|Year : 2013 | Volume
| Issue : 1 | Page : 30-32
Solitary lupus vulgaris of pinna: A rare presentation
Shweta Gogia, Alok Agarwal
Department of ENT, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi, India
|Date of Web Publication||6-Mar-2013|
House no. 19, New Rohtak Road, Karol Bagh, New Delhi - 110 005
Source of Support: None, Conflict of Interest: None
Lupus vulgaris is a rare manifestation of infection by Mycobacterium tuberculosis. Isolated involvement of the pinna is a rare clinical presentation, which can be a diagnostic dilemma. We present a case of a 35-year-old male who presented with a chronic, non-healing ulceration of the helical margin of the pinna, without any other sites of involvement. The histopathological evaluation of the lesion, led to the diagnosis of tuberculosis. The patient was given antitubercular regimen for six months, to which he responded with complete resolution of symptoms.
Keywords: Lupus vulgaris, Pinna, Tuberculosis
|How to cite this article:|
Gogia S, Agarwal A. Solitary lupus vulgaris of pinna: A rare presentation. Indian J Otol 2013;19:30-2
| Introduction|| |
The incidence of extra-pulmonary mycobacterium disease is on rise in many regions throughout the world.  Despite this it still remains an under diagnosed entity due to uncommon clinical presentations. Lupus vulgaris is the most common variant of cutaneous tuberculosis.  Solitary involvement of the pinna is rare and may present the clinician with a diagnostic dilemma. We here present a case of a 35-year-old male who presented with non-healing ulceration involving the right pinna for the past two years. The patient was investigated and diagnosed as tuberculosis of skin, and was subsequently treated with antitubercular regimen. The patient had complete resolution of symptoms and the normal contour of the were pinna restored after the completion of the therapy.
| Case Report|| |
A 35-year-old male presented to us with non-healing ulcer involving the helical margin and lobule of the right pinna for two years. The lesion was gradually progressive and associated with crusting and purulent discharge which was occasionally bloodstained. There was no preceding history of trauma to the ear or any other lesion on the ear. There was no history of any systemic illness in the past. The patient had received treatment in the form of antibiotics and local applications, but had no signs of improvement.
Physical examination revealed ulceration with crusting involving the entire helical margin and lobule of the right pinna. The ulcers were covered with blood clots and crusts. On careful removal of the crusts, granulations were seen, which bled on touch [Figure 1]. Rest of the external auditory canal and tympanic membrane was normal. The other ear was unremarkable. His general physical examination was normal. No similar lesion was seen anywhere else in the body.
|Figure 1: Ulceration involving the helical margin of the right pinna with slough-covered areas|
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The patient was taken up for routine hematological and biochemical examination, which was within normal limits. Tuberculin test at 48 h, using purified protein derivative was positive (17 mm × 14 mm-listeria type of reaction). Chest X-ray was normal. Eventually, incisional biopsy was done, which revealed epitheloid granuloma with caseation necrosis [Figure 2]. Culture of tissue, using direct fluorescent rapid culture (MB-3D) was negative. Enzyme linked immunosorbent assay (ELISA) for antitubercular immunoglobulin M (Ig M) was also done, in view of the negative culture report, which was found to be reactive in 1:200 dilutions. Thereby, the diagnosis was established to be that of tuberculosis.
|Figure 2: Histological slide showing a granuloma with giant cells and areas of necrosis suggestive of tuberculosis|
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The patient was started on antitubercular treatment which included isoniazid (300 mg), rifampicin (450 mg), pyrazinamide (1500 mg) and ethambutol (1200 mg) for two months. This was followed by isoniazid (300 mg) and rifampicin (450 mg) for four months. The patient had complete cure and resolution of the symptoms after the completion of the anti-tubercular regimen.
| Discussion|| |
The incidence of cutaneous tuberculosis in India has declined considerably in the past decade as a result of improvement in the standard of living, and stringent control measures adopted under the National Tuberculosis control program.  However, due to varied clinical forms which can present in atypical sites, this remains a misdiagnosed entity leading to delay in treatment. Lupus vulgaris is a progressive from of cutaneous tuberculosis. The characteristic lesion is a plaque composed of nodules of apple jelly color, which extends irregularly in some areas, while in others scarring occurs, causing considerable tissue destruction over many years.  In tropical countries including India, the sites of predilection are the buttocks and trunk.  As a result, tuberculosis is not usually considered in the differential diagnosis of cutaneous lesions involving the pinna and may present the clinician with a diagnostic dilemma. The head and neck are reported to be the most favored sites for lupus vulgaris in Western countries. 
Lupus vulgaris is a post-primary form of skin tuberculosis arising in previously sensitized individuals with only moderate immunity. It is caused by a re-infection of the skin with mycobacterium, exogenously or endogenously by hematological or lymphatic spread.  The lesion is usually solitary, but not uncommonly more than one site can be involved. The initial lesion is the lupus macula or papule, characterized by a brownish red color and a soft consistency. Gradual formation of larger patches is formed by peripheral enlargement and coalescence of smaller papules. The course of the disease is marked by ulceration and scarring, thus its clinical manifestations are diverse and a number of complications may occur. The ulcerative form of the disease is characterized by progressive necrosis and extensive obstruction. The granulation, which develops at the floor of the ulcer, leads to a vegetating papillomatous lesion. Scarring is a prominent feature of lupus vulgaris. Sometimes scarring with excessive deformations and mutilation is very prominent and keloid-like fibrosis may lead to disfigurement. Lupus vulgaris is chronic and without therapy its course usually leads to considerable disfigurement. The most dreaded complication of longstanding lupus vulgaris is malignant transformation of lesion. 
The diagnosis of lupus vulgaris is challenging due to the fact that the disease presents in varied forms with considerable morphological variability. Histopathology is an important tool in the diagnosis of the disease. Other modalities, which can support the diagnosis, include the culture of the tissue, ELISA for antitubercular-IgM, and polymerase chain reaction for DNA identification of Mycobacterium tuberculosis. 
| Conclusion|| |
In the above reported case, the nature of the lesion, which was frank ulcerative, caused a diagnostic dilemma. This being an unusual presentation, lupus vulgaris was not being considered as a probable diagnosis.
The histopathological report of the lesion was pivotal in establishing the diagnosis, and hence directing the treatment of the lesion. Since the culture for acid-fast bacilli was negative the diagnosis was established using ELISA for antitubercular IgM.
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[Figure 1], [Figure 2]