Tropical/Infectoparasitary Dermatology
Gummatous cutaneous tuberculosis associated with the use of infliximab for Crohn's disease
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array:1 [ 0 => "lucascampos@outlook.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Everton Carlos Siviero do" "apellidos" => "Vale" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "Maria de Lourdes" "apellidos" => "Ferrari" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 3 => array:3 [ "nombre" => "Lauro Damasceno de Carvalho" "apellidos" => "Faria" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Department of Gastroenterology, Faculty of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1515 "Ancho" => 905 "Tamanyo" => 87973 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulcerated nodules on the posterior region of the right thigh.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Immunobiologicals were introduced in the 1990s to treat inflammatory bowel diseases.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–3</span></a> Reactivation of latent infections resulting from the immunosuppression caused by these drugs may occur. Tuberculosis (TB) is more specifically associated with the use of tumor necrosis factor alpha antagonists.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">A 26-year-old female patient was diagnosed with Crohn's disease (CD) due to stomach enterorrhagia and abdominal colic. After therapeutic failure with prednisone, mesalazine, and azathioprine, infliximab 5 mg/kg was initiated. Despite the initial improvement in symptoms, she gradually worsened. After 14 months on infliximab, she maintained an active disease and weight loss, in addition to daily feverish peaks. She presented three subcutaneous erythematous nodules on the posterior region of the right thigh, of approximately 3 cm in diameter, without fluctuation or drainage. Subsequently, these lesions ulcerated, with well-defined edges and a necrotic background (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). Histopathology showed a nonspecific inflammatory process. Intestinal endoscopic biopsy (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>) demonstrated granulomas with non-caseous central necrosis and absence of acid-alcohol-fast bacilli (AAFB; <a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Due to the characteristics of the granulomas, the hypothesis of infection with <span class="elsevierStyleItalic">Yersinia pseudotuberculosis</span> was raised. The treatment with gentamicin and ceftriaxone was ineffective, with the onset of a new erythematous cutaneous nodule on the left thigh, which revealed the presence of AAFB on histopathological examination (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>) and genetic material of <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> by the rapid molecular test, confirming the diagnosis of gummatous tuberculosis. Computed tomography of the chest showed nonspecific nodules, and pulmonary involvement was not ruled out. Treatment with rifampicin, isoniazid, pyrazinamide, and ethambutol was instituted for six months. The ulcerated nodules healed completely after the third month, with no recurrence after one year of follow-up.</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Cutaneous TB accounts for approximately 1% of the cases of the disease.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> It can be subdivided into forms caused by direct inoculation, such as tuberculous chancre and TB verrucosa cutis, forms caused by contiguity and autoinoculation, such as scrofuloderma and periorificial TB, and forms caused by hematogenous dissemination, such as gummatous tuberculosis and acute miliary TB. Lupus vulgaris is likely to be caused through the three pathways. Tuberculids are forms in which an exacerbated immune response causes skin lesions, such as erythema induratum of Bazin, lichen scrofulosorum lichen, and papulonecrotic tuberculid.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Gummatous tuberculosis is rare and affects mainly immunosuppressed and malnourished children. It is characterized by subcutaneous erythematous nodules, which evolve with intense central necrosis, fistulization, and ulceration. It results from the acute hematogenous spread of a primary outbreak during periods of bacillemia. The tuberculin test is usually negative. Histopathology shows extensive necrosis, formation of loose granulomas, and high bacillary load. Molecular techniques also contribute to the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> The differential diagnosis includes panniculitis, syphilitic gumma, and hidradenitis suppurativa. The morphology and location of gummatous tuberculosis helps to differentiate it from other multibacillary forms, such as periorificial. The same treatment used for lung disease is recommended. Directly monitored treatment is recommended by the National Tuberculosis Control Program of the Ministry of Health of Brazil, and must be performed at home by primary care.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a> After TB treatment was completed, a good response to ustekinumab for Crohn’s disease was observed.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Financial support</span><p id="par0030" class="elsevierStylePara elsevierViewall">None declared.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Authors’ contributions</span><p id="par0035" class="elsevierStylePara elsevierViewall">Lucas Campos Garcia: Approval of the final version of the manuscript; drafting and editing of the manuscript; collection, analysis, and interpretation of data; intellectual participation in propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Everton Carlos Siviero do Vale: Approval of the final version of the manuscript; drafting and editing of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of the studied cases; critical review of the literature; critical review of the manuscript.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Maria de Lourdes Ferrari: Approval of the final version of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of the studied cases.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Lauro Damasceno de Carvalho Faria: Approval of the final version of the manuscript; intellectual participation in propaedeutic and/or therapeutic conduct of the studied cases.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">None declared.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:6 [ 0 => array:3 [ "identificador" => "xres1505260" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1366016" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 3 => array:2 [ "identificador" => "sec0010" "titulo" => "Authors’ contributions" ] 4 => array:2 [ "identificador" => "sec0015" "titulo" => "Conflicts of interest" ] 5 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2019-12-26" "fechaAceptado" => "2020-07-14" "PalabrasClave" => array:1 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1366016" "palabras" => array:4 [ 0 => "Crohn's disease" 1 => "Tumor Necrosis Factor Receptor-Associated Peptides and Proteins" 2 => "Molecular target therapy" 3 => "Skin tuberculosis" ] ] ] ] "tieneResumen" => true "resumen" => array:1 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">As the treatment of infectious and parasitic diseases improved, the prevalence of these conditions declined. However, with the expansion of the use of immunobiologicals, opportunistic infections have emerged, especially under atypical presentations. The present study reports the case of a patient treated with infliximab for Crohn's disease, who presented diarrhea, weight loss, abdominal pain, fever, and subcutaneous erythematous nodules that evolved with spontaneous fluctuation and ulceration. With the finding of alcohol-resistant bacilli and <span class="elsevierStyleItalic">Mycobacterium tuberculosis</span> DNA in a cutaneous fragment, through polymerase chain reaction, the diagnosis of gummatous tuberculosis was confirmed, probably secondary to hematogenous dissemination from an intestinal focus.</p></span>" ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">How to cite this article: Garcia LC, Vale ECS, Ferrari ML, Faria LDC. Gummatous cutaneous tuberculosis associated with the use of infliximab for Crohn's disease. An Bras Dermatol. 2021;96:228–30.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Study conducted at Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil.</p>" ] ] "multimedia" => array:4 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1515 "Ancho" => 905 "Tamanyo" => 87973 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Ulcerated nodules on the posterior region of the right thigh.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 484 "Ancho" => 1755 "Tamanyo" => 118444 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Colonoscopy showing an extensive ulcerated inflammatory process in the colon and ileum.</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 516 "Ancho" => 905 "Tamanyo" => 109080 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Non-caseating granulomas in the ileal mucosa (Hematoxylin & eosin, ×10).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 494 "Ancho" => 905 "Tamanyo" => 104098 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Presence of acid-alcohol-fast bacilli (AAFB; arrow) at histopathological examination of the skin (Ziehl-Neelsen, ×100).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:9 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "3rd European Evidence-based Consensus on the Diagnosis and Management of Crohn’s Disease 2016. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 19 | 8 | 27 |
| 2024 October | 107 | 70 | 177 |
| 2024 September | 159 | 73 | 232 |
| 2024 August | 159 | 112 | 271 |
| 2024 July | 139 | 122 | 261 |
| 2024 June | 123 | 82 | 205 |
| 2024 May | 84 | 77 | 161 |
| 2024 April | 91 | 81 | 172 |
| 2024 March | 92 | 79 | 171 |
| 2024 February | 86 | 88 | 174 |
| 2024 January | 74 | 56 | 130 |
| 2023 December | 88 | 64 | 152 |
| 2023 November | 106 | 71 | 177 |
| 2023 October | 66 | 73 | 139 |
| 2023 September | 72 | 70 | 142 |
| 2023 August | 56 | 38 | 94 |
| 2023 July | 74 | 31 | 105 |
| 2023 June | 48 | 44 | 92 |
| 2023 May | 53 | 28 | 81 |
| 2023 April | 39 | 23 | 62 |
| 2023 March | 60 | 43 | 103 |
| 2023 February | 65 | 31 | 96 |
| 2023 January | 48 | 40 | 88 |
| 2022 December | 59 | 35 | 94 |
| 2022 November | 56 | 51 | 107 |
| 2022 October | 112 | 80 | 192 |
| 2022 September | 47 | 58 | 105 |
| 2022 August | 46 | 31 | 77 |
| 2022 July | 45 | 54 | 99 |
| 2022 June | 50 | 50 | 100 |
| 2022 May | 44 | 61 | 105 |
| 2022 April | 67 | 53 | 120 |
| 2022 March | 36 | 71 | 107 |
| 2022 February | 27 | 36 | 63 |
| 2022 January | 57 | 89 | 146 |
| 2021 December | 38 | 59 | 97 |
| 2021 November | 50 | 62 | 112 |
| 2021 October | 54 | 83 | 137 |
| 2021 September | 43 | 75 | 118 |
| 2021 August | 50 | 42 | 92 |
| 2021 July | 41 | 50 | 91 |
| 2021 June | 88 | 80 | 168 |
| 2021 May | 141 | 122 | 263 |
| 2021 April | 454 | 346 | 800 |
| 2021 March | 69 | 50 | 119 |
| 2021 February | 11 | 13 | 24 |
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