Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters in Response to Previous Publication
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Net Letter
2014:80:4;381-381
doi: 10.4103/0378-6323.136995
PMID: 25035384

Borderline tuberculoid leprosy with scrofuloderma: An uncommon association

Sneha Ghunawat, Shivani Bansal, Bijaylaxmi Sahoo, Vijay Kumar Garg
 Department of Dermatology, Maulana Azad Medical College, New Delhi, India

Correspondence Address:
Sneha Ghunawat
C-3 Tower 10, New Moti Bagh, New Delhi - 110 023
India
How to cite this article:
Ghunawat S, Bansal S, Sahoo B, Garg VK. Borderline tuberculoid leprosy with scrofuloderma: An uncommon association. Indian J Dermatol Venereol Leprol 2014;80:381
Copyright: (C)2014 Indian Journal of Dermatology, Venereology, and Leprology

Sir

The incidence of pulmonary tuberculosis with leprosy varies from 2.5-7.7% in India to 13.4% in South America. [1] However, the simultaneous occurrence of leprosy and cutaneous tuberculosis is uncommon.

A 70-year-old male presented to us with complaints of pain and limitation of movement of the right shoulder joint for two years. A few months ago, he noticed a single non-healing sinus with yellowish colored discharge in the middle of the right arm.

On dermatological examination, a single sinus with puckered scarring overlying a hypoaesthetic macule of size 5 Χ 7 cm was noted on the lateral aspect of the right midarm [Figure - 1]a. No regional lymphadenopathy was observed. On further examination, multiple well- to ill-defined hypopigmented macules were observed on the trunk and extremities [Figure - 1]b with ill-defined borders, dry surface and sparseness of hair. The sensations of temperature, pin prick and superficial touch were impaired over these lesions. Movement of the right shoulder joint was limited beyond 30 degrees of abduction. The ulnar nerves were firm, non-tender and enlarged on both sides.

Figure 1: (a) Single non-healing sinus present over a hypopigmented macule, (b) Multiple hypopigmented macules on the limb

All hematological and biochemical investigations were within normal limits except the erythrocyte sedimentation rate which was 26 mm at the end of the first hour. Slit skin smear from the hypopigmented, hypoesthetic macules did not show any acid-fast bacilli. Mantoux test reading was 26 mm induration after 48 hours. Radiological examination of chest was normal, whereas X-ray of the right shoulder joint showed a lytic lesion in the head of humerus with an overlying cortical breach [Figure - 2]a. Sinogram obtained by injecting radio opaque dye through the opening of the cutaneous sinus delineated a communicating path between the skin lesion and the underlying bone [Figure - 2]b.

Figure 2: (a) X-ray PA view of the right shoulder showing a lytic lesion in the head of humerus, (b) Sinogram delineating the communicating path between the sinus and the underlying bone

Histopathological examination from the hypopigmented lesion below the discharging sinus revealed an epithelioid cell granuloma with lymphocytic infiltrate [Figure - 3]a. Fite Faraco stain did not show acid-fast bacilli. Histopathological evaluation from the wall of the sinus tract revealed a granuloma in the mid-dermis composed of epithelioid giant cells, lymphocytes and plasma cells with evidence of suppuration [Figure - 3]b. However, tissue polymerase chain reaction and culture for Mycobacterium tuberculosis were negative. Bone biopsy from the lytic lesion in the humerus revealed a tuberculoid granuloma with caseous necrosis [Figure - 3]c. No acid-fast bacilli were found in the wall of the sinus on Ziehl Neelsen staining.

Figure 3: (a) Epithelioid cell granuloma with lymphocytic infiltrate. (H and E, ×100), (b) Biopsy from the sinus tract wall showing epithelioid granuloma located in the mid dermis. (H and E, ×100), (c) Well-defined granuloma with caseous necrosis seen in the bone marrow (H and E, ×100)

Based on the clinical and histopathological findings, a diagnosis of borderline tuberculoid leprosy with scrofuloderma was made. World Health Organisation Directly Observed Therapy- Short course (DOTS) Category I anti-tubercular therapy along with multibacillary multidrug therapy (MB-MDT) for leprosy (except the monthly supervised dose of rifampicin) was prescribed for a duration of one year.

The relationship of leprosy and tuberculosis is enigmatic. The simultaneous occurrence of the two infections has been argued against due to a number of reasons. Firstly, both the diseases share many similarities in that both are caused by gram positive, acid fast mycobacteria and are characterized histopathologically by a granulomatous inflammatory response. The 65 kilodalton antigens of M. leprae, M. tuberculosis and M. bovis display greater than 95% homology in amino acid sequence as evidenced by conversion of both lepromin and tuberculin intradermal test after injection of bacillus Calmette-Guerin (BCG). [2] Lastly, the higher reproductive rate of the tubercular bacilli as compared to lepra bacilli does not allow both infections to occur simultaneously. [3] However, a few case reports [Table - 1] [4],[5],[6],[7] including the present one clearly illustrate that if at all there exists cross immunity between the two bacilli, it is only partial and the two bacilli can co-exist by eliciting specific cell mediated immunity mediated by different sub-populations of CD4/CD8 cells. [7]

Table 1: Reports of concurrent occurrence of cutaneous tuberculosis with leprosy

Dixit et al., [6] reported a 65-year-old woman with borderline lepromatous leprosy who developed multiple discharging tubercular sinuses while on steroid therapy for type 1 reaction. This case emphasizes the need to recognize both infections because steroid therapy for reaction in leprosy may exacerbate underlying tuberculosis. In addition, monthly dosing of rifampicin in leprosy may contribute to acquired drug resistance and reduced effectiveness if there is concurrent tuberculosis.

Our case of dual infection with M. leprae and M. tuberculosis is of particular interest because the lesion of one disease presented directly over the lesion of the other.

References
1.
Singh M, Kaur S, Kumar B, Kaur I, Sharma VK. The associated diseases with leprosy. Indian J Lepr 1987;59:315-21.
[Google Scholar]
2.
Kumaran MS, Dogra S, Kaur I, Kumar B. Lichen scrofulosorum in a patient with lepromatous leprosy after BCG immunotherapy. Lepr Rev 2005;76:170-4.
[Google Scholar]
3.
Ravindra K, Sugareddy, Ramachander T. Coexistance of borderline tuberculoid Hansen's disease with tuberculosis verrucosa cutis in a child-a rare case. Indian J Lepr 2010;82:91-3.
[Google Scholar]
4.
Patki AH, Jadhav VH, Mehta JM. Leprosy and multicentric lupus vulgaris. Indian J Lepr 1990;62:368-70.
[Google Scholar]
5.
Pinto J, Pal GS, Kamnath N. Cutaneous tuberculosis with Leprosy. Indian J Dermatol Venereol Leprol 1991;57:303-4.
[Google Scholar]
6.
Dixit VB, Pahwa US, Sen J, Jain VK, Sen R. Cold abscesses and scrofuloderma in patient with lepromatous leprosy. Indian J Lepr 1991;63:101-2.
[Google Scholar]
7.
Rao GR, Sandhya S, Sridevi M, Amareswar A, Narayana BL, Shantisri. Lupus vulgaris and borderline tuberculoid leprosy: An interesting co-occurrence. Indian J Dermatol Venereol Leprol 2011;77:111.
[Google Scholar]

Fulltext Views
214

PDF downloads
136
Show Sections