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Indian Journal of Surgical Oncology
ISSN 0975-7651
Volume 2
Number 3
Indian J Surg Oncol (2011) 2:215-217
DOI 10.1007/s13193-011-0104-4
A Rare Case of Lupus Carcinoma of
External Nose
Vadisha Srinivas Bhat, Satheesh Kumar
Bhandary, M.Shwetha Shenoy, Sathish
Chandra BK & Girish BS
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CASE REPORT
A Rare Case of Lupus Carcinoma of External Nose
Vadisha Srinivas Bhat &Satheesh Kumar Bhandary &
M. Shwetha Shenoy &Sathish Chandra BK &Girish BS
Received: 15 June 2011 / Accepted: 14 November 2011 / Published online: 29 November 2011
#Indian Association of Surgical Oncology 2011
Introduction
Cutaneous tuberculosis was once a common disease. In
the recent decade because of improved living environ-
ment, BCG vaccination and effective antituberculous
drugs, this disease is less common. Different forms of
cutaneous tuberculosis are lupus vulgaris, scrofulo-
derma, tuberculosis verrucosa cutis, lichen scrofuloso-
rum, erythema induratum, papulonecrotic tuberculid
[1].
Amongst these morphological variants commonest one
is lupus vulgaris constituting 59% of total skin tuberculosis.
This is a chronic, progressive and tissue-destructive form of
cutaneous tuberculosis seen in patients with moderate or
high degree of immunity. Head and neck regions are the
commonest sites involved by lupus vulgaris in European
countries [2].
Lupus vulgaris can undergo malignant change in 0.5% to
10.5%. The interval from the onset of lupus vulgaris to the
occurrence of malignancy ranges from 2 to 79 years. Lupus
vulgaris undergoing malignant change is referred to as
lupus carcinoma [3].
Case Report
A 39 years old man, presented to the ENT department
of K.S.Hegde Charitable Hospital, Mangalore, Karna-
taka with 3 months history of ulcer over the right ala
of the external nose. Initially it started as an erythem-
atous lesion over the external nose, which later
ulcerated.
His general physical and systemic examination was
within normal limits. There was an ulcer over the
lower third of external nose measuring 3 cm ×2 cm.
The edges were raised; floor was covered with the
crust. Surrounding skin was erythematous and thick-
ened with intact sensations (Fig. 1). Anterior rhinoscopy
did not reveal any abnormality. There was no cervical
lymphadenopathy.
We considered the differential diagnosis of Carcinoma
and Lupus vulgaris. Biopsy of the lesion was taken, the
histopathology showed features of non specific ulcer. The
tissue from the ulcer was sent for Polymerase chain reaction
(PCR) for mycobacterium tuberculosis which showed the
DNA of the bacteria. The diagnosis of lupus vulgaris was
confirmed.
The patient was administered anti-tubercular therapy
consisting of rifampicin (450 mg), isoniazid (300 mg),
pyrizinamide (1,500 mg) and ethambutol (800 mg) daily for
2 months, followed by two drugs (rifampicin and isoniazid)
for the next 4 months. His lesion completely resolved over
6 months. He was on regular follow up (Fig. 2).
V. S. Bhat (*):S. K. Bhandary :M. S. Shenoy :S. C. BK :
G. BS
K S Hegde Medical Academy,
Deralakatte,
Mangalore, Karnataka 575018, India
e-mail: bvadish@yahoo.co.in
V. S. Bhat (*):S. K. Bhandary :M. S. Shenoy :Sathish CBK :
Girish BS
Indian J Surg Oncol (July–September 2011) 2(3):215–217
DOI 10.1007/s13193-011-0104-4
Author's personal copy
Two years after the remission of the lesion, he developed
an ulcer over the right nasal ala over the same site of the
healed lupus ulcer. This ulcer was 1 cm× 1 cm in dimension
(Fig. 3). There was induration of 0.5 cm around the ulcer.
On anterior rhinoscopy no abnormality was detected. No
neck nodes were palpable. Systemic examination was
within normal limits.
A possibility of recurrence of lupus vulgaris was
thought. Wedge biopsy of the lesion was taken. Histopath-
ological features were suggestive of well differentiated
squamous cell carcinoma.
Patient underwent Wide excision of the lesion with a
margin of 2 cm and reconstruction of the resultant defect
with forehead rotational flap (Fig. 4). Post operative period
was uneventful and patient recovered well (Fig. 5). Flap
division was done after 6 weeks (Fig. 6).
Patient is on regular follow up and there is no evidence
of recurrence in 1 year.
Discussion
Lupus vulgaris is the most common variant of cutaneous
tuberculosis which may be acquired by hematogenous,
lymphatic spread or direct inoculation. Lupus vulgaris can
be diagnosed clinically by diascopy in which the plaques
showed apple-jelly colour.
The diagnosis can be confirmed by biopsy which shows
granuloma formation with Langerhan cell and epitheloid
cell infiltration. PCR test often yields positive results [4].
The most important complication of lupus vulgaris is
malignant transformation. The incidence of carcinoma
Fig. 2 After ATT
Fig. 3 Lupus carcinoma
Fig. 4 Excision and forehead flap- intra operatice picture
Fig. 1 Lupus vulgaris
216 Indian J Surg Oncol (July–September 2011) 2(3):215–217
Author's personal copy
varies from 0.5% to 10.5%. The interval from the onset of
lupus vulgaris to the occurrence of malignancy ranges from
2 to 79 years [3].
Malignant transformation of lupus vulgaris may be from
tubercular tissue itself or from the healed scars of previous
lupus lesion. The etiology of lupus carcinoma remains
unknown. X- ray therapy, chronic inflammation through
reactive oxygen species produced by activated inflamma-
tory cells, cicatrical changes; physical and chemical trauma
and sunlight are other factors giving rise to carcinoma [5].
Carcinomatous changes to basal and squamous cell carci-
nomas are reported in literature.
Squamous cell carcinoma of the external nose is managed
surgically. Small size lesion can be removed by excision, laser
excision or cyrosurgery. Mohs surgery has shown highest cure
rate. It is advised for lesions larger than 2 cm across, poorly
defined margins, recurrent lesions. If surgically removable,
lymph node dissection is also advised [6].
In our patient, since the disease was involving the nose;
the main challenge was not only to remove the disease, but
also to provide good cosmesis. This was successfully done
by wide excision followed by forehead rotation flap. Since
the disease was limited to the nose without any clinical
lymph node enlargement, no adjuvant therapy was offered
and he was advised regular follow up.
References
1. Tappeiner G, Wolff K (2003) Tuberculosis and other mycobac-
terial infections. In: Freedberg IM, Eisen AZ, Wolff K, Austen
KF, Goldsmith LA, Katz SI (eds) Fitzpatrick’s dermatology in
general medicine, vol 2. McGraw hill, New York, pp 1933–
1950
2. Ramesh V, Misra RS, Jain RK (1987) Secondary tuberculosis of
skin: clinical features and problems in laboratory diagnosis. Int J
Dermatol 26:578–581
3. Kanitakis J, Audeffray D, Claudy A (2006) Squamous cell
carcinoma of the skin complicating lupus vulgaris. J Eur Acad
Dermatol Venereol 20:114–116
4. Savin JA (1992) Mycobacterial infections. In: Champion RH,
Burton IL, Ebling FJG (eds) Textbook of dermatology, 5th edn.
Blackwell Science, London, pp 1033–63
5. Ekmekci TR, Koslu A, Sakiz D et al (2004) Squamous cell
carcinoma arising from lupus vulgaris. J Eur Acad Dermatol
Venereol 19:511–513
6. Pathak D, Thapa A (2009) squamous cell carcinoma arising in
extensive and chronic lupus vulgaris. Egyptian Dermatology
Online Journal December 5(2):16
Fig. 6 After flap division
Fig. 5 Forehead flap reconstruction post op
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