Patient: Description of the condition (onset time, main symptoms, hospital visited, etc.): A year ago, red circular papules started to appear on the skin of the lower extremities, which were all crusted with blood after scratching due to itching. The rash was most frequent on the extensor side of the lower extremities, and gradually on the buttocks, back, abdomen and upper extremities. In March 2010, he visited the dermatology department of a tertiary care hospital and was suspected of having nodular itchy rash. After that, he was treated as nodular itchy rash, with compound glycopyrrolate, cetirizine, keratan, epalmatine, raglan polyside, hydroxychloroquine, topical fulvicin, halometasone ointment, topical and intramuscular injection of Depo-Provera, and also treated with UVB 20 times, but it was not significantly controlled, and the lesions were more severe and extensive than before. In January 2011, I visited the dermatology department of another hospital and underwent tuberculin (PPD) test and skin pathology, and the PPD test result was strongly positive, and the pathology report: tuberculous small vasculitis, combined with the clinical diagnosis of papulonecrotic tuberculosis rash. I would like to ask Dr. Jiang: 1. How should papulonecrotic tuberculosis rash be treated? 2. How should I interpret the different results of the two skin pathologies? Here are the photos of the lesions in October and March of last year from the Department of Dermatology, China-Japan Friendship Hospital of Jilin University
Jiang Zhongmin, Department of Dermatology, Sino-Japanese Friendship Hospital of Jilin University: The pathology results are related to the representativeness of the sampling site, and the report with typical lesions should prevail.
Patient: Thank you for your reply! I have no past history of tuberculosis. I had an X-ray two weeks ago because of fever, and there was no problem in my lungs, and no abnormalities in my abdomen and germline ultrasound. However, I don’t know why the PPD test came back strongly positive. The dermatology department at my current hospital has no experience in treating “papulonecrotic tuberculosis rash” and I would like to ask Dr. Jiang for guidance: 1. whether other tests are needed? 2. which drugs should be used for anti-tuberculosis treatment? How long should I take them?
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University: You can take anti-tuberculosis treatment directly, usually with a triple drug: remifentan, rifampin, ethambutol, for at least 6 months, but you can also go to the tuberculosis hospital for consultation.
Patient: Thank you for your reply! I have seen the pathological slides of this examination with specialists from other hospitals, and they all think it is a nodular itchy rash, not a papular necrotizing TB rash. I don’t know what to treat, but a friend suggested that I bring the pathology slides to you for a consultation.
JIANG Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University: You can come to my clinic according to my clinic hours. The final judgment should be fully integrated with clinical and pathological aspects, and it is better to have 2 pathological slides. Click here for my clinic hours
Patient: Thank you very much Dr. Jiang for your consultation! I would also like to ask you a question, the lesions are still itchy and painful, do I need to use medication to improve these symptoms?
The dermatology department of Jilin University Sino-Japanese Friendship Hospital, Jiang Zhongmin: After seeing the slides, although the pathological changes are not very typical, based on experience, the diagnosis is still definite, adherence to treatment can achieve healing, systemic internal medication for a period of time can improve most of the symptoms, external medication can be used for the more severe symptoms of the rash, you can use Eloson, Bactrim, but can not replace the internal medication.
Patient: Thank you for your reply! I will stick to the treatment. One more question for Mr. Jiang, how long do I need to use compound glycyrrhizin and Skincam?
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University: Compound glycyrrhizin tablets are taken orally for 1-2 months or longer, and Skikang is best started after the rash has mostly subsided, such as after 1 month, with 1 intramuscular injection every other day for 1-3 months.
Patient: Thank you very much for your guidance! I have been on treatment for nodular itchy rash for a while, and I had 1 intramuscular injection of Depo-Provera 5 weeks ago, and I have been on treatment with compound glycyrrhizin and Stryker for the past month, and my condition is better than before. Is it okay to continue taking glycopyrrolate for another 1-2 months? Should I continue to use Stryker or wait until the lesions are better? Do I need to take any other liver-protective medication?
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University: Start with oral anti-tuberculosis drugs (at least 3 months), 1-2 months with compound glycyrrhizin, and not with Depo-Provera, and stop with Skikang for 1 month, and then use it for 1-3 months after the disease is basically controlled to prevent relapse. Compound glycyrrhizin controls the rash and has a hepatoprotective effect, and other hepatoprotective drugs such as inosine tablets and vitamin E can also be added.
Patient: Thank you for your reply! I have been taking medication for this, but the lesions have not improved significantly, basically no itching, but the rash is red and the pressure is obvious. Also a week ago I started to have a low fever (37.2-37.5 degrees) in the afternoon, and my lower limbs feel sore and fatigued, so I wonder if it is related to the skin lesions? Is it necessary to treat with other medications?
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University: The fever and soreness symptoms may still be symptoms of TB toxemia. The treatment effect of TB rash is slower than that of TB because of the involvement of metabolic factors, and there may be some aggravation of symptoms due to the bactericidal effect and release of more bacteriophage antigens during the initial treatment of TB, which may get better with continued treatment, and TB drugs may also cause fatigue.
Patient: Thank you, Mr. Jiang, for your reply! I went to the hospital today for blood tests and my blood count and liver function were normal. I would like to ask you two questions about the blood sedimentation and blood uric acid test results: 1. Three weeks ago (February 11, no fever at that time) the blood sedimentation test result was 9mm/1h, today the blood sedimentation (27mm/1h) is significantly higher than the original, I wonder if the disease is serious? Or is there a possibility of other diseases? The body temperature is still 37.5 degrees. The blood uric acid test result three weeks ago (Feb. 11) was 210umol/L. The previous tests were at the lowest of the normal range, but today’s test result is 395umol/L, which is much higher than before and is close to hyperuricemia. I have looked up the instructions for several anti-tuberculosis drugs and found that taking ethambutol has been associated with adverse effects of hyperuricemia and gout. I have been watching my diet for the last two months and have not eaten any food that can raise my blood uric acid, so I personally feel that taking ethambutol has raised my blood uric acid level. Is there any way to prevent this side effect of ethambutol? I am worried that if I take it for a while longer, it will really become hyperuricemia or gout.
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University.
Based on your detailed medical history, I envision the course about the evolution of your disease, but hopefully it fits your situation to bring confidence to persist in treatment.
Your tuberculosis has been latent or critically active for many years, and before you came to the clinic, due to the use of hormones, the tuberculosis bacilli multiplied rapidly and increased exponentially or geometrically, but there was no normal fever and immune fatigue response due to the suppression of immunity, and there was even the illusion of improvement, and only after the effect of hormones disappeared (the effect of Depo-Provera can last up to 1 month), the normal fever and fatigue response to the already significantly increased tuberculosis bacilli gradually returned. Anti-tuberculosis drugs can only kill a small amount of bacteria in the reproduction phase, and a long enough course of treatment is needed until all TB bacteria have gone through the reproduction phase before they can be completely eliminated.
The increase in blood uric acid should be related to TB drugs, but it will not lead to gout disease, which is a primary abnormal metabolic disease. The increase caused by drugs will recover with the discontinuation of drugs, and the benefits far outweigh the disadvantages, such as special reactions, and specific consultation with specialists in internal medicine or TB.
Patient: Thank you very much for your reply! I feel that your analysis makes a lot of sense. In fact, I had a strong positive PPD test several years ago, but it is said that many people have a strong positive test, which is not meaningful for adults, so I didn’t care about it, and I have been in good health for many years. A year ago I started to use Depo-Provera 6 times for skin problems, and at first I felt that the effect was okay, but then it was not so obvious, and I kept trying to treat it, but the lesions were getting worse. Is it true that a strong positive PPD means that I am infected with TB? Is it possible to have a false positive test? I took the PPD test 3 days after I received a dose of Depo-Provera, does it affect the test result? Also, is there any dietary restriction for my current condition? Thank you very much for your analysis and guidance, which has given me the confidence to persevere with my treatment. I will ask you for advice or come to the hospital for follow-up when I encounter problems in the “long” treatment process.
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University: A positive PPD must be a history of tuberculosis infection or BCG vaccination, and China and India are areas with a high prevalence of tuberculosis infection and a high rate of positivity. A strong positive is much more significant and indicates a history of recent infection or recent BCG vaccination. Tuberculosis infection does not always develop, which is the reason for ignoring the significance of a positive test. The development of disease depends on the balanced relationship between immunity and the amount of infection, with many influencing factors and a variety of manifestations. The PPD response is diminished with hormones, indicating that the actual intensity of your PPD may be stronger than observed and more indicative of TB infection. There are no special dietary restrictions.
Patient: Thank you, Mr. Jiang, for your guidance! At present, my condition is not as fast as I expected, but in general the lesions seem to be gradually improving. I had a blood test yesterday, and I have a few questions for Mr. Jiang. 1. The liver function test results show that glutamyl transpeptidase (55) is already above the normal range and cholinesterase (15476) is also rising. In order to prevent liver damage, I have been taking compound glycyrrhizin tablets (3 tablets twice daily) and creatinine tablets (3 tablets twice daily), do I need to add other liver-protective drugs to my current condition? I am worried that the anti-tuberculosis drugs will continue to worsen the abnormal liver function. 2. A week ago, I started to have a little fever due to a cold, and after that, I sometimes have trouble breathing at night when I sleep, and it gets better when I sit up. X-rays were taken yesterday and showed enhanced texture in both lungs and no active lesions were found in both lungs. The routine blood test showed an increase in the percentage and number of eosinophils, I don’t know if this is caused by skin lesions or respiratory infections. Do I need to use other medication for this condition?
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University.
Slow good is more solid and lasting than fast good. Eosinophil increase is related to allergy, infectious metaplasia can also cause eosinophil increase, and transaminases are mildly elevated, it should not be a big problem, consult with internal medicine doctor again, if you are worried, anti-tuberculosis drugs are temporarily taken orally once every other day, it has less influence on the efficacy, but also ask respiratory department to further exclude tuberculosis activity.
Is Stryker still being used? Did the swollen submandibular lymph nodes appear only after the flu? Two or three anti-tuberculosis drugs?
Patient: Thank you very much for your reply, Mr. Jiang. I am continuing to use Skikon. I was hospitalized a few days ago for fever and had some tests done. CT examination of lungs: enhanced texture in both lungs, small nodule-like high-density shadow seen in the upper lobe of the right lung. Inflammatory nodules in the upper lobe of the right lung were considered to be more likely. Serum Mycobacterium tuberculosis antibody test was negative; blood sedimentation was 15 mm/1 h. Routine blood tests were still eosinophilic. The liver function which was mildly abnormal has returned to normal. I would like to ask Mr. Jiang: 1. The PPD test was strongly positive more than 3 months ago, but the serum Mycobacterium tuberculosis antibody test is negative this time, what does it mean? Is it a negative TB infection? The respiratory doctor said that I do not have TB and that the CT image is not consistent with TB, and the blood sedimentation is not high. I am still on three kinds of anti-TB drugs, and although the skin lesions have improved, there are still a lot of skin lesions and some new rashes. Is it possible to reduce the anti-tuberculosis drugs to isoniazid and rifampin? Or should I keep taking three? Should I continue to use compound glycopyrrolate tablets and Skidmore? Do I need to go to a follow-up appointment next week to consider medication adjustment?
Jiang Zhongmin, Department of Dermatology, China-Japan Friendship Hospital, Jilin University: 1) The significance of TB antibodies is not as great as that of the tuberculin test, and there are often cases of definite TB with negative TB antibodies. 2) A complete judgment of chest radiographs cannot be made in isolation from the overall systemic consideration and historical background analysis, but also with reference to pathological judgment and a series of established facts, although it is impossible to do pulmonary pathology and can only be indirectly inferred from skin pathology. . In this sense, it is possible that CT and blood sedimentation exclude only active tuberculosis and high-density shadows (size?) in the lungs. still does not exclude old TB lesions and may even further confirm previous judgments. (3) It is best to do a control analysis with previous and subsequent chest films, and ultimately a more experienced respiratory or radiologist should make the judgment. 4) Complete control of TB rash is later than complete control of TB because hypersensitivity to old TB foci also exists in the allergic body, and the intensity of response to decreasing TB bacilli still fluctuates with changes in body status and immune status until complete control is achieved. 5) Take another look and refer to all the latest new test information.
Patient: Thank you for your response. I will go for a follow-up appointment next week when you are out.