Disseminated lupus vulgaris presenting as granulomatous folliculitis

A 69-year-old man presented with a 3-year history of scattered, grouped, asymptomatic follicular papules, pustules, and nodules tending toward coalescence into large geographic aggregates. Repeated cutaneous biopsy specimens showed granulomatous folliculitis with negative Ziehl-Neelsen stains. Finally, biopsy material submitted for mycobacterial culture grew Mycobacterium tuberculosis. No evidence of active systemic tuberculosis was found. The patient had a very rare form of tuberculosis, disseminated lupus vulgaris, presenting with granulomatous folliculitis, which is usually not seen in lupus vulgaris. The lesions resolved after an 18-month course of isoniazid and rifampin. The unusual clinical and histologic presentation as well as occasional partial remissions following a variety of nonspecific empiric therapies delayed diagnosis despite multiple evaluations. This case illustrates the importance of obtaining mycobacterial cultures from skin biopsy specimens in addition to special stains whenever cutaneous tuberculosis is suspected.