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Simultaneous occurrence of papulonecrotic tuberculid and lichen scrofulosorum associated with mediastinal tuberculous lymphadenitis

Simultaneous occurrence of papulonecrotic tuberculid and lichen scrofulosorum associated with mediastinal tuberculous lymphadenitis Tuberculids form a group of disorders characterized by cutaneous hypersensitivity to Mycobacterium tuberculosis that occur in patients with moderate to high levels of immunity against the organism. The inability to culture M. tuberculosis, together with reports of tuberculid-like eruptions after BCG vaccination and other mycobacterial infections, supports this concept. Recently, mycobacterial DNA has been detected, albeit inconsistently, in tissue specimens from all tuberculids. The three tuberculids are papulonecrotic tuberculid (PNT), lichen scrofulosorum (LS), and erythema induratum of Bazin (EIB). A 34-year-old Pakistani man presented with a 1-year history of an asymptomatic cutaneous eruption (Fig. 1a), initially appearing on the back and then spreading over his trunk and extremities, sparing the face and palmoplantar regions. The patient had periodic fever and weight loss. On physical examination, clustered lichenoid papules were seen over his trunk and extremities, especially in the upper trunk (Fig. 1b), associated with multiple, tender, 8–10 mm, necrotic papules, some with central ulceration, mostly on the legs and lumbar region (Fig. 1c). Biopsy of an upper back shiny lesion (Fig. 2a) revealed focal lichenoid tuberculoid granulomatous inflammation, and a second biopsy of a papulonecrotic lesion (Fig. 2b) demonstrated wedge-shaped necrosis in the upper dermis and epidermis and a predominantly perivascular lymphohistiocytic infiltrate with focal granuloma formation. Mycobacterium tuberculosis bacilli were not detected via Ziehl-Neelsen staining or cultures, neither via PCR assay. Chest tomography revealed tuberculous lymphadenopathy of the hilar and mediastinal lymph nodes. Mantoux test was strongly positive (induration of 26 mm at 48 hours), and Quantiferon-TB Gold assay was positive.