Abstract

60-year-old lady presented with chronic non healing ulcer of the left arm for 1 year and 3 months duration. She had received treatment for cutaneous leishmaniasis and atypical mycobacterial infection with a poor response. The ulcer started spontaneously and gradually increased in size. It was painless and no purulent discharge was present. Patient had mild dry cough and loss of appetite and loss of weight. She had no history or contact history of tuberculosis. No arthralgia, red eyes or other skin eruptions noted. No recurrent upper respiratory symptoms, oral/nasal ulcers or frothy urea/haematuria. Her systemic review and past medical history were unremarkable. Examination revealed well defined pinkish indurated plaque measuring 15x10 cm size with multiple shallow ulcers with granulation tissue and purulent exudate. No rolled, everted, indurated violaceous overhanging edges present. No cutaneous manifestations of tuberculosis, sarcoidosis, connective tissue diseases or systemic vasculitis were noted. She was thinly built but rest of the general and systemic examination findings were unremarkable. Skin biopsies were compatible with granulomatous inflammation with few foci of necrosis. No central caseation was noted and epithelioid granulomas had a lymphocytic cuff. No vasculitis was noted in the histology. All special stains were negative including ziehl-neelsen, PAS, Grocott, gram stains. Tissue cultures were negative for bacteria, mycobacteria, fungi and leishmaniasis. Tissue biopsy for mycobacterial PCR was negative. Moreover, sputum AFB x3, and TB Quanti FERON gold test were negative. Haematological, biochemical and imaging studies were arranged in order to evaluate for possible differential diagnosis such as Tuberculosis, Atypical mycobacterial infections, Sarcoidosis,