Papulonecrotic tuberculid

Abstract

A 30-year-old man presented with a 6 year history of recurrent, multiple asymptomatic raised lesions over his back and bilateral upper limbs. He had been treated repeatedly for a case of recurrent boils with oral and topical antibiotics. Some of the lesions had healed spontaneously leaving behind unsightly scars. The patient denied any history of associated fever, chronic cough, weight loss, and drug intake prior to the onset of lesions. There was no recognized contact with tuberculosis patients. General and systemic examination was essentially normal. Dermatological examination revealed the presence of multiple, well-defined, hyperpigmented crusted papules of 0.5-1.0 cm in size, distributed symmetrically over his entire back, extensor surface of bilateral forearm, arm, and bilateral dorsum of foot, interspersed with atrophic varioliform scarring (Figures 1 and 2). Routine laboratory workup was normal. Tuberculin (Mantoux) was strongly positive at 72 hours (23 × 23 mm) with central necrosis (Figure 3). Sputum for acid fast bacilli culture, chest radiograph, ultrasound abdomen, and pelvis did not reveal any abnormality. A biopsy specimen taken from a crusted papule over his forearm (Figure 4) showed fibrinoid necrosis, surrounded by mixed inflammatory infiltrate filling the entire dermis along with a few ill-defined epitheloid granulomas and lymphocytoclastic vasculitis. These are consistent with papulonecrotic tuberculid.The patient was started on a four drug combination therapy of rifampicin, isoniazid, pyrazinamide, and ethambutol for two months initially followed by a combination of rifampicin and isoniazid to complete a total of 6 months of standard antitubercular therapy. The patient responded well and all of the lesions eventually healed.

Papulonecrotic tuberculides as a key to the diagnosis of tuberculosis: a case report

“…However, up to 40% of cases may coexist with extracutaneous tuberculosis. 1,4 It is important to screen for systemic tuberculosis in the presence of these lesions, even if initial microbiological and radiological tests are normal, as was the case with our patient. 1,5 In the past, treatment was based on single-dose isoniazid.…”

“…However, with the emergence of resistance, current regimens advocate combined treatment with isoniazid, rifampin, pyrazinamide, and ethambutol for a duration of 7 to 18 months. 4,5 In conclusion, we report a case of CTB in a nonendemic area. With the increase in globalization, it is essential for every dermatologist to consider the possibility of CTB.…”

“…The initial diagnosis is clinical and should be confirmed with a skin biopsy. 3,4 It typically shows necrotizing granulomatous vasculitis with granulomatous foci containing giant cells. 4 The Ziehl-Neelsen stain and mycobacterial cultures are usually negative.…”

“…3,4 It typically shows necrotizing granulomatous vasculitis with granulomatous foci containing giant cells. 4 The Ziehl-Neelsen stain and mycobacterial cultures are usually negative. Similarly, up to 50% of molecular studies using nucleic acids tend to be negative.…”

Tuberculide papulonécrotique

“…Les tuberculides sont des réactions d’hypersensibilité à des antigènes mycobactériens avec peu d’inclusions intralésionnelles de mycobactéries 1 . Les tuberculides sont une réponse immunologique à la présence de formes dégénérées de M. tuberculosis ou de fragments d’antigènes provenant d’un foyer tuberculeux occulte ou inapparent ailleurs dans l’organisme 2 . Quant aux tuberculides papulonécrotiques, il s’agit d’une forme peu courante de tuberculide qui touche principalement les personnes jeunes et immunocompétentes 1 , 2 .…”