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Unusual Presentation of Scrofuloderma in an Immunocompetent Patient

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Unusual Presentation of Scrofuloderma in an Immunocompetent Patient LETTER TO THE EDITOR Unusual Presentation of Scrofuloderma in an Immunocompetent Patient Sir, Figure 1a: Left cheek; showing Figure 1b: Complete regression of Cutaneous tuberculosis has many faces; from papules and nodules coalescing to lesions after treatment. form a plaque. paucibacillary tuberculosis verrucosa cutis to multibacillary acute miliary tuberculosis.1 Scrofuloderma also called as tuberculosis colliquativa cutis is the second most common type of cutaneous tuberculosis following lupus vulgaris.2 It is characterized by a bluish- red nodule overlying an infected lymph gland, bone or joint that breaks down to form an undermined ulcer with a granulating tissue at the base.3 Unusual site and atypical morphological appearance can confuse this Figure 2a: Showing epithelioid Figure 2b: Showing atrophied entity with other clinically mimicking conditions. granuloma containing langerhans epidermis, epithelioid granuloma giant cells surrounded by lympho- containing langerhans giant cells A twenty eight-years old, otherwise, healthy male, cytes (H and E; x10). (H and E; x40). presented with multiple erythematous papules and nodules on his left cheek persisting for the last 8 months. In the present case, morphology of plaque and site There was history of on and off seropurulent discharge. involved suggested cervico facial actinomycoses as first There was no history of similar complaints in the clinical possibility. The absence of sulphur granules and family or contact with tubercular patient. There was negative culture report for actinomycetes helped us to no history of past treatment for these complaints. delineate this condition. Nocardiosis was also ruled out Cutaneous examination revealed seven ill to well on the basis of absence of gram-positive branched- defined papules and nodules coalesced to form a plaque filaments. Leprosy was marked out on the basis of over left cheek. Few lesions had puckered scaring clinical presentation and biopsy findings. Botryomycosis (Figure 1a). No lesions were present over the mucosal is a chronic inflammatory condition due to a bacterial 4 side. Submandibular lymph nodes were significantly infection. The condition was ruled out on the basis of enlarged; non tender, matted with freely mobile skin over absence of bacteria from pus or biopsy specimen. the nodes. Patient was investigated with the differential Histopathological finding, significantly positive Mantoux diagnosis of cervicofacial actinomycosis, scrofuloderma, test, positive PCR for Mycobacterial tuberculosis and non tubercular mycobacterium infection, nocardiosis, complete resolution of lesions with anti tubercular drugs leprosy and botryomycosis. confirmed the diagnosis. Erythrocyte sedimentation rate was 35 mm 1st hour, and To conclude, this case is being reported for the unusual Mantoux reading was 15 mm at 72 hours. Ziehl Neelsen site and atypical presentation of scrofuloderma in an stain and culture for acid fast bacilli were non immunocompetent individual. contributory, absence of microorganism on gram stain and pus culture ruled out other bacterial infections. HIV REFERENCES screening was negative. Skiagram of chest as well as of 1. Bloom BR, Small PM. The evolving relation between humans face for underlying bone involvement was normal. PCR and Mycobacterium tuberculosis. N Engl J Med 1998; 338:677-8. was positive for Mycobacterial tuberculosis. Histo- 2. Iftikhar U, Nadeem M, Aman S, Hasnain Kazmi A. pathological examination showed atrophied epidermis, Scrofuloderma: a common type of cutaneous tuberculosis: epithelioid granuloma containing Langerhans giant cells a case report. J Pak Assoc Dermatol 2011; 21:61-5. surrounded by lymphocytes that scotched the doubts 3. Müller H, Eisendle K, Zelger B, Zangerle R. Bilateral and confirmed the diagnosis of scrofuloderma (Figure 2a scrofuloderma of the axilla masquerading as hidradenitis and b). The patient was started on antitubercular drugs suppurativa. Acta Derm Venereol 2008; 88:629-30. (isoniazid, rifampicin, ethambutol and pyrazinamide). 4. Hartley M. Botryomycosis, pyodermavegetans [Internet]. 2010. Complete regression of the lesion was seen after 6 Available from: http://dermnetnz.org/bacterial/botryomycosis. months of therapy (Figure 1b). html 306 Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (4): 306-307 Letter to the editor Nidhi Jindal1, Sarabjit Kaur1, Richa Jindal2, Vijay Kumar 3 Department of Hematology, Sir Ganga Ram Hospital, New Jain1 and Jeevan Kumar3 Delhi, India. 1 Department of Dermatology, Postgraduate Institute of Correspondence: Dr. Sarabjit Kaur, House No. 401, Sector Medical Sciences, Rohtak, Haryana, India. 14, Rohtak, Haryana, India. 2 Department of Pathology, St. Stephen Hospital, New Delhi, E-mail: [email protected] India. Received: June 12, 2014; Accepted: October 15, 2014. Journal of the College of Physicians and Surgeons Pakistan 2015, Vol. 25 (4): 306-307 307.
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