Penis tuberculid (papulonecrotic tuberculid of the glans penis): treatment with a combination of rifampicin and an extract from tubercle bacilli (T.B. vaccine)

Tubercúlide papulonecrótica

As tubercúlides são reações de hipersensibilidade cutânea aos antígenos do Mycobacterium tuberculosis. Este é o caso de uma mulher de 45 anos que procurou a Unidade Básica de Saúde (UBS) com um quadro de eritema nodoso com mais de 10 anos de evolução, de etiologia desconhecida, e que evoluía como nódulos em pescoço e membros, que se tornavam úlceras necróticas, cicatrizavam e recidivavam periodicamente. Biópsias das lesões evidenciavam um processo inflamatório granulomatoso com extensa necrose, sugestivo de tuberculose, mas sem a presença do bacilo. Após anos sem tratamento adequado, finalmente levantou-se a hipótese de tubercúlide papulonecrótica. A paciente iniciou tratamento com o esquema básico (2RHZE/4RH) e dessensibilização vacinal, recebendo alta por cura.

Diseases masking and delaying the diagnosis of urogenital tuberculosis

As urogenital tuberculosis (UGTB) has no specific clinical features, it is often overlooked. To identify some of the reasons for misdiagnosing UGTB we performed a systematic review. We searched in Medline/PubMed papers with keywords 'urogenital tuberculosis, rare' and 'urogenital tuberculosis, unusual'. 'Urogenital tuberculosis, rare' presented 230 articles and 'urogenital tuberculosis, unusual' presented 81 articles only, a total of 311 papers. A total of 34 papers were duplicated and so were excluded from the review. In addition, we excluded from the analysis 33 papers on epidemiological studies and literature reviews, papers describing non-TB cases and cases of TB another than urogenital organs (48 articles), cases of congenital TB (three articles), UGTB as a case of concomitant disease (16 articles), and UGTB as a complication of BCG-therapy (eight articles). We also excluded 22 articles dedicated to complications of the therapy, which made a total of 164 articles. Among the remaining 147 articles we selected 43 which described really unusual, difficult to diagnose cases. We also included in our review a WHO report from 2014, and one scientific monograph on TB urology. The most frequent reasons for delayed diagnosis were absence typical clinical features of UGTB, and the tendency of UGTB to hide behind the mask of another disease. We can conclude that actually UGTB is not rare disease, but it is often an overlooked disease. The main reasons for delayed diagnosis are vague, atypical clinical features and a low index of suspicion.

Tuberculid of the penis with a scab on the nodule

Tuberculids of the penis are extremely rare. The clinical features of tuberculids of the penis have been reported as ulceration or scars. We have experienced a case of tuberculid of the penis that appeared as a scab on nodule. A 56-year-old man presented with a 4-month history of a painless subcutaneous nodule at the glans penis. Pathological findings of the nodule showed granulomatous inflammation. Tuberculin tests were strongly positive, but tubercle bacilli could not be detected. The diagnosis was tuberculid of the penis and the patient received antituberculosis chemotherapy. The present paper reports an interesting and rare case of tuberculid of the penis with a scab on nodule.

Papulonecrotic tuberculide: a forgotten cutaneous manifestation of tuberculosis

A 30-year-old Chinese man presented with a 2-month history of enlarging neck masses and a widespread rash. He had first noticed the swellings 10 years ago when a diagnosis of tuberculosis was made. The lymphadenopathy improved after anti-tuberculous therapy but never completely regressed. Seven years later, a skin eruption developed over his limbs and trunk. He described recurring crops of asymptomatic reddish papules which discharged a yellowish fluid and subsequently healed with scarring and hyperpigmentation. There was no pruritus or tenderness and no pulmonary symptoms.

Clinical examination revealed a non-tender, 10 cm, firm and ovoid mass with overlying erythema in the right anterior triangle of his neck (Figure 1) with several smaller lumps on the other side. There was a widespread eruption on his trunk and limbs, sparing the face, palms, sole and scalp (Figure 2). Recent lesions consisted of 1cm erythematous papules with a scaly collarette (Figure 3). Older lesions had left atrophic scarring and hyperpigmentation. A clinical diagnosis of papulonecrotic tuberculide was made.

An X-ray of the chest was normal. Serum immunoglobulins (IgG, A and M) were moderately elevated. Erythrocyte sedimentation rate and C-reactive protein level were normal. Syphilis serology was negative. A Heaf test was strongly positive (Figure 4).

Fine needle aspirations of the neck mass were negative for microscopic identification of acid-fast bacilli and for malignancy. On the other hand, a lymph node biopsy on the left side revealed fragments of connective tissue showing granulomatous inflammation and non-caseating necrosis. Occasional acid-fast bacilli were seen with a Ziehl-Neelsen stain. Skin biopsies were taken of recent, established and old lesions. The histological features of the established lesion were diagnostic, showing a florid, acute on chronic, perivascular and periappendiceal inflammmatory infiltrate involving both the superficial and deep dermis. There was also evidence of lobular panniculitis with fibrinoid necrosis of medium-sized arterial vessels, venulitis and extensive endothelial cell swelling. Histological features of the other two skin specimens were non-specific. No organisms were identified with special stains.

Anti-tuberculous therapy with rifampicin, isoniazid and pyrazinamide was started and 2 weeks after treatment, the patient reported a complete cessation in the development of new skin lesions. His skin remains in remission after 6 weeks of treatment.

Papulonecrotic tuberculid secondary to disseminated Mycobacterium avium complex

BACKGROUND

Papulonecrotic tuberculid is a rarely reported cutaneous reaction to the mycobacterium bacillus. It is most often encountered in association with tuberculosis. The clinical and histologic picture of the entity is a distinctive one, but the etiology of the disease process is uncertain. Therapy directed against the causative organism is dramatically successful.

METHODS

A 35-year-old white man with AIDS was referred to the Dermatology clinic for evaluation of a widespread skin eruption. The skin lesions were biopsied for histopathology and culture. From the cutaneous cultures Mycobacterium avium complex (MAC) organisms were grown.

RESULTS

We report the first case of papulonecrotic tuberculid manifestation in an AIDS patient with disseminated MAC. Unusual features seen in this case include the predominance of pruritic eschars rather than asymptomatic papules and the confirmation by special stains of mycobacterium organisms within the skin biopsy. Papulonecrotic tuberculid has not been previously associated with either MAC or AIDS.

CONCLUSIONS

Papulonecrotic tuberculid should be a diagnostic consideration in immunocompromised patients with MAC whose clinical and histologic features are compatible with this rare entity.

Papulonecrotic tuberculid in a 9-year-old American girl: case report and review of the literature

Papulonecrotic tuberculid is a rare cutaneous manifestation of tuberculosis that can also be associated with other mycobacteria. Clinically, it is an asymptomatic, recurrent eruption of papules with a necrotic center in a symmetric, acral distribution. Tubercle bacilli are not present in skin biopsies. The eruption resolves promptly with antituberculoid therapy. Few patients with this entity have been reported in the United States over the last 50 years. We report a 9-year-old, otherwise healthy, American girl whose sole initial findings were lesions of papulonecrotic tuberculid secondary to Mycobacterium tuberculosis.