ARTICLE
The increased incidence of tuberculosis observed in developed countries
over the past few years is frequently associated with AIDS and immunosuppressive
therapies [1-3].
In this article we describe a case of lupus vulgaris associated with
tuberculosis of the lung in an immunocompetent patient, which was not
recognized for a long time and in which the use of specific therapy brought
about the clinical resolution of the disease.
Faced with a chronic dermatosis of an unknown nature, the possibility
of a tubercular aetiology must not be forgotten.
Case report
A 74-year-old Caucasian man came to our notice complaining of the presence
of multiple erythematous plaques on his back (Fig.
1) and an inflammatory alopecic area on his scalp. The lesions
were associated with a burning sensation and aching which was both spontaneous
and brought on by palpation. The patient's history revealed that he was
an alcoholic. There were no systemic symptoms such as tiredness, loss
of appetite, nocturnal perspiration. The pathological and family history
were negative as regards tuberculosis.
On physical examination he appeared thin. A swollen lymph node was present;
this was located under the left armpit and was mobile and not painful.
The patient was apyretic. Routine blood tests gave normal values. Proteic
electrophoresis showed an increase of proteins in the acute phase and
of polyclonal immunoglobulins.
The search for anti-HIV antibodies gave negative
results. The chest X-ray showed the presence of multiple non-homogeneous
radio-dense areas with bilateral apical fibrosis and a vascular-like hilus.
A cutaneous biopsy taken from a lesion on the back showed a granulomatous
infiltration throughout the thickness of the dermis with multiple groupings
of epithelioid elements and rare Langhans' type giant cells (Fig.
2).
At the centre of certain nodules there was a caseous necrosis. The search
for acid-resistant bacilli was negative. An histopathological diagnosis
of tuberculoidal granuloma was made.
The tuberculin allergometry was strongly positive at 24 hrs and 48 hrs.
The search for mycobacterium in the urine and faeces was negative. Examination
of the tissue cultures revealed a tubercular mycobacterium of the hominis
variety. On the basis of the antibiogramme, treatment was begun based
on Rifampicin 600 mg/day, Pyrazinamide 1,500 mg/day and an association
of Ethambutol + Isoniazid + Pyridoxine respectively at the dose of 1.2,
0.3 and 0.15 g/day. The skin lesions improved.
Almost two years later, the dermatological, radiological and haematochemical
tests demonstrated that the patient was free from the disease (Fig.
3).
Discussion
Lupus vulgaris may appear at the primary site of inoculation. It can
also be result of a virulent transformation of the Calmette-Guerin bacillus
used for vaccination. In developed countries the highest incidence occurs
in the second and third decades of life, whilst in temperate climates
children are most commonly affected. There is also a prevalence in males.
In western countries the face is most frequently involved in particular
the nose and cheeks, whilst in tropical and sub-tropical regions the lower
extremities and buttock are the most frequently affected sites and it
is possible to discover the involvement of atypical areas of the body.The
lesions are generally solitary and asymptomatic. The presence of multiple
lesions is rare and generally present in patients with active or post-exanthematic
lung tuberculosis.
Clinically, the visual aspect is that of tender
nodules, that develop very slowly as a polycyclic spot with keratotic
borders. Areas with scars and crusts may coexist [4, 5].
The case we have presented is interesting for a number of reasons. In
the first place we were dealing with an immunocompetent patient, where,
however, alcoholism had had an important role.
The lesions differed from the classical cases in that they were multiple,
widespread and located on the thorax and scalp, thus in secondary areas.
Finally, it is important to consider the excellent response to the triple
therapy with a regression of the dermatological symptoms and good control
of the pulmonary symptoms.
Our observation stresses the necessity of considering this specific
aetiology when faced with chronic infiltrating dermatosis associated with
past and present pulmonary disease.
REFERENCES
1. Inwald D, Nelson M, Cramp M, et al. Cutaneous manifestations
of mycobacterial infection in patients with AIDS. Br J Dermatol
1994; 130: 111-4.
2. Collins FM. Mycobacterial disease, immunosuppression, and acquired
immunodeficiency syndrome. Clin Microbiol Rev 1989; 2: 360-77.
3. Taylor AEM, Corris PA. Cutaneous tuberculosis in an immunocompromised
host: an unusual clinical presentation. Br J Dermatol 1995; 132:
155-6.
4. Farina MC, Gegundez MI, Piquè E, et al. Cutaneous tuberculosis:
a clinical, histopathlogic and bacteriologic study. J Am Acad Dermatol
1995; 33: 433-40.
5. Marcoval J, Servitje O, Moreno A, et al. Lupus vulgaris. Clinical,
histopathologic and bacteriologic study of 10 cases. J Am Acad Dermatol
1992; 26: 404-7.
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