Ulcerative Lupus Vulgaris Primarily Involving the Ear Lobule.

Sir,

Lupus vulgaris (LV) is the most common clinical variant of cutaneous tuberculosis. It was first described by Erasmus Wilson in 1865.[1] Clinically, the early lesions of LV are characterized by soft reddish brown plaques with an ‘apple jelly nodule’ appearance on diascopy and in the later stages present with healing and scarring in one area and active disease in another.[2] The different forms of LV include plaque, ulcerative or mutilating, vegetating, tumor-like, and papular and nodular forms.[3] We report an unusual case of ulcerative type of LV of the ear lobe.

A 24-year-old girl presented to our department with ulceration of the left earlobe for 6 months. It started as a papule which slowly increased in size and broke down to form an ulcer. She did not give any history of trauma or ear piercing prior to the onset of the lesion. There was also no history of tuberculosis in the past or a family history of the same. There was no history suggestive of immunosuppression.

The cutaneous examination showed a well-defined ulcer of size 1 × 2 cm on the tip of the left earlobe [Figure 1]. The margins were undermined and the floor was covered with slough [Figure 2]. The surrounding skin was erythematous with mild scaling. The general and systemic examination was normal. A Mantoux test showed an induration of size 11 × 12 mm after 48 hours. Chest X ray was normal. PCR (Polymerase Chain Reaction) and BACTEC (Becton Dickinson Diagnostic Instrument Systems) tests were not done due to financial constraints.

Figure 1

An ulcer over the left ear lobe

Figure 2

The ulcer base shows slough with surrounding erythema

The histopathological examination of the skin biopsy showed ulceration of the epidermis and confluent epithelioid granulomas in the mid and deep dermis. The epithelioid granulomas showed minimal central caseous necrosis and peripheral palisades of histiocytes and lymphocytes [Figures 3 and 4]. However, Ziehl–Neelsen stain was negative for acid-fast bacilli. The features were consistent with granulomatous skin lesion. Other routine blood investigations were unremarkable. A final diagnosis of ulcerative LV was made due to the presence of caseating granulomas on histopathology and positive Mantoux test. The patient was treated with Cat 1 anti-tubercular treatment (ATT) under the Revised National Tuberculosis Control Programme which resulted in complete healing of the ulcer [Figure 5].

Figure 3

Epithelioid granuloma with minimal central caseous necrosis (H and E, 40×)

Figure 4

Epidermis is focally ulcerated with dermis showing confluent epithelioid granulomas (H and E, 4×)

Figure 5

The ulcer healed with scar formation after 6 months of anti-tubercular therapy

The ulcerative type of LV is uncommon and it is characterized by scarring and deformity. The mode of infection is thought to be endogenous or exogenous inoculation following minor trauma.[1] In India, the common sites of involvement are buttocks, thighs, and legs, whereas in the European population, the head and neck are most commonly involved.[4] In a study done in India, ulcerative type of LV was the least common (14.2%).[5] Case reports of LV affecting the face indicate that the cheeks and nose are the most frequently affected sites.[6] Although the pinna may be involved by contiguity from a cheek lesion, primary involvement of the ear lobe is extremely rare.[78910]

The above case reported here is unusual because of the exclusive involvement of the ear lobe and the occurrence in an immunocompetent girl without any past or family history of tuberculosis. Long-standing ulcerative LV in addition to scarring and deformity can lead to squamous cell carcinoma. Clinical dermatologists need to be aware of the myriad clinical presentations of this condition and make a correct diagnosis, and promptly treat as it can be disfiguring and destructive.

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Conflicts of interest

There are no conflicts of interest.