Multifocal Cutaneous Tuberculosis in Immunocompetent Individual

Abstract

A 20-year-old female presented with non tender, fluctuant, soft swelling of left elbow, inability to flex elbows fully, plaques over both arms. On examination, there were 6 well defined erythematous scaly plaques, around 4-6 cm in diameter, involving both the arms. A single ulcer with purulent crust present over extensor aspect of left forearm. Atrophic scars were present over right elbow and right breast. Hyperpigmented puckered scar with multiple discharging sinuses were present over right forearm. There was no lymphadenopathy. On diascopy, "apple jelly" nodules were appreciated in form of yellowish discolouration after applying pressure with slide over the lesion. A fluctuant swelling of 8×11 cm size was present over extensor aspect of left arm along with swollen right elbow, due to which she was not able to flex her elbow completely [Table/ Fig-1]. Range of motion was 40 and 50 degree flexion at left and right elbow respectively. All lesions appeared in the span of 3 years. No past history of pulmonary TB. There was no history of trauma. She was vaccinated with BCG vaccine with a vaccine scar over her left deltoid. Her height was 137cm and weighed 42kg with significant undernourishment. She lives in overcrowded slum with poor hygienic conditions. Her aunt was suffering from pulmonary tuberculosis. Lupus vulgaris and scrofuloderma were suspected in the same case as erythematous plaques and puckered scar with sinus formation were there.Mantoux test was positive (>15mm induration and 22mm horizontal extension). Pus discharge from the ulcer was negative for grams and AFB stain didn't show any growth on routine culture. ELISA for HIV was nonreactive. Biopsy was taken from the erythematous plaque as well as puckered scar which showed mild hyperplasia of epidermis with multiple granulomas in dermis containing Langhans giant cells, epitheloid cells, lymphocytes and plasma cells suggestive of lupus vulgaris at both the sites. Reticular dermis was normal. No caseation necrosis was seen in both biopsies [Table /Fig-2 aBstRaCtMost common form of cutaneous tuberculosis (TB) is lupus vulgaris, which usually occurs in previously sensitized individuals who have a high degree of tuberculin sensitivity. Various forms including plaque, ulcerative, hypertrophic, vegetative, papular, and nodular forms have been described. We are reporting a case of a young female, who presented with 6 well defined erythematous scaly plaques involving both arms and a puckered scar on right forearm and right breast. Clinically, it was looking like lupus vulgaris with cold abscess, few lesions mimicking scrofuloderma, but skin biopsy from both the types of lesions revealed lupus vulgaris. Patient improved with Anti Tuberculous Therapy and surgical drainage of underlying cold abscess.[

Cutaneous tuberculosis in Rio de Janeiro, Brazil: description of a series of 75 cases

“…37 Patients with these TB forms are generally paucibacillary and considered to have a moderate to high degree of immunity against the bacillus. The association with extracutaneous TB is rare [38][39][40][41][42] but occurred in our cohort (one patient in each group). When these clinical variants are on extremities, they may confound each other.…”

Cutaneous Disorders of the Breast

“…• Definition: Lupus vulgaris is a chronic, progressive, postprimary, paucibacillary form of cutaneous tuberculosis, occurring in a person with a moderate to high degree of immunity (Mehta et al 2015a). It is caused by Mycobacterium tuberculosis or less commonly Mycobacterium bovis.…”

Long standing untreated multifocal cutaneous tuberculosis with development of breast carcinoma

“…Multifocal cutaneous TB is rare in immunocompetent individuals. Multifocal LV patients presenting as erythematous plaques[ 2 ] have been described in the immunocompetent. A case of multifocal ulcerative lupus in malnourished[ 3 ] and another with a granulomatous folliculitis-like presentation[ 4 ] have been reported in the past.…”