Lupus vulgaris: a narrative review

Lupus vulgaris (LV) is a type of paucibacillary cutaneous tuberculosis that can occur due to inoculation, lymphatic, or hematogenous route. It occurs in a previously sensitized individual with high immunity to tuberculosis. LV can have different morphology of presentation, which can lead to difficulty in diagnosis. The Tuberculin test is strongly positive. Histopathology will show epithelioid granulomas in the superficial dermis and acid-fast bacilli rarely demonstrable within the granulomas. Dermoscopy will show focused linear vessels on a yellow to orange background. Culture is the gold standard for diagnosis, but its positivity rate is low. Mycobacterium tuberculosis bacilli can be detected using polymerase chain reaction from the lesions. Histopathology, tuberculin test, dermoscopy, molecular test, and culture would help diagnose LV. This review discusses the introduction, pathogenesis, clinical features, differential diagnosis, investigations, complications, and treatment of lupus vulgaris in detail. This review can help the dermatologist understand the condition better with appropriate diagnosis and therapy.

Atypical presentations of cutaneous tuberculosis: Series of 10 cases

Cutaneous tuberculosis classically presents as Lupus vulgaris, scrofuloderma, tuberculosis verrucose cutis and tubercular abscess. Hypersensitivity reaction to the bacilli leads to Lichen scrofulosorum and papulonecrotic tuberculids. At the same time, it can have myriad of clinical presentations, many of which are still undescribed. It is important to regularly update ourselves with these unusual manifestations so as to ensure early treatment and reduction of overall morbidity. In this case series tuberculosis manifesting as rapidly progressing diffuse facial granulomas, sporotrichoid tuberculosis, tuberculosis mimicking squamous cell carcinoma, scrofuloderma as tubercular ulcer, lupus vulgaris with nasal septal perforation, lupus vulgaris resembling furuncle, psoriasis, dermatitis and BT Hansen are described in immunocompetent individuals. These cases highlight the importance of recognition of atypical forms of cutaneous tuberculosis to minimize scarring and dissemination of bacilli.

Giant Arcuate Lupus Vulgaris with Rapid Progression: A Case Report

Lupus vulgaris is the commonest form of cutaneous tuberculosis. It is a chronic and slowly progressive disease. It can be transmitted either through hematogenous or lymphatic spread but most commonly through contiguous extension.There are many reports on different form of lupus vulgaris but there are only a few reports on large sized lupus vulgaris. Here, we report a case of 75-year-old man with a giant lupus vulgaris rapidly progressing in just two year's duration. Keywords: cutaneous tuberculosis;lupus vulgaris; Nepal.

Drug-Induced Lupus Associated with Synthetic Conjugated Estrogens

Objective:

To report a case of drug-induced lupus (DIL) in a patient taking Cenestin, a combination product of synthetic conjugated estrogens.

Case Summary:

A 54-year-old white female presented with a 4 month history of bilateral arm pain that developed and progressively worsened after initiating Cenestin 0.625 mg daily. The patient's symptoms, findings on physical examination (eg, degenerative changes of the acromioclavicular joint), and laboratory test results (eg, antinuclear antibody titer 1–640 [normal <1–40]) were suggestive of DIL. Her symptoms rapidly resolved with discontinuation of Cenestin and promptly resumed with reinitiation of the drug. Laboratory test values also improved significantly with discontinuation of Cenestin. Based on these findings and the Naranjo probability scale score, this reaction was probably associated with Cenestin.

Discussion:

DIL differs from systemic lupus erythematosus in that it is caused by prolonged exposure at adequate doses to a drug rather than being an autoimmune reaction. The most commonly reported and studied medications are hydralazine, quinidine, and procainamide. Other medications have been associated with DIL; however, data are limited in these reports, especially with estrogen. There have been no previous reports in the literature of synthetic estrogen products associated with DIL.

Conclusions:

A diagnosis of DIL can be very challenging to make, especially since there are no clear criteria on which to base it. While estrogen has rarely been reported to be associated with DIL, it may be considered as a possible cause.

Cutaneous Tuberculosis Occurring After a Skin Cut in a Child

BACKGROUND

Tuberculosis is a common problem in Turkey, and cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis. Herein, the authors describe a case of cutaneous tuberculosis (lupus vulgaris) occurring after contact with a sheep.

CASE

A 15-year-old boy was admitted to Marmara University School of Medicine Pendik Training and Research Hospital (Istanbul, Turkey) with delayed wound healing on the left index finger and left axillary lymphadenopathy. His medical history was unremarkable except for a wound incurred when he slaughtered a sheep 3 months before. One month after this injury, the patient developed enlargement of the left axillary lymph node on the side of the wounded extremity, and the wound turned a dark black color. The biopsy specimens obtained from the wounded skin and lymph nodes showed granulomatous reaction, but acid-fast bacilli (AFB) could not be shown with Ehrlich-Ziehl Neelsen staining. The patient tested positive in an interferon-gamma release assay. Computerized tomography scans of the thorax were normal, and early morning gastric lavage specimen was negative for AFB. The wound and axillary lymphadenopathy disappeared after institution of anti-tuberculosis therapy.

CONCLUSION

Tuberculosis infection must be considered in chronic skin lesions with granulomatous reaction occurring in countries with high prevalence of tuberculosis.

Complement-fixing properties of antinuclear antibodies distinguish drug-induced lupus from systemic lupus erythematosus

The immunofluorescence antinuclear antibody (ANA) test has been widely used to monitor autoimmune disease, but its value for diagnostic purposes is compromised by low specificity and high prevalence in disease-free individuals. The capacity of autoantibodies to fix serum complement proteins when bound to antigen is an important effector function because this property is associated with acute and chronic inflammatory processes. The current study evaluates the complement-fixing properties of antinuclear antibodies (CANA) in three well-defined and clinically-related patient groups: systemic lupus erythematosus (SLE), drug-induced lupus (DIL) and drug-induced autoimmunity (DIA). Of 20 patients diagnosed with SLE, 90% displayed complement-fixing ANA while this feature was present in only two of 18 patients with DIL and no patients with DIA without associated disease even though the mean ANA titres were similar among these patient groups. CANA was significantly correlated with anti-Sm activity. Because SLE but not DIL or DIA can be a life-threatening disease associated with complement consumption in vivo, these results demonstrate that measurement of CANA is a diagnostically useful tool and may have immunopathologic implications.

Neonatal lupus syndromes

The neonatal lupus syndromes (NLS), while quite rare, carry significant mortality and morbidity in cases of cardiac manifestations. Although anti-SSA/Ro-SSB/La antibodies are detected in .85% of mothers whose fetuses are identified with congenital heart block (CHB) in a structurally normal heart, when clinicians applied this testing to their pregnant patients, the risk for a woman with the candidate antibodies to have a child with CHB was at or below 1 in 50. While the precise pathogenic mechanism of antibody-mediated injury remains unknown, it is clear that the antibodies alone are insufficient to cause disease and fetal factors are likely contributory. In vivo and in vitro evidence supports a pathologic cascade involving apoptosis of cardiocytes, surface translocation of Ro and La antigens, binding of maternal autoantibodies, secretion of profibrosing factors (e.g., TGFb) from the scavenging macrophages and modulation of cardiac fibroblasts to a myofibroflast scarring phenotype. The spectrum of cardiac abnormalities continues to expand, with varying degrees of block identified in utero and reports of late onset cardiomyopathy (some of which display endocardial fibroelastosis). Moreover, there is now clear documentation that incomplete blocks (including those improving in utero with dexamethasone) can progress postnatally, despite the clearance of the maternal antibodies from the neonatal circulation. Better echocardiographic measurements which identify first degree block in utero may be the optimal means of approaching pregnant women at risk. Prophylactic therapies, including treatment with intravenous immunoglobulin, await larger trials. In order to achieve advances at both the bench and bedside, national research registries established in the US and Canada are critical.

Tropical and exotic dermatoses and ulcers

BACKGROUND

Tropical dermatoses and ulcers, although essentially unique to tropical and subtropical areas, are occasionally seen in Australian general practice on returning travellers and migrants from endemic countries.

OBJECTIVE

This article will discuss important causes of tropical and exotic ulcers occasionally seen in Australia.

DISCUSSION

As tropical ulcers may mimic many other causes of skin ulceration and nodules, a history of recent travel should arouse clinical suspicion. The time frame since exposure to the causative organism is an important feature in the diagnostic process. For example, pyodermas and cutaneous larva migrans present a few days after contact with the causative agents, whereas leishmaniasis, cutaneous tuberculosis, atypical mycobacterial diseases (swimming pool granulomas) and tropical mycosis take weeks to months to appear.

The great mimickers of rosacea

Although rosacea is one of the most common conditions treated by dermatologists, it also is one of the most misunderstood. It is a chronic disorder affecting the central parts of the face and is characterized by frequent flushing; persistent erythema (ie, lasting for at least 3 months); telangiectasia; and interspersed episodes of inflammation with swelling, papules, and pustules. Understanding the clinical variants and disease course of rosacea is important to differentiate this entity from other conditions that can mimic rosacea. Herein we present several mimickers of rosacea that physicians should consider when diagnosing this condition.

Lupus vulgaris: unusual presentation on face

Lupus vulgaris is a variant of cutaneous tuberculosis. As the disease has potential to mutilate when left untreated, leaving deforming scars and disfigurement, an early diagnosis is of paramount importance. Though the common type is plaque type, rarely mutilating and vegetative forms also are found. A 28 year old female, labourer presented with progressive annular plaque over right side of cheek extending upto right lower lid and ala of nose. There were two satellite plaques near the right side of giant lesion. On diascopy apple jelly nodule was seen. There was no regional lymhadenopathy. Histopathological examination showed many granulomas in upper dermis extending to deep dermis comprising of epitheloid cells with langhans' type of giant cells, lymphocytic infiltration & focal necrosis suggestive of lupus vulgaris. The consequences of failing to make an early diagnosis can be disastrous for the patients, as the progression of the disease can lead to necrosis, destruction of bones and cartilage leading to permanent deformity. Thus it is vital for clinicians to have a high index of suspicion of such atypical forms and take biopsy samples for histological and bacteriological studies.

Lupus Vulgaris Erythematoides: report of a patient initially misdiagnosed as dermatitis

A small percentage of patients with tuberculosis present with cutaneous findings, which may be difficult to diagnose. We present a patient diagnosed with a rare, non-scarring form of cutaneous tuberculosis (CTB), classically termed as lupus vulgaris erythematoides.

Lupus vulgaris of external nose--a case report

Lupus vulgaris is the most common morphological variant of cutaneous tuberculosis accounting for approximately 59% of cases of cutaneous tuberculosis in India. We present a case of lupus vulgaris of external nose diagnosed early and treated with CAT-3 RNTCP regimen for six months without any nasal deformity except for a small scar over the dorsum of the nose. Patient followed up for one year after completion of the prescribed regimen, there being no recurrence of the lesion.

Lupus vulgaris diagnosed after 37 years: a case of delayed diagnosis

Lupus vulgaris is the most common chronic, progressive form of cutaneous tuberculosis. Lesions are generally solitary and found on the head and neck region. Cutaneous tuberculosis can present with different clinical appearances. Therefore, it does not necessarily have characteristic findings and can be difficult to diagnose. Although there were typical clinical findings, the diagnosis of our case was delayed because of its asymptomatic course.

Various faces of Hansen's disease

Leprosy is a chronic granulomatous disease caused by Mycobacterium leproe. Leprosy once considered a taboo is still misdiagnosed and underdiagnosed. In many cases leprosy is treated as common disorders like psoriasis, pyoderma, angioedema, pre vitiligo. Leprosy can present in many diverse ways which can be confused with many treatable and non treatable, infectious and non infectious forms. Leprosy is considered on the verge of elimination. But Leprosy cases are being newly diagnosed day by day. Here we are presenting 4 atypical cases of leprosy which did not seem to have classical presentation but were diagnosed as leprosy when investigated.

Leprosy mimicry of lupus vulgaris and misdiagnosis of leprosy--a case report

Leprosy and tuberculosis (TB) both are still rampant in India. Leprosy predominantly presents through skin manifestations whereas cutaneous manifestations of TB though not so frequent but are not rare. Lupus vulgaris (LV), the commonest of all cutaneous manifestations of TB, mimics leprosy very closely and may prompt the examiner to misdiagnose leprosy, especially, by health workers (HW), in a field situation, where leprosy is diagnosed and treated on clinical basis alone as per NLEP guidelines. Because of existing stigmata, such wrong diagnosis can put the patient and the party under psychological stress and creates unnecessary complications.

Disseminated lupus vulgaris

A 28-year-old woman presented with reddish raised, shiny lesions over the face and ears present for the past 3 years. Four years ago, she developed in her left axilla a nodule that became fluctuant and tender, which ruptured to discharge seropurulent material. It subsided after the patient had received antibiotics for 6 months, leaving puckered scarring. There was no history of antituberculous treatment. After 1 year, she developed papulonodular lesions on her face, nose, and ears. There was now a history of malaise, fever, dry cough, and anorexia and weight loss for the past 2 months. The patient was fully vaccinated in childhood, including against varicella infection. The general physical examination revealed lymphadenopathy involving cervical, axillary, and inguinal lymph nodes 0.5 x 0.5 cm to 1 x 1.5 cm, firm in consistency, and nontender. They were discrete except in the left axilla where multiple matted lymph nodes were present with overlying scarring and a papule. Her systemic examination was normal. Cutaneous examination showed a shiny erythematous plaque 3x2 cm with central atrophy and scarring on the face (Figure). It was comprised of multiple shiny nontender soft papules arranged in annular configuration. Similar discrete papules and nodules with adherent fine scaling were seen bilaterally on the alar prominence of the nose, lower lip, and post-auricular area. On diascopy, apple jelly nodules were seen. The hemogram, liver function tests, and renal function tests were normal, except for an elevated erythrocyte sedimentation rate. The Mantoux test showed erythema and an induration of 20 x 20 cm. A posteroanterior view on the chest x-ray showed fibrotic changes suggestive of pulmonary tuberculosis. Ultrasonography of the abdomen and pelvis showed no tubercular foci. Human immunodeficiency virus serology by enzyme-linked immunosorbent assay with 3 different kits was nonreactive. Histopathology from a nodule showed a focally thinned-out epidermis with follicular plugging and multiple epithelioid cell granulomas, rimmed by lymphocytes in the deeper portion of the dermis, mainly peri-appendageal. Stain for acid-fast bacteria was negative. Cultures from the skin lesions were negative. The patient was diagnosed as having lupus vulgaris with multiple lesions of varying morphology at different sites with pulmonary tuberculosis and healed lymph node involvement.

A nodulo-ulcerative lesion on the nose

Lupus vulgaris (LV) is a chronic, progressive, and potentially destructive form of cutaneous tuberculosis commonly seen in previously sensitized individuals with moderate to high immunity. We present a case of LV located on the nose of an 84-year-old female patient, discuss the diagnosis and treatment modalities, and emphasize the importance of having a high index of suspicion for this condition.

Lupus vulgaris of external nose with septal perforation--a rarity in antibiotic era

Lupus vulgaris (LV) is the commonest morphological variant of cutaneous tuberculosis. Case of LV of external nose extending to internal nose causing septal perforation is documented here. Histopathology of biopsy taken confirmed the diagnosis of LV. Patient responded well to Anti-tubercular therapy (ATT).

Lupus vulgaris with endopthalmitis--a rare manifestation of extrapulmonary tuberculosis in India

We report a case of 17-year-old girl who presented with gradual destruction of the nose along with endopthalmitis and loss of vision of the left eye. On nasal examination, left alae nasi and nasal cartilage was destroyed. Left eye showed signs of endopthalmitis with pthisis bulbi with complete loss of vision. Skin biopsy, FNAC of the lymph nodes were suggestive of tubercular etiology. However, patient did not have any evidence of pulmonary TB. We report this case due to the rare clinical features. The importance of a high index of suspicion and prompt treatment in such atypical forms to prevent morbidity cannot be over-emphasised.

Clinical profile of cutaneous tuberculosis in pediatric age

Childhood cutaneous tuberculosis is a common, yet understudied problem. Besides lupus vulgaris, scrofuloderma and tuberculosis verrucosa cutis which are frequently seen in adults, miliary tuberculosis, gumma and tubercular chancre are more often observed in children. Due to immaturity of immune system in children, chances of systemic tuberculosis are also more and warrant a thorough look for underlying systemic focus. Treatment of cutaneous tuberculosis includes short course antitubercular regimen consisting of rifampicin, isoniazid, ethambutol and pyrazinamide. Residual complications and ugly deformities affecting quality of life of a child can easily be prevented by ensuring early diagnosis. In late presentations, which are often the case, deformities should also be appropriately dealt with after the treatment for tuberculosis is completed.

Squamous cell carcinoma arising from long-term (50-year) Lupus vulgaris: is there a need for a close medical follow-up in such chronic diseases?

Skin manifestations of tuberculous infection (Mycobacterium tuberculosis) are represented by miliary tuberculosis of the skin, tuberculous chancre, scrofuloderma, tuberculosis verrucosa cutis, periorificial tuberculosis, and lupus vulgaris (LV). Among this group, LV is the most common skin condition, diagnosed in 10% of tuberculotic patients. The authors report herein a case of squamous cell carcinoma (SCC) arising from long-standing (50-year) LV and underline the need of an extensive follow-up of tuberculotic lesions.

[Therapy-resistant "psoriasis vulgaris"]

A 61-year-old patient had a 25-year history of erythematous scaling lesions, diagnosed and treated as psoriasis vulgaris. He presented with a growing nodule within the erythematous plaque. Biopsy shows epithelioid cell granulomas with prominent Langhans giant cells. There was no sign of a squamous cell carcinoma. The tuberculin test was strongly positive and M. tuberculosis complex was detected in the biopsy material by PCR. He was diagnosed with lupus vulgaris, the most frequent form of cutaneous tuberculosis. Other types include tuberculosis verrucosa cutis, tuberculosis cutis orificialis and disseminated military tuberculosis. The patient was treated with rifampicin, isoniazid, pyrazinamide and ethambutol for two months, following a four month treatment with rifampicin and isoniazid. The skin lesions rapidly resolved under antituberculotic treatment.

Psoriasiform lupus vulgaris

Tuberculosis is a major public health problem in both developing and developed countries. Cutaneous Tuberculosis constitutes a minor proportion of extra-pulmonary manifestations of Tuberculosis. Lupus Vulgaris (LV) is one of the clinical variants of Cutaneous Tuberculosis. A case of a large plaque type psoriasiform lesion of lupus vulgaris on the thigh, of 15 years' duration, in an 18-year-old girl is reported. This case highlights the ignorance level among the patients and consequent failure to avail proper anti-tuberculous treatment despite campaign in print and audio visual media.

Sporotrichoid cutaneous tuberculosis

Three patients with sporotrichoid cutaneous tuberculosis have been described. Two were children of either sex with lesions of lupus vulgaris along the lower limb and one woman had scrofuloderma along the left arm. Culture for Mycobacteria being negative, the diagnosis was based on the clinical picture, positive tuberculin test, granulomatous dermatitis on histopathology and regression with anti-tubercular DOTS therapy. Sporotrichoid presentation of scrofuloderma appeared to simulate sporotrichosis more than sporotrichoid lupus vulgaris. As seen from other reports and the present one, children and those just past adolescence have often been affected. Since sporotrichoid pattern is known to be usually associated with the less pathogenic atypical or non-tuberculous mycobacteria, it is speculated that the good lymphatic drainage and proneness to trauma that go with the high physical activity in these age groups may rarely result in this clinical presentation of cutaneous tuberculosis.

[Lupus vulgaris: isolation of Mycobacterium tuberculosis from the affected skin scraping and mucous membranes]

INTRODUCTION

In the second half of the last century skin tuberculosis has become a rarity. With the appearance of resistance to different kinds of pathogenes, HIV-immunodeficiency and decreasing standard of living, the incidence of skin tuberculosis increases. Lupus vulgaris is a chronic form of the secondary tuberculosis of the skin.

CASE REPORT

This is a case report of a 66-year-old woman who presented with a growing, painless, brownish-red, slab-shaped, jelly, cutanesous mass, 2.5 centimeters in diameter, on the tip of her nose, reaching the mucous membrane of the nose.

RESULTS

Apart from accelerated erythrocyte sedimentation rate (43/73) and a positive tuberculosis test (Mantoux 10 TU = 25x25 mm), all relevant findings were within reference values. Using Ziehl-Neelsen staining, no acido-resistent bacilli were found. The skin scraping sample, taken from the affected skin and the mucous membrane, was cultivated in Lowenstein medium base, and this resulted with cultivation of Mycobacterium tuberculosis. Using three-drug combination therapy for ten months, complete remission was achieved.

CONCLUSION

Successful cultivation of pathogens represents an absolute diagnostic criterion. We present a case of a woman with lupus vulgaris, because there is a small number of cases documented around the world where the diagnosis was confirmed by culture of Mycobacterium tuberculosis.

Lupus vulgaris of the popliteal fossa: a delayed diagnosis

Lupus vulgaris (LV) is the most common form of cutaneous tuberculosis. It commonly presents on the head and neck regions. The diagnosis may be difficult when LV occurs at unexpected regions or in unusual clinical forms. Sometimes special stains for the organism and mycobacterial cultures may be negative. Nevertheless, it is usually possible to reach the correct diagnosis of LV using clinical and histopathological findings. But at times, a therapeutic trial with antitubercular agents may be required.

Minocycline-induced lupus in adolescents: clinical implications for physical therapists

STUDY DESIGN

Resident's case problem.

BACKGROUND

In the United States, minocycline is a frequently prescribed medication for the treatment of moderate to severe acne, a common condition in adolescents. The use of minocycline has been associated with severe adverse effects that frequently comprise a musculoskeletal component, including drug-induced lupus. Physical therapists have the responsibility to identify drug reactions that mimic musculoskeletal symptoms. The patient described herein was a 15-year-old adolescent boy who had taken minocycline for 14 days. He was initially treated by his primary physician on the 15th day of minocycline therapy for symptoms of fever, joint swelling, and a rash. The patient presented to a physical therapist on the 22nd day with complaints of severe myalgia, arthralgia, and severely limited mobility secondary to pain. The patient was referred to a pediatric rheumatologist because of the systemic nature and severity of the symptoms.

DIAGNOSIS

The patient was subsequently diagnosed as having drug-induced lupus by a pediatric rheumatologist. The patient's myalgia and arthralgia subsided within 6 weeks, but his strength, coordination, and endurance did not reach their prior levels for 3 to 4 months.

DISCUSSION

Physical therapists who include a comprehensive pharmacovigilance component in their patient examination may recognize musculoskeletal symptoms that arise from a nonmusculoskeletal origin. Minocycline is commonly prescribed in the United States as an antibiotic and for treatment of acne and rheumatoid arthritis. Therefore, physical therapists should screen for minocycline use when an adolescent patient or a patient with rheumatoid arthritis presents with diffuse musculoskeletal symptoms. An automated medication monitoring system would provide physical therapists with a means of accessing current information on medication use.

Lupus vulgaris--a case diagnosed more than 20 years after onset

A 47-year-old Turkish woman developed an erythematous scaly plaque on her thigh over 20 years. Cutaneous sarcoidosis had been diagnosed eight years previously on a skin biopsy. We confirmed Mycobacterium tuberculosis infection by polymerase chain reaction and cultivation of the causative organism from lesional skin. After several months of antituberculous treatment with isoniazid, rifampicin, ethambutol and pyrazinamide, the lesion resolved.

Annular lupus vulgaris: an unusual case undiagnosed for five years

Tuberculosis is still a serious problem in both developing and developed countries. It is often confused with various cutaneous disorders both clinically and histopathologically.A 46-year-old woman attended our clinic with progressive, asymptomatic, annular skin lesions on her right upper extremity for 5 years. She had received many different therapies for these lesions at other institutions previously but these medications were not effective and the lesions deteriorated. On dermatological examination, well-demarcated, irregular bordered, violaceous colored, elevated and crusted annular lesions on her right hand dorsum and forearm were observed. She was diagnosed as having lupus vulgaris clinically and histopathologically. Antituberculosis therapy was administered and regression of the lesions started in the second week of medication.We report a case of long-standing, undiagnosed and uncommon, annular form of lupus vulgaris. We want to stress that clinical and histopathological findings are still important for the diagnosis of cutaneous tuberculosis.

Neonatal lupus

An otherwise healthy 5-week-old infant with erythematous plaques predominantly on the face and scalp presented to our dermatology clinic. The mother had been diagnosed with lupus erythematosus 2 years earlier but her disease was quiescent. Neonatal lupus is a rare condition associated with transplacental transfer of IgG anti-SSA/Ro and anti-SSB/La antibodies from the mother to the fetus. Active connective tissue disease in the mother does not have to be present and in fact is often absent. Although the cutaneous, hematologic and hepatic manifestations are transient, the potential for permanent heart block makes it necessary for this to be carefully ruled out. As in this case, the dermatologist may be the one to make the diagnosis and should be aware of the clinical presentation, work-up, and management of this important disease.