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International Journal of Dermatology, Vol. 33, No. 4, April t994 CAMEO PENILE LUPUS VULGARIS TELENSERIJAYAKA R JAISANKAR , M.D., BHAGAT H RAM GARG, M.D., BELUM SIVANAGI REDDY, M.D., BOMM I RIBA, M.B.B.S., AND ANIL l'RASAD RAMARAO , M.D. A 46-year-old man who is a weaver presented with penile ulcer of 18 months' duration. The problem started as a soli- tary painless eruption over the coronal sulcus, and in 2 months the lesions changed Into multiple, painless small ulcers followed by the development of inguinal swellings. There was no history of bleeding from the ulcers nor any urethral discharge. The patient was married and his wife gave no history suggestive of tuberculosis or genital ulceration, and on examination she was completely normal. Neither the patient nor his wife gave any history of extra- marital sex. No history of cough, hemoptysis, nor evening rise of temperature was present. The patient had lost con- siderable weight after the disease had started. He took penicillin injections, tablets, and capsules from various doc- tors, but there was no improvement. Past history revealed that the patient had been admitted for backpain and weak- ness of both lower limbs at a nearby hospital 19 years earli- er. He was diagnosed as having tuberculosis of the spine and was treated with antituberculous drugs for a period of 6 months. When he was discharged he stopped treatment on his own since his symptoms had disappeared. Examination of the genitalia revealed that the prepuce was easily retractable. Multiple shallow, nontender, non- bleeding, superficial ulcers of varying sizes, from 3 x3 mm to 8 x 8 mm, were present over the glans penis and the inner aspect of the prepuce (Fig. 1). Most of the ulcers were conflu- ent. They were pale pink with a granulomatous base and covered with a crust at a few areas. The margins of the ul- cers were undermined. On palpation there was neither in- duration nor tenderness. The inguinal lymph nodes on either side were enlarged, firm, matted, and nontender (Fig. 1). Prostate and scrotal contents were normal. Examination of the spine showed angular kyphosis over the upper half, but there was no sensory or motor deficit. The rest of the sys- temic examination, including that of the lungs, was normal. Investigations: Hemoglobin was normal. Erythrocyte sedi- mentation rate was elevated (38 mm after the first hour). Blood tests for HIV (VDRL and ELISA) were negative. A tissue smear for Donovan bodies, darkfield examination for Tre- ponema patlidum, Gram's smear for Haemophilus ducreyi, From the Departtnents of Dermatology and Pathology, Jawa- harlal Insritute of Postgraduate Medical Education and Re- search, Pondicherry, India. Address for correspondence: Telenseri J. Jaisankar, M.D., Assistant Professor, Department of Dertnatology, Jipmer, Pondicherry- 605006, India. and a Tzanck test for giant cells were negative. Mantoux test was strongly positive (32 mm) with vesiculation. Histopatho- logic examination of the biopsy obtained from the ulcer re- vealed multiple granulomata consisting of Langhans giant cells, epitheloid cells, and lymphocytes characteristic of lupus vulgaris (Fig. 2). Fine needle aspiration cytology from an inguinal lymph node showed a characteristic epitheloid cell response. A PA chest x-ray (15 x 12 cm) revealed a 2 x 2 cm opaque shadow suggestive of a lymph node in the right lung field at the junction of clavicle and superior medi- astinum (Fig. 3). Collapse and fusion of the vertebrae T-7 and T-8 were seen on the x-ray of the thoracic spine on an- terior posterior and lateral views. Examination of smear and culture for acid-fast bacilli (AFB) of urine and sputum were negative. Ultrasonography of the kidneys, ureters, and blad- der revealed no abnormality. Treatment and Follow-Up: Based on the clinical findings and the histopathology, the patient was diagnosed as hav- ing lupus vulgaris of the penis. Antituberculosis therapy, consisting of isonicotinic acid hydrazide INH 300 mg o.d., ri- fampicin 600 mg o.d., and pyrazinamide 1.5 g o.d. was Figure 1. Multiple superficial crusted penile ulcers on glans penis and inner aspect of prepuce. 272 Penile Lupus Viilgaris jaisiinkar cl al. K Figure 2. Characteristic tuberculous granuloma with Lang- hans giant cells, epitheloid cells, and lymphocytes, (hema- toxylin and eosin, original magnification x 100) started. After 2 months the ulcers had healed dramatically. He was discharged and advised to continue the same treat- ment for another 7 months. A repeat chest x-ray revealed no abnormality. DISCUSSION Tuberculosis of the penis was initially reported as a secondary manifestation of tuberculosis by Solowei- Tschnik in 1870.''-̂ Tuberculosis primarily affecting the penis was described by Fournier' in 1878. Penile tuberculosis is now uncommon except in China, where it occurs in about 4% of patients suffering from geni- tourinary tuberculosis.''-'' Although tuberculosis is still very common in India, reports of penile involvement are not proportionally numerous.''"''' We report here an unusual case of penile tuberculosis associated with tuberculosis of the spine and lymphadenitis and we stress the need for a careful histopathologic examina- tion. A wrong diagnosis of carcinoma may sometimes lead to needless amputation of the penis.'"'''' Initially , the diagnoses of granuloma venereum, car- cinoma, and erythroplasia of Queyrat were considered in the present case because of the clinical appearance and the chronicity of the lesions. The past history of spinal tuberculosis and the strongly positive Mantoux test suggested the diagnosis of tuberculosis. The typical granulomata and the eroded epidermis helped to clinch the diagnosis of lupus vulgaris (ulcerative type). Even though the ulcers were present around the urethral ori- fice, the diagnosis of orificial tuberculosis was exclud- ed because of the lack of characteristic histopathologic changes and absence of AHB in the sections.'̂ Eurther, on clinical examination, ultrasonography, and urine culture from AFB, genitourinary tuberculosis was ex- cluded. The diagnosis of papulonecrotic tuberculides was also considered but ruled out because of the ab- sence of history of waxing and waning of lesions and since the histopathology did not show central necrosis with associated endarteritis and endophlebitis.'̂ The ulcers may have developed as a result of exogenous im- plantation or hematogenous spread from an occult focus (perhaps the incompletely treated bony lesion) or from the tuberculous lymphadenitis. Lewis-̂ in 1946 reviewed the literature and collected 110 cases of penile tuberculosis. Most of these were in Jewish boys circumcized in the customary way, which has been abandoned now. In "ritual circumcision" Mohel the operator sucked the circumcised penis for hemostasis."* If Mohel suffers from pulmonary tuber- culosis he may transmit bacilli to the raw wound. Among the cases reviewed by Lewis, 14 were venere- al in origin, 12 due to normal coitus, and 2 due to oral Figure 3. Chest x-ray, PA view, showing an opaque shadow suggestive of a lymph node in the right lung field at the junc- tion of the clavicle and the superior mediastinum. 273 International Journal of Dermatology Vol. 33, No. , 1994 sex; of the rest, one was due to wearing infected clothes, 11 were secondary, and in the remaining 10 cases the nature of exposure was either not stated by the authors or could not be determined. In the 11 secondary types, 8 had genitourinary disease as the primary focus and 3 were due to hematogenous spread from the lungs. Lai et al.* reviewed 19 additional cases from the English literature since Lewis's publication in 1946; of these 14 were primary and the remaining secondary in nature. One primary case was attributed to coitus and the others fell in the undetermined category. Among the secondary cases, eight had genitourinary tuberculo- sis, three had pulmonary tuberculosis, one case had both lung and genitourinary tuberculosis, one badskin disease alone, and in the remaining cases the nature of lesions other than penile was not stated. Subsequent to Lai's review, there have been 16 arti- cles on this topic;'" *̂ the presentation varied from cav- ernositis''''" and papulonecrotic tuberculosis'̂ through a subcutaneous nodule^'' to chancre.^'' The primary focus in our patient is likely to be the inadequately treated spinal disease. Hematogenous spread has then occurred to the penis. In the 1970s and 1980s tubercu- losis became less common because of effective multi- drug chemotherapy. In recent years, because of the AIDS pandemic, tuberculosis has resurged. CONCLUSION While evaluating unusual genital lesions, tuberculosis should always be kept in mind. DRUG NAMES isoniazid: IHN, Niconyl, Nydrazid, Rolazid rifampicin: Rifadin, Rimactane REFERENCES 1. 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