A report describes a case of a 17-year-old girl with asymptomatic, slowly progressing lesions with a bilateral presentation on the submandibular areas, neck, anterior chest, axillae, back and occipital area, firstly noticed 5 to 6 years back, which was initially a small papule.

Examination revealed a well-defined, hypopigmented, large plaque of dimension 45 × 30 cm approximately with central atrophy, telangiectasia and islands of normal-appearing skin. The periphery was gyrate with crusted, verrucous like lesions and erythema. The left axillary region and submandibular region showed scarring suggesting the previous adenitis. She took some medication for the same whose details were not available.

The hemogram and biochemical investigations were normal but for relative lymphocytosis and increased erythrocyte sedimentation rate of 70 mm in the first hour. The Mantoux test was found to be strongly positive with a 17 mm induration in greatest diameter. Chest X-ray findings were not significant. Cough and sputum were not present and acid-fast bacilli (AFB) were also found to be negative. Enzyme-linked immunosorbent assay (ELISA) for HIV and polymerase chain reaction for Mycobacterium tuberculosis were also negative. 

Histopathological features of the peripheral crusted lesion showed hyperkeratosis, acanthosis and papillomatosis. Tuberculoid granulomas including epithelioid and Langhans giant cells were observed primarily in the upper dermis, along with lymphocytic infiltrate. AFB staining for tubercle bacilli was also negative.

The large plaque size and rapid progression prompted her for category I antitubercular treatment under DOTS. 2HRZE₃, isoniazid, rifampicin, pyrazinamide and ethambutol in a thrice-weekly dose for 2 months followed by 4HR₃ thrice-weekly for 4 months was initiated. Follow-up after 3 months of therapy revealed nearly 90% clearance of the lesions.

Source: Goyal T, Varshney A, Bakshi SK. Lupus vulgaris in a young girl. Ann Saudi Med. 2013;33(4):404-6.