Letter to the Editor International Journal of STD & AIDS 2014, Vol. 25(13) 969–970 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0956462414532448 std.sagepub.com
Penile lupus vulgaris: a rare presentation of primary cutaneous tuberculosis
Lupus vulgaris is an extremely chronic, progressive, paucibacillary form of cutaneous tuberculosis (TB). The lesion may be primary or secondary, depending on the presence or absence of TB elsewhere. It most commonly involves face, nose, ear, chin and neck. Lupus vulgaris of penis is an extremely rare clinical entity occurring at a very unusual site.1 A 28-year-old unmarried man presented with complaints of chronic non-healing ulcer over the glans penis for 5 years (see Figure 1). He reported an unprotected sexual contact, and after 20 days had developed a painless nodule. Later this nodule had developed into an ulcer. It gradually involved the adjacent areas on glans and some areas started to heal with scarring and deep fissures. On examination, there were two ulcers of 0.5–1.5 cm size with yellowish necrotic floor and elevated margin on the dorsum of the glans. Inguinal lymph nodes on the right side were enlarged, discrete, mobile and nontender. A Mantoux (1 TU) test was positive with erythema and induration of 16 mm after 48 h. VDRL and HIV were non-reactive. Sputum, stool and urine cultures were negative for acid-fast bacilli. Chest X-ray was normal. Biopsy from the edge of ulcer showed patchy nodular tuberculoid granulomatous infiltrate made up of lymphocytes, plasma cells, histiocytes and epithelioid cells with occasional Langhan’s giant cells. Overlying epidermis showed moderate spongioticpsoriasiform change. Underlying dermis showed fibroplasias (see Figure 2). On the basis of clinical feature, history and histopathological findings primary lupus vulgaris of glans penis diagnosis was made and anti-tubercular (rifampicin–isoniazid–pyrazinamide–ethambutol) treatment was started. Cutaneous TB is a form of extra pulmonary TB with varied clinical presentation determined by the route of infection as well as the status of cellular immunity of the host.2 Most of the cases can be differentiated by clinical and histopathological findings. Histopathology of lupus vulgaris predominantly
Figure 1. Ulcer and scarring of glans penis.
Figure 2. Histopathology showing tuberculous granulomatous infiltration.
Downloaded from std.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 9, 2015
970
International Journal of STD & AIDS 25(13)
shows mononuclear infiltration and upper dermal tubercles or tuberculoid structures whereas tuberculosis verrucosa cutis shows a neutrophilic infiltrate and middermal tuberculoid granulomata.3 Lupus vulgaris may be primary or secondary depending on the presence or absence of TB elsewhere. However, penile TB is extremely rare, comprising less than 1% of all cases of genital TB in men.4 The bacilli are inoculated into abrasions caused by vigorous sexual contact since the normal mucosa is highly resistant to TB.1 TB of the penis may affect the skin, glans or cavernous bodies. In most cases, the lesion appears as a superficial ulcer on the glans or around the corona as it is the most common part rubbed during sexual contact or with infected clothing.5 Lupus vulgaris is chronic and without therapy its course usually leads to considerable disfiguration. The most serious complication of long-standing lupus vulgarisis is the development of squamous cell carcinoma and basal cell carcinoma.6 We are reporting a case of primary penile lupus vulgaris secondary to unprotected sexual intercourse which is quite rare. References 1. Lal MM, Sekhon OS and DhaU JC. Tuberculosis of the penis. Indian Med Assoc 56:316-318. 2. Thakur BK, Verma S and Hazarika D. A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam. Indian J Dermatol 2012; 57: 63–65.
3. Prasad P and Rao LL. Lupus vulgaris with tuberculosis verrucosa cutis. Indian J Dermatol Venereol Leprol 1994; 60: 347–348. 4. Baveja CP, Vidyanidhi G, Jain M, et al. Drug-resistant genital tuberculosis of the penis in a human immunodeficiency virus non-reactive individual. J Med Microbiol 2007; 56: 694–695. 5. Pal DK, Kundu AK, Chakraborty S, et al. Tuberculosis of penis : report of two cases. Ind J Tub 1996; 43: 203. 6. Tappeiner G and Wolff K. Tuberculosis and other mycobacterial infections. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al. (eds) Dermatology in general medicine, 4th ed. New York: Mc Graw Hill, 1993, p.2379.
Esther Nimisha Department of Skin, VD & Leprosy, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India Gaurang Gupta Dermatology and Cosmetology, Skinplus Clinic, Greater Kailash, New Delhi, India Corresponding author: Gaurang Gupta, Skinplus Cosmetology Clinic, S Block, Greater Kailash, New Delhi, India. Email: [email protected]
Downloaded from std.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 9, 2015
Penile lupus vulgaris: a rare presentation of primary cutaneous tuberculosis
Lupus vulgaris is an extremely chronic, progressive, paucibacillary form of cutaneous tuberculosis (TB). The lesion may be primary or secondary, depending on the presence or absence of TB elsewhere. It most commonly involves face, nose, ear, chin and neck. Lupus vulgaris of penis is an extremely rare clinical entity occurring at a very unusual site.1 A 28-year-old unmarried man presented with complaints of chronic non-healing ulcer over the glans penis for 5 years (see Figure 1). He reported an unprotected sexual contact, and after 20 days had developed a painless nodule. Later this nodule had developed into an ulcer. It gradually involved the adjacent areas on glans and some areas started to heal with scarring and deep fissures. On examination, there were two ulcers of 0.5–1.5 cm size with yellowish necrotic floor and elevated margin on the dorsum of the glans. Inguinal lymph nodes on the right side were enlarged, discrete, mobile and nontender. A Mantoux (1 TU) test was positive with erythema and induration of 16 mm after 48 h. VDRL and HIV were non-reactive. Sputum, stool and urine cultures were negative for acid-fast bacilli. Chest X-ray was normal. Biopsy from the edge of ulcer showed patchy nodular tuberculoid granulomatous infiltrate made up of lymphocytes, plasma cells, histiocytes and epithelioid cells with occasional Langhan’s giant cells. Overlying epidermis showed moderate spongioticpsoriasiform change. Underlying dermis showed fibroplasias (see Figure 2). On the basis of clinical feature, history and histopathological findings primary lupus vulgaris of glans penis diagnosis was made and anti-tubercular (rifampicin–isoniazid–pyrazinamide–ethambutol) treatment was started. Cutaneous TB is a form of extra pulmonary TB with varied clinical presentation determined by the route of infection as well as the status of cellular immunity of the host.2 Most of the cases can be differentiated by clinical and histopathological findings. Histopathology of lupus vulgaris predominantly
Figure 1. Ulcer and scarring of glans penis.
Figure 2. Histopathology showing tuberculous granulomatous infiltration.
Downloaded from std.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 9, 2015
970
International Journal of STD & AIDS 25(13)
shows mononuclear infiltration and upper dermal tubercles or tuberculoid structures whereas tuberculosis verrucosa cutis shows a neutrophilic infiltrate and middermal tuberculoid granulomata.3 Lupus vulgaris may be primary or secondary depending on the presence or absence of TB elsewhere. However, penile TB is extremely rare, comprising less than 1% of all cases of genital TB in men.4 The bacilli are inoculated into abrasions caused by vigorous sexual contact since the normal mucosa is highly resistant to TB.1 TB of the penis may affect the skin, glans or cavernous bodies. In most cases, the lesion appears as a superficial ulcer on the glans or around the corona as it is the most common part rubbed during sexual contact or with infected clothing.5 Lupus vulgaris is chronic and without therapy its course usually leads to considerable disfiguration. The most serious complication of long-standing lupus vulgarisis is the development of squamous cell carcinoma and basal cell carcinoma.6 We are reporting a case of primary penile lupus vulgaris secondary to unprotected sexual intercourse which is quite rare. References 1. Lal MM, Sekhon OS and DhaU JC. Tuberculosis of the penis. Indian Med Assoc 56:316-318. 2. Thakur BK, Verma S and Hazarika D. A clinicopathological study of cutaneous tuberculosis at Dibrugarh district, Assam. Indian J Dermatol 2012; 57: 63–65.
3. Prasad P and Rao LL. Lupus vulgaris with tuberculosis verrucosa cutis. Indian J Dermatol Venereol Leprol 1994; 60: 347–348. 4. Baveja CP, Vidyanidhi G, Jain M, et al. Drug-resistant genital tuberculosis of the penis in a human immunodeficiency virus non-reactive individual. J Med Microbiol 2007; 56: 694–695. 5. Pal DK, Kundu AK, Chakraborty S, et al. Tuberculosis of penis : report of two cases. Ind J Tub 1996; 43: 203. 6. Tappeiner G and Wolff K. Tuberculosis and other mycobacterial infections. In: Fitzpatrick TB, Eisen AZ, Wolff K, et al. (eds) Dermatology in general medicine, 4th ed. New York: Mc Graw Hill, 1993, p.2379.
Esther Nimisha Department of Skin, VD & Leprosy, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India Gaurang Gupta Dermatology and Cosmetology, Skinplus Clinic, Greater Kailash, New Delhi, India Corresponding author: Gaurang Gupta, Skinplus Cosmetology Clinic, S Block, Greater Kailash, New Delhi, India. Email: [email protected]
Downloaded from std.sagepub.com at Kungl Tekniska Hogskolan / Royal Institute of Technology on March 9, 2015
