A 42-year-old woman presented with asymptomatic reddish papules, nodules, plaques, and patches on the right side of her face and on her forehead that had persisted for 5 years. These lesions had initially appeared as reddish papules on the right side of her forehead. The number of lesions had gradually increased, developing into erythematous infiltrated plaques and nodules with scales, and then extending to the upper right side of the face and almost the whole forehead. The lesions were persistent over 5 years, and the patient had no previous intervening medical treatment prior to referral to the authors' outpatient department for evaluation of the skin lesions. The patient did not recall any potential inducement or any possibility of receiving immunosuppressive therapy. Since the onset of the disease, the patient had not complained of systemic discomfort. Her general condition was good, and she did not have a history of hepatitis or tuberculosis.
Dermatological examination revealed a large area of erythematous infiltrated plaques and nodules with scales, sporadic ulcers, and scars on the upper right side of the patient's face and almost her whole forehead (Figure 1). No cervical or axillary lymph nodes were palpable.
No active pulmonary disease was detected by chest X-ray. Routine laboratory tests showed no noteworthy abnormalities. The results of human immunodeficiency virus antibody detection (conducted twice over 3 months) were negative. Cell-mediated immunity levels in peripheral blood cells from the patient were detected using a flow cytometer, (BD FACSCalibur ;BD Bioscience, San Jose, CA) and the CD4-positive T-cell count in the peripheral blood cells, as well as other cell counts, was normal. Specific stains (such as periodic acid-Schiff and Giemsa stains) for microorganisms were negative. Ziehl-Neelsen staining results were positive. Tissue cultures showed that colonies grown in Lowenstein-Jensen (L-J) medium at two different temperatures (32 C and 37 C) for 2-3 weeks developed pigmentation in the dark and in the light. Fungal and other standard bacterial cultures were negative. A skin biopsy, taken from a lesion on the patient's forehead, stained with hematoxylin and eosin showed hyperplastic epidermis and epithelioid cell granulomas that were composed of tissue cells and multinucleated giant cells; infiltration with lymphocytes and eosinophils was further observed (Figure 2).
During diagnostic evaluation, the patient was empirically administered oral clarithromycin and moxifloxacin. At the first stage of treatment, the lesions noticeably improved, and half of them were cured. However, during administration of the drugs, the platelet count declined to 30 x 109/L, which was considered to be an adverse reaction of moxifloxacin. After withdrawal from moxifloxacin, the palate count increased but the condition of the lesions deteriorated and the lesions became enlarged. Clarithromycin, amikacin, and ethambutol were then administered, resulting in slow improvement in the patient.