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第三章 杆菌性皮肤病
Bacillus Skin Infections
皮肤结核 Cutaneous Tuberculosis
由结核分枝杆菌直接侵犯皮肤或由其他脏器结核灶内的分枝杆菌经血行或淋巴系统播散到皮肤组织所致的皮肤损害。
皮肤结核临床表现各异,可分为外源性和内源性两大类。外源性主要包括结核性下疳、疣状皮肤结核。内源性主要包括急性粟粒性结核、腔口部皮肤结核和寻常狼疮。皮肤对结核杆菌的免疫反应可形成结核疹。
根据病史、典型临床表现和特征性病理改变诊断。结核分枝杆菌培养阳性是金标准,但阳性率较低。结核菌纯蛋白衍生物(PPD)或结核杆菌T细胞斑点试验(T-spot.TB)呈强阳性可辅助诊断,但非结核分枝杆菌感染或接种BCG均可以引起假阳性结果。分子诊断的应用有助于提高阳性率。
早期、足量、规则及联合用药。疗程至少在半年以上。常用的抗结核药有异烟肼、链霉素、利福平、利福喷丁、吡嗪酰胺、乙胺丁醇等。联合用药,如异烟肼、利福平、乙胺丁醇三联疗法。同时加强支持疗法。
是皮肤结核中最常见的类型。可发生于任何年龄。好发于面部、臀部等暴露部位。基本损害为粟粒到豌豆大的结节,玻片压后可呈苹果酱色。皮损可相互融合成片,呈橘红色。病程长的病例,皮损中央消退成萎缩性瘢痕,而周边则为活动损害,严重时可致毁容。
大多由于外源性结核杆菌接种到皮肤所致。好发于手指、手背、臀部等暴露部位。损害初起为单一结节,逐渐增大形成疣状增生的斑块,境界清楚。表面粗糙角化,呈乳头瘤状或结痂。损害中心常消退形成瘢痕,边缘则继续向外扩展。
又称腔口部皮肤结核(orificial tuberculosis)。发生在活动性内脏结核的患者,当分泌物或排泄物排出时,结核杆菌可接种于腔口部,引起病变。好发于口腔或肛门周围,溃疡大小不等,边缘呈潜行性,表面高低不平,有坏死组织及脓性分泌物。涂片可能查到结核杆菌。
好发于青年人。皮损对称散发于四肢伸侧、肘膝等处。偶可发生在外阴部,如龟头。基本损害为黄豆大结节,渐突出皮面,呈暗红色,中心坏死,表面结痂,痂下有凹陷性溃疡,愈后留瘢痕。皮疹常反复发生,成批出现。
患者有粟粒性肺结核,结核菌经血行播散。表现为全身散在分布的斑丘疹或丘疹,中央有坏死结痂,分泌物中可查到结核菌。如不及时治疗,预后不良。
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