Multiple Punched Out Ulcers and Scars over Glans: A Common Disease at Uncommon Site.

Sir,

A 40-year-old man presented with multiple asymptomatic ulcers over glans penis for the past 5 years. The ulcers used to heal with scarring. He denied any history of unprotected sexual exposure, any history of genital lesions, or discharge in his spouse; there was no history of trauma, drug intake, fever, cough, and constitutional symptoms with no personal or family history of tuberculosis. The patient was never vaccinated with Bacillus Calmette-Guérin.

Examination revealed multiple, indurated, nontender, well-defined ulcers of size 0.5 cm × 0.5 cm over the ventral and dorsal aspects of the glans. Multiple punched-out depressed scars were also present [Figure 1a]. Bilateral inguinal nontendered lymphadenopathies were present. Erythrocyte sedimentation rate was highly raised (50 mm in the 1st h). Tuberculin (Mantoux) test was strongly positive (20 mm × 20 mm). Ziehl–Neelsen (ZN) stain of the pus did not demonstrate any acid-fast bacilli (AFB). Punch biopsy revealed ulcerated epidermis with wedge-shaped area of necrosis, surrounded by a poorly formed granulomatous infiltrate composed of lymphocytes and macrophages [Figure 1b]. ZN stain for AFB was negative. Tissue cultures for bacteria and fungus were negative. He was treated with antituberculous treatment (ATT) for 6 months. Six weeks after the initiation of therapy, the existing lesions showed healing [Figure 1c].

Figure 1

(a) Multiple ulcers and scar over glans; (b) ulcerated epidermis with wedge-shaped area of necrosis, surrounded by a poorly formed granulomatous infiltrate composed of lymphocytes and macrophages (H and E, ×10); (c) posttreatment

Papulonecrotic tuberculids (PNTs) are characterized by recurrent eruptions of asymptomatic, dusky red papules, which ulcerate and crust, and heal after a few weeks with varioliform scarring.[1] This is explained by the hematogenous dissemination to the skin of mycobacterial antigens from an internal tuberculous focus in a hypersensitive patient.[2] Penile tuberculid is an extremely rare condition with majority of cases reported from Japan and South Africa.[3] A correct diagnosis of PNT on glans can be done on basis of characteristic irregular depressed scars, histopathological finding of tuberculous granuloma, and a good response to ATT.

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The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

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Conflicts of interest

There are no conflicts of interest.