A therapeutic trial of antituberculous therapy for suspected lupus vulgaris: How long does it take to see clinical improvement?

To the Editor: A 57-year-old Chinese-American woman, previously vaccinated with BCG, presented with a 2-year history of red-brown, ulcerating lesions involving the nose and medial aspect of her cheeks. She denied any systemic symptoms, personal history of tuberculosis, or prior treatment with antituberculous medications. Physical examination revealed crusted, gelatinous papules and plaques on the nasal tip, bilateral nasal alae, medial aspect of her cheeks, and nasofacial sulci with cartilaginous loss of the distal nasal tip and alae (Fig 1, A). Serologic testing for syphilis, HIV, and antineutrophilic cytoplasmic antibodies produced negative results. Intradermal tuberculin skin test read 48 hours postplacement revealed induration of 28 mm; chest radiographs were normal. Skin biopsy specimen revealed nodular collections of epithelioid histiocytes, without necrosis, surrounded by cuffs of lymphocytes, neutrophils, and plasma cells, consistent with granulomatous dermatitis with a sarcoidal pattern (Fig 2). Immunoperoxidase staining and tissue cultures for bacterial, mycobacterial, and fungal organisms in addition to polymerase chain reaction (PCR) of the skin biopsy specimen for mycobacterial DNA were negative. Fig 2Histopathology of nasal lesion. Low magnification showing dermal collections of epithelioid histiocytes forming sarcoidal granulomas surrounded by mixed inflammatory infiltrate. Insert, Higher magnification of representative granuloma composed of epithelioid histiocytes (thick arrow) surrounded by lymphocytes, neutrophils and plasma cells (thin arrow). (Hematoxylin-eosin stain; original magnifications: ×4; inset, ×20.) View Large Image Figure Viewer Download Hi-res image