Papulonecrotic tuberculid A18.4

Exanthematic, eminently chronic clinical picture occurring in relapses with necrotizing, scarring healing papules in a hyperergic reaction to tubercle antigens. About 1/4 of all tuberculids are papulonecrotic tuberculids.

Among the (now) overall rare tuberculids, papulonecrotic tuberculid is the most common form.

In countries, such as India, where the prevalence of tuberculosis is high, the presence of papulonecrotic tuberculids is still expected. The focus of infection is not detectable in the majority of cases.

A type III reaction or a type IV reaction is discussed (see below allergy). Pathogenetically, expired tuberculosis of other organs should play a role. The simultaneous occurrence with an active organ tuberculosis is rare! The concurrence with other tuberculids (e.g. erythema induratum - see below Nodular vasculitis) should be given.

Occurring primarily in female adolescents and younger adults.

Vasculitis, hyperergic: no hyperergic tuberculous reaction, no scarring

Pityriasis lichenoides et varioliformis acuta: no hyperergic tuberculous reaction, no scarring

Prurigo simplex subacuta: Absence of pruritus, no hyperergic tuberculous reaction

Anetoderma: Absence of pruritus, no hyperergic tuberculous reaction; no evidence of vasculitis.

Once diagnosed, patients respond very well to antituberculous therapy.

The synonymous use of the term 'tuberculosis cutis papulonecrotica' should be avoided as this term implies active tuberculosis of the skin.

A 30-year-old man presented with a 6-year history of recurrent, multiple asymptomatic, raised lesions on the back and arms. Previously, recurrent abscesses had been treated with oral and topical antibiotics. Some of the lesions had healed spontaneously with scarring.

The patient denied any history of fever, chronic cough, weight loss, and medication use prior to the appearance of the lesions. There was no known contact with tuberculosis patients. General and systemic examination was essentially normal. Dermatologic examination revealed the presence of multiple, well-demarcated, hyperpigmented, crusted papules 0.5-1.0 cm in size, symmetrically distributed over the entire back, the extensor side of both forearms, the arms, and the dorsum of both feet, interspersed with atrophic varioliform scars. Routine laboratory examinations were normal. Tuberculin (Mantoux) was strongly positive (23 × 23 mm) with central necrosis at 72 hours. Sputum test for acid-fast bacilli, chest radiography, ultrasonography of the abdomen and pelvis revealed no abnormalities. A biopsy from an encrusted papule on the forearm showed fibrinoid necrosis surrounded by a mixed inflammatory infiltrate filling the entire dermis, some poorly defined epithelioid granulomas, and lymphocytoclastic vasculitis.

The patient was initially treated with combination therapy of rifampicin, isoniazid, pyrazinamide, and ethambutol for two months, followed by a combination of rifampicin and isoniazid to complete a total of six months of standard antitubercular therapy. Under this therapy, all lesions healed.

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