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 Table of Contents  
CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 3  |  Page : 292-294

Sporotrichoid presentation of lupus vulgaris mimicking mycetoma


Department of Dermatology, AIIMS, Raipur, Chhattisgarh, India

Date of Web Publication12-Sep-2019

Correspondence Address:
Dr Namrata Chhabra
Department of Dermatology, AIIMS, Raipur, Chhattisgarh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_113_19

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  Abstract 


Most common form of cutaneous tuberculosis (TB) is lupus vulgaris (LV). Atypical presentation of LV is rare and may lead to delay in diagnosis and hence increase in morbidity. Here, we report a case of sporotrichoid form of LV in a 38 year old male who presented as cutaneous lesions mimicking mycetoma. High index of clinical suspicion and relevant investigations play a vital role in confirmation of diagnosis wherever atypical form of cutaneous TB is suspected.

Keywords: Lupus vulgaris, mycetoma, sporotrichoid


How to cite this article:
Khare S, Chhabra N, Ganguly S, Prabha N. Sporotrichoid presentation of lupus vulgaris mimicking mycetoma. Int J Mycobacteriol 2019;8:292-4

How to cite this URL:
Khare S, Chhabra N, Ganguly S, Prabha N. Sporotrichoid presentation of lupus vulgaris mimicking mycetoma. Int J Mycobacteriol [serial online] 2019 [cited 2019 Oct 19];8:292-4. Available from: http://www.ijmyco.org/text.asp?2019/8/3/292/266490




  Introduction Top


The most common form of cutaneous tuberculosis (TB) is lupus vulgaris (LV). Various forms described are plaque, ulcerative, hypertrophic, vegetative, papular, and nodular. Atypical presentation of LV is rare and may lead to delay in diagnosis and hence increase in morbidity. We report a case of sporotrichoid form of LV which was initially suspected as mycetoma.


  Case Report Top


A 38-year-old, otherwise, healthy male presented with large erythematous-indurated lesion of size 15 cm × 20 cm with multiple asymptomatic pus-discharging sinuses over the right gluteal region which has slowly progressed over the past 12 years. The patient had a history of intermittent fever for the past 3 years. There was no history of weight loss or any other systemic complaints. There was no previous history of TB in the patient or family. On examination, in addition to the above-mentioned lesion, he had multiple crusted plaques and atrophic scars along the medical aspect of the right lower leg, right groin area, and over the right buttock above the indurated plaque in a linear fashion [Figure 1]. The superficial veins of the right leg below the indurated plaque were dilated and very prominent [Figure 2]. Based on the history and clinical findings, differential diagnosis of mycetoma and an atypical form of cutaneous TB was made.
Figure 1: Single large erythematous-indurated plaque with multiple pus-discharging sinuses over the right gluteal region

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Figure 2: Dilated and tortuous superficial veins of the right leg below the indurated plaque

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The relevant laboratory investigations include raised erythrocyte sedimentation rate (22 mm/h) and positive Mantoux test (>14 mm). Scanty acid-fast bacilli (AFB) were seen on Ziehl–Neelsen staining from pus discharge, and no fungal elements were seen on KOH from pus discharge. Histopathology from the lesional biopsy showed patchy nodular tuberculoid granulomatous infiltrate [Figure 3], and the staining for AFB in histopathology was negative. Fungal culture and mycobacterial culture from the tissue sample showed no growth. Based on this, a diagnosis of sporotrichoid LV was made, and the patient was started on Category I antitubercular treatment (ATT).
Figure 3: Dermis shows patchy nodular tuberculoid granulomatous infiltrate in the dermis (H and E, ×100)

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  Discussion Top


Cutaneous TB occurs in 1%–2% of TB cases worldwide and is frequently found, especially in developing and tropical countries. It has various clinical manifestations including LV, scrofuloderma, TB verrucosa cutis, orificial TB, tuberculous gumma, tuberculous chancre, and acute cutaneous miliary TB.

LV, the most common variant of cutaneous TB, is chronic and progressive.[1] Erasmus Wilson coined the term “Lupus” to emphasize ulcerating and devouring character of lesions comparing the lesions to the ravages of wolf.[2] It is commonly found in patients who are sensitized to Mycobacterium tuberculosis. LV has five major clinical variations including plaque, hypertrophic or vegetation, tumor-like, papular or nodular, and ulcerative types. Although LV is common, its atypical and protean forms can challenge the diagnostic skills of treating clinician. Unusual variants include the frambesiform, gangrenous, ulcerovegetating, lichen simplex chronicus, myxomatous, and sporotrichoid types.[3] The predilection sites for LV are the face, neck, lower arms, chest, trunk, and leg. The face is the most commonly affected site in LV in Western countries with a frequent affliction of the nose and cheeks. In India, however, lower extremities, especially buttocks, are the most frequently affected site.

Sporotrichoid form of LV is an unusual variant that mimics sporotrichosis, a subcutaneous fungal disease.[4],[5] Bacilli follow the lymphatic channels and during transit provoke cutaneous granulomatous inflammation, resulting in a linear array of papular, nodular, and ulcerative lesions over time. It has been shown that sporotrichoid form is more common in children than in adults.[6],[7] The efficient lymphatic drainage in children and high physical activity that makes them prone to trauma may be responsible for this form. As it is a complex process and takes time, this presentation of LV is rare.[1] Various case reports with atypical presentation of LV are reported in the literature [Table 1].
Table 1: Case reports with atypical presentation of lupus vulgaris mimicking mycetoma and sporotrichosis

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Various unusual forms of LV are reported in the literature that mimicked other skin diseases, making it difficult to diagnose. Heo et al.[16] described a case of LV which was misdiagnosed as tinea and was treated for 10 years without relief. Saritha et al.[17] described three cases of LV mimicking actinomycosis and mycetoma which were diagnosed by histopathology and lesions resolved completely with ATT. The clinical presentation of our case with indurated lesions presenting in a linear fashion with multiple overlying discharging sinuses corroborates most likely with mycetoma, particularly sporotrichosis. Therefore, it was kept as our first clinical diagnosis; however, the investigations finally lead to the confirmation of LV.


  Conclusion Top


Noduloulcerative lesions with discharging sinuses are an unusual presentation of cutaneous TB. The purpose of presenting this case is to highlight the importance of strong clinical suspicion of cutaneous TB even in an atypical cutaneous manifestation like in this case. High clinical suspicion, histopathology, and response to antitubercular therapy can only establish the diagnosis of cutaneous TB in such mimicking dermatoses.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Khandpur S, Nanda S, Reddy BS. An unusual episode of lupus vulgaris masquerading as sporotrichosis. Int J Dermatol 2001;40:336-9.  Back to cited text no. 1
    
2.
Wolf K, Tappineir G. Tuberculosis and atypical mycobacterial infections. In: Fitzpatrick TB, Eiesen AZ, Wolf K, editors. Mycobacterial Diseases. New York: Mcgraw Hill; 1987. p. 2152-70.  Back to cited text no. 2
    
3.
Wozniacka A, Schwartz RA, Sysa-Jedrzejowska A, Borun M, Arkuszewska C. Lupus vulgaris: Report of two cases. Int J Dermatol 2005;44:299-301.  Back to cited text no. 3
    
4.
Vashisht P, Sahoo B, Khurana N, Reddy BS. Cutaneous tuberculosis in children and adolescents: A clinicohistological study. J Eur Acad Dermatol Venereol 2007;21:40-7.  Back to cited text no. 4
    
5.
Kumar B, Rai R, Kaur I, Sahoo B, Muralidhar S, Radotra BD, et al. Childhood cutaneous tuberculosis: A study over 25 years from Northern India. Int J Dermatol 2001;40:26-32.  Back to cited text no. 5
    
6.
Pau WS, AlSaffar H, Weinstein M, Kitai I. Sporotrichoid-like tuberculosis. Pediatr Infect Dis J 2009;28:1135-6.  Back to cited text no. 6
    
7.
Remenyik E, Nagy B, Kiss M, Veres I, Sápy M, Horkay I, et al. Sporotrichoid cutaneous Mycobacterium tuberculosis infection in a child. Acta Derm Venereol 2005;85:375-6.  Back to cited text no. 7
    
8.
Sehgal VN, Srivastava G, Ahuja P, Koranne RV, Sharma VK. Unusual clinical manifestations of cutaneous tuberculosis. J Dermatol 1988;15:334-8.  Back to cited text no. 8
    
9.
Sharma S, Choudhary R, Juneja M, Grover C, Nagi Reddy BS. Cutaneous tuberculosis mimicking sporotrichosis. Indian J Pediatr 2005;72:86.  Back to cited text no. 9
    
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Ramesh V. Sporotrichoid cutaneous tuberculosis. Clin Exp Dermatol 2007;32:680-2.  Back to cited text no. 10
    
11.
Nagesh TS, Akhilesh A. Sporotrichoid cutaneous tuberculosis. Indian J Dermatol Venereol Leprol 2014;80:279.  Back to cited text no. 11
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12.
Maheshwari A, Tiwari S, Mathur DK, Bhargava P. Sporotrichoid lupus vulgaris: A rare presentation. Indian Dermatol Online J 2015;6:120-1.  Back to cited text no. 12
[PUBMED]  [Full text]  
13.
Dash M, Pradhan S. Lupus vulgaris in classical sporotrichoid pattern. Indian Dermatol Online J 2016;7:317-8.  Back to cited text no. 13
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14.
Prakash V, Verma AK, Joshi A, Kumar V, Kant S, Mishra AK. Tuberculosis of foot mimicking mycetoma. J Mahatma Gandhi Inst Med Sci 2017;22:107-9.  Back to cited text no. 14
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15.
Vora RV, Diwan NG, Singhal RR. Cutaneous tuberculosis mimicking a mycetoma. J Postgrad Med 2018;64:174-6.  Back to cited text no. 15
[PUBMED]  [Full text]  
16.
Heo YS, Shin WW, Kim YJ, Song HJ, Oh CH. Annular lupus vulgaris mimicking tinea cruris. Ann Dermatol 2010;22:226-8.  Back to cited text no. 16
    
17.
Saritha M, Parveen BA, Anandan V, Priyavathani MR, Tharini KG. Atypical forms of lupus vulgaris – A case series. Int J Dermatol 2009;48:150-3.  Back to cited text no. 17
    


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