lupus vulgaris is the most common type of cutaneous tuberculosis , with most varied manifestations .
it is a chronic and progressive form occurring in individuals with high degree of tuberculin sensitivity and moderate immunity .
a characteristic feature of lupus vulgaris is its extremely chronic course with slow but steady growth of the lesions over a period of many years , even decades .
we report a case of lupus vulgaris with very large sized , multiple plaques occurring at less common sites .
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 ] .
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 .
clinical photograph showing a large plaque over right upper limb and right side of the chest before treatment 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  45 cm.plaque no .
2 : about 6  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 . 
  plaque no .
1 : involving right upper limb , right side of the chest and back measuring about 60  45 cm . 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 .
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  20 mm at 72 h. chest x - ray was normal .
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 ] .
skin biopsy showing hyperplastic epidermis , upper and mid dermis showing noncaseating epitheloid granulomas with langhan 's type of giant cells 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 7080% of improvement .
after 12 weeks , there was almost total healing of the lesions [ figure 3 ] .
it usually occurs through contiguous extension of the disease from underlying affected tissue or hematogenous or lymphatic spread .
lupus vulgaris is the most common type of cutaneous tuberculosis in india and commonly seen in the lower half of the body involving legs , thighs , buttocks , and feet .
it is attributed to the habit of children playing without clothing or shoes and defecating in the open .
pyogenic infection of the gluteal region is also common in india and the breach in the integrity of the skin can serve as a portal of entry for the afb .
the initial lesion is a small , reddish - brown papule or nodule which later forms larger plaques by peripheral enlargement and coalescence that show evidence of healing and scarring in one area and activity in another .
atrophic scarring , with or without ulceration , is a prominent feature of lupus vulgaris .
the common variants are : plaque form , ulcerative and mutilating form , vegetative form , papular and nodular form and tumor - like ( hypertrophic ) form .
the plaque form is the common type that presents as flat plaques with irregular or serpigenous edges , surface may be smooth or covered with psoriasiform scale .
large plaques may show irregular areas of scarring with islands of active lupus tissue , the edge may be thickened and hyperkeratotic .
histopathology shows tuberculoid granulomas composed of lymphocytes , plasma cells , epitheloid cells and giant cells , scant or absent central caseation , in the superficial dermis .
after a thorough search of the literature , the largest size of lupus vulgaris lesion we could find was 30  25 cm .
ours may be the first case showing largest lesions measuring 60  45 cm and 40  50 cm .
other special features in our case were multiplicity ( lv commonly presents as a single lesion ) and extreme chronicity of the lesions , and occurrence at less common sites such as upper limb , chest , and back .
this case also shows the level of ignorance among patients and consequent failure to take proper anti - tuberculous treatment despite extensive campaign in print and audiovisual media .
 cutaneous tuberculosis continues to be an important public health problem even with the availability of highly effective anti - tuberculous drugs . 
 it constitutes 0.1% of all cases of extrapulmonary tuberculosis . 
 lupus vulgaris is the most common form of cutaneous tuberculosis that occurs in previously sensitized individuals with a moderate degree of immunity against tubercle bacilli . 
 the different types of lupus vulgaris include plaque , ulcerative , vegetative , papular and nodular , and tumor forms . a 40-year - old man presented with large multiple plaques over right upper limb , right side of chest and back , and right lower limb for the past 30 years . 
 histopathology showed numerous noncaseating granulomas with langhan 's type of giant cells . 
 the mantoux test showed strong positivity and there was excellent response to anti - tuberculous treatment . 
 this case is being reported because of its extreme chronicity of 30 years duration , unusually large size and multiplicity of lesions . 
INTRODUCTION
CASE REPORT
DISCUSSION