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Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 208-210

Tuberculosis verrucous cutis mimicking chromoblastomycosis: A case report and diagnostic challenges

Department of Dermatology and Venereology, Medical Faculty of Sriwijaya University/Dr. Mohammad Hoesin General Hospital, Palembang, Indonesia

Date of Submission10-Apr-2022
Date of Decision20-May-2022
Date of Acceptance28-May-2022
Date of Web Publication14-Jun-2022
Date of Print Publicaton14-Jun-2022

Correspondence Address:
Kiki Septiafni
Department of Dermatology and Venereology, Medical Faculty of Sriwijaya University/Dr. Mohammad Hoesin General Hospital, Jendral Sudirman Street KM 3, 5 Palembang
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijmy.ijmy_57_22

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Tuberculosis verrucous cutis (TBVc) is a skin infection caused by M. tuberculosis, characterized by the presence of a solitaire verrucous plaque but may present as a varies of different clinical morphologies on the finger and or feet. The diagnosis is often late because of its mimicking other diseases with different etiology. Bacterial culture examination is negative because there are few pathogens in the lesion. Meanwhile, other diagnostic methods provide lower sensitivity and specificity which add further diagnostic challenges. We presented one case report of TBVc mimicking chromoblastomycosis. A 26-year-old man complain a multiple papule-plaque verrucose on the dorsum of the right foot and extending to all of fingers for 2 years ago. The first lesion appears as a small papule verrucous then progressively to form plaque with curst yellow-red and central healing. Examination of bacterial culture with Ziehl–Neelsen stain and GeneXpert did not find M. tuberculosis but could not rule out the diagnosis of TBVc. The diagnosis was established based on the correlation of clinical manifestations and dermoscopy with histopathological examination. To date, there is no gold standard for TBVc testing. Correlation analysis of clinical manifestations, dermoscopy, and histopathology can be considered to establish the diagnosis of TBVc, especially if the culture is negative and the limitations of polymerase chain reaction tools.

Keywords: Culture, dermoscopy, histopathological examination, tuberculosis verrucous cutis

How to cite this article:
Septiafni K, Pamudji R, Rusmawardiana R, Argentina F. Tuberculosis verrucous cutis mimicking chromoblastomycosis: A case report and diagnostic challenges. Int J Mycobacteriol 2022;11:208-10

How to cite this URL:
Septiafni K, Pamudji R, Rusmawardiana R, Argentina F. Tuberculosis verrucous cutis mimicking chromoblastomycosis: A case report and diagnostic challenges. Int J Mycobacteriol [serial online] 2022 [cited 2022 Aug 11];11:208-10. Available from: https://www.ijmyco.org/text.asp?2022/11/2/208/347519

  Introduction Top

Tuberculosis verrucosa cutis (TBVc) is a type of cutaneous tuberculosis; it appears as a result of an immunologic reaction from exogenous inoculation or reinfection reaction in individuals who have been sensitized to Mycobacterium tuberculosis. Indonesia is a tuberculosis endemic country, and TBVc cases are frequently reported.[1] The incidence of TBVc is more common in men than women, with a ratio of 2:1.[2] M. tuberculosis inoculation can occur in traumatized body parts such as hands, feet, and buttocks. Although rare, inoculation can occur while sitting or exercising through contaminated soil.[3] The clinical manifestations of TBVc vary and resemble other skin disorders, so diagnosis is often delayed.[4]

Until now, the gold standard for cutaneous TB is the culture of M. tuberculosis, but the sensitivity and specificity are low. A negative culture or staining of M. tuberculosis cannot rule out the diagnosis of cutaneous tuberculosis.[4] This leads to diagnosis requires correlation between clinical manifestations,[5] dermoscopy,[6] hitopatologic examination and bacterial examination sach as Ziel Neelsen stain, polymerase chain reaction (PCR), and culture of microbiologic.[5] The purpose of this case report is to determine the correlation of clinical manifestations, dermoscopy and histopathological examination in establishing the diagnosis of TBVc which mimicking chromoblastomycosis.

  Case Illustration Top

A 26-year-old man came with a complaint about 2 years ago that several nodules verrucous resembled a brown wart on the dorsal of the right foot. The lesion slowly extended to the wrist and toes of the right foot, and the middle of the lesion seems to be healed. Some nodules sometimes ooze pus and dry into a reddish yellow crust [Figure 1]. Complaints of itching, prolonged cough, and night sweats were denied. The history of leg injuries was denied. The patient applied Kalusol® cream every day for 2 weeks, but there was no improvement. Physical examination revealed no enlarged lymph nodes. The dermoscopy examination showed papillated with a red-yellow base and thick white scales and partly covered with yellow-reddish yellow crusts [Figure 2]. Histopathological examination of HE staining [Figure 3] showed hyperplastic epidermis, lined with complex squamous epithelium, keratin, hyperkeratosis, parakeratosis, and partial follicular plugging with neutrophil inflammatory cell infiltration with elongated rate ridges. In dermis show collagenized fibrocollagenous connective tissue, lymphocytic inflammatory cells, plasma, few eosinophil cells including granulomas consisting of epithelioid cells, multinucleated Langerhans giant cells, caseous necrosis, surrounded by lymphocytes, and perivascular inflammatory cells. Examination of bacterial culture with Ziehl–Neelsen stain and GeneXpert did not reveal M. tuberculosis. The chest X-ray is normal. The differential diagnosis of chromoblastomycosis was ruled out by histopathological examination with periodic acid–Schiff and fungus was not found. The patient was diagnosed with tuberculosis cutis verrucosa and was given antituberculosis drugs.
Figure 1: A.Skin lesion: Erythematous-brown verrucous papules, dry white scales, and reddish-yellow crusts

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Figure 2: Dermoscopy: papillated with a yellow-red base, white-yellow-brown scales and partially covered with red-brown crusts

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Figure 3: Histopathologic: hyperplasia, hyperkeratosis, follicular plugging, parakeratosis (100x magnification); mini size: caseous necrosis (↑), Langerhans giant cell (↑) (400x magnification)

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  Discussion Top

Tuberculosis cutis verrucosa (TBVc) is one of the manifestations of extrapulmonary tuberculosis and is commonly found in tuberculosis endemic countries such as Indonesia.[1] In tropical countries, TBVC is often found in the lower extremities,[5] as seen in our patient. TBVc lesions begin as asymptomatic wart papules that enlarge slowly, irregular edges with an involuted center and extensive atrophic or papillary scars with fissures. However, the clinical manifestations of TBVc are often atypical, and the culture found few M. tuberculosis (paucibacillary) so that it becomes a challenge in the diagnosis.[2] The case report of Wedy et al. showed that the culture results found only a few M. tuberculosis bacteria, and negative Ziehl–Neelsen staining was associated with the type of paucibacillary TBVc lesion.[7] Immunological tests such as the Mantoux test have a high diagnostic value but are routinely performed in pediatric patients.[1] We report a case of TBVc in an immunocompetent patient with no history of pulmonary TB, and M. tuberculosis cultures with Ziehl–Neelsen and GeneXpert staining were negative. In this case, the Mantoux test was not performed. We performed dermoscopy and histopathological investigations to confirm the diagnosis.

Jakhar et al. reported a case of TBVc showing a good correlation between dermoscopy and histopathological features for the diagnosis of TBVc. The results of dermoscopy in the form of thick white scales showed histopathological hyperkeratosis, the papillated surface indicated the presence of papillomatosis, and the yellow globular structure showed epithelioid cell granuloma with Langerhans giant cells.[6] The differential diagnosis of chromoblastomycosis can be ruled out because there is no medlar body image, and histopathological examination is confirmed. Subhadarshani and Yadav reported a case of chromoblastomycosis diagnosis based on dermoscopy and histopathology found in medlar bodies.[8]

PCR examination from skin lesions can detect mycobacterial DNA and has high sensitivity for the diagnosis of TBVc. However, in developing countries, PCR examinations are not routinely carried out.[3] Tan et al. reported that in the case of multibacillary PCR, the sensitivity and specificity was up to 100%, while in the paucibacillary case, TBVc was 55% and lupus vulgaris was 60%.[9] In our case, no PCR examination of skin lesions was performed; the diagnosis of TBVc was based on the correlation of clinical manifestations, dermoscopy, and histopathological examination.

  Conclusion Top

Clinical manifestations of TBVc often resemble other chronic skin diseases. In cases of TBVc with Ziehl–Neelsen staining, the culture was negative; the diagnosis can be made based on the correlation of clinical manifestations, dermoscopy, and histopathological examination.


Larger research samples and prospective research methods are needed.

Declaration of patient consent

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

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Roelan T. Practical review of diagnosis and management of cutaneous tuberculosis in Indonesia. Eur J Med Health Sci 2021;3:25-30.  Back to cited text no. 1
Belgaumkar VA, Chavan RB, Suryataley PR, Salunke AS, Patil PP, Borade SM. Tuberculosis verrucosa cutis: Case report of a diagnostic challenge. Int J Res Dermatol 2018;4:265.  Back to cited text no. 2
Asmarani Y, Mulia RC, Adriani A. A large verrucous plaque on the buttocks: A case report of an atypical presentation of tuberculosis verrucosa cutis. Pan Afr Med J 2020;37:131.  Back to cited text no. 3
Khadka P, Koirala S, Thapaliya J. Cutaneous tuberculosis: Clinicopathologic arrays and diagnostic challenges. Dermatol Res Pract 2018;2018:7201973.  Back to cited text no. 4
Miranda E, Widaty S, Sirait S, Rizky LA, Menaldi SL, Lim HW . Correlation between clinical and histopathological findings of five puzzling cases of cutaneous tuberculosis. J Gen Dermatol Venereol Indones 2020;5:48-55.  Back to cited text no. 5
Jakhar D, Gupta RK, Sarin N. Dermoscopy of tuberculosis verrucosa cutis. Indian Dermatol Online J 2021;12:206-7.  Back to cited text no. 6
  [Full text]  
Wedy GF, Passero LF, Criado PR, Belda W Jr. A case of tuberculosis verrucosa cutis in Brazil undiagnosed for 15 years. Braz J Infect Dis 2021;25:101593.  Back to cited text no. 7
Subhadarshani S, Yadav D. Dermoscopy of chromoblastomycosis. Dermatol Pract Concept 2017;7:23-4.  Back to cited text no. 8
Tan SH, Tan HH, Sun YJ, Goh CL. Clinical utility of polymerase chain reaction in the detection of Mycobacterium tuberculosis in different types of cutaneous tuberculosis and tuberculids. Ann Acad Med Singapore. 2001;30:3-10.  Back to cited text no. 9


  [Figure 1], [Figure 2], [Figure 3]


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