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Picture of the Month—Diagnosis Denouement and Discussion Scrofuloderma With Lupus Vulgaris he result of tuberculin skin testing was positive, with vised National Tuberculosis Control Programme, the di- a20ϫ25-mmindurationassociatedwithvesiculation. rectly observed short-course chemotherapy strategy (DOTS), Thesputumexaminationresultforacid-fastbacilliwas a globally accepted standard for treatment of all forms of tu- T 13 negative. Pus aspirated from the cold abscess, and a smear from berculosis, is followed. In the initial intensive phase of treat- the ulcers did not reveal any mycobacteria on Ziehl-Neelsen ment, isoniazid, 10 to 15 mg/kg; rifampicin, 10 mg/kg; pyra- acid-fast stain; however, a biopsy specimen from the skin le- zinamide, 15 to 30 mg/kg; and ethambutol, 15 to 25 mg/kg, sion and sinuses revealed tuberculous granulomatous infec- are given 3 times a week on alternate days for 2 months, while tion. Routine culture eventually grew Mycobacterium tubercu- in the immediate continuation phase, isoniazid and rifam- losis, and the patient was diagnosed as having scrofuloderma picin are given in the same doses 3 times a week for 4 months. (SCD) and lupus vulgaris (cutaneous tuberculosis). He re- DOTS has the advantage of directly supervised treatment that sponded well to drainage of cold abscesses and standard an- increases the cure rate, decreases transmission of disease, and tituberculous drug therapy, composed of isoniazid, rifampi- prevents emergence of multidrug-resistant tuberculosis while cin sodium, pyrazinamide, and ethambutol hydrochloride. minimizing adverse effects due to drugs. In SCD resulting The incidence of cutaneous tuberculosis, which forms a from tuberculous lymphadenitis, arthritis, or osteomyelitis, minute proportion of extrapulmonary tuberculosis, has de- surgery in the form of aspiration, incision and drainage, de- creased from 2% to 0.15% in India.1 In the West, it is rarely en- bridement, curettage, and partial or total excision of the cold countered. Lupus vulgaris, SCD, tuberculosis verrucosa cu- abscesses and underlying pathological lymph nodes or ribs tis, tuberculous gumma, tuberculids, tubercular chancre, acute may be necessary. Surgical excision becomes essential in pa- miliary cutaneous tuberculosis, and orificial tuberculosis con- tients with persistent residual disease despite the full course stitute the diverse forms of cutaneous tuberculosis.2-4 A patient of chemotherapy or in instances of infection by atypical my- may have a combination of 1 or more types of cutaneous cobacteria, in which the response to conventional chemo- tuberculosis.2-4 Cutaneous tuberculosis arises as a result of ex- therapy is poor. ternal inoculation, underlying tuberculous pathological fea- tures, or hematogenous/lymphatic spread from visceral Accepted for Publication: April 6, 2007. tuberculosis.2-4 Common locations for cutaneous tuberculo- Correspondence: Dipesh D. Duttaroy, MS, MBBS, Depart- sis are the head, neck, supraclavicular fossae, axillae, groin, ex- ment of Surgery, Government Medical College and Sir tremities, trunk, and buttocks.3-5 There is a general consensus Sayajirao General Hospital, Baroda, Gujarat 390001, India that lupus vulgaris and SCD are the most common types.3-7 ([email protected]). Scrofuloderma is more common in children and younger Author Contributions: Study concept and design: D. D. Dut- taroy and Jagtap. Acquisition of data: Bansal and B. Dut- individuals than in adults.1,2,8,9 It develops as a result of skin taroy. Analysis and interpretation of data: D. D. Duttaroy, Jag- breakdownoverlyingtuberculousfoci,suchasaninfectedlymph tap, and Bansal. Drafting of the manuscript: D. D. Duttaroy, node, bone, or joint, and manifests as gradually enlarging, pain- Jagtap, Bansal, and B. Duttaroy. Critical revision of the manu- less, subcutaneous nodules that ulcerate with the development script for important intellectual content: D. D. Duttaroy. Ad- of sinus tracts in the overlying skin. In contrast, lupus vulgaris ministrative, technical, and material support: D. D. Duttaroy. presents with small, reddish brown, sharply marginated pap- Study supervision: D. D. Duttaroy, Bansal, and B. Duttaroy. ules and plaques that enlarge by peripheral extension and leave Financial Disclosure: None reported. areas of central atrophy. They may be seen in plaque, ulcer- ative, vegetative, and nodular forms. The association of cutaneous tuberculosis with systemic pulmonary disease is REFERENCES variable. In the literature reviewed,2,6,7,9,10 the incidence of pulmonary tuberculosis in patients with SCD and lupus vul- 1. Gopinathan R, Pandit D, Joshi J, Jerajani H, Mathur M. Clinical and morphological variants of cutaneous tuberculosis and its relation to mycobacterium species. Indian garis varied between 0% and 16% during the past decade. J Med Microbiol. 2001;19(4):193-196. While M tuberculosis is the causative agent in most af- 2. Kumar B, Muralidhar S. Cutaneous tuberculosis: a twenty-year prospective study. Int J Tuberc Lung Dis. 1999;3(6):494-500. fected patients, atypical mycobacteria, such as Mycobacte- 3. Yates VM, Rook GAW. Mycobacterial infections. In: Burns T, Breathnach H, Cox N, Grif- rium scrofulaceum and Mycobacterium avium, may be the fiths C, eds. Rook’s Textbook of Dermatology. Vol 2. 7th ed. Oxford, England: Blackwell cause in immunocompromised patients.1 Science; 2004:28.1-28.39. 4. Tappeiner G, Wolff K. Tuberculosis and other mycobacterial infections. In: Freedberg The differential diagnosis also includes chronic nonspe- IM, Eisen AZ, Wolff K, et al, eds. Fitzpatrick’s Dermatology in General Medicine. 5th cific granulomatous infections; cervicofacial actinomyco- ed. New York, NY: McGraw-Hill Co; 1999:2274-2292. 5. Arya L, Koranne RV, Deb M. Cutaneous tuberculosis in children a clinico- sis; deep fungal infections, such as cutaneous blastomyco- microbiological study. Indian J Dermatol Venereol Leprol. 1999;65(3):137-139. sis and coccidioidomycosis; and, rarely, Hodgkin lymphoma 6. Mlika RB, Tounsi J, Fenniche S, Hajlaoui K, Marrak H, Mokhtar I. Childhood cutane- infiltrating the skin. ous tuberculosis. Dermatol Online J. 2006;12(3):11. 7. Ramesh V, Misra RS, Beena KR, Mukherjee A. A study of cutaneous tuberculosis in Auramine-rhodamine fluorescent stain is more sensitive children. Pediatr Dermatol. 1999;16(4):264-269. than Ziehl-Neelsen acid-fast stain in detecting mycobacte- 8. Ray M, Kataria S, Singhi P. Unusual presentation of disseminated tuberculosis. In- ria. Routine culture using Lowenstein-Jensen medium is time- dian Pediatr. 2002;39(1):88-91. 9. Kumar B, Rai R, Kaur I, Sahoo B, Muralidhar S, Radotra BD. Childhood cutaneous consuming and is being replaced by radiometric broth cul- tuberculosis. Int J Dermatol. 2001;40(1):26-32. ture, which reduces the bacterial recovery time of 3 to 4 weeks 10. Umapathy KC, Begum R, Ravichandran G, Rahman F, Paramasivan CN, Ramanathan VD. Comprehensive findings on clinical, bacteriological, histopathological and therapeutic as- by half. A polymerase chain reaction amplification tech- pects of cutaneous tuberculosis. Trop Med Int Health. 2006;11(10):1521-1528. nique, although expensive, is a rapid and sensitive method 11. Padmavathy L, Rao L, Veliath A. Utility of polymerase chain reaction as a diagnostic tool for early diagnosis of pediatric tuberculosis.11,12 in cutaneous tuberculosis. Indian J Dermatol Venereol Leprol. 2003;69(3):214-216. 12. Soini H, Musser JM. Molecular diagnosis of mycobacteria. Clin Chem. 2001;47(5):809-814. Standard multidrug antituberculous chemotherapy re- 13. Khatri GR, Frieden TR. The status and prospects of tuberculosis control in India. Int mains the gold standard of treatment. In India, per the Re- J Tuberc Lung Dis. 2000;4(3):193-200. (REPRINTED) ARCH PEDIATR ADOLESC MED/ VOL 161 (NO. 12), DEC 2007 WWW.ARCHPEDIATRICS.COM 1212 ©2007 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021.
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