hard and soft palate, infiltrates are formed that spread to the mucous membrane of the larynx and vocal cords, as a result of which hoarseness of the voice occurs, and then aphonia. Disappearance of sensitivity in the centers is characteristic.

Lepromotous type.

It is characterized by a complete lack of body resistance to the pathogen, the development of macrophage granulomas with a tendency to unlimited intracellular reproduction of mycobacteria leprosy. Process desorption and negative lepromine test.

Tuberculoid type.

It is characterized by a pronounced resistance of the body to mycobacterium leprosy, the development of tuberculoid granuloma. The tendency to limit the process, small bacilli and positive lepromine test.

undifferentiated form.

Assumes an indeterminate immune response of the body. Morphological non-specific lymphocytic infiltrate, low bacillarity, positive-negative lepromine test.

Diagnostic principles.

characteristic clinical picture.

History data (being in leprosy-endemic areas, prolonged contact with a patient with leprosy).

Material sampling (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 is by infecting mice in the pulp of their paw pads. Armadillos and certain types of monkeys are also used as experimental animals.

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, diucyphon, dimocyphon; rifampicin; lampren (clofazimine).

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

According to the Zagorsk leprosarium, patients with lepromatous type are treated for 3 to 5 years in a hospital, and then for life - treatment on an outpatient basis. With tuberculosis type - 1 year of inpatient treatment, all life - on dispensary observation. Persons who have been 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 in the leper colony of identified patients;

determination of the circle of persons to whom the patient could transmit the infection;

preventive treatment of family members aged 2-60 years;

health education work.

A disease such as lupus erythematosus develops rather slowly, but carries many negative consequences. It often develops into a chronic form. Treatment can take years. At risk of this disease are adults with weak immunity and children. The disease affects the layer of the epidermis. A strong irritation appears on the skin, which, in the course of the progression of the disease, quickly grows over the entire area of the body. Infected cells disrupt blood flow and tissue regeneration. It is possible to stop the development of the pathological process by starting the treatment of the disease in time.

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

Symptoms of the disease, in which it is necessary to consult 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 sweatshirt. But then small tubercles (lupomas) of a rounded shape appear on the skin. The location of irritation gradually grows. On the skin there is severe dryness and the appearance of ulcers and scars.
Deterioration of the general condition. The patient complains of fatigue, malaise, poor sleep, 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 the qualification, tuberculous lupus is divided into 2 types - flat and tuberous. At the first neoplasms do not protrude above the surface of the epidermis. In the second case, 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. With improper or untimely treatment, the resulting scars can disfigure the patient.

Initially, cutaneous lupus can be confused with dermatitis. For any rashes on the body that do not go away for several days, you should seek help from a doctor. Early diagnosis of the disease gives more chances for successful treatment.

Symptoms of lupus tuberculosis are:

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

It is important not to ignore the symptoms of cutaneous lupus erythematosus, especially if the disease affects the tissues of the nose, auricles, cheeks and forehead. Modern medical methods make it possible to deal with this disease at the proper level.

Unfortunately, in most cases, tuberculosis lupus is diagnosed late. Registered only 20% of patients who sought medical help at an early stage of the disease. Treatment is long and difficult.

The causes of the onset of the disease can be:

severe mechanical injury. The impetus for the development of lupus can be a deep cut, laceration, dissection, etc. Infections hidden in the skin, when provoking factors are created and immunity is reduced, are activated and become the cause of the development of tuberculosis;
hormonal disbalance. At risk are patients who have chronic diseases of the endocrine system. Overweight people are also at greater risk. 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. With the help of medicines on this basis, they fight such ailments as rheumatism, allergic dermatitis, colitis, inflammation of the genitourinary system, pancreatitis, etc. Corticosteroids are hormonal drugs, so other troubles may arise with their long-term use;
chemotherapy. Another reason for the appearance of skin tuberculosis. Treatment of cancer in this way helps to fight malignant tumors. But chemotherapy has a negative effect on the immune system. The patient's body, when it encounters an infection, cannot resist it.

It is also important what kind of life a person leads. People who lead an unhealthy lifestyle are also at risk for lupus erythematosus. Bad habits (alcohol, drugs, smoking), malnutrition, 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 requires special attention of the infectious disease specialist. That is, the treatment of this disease is prescribed not by one doctor, but by several. Often, skin tuberculosis is accompanied by the formation of malignant tumors throughout the body. In such cases, the help of an oncologist is required. The final diagnosis is also made after the consultation.

A complete examination of the patient includes the following steps:

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

It is almost impossible to determine tuberculosis of the skin by eye. To make a diagnosis, a number of studies are required. Therefore, do 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 consists in the use of complex 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, concomitant adverse factors, and reactions to drugs.

Treatment for lupus tuberculosis includes:

direct effect on the pathogen. To do this, the patient is prescribed drugs whose active substances kill mycobacteria or slow down the process of their spread throughout the body.
Increase general immunity. The better the protective functions of the body work, the better it fights against 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 to consolidate the result of previous anti-infective therapy.
symptomatic treatment. Doctors also prescribe drugs that help fight the discomfort that the disease provokes - antipyretics, painkillers, antihistamines and other drugs.
local therapy. It includes the use of various ointments, creams, lotions, etc., which helps with itching, as well as other unpleasant sensations, resists the spread of mycobacteria, getting into wounds and ulcers of other infections.

Patients are treated only in tuberculosis dispensaries. Getting rid of the disease at home is almost impossible and risky for people who live with an infected person.

With irrational treatment of the disease, the patient's general condition can significantly worsen, 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, mug, ugliness. This applies to those patients in whom lupus manifests itself on the skin of the forehead, cheeks, nose, and auricles. The necrological process of tissues develops rapidly and is irreversible. A person remains with large scars and scars on his face for the rest of his life. Only a photo of such patients with complications after the disease is already frightening;
severe depression. Patients with lupus often have a worsening emotional state. Every third patient suffers from a mental disorder. This is due to the loss of attractiveness, constant lack of sleep and irritation. All this suppresses the patient so much that he ceases to adequately assess the environment and becomes isolated;
oncology. There are quite a few cases where lupus develops into the 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 one give up.

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

It's not much, but it's 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, this should be discussed with the doctor.

Prevention

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

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

Carrying out vaccination. When this is done, 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.
Avoid contact with infectious patients. This applies to those who have signs of the development of the disease on the face, that is, it is visible to the naked eye. It is worth limiting any contact with such people, especially children under the age of 10 years.
Compliance with the rules of personal hygiene. After traveling by public transport, going to the store, clinic and other crowded places, it is imperative to wash your hands with soap and water.
Healthy lifestyle. To strengthen general immunity, you should get rid of bad habits, learn self-control, follow the recommendations of proper nutrition, work and rest, and play sports.

Lupus is scary and dangerous. A characteristic sign of its manifestation is the formation of cranial spots throughout the body, which grow rapidly in size.

To protect your health, you can learn more about disease prevention from a specialist. Also, such lectures are 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. Approximately half of the patients with lupus vulgaris occur against the background of benign tuberculosis of the internal organs, most often pulmonary tuberculosis.

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

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

The primary morphological element of a skin rash in lupus is a tubercle (lupoma), which is a formation slightly elevated above the level of the skin or embedded in its depths from a pinhead to a lentil. The tubercles are brownish-red in color and soft in texture. With diascopy, a translucent yellowish-brown ("rusty") spot remains in place of the tubercles, the so-called "apple jelly" symptom. The presence of this symptom is explained by the large amount of lipids present in the epithelioid cells of tuberculoid granulomas. When pressing on the tubercles with a blunt probe, a hole is formed and they are easily pierced. Upon removal of the probe, a drop of blood appears from the hole formed by it. The cause of this so-called probe symptom is a sharp thinning of the epidermis and the destruction of the middle part of the dermis by a tuberculous infiltrate. There are several forms of lupus vulgaris.

1. Flat lupus(l. v. planus). The most frequent and typical form of the disease, characterized by the appearance of the above-described lupus. Initially, they are grouped, and then merge into a continuous infiltrate, which slowly increases by peripheral growth due to the addition of new tubercles. After many months, the tubercles resolve with the formation of a white cicatricial atrophy, which gathers into a fold like crumpled tissue paper. A feature of lupus is the appearance of new tubercles in areas of cicatricial atrophy. Lupus flat affects mainly the skin of the face, especially the nose, auricles, cheeks, scalp, less often the buttocks, upper and lower extremities.

2. Spotted lupus(lupus spot) is characterized by small spots, 2–10 mm in size, resembling. Spots grow slowly with peripheral growth, with diascopy they give a symptom of "apple jelly" in the form of separate dots, closely adjacent to each other. After many years, lupus spots transform into more severe forms of the disease.

3. Psoriasiform lupus(l. v. psoriasiformis) is distinguished by the accumulation of silver-white scales on the surface of the lupus infiltrate, as a result of which a similarity is created with.

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 trauma to the focus of lupus and complications of pyogenic infection. Lupus ulcers are superficial, have uneven, scalloped edges, their bottom is fine-grained, covered with scanty purulent discharge, bleeds easily. Located on open areas of the skin, they are easily covered with bumpy purulent-bloody crusts.

6. Mutilating lupus(l. v. mutilans). Occurs when the tuberculosis process affects the skin and underlying tissues (periosteum, bones) of the fingers, which leads to the destruction and rejection of the latter.

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

Lupus vulgaris can affect the mucous membranes of the nose and mouth (in isolation or together with the skin). Nasal involvement is a characteristic symptom of 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 is shortened and sharpened, taking the form of a bird's beak. With an isolated lesion of the mucous membrane, a soft, tuberous cyanotic infiltrate is formed in it, which bleeds easily and disintegrates with the formation of an ulcer. When the process is localized on the mucous membrane of the nasal septum, its cartilaginous part is destroyed and perforation is formed. In advanced cases, lupus can significantly destroy the soft tissues of the 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 bluish-red tubercles. In the future, an ulcer is formed, which has irregular, small-scalloped outlines, a granular bottom covered with a yellow coating. Individual tubercles form around the ulcer.

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

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

Tuberculous (common) lupus

Differential Diagnosis

"Differential diagnosis of skin diseases"
Guide for doctors
ed. B. A. Berenbein, A. A. Studnitsina

Tuberculosis cutis is caused by Mycobacterium tuberculosis. Skin lesion develops, as a rule, against the background of a general tuberculosis infection (tuberculosis of the lungs, lymph nodes, bones) as a result of the penetration of Mycobacterium tuberculosis into the skin by lympho- or hematogenous route. Manifestations of tuberculous skin lesions are varied and depend on the type of mycobacteria, their virulence, body resistance, and environmental conditions.

Tuberculous (common) lupus(Lupus vulgaris) is the most common type of skin tuberculosis. In most cases, the disease occurs in childhood or adolescence, rashes are localized mainly on the face, much less often on the extremities, in the perianal region, in rare cases on the trunk. Rashes most often occur 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 deep, 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. Within a few months, the infiltration increases and the tubercles become more visible, but still in most cases they rise little above the skin (lupus vulgaris planus). Only in rare cases, lesions stand noticeably above the level of the skin (lupus vulgaris tumidus). In diascopy, the color of the elements changes to yellowish-brown (apple jelly symptom). The soft texture of the tubercles is characteristic, and therefore, when pressed with a probe, a persistent deepening occurs, and with more vigorous pressure, the element breaks, severe pain, bleeding (a symptom of probe failure) are noted.

Lupomas are prone to peripheral growth and fusion with the formation of continuous foci of various sizes and shapes. At first, 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 sores are superficial, with soft, undermined, uneven edges, and a light brown infiltrate remains around them. The bottom of the sores is covered with pus, granular due to the formation of granulations. Ulcerative lesions can spread peripherally (lupus vulgaris serpiginosus) or deep into, resulting in destruction of subcutaneous fat, cartilage of the nose and ears, which can lead to significant disfigurement (lupus vulgaris mutilans).

The course of lupus erythematosus is long, long-term without treatment. Scars remain at the site of ulcerative lesions. If the tubercles do not ulcerate, then after them there is a gentle cicatricial atrophy. The presence of typical lupomas in the area of the scar or atrophy is characteristic. With the long-term existence of lupus (somewhat more often in men), lupus-carcinoma may develop, mainly against the background of an ulcerative process.

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

Differential Diagnosis

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

Tuberculous lupus differs from tuberculous syphilis in that it occurs in early childhood (tertiary tuberculous syphilis is observed, as a rule, in adults), when it affects the cartilaginous, and not the bone (as with syphilis) part of the nose, the lesions slowly develop and spread ( in lupus, they often acquire sizes in just a few years, which they reach in syphilis within a few weeks from the moment the tubercles erupt), the process exists for a long time (with syphilis, months, with tuberculosis, decades).

Tuberculous elements with syphilis have a densely elastic consistency, with tuberculosis they are soft. Syphilides have a rich dark red color, lupomas are pale red with a yellowish tint. Tubercles in syphilis are located, as a rule, in isolation, and in tuberculous lupus they merge into continuous lesions. The different nature of ulcers and scars also matters. With tuberculous syphilis, the ulcers are deeper, have steeply cut edges, are surrounded by a dense roller of infiltrate, their bottom is covered with necrotic decay. In tuberculosis, 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 case of lupus erythematosus, the scars are smooth, discolored, the presence of old or newly appeared lupomas in their area is characteristic. The phenomena of apple jelly and tube failure in syphilis are negative. Positive serological tests for syphilis are important in tertiary tubercular syphilis.

If the clinical signs are quite enough to make a differential diagnosis of tuberculous syphilis and tuberculous lupus in most cases, then it is difficult to distinguish these diseases histologically, since both diseases reveal a chronic inflammatory process such as an infectious granuloma. In favor of the diagnosis of syphilis, such signs as the predominance of plasma cells in the infiltrate, and not epithelioid cells, as in lupus erythematosus, significant proliferative changes in the vessels, more frequent detection of giant cells such as foreign bodies, and not white process epidermocytes, as in lupus erythematosus, may testify .

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

Tuberculous lupus differs from lymphocytoma in that it occurs 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, lupus erythematosus reveals granulomas consisting of epithelioid cells surrounded by a roller of lymphocytes, among which giant white process epidermocytes are determined.

Distinguishing lupus erythematosus from discoid lupus erythematosus is usually not difficult. At the same time, it is taken into account that lupus erythematosus develops in children, and lupus erythematosus, as a rule, in adults. With lupus erythematosus, 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 (in the form of a butterfly). Unlike lupus erythematosus, ulceration is often observed in the lesions, the presence of lupomas 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 lupus skin tuberculosis may improve somewhat in summer. In case of difficulty, a histological examination helps to establish the correct diagnosis, since the differences in the histological structure in these diseases are significant. So, with discoid lupus erythematosus, there are no tubercles (dermal disorders appear as 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 the basal cells), which can be observed in lupus erythematosus with a sufficient duration of the disease.

Differential diagnosis of lupus erythematosus with squamous cell carcinoma is carried out on the basis that the latter develops, as a rule, in adults, is a single tumor, is characterized by a much faster course than lupus erythematosus, metastasis already in the early period of development, deep ulceration, density of the edges of ulcers , lack of lupus, a tendency to scarring, apple jelly and probe failure phenomena, a different histological picture (deeply penetrating cancer cell proliferates in the dermis with eosinophilic protoplasm, resembling cells of the prickly layer, karyokinesis, cancerous "pearls" of layered prickly cells with keratinization). However, it must be taken into account that spinocellular epithelioma can develop against the background of long-term lupus erythematosus, especially after X-ray therapy. Signs of the beginning malignancy of the focus of lupus erythematosus can be the resistance of the ulcerative lesion to treatment, the rapid increase in the diameter and depth of the ulcer, the compaction of its edges, the crater-like nature of the ulcer.

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