Cutaneous tuberculosis chancre: case description in a child

or immunoglobulin heavy chain and T-cell gamma chain ene rearrangements. Based on the above findings, a diagosis of idiopathic CPL was rendered. The patient received urgical therapy. In the following-up seven years, the lesions id not reappear, and the patient was healthy. Cutaneous Pseudolymphoma (CPL) is not an uncommon ondition, which considers a group of benign cutaneous ymphoproliferative disorders and very rarely progresses to ymphoma. The clinical presentation of CPL has a wide specrum. The most common clinical manifestations are red o violaceous nodules, papules, or plaques on the exposed reas, especially on the face and neck. Subcutaneous nodles, as in our case, are the uncommon presentation of CPL, hich have been described in several cases occurring secndary to feline scratches or injection of vaccines.2--4 In ddition, the lesions in previous cases are all on extremYanping Bai: Approval of final version of the manuscript; conception and planning of the study. Zhancai Zheng: Approval of final version of the manuscript; conception and planning of the study; drafting and editing of the manuscript; critical review of the literature; critical review of the manuscript.


Ying Wang
, Sitong Li , Yanping Bai , Zhancai Zheng * Department of Dermatology, China-Japan Friendship Hospital, Beijing, China manifestations are variable and depend on several factors, such as the host's immune status. 1,2 The extrapulmonary forms of tuberculosis account for approximately 10% of cases, with 1% to 2% occurring on the skin. 3,4 Children have this form of disease more frequently, possibly due to the immaturity of their immune system.
An eight-year-old male patient presented with an erythematous papule on the medial aspect of the right thigh, which developed into an ulcerated nodule followed by the appearance of another ulcerated nodule nearby after a few days (Fig. 1). He denied local trauma or systemic symptoms. On dermatological examination, there was an indurated plaque with 2 well-defined lesions (measuring 3 × 2 cm and 2 × 1.5 cm), with a fibrin base and brownish edges, painful on palpation. The inguinal lymph nodes were palpable bilaterally. Ultrasound examination showed a mass immediately below the lesion, with lobulated contours and low vascular flow, extending to the deep adipose plane. The lymph nodes were enlarged, showing regular contours and loss of the usual architecture.
A wedge biopsy of the larger lesion was performed, which showed a granulomatous inflammatory process with areas of caseous necrosis, lymphohistiocytic inflammatory infiltrate, and Langerhans-type giant cells, favoring the diagnosis of tuberculosis.
The fungal screening tests (Grocott-Gomori and periodic acid Schiff stains) and search for acid-alcohol-resistant bacilli by the Ziehl-Neelsen staining were negative. A direct fresh examination of lesion scrapings showed no amastigote forms of Leishmaniasis and the chest X-ray was normal, with a 19-mm PPD (purified protein derivative) test (Fig. 2). It was not possible to perform the serum PCR exam due to its unavailability at the time.
After a trial treatment for tuberculosis (Rifampicin, Isoniazid, Pyrazinamide for two months; Rifampicin and Isoniazid for four months) was initiated, the patient showed significant lesion improvement, with local healing (Fig. 3).
Cutaneous tuberculosis chancre constitutes a rare form of CTB and is equivalent to the primary pulmonary complex. Also called primary inoculation chancre, it develops in people not previously sensitized, occurring more frequently in children. It occurs by direct inoculation into the skin after local, often unnoticed, trauma, with subsequent appearance of an ulcerated inflammatory papule, plaque or nodule, and regional lymphadenopathy. 1 Histopathology varies according to the time lapse after inoculation: initially, there is a nonspecific acute inflammatory infiltrate. Subsequently, granuloma formation and a decrease in the  number of bacilli occur. In most samples, the bacilli will not be observed even with special staining, which makes other complementary tests useful, such as PPD and/or serum PCR, clinical follow-up, and, often, therapeutic testing. When there is clinical suspicion, a histopathological examination with suggestive features, plus a strongly reactive positive PPD, the diagnosis should be suspected. Treatment is similar to that of pulmonary forms of the disease. 4,5 Financial support None declared.
intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.
Lívia Caramaschi Florêncio: Drafting and editing of the manuscript; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.
Vidal Haddad Junior: Drafting and editing of the manuscript; effective participation in research orientation; intellectual participation in the propaedeutic and/or therapeutic conduct of the studied cases.

Dear Editor,
Eruptive collagenoma is a rare connective tissue nevus, which presents with asymptomatic, multiple, discrete, firm, slightly elevated, skin-colored, or reddish papules on the trunk and extremities. We describe herein a rare case of eruptive collagenoma on the back of a juvenile patient with Down syndrome. A 14-year-old boy with Down syndrome and a previous history of anorectal anomaly visited our Dermatology Department, complaining of asymptomatic eruption on his back. He had no family history of connective tissue nevi. Physical examination showed several red-brown or whitish papules on his back (Fig. 1). There were no eruptions in other locations. One of the papules was removed under local anesthesia. A biopsy specimen revealed relatively wellcircumscribed areas with increased collagenous fibers in the upper to mid-dermis ( Fig. 2A). Lack of elastic fibers as compared with surrounding dermis was observed in Elastica Masson (Fig. 2B), Elastica van Gieson and Weigert staining. A diagnosis of collagenoma was made. No specific treatment was given.
Several cutaneous manifestations are associated with Down syndrome, including atopic eczema, seborrheic eczema, alopecia areata, vitiligo, psoriasis, tinea, syringoma, and milia-like calcinosis cutis. 1 By contrast, connective tissue disorders such as collagenoma, connective ଝ Study conducted at the Department of Dermatology of Fukushima Medical University, Fukushima, Japan. tissue nevi, anetoderma, and elastosis perforans serpiginosa, are rare. Eruptive or solitary collagenoma is rarely seen in patients with Down syndrome. 2---4 Among the previously reported 5 patients and our patient, 2 were male, and 3 were pediatric patients; and age ranged between 7 and 47 years old. The affected sites were the neck, chest, back, abdomen, buttock, groin, sacrococcygeal region, thighs, hands, and arms. Four patients developed multiple lesions, while 2 patients developed solitary lesions. The etiology of collagenoma in Down syndrome remains unknown; however, premature aging due to impaired DNA repair or altered free radical metabolism may be involved. 1 The genetic locus for superoxide dismutase, a key enzyme in free radical metabolism is located in chromosome 21. Moreover, in the skin of fetuses with trisomy 21, overexpression of Figure 1 Small oval, slightly reddish or skin-colored papules scattered on the back (arrow).