Case report: Painful, swirling skin lesions a rare symptom of undiagnosed pulmonary tuberculosis

A patient presenting with painful, swirling skin lesions, chills, and weight loss was found to be suffering from erythema gyratum repens (EGR), a rare and striking skin condition that is associated with underlying malignancy in most cases, but in some cases can stem from an autoimmune disease, messenger RNA-based vaccines against COVID-19, or in rare cases, tuberculosis (TB).

The patient's doctors had been initially falsely reassured by a negative TB screening test, though further TB testing should have been pursued because she was from a TB-endemic country and had abnormal lung imaging. Thorough investigation for suspected TB was extremely important because treatment of EGR requires addressing the underlying cause of the immune phenomenon. Once the patient was treated for TB, her symptoms cleared. The case report from authors at Stanford University is published in Annals of Internal Medicine.

EGR is a very rare skin condition causing painful lesions that appear in a distinct circular pattern. The patient's lesions affected her face, neck, trunk, extremities, palms, and soles. Initially, clinicians believed that her rash was a rare reaction to empagliflozin, which the patient had begun taking for diabetes. However, despite discontinuation of the medication and treatment with prednisone and doxycycline, the rash continued to progress. Since EGR is often caused by an underlying malignancy, the patient was screened for cancers, and none were found. Only after imaging of the chest and sputum analysis did clinicians identify the problem—pulmonary tuberculosis.

The authors say that clinicians should learn to recognize EGR's annular, or polycyclic, ring-within-ring skin lesions because accurate diagnosis is critical for determining the appropriate treatment. If EGR is identified, the next step is finding and treating the underlying cause.