Journal of J M e d A l l i e d S c i 2 0 1 3 ; 3 ( 2 ) : 88- 90 M edical www.jmas.in & Allied Print ISSN: 2 2 3 1 1696 Online ISSN: 2231 1 7 0 X Sciences

Clinic

A case of erythematous lesions over the face

Kamal Ahmed1, Hardeep Singh2, Sameera Amreen1, Iqbal Ahmed1 1Department of Dermatology & STD, Owaisi Hospital & Research Centre, Deccan College of Medical Sciences, Kanchanbagh, Hyderabad-500058, Andhra Pradesh, India. 2Department of Plastic Surgery, Bangalore Medical College, Bangalore, Karnataka, India. Article history: Abstract

Received 26 April 2013 A 42 -year-old Indian woman presented with a 6 months history of Revised 26 July 2013 Accepted 27 July 2013 a reddish lesions over her nose. The lesion gradually progressed Early online 28 July 2013 to involve the left cheek. Clinical examination revealed multiple Print 31 August 2013 painless erythematous papules with superficial crusting involving

the ala of the nose and extending on the left cheek. Corresponding author

Kamal Ahmed Assistant Professor, Departmant of Dermatology & STD, Owaisi Hospital & Research Centre, Key words: Erythematous lesion, face, vulgaris Kanchanbagh, Hyderabad-500058, Andhra Pradesh, India Phone: +91-9966011525 Fax: +91-40-24340235 © 2013 Deccan College of Medical Sciences. All rights reserved. Email: [email protected]

upus vulgaris is a chronic, progressive and The disease commonly affects the nose and nasal the commonest form of secondary cutaneous cartilages2. The nasal bones are however spared. L tuberculosis1. It develops in a previously sen- Ulceration, necrosis and scarring occur with de- sitized host having a high degree of struction of deeper tissues and cartilage leading to sensitivity. The condition is more common in males gross deformities and contractures. Direct exten- than in females and lupus vulgaris usually occurs sion or lymphatic spread from the nasal focus may through hematogenous or lymphatic spread from also involve the soft and hard palate, gingiva, la- an underlying infective focus2. Rarely it may devel- rynx and pharynx2. op following direct inoculation of the bacilli into skin Case report or at the site of Bacille Calmette-Guerin (BCG) vaccination2,3. A 42 year old Indian woman presented with a 6 months history of a reddish lesions over her nose. Clinically it is characterized by soft reddish-brown The lesion gradually progressed to involve the left plaques with apple jelly nodules on diascopy. The cheek. There was no history of fever, pain in the lesions pursue a chronic course over several years lesion or ulceration in the lesion. There was no and grow by peripheral extension and central scar- 1 history of similar lesion in the family. She had re- ring . The diverse clinical forms of lupus vulgaris ceived BCG vaccination in childhood. include popular, nodular, plaque, ulcerative, veget- ative and tumour-like lesions. In India, trunk, but- Clinical examination revealed multiple painless tocks and extremities are the predominant sites erythematous papules with superficial crusting in- affected, in the West the lesions favour head and volving the ala of the nose and extending on the neck2,4. left cheek (Fig 1). The nasal septum, lips and oral

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Ahmed K et al Erythematous lesions over the face

mucosa were normal. There was no regional or test) was highly positive with an induration of distant and general physical and 16x18 mm. systemic examination was normal. In this case various differential diagnoses consi- dered were lupus vulgaris, Hansen's disease, We- gener's granulomatosis and midline . However, based on clinical features, histology and highly positive tuberculin test, lupus vulgaris was regarded as the most likely diagnosis. Anti- tuberculous therapy (ATT) (6 month regimen, 2HRZE + 4HR) was started. Clinical improvement was observed within one month and at the end of six months of therapy, the ulcerated plaque had completely resolved (Fig 3).

Fig 1. Multiple painless erythematous papules with superficial crusting

Fig 3. Clinical improvement after 6 months of treatment with ATT Discussion The clinical differential diagnosis of lupus vulgaris includes various infective and non-infective disord- ers showing a predilection for nose and adjoining areas of face. Atypical mycobacterial infections due to M. avium intracellulare complex and M. for- tuitum chelonae complex that may present with Fig 2. HPE revealing non-caseating epithelioid cell erythematous nodules, plaques, and along with Langerhan's type cells surrounded by lymphocytes (H&E,40X) non-healing ulcers, have been misdiagnosed as lupus vulglaris5. However, the culture characteris- Biopsy from the ulcerated plaque showed non- tics help to reach a correct diagnosis. Leishmania- caseating epithelioid cell granulomas along with sis, characterized by cutaneous ulceration and in- Langerhan's type cells in the dermis, surrounded volvement of oro-nasal mucosa, may progress to by lymphocytes (Fig 2). Involvement of nerve fibres destruction of the central structures of face includ- by granulomas or features of vasculitis were not ing nose6. Histopathology show a granulomatous observed. Special stains for acid-fast bacilli and infiltrate and Leishman-Donovan bodies fungi and bacterial, mycobacterial and fungal cul- representing the parasites, which can be grown on tures were negative. Routine laboratory investiga- culture6. is another chronic infec- tions including complete blood counts, biochemical tive granulomatous disorder caused by Klebsiella profile, liver function tests, urine analysis and chest rhinoscleromatis that causes destruction of nose x-ray were normal. Serology for , ELISA for and other structures of upper respiratory tract. Di- human immunodeficiency virus (HIV), sputum for agnosis is established on histology showing cha- acid fast bacilli and anti-nuclear antibodies were racteristic Miculikz cells in the deep dermis7. negative. An intradermal tuberculin test (Mantoux

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Ahmed K et al Erythematous lesions over the face

The cartilage destruction of nose in lupus vulgaris lating disorders enables an early diagnosis of lu- is similar to that seen in Hansen's disease, howev- pus vulgaris of nose. Timely commencement of er, loss of lateral eyebrows and diffuse infiltration proper anti-tuberculous treatment can help to of face and ear lobes are unique to . Syphi- achieve an early cure and can prevent the irrevers- lis, another chronic condition, should be ruled by ible destructive lesions of face of this chronic infec- serology and special histological stains. tion. Amongst non-infective disorders, nasal septal de- Acknowledgments: None fects can be observed in Wegener's granulomato- Conflict of interest: None sis (WG), midline granuloma and . WG, a systemic vasculitis, primarily involves the upper References and lower respiratory tracts and kidneys, mucosal 1. Kumar B and Muralidhar S. Cutaneous : a abnormalities of nose and paranasal sinuses range twenty year prospective study. Int J Tuberc Lung Dis 1999; from diffuse mucosal thickening, anti-neutrophil 3:494-500. cytoplasmic antibody test and presence of necro- 2. Sehgal VN and Wagh SA. Cutaneous tuberculosis. Cur- tizing granulomatous vasculitis on histopathology8. rent concepts. Int J Dermatol 1990; 29:237-252. 3. Kanwar AJ. Lupus vulgaris following BCG vaccination. Int Lupus pernio, a variant of cutaeous sarcoidosis, J Dermatol 1988; 27:525-526. showing chronic persistent violaceous nodules un- 4. Khandpur S, Nanda S, Reddy BSN. An unusual episode of der tip of nose to exuberant plaques spreading lupus vulgaris masquerading as sporotrichosis. Int J Der- across nose to both cheeks may also be mistaken matol 2001; 40:336-339. 9 5. Kullavanijaya P, Sirimachan S, Surarok S. Primary cuta- for lupus vulgaris . Other sites of predilection for neous infection with avium intracellular lupus pernio include lips, eyelids, ear and fingers. complex resembling lupus vulgaris. Br J Dermatol 1997; There may be intrathoracic involvement along with 136:264-266. bone and eye lesions and histology and radiologi- 6. Landau M, SrebrnikA, Brenner S. Leishmaniasis recidi- vans mimicking lupus vulgaris. Int J Dermatol 1996; cal features can help in differentiating this variant 35:572-573. of sarcoidosis from lupus vulgaris. The diagnosis of 7. Goafar HA and Hassi MH. Skin affection in rhinosderma. A lupus vulgaris is often missed initially due to lack of clinical, histological and electron microscopic study on four awareness of the disease and chronic atypical clin- patients. Ada Otolaryngol 1988; 105:494-499. 8. Yang C, Talbot JM, Hwang PM. Bony abnormalities of the ical presentation. Thus a high index of clinical sus- paranasal sinuses in patients with Wegener's granuloma- picion helped by morphology and histology and tosis. Am J Rhinol 2001; 15:121-125. appropriate investigations to rule out closely simu- 9. James DG. Lupus pernio. Lupus 1992; 1:129-131.

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