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87 (
4
); 562-565
doi:
10.25259/IJDVL_1008_20
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Lupus vulgaris masquerading as tumorous growth

Department of Dermatology and Venereology, AIIMS, Bhubaneswar, Odisha, India
Department of Surgery AIIMS, Bhubaneswar, Odisha, India
Department of Pathology, AIIMS, Bhubaneswar, Odisha, India
Corresponding author: Dr. Chandra Sekhar Sirka, Department of Dermatology and Venereology, AIIMS, Bhubaneswar, Sijua, Patrapada - 751 019, Odisha, India. csirka2006@gmail.com
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How to cite this article: Sirka CS, Rout AN, Kumar P, Purkait S. Lupus vulgaris masquerading as tumorous growth. Indian J Dermatol Venereol Leprol 2021;87:562-5.

Sir,

Lupus vulgaris is the most common form of cutaneous tuberculosis in adults in India. Various clinical forms described include plaque-like, ulcerative, hypertrophic, vegetative, papular and nodular forms.1 Tumor-like and bulbous lesions have been described rarely in the literature.2-8 We report a case of lupus vulgaris which had resulted in tumorous transformation and distortion of the toes, causing confusion and delay in diagnosis and treatment leading to chronicity of the lesion and deformity.

A 47-year-old male cook was referred to our outpatient department with tumor-like swellings on the distal right foot for 15 years. There was no history of trauma to the limb or any history of tuberculosis among close contacts. He had taken various medications with no improvement. The lesion started as redness and swelling of his second toe initially, following which in a few months, the toe got deformed and areas of depigmentation and verrucosity were visible [Figure 1a]. The lesions on the other parts started as nodules which enlarged and coalesced to form larger plaques [Figures 1b and c]. The bulbous swelling of the toes with a narrow base produced a pedunculated appearance. Few plaques spontaneously healed over a few months leaving atrophic and puckered scars [Figure 1a]. There were no palpable lymph nodes or any systemic symptoms. Based on these clinical features and evolution, possibilities of lupus vulgaris, chromoblastomycosis and cutaneous malignancy were considered.

Figure 1a:: Gross swelling with the fleshy tumor-like transformation of the toes
Figure 1b:: Surface of the toes showing areas of verrucosity; nails visible on each of the toe
Figure 1c:: Lateral view showing verrucosity on the surface of the nodular lesions and erythematous plaques with verrucosity

Hematological tests, renal and liver function tests were within normal limits. Screening for HIV was negative. The Mantoux test was positive (18 mm). X-ray of the chest was normal. X-ray of the feet showed distorted phalanx bones [Figure 1d]. The Erythrocyte sedimentation rate was 60 mm in 1st h. Biopsy from the lesion showed features suggestive of lupus vulgaris [Figures 2a-c]. Based on the clinical and laboratory findings, he was started on antitubercular therapy. After 6 months, there was an improvement in the verrucous part but leg swelling with smooth scars persisted [Figures 3a-c]. He was referred to the department of plastic surgery for reconstructive surgery.

Figure 1d:: X-ray of the right foot showing grossly distorted toes bones
Figure 2a:: Scanner view showing hyperkeratotic and acanthotic epidermis and the presence of multiple granulomas in deep dermis (H&E, ×40)
Figure 2b:: High power view showing epithelioid cell granuloma with Langhans type giant cells and lymphohistiocytic infiltration in the surrounding area (H&E, ×400)
Figure 2c:: Modified Ziehl–Neelsen stain showing acid-fast bacilli (Modified ZN, ×1000)
Figure 3a:: Healing in the form of complete improvement of the surface verrucosity
Figure 3b:: Healing in the form of complete improvement of the surface verrucosity
Figure 3c:: Healing in the form of complete improvement of the surface verrucosity

The morphological presentation of lupus vulgaris is variable, thus, causing a diagnostic dilemma many times. The rare presentations include nodular, vegetating and papular forms.1

However, lupus vulgaris presenting as tumor-like and bulbous lesions is rare.2-8 [Table 1] In all the previously reported cases, tumor-like lesions were studded over the plaques of lupus vulgaris lesions, whereas in the present case, swelling and distortion of the toes had resulted in a nodular and bulbous look; which is evident from the presence of nail in each tumor-like growth and X-ray showing distorted phalanges and the toe bones.

Table 1:: Table enlisting tumor-like morphological presentations of lupus vulgaris
Serial number Authors Morphology
1 Garg et al.2 28-year female
shiny erythematous plaque 3×2 cm with central atrophy and scarring on the face
Multiple shiny nontender soft papules arranged in annular configuration
discrete papules and nodules with adherent fine scaling bilaterally on the Alar prominence of the nose, lower lip and postauricular area
Diascopy apple jelly nodule
2 Pilani et al.3 28-year-old female, laborer
Progressive annular plaque over the right side of cheek extending up to right lower lid and ala of nose
Two satellite plaques near the right side of giant lesion
Diascopy apple jelly nodule
3 Lu et al.4 47 years female
Massively enlarged earlobe with bluish-red or violaceous indurated plaques and nodules, with edema and ulceration
4 Gunawan et al.5 15 years female
Erythematous plaque on the cheek and erythematous nodule on the index finger of the left hand
Diascopy test(“apple jelly” sign): negative
Multifocal skeletal TB(vertebrae and knee joint)
5 Hruza et al.6 69-year-old male
Scattered, grouped, asymptomatic follicular papules, pustules, and nodules tending toward coalescence into large geographic aggregates
6 Kempter et al.7 61-year-old patient
25-year history of erythematous scaling lesions, wrongly diagnosed and treated as psoriasis vulgaris
Nodular growth within the erythematous plaque
7 Bräuninger et al.8 74 years female
Nodular infiltrations and confluating tumors

TB: tuberculous

Diagnosis is mostly confirmed from raised erythrocyte sedimentation rate, lymphocytosis, positive Mantoux test and histology suggestive of tuberculoid granuloma. In the present case, the biopsies from the plaques and nodular looking lesion were suggestive of tuberculosis and he had raised erythrocyte sedimentation rate and positive Mantoux test.

Morphological differentials include squamous cell carcinoma, chromoblastomycosis and mycosis fungoides; however, the presence of tuberculoid granuloma on the biopsy can differentiate lupus vulgaris from other conditions.

A therapeutic trial of triple antituberculosis therapy: isoniazid, rifampicin and pyrazinamide may be considered in cases where the diagnosis is difficult. A clinical response would be expected within 4–6 weeks.9 In our case also the lesions showed improvement in the verrucous parts in 6 months.

We report a case of lupus vulgaris which had resulted in tumorous transformation and distortion of the toes, which had caused confusion and delay in diagnosis and led to the chronicity of the lesion and deformity, even in today’s era.

From the present case, we would like to suggest that lupus vulgaris on feet may masquerade as a tumor due to swelling and deformity of the toes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

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