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 Table of Contents  
CASE REPORT
Year : 2020  |  Volume : 9  |  Issue : 2  |  Page : 220-222

Tuberculous verrucosa cutis with a sporotrichoid distribution


1 Department of Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India
2 Department of Pathology, Venereology and Leprosy, All India Institute of Medical Sciences, Rishikesh, Uttrakhand, India

Date of Web Publication29-May-2020

Correspondence Address:
Aditi Dhanta
Department of Dermatology, Venereology and Leprosy, All India Institute of Medical Sciences, Rishikesh - 249 203, Uttrakhand, India
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_19_20

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  Abstract 


Tuberculosis verrucosa cutis (TBVC) is a common paucibacillary form of cutaneous tuberculosis caused by exogenous reinfection in previously sensitized individuals. The typical morphology is usually observed as a single verrucous plaque with inflammatory borders mostly on the hands, knees, ankle, and buttocks; however, several atypical morphologies of the lesions have also been described. TBVC occurring in sporotrichoid pattern is relatively rare. We report a case of a rare sporotrichoid presentation of TBVC in a 38-year-old male patient in the absence of any primary tuberculous focus.

Keywords: Cutaneous tuberculosis, sporotrichoid, tuberculous verrucosa cutis


How to cite this article:
Arora K, Dhanta A, Kansal NK, Joshi P. Tuberculous verrucosa cutis with a sporotrichoid distribution. Int J Mycobacteriol 2020;9:220-2

How to cite this URL:
Arora K, Dhanta A, Kansal NK, Joshi P. Tuberculous verrucosa cutis with a sporotrichoid distribution. Int J Mycobacteriol [serial online] 2020 [cited 2020 Jul 11];9:220-2. Available from: http://www.ijmyco.org/text.asp?2020/9/2/220/285220




  Introduction Top


Cutaneous tuberculosis (TB) forms a small proportion of extrapulmonary TB.[1] It is mostly caused by exogenous reinfection in previously sensitized individuals. TB verrucosa cutis (TBVC); also known as warty TB, anatomist's warts, or prosector's warts; is an indolent, warty plaque-like form of paucibacillary cutaneous TB, resulting from inoculation of Mycobacterium TB into the skin of a previously infected patient, with moderate-to-high degree immunity.[2] It is usually observed as a single verrucous plaque with inflammatory borders. We report a rare presentation of TBVC, the patient presented with multiple lesions placed close to each other in a linear pattern over the right hand extending forearm in sporotrichoid pattern for 6 months, in an otherwise healthy individual.


  Case Report Top


A 38-year-old male presented with the chief complaint of a verrucous lesion over the right hand, extending to the forearm for the past 6 months. The lesion first started as a small, asymptomatic, and warty papule which progressed over time to become a painful verrucous plaque. Detailed history revealed that he is a construction worker by occupation and sustained a trauma from iron rod 1 year back which led to clawing of the right little and ring finger and the development of these lesions 6 months later.

On cutaneous examination, multiple well-defined discrete to coalescent verrucous plaques with areas of crusting and erosions were present over the right dorsum of the hand, palms, flexor, and extensor aspect of the forearm. Few areas of depigmentation were present between the verrucous plaques over the dorsum of the hand [Figure 1]a and [Figure 1]b. Based on the clinical findings, differentials of TBVC and chromoblastomycosis were made. Skin biopsy was performed and sent for histopathology, fungal, and acid-fast bacilli culture. Pathological examination revealed hyperkeratosis, parakeratosis, papillomatosis, and irregular acanthosis with lymphocytes focal exocytosis. In addition, there was pandermal infiltrate denser in superficial dermis along with the formation of epithelioid granulomas containing Langhans type multinucleate giant cells [Figure 2]a and b]. All other routine blood investigations were normal. The chest radiograph was normal; mantoux test measured 15 mm.
Figure 1: (a and b) Multiple verrucous plaques with linear pattern present over the dorsal aspect of the right hand, palm extending to the forearm

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Figure 2: (a) Hyperkeratosis, parakeratosis, papillomatosis, and irregular acanthosis with multiple dense granulomas in superficial dermis (×10, H and E), (b) well-defined granulomas composed of epithelioid cells and Langhans multinucleate giant cells in the papillary dermis (×40, H and E)

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After clinicopathological correlation, a diagnosis of sporotrichoid TBVC was made and the patient was started on antitubercular therapy (ATT)-isoniazid, rifampicin, ethambutol, and pyrazinamide once daily for 2 months, which was followed by isoniazid, rifampicin, and ethambutol once daily for 4 months. Within 1 month, the lesions flattened out and resolved completely in 2 months [Figure 3]a and [Figure 3]b.
Figure 3: (a and b) Resolution of the lesions 2 months after treatment

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  Discussion Top


TB is a global health problem with predominance in resource-poor countries. Cutaneous TB constitutes about 1.5% of all extrapulmonary TB. It includes lupus vulgaris and TBVC at its one end and scrofuloderma and TB cutis orificialis at the other end with a decrease in cell-mediated immunity across the spectrum.[3] In India, TBVC is probably the third-most common form after lupus vulgaris and scrofuloderma.[4] Inoculation occurs at sites of minor wounds or abrasions, sometimes from the patient's own sputum. Clinically, deep fungal infections such as blastomycosis, chromomycosis, fixed sporotrichosis, callosities, lupus vulgaris, tertiary syphilis, and cutaneous warts can be kept as differentials.

Psoriasiform, keloidal, crusted, exudative, sporotrichoid, destructive, tumor-like, and exuberant granulomatous forms are the main variants of TBVC which can also mimic the differentials of TBVC itself.[5] Sporotrichoid form of TBVC is an unusual variant that mimics sporotrichosis, a subcutaneous fungal disease.[6] It is proposed that bacilli follow the lymphatic channels and during transit, provoke cutaneous granulomatous inflammation resulting in a linear array of lesions over time. It has been shown that sporotrichoid form is more common in children than in adults because of the efficient lymphatic drainage in children and high physical activity that makes them prone to trauma.[7],[8]

In this case, the patient presented with multiple lesions of TBVC placed close to each other in sporotrichoid patterns over the right hand. However, multifocal cutaneous lesions without any other tubercular focus in the body are quite rare. In our case, histopathological characteristics and response to ATT confirmed the diagnosis of TBVC. There are only very few reports on cases of TBVC with multifocal involvement and sporotrichoid spread.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for the images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published, and due efforts will be made to conceal the identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Yates VM, Rook GA. Mycobacterial infection. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7th ed. Oxford: Blackwell Scientific Publications; 2004. p. 28.  Back to cited text no. 1
    
2.
Sehgal VN, Wagh SA. Cutaneous tuberculosis. Current concepts. Int J Dermatol 1990;29:237-52.  Back to cited text no. 2
    
3.
Vora RV, Diwan NG, Rathod KJ. Tuberculosis verrucosa cutis with multifocal involvement. Indian Dermatol Online J 2016;7:60-2.  Back to cited text no. 3
[PUBMED]  [Full text]  
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.
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. 5
    
6.
Ramesh V. Sporotrichoid cutaneous tuberculosis. Clin Exp Dermatol 2007;32:680-2.  Back to cited text no. 6
    
7.
Khare S, Chhabra N, Ganguly S, Prabha N. Sporotrichoid presentation of lupus vulgaris mimicking mycetoma. Int J Mycobacteriol 2019;8:292-4.  Back to cited text no. 7
[PUBMED]  [Full text]  
8.
Hadj I, Meziane M, Mikou O, Inani K, Harmouch T, Mernissi FZ. Tuberculous gummas with sporotrichoid pattern in a 57-year-old female: A case report and review of the literature. Int J Mycobacteriol 2014;3:66-70.  Back to cited text no. 8
  [Full text]  


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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