A 25-year-old male presented with an asymptomatic papulo-pustular
eruption over the glans penis. The clinical features and investigations
were suggestive of papulonecrotic tuberculids of the glans penis. He
had an underlying bilateral active tuberculous epididymo-orchitis and a
healed focus of pulmonary tuberculosis

Murthy SC, Udagani MM, Kajagar BM

Bioline International

Indian J Dermatol Venereol Leprol November-December 2003 Vol 69 Issue 6 408408 CMYKTuberculous epididymo-orchitis and papulonecrotic tuberculids of theglans penisS. Chidambara Murthy, M. M. Udagani, Basavaraj M. KajagarDepar tments of Dermatology and Venereology and Surgery, S. N. Medical College and HSK Hospital and Research Centre, Bagalkot -587101, India.Address for correspondence: Dr. S. Chidambara Mur thy, Department of Dermatology and Venereology, S. N. Medical College & HSK Hospital& Research Centre, Bagalkot - 587101 , India. E-mail: chidumur thy@Yahoo.comABSTRACTA 25-year-old male presented with an asymptomatic papulo-pustular eruption over the glans penis. The clinical featuresand investigations were suggestive of papulonecrotic tuberculids of the glans penis. He had an underlying bilateralactive tuberculous epididymo-orchitis and a healed focus of pulmonary tuberculosis.KEY WORDS: Genital tuberculosis, Tuberculids, Penile tuberculidsINTRODUCTIONTuberculosis is still a major cause of morbidity indeveloping countries like India. Cutaneous tuberculosisis also not uncommon in our country. Tuberculidsrepresent a cutaneous hypersensitive response to anunderlying focus of tuberculosis. Papulonecrotictuberculids over the glans penis is a rare occurrence.We report papulonecrotic tuberculids of the glans penismanifesting secondary to bilateral tuberculousepdidymo-orchitis.CASE REPORTA 25-year-old male presented with recurrent crops ofmultiple asymptomatic papulo-pustules over the glanspenis of 3 months’ duration. These used to resolvespontaneously in a few days with scarring. He had anasymptomatic, right sided scrotal swelling of the sameduration. He was treated with injection benzathinepencillin, systemic antibiotics and various topicalapplications before referral. There was no history oftrauma, drug intake, fever, cough and constitutionalsymptoms. There was no personal or family history oftuberculosis. The patient denied exposure to sexuallytransmitted diseases. He had not been vaccinated withBCG.Examination revealed a few erythematous, nontender,papules, pustules, and confluent pitted scars over theglans penis (Figure 1). There was right sided hydrocelewith a firm, indurated, mildly tender epididymis and athickened vas with orchitis. There was thickening ofthe epididymis and vas with a beaded appearance onthe left side. There was no significant inguinallymphadenopathy. Muco-cutaneous, appendageal andsystemic examinations were normal.The following are results of relevant investigations:neutrophilia (73%) absolute eosinophil count 150, ESRCase ReportHow to cite this article: Murthy SC, Udagani MM, Kajagar BM. Tuberculous epididymo-orchitis and papulonecrotic tuberculids of the glanspenis. Indian J Dermatol Venereol Leprol 2003;69:408-10.Received: September, 2003. Accepted: December, 2003. Source of Support: Nil.Indian J Dermatol Venereol Leprol November-December 2003 Vol 69 Issue 6409CMYK409(Westergren’s method) 70 mm/hr, blood VDRL non-reactive, HIV-1 and-2 (ELISA) negative, and Mantouxtest strongly positive (25 x 20 mm induration). Thechest X-ray showed evidence of healed tuberculosis.X-ray and ultrasound KUB were normal. Ultrasoundexamination of the scrotum showed evidence ofhydrocele, and patchy calcifications of the epididymis,vas, and seminal vesicles on both sides. Urine culturefor bacteria/AFB growth was negative. Pus from apustule showed no organisms on Grams and Ziehl-Neelsen staining and culture. The patient refused semenanalysis. Fine needle aspiration from a nodule of thevas showed features consistent with tuberculosis.Histopathology from a papule over the glans wasconsistent with papulonecrotic tuberculids.He was put on antitubercul no treatment (ATT) for sixmonths. Two weeks after the initiation of therapy, theexisting lesions over the glans had healed. Furtherfollow-up showed improvement in the condition andno recurrence.DISCUSSIONThe concept of tuberculids was introduced by Darierin 1896. Tuberculids are symmetric eruptions inresponse to an internal focus of tuberculosis in anindividual with a moderate or high degree of immunity.Papulonecrotic tuberculids are asymptomatic,symmetrical, dusky red papules which heal withscarring. The sites of predilection are the elbows, knees,legs, hands, feet, but the ears, face, buttocks and peniscan be affected.1 Involvement of the glans penis wasfirst described by Hellerstrom and later by Bafverstedtand Hageman and Granroth.2 The occurrence iscommoner in Japan and has been termed as penistuberculides. 3 A few reports have been documentedfrom other parts of the world from India.2,4-8The basic diagnostic criteria for papulonecrotictuberculids are: a strongly positive Mantoux test, typicalclinical features, a tuberculoid histology withendarteritis and thrombosis of the dermal vessels, andresponse to ATT.2 The histological findings may besometimes inconclusive, showing a non-specific ortuberculoid picture. 4 The spectrum of histologicalfindings ranges from acute leukocytoclastic vasculitisin early lesions to mature granuloma formation in olderones. The proof of diagnosis rests on the unequivocalresponse to ATT.5An analysis of 91 cases of papulonecrotic tuberculidsshowed a deep focus in about one-third of the cases(38%). Involvement of lymph glands was the commonestand a urogenital focus the least common. 9 Themmajority of cases of papulonecrotic tuberculids of glanspenis reported2-4,6,8 earlier lacked an underlyingtuberculous focus, but our case had an active focus.Our case was unique in that there was an associationof healed pulmonary focus, bilateral activetuberculous epidydmo-orchitis with involvement ofthe seminal vesicles and papulonecrotic tuberculidsof the glans penis, which to the best of our knowledgehas not been reported earlier. Kashima et al reviewed26 cases of penile tuberculids reported for the last 13years, who found co-existing tuberculosis elsewherein four cases only.10Although tuberculosis is common, tuberculids of thepenis are rarely reported even in endemic countrieslike India. Diagnosis is possible by awareness of thecondition, strong suspicion and relevant investigations.An underlying active or healed focus of tuberculosisshould be thoroughly searched for.REFERENCES1. Gawkrodger DJ. Mycobacterial infections. In: Champion RH,Murthy SC, et al: Tuberculous epididymo-orchitis and papulonecrotic tuberculids of the glans penisFigure 1:Lesions involving glans penisIndian J Dermatol Venereol Leprol November-December 2003 Vol 69 Issue 6 410410 CMYKBurton JL, Burns DA, Breathnach SM, editors. Rook/Wilkinson/Ebling Textbook of Dermatology. 6th ed. Oxford: BlackwellScience; 1998. p. 1199-200.2. Jeyakumar W, Ganesh R, Mohanram MS, ShanmugasundararajA. Papulonecrotic tuberculids of the glans penis: case report.Genitourin Med 1988;64:130-2.3. Nishigori C, Taniguchi S, Hayakawa M, Imamura S. Penistuberculides: Papulonecrotic tuberculides on the glans penis.Dermatologica 1986;172:93-7.4. Stevanovic DV. Papulonecrotic tuberculids of glans penis. ArchDermatol 1958;78:760-1.5. Israelewicz S, Dharan M, Rosenman D, Steinfeld M, ZuckermanF. Papulonecrotic tuberculid of the glans penis. J Am AcadMurthy SC, et al: Tuberculous epididymo-orchitis and papulonecrotic tuberculids of the glans penisDermatol 1985;12:1104-6.6. Pavithran K, Vijayadharan M, Gangadharan C. Papulonecrotictuberculid on glans penis. Indian J Dermatol Venereol Leprol1982;48:42-4.7. Kumar B, Sharma VK. Papulonecrotic tuberculides on glanspenis. Dermatologica 1987;174:151-2.8. Anoop UC, Pavithran K. Genital tuberculosis. Indian J DermatolVenereol Leprol 2002;68:164-5.9. Morrison JGL, Fourie ED. The papulonecrotic tuberculide. Br JDermatol 1974;91:263-70.10. Kashima M, Mori K, Kadono T, Nakabayashi Y, Shibayama E,Mizoguchi M. Tuberculide of the penis without ulceration. BrJ Dermatol 1999;140:757-8.AnnouncementAsian Society for Pigment Cell Research (ASPCR)This is to announce the formation of Asian Society for Pigment Cell Research (ASPCR) under the umbrella of InternationalFederation of Pigment Cell Societies (IFPCS). The parent body (IFPCS) is an organization composed of regional ornational societies which are specifically dedicated to the study of and investigations on pigment cells and pigmentation.The purpose of this Society will be to promote research on pigment cells and pigmentary disorders in a broad senseand the exchange of information among its members, as well as members of the international community. ThisSociety will provide the forum for interactive discussions by bringing together clinicians (dermatologists and otherphysician with broad interest in pigmentation) and basic researchers from various disciplines, including developmentalbiology, biochemistry, cell and molecular biology, immunology, pharmacology and toxicology, chemistry and physics.The other benefits of joining this society are: subsidized subscription to the journal ‘Pigment Cell Research’ (theofficial publication of the International Federation of Pigment Cell Societies), eligibility for travel awards to attendannual meeting as well as International Pigment cell Conferences (International Pigment cell Conferences are theworld assemblies held once in 3 years), IFPCS Visiting Scientist Award (The IFPCS has set up a fund to supportinvestigators in pigment research who wish to take a short international sabbatical trip to further their research).For further information please contact:ASPCR SecretariatDepartment of Dermatology, Venereology and LeprosyPostgraduate Institute of Medical Education and Research, Chandigarh - 160012, India.Web: www.aspcr.net    E-mail: aspcr@sify.com

Tuberculous epididymo-orchitis and papulonecrotic tuberculids of the glans penis

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