Wednesday, August 01, 2012

65 yo woman with nodulo-ulcerative leg lesions

Abstract:  65 yo woman with 4 year history of papules and nodules and 2 - 3 month history of papulo-ulcerative lesions on the legs

HPI:  This 65 yo woman has had leg lesions for ~ four years.  Initially, papules and small nodules. Over the past few months a number of these have become ulcerative.  She had lymphadenopathy two years ago and a lymph node biopsy was interpreted as sarcoidosis.  Her CXR was normal and no treatment was rendered,

O/E:  Healthy appearing woman with numerous 8 - 10 mm nodules on both lower extermities.  Similar lesions were ulcerative. Remainder of cutansous examination unremarkable.

Clinical Photos:

Pathology:  Small noncaseating epitheliod granulomas containing multinucleated giant cells within a dense fibrotic stroma and a perivascular plasmacytic infiltrate at the periphery.  Rare elongate acid-fast bacilli are seen in two granulomas.

40x (AFB)

Diagnosis: Necrobiosis-like variant of sarcoidosis.  What is the significance of rare AFBs?  She will have PPD and work-up to rule out TBC.

Questions:  Do you have alternative diagnoses? How would you treat her?

1.  Necrobiosis lipoidica-like skin lesions in systemic sarcoidosis.
Igawa K, Maruyama R, Satoh T, Yokozeki H, Katayama I, Nishioka K.

J Dermatol. 1998 Oct;25(10):653-6.
A 62-year-old woman with systemic sarcoidosis developed erythematous plaques on her lower legs. Clinically, two kinds of skin lesions were distinguished; one type formed brownish-red plaques with induration suggesting plaque-type skin sarcoid, and the other formed purplish erythematous plaques with atrophic centers resembling necrobiosis lipoidica. In spite of this clinical appearance, a biopsy specimen from one of the latter lesions revealed typical skin sarcoid histology composed of discrete non-caseating granulomas, while that from one of the other lesions showed necrobiotic changes of collagen bundles surrounded by epitheloid histiocytes and foreign-body giant cells. Because cutaneous involvement of sarcoidosis may mimic necrobiosis lipoidica clinically and/or histologically, we diagnosed her skin lesions as necrobiosis-like skin sarcoid.

2. Histologic observations of variably acid-fast pleomorphic bacteria in systemic sarcoidosis: a report of 3 cases.
Cantwell AR Jr. Growth. 1982 Summer;46(2):113-25.
Abstract: Tissue sections of skin and lymph nodes from three consecutively diagnosed cases of systemic sarcoidosis were studied for the presence of acid-fast bacteria, utilizing routine and acid-fast staining techniques recently recommended for the demonstration of cell-wall-deficient bacteria (L-forms). Evidence of variably acid-fast cocco-bacillary forms was present within the biopsy material of all the patients. The combined findings of variably sized, predominantly coccoid forms, along with larger forms resembling L-form "large bodies," and short acid-fast rods all suggest that cell-wall-deficient bacteria (possibly related to the mycobacteria or corynebacteria) may be present in cases of sarcoidosis. 


  1. Nidal A. ObaidatAugust 01, 2012

    I think this is a case of either papulonecrotic tuberculid or erythema induratum, linked to tuberculosis.
    Thorough investigation for systemic TB is advised: CXR, PPD, quantiferon gold test, and possibly tissue culture.

  2. Does she get pedicures? If so, I would consider pedicure-associated nontuberculous mycobacterial furunculosis. Steve Higgins

  3. Jag Bhawan, MD has left a new comment on this"65 yo woman with nodulo-ulcerative leg lesions":

    It is interesting to point out that we have reported mycobacterial DNA by PCR in 16 out of 20 cases of sarcoidosis( Li et al. 1999.

    Moreover,in another study, Drake et al. (2002) repoterd 16S rRNA or rpoB sequences from 15 of 25 patients with sarcoidosis specimens (60%)

    Thus the presence of mycobacteria in sarcoidosis is not surprising.

    1.Li N, Bajoghli A, Kubba A, Bhawan J.Identification of mycobacterial DNA in cutaneous lesions of sarcoidosis.
    Jour Cutan Pathol. 1999 Jul;26(6):271-8.

    2.Drake WP, Pei Z, Pride DT, Collins RD, Cover TL, Blaser MJ. Molecular analysis of sarcoidosis tissues for mycobacterium species DNA. Emerg Infect Dis. 2002 Nov;8(11):1334-41.

  4. Nidal A. ObaidatAugust 11, 2012

    I respect the comment made by Dr Bhawan. However, I will be very reluctant to use steroid for an AFB-positive condition. Personally I would treat as TB.

  5. I would go with Nidal. It might be papulonecrotic tuberculide. It was once thought that no bacilli could be found in these lesions as they were hypersensitivity manifestation of TB, now it has been corrected that bacilli can even be found from the tuberculids.


We welcome your comments. We endeavor to serve your patients and you. If you want us to respond, please add your name and email address. Some people have trouble uploading comments. In that case, please send comments directly to Thank you.