A clinicopathologic approach to granulomatous dermatoses

Therapeutic and cosmeceutical role of glycosylated natural products in dermatology

Natural products (NPs) remain the primary source of pharmacologically active candidates for drug discovery. Since time immemorial, NPs have attracted considerable attention because of their beneficial skin effects. Moreover, there has been a great interest in using such products for the cosmetics industry in the past few decades, bridging the gap between modern and traditional medicine. Terpenoids, Steroids, and Flavonoids having glycosidic attachment have proven biological effects with a positive impact on human health. NPs derived glycosides are mainly found in fruits, vegetables, and plants, and most of them have a special reverence in traditional and modern medicine for disease prevention and treatment. A literature review was performed using scientific journals, Google scholar, Scifinder, PubMED, and Google patents. These scientific articles, documents, and patents establish the significance of glycosidic NPs in the areas of dermatology. Considering the human inclination to the usage of NPs rather than synthetic or inorganic drugs (especially in the area of skin care), in the present review we have discussed the worth of NP glycosides in beauty care and skin-related therapeutics and the mechanistic pathways involved.

Cutaneous Sarcoidosis

Sarcoidosis is a chronic, multisystem, inflammatory disorder of unknown etiology that is characterized by noncaseating granulomas that impair normal organ functioning. Sarcoidosis predominantly affects the lungs, but the skin is often cited as the second most frequently involved organ. Cutaneous manifestations of sarcoidosis are highly variable and ongoing research seeks to better understand the relationship between clinical morphology and disease prognosis. Skin findings in patients with sarcoidosis can be "specific," in which sarcoidal granulomas infiltrate the skin, or they can represent a "nonspecific" reactive inflammatory process, as is seen in calcinosis cutis and erythema nodosum. Cutaneous sarcoidosis can be the initial presenting sign or develop later in the course of the disease. In some patients, the skin will be the most involved and impactful organ system and will drive therapy. In other cases, the skin will be an incidental or minor finding, but may be easily accessible for biopsy to confirm the diagnosis. There are many potential therapies for sarcoidosis, though no one therapy is universally effective.

Subcutaneous Panniculitis-Like T-Cell Lymphoma With Granulomas as the Predominant Feature

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare primary cutaneous lymphoma preferentially localized in the subcutaneous adipose tissue and composed of cytotoxic T cells with an α/β immunophenotype. The neoplastic T cells can be variably admixed with other inflammatory cells, including histiocytes, which can rarely form noncaseating granulomas. We present a case of SPTCL in which granulomas are the predominant feature, composing 75%-80% of the inflammatory infiltrate. The top differential diagnoses included infectious and autoimmune etiologies. However, special stains for microorganisms were negative, and immunohistochemical analysis of the atypical lymphocytes showed a CD3, CD8, TIA-1+, T-cell receptor (TCR) beta+, and CD4 infiltrate with a high Ki67 proliferation index of approximately 30%. TCR gene rearrangement studies by polymerase chain reaction with confirmation by high-throughput sequencing were necessary to exclude an autoimmune etiology, specifically lupus erythematosus panniculitis. To the best of our knowledge, only 1 other case of SPTCL with prominent granulomas has been reported in the literature. It is important for dermatopathologists to recognize this presentation of SPTCL. SPTCL with predominant granulomas should be included in the differential diagnosis of granulomatous panniculitis along with infectious and autoimmune panniculitides as well as other granulomatous lymphomas.

Keratoacanthomatous Changes: Unifying the Histologic Spectrum of Actinic Granuloma

Actinic granuloma (AG) manifests as annular plaques on sun-damaged skin. There remains no universal consensus on the nosology, etiology, or clinicopathologic criteria of AG as a distinct entity. Broadly, AG is characterized by granulomatous inflammation, multinucleated giant cells, elastophagocytosis, and the absence of mucin and necrobiosis. It is not uncommon, however, to encounter overlapping histological features of other granulomas, such as granuloma annulare and necrobiosis lipoidica, confounding the diagnosis of this controversial entity. Herein, we describe 2 cases of AG with features of granuloma annulare and necrobiosis lipoidica, supporting the concept of AG as a histologic spectrum. These 2 cases displayed dilated follicular infundibula and pseudoepitheliomatous hyperplasia analogous to changes in keratoacanthomas. These unique epithelial changes, in tandem with characteristic elastin alterations and clinical findings, are helpful and unifying features that permit accurate diagnosis of this controversial entity.

Infectious Granulomatous Dermatitis at a Tertiary Care Centre in North Maharashtra: A Histopathological Study

INTRODUCTION

Infectious granulomatous dermatitis is a distinctive entity of chronic inflammation. Recognizing the aetiology of granulomatous lesion is challenging to the dermatopathologist. The definitive diagnosis of the granulomatous lesions of skin with identification of aetiological agent is very essential for specific treatment and an appropriate desirable outcome.

AIM

To study the histomorphology of various granulomatous lesions of skin and classify them, accordingly into different categories.

MATERIALS AND METHODS

A retrospective study of skin biopsies received in the Department of Pathology over a period of five years (June 2009-June 2014) was objectively reviewed. The skin biopsies diagnosed histopathologically as granulomatous dermatitis on H&E stained sections were selected. Complete clinical and relevant history were recorded. Special stains were employed whenever required.

RESULTS

A total of 137 cases exhibited granulomatous reaction pattern. Among the granulomatous lesions of skin, tuberculoid granulomas were seen in 109 cases (79.56%), foreign body type in 12 cases (8.75%), suppurative and necrobiotic granulomas each in 7 cases (5.1%) and histiocytic and mixed inflammatory type each in one case (0.7%). Leprosy was the most common granulomatous lesion in 66.4% of the cases (91/137).

CONCLUSION

Leprosy was the most common granulomatous lesion with Borderline Tuberculoid Leprosy (BTL) as common sub type followed by tuberculoid leprosy. Hence the combination of clinical data and histomorphological findings are essential for establishing an accurate diagnosis of granulomatous lesion of skin.

Granulomatous & histiocytic dermatitides

Granulomas of the skin may be classified in several ways. They are either infectious or non-infectious in character, and they contain areas of necrobiosis or necrosis, or not. Responsible infectious agents may be mycobacterial, fungal, treponemal, or parasitic organisms, and each case of granulomatous dermatitis should be assessed histochemically for those microbes. In the non-infectious group, examples of necrobiotic or necrotizing granulomas include granuloma annulare; necrobiosis lipoidica; rheumatoid nodule; and lupus miliaris disseminates faciei. Non-necrobiotic/necrotizing and non-infectious lesions are exemplified by sarcoidosis; foreign-body reactions; Melkersson-Rosenthal syndrome; Blau syndrome; elastolytic granuloma; lichenoid and granulomatous dermatitis; interstitial granulomatous dermatitis; cutaneous involvement by Crohn disease; granulomatous rosacea; and granulomatous pigmented purpura. Histiocytic dermatitides that do not feature granuloma formation are peculiar reactions to infection, such as cutaneous malakoplakia; leishmaniasis; histoplasmosis; lepromatous leprosy; rhinoscleroma; lymphogranuloma venereum; and granuloma inguinale.

Sarcoidosis Can Present with Necrotizing Granulomas Histologically: Two Cases of Ulcerated Sarcoidosis and Review of the Literature

Background:

Sarcoidosis is a systemic inflammatory disorder with cutaneous involvement present in 25% of cases. The presence of naked granulomas histologically is the hallmark of sarcoidosis. The presence of necrotizing granulomas is highly suggestive of other granulomatous conditions and leads the clinician to pursue other diagnoses, such as infectious causes.

Objectives:

We describe two cases of sarcoidosis in which necrotizing granulomas were present on biopsy. Both patients had ulcerated cutaneous lesions of sarcoidosis. In one case, the presence of these atypical histologic features led to a delay in diagnosis of almost 10 years. We review the various histopathologic findings associated with cutaneous sarcoidosis and discuss a potential connection between ulcerated sarcoidosis and atypical histologic findings.

Conclusion:

When atypical histopathologic features are present, the differential diagnosis of sarcoidosis should not be excluded.

Clinical and histopathological analysis of specific lesions of cutaneous sarcoidosis in Korean patients

BACKGROUND

Sarcoidosis is a multi-systemic, non-caseating, granulomatous disorder of unknown origin.

OBJECTIVE

The purpose of our investigation was to describe the clinicopathological characteristics of specific lesions of cutaneous sarcoidosis and treatment outcomes in Korean patients.

METHODS

A retrospective review was made of 31 patients who were diagnosed with sarcoidosis at Severance Hospital, Yonsei University Health System in Korea between 2000 and 2008; these patients were enrolled in this study. The diagnosis of cutaneous sarcoidosis was made in 17 of the patients. They were confirmed by histopathologic examinations. The clinical features were analyzed through review of medical records, and histopathologic and radiologic examinations.

RESULTS

The patients' primary complaints were cutaneous symptoms (51.6%) and respiratory symptoms (32.3%). The most common presentation of cutaneous sarcoidal lesions was the nodule-plaque form (41.2%) and systemic organ involvement was observed in six cases (35.3%). Treatment modalities included steroid, hydroxychloroquine, cyclosporine, topical tacrolimus, and pulsed dye laser. In our series, five patients (30%) achieved complete resolution of the cutaneous lesions and 10 patients (60%) showed partial resolution after corticosteroid treatment. Also, patients without extracutaneous symptoms responded better to corticosteroid treatment compared to patients with systemic involvement.

CONCLUSIONS

These data reveal the diversity of clinical and histopathologic findings of cutaneous sarcoidosis in Korea.

Granulomas in acquired immunodeficiency syndrome-associated cutaneous Kaposi sarcoma: evidence for a role for Mycobacterium tuberculosis

BACKGROUND

Co-lesional acquired immunodeficiency syndrome-associated cutaneous Kaposi sarcoma (AIDS-KS) and Mycobacterium tuberculosis-associated granulomatous inflammation are undocumented.

METHOD

Retrospective appraisal of skin biopsies with co-lesional AIDS-KS and microscopic tuberculosis (TB).

RESULTS

Sixteen biopsies from nine males and seven females form the study cohort. Histological assessment confirmed nodular and plaque KS in 12 and 4 cases each, respectively. Necrotizing, non-necrotizing and a combination of necrotizing and non-necrotizing granulomatous inflammation were present in nine, two and five biopsies each, respectively. The identification of acid fast bacilli on Ziehl-Neelsen staining and M. tuberculosis on polymerase chain reaction confirmed co-lesional TB in 15/16 biopsies. Co-lesional AIDS-KS and lichen scrofulosorum, hitherto undocumented, were confirmed in one biopsy. The histopathological findings served as a marker of human immunodeficiency virus (HIV) infection, visceral TB, therapeutic noncompliance and multidrug resistant pulmonary TB in nine, eight, five and one patient, respectively. M. tuberculosis was cultured from sputum or nodal tissue of all patients.

CONCLUSION

Granulomatous inflammation in KS requires optimal histopathological and molecular investigation to confirm an M. tuberculosis origin. The cutaneous co-lesional occurrence of AIDS-KS and microscopic TB may serve as the sentinel clue to HIV infection, systemic TB, therapeutic noncompliance or multidrug resistant TB.

Alopecia: manifestação cutânea rara de sarcoidose

A sarcoidose é doença granulomatosa multissistêmica que geralmente compromete o trato respiratório e os linfonodos hilares. A pele é comumente afetada, mas raramente o couro cabeludo. Dois casos de sarcoidose com lesões no couro cabeludo são relatados: o primeiro, em paciente negra apresentando áreas de alopecia no couro cabeludo associada a outras lesões cutâneas; e o segundo, em paciente branca, portadora de sarcoidose pulmonar, com alopecia como manifestação cutânea isolada. A sarcoidose de couro cabeludo merece especial atenção, pois nos pacientes com essa forma de lesão cutânea existe alta incidência de acometimento sistêmico.

Cutaneous sarcoidosis: differential diagnosis

Sarcoidosis is a multisystem disease with cutaneous lesions present in 20%-35% of patients. Given the wide variability of clinical manifestations, it is one of the "great imitators," making it necessary to consider clinical, epidemiological, radiographic, laboratory, and histopathological criteria to make the diagnosis. Cutaneous lesions have been classified as specific and nonspecific, depending on the presence of noncaseating granulomas on histologic studies. Specific lesions include maculopapules, plaques, nodules, lupus pernio, scar infiltration, alopecia, ulcerative lesions, and hypopigmentation among others. Nail, mucosal, and childhood sarcoidosis represent a distinct subset of the disease process. The most common nonspecific lesion is erythema nodosum. Others include calcifications, prurigo, erythema multiforme, nail clubbing, and Sweet syndrome. The importance of considering cutaneous sarcoidosis in the clinical differential diagnosis of a given skin lesion relies on the association with systemic involvement and the convenience of the skin as a tissue source for histologic analysis.

Hansen disease in the United States in the 21st century: a review of the literature

In this article we review the recent literature on Hansen disease (leprosy). We searched published literature through PubMed (National Library of Medicine) and extracted data through direct review of the literature and pathologic slides. Hansen disease continues to occur in the United States, including among the native-born population. Inclusion of the disease in the differential diagnosis is key to confirmation. Current epidemiology, classification systems, prevention measures, and therapy are reviewed.

Non-infectious granulomatous dermatitis: a clinicopathological study

BACKGROUND

Granulomatous dermatitis frequently presents a diagnostic challenge to dermatopathologists because an identical histologic picture is produced by several causes, and conversely, a single cause may produce varied histologic patterns.

METHODS

A retrospective analysis of skin biopsies received over a period of 7 years was performed, and cases of non-infectious granulomatous dermatitis diagnosed on histopathological examination were retrieved.

RESULTS

Out of a total of 586 cases of granulomatous dermatitis, 71 cases (12.11%) were categorized as non-infectious granulomatous dermatitis on the basis of clinicopathological findings. Further subcategorization was done based on morphology of granulomas as epithelioid granulomas; 15 cases of sarcoidosis, 21.1%, one case of Crohn's vulvitis, 1.4%, necrobiotic granulomas; 11 cases of granuloma annulare, 15.4%, two cases of rheumatoid nodule, 2.8%, 10 cases of foreign body granulomas, 14.0%; 32 cases of miscellaneous group, 45%.

CONCLUSIONS

Morphology alone is seldom specific and cannot be used as a diagnostic tool for identification of specific diseases. Adequate clinical data and work up in combination of pathological resources can help in elucidation of specific etiology of granulomatous dermatitis. Mohan H, Bal A, Dhami GP. Non-infectious granulomatous dermatitis: a clinicopathological study.

A Case of Lupus vulgaris Successfully Treated with Antituberculous Therapy despite Negative PCR and Culture

A 14-year-old boy presented with a pink firm plaque with well-defined borders in the right infra-orbital skin area. On diascopy, the infiltrate exhibited a typical apple-jelly appearance. No acid-fast bacilli could be demonstrated. A polymerase chain reaction (PCR) assay did not reveal the presence of mycobacteria in a lesional biopsy sample. Culture of biopsied tissue on Loewenstein-Jensen medium was negative. Although the tuberculosis culture and PCR did not confirm tuberculosis, a diagnosis of lupus vulgaris was made considering the clinical and histopathological findings. After a 9-month antituberculous therapy, the lesion disappeared. We believe that a diagnosis of lupus vulgaris still depends more on clinical and histopathological findings than on tuberculosis culture or PCR.

The histologic spectrum of cutaneous sarcoidosis: a study of twenty-eight cases

BACKGROUND

Naked sarcoidal granulomas (NSGs) are the characteristic histologic finding in sarcoidosis. This descriptive study was designed to identify the frequency of other histologic changes in cutaneous sarcoidosis.

METHODS

The slides from 28 sequential biopsies previously diagnosed as sarcoidosis in patients with known systemic sarcoidosis were reviewed.

RESULTS

Classic NSGs were identified in 25 biopsies (89%). Four biopsies contained tuberculoid granulomas, two with neutrophils suggesting infection (cultures negative). Five biopsies contained interstitial granulomas that resembled granuloma annulare and necrobiosis lipoidica in one case each. Additional histologic findings included birefringent foreign material in 14 biopsies (50%), focal necrosis (43%), elastophagocytosis (39%), linear peri-neural granulomas resembling leprosy (25%), increased dermal mucin (18%) and lichenoid inflammation (14%) [two with plasma cells resembling syphilis (7%)]. In all but three cases, the clinical morphology of the lesions suggested sarcoidosis. Special stains for mycobacteria and fungi were negative.

CONCLUSIONS

The histologic changes in cutaneous sarcoidosis are more diverse than previously recognized. In sarcoidosis, foreign material may be a frequent nidus for cutaneous granuloma formation. Histologic examination without the clinical history could lead to a misdiagnosis of leprosy, syphilis, other infectious granulomas, rosacea, granuloma annulare, necrobiosis lipoidica, and foreign body reaction in selected cases from this series.

Delayed diagnosis in a case of lupus vulgaris with unusual localization

Lupus vulgaris is the most common form of cutaneous tuberculosis, and the usual sites of involvement are the head and neck. We present a forty-six-year-old woman with lupus vulgaris on the external surface of the left leg and foot, an unusual site. Based on histopathological and clinical features, this case was diagnosed as lupus vulgaris with unusual localization.

Possible role of Mycobacterium tuberculosis complex in Melkersson-Rosenthal syndrome demonstrated with Gen-Probe amplified Mycobacterium tuberculosis direct test

Melkersson-Rosenthal (MRS) syndrome is characterized by a classical triad of recurrent or persistent orofacial swelling, peripheral facial nerve paralysis and lingua plicata. Granulomatous cheilitis (GC) is regarded as a monosymptomatic form of MRS. The exact aetiologies of MRS and GC are unknown. In this study we investigated the possible role of mycobacteria in these two conditions. A ribosomal RNA amplification-based Gen-Probe amplified Mycobacterium tuberculosis direct test was used to investigate the presence of M. tuberculosis complex in paraffin-embedded skin biopsy specimens from five patients with MRS and one patient with GC. Three of the six specimens were shown to be positive using this system; one of the positive specimens also showed positive Ziehl-Neelsen staining. These results suggest a possible mycobacterial aetiology for MRS and GC.

Polymerase chain reaction based detection of Mycobacterium tuberculosis in tissues showing granulomatous inflammation without demonstrable acid-fast bacilli

BACKGROUND

Cutaneous tuberculosis is especially difficult to distinguish from other granulomatous dermatoses. We used polymerase chain reaction (PCR) to evaluate the incidence of cutaneous tuberculosis and atypical mycobacterial infection in formalin-fixed, paraffin-embedded tissues with unspecified granulomatous inflammation and negative results for acid-fast bacilli (AFB), and analyzed the pattern of cutaneous tuberculosis in this group of patients.

METHODS

A total of 38 specimens which had been collected from 36 patients and fulfilled the criteria for tissues described above were used in this study. Two different primer pairs targeting the gene encoding for 16S ribosomal RNA (common to all mycobacteria) and the insertion sequence IS6110 (specific for M. tuberculosis complex) were used in the PCR assays. The clinical characteristics, histopathologic findings, and culture results of the patients were also analyzed.

RESULTS

Four specimens were excluded from the analysis due to the lack of internal control testing. Of the remaining 34 specimens, 22 were PCR positive for the 16S rRNA gene. Among them, 18 specimens were PCR positive for both the 16S rRNA gene and IS6110. Cutaneous tuberculosis could be diagnosed in these 18 cases (56.2%). Out of the 18 cases, there were 8 women and 10 men. The age range was 15-77 years (mean: 44.2 years). After reviewing their clinical presentation, 11 cases were considered as tuberculosis verrucosa cutis, 6 cases as lupus vulgaris, and 1 case as erythema induratum. The remaining 4 cases (12.5%) positive only for 16S rRNA gene were considered as possible atypical mycobacteria infection.

CONCLUSIONS

These results show that in paucibacillary form of cutaneous tuberculosis with unclassical clinical and histological presentation, this PCR system provides rapid and sensitive detection of M. tuberculosis DNA in formalin-fixed, paraffin-embedded specimens. Cutaneous tuberculosis represents a significant proportion in specimens showing granulomatous inflammation. In areas like Taiwan, where prevalence of pulmonary tuberculosis is still high, tuberculosis verrucosa cutis and lupus vulgaris are common forms of cutaneous tuberculosis and are seen more frequently than atypical mycobacterial infection.

Sarcoidosis

Sarcoidosis is a systemic granulomatous disease of unknown cause that most commonly affects the lungs, lymph nodes, skin, eyes, spleen, bone, and glandular tissue. The diagnosis is made when characteristic histologic findings are demonstrated and other granulomatous processes are excluded. It can be an acute or chronic debilitating disease, but in patients with acute disease the process can be self-limited. Multiple therapeutic options have been described both for the cutaneous and systemic lesions of sarcoidosis. Steroids, however, remain the cornerstone of therapy.

Sarcoidosis

Sarcoidosis is a systemic noncaseating granulomatous disorder of unknown origin. The cutaneous manifestations of sarcoidosis often enable the dermatologist to be the first physician to make the diagnosis. This article reviews essential sarcoidosis pathophysiology, clinical polymorphisms, systemic evaluation, and treatment modalities for cutaneous sarcoidosis to further enhance the dermatologist's understanding of this disease entity.

LEARNING OBJECTIVE

At the conclusion of this learning activity, participants should be familiar with the theories of the pathogenesis of sarcoidosis, its cutaneous manifestations, its various syndromes and associations, and its presentation in children. Participants should also be more knowledgeable about diagnostic evaluation, measurement of disease progression, treatment modalities, and the prognosis and mortality data of sarcoidosis.

Actinically degenerate elastic tissue is the likely antigenic basis of actinic granuloma of the skin and of temporal arteritis

Staining technique is paramount for detecting and assessing the severe degeneration that occurs in the elastic tissues of the skin and its arteries in response to prolonged exposure to actinic radiation. With a selective "controlled" hematoxylin-and-eosin stain, actinically damaged ("elastotic") elastic tissue stains blue, as Unna described, and contrasts with normal and simply hyperplastic elastic tissue, which stains red. "Special" elastic stains such as Orcein and Verhoeff do not demonstrate this difference. When resorptive (elastolytic) giant cell reactions develop in relation to actinically degenerate elastic tissue of the skin, the papules that arise tend to form expanding, annular rings. A previously used and appropriate name for these autoimmune lesions in the skin is actinic granuloma because this name highlights the likely actinic origin and pathogenesis of many such lesions. Granulomatous inflammation in connection with actinically degenerate internal elastic lamina appears to be the basis of temporal arteritis. Actinic granulomas may occur in the skin concurrently with temporal arteritis. A recent study of temporal arteritis strongly relates its elastic tissue changes to those of "accelerated" atherosclerosis.

Vaccine-induced necrobiotic granuloma

We report two cases of necrobiotic palisaded granulomas which developed at the site of intradermal hepatitis B vaccination. To the best of our knowledge, this kind of reaction has not been reported previously.

Immunophenotyping of a sarcoidal granuloma in a scar, a manifestation of a possible autoimmune process

BACKGROUND

Old scars rarely develop sarcoid lesions. To determine whether the immunophenotype of the cellular infiltrate found in sarcoid in scarred skin resembled that seen in sardoidosis, we performed routine staining with hematoxylin and eosin, as well as immunophenotyping of a sarcoid lesion in a scar. Currently, there is controversy about the etiology of sarcoidosis in general and about sarcoidal granulomas in scars in particular. A new hypothesis is suggested in this case report.

OBJECTIVE

The purpose was to determine whether the cellular infiltrate in a sarcoidal granuloma in an old scar was similar to that in sarcoidosis.

METHODS

Staining with hematoxylin and eosin as well as immunophenotyping was performed using standard techniques.

RESULTS

The dermis of the sarcoid lesion demonstrated predominantly macrophages, followed by CD-4+ T-helper cells. CD-8+ cytotoxic suppressor cells were rare.

CONCLUSIONS

The lymphoid cell infiltrate in a sarcoidal granuloma found in a scar is similar to that found in sarcoidosis. Furthermore, the staining pattern of sarcoid described in this paper and a review of the data in the literature suggest that sarcoidosis shares many characteristics of diseases with an autoimmune origin. Thus, we suggest that sarcoid isolated to scars represents a more benign variant of sarcoidosis, a possible systemic autoimmune disease.

Lupus miliaris disseminatus faciei--the DNA of Mycobacterium tuberculosis is not detectable in active lesions by polymerase chain reaction

There has been a controversy as to the origin of lupus miliaris disseminatus faciei (LMDF). It was originally thought to be associated with tuberculosis, due to its histopathological similarity. Recently, this association has been doubted, although there remain reported cases of LMDF associated with Mycobacterium tuberculosis. Three patients with the clinical and histopathological features of LMDF are described. Skin from these patients was analysed by polymerase chain reaction (PCR) using two different oligoprimers for the detection of 123 bp and 165 bp DNA fragments specific for M. tuberculosis complex. With these two PCR systems, no M. tuberculosis DNA was detected in any of the LMDF patients. It was present in all positive controls and absent in all negative controls. In this study we could not demonstrate an association between LMDF and tuberculosis.