Title : Tuberculosis verrucosa cutis: An uncommon cause of a chronic verrucous plaque in an elderly patient
Abstract:
Background: Tuberculosis verrucosa cutis (TBVC) is a rare paucibacillary form of cutaneous tuberculosis resulting from direct inoculation of Mycobacterium tuberculosis into the skin of previously sensitized individuals. It accounts for only a small proportion of extrapulmonary tuberculosis and often presents as chronic verrucous plaques that mimic inflammatory, fungal, or neoplastic skin diseases, leading to delayed diagnosis. Early recognition is essential, particularly in tuberculosis-endemic countries like the Philippines, to prevent prolonged morbidity and initiate timely treatment.
Case Description: An 81-year-old male with a history of chronic heart failure presented with progressive bilateral lower extremity edema and exertional dyspnea. Two years prior, he had been admitted for acute heart failure and was discharged on guideline-directed medical therapy; however, he was poorly compliant with medications and follow-up. Over time, he developed recurrent bipedal edema with progressive hyperpigmentation. Three months before admission, arterial duplex ultrasonography demonstrated peripheral arterial occlusive disease with greater than 50% stenosis of the left mid-posterior tibial artery without evidence of deep vein thrombosis. One month before admission, multiple irregular erythematous plaques with adherent yellowish scales developed over the right leg. Dermatologic evaluation at the Research Institute for Tropical Medicine established the diagnosis of tuberculosis verrucosa cutis based on clinicopathologic findings, and standard anti-tuberculosis therapy was initiated. Despite treatment, persistent lower extremity edema prompted hospital admission for further evaluation and management.
Discussion: Tuberculosis verrucosa cutis is a rare form of cutaneous tuberculosis that often resembles chronic inflammatory skin diseases, fungal infections, or skin cancer, making diagnosis difficult. In this patient, advanced age, heart failure, vascular disease, and chronic leg edema delayed recognition. This case emphasizes the importance of considering cutaneous tuberculosis in persistent verrucous or hyperkeratotic skin lesions, especially in tuberculosis-endemic areas. Early skin biopsy with histopathologic and microbiologic evaluation is essential for accurate diagnosis and timely initiation of anti-tuberculosis treatment, helping improve patient outcomes.
