Article Text
PDF
Statistics from Altmetric.com
Description
A 78-year-old man complained of pruritic skin lesions over the trunk and all limbs and occasional fever for 3 months. He had papulonodular skin lesions with erythematous base involving anterior as well as posterior aspects of the trunk and all limbs with predilection for extensor surface (figure 1). Mantoux test was negative. Skin biopsy showed features of papulonecrotic tuberculid (figure 2) with a negative Mycobacterium tuberculosis PCR and acid-fast bacilli stain. CT scan of the chest and abdomen showed multiple, enlarged mediastinal and retroperitoneal lymph nodes (largest 2.4 cm). Trucut biopsy and immunohistochemistry from retroperitoneal node revealed features of classical Hodgkin’s lymphoma, nodular sclerosis variety with CD15 and CD30 positivity. In the absence of conclusive evidence of tuberculosis, he was treated with chemotherapy alone (oral prednisolone, etoposide, procarbazine and cyclophosphamide). Two months later, he is asymptomatic with partial resolution of skin lesions.
Papulonodular skin lesions with erythematous base involving lower limbs (A), upper limb (B), anterior as well as posterior aspect of trunk (C, D) with predilection for extensor surface. Inset (E) showing distinct papulonodular lesions.
(A) Skin biopsy showing wedge-shaped dermal necrosis with its broad base toward the epidermis and vasculitis, H&E ×40. (B) Skin biopsy showing vasculitis and interstitial granuloma with histiocytes, lymphocytes and few epithelioid cells, H&E × 400.
Papulonecrotic tuberculid possibly results from hypersensitivity to M. tuberculosis. Isolation of Mycobacterium from cultures as well as by PCR has been described in the previously reported cases.1 There has been evidence that antitubercular therapy is the treatment of this condition.2
Paraneoplastic skin lesions have been associated with Hodgkin’s lymphoma like icthyosis, acrokeratosis, urticaria, erythema multiforme and hyperpigmentation.3 However, there has not been any case report of Hodgkin’s lymphoma presenting with papulonecrotic tuberculid when searched on PubMed. In our case, there was clinical and histopathological evidence of both the diseases in the same individual.
Learning points
Papulonecrotic tuberculid is a rare manifestation of hypersensitivity to Mycobacterium tuberculosis.
In immunocompromised patient, the purified protein derivative test, acid-fast bacilli stain and culture all might be negative; however, typical histopathological features can clinch the diagnosis of papulonecrotic tuberculid.
Footnotes
Contributors KM, AJ, KN and PM were involved in patient care at various stages. KN prepared the histopathology slides. KM and AJ prepared the manuscript, while all authors read it and agreed to it.
Competing interests None declared.
Patient consent Obtained.
Provenance and peer review Not commissioned; externally peer reviewed.