Delayed diagnosis in a case of lupus vulgaris with unusual localization

Lupus vulgaris is the most common form of cutaneous tuberculosis, and the usual sites of involvement are the head and neck. We present a forty-six-year-old woman with lupus vulgaris on the external surface of the left leg and foot, an unusual site. Based on histopathological and clinical features, this case was diagnosed as lupus vulgaris with unusual localization.     

Co-existence of atypical tuberculid with lupus vulgaris

Cutaneous tuberculosis (CTB) is an uncommon form of extra-pulmonary tuberculosis accounting for ≤2% of mycobacterium tuberculosis cases and is more often reported from developing countries. Tuberculid, a cutaneous hypersensitivity reaction to mycobacteria or its fragments, is a another rare cutaneous manifestation seen in association with tuberculosis of other organ systems including tuberculous lymphadenitis, pulmonary tuberculosis, etc. Co-occurrence of a tuberculid with CTB is extremely rare. Herein we report a childhood case of lupus vulgaris, a type of CTB, associated with an atypical presentation of tuberculid.     

大腿寻常狼疮1例

报告大腿寻常狼疮1例.患者男,68岁.右大腿红斑、丘疹、斑块伴瘙痒30年.皮损组织病理检查示真皮浅层肉芽肿性炎,部分结节中央疑有坏死物,并见多核巨细胞、淋巴细胞浸润,真皮全层小血管周围少量淋巴细胞及个别浆细胞浸润.抗酸染色阳性,T-SPOT.TB检测阳性.PPD试验(++++).诊断:寻常狼疮.     

Inoculation lupus vulgaris.

An 11-years-old girl with lupus vulgaris on the right buttock following inoculation is described. The diagnosis was formed by the history, morphological characteristics, Mantoux test, histopathology, and was supported by an affirmative response to short course intensive chemotherapy (6 months). This route of infection acquires special significance with the worldwide-spread of HIV infection.     

右上肢带状寻常狼疮一例

患者,男,18岁.右手背至前臂伸侧带状分布暗红斑、丘疹9个月.皮损组织病理示真皮上部可见较多上皮样细胞、淋巴细胞和多核巨细胞浸润形成结核样肉芽肿.诊断:寻常狼疮.治疗:给予标准四联抗结核(异烟肼0.3 g/d,利福平0.45 g/d,吡嗪酰胺1.25 g/d,乙胺丁醇0.75 g/d),6个月后皮损大部分变平、消退.     

Relevant diagnostic implications of the therapeutic challenge with antitubercular therapy in an unusual case of sarcoidosis mimicking lupus vulgaris

Cutaneous manifestations in sarcoidosis are seen in 25–35% of patients with systemic disease and may be the sole manifestation in few patients. It is known that isolated cutaneous sarcoidosis is a great mimicker and can be easily misdiagnosed as other granulomatous conditions especially lupus vulgaris in regions with high burden of tuberculosis (TB). Here we present a case with cutaneous sarcoidosis who was initially misdiagnosed and treated as bifocal lupus vulgaris with antitubercular therapy (ATT) for 6 months. This nonresponsiveness to therapy prompted us to investigate the patient further for other differentials, failing which a diagnosis of cutaneous sarcoidosis was made and the patient was treated with oral steroids and methotrexate with complete clearance of lesions after 14 weeks of therapy. Our case reemphasizes the value of therapeutic trial of ATT in diagnosis of cutaneous TB and highlights the remarkable clinical mimic of sarcoidosis with lupus vulgaris.     

A case of multifocal lupus vulgaris that preceded pulmonary tuberculosis in an immune compromised patient

We describe the rare case of a Japanese male with multifocal lupus vulgaris that preceded asymptomatic pulmonary tuberculosis and adult T-cell leukemia/lymphoma (ATL). He visited our hospital with multiple reddish plaques and erythema of 4-12 months duration. A skin biopsy revealed non-caseating epithelioid granulomas. Mycobacterium tuberculosis was detected by polymerase chain reaction (PCR)-hybridization from a skin biopsy specimen and was also isolated from a culture of the skin biopsy sample. The result of chest roentogenography was compatible with pulmonary tuberculosis. In addition, the diagnosis of ATL was based upon the presence of atypical lymphocytes with convoluted nuclei in his peripheral blood and a positive anti-ATL antibody reaction. Cases of cutaneous tuberculosis presenting with unusual clinical features may be on the increase, accompanying the spread of tuberculosis in immunosuppressed patients, including those with ATL and acquired immunodeficiency syndrome (AIDS).     

Lupus vulgaris over a tattoo mark – inoculation tuberculosis

Lupus vulgaris developing after tattooing and remaining exclusively confined to it, in a 40-year-old-lady is reported. The tattooing was done one year earlier by a roadside tattoo artist. Diagnosis was suggested by the clinical features and confirmed by histopathology.     

Lupus vulgaris developing at the site of misdiagnosed scrofuloderma

Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis primarily occurring in developing countries. The recent increase in the incidence of tuberculosis, especially due to human immunodeficiency virus (HIV) infections, has led to a resurgence of extrapulmonary forms of this disease. We describe a case of lupus vulgaris in a 33-year-old woman who had a 5-year history of a slowly growing plaque on her neck. The lesion was located at the site of surgery repairing the scar resulting from the incision of a subcutaneous abscess during childhood. This lesion was misdiagnosed as bacterial abscess. Histopathologic examination of the plaque revealed non-caseating tuberculoid granulomas consisting of lymphocytes, epithelioid and giant cells. Staining for acid-fast bacilli and culture from biopsied tissue was negative. Polymerase chain reaction (PCR) for detection of Mycobacterium tuberculosis DNA, performed on a skin biopsy specimen, was positive. A diagnosis of lupus vulgaris developing at the site of a previous misdiagnosed scrofuloderma was made. Conventional antitubercular therapy with rifampicin, isoniazid and ethambutol was administered for 6 months, resulting in resolution of the lesion.     

系统性红斑狼疮并发寻常型天疱疮

报告1例系统性红斑狼疮并发寻常型天疱疮.患者女,42岁.面部出现红色斑丘疹伴四肢关节疼痛4年,同时出现光敏、血液系统异常,血清抗核抗体、抗ds-DNA抗体均阳性.2年前口腔黏膜反复出现糜烂,后躯干、四肢出现水疱,水疱破溃后形成不易愈合的糜烂面,经皮损组织病理检查、免疫荧光检查,诊断为寻常型天疱疮.     

Case of lupus vulgaris diagnosed 50 years after onset

Cutaneous tuberculosis is an infrequent form of extrapulmonary tuberculosis, but is a symptom that can lead to diagnosis of tuberculosis. We describe a case of lupus vulgaris in a 79-year-old woman who had a 50-year history of a slowly growing plaque on her right cheek. She visited many hospitals without resolution and the plaque gradually enlarged. Recently, she was misdiagnosed with eczema and prescribed topical steroids that had no effect, and she subsequently visited our outpatient clinic. A diagnosis of lupus vulgaris was made based on histopathology, culture and polymerase chain reaction, and isoniazid, rifampicin and ethambutol were administered as antituberculosis treatment. Although the incidence of cutaneous tuberculosis has decreased significantly in developed countries, knowledge and awareness of the disease are still of importance for proper diagnosis and treatment.     

Lupus vulgaris: Difficulties in diagnosis

Lupus vulgaris is one of the most common forms of cutaneous tuberculosis. It presents a diagnostic challenge due to its paucibacillary nature. This is a report of a case of a delayed diagnosis of lupus vulgaris, presenting as perianal and peristomal plaques, followed by a review of the diagnostic tools for lupus vulgaris and their limitations.     

A case of nodular cutaneous lupus mucinosis

The patient was a 44-year-old female. She was diagnosed as having systemic lupus erythematosus at the age of 21 years and had been receiving systemic steroid treatment (5 mg prednisolone/day). Nodules began to appear on her neck, chest and back from June in 2000, and she was referred to our clinic for examination and treatment. Examination of a biopsy sample of an eruption on the neck revealed mucin deposition in the dermis. Based on the clinical and histopathological findings, she was diagnosed as having typical nodular cutaneous lupus mucinosis. The dose of steroid was increased, and the eruptions gradually disappeared.     

结节性皮肤狼疮黏蛋白病

报告1例盘状红斑狼疮并发结节性皮肤狼疮黏蛋白病。患者男,45岁因而颈部红斑、皮肤萎缩20余年．背部、双上肢斑块、结节半年余就诊实验室检查抗核抗体（ANA）（＋）,滴度1：320．抗ds—DNA抗体、抗Sm抗体均（-）,背部皮损组织病理检查提示真皮中上部大量黏蛋白沉积。     

How Finsen's light cured lupus vulgaris

In 1903, Niels Ryberg Finsen was awarded the Nobel Prize for his invention of light therapy for skin tuberculosis (lupus vulgaris). The mechanism of action has not been shown; thus, we wanted to elucidate the mechanism of Finsen's light therapy. We measured radiation that could be transmitted through his lens systems and absorption of the stain solution filters in the lamps, and related the obtained results to the possible biological effects on Mycobacterium tuberculosis. Judged from transmission characteristics all tested lens systems were glass lenses (absorbing wavelength < 340 nm). The tested filters likewise absorbed wavelengths < 340 nm. The methylene blue solution used to absorb heat, blocked out wavelengths below 340 nm and between 550 and 700 nm. Furthermore, fluorescence of M. tuberculosis indicated the presence of porphyrins and HPLC analysis of sonicated M. marinum showed that coproporphyrin III was present, which highly justified that porphyrins were present in M. tuberculosis. Production of singlet oxygen through radiation of porphyrins with light of e.g. 400 nm seems to be a most plausible explanation why Finsen's therapy worked in spite of the lack of shortwave ultraviolet radiation, which Finsen believed was the most effective radiation for treating skin tuberculosis.     

Rapidly developing giant sized lupus vulgaris on the chest associated with bilateral scrofuloderma on the neck

Lupus vulgaris and scrofuloderma are the opposite poles of cutaneous tuberculosis. Lupus vulgaris of a giant size and scrofuloderma in the vicinity of this lesion were both present in a 70-year-old female patient. The purified protein derivative of tuberculin (PPD) skin test was strongly positive. In histopathological examination, granulomatous infiltration without caseation necrosis was seen in the dermis. The patient was treated with a four-drug therapy consisting of pyrazinamide (25 mg/kg), isoniazid (5 mg/kg), rifampin (10 mg/kg) and ethambutol (15 mg/kg) daily for 2 months, followed by dual therapy with isoniazid and rifampin for 6 months. Her cutaneous lesions significantly regressed after 4 months, leaving keloid scars.     

Lupus vulgaris: unusual presentations over the face

Lupus vulgaris (LV) is the most common morphological variant of cutaneous tuberculosis. However, the occurrence of bizarre clinical presentations over atypical sites often leads to misdiagnosis and inappropriate treatment causing significant morbidity. This report seeks to highlight two unusual cases of lupus vulgaris occurring on the face of immunocompetent women and remarkably mimicking periorbital cellulitis and basal cell carcinoma, respectively. The diagnosis was confirmed by histopathology, an enzyme-linked immunosorbent assay (ELISA) test for Mycobacterium tuberculosis and polymerase chain reaction (PCR). With four-drug antitubercular therapy, both patients had a dramatic response.     

Cutaneous Mycobacterium fortuitum infection mimicking lupus vulgaris

We report a woman with a lupus vulgaris-like skin eruption caused by Mycobacterium fortuitum. The presence of mycobacteria was confirmed with tissue culture and also the detection of mycobacterial heat shock protein 65 (hsp65) DNA in the biopsy specimen. The eruption resolved after treatment with amikacin and clarithromycin. Lupus vulgaris-like lesions might be included in the clinical spectrum of infections caused by rapidly growing mycobacteria.     

线状盘状红斑狼疮伴皮肤钙沉着症1例

报告1例线状盘状红斑狼疮伴皮肤钙沉着症。患者女,36岁。因左侧头皮,额部,颧部和颊部带状萎缩性红斑20余年,局部起白色小结节2年就诊。皮肤科检查见左侧头皮额部,颧部和颊部有一纵行的带状萎缩性红斑,表面和毛细血管扩张和粘着性鳞屑,在额部萎缩性红斑上可见一半粒绿豆大的白色小结节,质硬,实验室检查示血钙和血磷均正常。分别取萎缩性红斑和白色小结节行组织病理检查,符合盘状红斑狼疮和皮肤钙沉着症组织病理学改变。