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 Table of Contents  
LETTER TO EDITOR
Year : 2020  |  Volume : 7  |  Issue : 1  |  Page : 36-37

Varied presentation of cutaneous tuberculosis in a patient


1 Department of Dermatology, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi, India
2 Department of Pathology, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi, India

Date of Submission11-Dec-2019
Date of Decision05-Apr-2020
Date of Acceptance13-Apr-2020
Date of Web Publication02-Jun-2020

Correspondence Address:
Prekshi Bansal
Department of Dermatology, Dr. Ram Manohar Lohia Hospital and PGIMER, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijdpdd.ijdpdd_63_19

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How to cite this article:
Rani S, Bansal P, Ahuja A, Agrawal D. Varied presentation of cutaneous tuberculosis in a patient. Indian J Dermatopathol Diagn Dermatol 2020;7:36-7

How to cite this URL:
Rani S, Bansal P, Ahuja A, Agrawal D. Varied presentation of cutaneous tuberculosis in a patient. Indian J Dermatopathol Diagn Dermatol [serial online] 2020 [cited 2020 Aug 14];7:36-7. Available from: http://www.ijdpdd.com/text.asp?2020/7/1/36/285809



Sir,

A 29-year-old male farmer presented with a 2 year history of gradually increasing asymptomatic multiple brownish-red raised lesions and extensive swelling over his left lower limb. Lesion started with raised papule over left leg with gradual progression associated with intermittent pus discharge and swelling of lower limb. Preceding history of trauma was present and there was absence of history of chronic illness, prolonged fever or weight loss. General and systemic examination were normal. Cutaneous examination revealed grossly edematous left foot with multiple well defined hyperkeratotic, verrucous and crusted plaques of varying sizes distributed on heel, antero-posterior and medial side of leg associated with foul smelling discharge and atrophic and puckered scars on left groin and leg [Figure 1]. A smooth nontender fluctuant swelling measuring approximately 5 cm × 4 cm with restricted mobility was present over right elbow.
Figure 1: Multiple hyperkeratotic and verrucous plaques with pus discharge on edematous left lower limb

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Diascopy didn't reveal any specific colour change suggestive of lupus vulgaris. We considered the differential diagnosis of cutaneous tuberculosis, chromoblastomycosis and blastomycosis. Routine biochemical tests including random blood sugar as well as acute inflammatory markers; erythrocyte sedimentation rate and C reactive protein were within normal range. Chest X-ray was normal. Enzyme linked immunosorbent assay for human immunodeficiency virus 1, 2 was negative. Mantoux test was positive with induration of 20 mm. Skin biopsy from verrucous plaque on leg showed hyperkeratosis, acanthosis, dermal dense lymphohistiocytic infiltration with many epithelioid cell granulomas with Langhans giant cells and occasional central necrosis [Figure 2] and [Figure 3]. Acid-fast bacilli and fungal elements were absent in both biopsy and tissue as well as pus culture. Left leg radiography showed irregular soft tissue density along tibia and well defined lytic lesion with sclerotic border indicating tubercular etiology. Magnetic resonance imaging of leg showed multi-loculated collection within the diffusely thickened subcutaneous tissue and skin over lateral aspect of knee. Fine needle aspiration cytology from fluctuant swelling over the right elbow revealed dense partially degenerated inflammatory cells comprising polymorphs and lymphocytes in a background of abundant necrosis. Finally, a diagnosis of multifocal tuberculosis verrucosa cutis (TBVC) coexisting with tuberculous gumma was made. Anti tuberculosis therapy (ATT) was initiated and visual improvement was observed with persistent left foot swelling even after 5 months of ATT [Figure 4].
Figure 2: Low power photomicrograph showing hyperkeratosis, parakeratosis and irregular acanthosis. Dermis shows multiple granulomas and lymphocytes (H and E, ×10)

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Figure 3: High power photomicrograph showing well formed epithelioid cell granulomas with focal central necrosis, giant cells and surrounding lymphocytic infiltrate (H and E, ×40)

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Figure 4: Healing plaques and absence of discharge on left lower limb while on anti tuberculosis therapy

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Tuberculosis shows varied pattern of cutaneous involvement depending on the host immunity with paucibacillary TBVC in high immunity individuals to multibacillary tuberculous gumma seen in poor immunity. While TBVC occurs commonly due to exogenous re-infection attributed to trauma and habitual practices,[1] skeletal involvement demonstrates late reactivation of foci disseminated during a prior pulmonary infection which resolves without any residual radiographic change in 1%–2% cases.[2] Since presensitized individuals mount good immune response, TBVC rarely manifests multifocally in immunocompetent persons.[3]

Tuberculous gumma presents as subcutaneous nodules or soft abcesses over the extremities and trunk in immunosuppressed patients due to hematogenous spread from a primary infective foci. Exogenous spread is rare.[4] Different morphologies of cutaneous tuberculosis in a single patient within short time span is rare especially if both reflect different immune status.[5] The occurrence of multifocal TBVC in our patient could be viewed as representing deteriorating immunity, poor nutrition and inadequate treatment. This is supported by the appearance of tuberculous gumma within short interval. Moreover, pattern of cutaneous tuberculosis is altered by fluctuating host immunity which manifested in our patient. The initiation of ATT lead to cutaneous improvement but foot-swelling persisted.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Padmavathy L, Lakshmana Rao L, Ethirajan N, Ramakrishna Rao M, Subrahmanyan EN, Manohar U. Tuberculosis verrucosa cutis (TBVC)-foot with miliary tuberculosis. Indian J Tuberc 2007;54:145-8.  Back to cited text no. 1
    
2.
Sethuraman G, Kaur J, Nag HL, Khaitan BK, Sharma VK, Singh MK. Symmetrical scrofuloderma with tuberculosis verrucosa cutis. Clin Exp Dermatol. 2006;31:475-7.  Back to cited text no. 2
    
3.
Chahar M, Dhali TK, D'souza P. Multifocal tuberculosis verrucosa cutis. Dermatol Online J 2015;21. pii: 13030/qt80j7q792.  Back to cited text no. 3
    
4.
Parker L, Babu S. Tuberculous gumma: A forgotten entity in the UK. BMJ Case Reports. 2013;2013. pii: bcr2013010462. doi: 10.1136/bcr-2013-010462.  Back to cited text no. 4
    
5.
Rambhia K, Kharkar V, Mahajan S, Khopkar U. Multifocal tuberculous gummas and bilateral scrofuloderma followed by papulonecrotic tuberculids developing during anti-tubercular therapy. Indian J Dermatol Venereol Leprol. 2016;82:424-6.  Back to cited text no. 5
    


    Figures

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



 

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