Case Report

TUBERCULOSIS VERRUCOSA CUTIS (TBVC) - FOOT WITH MILIARY TUBERCULOSIS

L. Padmavathy1, L. Lakshmana Rao2, N. Ethirajan3, M. Ramakrishna Rao4, E.N. Subrahmanyan5 and U. Manohar6 (Original received on 7.12.2006. Revised version on 19.3.2007. And accepted on 17.4.2007)
Summary: Tuberculosis Verrucosa Cutis (TBVC) or warty tuberculosis is a variant of cutaneous tuberculosis in patients with good cell mediated immunity (CMI) to Mycobacterium Tuberculosis, while Miliary Tuberculosis is associated with very poor CMI. Two widely different clinical presentations in the same patient are very rare and being reported

[Indian J Tuberc 2007; 54:145-148]

Key words: Tuberculosis Verrucosa Cutis (TBVC), Warty Tuberculosis, Miliary Tuberculosis, Cell Mediated Immunity (CMI)

INTRODUCTION Tuberculosis Verrucosa Cutis [TBVC] or warty tuberculosis is a verrucous form of skin tuberculosis in patients previously sensitized individuals due to exogenous re-infection with M.tuberculosis or M. bovis and reflects good Cell Mediated Immunity [CMI]1. In the past the disease was usually found among pathologists, autopsy room attendants, butchers and undertakers2. The various other synonyms for this condition are warty tuberculosis, TBVC, lupus verrucosis, verruca necrogenica, prosectors wart, butchers wart, anatomists wart, post-mortem wart 3. Miliary tuberculosis is characterized by multiple small (millet seed sized) tuberculous granulomas in many organs and results from hematogenous dissemination of the organisms, usually from secondary pulmonary tuberculosis. However, occasionally dissemination can occur from primary pulmonary tuberculosis or from other sites 4. Miliary dissemination to practically all organs in the body may reflect immuno-deficiency.

Occurrence of these two forms of cutaneous tuberculosis in the same individual is uncommon and hence the report. CASE REPORT A 30-year old male presented with the complaint of an ulcerated cauliflower like growth on the plantar aspect of the right foot for two years. He gave a history of ulcer on the shaft of penis for 6 months, loss of weight and appetite with productive cough without hemoptysis for 3 months. Patient had a low grade, continuous fever with evening rise of temperature for 2 weeks and had been vomiting for 2 days. There was no family history of pulmonary tuberculosis. He had been married for 7 years with no issues. There was no pre-marital or extra-marital sexual contact. He was addicted to alcohol. Physical examination revealed an emaciated, febrile man. There was a tracheal shift to the right, with bronchial breath sounds in right infra clavicular region. Many coarse crepitations could be heard all over in both the lung fields. Per-abdomen

1. Dermatologist, Urban Health Centre, Division of Community Medicine 2. Professor & Head of Department of Pathology 3. Professor & Head of Department, Community Medicine 4. Professor of Medicine 5. Chief Medical Officer, Urban Health Centre 6. Reader in Pathology Rajah Muthiah Medical College, Annamalai University, Annamalai Nagar, Chidambaram Correspondence: Dr. L. Padmavathy, B3, RSA Complex, Annamalai University, Annamalai Nagar - 608 002, (Tamil Nadu) Phone: 04144-238086 (R), E-mail: Padmavathy.Lanka@gmail.com

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Fig.1: Well defined, hyperkeratotic, nontender, verrucous plaque 8cm x 6cm, on the right sole examination, no organomegaly was noted. There was no generalized lymphadenopathy. Cutaneous examination revealed a well defined, hyperkeratotic, nontender, verrucous plaque 8cm x 6cm, on the plantar aspect of right foot (Fig No.1). There was no inguinal lymphadenitis. A firm indurated, depigmented scar was seen on the shaft of penis (Fig No. 2). The testes and epididymis were tender and enlarged on both sides. While in hospital, he developed generalized tonic and clonic seizures with the signs and symptoms of meningitis like positive Kernings and Babinski signs, neck rigidity, and diminished reflexes in all four limbs. Fundus examination revealed hyperemia in discs with evidence of choroid tubercles in both eyes, but no papilloedema. He also had hematuria. INVESTIGATIONS X-Ray chest revealed bilateral Pulmonary Tuberculosis with miliary mottling. A skin biopsy

Fig.2: Firm indurated, depigmented scar on the shaft of penis.

from the plantar lesion revealed the characteristic tuberculous granulomas in the dermis composed of epithelioid cells, Langhans giant cells and lymphocytes in the dermis with marked hyperkeratosis and parakeratosis of the stratified squamous epithelium suggestive of TBVC. (Fig No: 3 & 4). ACT scan of brain showed a non communicating hydrocephalus with post meningitic sequelae. CSF examination revealed Protein 150 mg%; Sugar: 52 mg%; Chlorides: 86 m.mols/ L; TC 180 cells /c mm; P: 80%; L: 20%; AFB- negative. A hematoma in the urinary bladder was noticed on ultra sonogram of abdomen. He was not a diabetic. Both his VDRL and HIV results and also sputum smears for AFB were negative. Mantoux test was not done in this patient in view of his poor general health and also since the Mantoux positivity is not of much clinical significance as our patient hails from an endemic region. A clinical diagnosis of TBVC foot with miliary tuberculosis was entertained. Patient was started on category I anti-tuberculous therapy with INH, Rifampicin, Pyrazinamide, Ethambutol and corticosteroids along with other supportive drugs.

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Fig.3: Bx from skin lesion showing marked hyperkeratosis, parakeratosis and acanthosis X40m H&E In a few days, there was significant improvement in the general condition of the patient. He was discharged after 2 months stay in the hospital. However, the patient returned after 10 days with altered sensorium, icterus and lower limb paresis. ATT was withheld as the icterus was presumed to have been due to the drugs. Once the serum bilirubin levels were brought under control with conservative management, category I anti-tuberculous treatment was resumed after 3-4 weeks, initially with INH, followed by Pyrazinamide, Rifampicin and Ethambutol, at weekly intervals. The patient improved significantly. The foot lesion healed well, but he had residual paresis in both lower limbs DISCUSSION Most cases of TBVC are due to an exogenous re-infection in individuals with marked cutaneous hypersensitivity and good immunity, while auto-inoculation from sputum may cause the lesions rarely. However, in our patient the skin lesions apparently preceded the miliary dissemination by many months and his sputum smear was repeatedly

Fig.4: Bx from lesion on sole of foot showing epithelioid cell granulomas with Langhans giant cells in dermis. X 40 H&E negative. Partly due to the immunological background and partly due to the specific terrain of the acral skin, there is a strong tendency to verrucous hyperplasia and fibrosis in these lesions 5 as was observed in our patient. The TBVC lesions have frequently been reported on the hands in Europe and on the lower limbs in the eastern countries6. The asymptomatic lesions of TBVC occur at sites of trauma, as might be presumed in our patient who walks barefoot. Repeated biopsy studies were reportedly more rewarding for culture of M.tuberculosis4. Due to poor general condition of this patient, further biopsies for isolation of AFB could not be undertaken. Miliary tuberculosis usually results from secondary pulmonary tuberculosis, or occasionally from even primary pulmonary tuberculosis or from other sites 7. Miliary dissemination to CNS, eye and urinary bladder indicates some sort of immunodeficiency though our patient was HIV negative.

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Our patient responded to standard ATT. The lesion on sole healed well, though he had residual paresis in both lower limbs, for which he is being given physiotherapy. The co-existence of TBVC [found in patients with good CMI] and miliary tuberculosis [common in persons with poor immunity] is uncommon and hence reported. ACKNOWLEDGEMENTS The authors thank the authorities for facilities provided in carrying out the work and permission to publish the article. REFERENCES
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