Lupus Vulgaris Mimicking Basal Cell Carcinoma- A Case Report

Dr. Pradip Sarkar

MD (Dermatology)

Assistant professor

Department of Dermatology

Medical College Kolkata, West Bengal

Introduction

Lupus vulgaris is progressive, paucibacillary form cutaneous tuberculosis seen in patients sensitized to M. Tuberculosis 1 Mainly such conditions are visible in patients with moderate to low degree of immunity. This is susceptible to all age group equally with three to four times more chances of females as compared to males. The most salient histopathology trait spotted was tubercle formation with or without caseation, encircle by some epitheliod histiocytes.2 The head and the neck regions are most likely being affected.3 Spontaneous involution takes place with addition of new lesions within old scar. No improvement is seen without appropriate therapy. Some other features like atrophy with extravagant hyperkeratosis were also observed. There are five variations of lupus vulgaris: hypertrophic or vegetation, plaque, tumour-type, papular or nodular and ulcerative types.2

Basal cell carcinoma is mainly observed in skin areas that are more prone to sun exposures and it is mainly a non melanoma skin cancer which was also known as basal cell epithelioma, with increasing prevalence rates. It is a slow growing tumour with fewer chances for metastasis and lesser fatality rate and can turn highly destructive when treatment is inadequate or delayed. It mainly emerges as flesh- or pink-colored, pearly papules surrounded by ulceration or telangiectatic vessels.2

26 subtypes of BCC have been reported up till now, amongst which most common are nodular, micro nodular, superficial, morpheaform, infiltrative and fibroepithelial. Majority cases are amelanotic but fluctuating amounts of melanin is found on these tumours. Method of treatment involved is excision, electrodesiccation and curettage (EDC), cryosurgery and Mohs micrographic surgery. These methods are restricted for localised BCC and offers 95% cure rates.4

Here we report an interesting case of lupus vulgaris mimicking basal cell carcinoma.

Case Report

A 65 years old male farmer by occupation presented to our outpatient department with one year history of small skin bump on his nose which on given period of time slowly progressed further. The patient initially came with complaints of pain, ulceration pigmented raised lesion over his nose. There was no history of any predisposing factors such as radiation burns, immunocompromised status and arsenic exposure. No significant past, family and medical history. On cutaneous examination revealed ulcerative plaque on nose with crust and well defined border (Figure 1). Ulcer border was found to be undermining with swallow base. Clinically it was indicating lupus vulgaris with peculiar atrophy at one end and progression at other end. On further evaluation of the lesion for indicated basal cell carcinoma (BCC), squamous cell carcinoma (SCC), cutaneous tuberculosis. Histopathological examination showing caseating granuloma. There was no lymph node involvement which indicated no lymphadenopathy. There was no bone involvement as well. Final diagnosis was made lupus vulgaris.

Diagnosis

Basal cell carcinoma (BCC) is a type of skin cancer, usually slowgrowing and found mainly in sun damaged areas. To diagnose BCC, a dermatologist will usually start by examining the skin for any suspicious growths or changes. Clinically it was indicating lupus vulgaris with peculiar atrophy at one end and progression at other end.2 Biopsy was also performed where a small sample of tissue is taken from the suspicious area and examined under a microscope to determine if it is cancerous. On further evaluation of the lesion for indicated basal cell carcinoma, squamous cell carcinoma, cutaneous tuberculosis.5 The lesions were sharp bordered, irregular, brownishred plaques on physical appearance with noticeably swollen nose. Ulcer border was found to be undermining with swallow base. Histopathology of the lesion on the nose showed a granulomatous tubercle. Biopsy also revealed ulcerated area encircled superficially by crusts, some giant cells within. The patchy area had atrophic plaque with some ulceration on the extremes. There was no lymph node involvement which indicated no lymphadenopathy. There was no bone involvement as well. Final diagnosis suggested was lupus vulgaris. Other tests, such as an imaging scan or a blood test may also be ordered if the dermatologist suspects that the cancer has spread beyond the skin.

Discussion

This case report seeks to highlight unusual cases of lupus vulgaris involving the nose and mimicking basal cell carcinoma. Lupus vulgaris is earliest recognized chronic, destructive, slowly progressive type of cutaneous tuberculosis. Mainly observed on sun-damaged skin by atrophy, scarring and ulcerative lesions. Sometimes associates with, lymph node bone and lung. Primary areas of target are the head and neck regions. On persistent cases, patients have developed squamous cell carcinoma, basal cell carcinoma and sometimes associated with deformity.6

It is a reinfection tuberculosis originating externally by direct inoculation of the bacilli or internally by haematogenous or lymphatic spread from affected area in host. In this case the lesion imitated basal cell carcinoma by keeping in mind the occupation of the patient involving maximum sun time exposure. The physical appearance depicting a nodulo-ulcerative plaque with undermine border and no lymphadenopathy. There was appearance of new lesions in the areas of old scar. 90% of skin cancers consist of basal cell carcinoma and squamous cell carcinomas originating from basal keratinocytes of the epidermis and sometimes from hair follicle and sebaceous glands.7

Conclusion

Cutaneous tuberculosis is one of the causes of basal cell carcinoma. Basal cell carcinoma is a malignant tumour arriving from keratinocytes of the epidermis leading to skin cancer. In above mentioned case patient was experiencing lupus vulgaris which later turned out to be secondary malignancy which on histopathological examination confirmed to be basal cell carcinoma. From the above case presentation we can conclude that, there are rare chances of long lasting lupus vulgaris which eventually developed into malignancy case. We can hence conclude that cutaneous tuberculosis abides to be a great mimic of skin cancers including squamous and basal cell carcinoma. Diagnosis of such a case is difficult thus it is essential to carry out wide excision of the affected area especially the affected and scared region. Although the cases of cutaneous tuberculosis are rare but still its diagnosis and treatment are very fundamental for both patient and public health. Early diagnosis and treatment may be helpful to

stop prevailing of skin cancer.

References

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2. Pai VV, Naveen KN, Athanikar SB, Dinesh US, Divyashree A, Gupta G. A clinico-histopathological study of lupus vulgaris: A 3 year experience at a tertiary care centre. Indian Dermatol Online J. 2014 Oct;5(4):461-5. Doi: 10.4103/2229-5178.142497. PMID: 25396129; PMCID: PMC4228641.

3. Theodosiou, G., Papageorgiou, M., & Mandekou-Lefaki, I. (2018). An Unusual Presentation of Lupus Vulgaris and the Practical Usefulness of Dermatoscopy. Case Reports in Dermatological Medicine, 2018, 1–3. Doi:10.1155/2018/1036162

4. Mcdaniel B, Badri T, Steele RB. Basal Cell Carcinoma. [Updated 2022 Sep 19]. In: statpearls [Internet]. Treasure Island (FL): statpearls Publishing; 2022 Jan-. Available from: https://www.ncbi. nlm.nih.gov/books/NBK482439/

5. Abhinesh N, Danny C G, Srinivasan S, Pravin A. Basal cell carcinoma masquerading as lupus vulgaris - A case report. IP Indian J Clin Exp Dermatol 2021;7(2):172-174.

6. Kate MS, Dhar R, Borkar D B, Ganbavale DR. Longstanding lupus vulgaris with basal cell carcinoma. Indian J Pathol Microbiol 2009;52:58890

7. Khandpur, S., & Reddy, B. (2003). Lupus vulgaris: unusual presentations over the face. Journal of the European Academy of Dermatology and Venereology, 17(6), 706–710. Doi:10.1046/j.14683083.2003.00838.x