Papulonecrotic Tuberculid in Children

Abstract

Papulonecrotic tuberculid (PNT), a form of cutaneous tuberculosis (TB), is uncommon in children. We identified eight children (six girls and two boys) with PNT. Their ages ranged from 19 to 139 months (median 47.5 months, mean:64.75 months). Skin lesions had been present for 2-24 weeks (median: 4 weeks) before diagnosis. All patients displayed scattered papulo- and/or pustulonecrotic lesions on the limbs, and the ears were involved in six patients. Lesions healed with varioliform scars. Associated pulmonary TB was present in seven patients. Additional clinical findings included fever (n = 4), hepatomegaly (n = 4), lymphadenopathy (n = 3), phlyctenular conjunctivitis (n = 3), and splenomegaly (n = 2). Histology of eight biopsies showed ulceration (n = 6), dermal necrosis (n = 6) (follicle-centered in two), granulomatous inflammation (n = 6) (palisading granuloma-like in three), superficial and deep infiltrate of lymphocytes (n = 7), erythrocyte extravasation (n = 7), and subepidermal edema (n = 3). Vasculitis was not a feature. A Ziehl-Neelsen stain was negative in all. Glycosaminoglycans were not increased. Immunohistochemistry found a predominance of T lymphocytes, macrophages, a few antigen-presenting cells, and no B lymphocytes, consistent with a type IV hypersensitivity reaction. Polymerase chain reaction (PCR) performed on deparaffinized tissue identified M. tuberculosis DNA in one biopsy. All patients received combination anti-TB treatment for 6 months. Six patients were compliant and were followed up for 6-30 months. Skin lesions and pulmonary TB healed in all. PNT in children resembles the adult form, but phlyctenular conjunctivitis and associated TB are more common, scrofuloderma and concomitant erythema induratum of Bazin are unusual, and vasculitis is not found. In cases where M. tuberculosis DNA can be confirmed with PCR, papulonecrotic TB is perhaps the more appropriate nomenclature.

Papulonecrotic tuberculid—clinicopathologic and molecular features of 12 Indian patients

“…It is generally seen in young adults, as in the present study [5,6]. Only one patient had concurrent HIV infection.…”

“…Tuberculids include lichen scrofulosorum (the commonest), erythema induratum of Bazin and papulonecrotic tuberculid. PNT is a rare tuberculidwith very few case series in literature [5,6,7]. Indian data is limited mainly to case reports or to broader studies on cutaneous TB in general [8,9,10].…”

Cutaneous tuberculosis in children: The Indian perspective

“…Jordaan et al reported eight children with papulonecrotic tuberculids (PNT), of which seven had associated pulmonary TB and three had phlyctenular conjunctivitis. [31] It has also been reported in children with active tubercular lymphadenitis and disseminated LV. [32,33] However, PNT has been infrequently reported in Indian children, with only four cases in the series by Vashisht et al [11] Histology shows wedge-shaped necrosis with nonspecific perivascular infiltrates or tubercular granulomas surrounding the necrosis.…”

“…While Vashisht et al and Ramdial and colleagues found vasculitis as a prominent feature in their cases, Jordaan et al did not observe it any of their children with PNT. [11,31,34] Although AFB are not demonstrable in papulonecrotic skin lesions, M. tuberculosis DNA is frequently detected by PCR. [35] Jordaan et al have suggested that in cases where M. tuberculosis DNA can be confirmed by PCR, the term "papulonecrotic tuberculosis" should be preferred over "papulonecrotic tuberculid."…”

“…[35] Jordaan et al have suggested that in cases where M. tuberculosis DNA can be confirmed by PCR, the term "papulonecrotic tuberculosis" should be preferred over "papulonecrotic tuberculid." [31] Erythema induratum of Bazin (EIB) This is another tuberculid characterized by subcutaneous nodules over the posterior legs, which break down into deep ulcers followed by crusting and finally heal with atrophic scarring. It is very uncommon in children, with only few cases reported till date and no childhood case from India.…”