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Tuberculosis Verrucosa Cutis Presenting As an Annular Hyperkeratotic Plaque

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Tuberculosis Verrucosa Cutis Presenting As an Annular Hyperkeratotic Plaque CONTINUING MEDICAL EDUCATION Tuberculosis Verrucosa Cutis Presenting as an Annular Hyperkeratotic Plaque Shahbaz A. Janjua, MD; Amor Khachemoune, MD, CWS; Sabrina Guillen, MD GOAL To understand cutaneous tuberculosis to better manage patients with the condition OBJECTIVES Upon completion of this activity, dermatologists and general practitioners should be able to: 1. Recognize the morphologic features of cutaneous tuberculosis. 2. Describe the histopathologic characteristics of cutaneous tuberculosis. 3. Explain the treatment options for cutaneous tuberculosis. CME Test on page 320. This article has been peer reviewed and approved Einstein College of Medicine is accredited by by Michael Fisher, MD, Professor of Medicine, the ACCME to provide continuing medical edu- Albert Einstein College of Medicine. Review date: cation for physicians. October 2006. Albert Einstein College of Medicine designates This activity has been planned and imple- this educational activity for a maximum of 1 AMA mented in accordance with the Essential Areas PRA Category 1 CreditTM. Physicians should only and Policies of the Accreditation Council for claim credit commensurate with the extent of their Continuing Medical Education through the participation in the activity. joint sponsorship of Albert Einstein College of This activity has been planned and produced in Medicine and Quadrant HealthCom, Inc. Albert accordance with ACCME Essentials. Drs. Janjua, Khachemoune, and Guillen report no conflict of interest. The authors discuss off-label use of ethambutol, isoniazid, pyrazinamide, and rifampicin. Dr. Fisher reports no conflict of interest. Tuberculosis verrucosa cutis (TVC) is a form evolving cell-mediated immunity. TVC usually of cutaneous tuberculosis that results from acci- begins as a solitary papulonodule following a dental inoculation of Mycobacterium tuberculosis trivial injury or trauma on one of the extremi- in a previously infected or sensitized individ- ties that soon acquires a scaly and verrucous ual with a moderate to high degree of slowly surface. The lesion, which is usually persistent, expands slowly over several months or years with or without central clearing and atrophy. We Accepted for publication February 27, 2006. Dr. Janjua is a specialist, Ayza Skin and Research Center, report a case of TVC in a 15-year-old girl that was Lalamusa, Pakistan. Dr. Khachemoune is Assistant Professor, undiagnosed for 10 years. The diagnosis was Ronald O. Perelman Department of Dermatology, New York confirmed by a positive mycobacterial culture University School of Medicine, New York. Dr. Guillen is an intern, and characteristic histopathologic findings of the University of Illinois, Chicago. biopsy specimens. The patient responded well Reprints: Amor Khachemoune, MD, CWS, Ronald O. Perelman Department of Dermatology, New York University School of to antituberculous therapy (ATT), and the lesion Medicine, 530 First Ave, Suite 7R, New York, NY 10016 resolved with residual scarring. (e-mail: [email protected]). Cutis. 2006;78:309-316. VOLUME 78, NOVEMBER 2006 309 Tuberculosis Verrucosa Cutis Figure 1. Well-defined, verrucous, thick, scaly, linear Figure 2. Pseudoepitheliomatous epidermal hyperplasia plaque on the right knee at presentation. and well-formed tuberculous granulomas in the papillary and reticular dermis (H&E, original magnification 3100). Case Report The remainder of the physical examination A 15-year-old girl presented with a 10-year his- showed unremarkable findings. A bacillus tory of a slowly enlarging asymptomatic warty Calmette-Guérin vaccination scar could be identi- plaque over the right knee. The lesion started fied on the left deltoid. Routine blood and urinalyses as a small asymptomatic red papule following a results were within reference range. Purified protein trivial injury and slowly progressed over several derivative test results were strongly positive (.15 mm months to form a large warty plaque covered of induration after 72 hours). Findings from a chest with a thick scale. The patient and her mother x-ray revealed no evidence of pulmonary disease. reported that the lesion also would get tender, Histopathologic examination results of a biopsy intermittently discharging yellowish exudate. specimen taken from the lesion revealed marked The lesion initially was treated with home rem- epidermal hyperkeratosis, acanthosis, pseudoepi- edies and later with topical steroids and oral theliomatous hyperplasia, and multiple well-formed antibiotics prescribed by local physicians, but the tuberculous granulomas in the dermis (Figure 2). lesion continued expanding slowly to involve a Each of the granulomas consisted of large numbers of large area of the right knee and upper leg. There lymphocytes, neutrophils, histiocytes, and Langhans was neither a family history of nor any known giant cells (Figure 3). However, caseation necrosis contacts with tuberculosis. was not present, and acid-fast bacilli could not be Results of a physical examination revealed a found. Mycobacterium tuberculosis was cultured from 437-cm, large, well-defined, verrucous, thick, scaly, the biopsy specimen. linear plaque situated over the right knee with Daily oral antituberculous therapy (ATT) involvement of the lower aspect of the anterior (rifampicin 450 mg/d, isoniazid 300 mg, and thigh and the right anterior upper aspect of the pyrazinamide 1200 mg) was recommended for leg. Central clearing with atrophy gave the lesion 3 months (Figure 4). The patient responded well to the a somewhat annular shape (Figure 1). Diascopy treatment and there was perceptible regression results did not show an apple jelly–brown color. of the skin lesion. Treatment was continued with Regional lymph nodes were not palpable. rifampicin 450 mg/d and isoniazid 300 mg/d for 310 CUTIS® Tuberculosis Verrucosa Cutis Figure 3. A well-formed noncaseating tubercle consisting of lymphocytes, neutrophils, histiocytes, and Langhans giant cells (H&E, original magnification 3400). another 6 months, resulting in complete regression of the lesion with residual scarring. Comment Tuberculosis is a serious public health concern in Figure 4. Regression of the lesion after 3 months of anti- developing countries due to lower socioeconomic tuberculous therapy. status, malnutrition, and overcrowding; addition- ally, the morbidity and mortality rates of the disease are increasing rapidly in these countries. The inci- TVC is a form of cutaneous tuberculosis that dence of tuberculosis also is on the rise in developed results from accidental inoculation of M tuberculosis countries, including the United States and United into the skin through open wounds or abrasions in Kingdom, both of which were previously considered previously infected or sensitized individuals with a free of this disease.1,2 moderate to high degree of immunity,6 as opposed Systemic tuberculosis was well-documented in to tuberculosis chancre, which occurs in uninfected ancient medical scriptures, but its first intelligent or unsensitized individuals. Individuals vaccinated description, phthisis (to waste away), was given with the bacillus Calmette-Guérin vaccine have by Hippocrates (circa 460–376 BC).3 Cutaneous been sensitized and carry a higher risk of developing tuberculosis makes up only a small proportion of the TVC.7 In low socioeconomic environments, chil- cases of extrapulmonary tuberculosis. Children and dren can be infected by playing on ground contami- immunocompromised adults are at increased risk of nated with tuberculous sputum.8 Autoinoculation of developing this form of the disease.3 a wound with a patient’s own tuberculous sputum Cutaneous tuberculosis may present in a number of rarely causes TVC.7 The sites of predilection for diverse clinical forms (Table). The 4 major categories inoculation tuberculosis in children are the lower of cutaneous tuberculosis that have been described extremities (ie, knees, thighs, and buttocks) because inthe literature include: (1) inoculation from these areas are most likely to be traumatized. In an exogenous source (ie, tuberculous chancre, adults, fingers and hands frequently are involved. tuberculosis verrucosa cutis [TVC]); (2) endog- The historically well-known “prosector’s wart” is enous cutaneous spread either contiguous or by considered a prototype of TVC and is caused by autoinoculation (ie, tuberculosis cutis orificialis, accidental inoculation during autopsy.4 scrofuloderma); (3) hematogenous spread (ie, lupus The diagnosis of TVC should be based on vulgaris, acute miliary tuberculosis, tuberculosis ulcer/ history and evolution of the disease, cardinal gumma/abscess); and (4) tuberculids (ie, erythema morphologic features, histopathologic characteris- induratum [Bazin disease], papulonecrotic tubercu- tics, and mycobacterial culture of the biopsy speci- lids, lichen scrofulosorum).4,5 men. The lesions of TVC typically are asymptomatic VOLUME 78, NOVEMBER 2006 311 Tuberculosis Verrucosa Cutis 312 CUTIS Clinical Presentations of Cutaneous Tuberculosis* ® Mode of Infection Type of Cutaneous Status of Sensitivity/ or Transmission Tuberculosis Previous Infection Clinical Presentation Differential Diagnosis Exogenous Tuberculous chancre Nonsensitized; Painless brown papule 2–4 wk Sporotrichosis, blastomycosis, negative TB test after inoculation; may progress histoplasmosis, coccidioido- to nodule, plaque, or ulcerate; mycosis, nocardiosis, syphilis, children typically affected; face leishmaniasis, yaws, tularemia, and extremities are commonly atypical mycobacterial infec- involved,
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