S.E. Donoghue , M. Gupta , S. Kossard
Papular necrotic tuberculid (PNT) is commonly described on the extensor aspects of the arms, with the head, neck and trunk uncommon sites. We describe the case of a 28 year old man who emigrated from Bangladesh and presented with multiple papulonecrotic lesions concentrated over his face, upper trunk and scalp. Although acneiform in appearance, his skin eruption failed to respond to traditional anti-acne treatments with his general practitioner. Upon dermatological review the clinical appearance was suggestive of papular necrotic tuberculid despite its distribution and biopsies performed demonstrated necrotising granulomas suggestive of PNT. Clinical examination revealed multiple cervical and some axillary lymphadenopathy with CT chest conﬁ rming this. Tissue culture from skin and axillary nodes failed to demonstrate mycobacterium despite the presence of granulomatous inﬂ ammation. Serum ACE, Quantiferon gold and Mycobacterium PCR also returned as negative. With a high degree of suspicion of PNT based on histological and clinical ﬁ ndings, despite no microbiological evidence of TB infection, TB therapy was instituted. Following initiation of TB therapy a signiﬁ cant improvement was observed. This case emphasizes the need in Australia’s current climate to remain sensitised to conditions normally seen only in developing countries. It also highlights the importance of clinical and histological ﬁ ndings in both making a diagnosis and choosing appropriate treatment, with 30–40% of PNT cases failing to identify mycobacterium TB on culture or PCR.