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Notes: Background. Tumor necrosis factor-alpha (TNF) is an important mediator of immunologic responses to chronic infections. Method. Sera from 25 patients with acute reactions (6 with type 1 upgrading, 8 with type 1 downgrading, and 11 with type 2 reaction) were assayed for TNF before treatment and after clinical remission of the acute episode. The results were compared with serum TNF levels in healthy controls and fresh pauci-and multibacillary leprosy patients. Results. TNF levels in acute reactions were higher than in the control groups (significant only in upgrading reaction). In type 1 reaction, serum TNF concentrations fell to approximately the levels of the control patients following treatment and clinical remission. In type 2 reaction, however, levels of TNF were seen to rise further (became statistically significant) as a result of therapy induced clinical remission. Conclusions. The rise in TNF-A level in reactions in leprosy is significant and indicates its active role in immunopathogenesis. The corresponding decline in TNF-a levels seen following regression of type 1 (lepra) reactions was not observed in the case of type 2 (ENL) reaction. This probably reflects the enhancement of cellular immunity in such cases and/or an attempt by the immunologic process to overcome specific inhibitors.

Notes: A 39-year-old housewife sustained inadvertent trauma to the right index finger about 6 years ago, whilst stitching clothes. A couple of weeks later, the site of trauma became hard and gritty. Ever since, it has progressed slowly, without any appreciable outward sign. It was not associated with any discomfort/pain. Consequent on an opinion from a surgeon, it was decided to operate on the right index finger. During the operation, under local anesthesia, a hard and gritty material was removed. The material was subjected to histopathologic study. Several stitches were applied to the wound. It failed to respond to antimicrobial therapy over a 4-week period, prompting the patient to seek another opinion. Examination of the skin surface revealed a plaque with an irregular configuration on and around the distal interphalangeal joint of the right index finger. It was erythematous and pigmented. The top of the plaque was irregular and had alternating elevations and depressions (〈link href="#f1"〉Fig. 1). Diascopy was negative for apple jelly nodule. A bacillus Calmette–Guérin (BCG) vaccination scar was identified on the left deltoid. There was no regional lymphadenopathy or systemic abnormality. Mantoux test with intradermal injection of 0.1 mL SPAN's tuberculin (purified protein derivative/5 tuberculin units/0.1 mL) (Span Diagnostic Ltd., Murat, India) was negative after 72 h. Investigations, including total and differential leukocyte count, erythrocyte sedimentation rate, serum biochemistry, and renal and liver function tests, were within the normal range, as was a chest X-ray.〈figure xml:id="f1"〉1〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD2019:IJD_2019_f1"/〉Tuberculosis verrucosa cutis before (a) and after (b) antitubercular therapy (ATT)Hematoxylin and eosin-stained sections prepared from the biopsy taken from the lesion revealed noteworthy changes in the epidermis and the dermis. The former was marked by the presence of hyperkeratosis, acanthosis, and papillomatosis, whilst the latter contained tubercle granulomas. Each of the granulomas was well formed and consisted of large numbers of lymphocytes, histiocytes, and foreign body (Langerhans’) giant cells (〈link href="#f2"〉Fig. 2). Caseation necrosis and acid-fast bacilli could not be demonstrated. The preceding revelations were fairly conducive to the diagnosis. Accordingly, antitubercular therapy (ATT), comprising 450 mg of rifampicin, 300 mg of isonicotinic acid hydrazide, and 800 mg of ethambutol, was recommended for oral administration each day for 60 days. The outcome of the treatment was satisfactory, resulting in perceptible regression of the skin lesion (〈link href="#f1"〉Fig. 1b). The patient was advised to continue the treatment for another 30 days, after which 450 mg of rifampicin and 300 mg of isonicotinic acid hydrazide were to be continued for another 6 months.〈figure xml:id="f2"〉2〈mediaResource alt="image" href="urn:x-wiley:00119059:IJD2019:IJD_2019_f2"/〉Tuberculosis verrucosa cutis depicting well-formed tubercle(s) comprising lymphocytes, histiocytes, neutrophils, and a few giant cells (hematoxylin and eosin, × 100)

Notes: Sera from 25 patients with type 1 (Lepra), upgrading and downgrading, and type 2 (erythema nodosum leprosum [ENL]) reactions were assayed, during the reaction and after its clinical remission, for changes in levels of alpha-1–antitrypsin (AIA) and C-reactive protein (CRP). The results were compared with those from normal healthy adults and patients of leprosy without history and/or clinical evidence of reaction. The AIA levels correlated better with changes in status of type 1 reaction; whereas CRP levels correlated well with alterations in type 2 reactions and were definitely superior to AIA in this situation for monitoring the course of these episodes.

Notes: Fifty-four patients with cutaneous tuberculosis, consisting of 23 with lupus vulgaris,22 with scrofuloderma, and nine with verrucosa cutis, were investigated for cell-mediated immunity, through estimation of peripheral total T lymphocytes (CD3+), CD4+ (helper/inducer), and CD8+ (cytotoxic/suppressor) lymphocytes, by immunohistochemical staining of peripheral blood smears, using specific monoclonal antibodies and the alkaline phosphatase-antialkaline phosphatase (APAAP) method. Absolute values of total T lymphocytes (CD3+), and CD4+ and CD8+ subsets, were found to be significantly raised in scrofuloderma, but the percentage values and the CD4+/CD8+ ratio remained unaltered. In tuberculosis verrucosa cutis, only the percentage of the CD8+ subset of T lymphocytes was found to be significantly lowered, and this altered the CD4+/CD8+ ratio. No significant change was observed in the peripheral blood T cells and their subpopulations in patients suffering from lupus vulgaris.

Notes: Background  Lichen scrofulosorum is considered a rare form of cutaneous tuberculosis. Current information is based on case reports and case series with a small number of patients.Methods  Thirty-nine patients with Lichen scrofulosorum were followed during the period January 1996 to December 2002. Clinical details (age, sex, duration of disease, associated tubercular lesions, extent and distribution of skin lesions), laboratory parameters (hemoglobin, total leucocytic counts, erythrocyte sedimentation rate, Mantoux test, presence of BCG scar), and response to antitubercular treatment were recorded and analyzed.Results  7.6% patients of all (511) patients with cutaneous tuberculosis had LS. 22 (56.4%) were males and 32 (84%) were below 15 years of age. Twenty-eight (72%) had an associated focus of tuberculosis elsewhere in the body; 13 (33%) had tubercular lymphadenopathy, while 11 (28%), three (8%) and six (15%) had pulmonary tuberculosis, intracranial tuberculosis and other forms of cutaneous tuberculosis, respectively. Six (15%) had tubercular focus at multiple sites. Eleven (28%) had no other identifiable focus of tuberculosis. Twenty-eight (72%) had evidence of receiving BCG vaccination. Trunk was the commonest (100%) affected site. The two groups with and without associated tubercular focus were not different with respect to age, sex, duration of disease, hemoglobin, total leukocyte count, erythrocyte sedimentation rate, Mantoux test positivity, and presence of BCG scar. Mycobacteria tuberculosis could not be detected either on acid fast bacilli (AFB) staining or on culture from biopsies of LS lesions. All patients (including those without evidence of tubercular focus) responded to antitubercular treatment, signifying an underlying occult tubercular focus as etiology.Conclusions  Lichen scrofulosorum is an uncommon but not rare cutaneous manifestation of tuberculosis. A high index of suspicion and awareness is required for diagnosis. Systemic tuberculosis is often associated with LS and a prior BCG inoculation does not protect against development of LS. Response to antitubercular treatment is good irrespective of the presence or absence of associated tubercular focus.