Case Presentation
by Dr. Henry Foong
Ipoh, Malaysia
by Dr. Henry Foong
Ipoh, Malaysia
A 50-yr-old man presented with painful fissures at the right perianal area for one month. It started as a small lesion and subsequently increased in size. it was occasionally painful.
He had seen a general surgeon previously and was treated with recurrent courses of antibiotics but had not improved. There was no bleeding per rectal. He had no history of contact with TB.
He had seen a general surgeon previously and was treated with recurrent courses of antibiotics but had not improved. There was no bleeding per rectal. He had no history of contact with TB.
Examination showed an ulcerated indurated plaque 8 x 22 cm on the right perianal area extending to the right gluteal area. A similar plaque 3 x 7 cm was noted on the left perianal area. The edge of the lesion was irregular, slightly raised and nodular. His regional nodes were not enlarged.
A skin biopsy was performed. Section shows a fragment of skin composed of epidermis and dermis. A granulomatous inflammation is seen in the dermis. The granulomas are composed of epithelioid cells, lymphocytes and plasma cells. Infiltrates of neutrophils and eosinophils are also seen. Multi-nucleated giant cells and Langhan's giant cells are seen. In one granuloma caseation necrosis is seen. The overlying epidermis is unremarkable. There is no evidence of malignancy. Ziehl-Neelsen stain for acid fast bacilli is negative.
Periodic acid Schiff stain for fungi is negative.
Periodic acid Schiff stain for fungi is negative.
Diagnosis: Cutaneous tuberculosis (lupus vulgaris)
Discussion
Base on the clinical and histopathological examination features this patient most likely has cutaneous tuberculosis (lupus vulgaris). The word "lupus" means wolf and indeed the appearance of the face chewed by a wolf. Apart from the face, it can also affect the buttocks and the legs. The plaque type as seen in this patient is the commonest, though there are several variants eg ulcerative, hypertrophic, vegetating and nodular type. 0.5 to 10% develop complications of malignancy eg SCC/BCC.The diagnosis of cutaneous TB is often delayed when the index of suspicion is low. Hence, it is often missed when it should not be missed because of its sequelae.
We welcome comments. If you have trouble uploading them, you can send them to DJ Elpern and he will upload them. Thank you!
Within an hour of uploading this, Professor Sharquie alerted us to a similar case he published this year. See Reference 1.
Reference:
We welcome comments. If you have trouble uploading them, you can send them to DJ Elpern and he will upload them. Thank you!
Within an hour of uploading this, Professor Sharquie alerted us to a similar case he published this year. See Reference 1.
Reference:
1. Granulomatous Reaction at the Site of Positive Tuberculin
Skin Test is a Marker of Active TB (Clinical and Histopathological Study) American Journal of Dermatology and Venereology 2019; 8(4): 55-60 Khalifa E. Sharquie, Adil A. Noaimi, Fatima A. Khalaf Department of Dermatology, College of Medicine, University of
Baghdad, Iraq FREE FULL TEXT [Courtesy of Professor Sharquir)
Mathur M, Pandey SN. Kathmandu Univ Med J (KUMJ). 2014 Oct-Dec;12(48):238-41.
No comments:
Post a Comment
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 djelpern@gmail.com. Thank you.