Arch Dis Child doi:10.1136/archdischild-2013-303906
  • Images in paediatrics

A painless pigmented pinna lesion

  1. Yogesh M Bhatt
  1. Correspondence to Yogesh M Bhatt, Department of Paediatric Ear, Nose and Throat Surgery, Royal Manchester Children's Hospital, Oxford Road, Manchester M13 9WL, UK; bhatt_ym{at}
  • Accepted 14 March 2013
  • Published Online First 11 April 2013

Case report

A 15-year-old boy presented with a 2-month history of a painless lesion on the right earlobe and multiple neck lumps. He had emigrated from Pakistan 4 years earlier and had received the Bacillus Calmette–Guérin (BCG) vaccine at birth. He denied systemic or respiratory symptoms. On examination, a 14 mm soft painless pigmented lesion on the pinna was noted (figure 1). Multiple discreet lymph nodes were palpable on either side of the neck. A Mantoux test was positive but a chest x-ray was unremarkable. Excision biopsy for histology and culture from the ear and representative lymph node showed multiple caseating granulomata with acid-fast bacilli (AFB) on Ziehl–Neelsen staining. Subsequent culture grew Mycobacterium tuberculosis, which was treated with a 6-month course of antituberculosis treatment, to good effect.

Figure 1

Clinical photograph of right ear lobe: lupus vulgaris.


Lupus vulgaris represents the most common form of cutaneous tuberculosis in Pakistani children and primarily affects the head and neck.1 It may occur following direct inoculation or endogenous spread,2 presenting as a soft painless nodule with a red-brown ‘apple jelly’ appearance on diascopy. BCG vaccination does not appear to prevent cutaneous tuberculosis.3 The diagnosis is made by clinical examination, supported by tuberculin skin test, histology and culture from the active lesion margin.4 AFB are seen in approximately 20% of skin biopsies.5 The standard regimen for skin tuberculosis consists of an initial 2 months of intensive-phase therapy with isoniazid, rifampicin, ethambutol and pyrazinamide followed by 4 months of maintenance therapy with isoniazid and rifampicin.6


  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; externally peer reviewed.


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