Case Study
Early Onset of Squamous Cell Carcinoma Arising From Tuberculosis Verrucosa Cutis

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Abstract

A 72-year-old man presented with a chronic scaly verrucous plaque over his right knee for nine months. The lesion was preceded by a well healed scar sustained five years back from a road traffic accident. He was given multiple courses of systemic antibiotic and antifungal medications but to no avail. A skin biopsy confirmed cutaneous tuberculosis. The area of plaque subsided significantly with antituberculosis treatment. However, during the second month of treatment, a new onset of a red fleshy granulating growth developed on the pre-existing site. A repeat skin biopsy revealed squamous cell carcinoma (SCC). He was subsequently referred for surgical excision.

This is presumably the first reported case of SCC arising from tuberculosis verrucosa cutis. While most malignant transformations from tuberculosis has been thought to develop after a long period of time (usually more than twenty-five years), this case report showed that it may also occur within a short period of time. Awareness on this condition is important because any delay in diagnosis and treatment may have detrimental consequences.

Introduction

Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis comprising less than 1% of all tuberculosis.1 Studies have shown that the Bacillus Calmette–Guérin (BCG) vaccine may not effectively prevent cutaneous tuberculosis.2, 3 Furthermore, advances in travelling modes and a significant increase in labour immigration may also lead to an increased incidence of tuberculosis in the future. As an infectious but treatable disease, a high level of awareness regarding cutaneous tuberculosis is important among the medical fraternity.

Section snippets

Case report

A 72-year-old man with underlying diabetes, hypertension and dyslipidemia presented with a chronic crusted lesion over his right knee for nine months (Fig. 1) prior to referral to our clinic. The lesion was preceded by a well healed scar from an abrasion wound sustained five years back from a road traffic accident. The lesion had progressively enlarged over time with crack fissures and purulent discharge. He was given multiple courses of systemic antibiotic and antifungal medications but to no

Discussion

Diagnosis of cutaneous tuberculosis is challenging and highly dependent on clinical correlation. All diagnostic tests for cutaneous tuberculosis have a much lower sensitivity and specificity compared to pulmonary tuberculosis (PTB). It is common to get a negative Ziehl–Nielsen stain, tuberculosis PCR and MTB C&S because of its low sensitivity.4, 5

TBVC is a form of cutaneous tuberculosis common in Asia,6, 7 usually involving the upper and lower extremities. It is usually caused by exogenous

Conclusion

We hope that the sharing of this case may aid similar encounters in future, especially in tropical countries where M. tuberculosis abounds. Clinicians should be alert to the possibility of cutaneous tuberculosis with malignant changes if treatment response deviates from its expected course. A high index of suspicion is of utmost importance to prevent complications arising from delayed treatment.

Acknowledgments

The authors sincerely thank Dr Othman Abdullah and Dr Mohd Faizal Abu Seman from Department of Pathology, Hospital Sultan Abdul Halim for providing the histopathological pictures, and Mme. Lee Jong Koh for critical reading and useful comments on this manuscript.

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