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LETTER TO THE EDITOR
Year : 2016  |  Volume : 7  |  Issue : 1  |  Page : 60-62  

Tuberculosis verrucosa cutis with multifocal involvement


1 Department of Skin and VD, Pramukhswami Medical College, Karamsad, Gujarat, India
2 Department of Pathology, Pramukhswami Medical College, Karamsad, Gujarat, India

Date of Web Publication18-Jan-2016

Correspondence Address:
Dr. Rita V Vora
Department of Skin and VD, Pramukhswami Medical College, Karamsad, Gujarat
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2229-5178.174325

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How to cite this article:
Vora RV, Diwan NG, Rathod KJ. Tuberculosis verrucosa cutis with multifocal involvement. Indian Dermatol Online J 2016;7:60-2

How to cite this URL:
Vora RV, Diwan NG, Rathod KJ. Tuberculosis verrucosa cutis with multifocal involvement. Indian Dermatol Online J [serial online] 2016 [cited 2019 Dec 6];7:60-2. Available from: http://www.idoj.in/text.asp?2016/7/1/60/174325

Sir,

Tuberculosis (TB) is a mycobacterial infection that occurs commonly due to infection with Mycobacterium tuberculosis or Mycobacterium bovis, reflecting immunity of an individual [1] TB is a major public health concern due to its high prevalence with higher morbidity and mortality. Cutaneous tuberculosis is mostly caused by exogenous reinfection in previously sensitized individuals.[2] Inoculation occurs at sites of minor wounds or abrasions, sometimes from the patient's own sputum. Cutaneous tuberculosis includes lupus vulgaris and tuberculosis verrucosa cutis (TBVC) at its one end and scrofuloderma and tuberculosis cutis orificialis at the other end with decrease in cell-mediated immunity across the spectrum. In India, the incidence of cutaneous tuberculosis has fallen and is rare in developed countries.[3] We hereby report a case of TBVC with mutifocal as well as extensive involvement.

A 60-year-old woman presented in surgical department with verrucous crusted lesions over right lower limb since 12 years with foul-smelling discharge from the lesion since 3–4 months. Surgeons clinically diagnosed her as squamous cell carcinoma and provisionally planned for surgical intervention. Surgeons referred the patient to skin department for a second opinion. Detailed history taking revealed that 12 years prior, she sustained a thorn prick over her right great toe, which evolved into warty lesion. There was gradual involvement of right foot, leg, and knee over a period of 12 years. On examination, there were well-demarcated, oval, dry, verrucous, thick, crusted plaques present over anterior aspect of right knee [Figure 1]a, anterior aspect of right leg [Figure 1]b, and whole foot with a few islands of normal skin and atrophy, [Figure 1]c and [Figure 1]d associated with foul smell. Chest and leg radiographs were normal; Mantoux test was negative and erythrocyte sedimentation rate was 55 mm/hr. HIV was nonreactive. Other investigations results were normal. Histopathological examination showed hyperkeratosis, acanthosis with pseudoepitheliomatous hyperplasia of the epidermis [Figure 2]. Below the epidermis, polymorphs with abscess formation and multiple ill-defined granulomas were observed [Figure 3]. Granuloma comprised epithelioid cells with Langhans type of multinucleated giant cells, foreign body type of giant cells, with scanty lymphocytes [Figure 4], suggestive of tuberculosis verrucosa cutis. ATT category 1 (rifampicin 450 mg, pyrazinamide 1500 mg, isoniazid 600 mg) was started. After 3 months of treatment the patient's condition improved.
Figure 1: (a) Well-defined hyperkeratotic verrucous plaque over right knee. (b) Thick hyperkeratotic plaque with crusting and atrophy over right lower leg. (c) Hyperkeratotic verrucous plaque with depigmentation and central atrophy over dorsum of foot. (d) Hyperkeratotic verrucous plaque involving ankle and toes

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Figure 2: Hyperkeratosis, papillomatosis, acanthosis of epidermis (H and E, ×4)

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Figure 3: Abscess formation in upper dermis, and presence of granulomas (H and E, ×10)

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Figure 4: Granuloma comprising epitheliod cells, Langhans type of multinucleated giant cells surrounded by scanty lymphocytes. (H and E, ×40)

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TBVC is also known as warty tuberculosis, prosector's wart, butcher's wart, anatomist's wart, and postmortem wart. The incidence of TBVC varies but is seen frequently in Asia. In India, TBVC is probably the third most common form after lupus vulgaris and scrofuloderma.[4] TBVC results from direct inoculation of the bacilli into the skin of previously infected patients having intact immunity. TBVC usually occurs on the hands in adults and on the lower extremities in children.[5] Walking barefoot frequently increases risk to developing TBVC on the sole. Psoriasiform, keloidal, crusted, exudative, sporotrichoid, destructive, tumor-like, and exuberant granulomatous [6] forms are the main variants of TBVC, which can also mimic the differentials of TBVC itself. The diagnosis is mainly based on clinical appearance, tuberculin tests, culture, and microscopic and histopathological features. The histopathological features are characterized by marked pseudoepitheliomatous hyperplasia of the epidermis with hyperkeratosis and dense inflammatory cell infiltrate consisting of neutrophils, lymphocytes, and giant cells. The presence of granulomatous infiltrates is a cardinal sign. Typical tuberculous foci with caseating necrosis are not commonly seen in TBVC.[1] Clinically deep fungal infections such as blastomycosis, chromomycosis, fixed sporotrichosis, callosities, bacterial infections such as lupus vulgaris, tertiary syphilis, and cutaneous warts can be kept as differentials. Inflammatory dermatoses, including psoriasis, lichen simplex chronicus, and hypertrophic lichen planus, may also mimic this clinical picture. Differentiation from inflammatory diseases may be made by histopathological findings and culture of microbacteria. A dramatic response to antitubercular therapy is commonly seen in most of the cases. In our case, there was multifocal involvement, withverrucous, thick, crusted plaques with foul smell, which is usually not seen in tuberculosis verrucosa cutis; this was leading to a diagnostic dilemma. Eventually, histopathological characteristics and response to antitubercular therapy confirmed the diagnosis of tuberculosis verrucosa cutis.

 
   References Top

1.
Sehgal VN, Wagh SA. Cutaneous tuberculosis. Current concepts. Int J Dermatol 1990;29:237-52.  Back to cited text no. 1
    
2.
Aliaðaoðlu C, Atasoy M, Güleç AÝ, Özdemir Þ, Erdem T, Engin RÝ. Tuberculosis Verrucosa Cutis. Eur J Gen Med 2009;6:268-73.  Back to cited text no. 2
    
3.
Gopinathan R, Pandit D, Joshi J, Jerajani H, Mathur M. Clinical and morphological variants of cutaneous tuberculosis and its relation to mycobacterium species. Indian J Med Microbiol 2001;19:193-6.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Kumar B, Muralidhar S. Cutaneous tuberculosis: A twenty-year prospective study. Int J Tuberc Lung Dis 1999;3:494-500.  Back to cited text no. 4
    
5.
Foo CC, Tan HH. A case of tuberculosis verrucosa cutis-undiagnosed for 44 years and resulting in fixed flexion deformity of the arm. Clin Exp Dermatol 2005;30:149-51.  Back to cited text no. 5
    
6.
Iizawa O, Aiba S, Tagami H. Tuberculosis verrucosa cutis in a tumour-like form. Br J Dermatol 1991;125:79-80.  Back to cited text no. 6
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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