Editor,—A 27 year old promiscuous, married man presented with recurrent episodes of ulceration of the penis of 12 years' duration. Each episode began with a painful small raised lesion which got ulcerated and finally healed spontaneously in 2–3 months. The present episode of painful ulceration had been lasting for 6 months or so. In spite of various treatments received from various private practitioners, his genital sore did not respond.

On physical examination, this moderately nourished individual had a single well defined ulcer on the glans penis near the urethral meatus, measuring 8 × 5 mm. The edge of the ulcer was undermined and its floor had necrotic slough. The ulcer had perforated deeply into the urethra, resulting in dribbling of urine through it (fig 1). Multiple puckered scars over the glans penis circumferentially, just distal to the coronal sulcus, were evidence of previous episodes of similar ulcerations. The inguinal lymph nodes were not significantly enlarged. His systemic examination was unremarkable.

The haemogram revealed a raised erythrocyte sedimentation rate (64 mm in the first hour). The Mantoux test was strongly positive (20 × 20 mm). VDRL and HIV serology was non-reactive. Radiological investigations did not demonstrate any focus of tuberculosis in the chest or genitourinary system. Smear and culture of discharge from the ulcer and also of urine for acid fast bacilli were negative. Histopathological examination of the ulcer (glans penis) revealed ulcerated epidermis. In the deep dermis, by the side of the ulceration, there were caseating tuberculous granulomas along with perivascular inflammatory infiltrate with vessel wall thickening and endothelial cells swelling. Fite's stain for acid fast bacilli was negative. These features were consistent with the diagnosis of papulonecrotic tuberculide. The patient was treated with a four drug regimen for antituberculous therapy to which he responded favourably. At the end of 2 months, the ulcer had healed completely.

Even though it is considered to be rare, tuberculosis of the penis may manifest as primary, secondary, or papulonecrotic tuberculide type.^1–4 Clinically, it may present as superficial ulcers of the penis or tuberculous cavernositis.² Papulonecrotic tuberculide, a form of cutaneous tuberculosis, represents an allergic reaction to bursts of antigens reaching highly immune skin following haematogenous spread from an internal focus. The tuberculous focus is often not clinically active at the time of eruption⁵ as seen in our case. The diagnosis of papulonecrotic tuberculide in our case was based on the well laid down criteria.^{3, 4}

Papulonecrotic tuberculides are mostly extragenital, but rarely genitalia may be involved.³ Sometimes, the glans penis alone may be involved as in our patient and then diagnosis becomes difficult. Under these circumstances, it needs to be differentiated from atypical soft sore, syphilis, recurrent herpes simplex, and malignant ulcer.⁴ The diagnosis of such cases rests on biopsy, tuberculin testing and, in doubtful cases, a therapeutic test is usually decisive.^1–4 The possibility of tuberculosis as a cause of chronic ulcer on the penis has to be kept in mind especially in countries like India, where tuberculosis is still prevalent.

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Figure 1

Glans penis showing both ulcer and puckered scarring.