Introduction

Warty tuberculosis, known as 'tuberculous verrucosa cutis', is the most common form of skin tuberculosis in the East, particularly India ₁ . It results from direct inoculation of the micro-organism into the skin of a previously infected person with moderate or high degree of immunity. This may happen by ,accidental super-infection from an extraneous source, auto-inoculation from sputum in a patient with active tuberculosis and sitting or playing in dirty surroundings where tubercle bacilli are present ₂ .We report here a case of Tuberculosis verrucosa cutis of great toe because of its clinical interest.

Case Report

A 35 years old male, technician by occupation presented with history of pain, swelling, pus dischage from great toe of Right foot and low grade fever for the last 1 month. He was non smoker. His parents, brother, sisters are alive and healthy. General examination revealed that patient is of thin built with multiple discharging sinuses over the right great toe. There were no sign of anaemia. There was no significant lymphadenopathy. His resting pulse rate was 92/min and blood pressure was 112/68mmHg. Respiratory system examination was within normal limit .His Cardio Vascular System, Central Nervous System and abdominal systems were also in normal limit. His Haemoglobin was 14 Gm%; Total Leucocyte count was 9,900/cmm: Neutrophils 47%, Lymphocytes 43%, Monocytes 7% and Eosinophils 1%. His chest x-ray was normal. His x-ray Antero-Posterior and Lateral view of right foot revealed osteoporotic changes over right first phalnx. Biopsy was taken from the lesion in great toe of right foot that revealed squamous cell carcinoma. But the clinical feature of the patient was not consistant with malignancy. So the patient was reevaluated in the line of tuberculosis. His PPD was done showed 21 mm induration. Pus was sent for acid fast bacilli revealed positive on three consecutive days. Repeat biposy of ulcer was done that revealed granuloma composed of epitheloid cells, lymphocytes and multinucleated giant cells –suggestive of tuberculosis verrucosa cutis.

He was put on antitubercular drugs (RHZ) and after one month of chemotherapy discharging sinuses over great toe disappeared. The patient took ATT for 11 months on his own. After 11 months, when patient came ATT stopped as he was asymptomatic since last 6 months.

Discussion

Tuberculosis verrucosa cutis is an indolent warty plaque that occurs after direct inoculation of Tuberculosis into the skin of individuals previously infected with Mycobacterium tuberculosis or Mycobacterium bovis. Reinfection tuberculosis can result from accidental exposure to tuberculous tissue in high-risk groups, such as physicians, pathologists, and laboratory workers (anatomists' wart, prosectors' wart, verruca necrogenica). Farmers, butchers and veterinarians contract this form of reinfection tuberculosis from tuberculous cattle. Individuals, especially children from lower socioeconomic groups, also can contract this lesion after contact with tuberculous sputum. Male-to-female ratio is almost equal. Although no age group is exempt, most patients show clinical infection within the first 3 decades of life. In a 10-year (1983-1992) retrospective survey of patients seen in governmental dermatology clinics in Hong Kong ₃ . The detected incidence of cutaneous tuberculosis among patients was 179 per 267,089 (0.07%). Among patients with cutaneous tuberculosis, 15% had classic cutaneous tuberculosis (approximately 5% each of lupus vulgaris, Tuberculosis verrucosa cutis, and scrofuloderma), and 85% had tuberculids. In a tertiary-care hospital in northern India, 0.1% of dermatology patients seen from 1975-1995 had cutaneous Tuberculosis ₄ . Lupus vulgaris was the most frequent manifestation (55%), followed by scrofuloderma (27%), Tuberculosis verrucosa cutis (6%), tuberculous gumma (5%), and tuberculids (7%).

Lesions most commonly occur on the hands and, in children, the lower extremities. Infection starts as an asymptomatic warty papule often mistaken for verruca vulgaris. Slow growth and irregular peripheral extension occur. The lesion may show central involution with an atrophic scar or form massive papillary excrescence with fissures. Pus and keratinous material may extrude from these fissures. Treatment part includes anti-tubercular drugs ₅,₆ .

In this presenting case initial diagnosis (Histopathological) was in favour of malignancy but on clinical background case did not appear to be malignant. So patient was reevaluated that revealed Tuberculosis verrucosa cutis and responded well to antituberculosis treatment.

Correspondence to

Dr. S.K. Verma M.D. Associate Professor Department of Pulmonary Medicine C.S.M. Medical University, UP,Lucknow (India)- 226003 E-mail: drskverma@rediffmail.com Phone: - (Resi.) 0522-2254346, Mob-09415783700 FAX: 0522-2255167