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 Table of Contents  
LETTER TO THE EDITOR
Year : 2017  |  Volume : 37  |  Issue : 1  |  Page : 30-32

Psoriasiform lupus vulgaris


Department of Dermatology & Venereology, Pramukhswami Medical College, Karamsad, Gujarat, India

Date of Submission07-Sep-2016
Date of Acceptance15-Feb-2017
Date of Web Publication2-Jun-2017

Correspondence Address:
Pragya A Nair
Department of Dermatology & Venereology, Pramukhswami Medical College, Karamsad 388325, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1110-6530.207491

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How to cite this article:
Nair PA, Jiwani NB. Psoriasiform lupus vulgaris. Egypt J Dermatol Venerol 2017;37:30-2

How to cite this URL:
Nair PA, Jiwani NB. Psoriasiform lupus vulgaris. Egypt J Dermatol Venerol [serial online] 2017 [cited 2017 Jun 28];37:30-2. Available from: http://www.ejdv.eg.net/text.asp?2017/37/1/30/207491

A 59-year-old woman presented with lesions over both legs, the scalp, and the left forearm associated with mild burning and itching since 5 months. She consulted many practitioners and was treated for acute eczema. There was no history of trauma at the site. No specific family history was elicited. The patient was a known case of hypertension on treatment since 4 years with no other comorbidities.

On examination, multiple erythematous excoriated papules over the left forearm and fingers ([Figure 1]a) and erythematous scaly plaques with mild atrophic changes over both legs and the dorsum of feet ([Figure 1]b) were present. Erythematous papules with fine scales, few of them excoriated over the posterior hairline extending up to the nape of the neck ([Figure 1]c), were present. Finger nails showed dystrophic changes. No lymphadenopathy was noted. Differential diagnoses were psoriasiform eczema and psoriasis.
Figure 1 (a) Multiple erythematous excoriated papules over the left forearm. (b) Erythematous scaly plaques and mild atrophic changes over both legs and feet. (c) Erythematous scaly papules over the posterior hairline extending up to the nape of the neck.

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Biopsy obtained from the forearm showed multiple ill-formed epitheloid granulomas in the dermis with scanty caseous necrosis and giant cells suggestive of mycobacteriosis of the skin ([Figure 2]a). On follow-up visit, the Montoux test and chest radiography performed were normal. Routine investigations showed total count, 5300/cm3; differential count, 68, 24, 4, 4; hemoglobin, 12.1 g/dl; platelet, 262 000/ml, and erythrocyte sedimentation rate, 64 mm. HIV testing showed her seronegative. There were no complaints of fever, cough, weight loss, and abdominal pain. Repeat biopsy was obtained from the leg, which showed hyperkeratosis and acanthosis of the epidermis along with granulomas comprising Langerhans cells, epitheloid cells, lymphocytes, and plasma cells in the dermis ([Figure 2]b); this supports the findings of first biopsy. The patient was administered category-I antituberculous drugs for 6 months. After 3 months of treatment, lesions over the scalp resolved and improvement was seen over legs.
Figure 2 (a) Multiple ill-formed epitheloid granulomas in the dermis with scanty caseous necrosis and giant cells (×10). (b) Hyperkeratosis and acanthosis of the epidermis with granulomas comprising Langerhans cells, epitheloid cells, lymphocytes and plasma cells in the dermis (×40).

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Cutaneous tuberculosis (CTB) is caused by Mycobacterium tuberculosis in the majority of cases and accounts for 0.1–0.9% of total dermatology outpatients in India [1]. Cutaneous involvement represents only 2% of extrapulmonary tuberculosis [2]. The incidence of CTB has fallen from 2 to 0.15% in India, due to the availability of effective antituberculosis drugs, elimination of dairy herds, and general improvement in the living standards; however, it is rare in developed countries [3].

Lupus vulgaris (LV) called as ‘tuberculosis luposa’ or ‘tuberculosis luposa cutis’ is a chronic, progressive and most common form of CTB with multitude of presentations such as nodules, vegetating lesions, and ulcerated or tumoriform lesions, and mimics diseases such as discoid lupus erythematosus, psoriasis, sporotrichosis, actinomycosis, and mycetoma [4]. Lesions occur in normal skin as a result of direct extension from underlying deeper tuberculosis focus, by lymphatic or hematogenous spread, after primary inoculation, BCG vaccination or in scars of old scrofuloderma. It occurs in people with moderate or high degree of immunity and is three times more common in female population [5].

It represents a real diagnostic challenge because the cutaneous tissue slightly favors the reproduction of bacilli. The clinical variants of tuberculosis include hypertrophic, plane, ulcerative, and scarring forms in addition to mucosal (nasal, oral, and conjunctival) lesions. Rarely psoriasiform mutilating, vegetative, and nodular lesions occur [6].

Lesions usually are small, solitary, nodular, sharply defined, and reddish-brown with a gelatinous consistency (called apple jelly nodules), but two or more sites may be simultaneously involved as in our case. Persistent lesions may damage the underlying tissue and ulcerate, causing severe disfigurement and an increased risk for cancer. The head and neck are the sites commonly affected in European countries, whereas buttocks, thighs, and legs are common sites of involvement in Indian patients [7]. In this case, multiple sites were involved, such as legs, the dorsum of feet, the forearm, and the scalp, which is seen rarely.

Histopathology of LV reveals typical epithelioid granulomas in the upper dermis, with lymphocytes and Langerhans giant cells in 80% of cases. The hypertrophic form additionally shows the presence of epidermal hyperkeratosis, papillomatosis, and acanthosis. Necrosis is not seen and fibrosis is evident in areas of healing and scarring. Acid-fast bacilli are scanty and difficult to detect using staining methods or mycobacterial culture.

The primary focus was clinically inapparent in our patient as also opined by Padmavathy et al. [6]. False-negative reactions to M. tuberculosis may be seen as in our case, which is common in patients with disseminated infection such as miliary tuberculosis or in immunosuppressed states such as severe malnutrition in children or HIV infection.

There is a delay in the diagnosis because CTB is not always considered in the differential diagnosis of atypical or nonhealing skin lesions. In our case, patients’ lesions simulated psoriasiform eczema, which on biopsy turned out to be cutaneous mycobacteriosis.

LV can be differentiated from psoriasis by negative auspitz sign, no nail or joint involvement, and winter aggravation. Along with the morphology of lesion, complete history taking is very important to rule out other diagnoses. One should proceed to biopsy in such cases to confirm the diagnosis.

CTB should be treated with isoniazid, rifampicin, pyrazinamide, and ethambutol given for 2 months (intensive phase), followed by isoniazid and rifampicin given for the next 4 months (continuation phase) [8]. The diagnostic value of culture and PCR is less, and hence diagnosis is mainly dependent on clinical features, histopathological findings, and retrospective review of response to treatment.

Despite the availability of effective chemotherapy and implementation of strategic health programs, tuberculosis still remains a formidable infection globally and an economic burden for resource-constrained countries. Prompt response with atypical presentation leads to a swift diagnosis and timely treatment and results in high patient satisfaction, which is of paramount importance.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Pandhi D, Reddy BS, Chowdhary S, Khurana N. Cutaneous tuberculosis in Indian children: the importance of screening for involvement of internal organs. J Eur Acad Dermatol Venereol 2004; 18:546–551.  Back to cited text no. 1
[PUBMED]    
2.
Kumar B, Muralidhar S. Cutaneous tuberculosis: a twenty-year prospective study. Int J Tuberc Lung Dis 1999; 3:494–500.  Back to cited text no. 2
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3.
Sehgal VN, Srivastava G, Khurana VK, Sharma VK, Bhalla P, Beohar PC. An appraisal of epidemiologic, clinical, bacteriologic, histopathologic and immunologic parameters in cutaneous tuberculosis. Int J Dermatol 1987; 26:521–526.  Back to cited text no. 3
    
4.
Saritha M, Parveen BA, Anandan V, Priyavathani MR, Tharini KG. Atypical forms of lupus vulgaris − a case series. Int J Dermatol 2009; 48:150–153.  Back to cited text no. 4
[PUBMED]    
5.
Jain VK, Aggaral K, Jain S, Singh S. Hypertrophic lupus vulgaris: an unusual presentation. Indian J Dermatol 2009; 54:287–289.  Back to cited text no. 5
    
6.
Padmavathy L, Lakshmana RL, Ethirajan N, Dhanlaklshmi M. Psoriasiform lupus vulgaris. Indian J Tuberc 2008; 55:97–99.  Back to cited text no. 6
    
7.
Sacchidanand S, Sharavana S, Mallikarjun M, Nataraja HV. Giant lupus vulgaris: a rare presentation. Indian Dermatol Online J 2012; 3:34–36.  Back to cited text no. 7
    
8.
Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM. Cutaneous tuberculosis: diagnosis and treatment. J Clin Dermatol 2002; 3:319–328. Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM.  Back to cited text no. 8
    


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