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Papulonecrotic Tuberculids Workup

  • Author: Manuel Valdebran, MD; Chief Editor: William D James, MD  more...
 
Updated: Jan 12, 2015
 

Laboratory Studies

Patients should be evaluated for evidence of active tuberculosis or other forms of mycobacterial infection. Tuberculous involvement of the female genital tract may account for the increased incidence in females, and a culture of menstrual fluid and endometrial biopsy may be of value in excluding occult disease.

CBC count, chemistry panel, and urinalysis should be performed.

The erythrocyte sedimentation rate is often very high and can be used to monitor treatment. It decreases 4-6 weeks after treatment is started.

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Imaging Studies

Chest radiography is needed to rule out active or past pulmonary tuberculosis. Abdominal radiographs may show lymph node calcifications typical of tuberculosis.

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Other Tests

Purified protein derivative (PPD) intradermal skin tests are usually strongly positive. Some authors require this result for diagnosis. However, false-negative negative results can occur in the setting of immunosuppression.

QuantiFERON®-TB Gold test can also be used to confirm latent tuberculosis infection, avoiding the risk of severe skin reactions that may occur with PPD testing.[12]

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Histologic Findings

The histologic features vary with the timing of the biopsy. In an early lesion, evidence of a vasculitis, which is typically leukocytoclastic with fibrinoid necrosis of the vessel wall and karyorrhectic debris, should be present. However, some authors have found that the primary lesion consists of lymphohistiocytic, rather than leukocytoclastic, vasculitis. It has been reported as a constant finding in a series of cases the presence of a psoriasiform epidermal hyperplasia.[2]

Characteristic of the disorder is the presence of perivascular spongy edema. Later, because of the obliterative vascular changes, a wedge-shaped area of focal dermal necrosis develops, surrounded by a granulomatous inflammatory infiltrate with giant cells and epithelioid histiocytes. Well-formed tuberculoid granulomas with Langerhans giant cells are not usually present in the lesions. Special stains for mycobacteria are typically negative.

The histologic differential diagnosis depends on the timing of the biopsy as well as the histologic appearance. In particular, inflammatory palisading granulomas (ie, granuloma annulare and infectious granulomas) may look similar as compared to those found occasionally in papulonecrotic tuberculid. However, the ability to exclude mucin and infectious organisms in effect rules out granuloma annulare and infectious granulomas, respectively.[13]

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Contributor Information and Disclosures
Author

Manuel Valdebran, MD Visiting Dermatopathology Fellow, University of California, San Francisco, School of Medicine

Manuel Valdebran, MD is a member of the following medical societies: International Dermoscopy Society, Medical Dermatology Society, Society for Pediatric Dermatology

Disclosure: Nothing to disclose.

Coauthor(s)

Dirk M Elston, MD Professor and Chairman, Department of Dermatology and Dermatologic Surgery, Medical University of South Carolina College of Medicine

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Specialty Editor Board

Michael J Wells, MD, FAAD Associate Professor, Department of Dermatology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine

Michael J Wells, MD, FAAD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, Texas Medical Association

Disclosure: Nothing to disclose.

Lester F Libow, MD Dermatopathologist, South Texas Dermatopathology Laboratory

Lester F Libow, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, Texas Medical Association

Disclosure: Nothing to disclose.

Chief Editor

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology, Society for Investigative Dermatology

Disclosure: Nothing to disclose.

Acknowledgements

David Barnette Jr, MD Voluntary Associate Clinical Professor, University of California San Diego School of Medicine

David Barnette Jr, MD is a member of the following medical societies: American Academy of Dermatology and American Society of Dermatopathology

Disclosure: Nothing to disclose.

Robert L Chen, MD, PhD Instructor, Department of Medicine, Section of Dermatology, University of Chicago Medical Center

Robert L Chen, MD, PhD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Dermatology Foundation, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

References
  1. Darier MJ. Des "tuberculides" cutanees. Ann Dermatol Syph. 1896. 7:1431-36.

  2. Tirumalae R, Yeliur IK, Antony M, George G, Kenneth J. Papulonecrotic tuberculid-clinicopathologic and molecular features of 12 Indian patients. Dermatol Pract Concept. 2014 Apr. 4(2):17-22. [Medline]. [Full Text].

  3. Sloan JB, Medenica M. Papulonecrotic tuberculid in a 9-year-old American girl: case report and review of the literature. Pediatr Dermatol. 1990 Sep. 7(3):191-5. [Medline].

  4. Iden DL, Rogers RS 3rd, Schroeter AL. Papulonecrotic tuberculid secondary to Mycobacterium bovis. Arch Dermatol. 1978 Apr. 114(4):564-6. [Medline].

  5. Freiman A, Ting P, Miller M, Greenaway C. Papulonecrotic tuberculid: a rare form of cutaneous tuberculosis. Cutis. 2005 Jun. 75(6):341-6. [Medline].

  6. Morrison JG, Fourie ED. The papulonecrotic tuberculide. From Arthus reaction to lupus vulgaris. Br J Dermatol. 1974 Sep. 91(3):263-70. [Medline].

  7. Senol M, Ozcan A, Aydin A, Karincaoglu Y, Sasmaz S, Sener S. Disseminated lupus vulgaris and papulonecrotic tuberculid: case report. Pediatr Dermatol. 2000 Mar-Apr. 17(2):133-5. [Medline].

  8. Milligan A, Chen K, Graham-Brown RA. Two tuberculides in one patient--a case report of papulonecrotic tuberculide and erythema induratum occurring together. Clin Exp Dermatol. 1990 Jan. 15(1):21-3. [Medline].

  9. Thappa DM, Karthikeyan K, Jayanthi S. Tuberculid in a child: transformation from papulonecrotic to lichen scrofulosorum. Pediatr Dermatol. 2003 Jan-Feb. 20(1):91-3. [Medline].

  10. Asiniwasis R, Dutil MT, Walsh S. Molluscum-Like Papules as a Presentation of Early Papulonecrotic Tuberculid in Association with Nodular Tuberculid in a Male with Asymptomatic Active Pulmonary Tuberculosis. J Cutan Med Surg. 2014 Aug 1. 18(0):1-4. [Medline].

  11. Chalermdamrichai P, Puavilai S, Jerasutus S, Boonsarngsuk V, Kiattboonsri S, Suwatanapongched T. Sarcoidosis presenting as papulonecrotic tuberculid-like lesions: report of a case. J Med Assoc Thai. 2004 Jul. 87(7):839-44. [Medline].

  12. Sim JH, Whang KU. Application of the QuantiFERON®-TB Gold test in erythema induratum. J Dermatolog Treat. 2014 Jun. 25(3):260-3. [Medline].

  13. Puri N. A clinical and histopathological profile of patients with cutaneous tuberculosis. Indian J Dermatol. 2011 Sep-Oct. 56(5):550-2. [Medline]. [Full Text].

  14. [Guideline] World Health Organization. Recommendations for Investigating Contacts of Persons with Infectious Tuberculosis in Low- and Middle-Income Countries. Available at http://apps.who.int/iris/bitstream/10665/77741/1/9789241504492_eng.pdf. Accessed: October 23, 2014.

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Bilaterally symmetric papulonecrotic lesions on the lower extremities.
 
 
 
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