A 35-year-old male was referred to our outpatient clinic with a large verrucous plaque and malodorous purulent discharge on the buttocks, thigh and scrotum. The lesion started two years ago as small, mildly pruritic and multiple plaques that were limited to the buttocks. Some painful and itchy nodules then developed over the lesions in the last five months. The nodules ulcerated and extended with foul-smelling seropurulent discharge. The lesions thickened and expanded rapidly covering the left buttock, thigh and scrotum, forming an annular hyperkeratotic plaque with central healing. The patient had been treated in a local hospital with antifungal and antibiotic therapy without significant improvement. There was no history of previous trauma. The patient worked in an oil palm plantation and often wore shorts and sat on the ground when working. The patient had a history of untreated cough and night sweats without fever in the past two years. There was no family nor household history of TB. Dermatological examination showed extensive verrucous plaque covered in dark dense crust over the buttocks, thigh and scrotum with an irregular border. Fissures and multiple ulcers were seen over the dense crust with foul-smelling seropurulent discharge (Figure 1). Routine blood workups were performed, with liver function, renal function and blood sugar levels were within normal limits. His leucocyte was slightly raised to 14.580/mul. Enzyme-linked immunosorbent assay (ELISA) for HIV was nonreactive. Mantoux test was positive and chest radiograph revealed extensive pulmonary TB.
Acid Fast Bacilli (AFB) were not found in the sputum specimen, but The GeneXpert was able to detect M. tuberculosis that was sensitive to rifampicin. Pus culture was performed and revealed Escherichia coli colonization. Skin biopsy of the lesion was performed and histopathology analysis showed marked pseudoepitheliomatous hyperplasia of epidermis, epithelioid granulomatous inflammation surrounding the caseous necrosis along with several Langerhans cells in the dermis and many lymphocytic infiltrates (Figure 2). AFB staining using Ziehl-Neelsen and culture on Lowenstein-Jensen medium were negative. Fungal infection was ruled out by negative potassium hydroxide (KOH) examination from the lesion skin scraping and negative Periodic Acid-Schiff (PAS) stain from the skin biopsy specimen. A multidisciplinary approach by referring to the Pulmonology department was carried out and anti-tuberculosis treatment (ATT) regimen 1 consisted of two-month intensive phase (Rifampicin 450mg, Isoniazid 225mg, Pyrazinamide 1200mg, Ethambutol 825mg daily) followed by four-month continuation phase (Rifampicin 450mg, Isoniazid 450mg three times a week) was given. At two-month follow-up, the skin lesions showed significant improvement and the lesions were completely resolved after four months of therapy leaving atrophic scars (Figure 3).