Letters to the Editor

A rrareare aassociationssociation ooff mmiliaryiliary 4 months of HR in a daily regimen. At the end of treatment, the foot lesion was completely cleared ppulmonaryulmonary tuberculosistuberculosis withwith [Figure 1] and radiological resolution of miliary ttuberculosisuberculosis verrucosaverrucosa cutiscutis shadowing was observed. Tuberculosis verrucsa cutis is also known as warty Sir, tuberculosis, prosector’s wart, butcher’s wart, and [1] Tuberculosis verrucosa cutis is a form of cutaneous verrucous tuberculosis. Lesions usually occur on tuberculosis occurring in patients with well preserved areas exposed to trauma such as hands, fingers and cell mediated immunity. The presence of miliary lower extremities. Physicians, pathologists and tuberculosis in a patient with tuberculosis verrucosa medical laboratory personnel are usually affected due cutis is a rare and unusual combination as they are at to handling of sputum and pathologic material. Indian two ends of an immunological spectrum. reports indicate that tuberculosis verrucosa cutis occurred most commonly on the lower extremities A 40-year-old male presented to our department with and buttocks whereas hands were most commonly [2] an ulcerated plaque over the plantar aspect of left foot involved elsewhere. for one year that was associated with swelling, pain and occasional watery discharge [Figure 1]. He also Warty tuberculosis is usually solitary but multiple gave history of low grade fever and cough over two lesions may occur. The lesion typically starts with a months. No other significant co-morbidities or contact painless, dusky red, firm, indurated nodule or papule with tuberculosis was present. He denied any previous that expands peripherally and is surrounded by anti-tubercular therapy. inflammation. Spontaneous central resolution with areas of atrophy surrounded by a verrucous keratotic Baseline investigations (hemogram, liver and renal surface or an annular plaque with a warty advancing function tests) were found to be normal. Cultures from border is seen. Occasionally pus and keratinous the wound discharge(bacterial, fungal and tubercular) material may be expressed from fissures in the warty were negative. Chest X-ray revealed bilateral miliary areas. Lymphadenopathy is usually absent and if seen, [3] mottling [Figure 2]. Computed tomography of the chest indicates secondary infection. showed characteristic miliary nodules bilaterally. There were no lesions in the abdominal organs. Ophthalmic Histopathology shows pseudoepitheliomatous examination showed absence of choroid tubercles. hyperplasia with marked hyperkeratosis, acanthosis, Mantoux test was negative. Sputum smear and dense inflammatory infiltrates with epitheliod cultures (on Lowenstein-Jensen medium) were also cells and giant cells in the mid-dermis. Typical negative. Flexible fibre-optic bronchoscopy showed tuberculosis granulomas with characteristic caseation inflamed left main stem and lingular bronchus. Acid are not common.[3] Tuberculosis verrucosa cutis is a fast bacilli(AFB) were not seen or grown from bronchial paucibacillary disease demonstrating very few bacilli. washings and mycobacteria were not detected by PCR. Mantoux reaction is markedly positive. The patient did not consent for trans-bronchial lung biopsy. ELISA for antibodies to HIV and HBsAg(Hepatitis Diagnosis is usually confirmed by typical clinical B surface antigen) were found to be negative. appearance, histopathological pattern, and a positive response to anti-tubercular treatment. The differential A skin biopsy from the plantar lesion revealed diagnoses include blastomycosis, chromomycosis, granulomas in the dermis composed of epithelioid fixed sporotrichosis, lesions caused by non-tubercular cells, Langhans giant cells and lymphocytes in the mycobacteria, lupus vulgaris, and tertiary syphilis. dermis with marked hyperkeratosis and parakeratosis of the overlying epidermis [Figure 3]. Based on these Kumar et al. in their study observed that cutaneous findings, a diagnosis of miliary tuberculosis with TB was associated with tuberculosis in other organs in tuberculosis verrucosa cutis was made. The patient 22% of patients. Organs commonly affected were lungs was started on category I anti tubercular therapy followed by bone, abdomen and CNS. The association given as follows: 2 months of HRZE (H-isoniazid; of tuberculosis verrucosa cutis with pulmonary R-rifampicin; Z-pyrazinamide; E-ethambutol) and tuberculosis was rare in their study.[4]

266 Indian Journal of Dermatology, Venereology and Leprology | May-June 2014 | Vol 80 | Issue 3 Letters to the Editor

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 Figure 1: TB verrucosa cutis - lesions - pre and post treatment patient with tuberculosis verrucosa cutis and explained it as part of the varied immunological response to infection.[6]

SSakaaka VVinodKumar,inodKumar, S.S. MMathanraj,athanraj, NNarhariarhari NarendraNarendra Kumar,Kumar, JJagannathanagannathan Venugopal,Venugopal, DebaduttaDebadutta BasuBasu1 Departments of Pulmonary Medicine and 1Pathology, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry UT, India

AAddressddress forfor correspondence:correspondence: Dr. S Saka VinodKumar, Department of Pulmonary Medicine, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, Puducherry UT, India. E-mail: [email protected] RREFERENCESEFERENCES Figure 2: Chest X-ray showing miliary nodules 1. PomeranzMK, OrbuchP, ShupackJ, BrandR. Mycobacteria and skin. In: RomWM, GarayS, editors. Tuberculosis. Vol.51.1st ed. London: Little Brown Co.;1996. p.657-74. 2. Aliağaoğlu C, Atasoy M, Güleç Aİ,Özdemir Ş, Erdem T, Engin Rİ. Tuberculosis verrucosa cutis. Eur J Gen Med 2009;6:268-73. 3. SehgalVN, SehgalR, BajajP, SriviastavaG, BhattacharyaS. Tuberculosis verrucosa cutis (TBVC). J Eur Acad Dermatol Venereol 2000;14:319-21. 4. Kumar B, Muralidhar S.Cutaneous tuberculosis: Atwenty-year prospective study. Int J Tuberc Lung dis 1999;3:494-500. 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. 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.

Figure 3: H and E staining shows tubercular granuloma (epitheliod Access this article online cells, lymphocytes and giant cells seen) Quick Response Code: Website: www.ijdvl.com Our patient had both tuberculosis verrucosa cutis and DOI: miliary tuberculosis which is a very rare association. 10.4103/0378-6323.132263 The presence of miliary tuberculosis in our patient was identified on routine screening for pulmonary PMID: ***** tuberculosis. Conversely, cutaneous involvement

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