Multiple punched out ulcers and scars over glans: A common disease at uncommon site

How to cite this article:
Dey P, Mandal S, Baisya S, Mallick S. Multiple punched out ulcers and scars over glans: A common disease at uncommon site. J Global Infect Dis 2022;14:122-3
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Dey P, Mandal S, Baisya S, Mallick S. Multiple punched out ulcers and scars over glans: A common disease at uncommon site. J Global Infect Dis [serial online] 2022 [cited 2022 Aug 28];14:122-3. Available from: https://www.jgid.org/text.asp?2022/14/3/122/354699

Sir,

A 40-year-old man presented with multiple asymptomatic ulcers over glans penis for the past 5 years. The ulcers used to heal with scarring. He denied any history of unprotected sexual exposure, any history of genital lesions, or discharge in his spouse; there was no history of trauma, drug intake, fever, cough, and constitutional symptoms with no personal or family history of tuberculosis. The patient was never vaccinated with Bacillus Calmette-Guérin.

Examination revealed multiple, indurated, nontender, well-defined ulcers of size 0.5 cm × 0.5 cm over the ventral and dorsal aspects of the glans. Multiple punched-out depressed scars were also present [Figure 1]a. Bilateral inguinal nontendered lymphadenopathies were present. Erythrocyte sedimentation rate was highly raised (50 mm in the 1st h). Tuberculin (Mantoux) test was strongly positive (20 mm × 20 mm). Ziehl–Neelsen (ZN) stain of the pus did not demonstrate any acid-fast bacilli (AFB). Punch biopsy revealed ulcerated epidermis with wedge-shaped area of necrosis, surrounded by a poorly formed granulomatous infiltrate composed of lymphocytes and macrophages [Figure 1]b. ZN stain for AFB was negative. Tissue cultures for bacteria and fungus were negative. He was treated with antituberculous treatment (ATT) for 6 months. Six weeks after the initiation of therapy, the existing lesions showed healing [Figure 1]c.

Figure 1: (a) Multiple ulcers and scar over glans; (b) ulcerated epidermis with wedge-shaped area of necrosis, surrounded by a poorly formed granulomatous infiltrate composed of lymphocytes and macrophages (H and E, ×10); (c) posttreatment

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Papulonecrotic tuberculids (PNTs) are characterized by recurrent eruptions of asymptomatic, dusky red papules, which ulcerate and crust, and heal after a few weeks with varioliform scarring.[1] This is explained by the hematogenous dissemination to the skin of mycobacterial antigens from an internal tuberculous focus in a hypersensitive patient.[2] Penile tuberculid is an extremely rare condition with majority of cases reported from Japan and South Africa.[3] A correct diagnosis of PNT on glans can be done on basis of characteristic irregular depressed scars, histopathological finding of tuberculous granuloma, and a good response to ATT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Research quality and ethics statement

The authors followed applicable EQUATOR Network (https://www.equator-network.org/) guidelines, notably the CARE guideline, during the conduct of this report.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1.Yates VM, Rook GA. Mycobacterial infections. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7th ed. Oxford: Blackwell Science; 2004. p. 28.