Letters to the Editor

RREFERENCESEFERENCES

1. Yu RC, Pryce DW, Macfarlane AW, Stewart TW. A histopathological study of 643 cutaneous horns. Br J Dermatol 1991;124:449-52. 2. Souza LN, Martins CR, de Paula AM. Cutaneous horn occurring on the lip of a child. Int J Paediatr Dent 2003;13:365-7. 3. Stavroulaki P, Mal RK. Squamous cell carcinoma presenting as a cutaneous horn. Auris Nasus Larynx 2000;27:277-9. 4. Skoulakis C, Theos E, Chlopsidis P, Manios AG, Feritsean A, Papadakis E. Giant cutaneous horn on squamous cell carcinoma of the lower lip. Eur J Plast Surg 2009;32:257-9. 5. Mutaf M. A rare perioral lesion: Cutaneous horn of the lower lip. Eur J Plast Surg 2007;29:339-41.

Figure 1: Left groin showing three linear scars with sinus and Access this article online crusted plaque and underlying swelling Quick Response Code: Website: www.ijdvl.com

DOI: 10.4103/0378-6323.125469

PMID: *****

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Sir, The prevalence of cutaneous among Figure 2: Hyperkeratotic plaque on the left foot various dermatology out-patient departments in India ranges between 0.1-0.5%.[1] Scrofuloderma is a was negative. X-ray chest, ultrasonography of the frequently encountered form of cutaneous tuberculosis abdomen was unremarkable. Skin biopsy taken from among children in India, where as vulgaris is both lesions revealed epithelioid cell granuloma with the most common form of cutaneous tuberculosis seen langhan’s-type of giant cells and dense collection of in most countries.[2] lymphocytes and plasma cells. Fite stain for acid-fast bacilli was negative. Biopsy tissue for polymerase An 11-year-old boy was brought for swellings in the chain reaction was negative for left groin and dorsum of left foot of 1½-year duration. tuberculosis. Characteristic morphology, positive His mother noticed three linear swellings in the left Mantoux test and histopathology corroborated in groin, which ulcerated to discharge serosanguinous establishing the diagnosis of scrofuloderma with fluid, leading to partial healing. Later, she observed a tuberculosis verrucosa cutis. small plaque on the dorsum of left foot. Examination revealed matted left inguinal lymphadenopathy and The most common sites of scrofuloderma are the chest, scar of bacillus Calmette-Guerin vaccination. There neck and axilla. There was no evidence of systemic were three linear scars on the left groin measuring involvement in the index case. However, systemic 3-5 cm in length and 0.5 cm in width [Figure 1]. involvement was reported in 21.3% of children with A well-circumscribed verrucous plaque of size cutaneous tuberculosis. It has been observed that 6 cm × 4 cm was noted on the dorsum of left bacillus Calmette-Guerin vaccinated patients are foot [Figure 2]. Diagnosis of scrofuloderma with less likely to develop disseminated tuberculosis. In tuberculosis verrucosa cutis was offered. Mantoux concert with this, the index case developed localized test was positive (18 mm). Smear and culture were cutaneous tuberculosis. Positive mantoux test in the negative for both Mycobacterium tuberculosis and index case concurs with the observation that the fungus. Serology for human virus majority (98.1%) of children with localized cutaneous

76 Indian Journal of Dermatology, Venereology, and Leprology | January-February 2014 | Vol 80 | Issue 1 Letters to the Editor tuberculosis exhibit positive reaction to Coexistence of scrofuloderma with tuberculosis antigen.[3] However, in India, mantoux reactivity verrucosa cutis in the same patient, as seen in the index does not correlate with the extent of the disease. In case, is rare. Both types of cutaneous tuberculosis conformity with the various Indian studies, none of have diverse underlying immunity as evidenced by children with cutaneous tuberculosis, including ours, CD4+/CD8+ ratio in the granuloma: Scrofuloderma were tested positive for human immunodeficiency with low level immunity and tuberculosis verrucosa virus by enzyme-linked immunosorbent assay. cutis with intermediate immunity. Gonul et al., Nonetheless, in a study of 231 patients with cutaneous reported such coexistence in a 35-year-old woman, tuberculosis (adults and children) only two tested who developed scrofuloderma in the left axilla and positive for human immunodeficiency virus.[4] It is tuberculosis verrucosa cutis on the dorsum of the left noteworthy that there was no report of coexistence hand at the same time.[5] The case under study also of any type of cutaneous tuberculosis among them, presented with scrofuloderma in the left groin and subscribing to the proposition that coexistence is tuberculosis verrucosa cutis on the dorsum of the seen mostly in immunocompetent patients. The left foot simultaneously. Interestingly, tuberculosis negative smear and culture for mycobacterium verrucosa cutis lesions in both cases are distantly tuberculosis in the reported case could be due placed from scrofuloderma lesions, albeit on the same to the small number of bacilli in the localized limb. Balabanova et al., have also reported coexistence cutaneous tuberculosis. Notably, tuberculous bacilli of tuberculosis verrucosa cutis with in could be demonstrated in only 22.5% of children a 68-year old peasant, who initially developed lupus with scrofuloderma.[3] In a study, using culture vulgaris on the chin and 3-months later developed on Lowenstein– Jensen’s medium, researchers tuberculosis verrucosa cutis on the left foot.[6] Of note, observed positive cultures in 51.05% of patients with is the distant location of tuberculosis verrucosa cutis scrofuloderma, 42.85% with tuberculosis verrucosa away from scrofuloderma/lupus vulgaris in all the three cutis and 13.3% with lupus vulgaris. Histopathology case reports including the index case. Sethuraman confirmed the diagnosis of tuberculosis in the index et al., reported coexistence of bilateral scrofuloderma case. In a study, classical tubercular histology was with tuberculosis verrucosa cutis in a 13-year-old girl observed in 47.5% of patients with scofuloderma who initially developed scrofuloderma involving both and 100% patients with tuberculosis verrucosa ankles and 5-year later developed tuberculosis verrucosa cutis.[3] Polymerase chain reaction for mycobacterium cutis over the same sites[7] [Table 1]. The bilateral tuberculosis was negative. However, in a study on involvement of scrofuloderma and the development of utility of polymerase chain reaction for cutaneous tuberculosis verrucosa cutis on the scrofuloderma at tuberculosis, it was found positive in 50% of cases same sites are noteworthy. Wilson-Jones also reported of scrofuloderma and 62.2% cases of tuberculosis coexistence of lupus vulgaris with papulonecrotic verrucosa cutis. Nonetheless, polymerase chain tuberculids in his study of 12-patients.[8] reaction provides rapid and sensitive detection of mycobacterium tuberculosis, particularly Coexistence of scrofuloderma and tuberculosis in paucibacillary tuberculosis. Furthermore, verrucosa cutis in the same patient is rare and more combination of dot hybridization with polymerase so in a child like the case under study. The physician chain reaction markedly increases the sensitivity and should be aware that a patient with one form of specificity of polymerase chain reaction in detecting cutaneous tuberculosis may also have another form as mycobacterium tuberculosis. well.

Table 1: Co-existence of different cutaneous tuberculosis with time gap between development Author Number of Co-existent cutaneous Time gap between development of Same site/ Age of the patients tuberculosis different cutaneous tuberculosis distant site patient Current report 1 SFD with TVC Same time Distant 11 years Gonul et al.[5] 1 SFD with TVC Same time Distant 35 years Balabanova et al.[6] 1 TVC with LV 3 months Distant 68 years Sethuraman et al.[7] 1 SFD with TVC 5 years Same 13 years Wilson-Jones[8] 12 LV with PNT Variable Distant Young adults SFD: Scrofuloderma, TVC: Tuberculosis verrucosa cutis, LV: Lupus vulgaris, PNT: Papulonecrotic tuberculids

Indian Journal of Dermatology, Venereology, and Leprology | January-February 2014 | Vol 80 | Issue 1 77 Letters to the Editor

AAngooringoori GnaneshwarGnaneshwar RaoRao CCASEASE 1 Department of Dermatology, SVS Medical College, Mahbubnagar, Andhra Pradesh, India A 21-year-old woman had suffered a recurrent papule and effusion on her right nipple [Figure 1a] for more AAddressddress forfor correspondence:correspondence: Prof. Angoori Gnaneshwar Rao, F-12, B-8, HIG-2, APHB, Baghlingampally, than 15 years. There was no pain, and the papule Hyderabad - 500 044, Andhra Pradesh, India. was not itchy. The patient had taken advice from a E-mail: [email protected] gynecologist and had been followed up for 7 years. RREFERENCESEFERENCES However, since no improvement was noted, the gynecologist did a biopsy of the nipple considering 1. Kumar B, Kaur S. Pattern of cutaneous tuberculosis in North breast cancer. Her family history was negative, and India. Indian J Dermatol Venereol Leprol 1986;52:203-7 the patient had no history of ichthyosis or eczema. 2. Amézquita R. Tuberculosis Cutis, aspects clinocos epidemiologicosen Mexico. Thesis, Acta Leprol, Vol 16. A skin examination showed crusting and effusion on Abstract in Excerpta Medica 1965; 19:674. the right nipple. 3. Kumar B, Rai R, Kaur I, Sahoo B, Muralidhar S, Radotra BD. Childhood cutaneous tuberculosis: A study over 25 years from northern India. Int J Dermatol 2001;40:26-32. CCASEASE 2 4. Umapathy KC, Begum R, Ravichandran G, Rahman F, Paramasivan CN, Ramanathan VD. Comprehensive findings on clinical, bacteriological, histopathological and therapeutic aspects A 19-year-old woman with asymptomatic verrucous of cutaneous tuberculosis. Trop Med Int Health 2006;11:1521-8. lesions on both nipples for 3 years was referred to the 5. Gonul M, Gul U, Kilic A, Soylu, S, Demiriz M, Kubar A. clinic. The lesions consisted of a round, rough plaque, Coexistence of tuberculosis verrucosa cutis with scrofuloderma-A case report. Turk J Med Sci 2008;38:495-9. 2 cm in diameter, on each nipple. They showed 6. Pramatarov K, Balabanova M, Miteva L, Gantcheva M. dark-brown discoloration and a cobbled hyperkeratotic Tuberculosis verrucosa cutis associated with lupus vulgaris. appearance [Figure 1b]. The patient was otherwise Int J Dermatol 1993;32:815-7. 7. Sethuraman G, Kaur J, Nag HL, Khaitan BK, Sharma VK, healthy and had no other skin lesions. Singh MK. Symmetrical scrofuloderma with tuberculosis verrucosa cutis. Clin Exp Dermatol 2006;31:475-7. CCASEASE 3 8. Wilson-Jones E, Winkelmann RK. Papulonecrotic tuberculid: A neglected disease in Western Countries. J Am Acad Dermatol 1986;14:815-26. A 16-year-old girl presented with a 1-year history of brown patches associated with pain and itching on her Access this article online nipples. On examination, we found brown, waxy scales Quick Response Code: Website: on both nipples [Figure 1c]. The patient’s nipples were www.ijdvl.com inverted. There was no history of eczema, Darier's

DOI: disease, or ichthyosis. 10.4103/0378-6323.125471 Biopsies performed in patients 1 and 3 revealed PMID: ***** papillomatous elongation of the epidermis with hyperkeratosis. A number of budding yeast cells were detected in the stratum corneum by periodic acid-Schiff (PAS) and Gomori methenamine silver MMalasseziaalassezia aassociatedssociated (GMS) staining [Figure 2]. hhyperkeratosisyperkeratosis ofof thethe nipplenipple inin Direct methylene blue staining of scrapings revealed yeast cells in all three patients [Figure 3]. Scales yyoungoung females:females: ReportReport ofof threethree were cultured and the colonies examined under ccasesases a microscope, which revealed yeast cells. Three strains recovered from the medium were identified as Malassezia species. Fungal DNA was extracted from Sir, paraffin-embedded tissues of patients 1 and 3, and Hyperkeratosis of the nipple and/or areola (HNA) is an from scales of patient 2, according to the method of unusual condition characterized by hyperpigmented, Sugita et al.[2] Overall colonization by all Malassezia verrucous, keratotic thickening of the nipple and/or species and colonization by M. globosa and M. restricta areola.[1] We report three cases of hyperkeratosis of the were determined by real-time polymerase chain nipple associated with Malassezia. reaction (PCR) analysis of the samples, performed

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