Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis seen in 1% of all cases. Lupus vulgaris is one of the most common types of cutaneous tuberculosis. Its cutaneous patterns may mimic other dermatologic conditions such as pyoderma gangrenosum. Clinical, diagnostics and histopathologic correlation is important in diagnosing lupus vulgaris.

This is a case of a 17-year-old Filipino male with multi-drug resistant Pulmonary Tuberculosis who presented with three-months history of erythematous papule that gradually progressed into plaque on the scalp, abdomen and left popliteal area with associated pruritus 5/10. The initial working diagnosis was cutaneous tuberculosis versus pyoderma gangrenosum. Incision biopsy revealed a granulomatous dermatitis surrounded by a dense mixed cell infiltrate of lymphohistiocytes from superficial to mid dermis suggestive of an infectious process. Chest radiograph confirmed pulmonary tuberculosis, interferon gamma detection by enzyme linked immunosorbent assay (Quantiferon TB Gold Plus) and nucleic acid amplification test (GeneXpert TB) further verified the presence of Mycobacterium tuberculosis (MTB). The patient was managed as lupus vulgaris, plaque type and started on second line anti-Koch’s medications. Excellent clinical response was seen after 3 months of treatment.

Lupus vulgaris is a challenging disease and may mimic a myriad of other cutaneous disorders, in this case pyoderma gangrenosum. This case highlights a high index of suspicion, trained clinical eye and multi-specialty care to diagnose and treat complicated cutaneous tuberculosis cases. In geographic locations where MTB is still endemic and drug resistance burdens pose complications in treatment, second line pharmacologic interventions for MTB treatment is a viable option.

Lupus vulgaris is a form of cutaneous tuberculosis (CTB) caused by Mycobacterium tuberculosis (MTB). It is characterized by a usually solitary, long-lasting skin lesion that most commonly develops on the head or neck, especially the nose, cheek, earlobe, or scalp.

A 69-year-old elderly, Filipino female presented with a 20-year history of progressively growing erythematous ulcerative plaques on the right arm and ear, with associated mild pruritus and pain. She appeared to be immunocompetent and had no clinically apparent underlying focus of TB infection. Tuberculin skin test (TST) showed a positive reaction and histopathologic examination revealed a chronic granulomatous dermatitis that is focally positive for acid-fast bacilli (AFB). She was given anti-koch’s therapy with subsequent resolution of the lesions.

The case report presents a rare instance of lupus vulgaris (LV) in a Filipino woman, characterized by large, ulcerative plaques on her body with no apparent infection source, emphasizing the need for early detection and Quantiferon-TB Gold (QFT-G) testing for diagnosis.

Cutaneous tuberculosis, a rare dermatologic condition with a wide spectrum of clinical findings depending on the source and immune status of patient. The common subtype is Lupus Vulgaris which is extremely chronic and progressive type
Case Management ; Lupus Vulgaris ; Tuberculosis

Cutaneous tuberculosis (TB) occurs rarely, comprising only approximately 1% of all extrapulmonary TB cases worldwide. This report presents an atypical clinical manifestation of Lupus vulgaris, the most common form of cutaneous TB. Typically, Lupus vulgaris presents as chronic erythematous plaques over the head and neck area. The patient, a 24-year-old male with limited support and financial resources, presented with chronic painful, non-healing ulcerated lesions on his left upper extremity. Diagnostic tests specific to TB infection, including culture, all turned out negative for TB. No improvement in the lesions was noted with antibacterial and antifungal therapies. Clinical course of the condition and histopathologic findings, though non-specific to TB, became the basis for diagnosis and treatment. Patient currently is on the 3rd month of anti-Koch’s treatment with noted gradual improvement in the character and appearance of the lesions. Lupus vulgaris could appear as ulcers and over the extremities though much less common, posing challenges in both diagnosis and treatment. Malignant transformation could develop if left untreated. Thus, careful and thorough examination of the patient and diligent follow-up and re-evaluation of lesions while considering the patient’s values, concerns and financial capacity, were necessary in successfully addressing both the biomedical and psychosocial aspect of the illness.
Skin Diseases ; Lupus Vulgaris

Systemic lupus erythematosus is an autoimmune disease for which glucocorticoids are the mainstay of treatment. Cushing's syndrome is caused by glucocorticoid excess, which can be either exogenous or endogenous. Although iatrogenic Cushing's syndrome is the most common form, especially in patients undergoing glucocorticoid treatment, endogenous glucocorticoid excess should be considered because it has a different treatment strategy. We describe a 51-year old woman with a longstanding history of SLE. She was treated with steroid and cytoxan pulse therapy and plasmapheresis. Her lupus activity had been stable for 7 years with low-dose glucocorticoid treatment. She showed excessive weight gain, easy bruising, moon facies, truncal obesity, acne, and menstrual disorder. Given her history of long-term steroid therapy, iatrogenic Cushing's syndrome was considered the most likely diagnosis; however, worsening features of Cushing's syndrome with a minimal dose of glucocorticoid led us to diagnose endogenous Cushing's syndrome due to a left adrenal adenoma. The patient underwent laparoscopic left adrenalectomy. Her SLE was controlled with transient low-dose glucocorticoid treatment, and her lupus activity remained stable without glucocorticoid treatment. This is the first reported case of concomitant endogenous Cushing's syndrome in a patient with preexisting SLE in Korea. This case shows the importance of differential diagnosis including exogenous Cushing's syndrome and endogenous Cushing's syndrome in autoimmune disease patients with glucocorticoid therapy.
Acne Vulgaris ; Adenoma ; Adrenalectomy ; Autoimmune Diseases ; Cushing Syndrome ; Cyclophosphamide ; Diagnosis ; Diagnosis, Differential ; Facies ; Female ; Glucocorticoids ; Humans ; Korea ; Lupus Erythematosus, Systemic ; Moon ; Obesity ; Plasmapheresis ; Weight Gain

No abstract available.
Interferon-gamma Release Tests* ; Lupus Vulgaris*

Cutaneous tuberculosis is an infrequent form of extrapulmonary tuberculosis. It is often clinically and histopathologically confused with various cutaneous disorders. A 36-year-old man attended our clinic with slowly progressive, asymptomatic, annular skin lesions on both the thighs and buttocks for 10 years. He consulted with many physicians and was improperly treated with an oral antifungal agent for several months under the diagnosis of tinea cruris, but no resolution of his condition was observed. A diagnosis of lupus vulgaris was made based on the histopathologic examination and the polymerase chain reaction assay. Anti-tuberculosis therapy was administered and the lesions started to regress.
Adult ; Buttocks ; Humans ; Lupus Vulgaris ; Polymerase Chain Reaction ; Skin ; Thigh ; Tinea ; Tuberculosis ; Tuberculosis, Cutaneous

BACKGROUND: Dermatophytosis is sometimes difficult to definitively diagnose if it has atypical clinical characteristics or the mycological tests are negative. For these cases, skin biopsy will be helpful to diagnose a fungal infection. OBJECTIVE: The purpose of the present study was to evaluate the clinical, histopathologic and mycologic characteristics of dermatophytosis patients who were initially diagnosed by skin biopsies. METHODS: We performed a retrospective study of the clinical characteristics and the histopathologic and mycologic features of 16 patients with dermatophytosis and who were initially diagnosed by skin biopsy. RESULTS: The final diagnosis of dermatophytic infections were tinea incognito (7 cases) and Majocchi's granuloma (9 cases). The main symptoms were pruritus (4 cases) and pain (2 cases). The skin lesions of tinea incognito and Majocchi's granuloma mimicked inflammatory skin disease, lupus vulgaris or deep mycosis. The most common site of involvement was the face. The possible predisposing factors causing tinea incognito and Majocchi's granulomas appeared to be application of steroid ointment (6 cases), physical trauma (2 cases) and diabetes mellitus (1 case). The histopathologic features of tinea incognito revealed the sandwich sign (100%) and neutrophils in the epidermis (71.5%) and dermis (71.5%). Majocchi's granuloma showed rupture of hair follicles (88.9%) and suppurative folliculitis (66.7%). With Periodic acid Schiff and methenamine silver staining, hyphae and spores could be identified on the horny layers, within the hair follicles and/or on the dermis in the biopsy specimens of all the cases. Culture of the causative organisms using dermal fragments and skin scales on Sabouraud media demonstrated Trichophyton rubrum (4 cases), T. mentagrophytes (3 cases) and Microsporum canis (3 cases). Systemic treatment with itraconazole or terbinafine for 2~10 weeks was effective, except for two cases. CONCLUSION: We consider that the histopatholgic findings may be of great help to diagnose a dermatophytosis that has atypical clinical characteristics or negative mycological tests. Fungal culture is also important for making an accurate diagnosis of dermatophytosis.
Biopsy ; Dermis ; Diabetes Mellitus ; Epidermis ; Folliculitis ; Granuloma ; Hair Follicle ; Humans ; Hyphae ; Itraconazole ; Lupus Vulgaris ; Methenamine ; Microsporum ; Naphthalenes ; Neutrophils ; Periodic Acid ; Pruritus ; Retrospective Studies ; Rupture ; Skin ; Skin Diseases ; Spores ; Tinea ; Trichophyton ; Weights and Measures

BACKGROUND: Histologic evidence of destruction of a cutaneous nerve by granulomatous inflammation is a feature of tuberculoid leprosy. However, identifying remnants of the nerve in the granuloma may be difficult in some instances because of morphologic similarities with granulomatous dermatoses, such as sarcoidosis, lupus vulgaris, tertiary syphilis, etc. OBJECT: The purpose of this study was to investigate the expressions of S-100 and EMA and to estimate area, thickness and density of nerves for differentiation tuberculoid leprosy from sarcoidosis. METHODS: Paraffin embedded tissues from patients of 11 tuberculoid leprosy, and 4 sarcoidosis were investigated for the expression of S-100, EMA and for the measurement of area, thickness, density of nerves by image analysis. RESULTS: S-100 staining in tuberculoid leprosy demonstrated fragmented, infiltrated, swollen nerves or the absence of dermal nerves(45.5%). All of the detectable nerves were identified within granulomas from tuberculoid leprosy, but nerves from sarcoidosis were widely distributed over inside(33.3%) or outside of the granulomas, perivascular, and periappendageal areas. There was no expression of EMA in skin lesions from leprosy, sarcoidosis, even in the site showing perineural thickening in S-100 stain. The cross-section area and the thickness of nerves were decreased in order of tuberculoid leprosy, sarcoidosis, and normal control group(p<0.05). The density of nerves was decreased in order of normal control group tuberculoid leprosy, and sarcoidosis with statistical significance between tuberculoid leprosy and sarcoidosis. CONCLUSION: It is possible to differentiate tuberculoid leprosy from sarcoidosis by the observation of the morphologic changes with S-100 protein stain and the measurement of the cross-section area, thickness and density with image analysis.
Diagnosis, Differential* ; Granuloma ; Humans ; Image Processing, Computer-Assisted* ; Inflammation ; Leprosy ; Leprosy, Tuberculoid* ; Lupus Vulgaris ; Paraffin ; S100 Proteins ; Sarcoidosis* ; Skin ; Skin Diseases ; Syphilis

BACKGROUND: Histologic evidence of destruction of a cutaneous nerve by granulomatous inflammation is a feature of tuberculoid leprosy. However, identifying remnants of the nerve in the granuloma may be difficult in some instances because of morphologic similarities with granulomatous dermatoses, such as sarcoidosis, lupus vulgaris, tertiary syphilis, etc. OBJECT: The purpose of this study was to investigate the expressions of S-100 and EMA and to estimate area, thickness and density of nerves for differentiation tuberculoid leprosy from sarcoidosis. METHODS: Paraffin embedded tissues from patients of 11 tuberculoid leprosy, and 4 sarcoidosis were investigated for the expression of S-100, EMA and for the measurement of area, thickness, density of nerves by image analysis. RESULTS: S-100 staining in tuberculoid leprosy demonstrated fragmented, infiltrated, swollen nerves or the absence of dermal nerves(45.5%). All of the detectable nerves were identified within granulomas from tuberculoid leprosy, but nerves from sarcoidosis were widely distributed over inside(33.3%) or outside of the granulomas, perivascular, and periappendageal areas. There was no expression of EMA in skin lesions from leprosy, sarcoidosis, even in the site showing perineural thickening in S-100 stain. The cross-section area and the thickness of nerves were decreased in order of tuberculoid leprosy, sarcoidosis, and normal control group(p<0.05). The density of nerves was decreased in order of normal control group tuberculoid leprosy, and sarcoidosis with statistical significance between tuberculoid leprosy and sarcoidosis. CONCLUSION: It is possible to differentiate tuberculoid leprosy from sarcoidosis by the observation of the morphologic changes with S-100 protein stain and the measurement of the cross-section area, thickness and density with image analysis.
Diagnosis, Differential* ; Granuloma ; Humans ; Image Processing, Computer-Assisted* ; Inflammation ; Leprosy ; Leprosy, Tuberculoid* ; Lupus Vulgaris ; Paraffin ; S100 Proteins ; Sarcoidosis* ; Skin ; Skin Diseases ; Syphilis