• Users Online: 2434
  • Print this page
  • Email this page


 
  Table of Contents  
LETTER TO THE EDITOR
Year : 2019  |  Volume : 10  |  Issue : 6  |  Page : 729-731  

Ulcerative lupus vulgaris primarily involving the ear lobule


1 Department of Skin and STD, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Mawdiangdiang, Shillong, Meghalaya, India
2 Department of Pathology, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Mawdiangdiang, Shillong, Meghalaya, India

Date of Web Publication1-Nov-2019

Correspondence Address:
Binod Kumar Thakur
Department of Skin and STD, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Mawdiangdiang, Shillong - 793 018, Meghalaya
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/idoj.IDOJ_436_18

Rights and Permissions

How to cite this article:
Chhangte MZ, Thakur BK, Verma S, Dey B. Ulcerative lupus vulgaris primarily involving the ear lobule. Indian Dermatol Online J 2019;10:729-31

How to cite this URL:
Chhangte MZ, Thakur BK, Verma S, Dey B. Ulcerative lupus vulgaris primarily involving the ear lobule. Indian Dermatol Online J [serial online] 2019 [cited 2019 Nov 12];10:729-31. Available from: http://www.idoj.in/text.asp?2019/10/6/729/270216



Sir,

Lupus vulgaris (LV) is the most common clinical variant of cutaneous tuberculosis. It was first described by Erasmus Wilson in 1865.[1] Clinically, the early lesions of LV are characterized by soft reddish brown plaques with an 'apple jelly nodule' appearance on diascopy and in the later stages present with healing and scarring in one area and active disease in another.[2] The different forms of LV include plaque, ulcerative or mutilating, vegetating, tumor-like, and papular and nodular forms.[3] We report an unusual case of ulcerative type of LV of the ear lobe.

A 24-year-old girl presented to our department with ulceration of the left earlobe for 6 months. It started as a papule which slowly increased in size and broke down to form an ulcer. She did not give any history of trauma or ear piercing prior to the onset of the lesion. There was also no history of tuberculosis in the past or a family history of the same. There was no history suggestive of immunosuppression.

The cutaneous examination showed a well-defined ulcer of size 1 × 2 cm on the tip of the left earlobe [Figure 1]. The margins were undermined and the floor was covered with slough[Figure 2]. The surrounding skin was erythematous with mild scaling. The general and systemic examination was normal. A Mantoux test showed an induration of size 11 × 12 mm after 48 hours. Chest X ray was normal. PCR (Polymerase Chain Reaction) and BACTEC (Becton Dickinson Diagnostic Instrument Systems) tests were not done due to financial constraints.
Figure 1: An ulcer over the left ear lobe

Click here to view
Figure 2: The ulcer base shows slough with surrounding erythema

Click here to view


The histopathological examination of the skin biopsy showed ulceration of the epidermis and confluent epithelioid granulomas in the mid and deep dermis. The epithelioid granulomas showed minimal central caseous necrosis and peripheral palisades of histiocytes and lymphocytes [Figure 3] and [Figure 4]. However, Ziehl–Neelsen stain was negative for acid-fast bacilli. The features were consistent with granulomatous skin lesion. Other routine blood investigations were unremarkable. A final diagnosis of ulcerative LV was made due to the presence of caseating granulomas on histopathology and positive Mantoux test. The patient was treated with Cat 1 anti-tubercular treatment (ATT) under the Revised National Tuberculosis Control Programme which resulted in complete healing of the ulcer [Figure 5].
Figure 3: Epithelioid granuloma with minimal central caseous necrosis (H and E, 40×)

Click here to view
Figure 4: Epidermis is focally ulcerated with dermis showing confluent epithelioid granulomas (H and E, 4×)

Click here to view
Figure 5: The ulcer healed with scar formation after 6 months of anti-tubercular therapy

Click here to view


The ulcerative type of LV is uncommon and it is characterized by scarring and deformity. The mode of infection is thought to be endogenous or exogenous inoculation following minor trauma.[1] In India, the common sites of involvement are buttocks, thighs, and legs, whereas in the European population, the head and neck are most commonly involved.[4] In a study done in India, ulcerative type of LV was the least common (14.2%).[5] Case reports of LV affecting the face indicate that the cheeks and nose are the most frequently affected sites.[6] Although the pinna may be involved by contiguity from a cheek lesion, primary involvement of the ear lobe is extremely rare.[7],[8],[9],[10]

The above case reported here is unusual because of the exclusive involvement of the ear lobe and the occurrence in an immunocompetent girl without any past or family history of tuberculosis. Long-standing ulcerative LV in addition to scarring and deformity can lead to squamous cell carcinoma. Clinical dermatologists need to be aware of the myriad clinical presentations of this condition and make a correct diagnosis, and promptly treat as it can be disfiguring and destructive.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Thomas M, Antony M. Cutaneous lupus vulgaris: Bringing the wolf out of the darkness. Glob Dermatol 2014;1:39-44.  Back to cited text no. 1
    
2.
Lu Y, Wang H, Zheng H, Li X. Bilateral “turkey ear” as a cutaneous manifestation of lupus vulgaris. Indian J Dermatol Venereol Leprol 2018;84:687-9.  Back to cited text no. 2
[PUBMED]  [Full text]  
3.
Yates VM, Mycobacterial Infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 8th ed, vol. 2. New York: WileyBlackwell; 2013. p. 31-31.41.   Back to cited text no. 3
    
4.
Nair PA, Mehta MJ, Patel BB. Ulcerative lupus vulgaris over nose, leading to cosmetic deformity. Indian J Dermatol 2015;60:104.  Back to cited text no. 4
[PUBMED]  [Full text]  
5.
Gunawan H, Achdiat PA, Hindritiani R, Essary ED, Ningtias LD, Siregar EP, et al. Various cutaneous tuberculosis with rare clinical manifestations: A case series. Int J Mycobacteriol 2018;7:288-91.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Kaimal S, Aithal V, Kumaran MS, Abraham A. Cutaneous tuberculosis of the pinna: A report of two cases. Int J Dermatol 2013;52:714-7.  Back to cited text no. 6
    
7.
Campanelli CD, Santoro AF, Webster CG, Lee JB. Symmetrically distributed orange eruption on the ears: A case of lupus vulgaris. Cutis 2001;67:311-4.  Back to cited text no. 7
    
8.
O'Donovan WJ. Lupus vulgaris of the ear lobule. Proc R Soc Med 1921;14:64-5.  Back to cited text no. 8
    
9.
Okazaki M, Sakurai A. Lupus vulgaris of the earlobe. Ann Plast Surg 1997;39:643-6.  Back to cited text no. 9
    
10.
Baylan O, Arca E, Ozcan A, Kisa O, Albay A, Doganci L. Polymerase chain reaction based detection of Mycobacterium tuberculosis complex in lupus vulgaris: A case report. Int J Tuberc Lung Dis 2004;8:1147-50.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

Top
 
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    References
    Article Figures

 Article Access Statistics
    Viewed59    
    Printed0    
    Emailed0    
    PDF Downloaded7    
    Comments [Add]    

Recommend this journal