Navigating the complexities: a case report on the varied presentation of lupus vulgaris

INTRODUCTION

Lupus vulgaris, a chronic form of cutaneous tuberculosis, presents a diagnostic challenge due to its diverse clinical manifestations and potential mimicry of other dermatological conditions.¹ It is characterized by nodular, plaque-like/ulcerative lesions and is predominantly seen in countries like India.^2,3 Despite its rarity in some regions, early recognition is crucial to prevent morbidity and scarring. Differential diagnosis encompasses various dermatological conditions, necessitating thorough evaluation for accurate identification and timely initiation of treatment.

This case report aims to illustrate clinical presentation, diagnostic workup, and management of Lupus vulgaris, emphasizing its significance in dermatological practice. Through detailed examination and histopathological analysis, we aim to enhance awareness of the diverse manifestations of this condition and underscore the importance of early intervention to prevent complications. Additionally, we aim to contribute to existing literature on lupus vulgaris, aiding dermatologists in recognizing and managing this condition effectively.

CASE REPORT

A 16-year-old girl presented with an asymptomatic lesion in the right axilla. The lesion initially manifested six months ago as a small raised bump, progressing into a pus-filled lesion, subsequently forming a crust and gradually spreading (Figure 1). There is no history of trauma, prolonged cough, sputum production, fever, night sweats, or weight loss in the patient. There is no family history of tuberculosis.

On examination, a single scaly, erythematous to brownish-colored, ill-defined plaque was identified over the right posterior axillary fold, measuring approximately 3×2 cm and extending to the upper inner arm. Additionally, a single enlarged axillary lymph node was noted on the right side. The patient also bears a BCG scar.

Considering clinical presentation, differential diagnosis includes lupus vulgaris, hidradenitis suppurativa, and keloid.

In the routine investigations, all parameters were within normal ranges, except for the following deviations: Hemoglobin level was measured at 9 gm%, and the ESR showed a slight elevation at 30 mm/hr. The Mantoux test yielded a positive result with a 22 mm induration.

Upon histopathological examination, the findings revealed a superficial dermis characterized by a dense inflammatory infiltrate. Notably, well-defined epithelioid granulomas of varying sizes were observed, accompanied by a presence of a few caseating granulomas and multinucleated giant cells (Figure 2).

The diagnosis for the presented case is lupus vulgaris. The recommended treatment follows category 1 protocols as per the revised national TB control programme (RNTCP). The patient underwent a 2-month course of isoniazid, rifampicin, pyrazinamide, and ethambutol, followed by isoniazid and rifampicin administered for four months leading to noticeable improvement in the lesions (Figure 3).

DISCUSSION

Lupus vulgaris, a chronic form of cutaneous tuberculosis, typically presents with characteristic clinical features such as nodular, plaque-like, or ulcerative lesions. It usually occurs through contiguous extension of the disease from underlying affected tissue or hematogenous or lymphatic spread.⁴ Lupus vulgaris is the most common type of cutaneous tuberculosis in India and commonly seen in the lower half of the body involving legs, thighs, buttocks, and feet.⁵ The commonly encountered clinical variants include classic plaque or keratotic type, hypertrophic, ulcerative, atrophic and planar.⁶

Histopathological examination shows the presence of tuberculoid granulomas within the superficial dermis, characterized by a composition of lymphocytes, plasma cells, epithelioid cells, and giant cells. Central caseation is either scant or absent. The epidermis typically displays hyperplasia, although instances of atrophy or ulceration may also be observed. Detecting tubercle bacilli in the histological specimens poses challenges due to their elusive nature.⁷

The recommended treatment for cutaneous tuberculosis entails an intensive phase, during which rifampicin (R-450 mg), isoniazid (H-600 mg), ethambutol (E-1200 mg), and pyrazinamide (Z-1500 mg) are administered three days a week for a duration of two months. Following the intensive phase, the continuation phase involves the administration of R-450 mg and H-600 mg three days a week for an additional four months. This therapeutic strategy has demonstrated effectiveness, with a significant proportion of cases showing positive response by the conclusion of the intensive phase, and no instances of reported relapses.⁸ Unconventional anatomical sites and unique clinical manifestations can occasionally arise, posing challenges in both diagnosis and treatment.^9-12

Early intervention is critical to prevent morbidity, risk of dissemination and scarring.

CONCLUSION

This case report highlights the diagnostic challenges and management of lupus vulgaris. In conclusion, the reporting of these cases serves the purpose of enhancing awareness regarding the diverse clinical presentations of lupus vulgaris, particularly when occurring at rarer sites and displaying atypical features. Emphasizing the significance of a heightened clinical suspicion, our findings underscore the pivotal role it plays in ensuring early diagnosis and timely initiation of treatment. By shedding light on these varied manifestations, we contribute to the collective knowledge that can ultimately aid in reducing the morbidity associated with Lupus vulgaris.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required

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