Indian Journal of Dermatology, Venereology and Leprology Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL) ISSN: 0378-6323 EISSN: 0973-3922 Vol. 71, Num. 2, 2005, pp. 134-135

Indian Journal of Dermatology, Venereology, Leprology, Vol. 71, No. 2, March-April, 2005, pp. 134-135

Letter To Editor

Ulcerative lupus vulgaris

Padmavathy L., Rao Lakshmana L.

Dermatologist, Urban Health Center, Departments of Community Medicine and Pathology, Rajah Muthiah Medical College, Annamalai University, Annamalai Nagar - 608 002
Correspondence Address: B 3 RSA Complex, Annamalai University, Annamalai Nagar - 608002, Tamil Nadu
drellellar@yahoo.com

Code Number: dv05045

Sir,

Lupus vulgaris is in most instances a chronic slowly progressive disease, occurring in patients with immunity produced by previous tuberculous infection. The individual lesions begin as reddish brown papules that coalesce to form a plaque with a serpiginous border. The plaque grows by peripheral extension, while healing at one end. Large ulcerative lesions are not commonly encountered. In western countries LV is common on the face, while in India, lesions are more often encountered on extremities and trunk. A case of a large ulcerative lesion of LV on sole is being reported.

A 15 year old girl presented with an ulcer on the right foot of 2½ years duration. It started as a small papule on the right sole which broke down and ulcerated. Over the course of a few months it spread to involve the whole sole. She did not have cough or fever. Family history of tuberculosis was negative.

On examination, she was found to be very emaciated. A large ulcer 15 cm x 8 cm, covered with slough, was seen on the right sole, extending onto the sides of the foot. [Figure - 1] Foul smelling, purulent discharge was present. Movements of foot were not restricted. Other systems were clinically normal, except for Bitot′s spots in the eyes.

All relevant hematological and biochemical investigations were within normal limits. There was no evidence of pulmonary tuberculosis and no bony pathology could be detected on X-Ray of the right foot. ELISA test for HIV infection, VDRL and Mantoux test were negative.

An initial biopsy done after controlling the super-added infection by antibiotics revealed only granulation tissue. However, a repeat biopsy showed a tuberculoid granuloma in the deep dermis. The tissue sections were however negative for AFB by the ZN stain. The patient was managed with standard antitubercular therapy. In two weeks, the ulcer showed signs of healing [Figure - 2] and by the end of two months the ulcer healed well with a thin atrophic scar.

The frequent localization of LV to the face in the West could be due to the rich and porous venous plexuses with stasis, cold and hypoxia, and impaired fibrinolysis and host defense at a lower temperature.[1] In India, LV was found to be the most common form of cutaneous tuberculosis, by different workers.[2],[3] The maximum incidence of the lesions was seen on the lower extremities[4] especially buttocks, probably due to accidental inoculation of children squatting on the ground, where M. tuberculosis might have been deposited from the infected sputum of a family member.[4],[5] Pyogenic infection of the gluteal region is common in India and the breach in the integrity of skin can serve as a portal of entry for the AFB.

The present case is highlighted for the rare incidence of the ulcerative form of lupus vulgaris and the large size of the ulcer. Since tuberculosis is a curable condition, awareness of the tuberculous etiology in any chronic ulcer goes a long way in ensuring a good prognosis.

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