|Year : 2014 | Volume
| Issue : 1 | Page : 53-55
Cutaneous tuberculosis, tuberculosis verrucosa cutis
Nilamani Mohanty, Bibhuti Bhusan Nayak
Department of Plastic Surgery, S.C.B. Medical College, Cuttack, Orissa, India
|Date of Web Publication||10-Dec-2013|
Department of Plastic Surgery, S. C. B. Medical College, Cuttack, Odisha
Source of Support: None, Conflict of Interest: None
Cutaneous tuberculosis because of its variability in presentation, wider differential diagnosis, and difficulty in obtaining microbiological confirmation continues to be the most challenging to diagnose for dermatologists in developing countries. Despite the evolution of sophisticated techniques such as polymerase chain reaction (PCR) and enzyme-linked-immunosorbent serologic assay (ELISA), the sensitivity of new methods are not better than the isolation of Mycobacterium tuberculosum in culture. Even in the 21 st century, we rely on methods as old as the intradermal reaction purified protein derivative standard test and therapeutic trials, as diagnostic tools. We describe a case which has been diagnosed and treated as eczema by renowned physicians for 2 years. Incisional biopsy showed the presence of well-defined granulomas and ZN staining of the biopsy specimen showed the presence of acid fast bacilli; a trial of ATT (antitubercular therapy) for 6 months lead to permanent cure of the lesion.
Keywords: Antitubercular therapy, Cutaneous tuberculosis, ZN stain
|How to cite this article:|
Mohanty N, Nayak BB. Cutaneous tuberculosis, tuberculosis verrucosa cutis. Med J DY Patil Univ 2014;7:53-5
| Introduction|| |
Similar to systemic tuberculosis, cutaneous tuberculosis (CTB) is diverse and highly variable in its clinical presentation. Though most of the cases of CTB can be diagnosed clinically but some cases really pose diagnostic challenges. The clinical presentation is determined by the route of infection as well as status of cellular immunity of the host. CTB is frequently elusive as it mimics a wide differential diagnosis and also evades microbiological confirmation even with the recently advanced sophisticated techniques.  Although rare, given its worldwide prevalence, it is important for clinicians to recognize the many clinical variants of CTB to prevent missed or delayed diagnoses.
| Case Report|| |
A 25-year daily laborer male presented with an irregular shaped lesion of size 4 × 6 cm over the dorsum of right foot with multiple small nodules (2-3 mm) over its surface since 2 years [Figure 1]. The lesion initially started as a small itchy papule over the dorsum of right foot which latter developed into a plaque with multiple wart like nodules over the lesion. There was history of intermittent serous discharge from the lesion. On examination an irregular firm non-tender hypertrophic verrucous plaque of size 4 × 6 cm with multiple surface nodularity situated over the dorsum of right foot was found. The base of the lesion was not fixed to the deeper structures with no notable regional or systemic nodal enlargement. There was no history of any constitutional symptoms pertaining to systemic tuberculosis. Neither the patient nor any of his family members have suffered from tuberculosis. The patient consulted physician and dermatologist after 6 months of the lesion and was diagnosed as eczema and treated with steroid cream and antihistaminic tablets. With treatment the pruritus diminished to some extent but the lesion gradually increased in size over 18 months to attain the present size. The patient was examined by a general surgeon who referred the patient to plastic surgery with the provisional diagnosis of nodular variety of basal cell carcinoma/epithelioma, anticipating wide excision followed by reconstruction.
|Figure 1: Photograph showing the lesion with surface nodularity over the dorsum of foot|
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|Figure 2: Photograph showing presence of well defined granulomas with epithelioid cells, langhan giant cells and caseation necrosis|
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|Figure 3: ZN stain photograph of the biopsy specimen showing presence of multiple acid-fast bacilli|
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The routine hematological examinations were within normal limits except a mild elevation of ESR (30 mm/first hr). Incisional biopsy of the lesion showed that there was presence of well-formed granulomas with epithelioid cells, langhan giant cells with caseation necrosis [Figure 2]. ZN stain of the biopsy specimen showed the presence of plenty of acid fast bacilli (AFB) [Figure 3]. A provisional diagnosis of CTB (tuberculosis verrucosa cutis) was made. Other investigations of systemic involvement like sputum for AFB was negative, X ray chest was normal, and Mantoux test was borderline (10 mm). Other advanced techniques of detecting AFB, such as PCR, ELISA, were not done as the patient was very poor and the techniques are not available in our institute. The culture of the lesion was not done so the type of mycobacterium involved was not determined. The patient was started ATT 4 drug regimen (HRZE) for 2 months and two drugs (HR) for 4 months, the lesion got completely cured with good cosmetic and functional outcome [Figure 4].
| Discussion|| |
CTB represents 1.5% of all cases of extra pulmonary tuberculosis.  Out of this lupus vulgaris is the most common type and the incidence of tuberculosis verrucous cutis was 4.76% of CTB. 
CTB can present with an unusual clinical and histological features causing delay in diagnosis.  CTB can be caused by Mycobacterium tuberculosis and Mycobacterium bovis. The lesion is more commonly acquired due to endogenous than exogenous infection. Mycobacterial culture remains the most reliable method to determine the presence of mycobacterias and their sensitivities, but the yield is often low and often takes many weeks. , Culture sensitivity is much lower than specificity, with sources ranging from 80% to 85% and 98.5%, respectively. 
Five factors that are important for the clinical presentation of CTB are (1) the pathogenicity of the organism, (2) its antibiotic resistance profile, (3) the portal of infection, (4) the immune status of the host, particularly the presence or absence of acquired immunodeficiency syndrome (AIDS) secondary to infection with human immune deficiency virus (HIV), and (5) various local factors in the skin (e.g. relative vascularity, trauma, lymphatic drainage, and proximity to lymph nodes).
Tuberculosis verrucosa cutis represents an inoculated exogenous infection of the skin in an individual who was previously exposed to tuberculosis and have high immunity as a single verrucous lesion with intermittent fissuring and serous or purulent discharge. Multiplicity of the skin lesion and systemic involvement may be due to poor health and hematogenous dissemination.
The diagnosis of Tuberculosis verrucosa cutis is based on history, evolution of the disease, cardinal morphological features and histopathological characteristics.
Our case is a young daily laborer male with no evidence of any systemic tuberculosis and obvious immune deficiency with normal vascularity of the affected leg and foot, having no functional impairment and pain in the foot, with no regional nodal enlargement, with negative family history, so the exogenous route is the most probable, as patient had forgotten the trival trauma to the foot. The patient was managed conservatively with ATT. Surgery was not done as the lesion was small and the result obtained is superior than could have obtained by surgical intervention.
| Conclusion|| |
Though the appropriate treatment was delayed by two years this patient could have easily been subjected to surgery after medical treatment was tried by physicians without success. Correct diagnosis was the key to success in this particular situation. So one should always keep in mind the rare clinical presentations of cutaneous tuberculosis that simulate various other cutaneous diseases when the conventional treatment fails.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]