A 65-year-old male patient presented our clinic with a 4-year history of recalcitrant skin lesions. He was being treated as presumptive clinical diagnosis as verruca vulgaris with multiple topical therapies, including creams containing 5-fluorouracil, salicylate, retinoids, 40% urea, and cryotherapy. Despite the medical interventions, the lesion has been growing steadily. At the first visit, a well-demarcated, hyperkeratotic verrucous plaque on the thenar region of his left hand was observed. The plaque had a surface area of 10 cm2 and was extending dorsally over the first interdigital fold (Fig. 1a). Except for the plaque, the patient's physical examination was unremarkable. On further questioning, the patient revealed that he had cared for a cow for a month for the religious "Feast of Sacrifice" 5 years ago. Due to the lesion's unresponsiveness to conventional verruca therapies, a tuberculin skin test (TST), a skin biopsy for histological examination, polymerase chain reaction, and culture were performed.
Histological sections showed epidermal hyperplasia and dermal noncaseous granulomas (Fig. 2a). TST resulted in 12-mm induration (Fig. 2b). The culture and polymerase chain reaction test results were positive for M. bovis. Based on clinical and laboratory findings, TBVC was diagnosed. Further diagnostic procedures revealed no other systemic involvement. Due to the patient's objection to therapy with a multiple drug regimen, an intralesional BCG injection was planned. A suspension from freeze-dried powder containing attenuated bacilli of M. bovis (prepared from a BCG culture [OncoTice ]) was prepared according to the manufacturer's instructions. 12.5 mg powderized BCG was diluted in 50 mL serum physiologic to obtain a suspension containing 0.4-1.6 x 107 CFU/mL. A total volume of 2,083 mL BCG was injected into a 10 cm2-plaque intralesionally (0.2 mL per cm2). The injected dose was calculated according to the ratio of one dose of OncoTice  to the mean urothelium surface area of an adult male without prostatic symptoms, which is 50 mL-240 cm2.
On the third day after the injection, an inflammatory reaction was observed. The plaque became edematous, erythematous (Fig. 3-f1). The patient had a fever of 38 C concurrently, which continued for one and a half day and was reduced with cold compresses. On the 10th day, erythema and edema were regressed, and the lesional area began to desquamate (Fig. 3-i1). On the 18th day, suppurative foci on the hand dorsum emerged and were drained by puncturing (Fig. 3-l1). Finally, on the 40th day, signs of acute inflammation were subsided without leaving any scars, and the lesional area shrank from 10 cm2 to 2.0 cm2 (Fig. 3-o1) (Fig. 1b). After that, the patient had to relocate to another city and was lost to our follow-up.