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CASE REPORT
Year : 2012  |  Volume : 13  |  Issue : 1  |  Page : 41-43

Perforation of nasal septum secondary to lupus vulgaris: A rare entity


Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh, India

Date of Web Publication23-Oct-2012

Correspondence Address:
Amrinder J Kanwar
Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


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  Abstract 

Lupus vulgris (LV) is a chronic, progressive, and destructive form of cutaneous tuberculosis. This occurs in moderate- to high-immunity patients against Mycobacterium tuberculosis, which a shows strongly positive Mantoux test. We present a case of LV located on the nose of a 14-year-old girl that led to nasal septal perforation. In this modern era of antibiotics, septal perforation secondary to LV is very rare.

Keywords: Cutaneous tuberculosis, nasal septum perforation


How to cite this article:
Kumar R, Agrawal S, Kanwar AJ. Perforation of nasal septum secondary to lupus vulgaris: A rare entity. Indian J Paediatr Dermatol 2012;13:41-3

How to cite this URL:
Kumar R, Agrawal S, Kanwar AJ. Perforation of nasal septum secondary to lupus vulgaris: A rare entity. Indian J Paediatr Dermatol [serial online] 2012 [cited 2019 Feb 19];13:41-3. Available from: http://www.ijpd.in/text.asp?2012/13/1/41/102813


  Introduction Top


Tuberculosis (TB) is a major health problem in developing countries. Tubercular infection could be pulmonary and extrapulmonary. The proportion of childhood TB (≤16 years) (CTB) has been found to be 18.7% of all cases of CTB, with lupus vulgris (LV) accounting for 40% of all cases. [1]


  Case Report Top


A 14-year-old girl presented with a 3-year history of a slowly progressing, asymptomatic, red-purple, raised lesion over the right side of the nose. Similar lesions developed in the surrounding areas and they coalesced to form plaque, resulting in destruction of the right ala nasi and nasal septal perforation since the last 1 year. She received topical and oral antibiotics. There was no history of nose piercing. There was no personal and family history of TB. History of fever, weight loss and cough was not present. She had received Bacille Calmette Guerin (BCG) vaccine.

On cutaneous examination, there was an erythematous, 3 cm × 4 cm plaque studded with multiple erythemato-violaceous papulonodular lesions predominantly over the tip and right side of the nose with destruction of the right ala nasi and around 6 mm nasoseptal perforation [Figure 1] and [Figure 2]. Nasoseptal perforation patency was positive by translumination.
Figure 1: Erythematous to yellowish plaque

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Figure 2: Nasal septal perforation with overlying papules

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The plaque showed "apple-Jelly" nodules under diascopy. Mantoux test was strongly positive with a 25 mm×25 mm area of induration with central vesiculation and necrosis. Laboratory investigation including complete hemogram and chest X-ray, and liver and renal function test and angiotensin convertase enzyme (ACE) level were normal, but ESR was raised (56 mm/h). Computed tomography scan showed perforation of the cartilaginous septum [Figure 3]. A biopsy was done from the margin of the perforated nasal septum and nodule present over the nose. Biopsy from sites revealed numerous epitheloid cell granuloma along within few giant cells. Stain for acid fast bacilli (AFB) was negative and cultures revealed no growth.
Figure 3: Computed tomography scan showing nasal septal perforation (arrow), enlarged view in inset

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Based on clinical examination, histopathology and strongly positive Mantoux test, a diagnosis of LV was made. The patient was started on antitubercular treatment (ATT) by initial 2-month intensive phase four-drug regimen of isoniazid (300 mg), rifampicin (450 mg), ethambutol (800 mg) and pyrazinamide (1000 mg), followed by 4-month of continuation phase with isoniazid and rifampicin. The patient had significant improvement in cutaneous lesion after 4 months of treatment and is still on ATT [Figure 4].
Figure 4: Resolution of lesions after 4 months of antitubercular treatment

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  Discussion Top


LV is the most common type of CTB, with an average prevalence of 0.37% among dermatology cases. [2] LV is two-times more common in females than in males, and is common in northern climates while being rare in tropics because it needs a moist and cold environment. [3] Head and neck are most commonly involved in Europeans, while in Indians, the trunk in adults and gluteal region and extremities in children are the most commonly involved. [4]

Lesion may appear on previous normal skin by hematogenous or lymphatic spread from distant tuberculos foci, at the site of BCG vaccination, primary traumatic inoculation or prior scrofuloderma. [5],[6],[7] As the mucocutaneous junction of the nasal septum is the most common site of trauma due to nose rubbing and picking, here the bacilli inoculation is common. Later on, disease may spread inwards to involve the nasal mucosa, and mainly effects the anterior cartilaginous part of the septum. [3]

Central healing with atrophy and peripheral extension is characteristic of LV lesions. Various types of LV are plaque, ulcerative/mutilating, tumor-like, vegetating, papulo-nodular forms. Unusual variants reported are annular from sporotrichoid and necklace form. [5],[8] Histopathology shows tuberculoid granulomas and Langerhen's giant cells without or with slight caseation necrosis. In chronic lesions, fibrosis may be seen. Bacilli are difficult to demonstrate. Diagnosis can be confirmed by polymerase chain reaction (PCR), and the sensitivity of PCR ranges from 50 to 72% in different studies. [9]

Several dematosis that should be differentiated from LV are discoid lupus erythematosus, sarcoidosis (Lupus pernio), lupoid leishmaniasis, tuberculoid leprosy, syphilitic gumma/tertiary syphilis, deep fungal infection, psuedolymphoma, Wegener's granulomatosis, granulomatous rosacea, necrobiotic xanthogranuloma, psoriasis and Bowen's disease. [5],[8]

A review of 74 patients with nasal septum perforation by Baril et al. showed 35 (47%) to be idiopathic, 29 (39%) due to trauma, eight (11%) due to inflammatory and two (3%) due to infectious causes. [10] There have been very few case reports of nasal septal perforation secondary to LV. [11],[12],[13]

According to the CDC recommendation, treatment of LV is divided into two phases. The initial intensive phase, lasting for 2 months, consists of four drugs: isoniazid (5 mg/kg), rifampicin (10 mg/kg), ethambutol (15 mg/kg) or streptomycin (15 mg/kg) and pyrazinamide (25 mg/kg); in the maintenance phase, two drugs are involved: rifampicin and isoniazid given daily, thrice or twice weekly for 4 months. [14]

Cutaneous tuberculosis is infrequently diagnosed entity mainly due lack of awareness on the part of the patient as well as the clinicians. Early diagnosis of LV, especially over the head and neck region, is important for prevention of any irreversible functional and cosmetic disfigurement.

 
  References Top

1.Kumar B, Rai R, Kaur I, Sahoo B, Muralidhar S, Radotra BD. Childhood cutaneous tuberculosis: A study over 25 years from Northern India. Int J Dermatol 2001;40:26-32.  Back to cited text no. 1
    
2.Khandpur S, Reddy BS. Lupus vulgaris: unusual presentations over the face. J Eur Acad Dermatol Venereol 2003;17:706-10.   Back to cited text no. 2
[PUBMED]    
3.Weir N, Golding-Wood DG. Infective rhinitis and sinusitis. In: Mackay IS, Bull TR, editors. Scott-Brown's Otolaryngology. 6 th ed. Oxford: Butterworth-Heinemann; 1997. p. 4/8/1-.4/8/49.   Back to cited text no. 3
    
4.Ramesh V, Misra RS, Beena KR, Mukherjee A. A study of cutaneous tuberculosis in children. Pediatr Dermatol 1999;16:264-9.   Back to cited text no. 4
[PUBMED]    
5.Barbagallo J, Tager P, Ingleton R, Hirsch RJ, Weinberg JM. Cutaneous tuberculosis: diagnosis and treatment. Am J Clin Dermatol 2002;3:319-28.   Back to cited text no. 5
[PUBMED]    
6.Kaur C, Sarkar R, Kanwar AJ. How safe is nose-piercing? Inoculation cutaneous tuberculosis revisited. Int J Dermatol 2003;42:645-6.   Back to cited text no. 6
[PUBMED]    
7.Motta A, Feliciani C, Toto P, De Benedetto A, Morelli F, Tulli A. Lupus vulgaris developing at the site of misdiagnosed scrofuloderma. J Eur Acad Dermatol Venereol 2003;17:313-5.   Back to cited text no. 7
[PUBMED]    
8.Velasco M, Vilata JJ. Tuberculosiscutánea. Piel 1999;14:397-410.   Back to cited text no. 8
    
9.Akoglu G, Karaduman A, Boztepe G, Ozkaya O, Sahin S, Erkin G, et al. A case of lupus vulgaris successfully treated with antituberculous therapy despite negative PCR and culture. Dermatology 2005;211:290-2.   Back to cited text no. 9
    
10.Diamantopoulos II, Jones NS. The investigation of nasal septal perforations and ulcers. J Laryngol Otol 2001;115:541-4.   Back to cited text no. 10
    
11.Baril L, Caumes E, Truffot-Pernot C, Bricaire F, Grosset J, Gentilini M. Tuberculosis caused by Mycobacterium africanum associated with involvement of the upper and lower respiratory tract, skin, and mucosa. Clin Infect Dis 1995;21:653-5.  Back to cited text no. 11
    
12.Matsumoto FY, Clivati Brandt HR, Costa Martins JE, Rivitti EA, Romiti R. Nasoseptal perforation secondary to lupus vulgaris. J Dermatol 2007;34:493-4.  Back to cited text no. 12
    
13.Garg A, Wadhera R, Gulati SP, Singh J. Lupus vulgaris of external nose with septal perforation- a rarity in antibiotic era. Indian J Tuberc 2010;57:157-9.  Back to cited text no. 13
    
14.Bass JB, Farer LS, Hopewell PC, O'Brien R, Jacobs RF, Ruben F, et al. Treatment of tuberculosis infection in adults and children. Am J Respir Crit Care Med 1994;149:1359-74.  Back to cited text no. 14
    


    Figures

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



 

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