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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 44-45

Curious case of coexistence of erythema induratum and penile papulonecrotic tuberculid


1 Department of Dermatology and Sexually Transmitted Diseases, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi, India
2 Department of Pathology, National Institute of Pathology, Safdarjung Hospital Campus, New Delhi, India

Date of Submission25-Mar-2020
Date of Acceptance05-Apr-2020
Date of Web Publication02-Jun-2020

Correspondence Address:
Geeti Khullar
Department of Dermatology and Sexually Transmitted Diseases, Vardhman Mahavir Medical College and Safdarjung Hospital, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_36_20

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How to cite this article:
Bhandari M, Khullar G, Sharma S, Ramesh V. Curious case of coexistence of erythema induratum and penile papulonecrotic tuberculid. Indian J Dermatopathol Diagn Dermatol 2020;7:44-5

How to cite this URL:
Bhandari M, Khullar G, Sharma S, Ramesh V. Curious case of coexistence of erythema induratum and penile papulonecrotic tuberculid. Indian J Dermatopathol Diagn Dermatol [serial online] 2020 [cited 2020 Nov 26];7:44-5. Available from: https://www.ijdpdd.com/text.asp?2020/7/1/44/285798



Sir,

Simultaneous occurrence of erythema induratum (EI) and papulonecrotic tuberculid (PNT) is occasionally reported in the literature.[1],[2] We describe a case of coexistent EI and penile PNT, in the absence of any identifiable internal focus of tuberculosis.

A 63-year-old Indian man presented with recurrent episodes of painful nodules on the thighs and legs for the past 3 years. For 1 year, he also complained of recurrent crops of erythematous papules that turned into pustules and subsequently into ulcers on the glans penis. He denied any history of fever, night sweats, weight loss, or cough. No past or family history of tuberculosis could be elicited. Physical examination revealed erythematous, indurated, tender subcutaneous nodules of size 1–2 cm on the extensor aspects of the thighs and legs [Figure 1]a. The second type of lesions comprised crusted erythematous papules and ulcers measuring 0.5 cm in diameter, with ragged irregular margins and yellowish slough on the floor over the glans penis [Figure 1]b. Regional lymphadenopathy was absent. Bacillus Calmette–Guérin vaccination scar was present on the left arm. Systemic examination was unremarkable. A histological examination from the nodule on the thigh revealed perivascular and interstitial lymphoplasmacytic and neutrophilic infiltrate in the upper and mid dermis. Deeper dermis and subcutaneous fat showed necrotizing epithelioid cell granulomas with multinucleated giant cells, small-vessel vasculitis, and necrotic adipocytes [Figure 2]a and [Figure 2]b. These features were consistent with EI. Biopsy specimen from crusted papule on the glans penis showed dense perivascular and interstitial infiltrate of lymphocytes and neutrophils throughout the dermis. The mid and deeper dermis showed areas of wedge-shaped necrosis with palisading histiocytes and surrounding vasculitis [Figure 2]c, [Figure 2]d, [Figure 2]e. These findings were consistent with PNT. Ziehl–Neelsen and periodic acid–Schiff stains were negative. Tissue culture and polymerase chain reaction for Mycobacterium tuberculosis were negative from both the biopsy specimens. Routine hematological, biochemical investigations, urine microscopy, and culture were unremarkable. Human immunodeficiency virus serology and Venereal Disease Research Laboratory test were negative. Mantoux reaction measured 25 mm ×29 mm. Chest radiograph and ultrasound of the abdomen, pelvis, and scrotum revealed no abnormality. The patient was treated with 6 months of antitubercular treatment comprising 2 months of isoniazid, rifampicin, ethambutol, and pyrazinamide and 4 months of isoniazid, rifampicin, and ethambutol, with complete resolution of lesions.
Figure 1: (a) Erythematous to hyperpigmented subcutaneous nodules on the extensor surface of the right thigh, (b) dusky erythematous papules with central crusting on the glans penis

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Figure 2: (a) Lower dermis shows perivascular and interstitial neutrophilic and lymphocytic infiltrate. There is granulomatous infiltrate around the necrotic adipocytes along with neutrophils surrounding and infiltrating the vessel walls (H and E, ×100), (b) higher magnification showing necrotizing granuloma in the subcutaneous tissue with leukocytoclastic vasculitis in the vicinity (H and E, ×200), (c) the epidermis demonstrates hyperkeratosis and parakeratosis. There is dense inflammation throughout the dermis concentrated around the vessels and in the interstitium (H and E, ×40), (d) the deep dermis showing wedge-shaped areas of necrosis with palisading of histiocytes around the necrobiotic foci and dense perivascular and interstitial infiltrate of neutrophils and lymphocytes (H and E, ×200), (e) higher magnification depicting endothelial swelling, neutrophils, and lymphocytes in the perivascular area and walls of the blood vessels and fibrinoid necrosis of the capillaries (H and E, ×400)

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Concurrent occurrence of more than tuberculid in the same patient is quite infrequent, with the combination of EI and PNT described most commonly.[1],[2],[3] Although cutaneous tuberculosis is endemic in India, the coexistence of EI and PNT has been reported in only one Indian patient.[3] Their concomitant occurrence reflects a morphological continuum and varying degrees of immune complex-mediated vasculitis and delayed hypersensitivity reaction.[1] Female predilection (F:M =2.5:1), typical acral distribution of EI and PNT, and absence of any detectable focus of tuberculosis in about 50% of the patients have been described in reports with concomitant EI and PNT.[1],[2],[3],[4] The interesting findings in our case were male patient and PNT involving only the glans penis. To the best of our knowledge, there has been no previous report of EI and penile PNT occurring together.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Chuang YH, Kuo TT, Wang CM, Wang CN, Wong WR, Chan HL. Simultaneous occurrence of papulonecrotic tuberculide and erythema induratum and the identification of Mycobacterium tuberculosis DNA by polymerase chain reaction. Br J Dermatol 1997;137:276-81.  Back to cited text no. 1
    
2.
Jordaan HF, Van Niekerk DJ, Louw M. Papulonecrotic tuberculid. A clinical, histopathological, and immunohistochemical study of 15 patients. Am J Dermatopathol 1994;16:474-85.  Back to cited text no. 2
    
3.
Dongre AM, Sanghavi SA, Khopkar US. Papulonecrotic tuberculid at the site of tuberculin test in a patient with concomitant erythema induratum and papulonecrotic tuberculid. Indian J Dermatol Venereol Leprol 2013;79:248-51.  Back to cited text no. 3
  [Full text]  
4.
Kim GW, Park HJ, Kim HS, Chin HW, Kim SH, Ko HC, et al. Simultaneous occurrence of papulonecrotic tuberculid and erythema induratum in a patient with pulmonary tuberculosis. Pediatr Dermatol 2013;30:256-9.  Back to cited text no. 4
    


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  [Figure 1], [Figure 2]



 

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