A 40-year-old man presented with large plaques of 30 years duration over right upper limb, right side of the chest and back, and right lower limb. The lesion started as a small papule over right upper limb near the elbow when he was 10 years old. Since then it steadily grew in size to involve whole of the limb and also the right side of the chest and back. He developed similar lesions, one over the right thigh after about 2 years of the first lesion that gradually enlarged to involve most of the thigh circumferentially and one more lesion over the left side of the back since one year [Figure 1]. The lesions were asymptomatic except for mild itching. There was no history of trauma prior to the onset of the lesions or the past history suggestive of tuberculosis of any part of the body. There was no family history of tuberculosis or contact with a tuberculosis patient. He consulted many doctors and applied various creams but of no help.
On examination, there were three plaques, two large and one small, with well-defined borders and irregular margins:
Plaque no. 1: involving right upper limb, right side of the chest and back measuring about 60 x 45 cm.
Plaque no. 2: about 6 x 3 cm over the left side of the back.
Plaque no. 3: over right thigh, involving circumferentially, measuring about 40 cm longitudinally and 50 cm circumferentially.
Within the plaque, there were areas of thick hyperkeratosis and large, thick adherent crusts on an erythematous base. Ulceration at some places and areas of scarring and atrophy in between the areas of hyperkeratosis were present. There was no regional or generalized lymphadenopathy. The patient could not extend the shoulder and elbow completely because of contracture. Systemic examination was normal.
Hematological investigations revealed anemia (Hb: 10.1 g%), raised erythrocyte sedimentation rate (67 mm/first hour). The Mantoux test was strongly positive with a reading of 22 x 20 mm at 72 h. Chest X-ray was normal. X-ray of the involved parts showed no evidence of underlying tissue infiltration. Sputum was negative for acid fast bacillus (AFB). Scrapings from crusts were negative for fungus. Culture for M. tuberculosis and fungus were negative. ELISA for HIV was nonreactive. Histopathologic examination of the biopsy specimen revealed hyperplastic epidermis, upper and mid-dermis showing numerous noncaseating epitheloid granulomas with Langhan's type of giant cells [Figure 2]. No fungal elements or AFB were seen on tissue section.
Based on clinical features and investigations, a diagnosis of lupus vulgaris was made and the patient was started on antitubercular treatment cat-I. There was dramatic improvement in skin lesions within 3 weeks and after 6 weeks the lesions showed 70-80% of improvement. After 12 weeks, there was almost total healing of the lesions [Figure 3].