An unusual episode of lupus vulgaris masquerading as sporotrichosis

Abstract

Case 1 A 24‐year‐old man presented with asymptomatic, gradually progressive plaques and nodules over the right knee extending to the thigh in a linear pattern of 3 months' duration. A year previously, he had been diagnosed with tuberculosis of the spine and had been advised to take antitubercular treatment; however, he chose to stop treatment on his own after 4 months of therapy as his spinal condition improved with a marked decrease in pain. There was no history of fever, systemic complaints, or any spinal or knee injury preceding the disease. His mother had received treatment for pulmonary tuberculosis 4 years previously. Dermatologic examination revealed well‐defined, brownish papules, plaques, and nodules of variable sizes, ranging from 3 cm to 6 cm, present over the right knee and front of the thigh in a linear pattern. The lesions were soft in consistency with ‘‘apple‐jelly’' nodules and the surrounding skin showed atrophic scarring (Fig. 1). 1 Plaques and nodules in a sporotrichoid distribution over the right lower limb (Case 1) All the hematologic and biochemical investigations were normal except for an elevated erythrocyte sedimentation rate (ESR) (48 mm/1 h). Venereal disease research laboratory (VDRL) test, enzyme‐linked immunoabsorbent assay (ELISA) for human immunodeficiency virus (HIV), and sputum examination for acid‐fast bacilli (AFB) were negative. Mantoux test with 1 tuberculin unit (TU) of purified protein derivative‐standard (PPD‐S) showed an induration of 25 × 20 mm. Blood culture and culture of the tissue homogenate for Mycobacterium tuberculosis, atypical mycobacteria, and fungal organisms revealed no growth. Slit skin smears from the plaque showed only lymphocytes and a few neutrophils. Immunoenzymatic test (ELISA) for antimycobacterial immunoglobulin M (IgM) antibody against the A 60 antigen complex was strongly positive (> 1 : 200 U). Histopathologic examination revealed a hypertrophic epidermis with noncaseating tuberculoid granulomas consisting of lymphohistiocytes, epithelioid cells, and Langhans' giant cells in the papillary and upper reticular dermis (Fig. 2a,b). No AFB were detected. Polymerase chain reaction (PCR) and guinea pig inoculation could not be performed due to a lack of facilities. 2 (a) Photomicrograph showing noncaseous tuberculoid granulomas in the papillary dermis (hematoxylin and eosin, × 40); (b) photomicrograph showing Langhans' giant cells (arrow) in the dense granuloma Skiagram of the chest was normal, although X‐ray of the lumbosacral spine revealed bony destruction of the sacral foramina. A magnetic resonance image (MRI) in the sagittal and axial plane was suggestive of caries of the fifth lumbar and sacral vertebrae with a large presacral and anterior epidural collection (Fig. 3). Computed tomography (CT) scan‐guided abscess drainage of the sacral region was performed and microscopic examination of the fluid revealed lymphocytes, polymorphs, macrophages, and a few AFB in a necrotic background. 3 Magnetic resonance image in the sagittal plane: caries ...

Lupus vulgaris: unusual presentations over the face

“…However, bizarre clinical forms over atypical sites continue to emerge sporadically, leading to misdiagnosis and delay in treatment. Unusual variants such as framboesiform, gangrenous, ulcerovegetating, lichen simplex chronicus and sporotrichoid types 4–6 have been added to the list of conventional morphological patterns of papular, nodular, plaque, ulcerative, vegetating and tumid forms.…”

Clinical Spectrum of Cutaneous Tuberculosis in Central India

“…Lupus vulgaris has been more commonly reported with this pattern in literature. [ 22 23 24 ] Ramesh V have reported scrofuloderma with sporotrichoid pattern over the upper limb in 20-year-old female. [ 25 ] We reported the same in a middle-aged female with the involvement of the forearm.…”

Sporotrichoid cutaneous tuberculosis

“…The incidence is rare, and as shown in this and a previous report, 1 it is seen in around 3% of all patients with cutaneous TB. It has been reported by others because of its rarity; 2,3 some of these reports have termed it segmental 4 or inverse sporotrichoid when the proximal half of the lower limb was affected due to retrograde lymphatic spread from the inguinal lymph nodes 5 . Multidrug‐resistant tubercle bacilli have also been isolated in a boy with a similar presentation 6 …”