A 73-year-old male patient consulted to our outpatient clinics with complaints of ever-increasing number of non-healing wounds with foul-smelling discharge. Skin wounds of the patient were firstly appeared on his hip five years ago, and became more numerous since then. Biopsy material obtained one year ago was evaluated as chronic granulomatous dermatitis. His personal medical history was unremarkable, while his two siblings died of tuberculosis, and his son was still receiving tuberculostatic therapy. On his dermatological examination, red-violet atrophic plaque lesions with irregular contours, and patchy areas of adhered yellow-brown crusts, and squamas localized on the frontal, parietal, temporal, and malar regions, nose, and left ear were observed. Seventeen- 18 plaque-shaped lesions measuring 2-15 cm in diameter with adhered brown crusts, and squamas, and also eroded areas 0.5 cm-2.0 cm in diameter localized as islets on the anterior, and posterior aspect of the trunk, also on both upper, and lower extremities were seen. In addition to eroded areas on similarly appearing plaque lesions localized on the gluteal region, an ulcerated lesion 4 cm in diameter, and 1-1.5 cm in depth striked our attention (Figure 1). Histopathological examination of the biopsy material revealed a large ulcerated area covered superficially with crusts, lymphocytic, and histiocytic infiltration, and giant cells within superficial, and middle layer of dermis, and granulomas more conspicuously on the periphery of the infiltrate (Figure 2).
Application of periodic acid-Shiff (PAS), and Erlich-Ziehl-Neelsen (EZN) staining couldn't detect any specific infectious agent. Laboratory analyses revealed anemia, hypoproteinemia, increased CRP, and sedimentation rate. With these clinical, and histopathological findings, the diagnosis of generalized lupus vulgaris was made. The patient with a 9 mm-PPD reaction size, but without systemic involvement received antituberculostatic treatment with 300 mg isonicotinic acid hydrazide, 600 mg rifampicin, 1500 mg ethambutol, and 3000 mg pyrazinamide for 2 months, then with 300 mg isonicotinic acid hydrazide, and 600 mg rifampicin for 4 months. At two months of the treatment, lesions regressed remarkably. At the end the sixth month all lesions healed with postinflammatory hyperpigmentation, hypopigmentation and/or atrophic scar (Figure 3).