Two cases of lupus vulgaris in childhood and review of the clinical challenges.

BACKGROUND: Lupus vulgaris (LV) is the most common form of cutaneous tuberculosis (TB) in Europe, nevertheless the overall incidence is low. It constitutes about 1.5% of all extra-pulmonary cases worldwide. A slight raise in TB incidence rates among children was recently registered in Germany, which can be explained by the increased immigration. PATIENTS AND METHODS: We present 2 cases of immigrated children who were diagnosed with Lupus vulagris, both clinically and histopathologically. Although the symptoms and the duration of the skin lesions were very different, both patients had a non-healing skin ulceration.In our cases cultures of the skin biopsy were positive for Mycobacterium tuberculosis and the lesions showed marked improvement in response to antituberculous treatment. In the first patient, it took 6 years between occurrence of skin lesions and final diagnosis. The second patient had an extracutaneous focus, namely abdominal TB. CONCLUSION: We report our experience and emphasize on recent advances in the diagnosis and treatment of paediatric skin TB.

Lupus vulgaris: unusual presentation on face.

Lupus vulgaris is a variant of cutaneous tuberculosis. As the disease has potential to mutilate when left untreated, leaving deforming scars and disfigurement, an early diagnosis is of paramount importance. Though the common type is plaque type, rarely mutilating and vegetative forms also are found. A 28 year old female, labourer presented with progressive annular plaque over right side of cheek extending upto right lower lid and ala of nose. There were two satellite plaques near the right side of giant lesion. On diascopy apple jelly nodule was seen. There was no regional lymhadenopathy. Histopathological examination showed many granulomas in upper dermis extending to deep dermis comprising of epitheloid cells with langhans' type of giant cells, lymphocytic infiltration & focal necrosis suggestive of lupus vulgaris. The consequences of failing to make an early diagnosis can be disastrous for the patients, as the progression of the disease can lead to necrosis, destruction of bones and cartilage leading to permanent deformity. Thus it is vital for clinicians to have a high index of suspicion of such atypical forms and take biopsy samples for histological and bacteriological studies.

Lupus vulgaris: a narrative review.

Lupus vulgaris (LV) is a type of paucibacillary cutaneous tuberculosis that can occur due to inoculation, lymphatic, or hematogenous route. It occurs in a previously sensitized individual with high immunity to tuberculosis. LV can have different morphology of presentation, which can lead to difficulty in diagnosis. The Tuberculin test is strongly positive. Histopathology will show epithelioid granulomas in the superficial dermis and acid-fast bacilli rarely demonstrable within the granulomas. Dermoscopy will show focused linear vessels on a yellow to orange background. Culture is the gold standard for diagnosis, but its positivity rate is low. Mycobacterium tuberculosis bacilli can be detected using polymerase chain reaction from the lesions. Histopathology, tuberculin test, dermoscopy, molecular test, and culture would help diagnose LV. This review discusses the introduction, pathogenesis, clinical features, differential diagnosis, investigations, complications, and treatment of lupus vulgaris in detail. This review can help the dermatologist understand the condition better with appropriate diagnosis and therapy.

Case Report: Clinical and Pathological Findings of Tuberculous Gumma: A Case Report and Literature Review.

Tuberculous gumma (TG) is a rare type of cutaneous tuberculosis thought to occur as a result of the hematogenous spread of Mycobacterium tuberculosis, which is more common in immunosuppressed individuals. An 8-year-old boy presented with a 2-month history of multiple indolent enlarging ulcerated nodules on his left upper extremity. He had a past medical history of bacille Calmette-Guerin vaccine induced lupus vulgaris. Skin biopsy of the nodules showed granulomas and neutrophil-dominated purulent inflammation. Ziehl-Neelsen staining was negative, and the cultures were positive for M. tuberculosis. Furthermore, the M. tuberculosis complex was identified using metagenomic next-generation sequencing. Standard antitubercular therapy was started at full doses, and the skin lesions had significantly improved 3 months later. Here we review the literature since 2000 and describe the clinical and pathological features of TG.

Unmasking the enigma: Investigating the clinicoepidemiological and histopathological dimensions of cutaneous tuberculosis in a Western Indian tertiary care hospital.

BACKGROUND AND AIM: Cutaneous Tuberculosis constitutes 1-1.5 % of extrapulmonary tuberculosis with a wide clinical spectrum which relies upon the portal of entry of mycobacteria and patient's immunity. Complications of cutaneous tuberculosis if treatment is delayed includes hazardous sequel like dissemination and disfigurement. Early diagnosis and cure is the ultimate way to prevent such complications. This has motivated us to study clinicoepidemiological, histopathological profile and outcome post treatment of cutaneous tuberculosis patients of our region in detail. METHODS: Total 78 patients were studied during the period of August 2018-2022, who were suspicious to have cutaneous tuberculosis clinically of which 54 were confirmed with histopathology. Patient related clinicoepidemiological data such as age, gender, past history of tuberculosis or contact history, chest-x ray, tuberculin test positivity was analysed in a retrospective manner. RESULTS: Among the 54 biopsy proven cases (33 women, 21 men) ranging from 6 to 76 years, 27 patients have been found to have Lupus Vulgaris followed by 15 cases of scrofuloderma. Acid fast bacilli were seen in 9 patients with majority in scrofuloderma. Histopathology revealed epithelioid cell granuloma without necrosis in 34 cases and caseation necrosis in 20 patients. 48 patients showed complete recovery with 6 months of Anti-Koch Treatment and some complications were observed in remaining. Limitation of this research was that long term follow up was not possible. CONCLUSION: Lack of familiarity might lead to overlooking of a standard presentation or misdiagnosis. So, an eagle eye with high degree of suspicion is crucial for control and prevention of morbidity and for improving socio-economic burden of cutaneous tuberculosis.

Ulcerated lupus vulgaris at the site of Bacille Calmette-Guérin vaccination.

We report a case of ulcerated lupus vulgaris occurring in 1.5-year-old boy at the Bacille Calmette-Guérin vaccination site within 6 months, which was diagnosed using histology and polymerase chain reaction. The lesion resolved with isoniazid and rifampicin therapy.

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.

Leprosy mimicry of lupus vulgaris and misdiagnosis of leprosy--a case report.

Leprosy and tuberculosis (TB) both are still rampant in India. Leprosy predominantly presents through skin manifestations whereas cutaneous manifestations of TB though not so frequent but are not rare. Lupus vulgaris (LV), the commonest of all cutaneous manifestations of TB, mimics leprosy very closely and may prompt the examiner to misdiagnose leprosy, especially, by health workers (HW), in a field situation, where leprosy is diagnosed and treated on clinical basis alone as per NLEP guidelines. Because of existing stigmata, such wrong diagnosis can put the patient and the party under psychological stress and creates unnecessary complications.

Various faces of Hansen's disease.

Leprosy is a chronic granulomatous disease caused by Mycobacterium leproe. Leprosy once considered a taboo is still misdiagnosed and underdiagnosed. In many cases leprosy is treated as common disorders like psoriasis, pyoderma, angioedema, pre vitiligo. Leprosy can present in many diverse ways which can be confused with many treatable and non treatable, infectious and non infectious forms. Leprosy is considered on the verge of elimination. But Leprosy cases are being newly diagnosed day by day. Here we are presenting 4 atypical cases of leprosy which did not seem to have classical presentation but were diagnosed as leprosy when investigated.

Lupus vulgaris diagnosed after 37 years: a case of delayed diagnosis.

Lupus vulgaris is the most common chronic, progressive form of cutaneous tuberculosis. Lesions are generally solitary and found on the head and neck region. Cutaneous tuberculosis can present with different clinical appearances. Therefore, it does not necessarily have characteristic findings and can be difficult to diagnose. Although there were typical clinical findings, the diagnosis of our case was delayed because of its asymptomatic course.

The cell cycle inhibitor p21 controls T-cell proliferation and sex-linked lupus development.

Here we show that the cell-cycle regulator p21 is involved in immune system function. T lymphocytes from p21-/- mice exhibit significant proliferative advantage over wild-type cells following prolonged stimulation, but not after primary activation. Consistent with this, p21-deficient mice accumulate abnormal amounts of CD4+ memory cells, and develop loss of tolerance towards nuclear antigens. Similar to human lupus, female p21-deficient mice develop antibodies against dsDNA, lymphadenopathy, and glomerulonephritis, leading to decreased viability. These data demonstrate a specialized role for p21 in the control of T-cell proliferation, tolerance to nuclear antigens, and female-prone lupus. These findings could be the basis for new therapeutic approaches to lupus.

Disseminated lupus vulgaris.

A 28-year-old woman presented with reddish raised, shiny lesions over the face and ears present for the past 3 years. Four years ago, she developed in her left axilla a nodule that became fluctuant and tender, which ruptured to discharge seropurulent material. It subsided after the patient had received antibiotics for 6 months, leaving puckered scarring. There was no history of antituberculous treatment. After 1 year, she developed papulonodular lesions on her face, nose, and ears. There was now a history of malaise, fever, dry cough, and anorexia and weight loss for the past 2 months. The patient was fully vaccinated in childhood, including against varicella infection. The general physical examination revealed lymphadenopathy involving cervical, axillary, and inguinal lymph nodes 0.5 x 0.5 cm to 1 x 1.5 cm, firm in consistency, and nontender. They were discrete except in the left axilla where multiple matted lymph nodes were present with overlying scarring and a papule. Her systemic examination was normal. Cutaneous examination showed a shiny erythematous plaque 3x2 cm with central atrophy and scarring on the face (Figure). It was comprised of multiple shiny nontender soft papules arranged in annular configuration. Similar discrete papules and nodules with adherent fine scaling were seen bilaterally on the alar prominence of the nose, lower lip, and post-auricular area. On diascopy, apple jelly nodules were seen. The hemogram, liver function tests, and renal function tests were normal, except for an elevated erythrocyte sedimentation rate. The Mantoux test showed erythema and an induration of 20 x 20 cm. A posteroanterior view on the chest x-ray showed fibrotic changes suggestive of pulmonary tuberculosis. Ultrasonography of the abdomen and pelvis showed no tubercular foci. Human immunodeficiency virus serology by enzyme-linked immunosorbent assay with 3 different kits was nonreactive. Histopathology from a nodule showed a focally thinned-out epidermis with follicular plugging and multiple epithelioid cell granulomas, rimmed by lymphocytes in the deeper portion of the dermis, mainly peri-appendageal. Stain for acid-fast bacteria was negative. Cultures from the skin lesions were negative. The patient was diagnosed as having lupus vulgaris with multiple lesions of varying morphology at different sites with pulmonary tuberculosis and healed lymph node involvement.