Generic selectors
Exact matches only
Search in title
Search in content
Search in posts
Search in pages
Filter by Categories
15th National Conference of the IAOMFP, Chennai, 2006
Abstract
Abstracts from current literature
Acne in India: Guidelines for management - IAA Consensus Document
Addendum
Announcement
Art & Psychiatry
Article
Articles
Association Activities
Association Notes
Award Article
Book Review
Brief Report
Case Analysis
Case Letter
Case Letters
Case Notes
Case Report
Case Reports
Clinical and Laboratory Investigations
Clinical Article
Clinical Studies
Clinical Study
Commentary
Conference Oration
Conference Summary
Continuing Medical Education
Correspondence
Corrigendum
Cosmetic Dermatology
Cosmetology
Current Best Evidence
Current View
Derma Quest
Dermato Surgery
Dermatopathology
Dermatosurgery Specials
Dispensing Pearl
Do you know?
Drug Dialogues
e-IJDVL
Editor Speaks
Editorial
Editorial Remarks
Editorial Report
Editorial Report - 2007
Editorial report for 2004-2005
Errata
Erratum
Focus
Fourth All India Conference Programme
From Our Book Shelf
From the Desk of Chief Editor
General
Get Set for Net
Get set for the net
Guest Article
Guest Editorial
History
How I Manage?
IADVL Announcement
IADVL Announcements
IJDVL Awards
IJDVL AWARDS 2015
IJDVL Awards 2018
IJDVL Awards 2019
IJDVL Awards 2020
IJDVL International Awards 2018
Images in Clinical Practice
In Memorium
Inaugural Address
Index
Knowledge From World Contemporaries
Leprosy Section
Letter in Response to Previous Publication
Letter to Editor
Letter to the Editor
Letter to the Editor - Case Letter
Letter to the Editor - Letter in Response to Published Article
LETTER TO THE EDITOR - LETTERS IN RESPONSE TO PUBLISHED ARTICLES
Letter to the Editor - Observation Letter
Letter to the Editor - Study Letter
Letter to the Editor - Therapy Letter
Letter to the Editor: Articles in Response to Previously Published Articles
Letters to the Editor
Letters to the Editor - Letter in Response to Previously Published Articles
Letters to the Editor: Case Letters
Letters to the Editor: Letters in Response to Previously Published Articles
Medicolegal Window
Messages
Miscellaneous Letter
Musings
Net Case
Net case report
Net Image
Net Letter
Net Quiz
Net Study
New Preparations
News
News & Views
Obervation Letter
Obituary
Observation Letter
Observation Letters
Oration
Original Article
ORIGINAL CONTRIBUTION
Original Contributions
Pattern of Skin Diseases
Pearls
Pediatric Dermatology
Pediatric Rounds
Perspective
Presedential Address
Presidential Address
Presidents Remarks
Quiz
Recommendations
Regret
Report
Report of chief editor
Report of Hon : Treasurer IADVL
Report of Hon. General Secretary IADVL
Research Methdology
Research Methodology
Resident page
Resident's Page
Resident’s Page
Residents' Corner
Residents' Corner
Residents' Page
Retraction
Review
Review Article
Review Articles
Revision Corner
Self Assessment Programme
SEMINAR
Seminar: Chronic Arsenicosis in India
Seminar: HIV Infection
Short Communication
Short Communications
Short Report
Special Article
Specialty Interface
Studies
Study Letter
Supplement-Photoprotection
Supplement-Psoriasis
Symposium - Contact Dermatitis
Symposium - Lasers
Symposium - Pediatric Dermatoses
Symposium - Psoriasis
Symposium - Vesicobullous Disorders
SYMPOSIUM - VITILIGO
Symposium Aesthetic Surgery
Symposium Dermatopathology
Symposium-Hair Disorders
Symposium-Nails Part I
Symposium-Nails-Part II
Tables
Technology
Therapeutic Guidelines
Therapeutic Guidelines - IADVL
Therapeutics
Therapy
Therapy Letter
View Point
Viewpoint
What’s new in Dermatology
View/Download PDF
Letter to the Editor
2014:80:3;266-267
doi: 10.4103/0378-6323.132263
PMID: 24823413

Miliary pulmonary tuberculosis with tuberculosis verrucosa cutis

Saka VinodKumar1 , S Mathanraj1 , Narhari Narendra Kumar1 , Jagannathan Venugopal1 , Debadutta Basu2
1 Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry UT, India
2 Department of Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry UT, India

Correspondence Address:
Saka VinodKumar
Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry UT
India
How to cite this article:
VinodKumar S, Mathanraj S, Kumar NN, Venugopal J, Basu D. Miliary pulmonary tuberculosis with tuberculosis verrucosa cutis. Indian J Dermatol Venereol Leprol 2014;80:266-267
Copyright: (C)2014 Indian Journal of Dermatology, Venereology, and Leprology

Sir,

Tuberculosis verrucosa cutis is a form of cutaneous tuberculosis occurring in patients with well preserved cell mediated immunity. The presence of miliary tuberculosis in a patient with tuberculosis verrucosa cutis is a rare and unusual combination as they are at two ends of an immunological spectrum.

A 40-year-old male presented to our department with an ulcerated plaque over the plantar aspect of left foot for one year that was associated with swelling, pain and occasional watery discharge [Figure - 1]. He also gave history of low grade fever and cough over two months. No other significant co-morbidities or contact with tuberculosis was present. He denied any previous anti-tubercular therapy.

Figure 1: TB verrucosa cutis - lesions - pre and post treatment

Baseline investigations (hemogram, liver and renal function tests) were found to be normal. Cultures from the wound discharge (bacterial, fungal and tubercular) were negative. Chest X-ray revealed bilateral miliary mottling [Figure - 2]. Computed tomography of the chest showed characteristic miliary nodules bilaterally. There were no lesions in the abdominal organs. Ophthalmic examination showed absence of choroid tubercles. Mantoux test was negative. Sputum smear and cultures (on Lowenstein-Jensen medium) were also negative. Flexible fibre-optic bronchoscopy showed inflamed left main stem and lingular bronchus. Acid fast bacilli (AFB) were not seen or grown from bronchial washings and mycobacteria were not detected by PCR. The patient did not consent for trans-bronchial lung biopsy. ELISA for antibodies to HIV and HBsAg (Hepatitis B surface antigen) were found to be negative.

A skin biopsy from the plantar lesion revealed granulomas in the dermis composed of epithelioid cells, Langhans giant cells and lymphocytes in the dermis with marked hyperkeratosis and parakeratosis of the overlying epidermis [Figure - 3]. Based on these findings, a diagnosis of miliary tuberculosis with tuberculosis verrucosa cutis was made. The patient was started on category I anti tubercular therapy given as follows: 2 months of HRZE (H-isoniazid; R-rifampicin; Z-pyrazinamide; E-ethambutol) and 4 months of HR in a daily regimen. At the end of treatment, the foot lesion was completely cleared [Figure - 1] and radiological resolution of miliary shadowing was observed.

Figure 2: Chest X-ray showing miliary nodules
Figure 3: H and E staining shows tubercular granuloma (epitheliod cells, lymphocytes and giant cells seen)

Tuberculosis verrucsa cutis is also known as warty tuberculosis, prosector′s wart, butcher′s wart, and verrucous tuberculosis. [1] Lesions usually occur on areas exposed to trauma such as hands, fingers and lower extremities. Physicians, pathologists and medical laboratory personnel are usually affected due to handling of sputum and pathologic material. Indian reports indicate that tuberculosis verrucosa cutis occurred most commonly on the lower extremities and buttocks whereas hands were most commonly involved elsewhere. [2]

Warty tuberculosis is usually solitary but multiple lesions may occur. The lesion typically starts with a painless, dusky red, firm, indurated nodule or papule that expands peripherally and is surrounded by inflammation. Spontaneous central resolution with areas of atrophy surrounded by a verrucous keratotic surface or an annular plaque with a warty advancing border is seen. Occasionally pus and keratinous material may be expressed from fissures in the warty areas. Lymphadenopathy is usually absent and if seen, indicates secondary infection. [3]

Histopathology shows pseudoepitheliomatous hyperplasia with marked hyperkeratosis, acanthosis, dense inflammatory infiltrates with epitheliod cells and giant cells in the mid-dermis. Typical tuberculosis granulomas with characteristic caseation are not common. [3] Tuberculosis verrucosa cutis is a paucibacillary disease demonstrating very few bacilli. Mantoux reaction is markedly positive.

Diagnosis is usually confirmed by typical clinical appearance, histopathological pattern, and a positive response to anti-tubercular treatment. The differential diagnoses include blastomycosis, chromomycosis, fixed sporotrichosis, lesions caused by non-tubercular mycobacteria, lupus vulgaris, and tertiary syphilis.

Kumar et al. in their study observed that cutaneous TB was associated with tuberculosis in other organs in 22% of patients. Organs commonly affected were lungs followed by bone, abdomen and CNS. The association of tuberculosis verrucosa cutis with pulmonary tuberculosis was rare in their study. [4]

Our patient had both tuberculosis verrucosa cutis and miliary tuberculosis which is a very rare association. The presence of miliary tuberculosis in our patient was identified on routine screening for pulmonary tuberculosis. Conversely, cutaneous involvement is a very rare and unusual presentation in miliary tuberculosis. [5] Whether military tuberculosis preceded the skin lesion or followed it is difficult to determine.

Tuberculosis verrucosa cutis can result both from inoculation and from endogenous spread. [4] The foot lesion can be explained by inoculation of mycobacteria while walking barefoot. Endogenous spread as a part of hemato-lymphatic dissemination to the skin in a patient with miliary tuberculosis is a rarer possibility. Sehgal et al. [3] reported a case of disseminated tuberculosis with tuberculosis verrucosa cutis and pulmonary involvement in an immunocompetent patient, similar to our case. Padmavathy et al. also reported miliary tuberculosis in a patient with tuberculosis verrucosa cutis and explained it as part of the varied immunological response to infection. [6]

References
1.
Pomeranz MK, Orbuch P, Shupack J, Brand R. Mycobacteria and skin. In: Rom WM, Garay S, editors. Tuberculosis. Vol. 51.1 st ed. London: Little Brown Co.;1996. p. 657-74.
[Google Scholar]
2.
Aliaðaoðlu C, Atasoy M, Güleç AÝ,Özdemir Þ, Erdem T, Engin RÝ. Tuberculosis verrucosa cutis. Eur J Gen Med 2009;6:268-73.
[Google Scholar]
3.
Sehgal VN, Sehgal R, Bajaj P, Sriviastava G, Bhattacharya S. Tuberculosis verrucosa cutis (TBVC). J Eur Acad Dermatol Venereol 2000;14:319-21.
[Google Scholar]
4.
Kumar B, Muralidhar S.Cutaneous tuberculosis: A twenty-year prospective study. Int J Tuberc Lung dis 1999;3:494-500.
[Google Scholar]
5.
del Giudice P, Bernard E, Perrin C, Bernardin G, Fouché R, Boissy C, et al. Unusual cutaneous manifestations of miliarytuberculosis. Clin Infect Dis 2000;30:201-4.
[Google Scholar]
6.
Padmavathy L, Lakshmana Rao L, Ethirajan N, Ramakrishna Rao M, Subrahmanyan EN, Manohar U.Tuberculousverrucosa cutis (TBVC)- foot with military tuberculosis. Indian J Tuberc 2007;54:145-8.
[Google Scholar]

Fulltext Views
213

PDF downloads
103
Show Sections