Sections from the growth showed granuloma formation along with areas of caseating necrosis
and Langhans type giant cells, suggestive of tuberculosis (Fig.
Pathologic examination of excised lymph nodes of the bilateral inguinal area showed reactive lymphoid proliferation and granulomatous inflammation with multinucleate giant cell formation, suggestive of mycobacterial disease; however, there was no evidence of caseating necrosis
or acid-fast bacilli.
These tubercles show characteristic amorphous caseating necrosis which may rupture into surrounding structures, such as the airway and blood stream, causing endobronchial or hematogenous dissemination.
In nodes undergoing necrosis, contrast-enhanced MR imaging shows rim enhancement with a central area of no enhancement representing caseating necrosis.
Findings on analysis of the primary ulcer--which contained caseating necrosis
with florid granulomas, Langerhans' giant cells, and abundant epithelioid cells--were strongly suggestive of tuberculosis (figure 3).
Investigations leading to the diagnosis are histologic analysis showing a granuloma with or without caseating necrosis
, and the microbiologic identification of Mycobacterium tuberculosis.