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A Rare Case of Scrofuloderma Dr SSRG International Journal of Medical Science ( SSRG – IJMS ) – Volume 4 Issue 8 – August 2017 A Rare Case of Scrofuloderma Dr. Gunjan Malavia1, Dr. Rushabh Parikh2, Dr. Archana Bhate3 1PG Resident, Department of Medicine, Dr. D.Y.Patil Medical College, Navi Mumbai 2Lecturer, Department of Medicine, Dr. D.Y.Patil Medical College, Navi Mumbai 3Head of the Department, Department of Medicine, Dr. D.Y.Patil Medical College, Navi Mumbai Abstract Scrofuloderma is a common type of II. CASE SCENARIO cutaneous tuberculosis characterized by a red A 66 year old male came with painful nodule overlying an infected lymph gland that swelling right submandibular region since 7 to 8 breaks down to form an undermined ulcer with a months. There were discharging sinuses from the granulating tissue at the base. Progression of the swelling. Patient also complained of difficulty in disease leads to irregular adherent masses, densely swallowing solid food and altered taste. The fibrous at some places while fluctuant and swelling was initially small and increased in size to discharging at others. It heals with a characteristic present size of 6cm x 8cm over 6 months. No puckered scarring at the site of infection. The history of tuberculosis in past. On examination, disease is caused by mycobacterium tuberculosis swelling was seen on the right side of face with and common anti-tubercular drugs are multiple well defined nodules with discharging recommended for treatment. sinuses, crusting and scaling. The local area was warm and erythmatous. The lymph nodes were not I. INTRODUCTION palpable. His hemoglobin, total counts were Cutaneous tuberculosis has a worldwide normal. ESR was 80 and mantoux test was distribution.1 Though, human disease with positive. CT Neck was suggestive multiple mycobacterium tuberculosis and M. Bovisusually enlarged lymph nodes in cervical and preverbral spreads by droplets, and the portal of entry is often area suggestive of ? Infective etiology/ ? the respiratory tract, skin can also be involved Neoplastic etiology. Myositis of right pterygoids primarily.2,3 Many types of cutaneous tuberculosis and edematous false vocal cords.HRCT Chest was like lupus vulgaris, scrofuloderma, tuberculosis normal. FNAC of lymph node was done which was verrucosa cutis, tuberculousgumma, orificial suggestive of chronic granulomatous lymphadenitis tuberculosis etc. are seen in our population.1,2,4 most like tubercular lymphadenitis. Skin biopsy Scrofuloderma, also called „tuberculosis showed pan dermal infiltrates composed mainly of colliquativa cutis‟ is a common form of cutaneous lymphocytes-- scrofuloderma. He was started on tuberculosis affecting children and young adults in antitubercular drugs. After few days the swelling which there is breakdown of skin overlying a started regressing in size, redness reduced. After tuberculous focus in the lymph node.1,4 Initially, few months swelling subsided leaving a very small there are firm painless, subcutaneous nodules that scar. Dysphagia improved and so as the taste gradually enlarge and suppurate.1,3,4 These lead to sensation. ulcers and sinus tracts with undermined edges and ultimately puckered scars.1 Diagnosis is usually III. DISCUSSION performed by needle aspiration biopsy or One-third of the world‟s population is excisional biopsy of the mass and the infected with m. tuberculosis and global burden of microbiological demonstration of stainable acidfast the disease continues to grow.1,5,7 The organism bacteria.3 PCR has a low sensitivity but high responsible for tuberculosis was identified more specificity.5,6 The best approach for treatment of than 100 years ago while a tuberculosis vaccine has this disorder is with conventional anti-tubercular been in use for over 60 years and chemotherapy for drugs while people in close contact with the over 30 years.8 Despite all these, the disease still patient, such as family members, should undergo remains a major international health problem.3,5,7 testing for tuberculosis.3The affected nodes can be The reasons may be malnutrition, low treated with electrosurgery, cryosurgery and socioeconomic conditions and multidrug resistant curettage with electrodessication as an adjunct strains of m. tuberculosis.3,9 In our case, swellings measure, with pharmacological therapy as the with draining sinuses, histopathology report, primary method of treatment.3 We report a case of positive result and good response to ATTfavoured scrofuloderma, a commonly seen variety of the diagnosis of scrofoluderma. The condition has cutaneous tuberculosis in our society. to be differentiated from some other similar clinical ISSN: 2393 - 9117 www.internationaljournalssrg.org Page 12 SSRG International Journal of Medical Science ( SSRG – IJMS ) – Volume 4 Issue 8 – August 2017 entities. Atypical mycobacterial infections pus or biopsy specimen. In nocardiosis, papulo- clinically mimic scrofuloderma. Differential nodular lesions occur on the limbs and trunk Diagnosis of discharging sinuses [1-3,6,10] leading to draining sinuses and the organisms are Atypical mycobacterial infection due to detected as gram-positive branched-filaments and mycobacterium scrofulaceum and m. branching at right angle is confirmatory.11,12 Avium-intracellulare Syphilitic gumma is a typical granulomatous lesion • actinomycosis of tertiary syphilis mainly found in the skin and • sporotrichosis bone.12,14 Cutaneous lesions are rounded, red to • botryomycosis flesh-coloured nodules which can occur anywhere. • nocardiosis The nodules may break down to form punched-out • syphiliticgumma ulcers leading to atrophic scars or can heal with no residue.12,14 In our case, there was no neurological The infection is seen in children, mainly or cardiovascular involvement and serological tests between the ages of 1 and 3 years. Submandibular for syphilis were also negative. The key elements and submaxillary nodes are typically involved and in the diagnosis of this infection are a high index of there are no constitutional symptoms. Primary skin suspicion, taking a history with an emphasis on disease caused by m. avium-intracellulare1 has exposure to any sufferer in the family or other been reported in rare instances, presenting as single potential sources and tissue biopsy for culture & or multiple, painless, scaly yellowish plaques or histopathology.3 Therapeutic regimens include anti- subcutaneous nodules with a tendency to ulceration tubercular treatment with four drugs for 1st two and a slowly progressive, chronic course. This months and then inh and rifampicin for 8 to 12 infection also causes lung disease or, less months. frequently, osteomyelitis and may produce a cervical lymphadenitis with sinus formation that is IV. CONCLUSION clinically indistinguishable from scrofuloderma. 1. Skin tuberculosis can present atypically without Both of these conditions were ruled out on the obvious features of tuberculosis like fever, basis of histopathology report for M. cough, weight loss, night sweats.. Tuberculosis.2,5,6Actinomycosis is characterized by 2. The high index of suspicion for tuberculosis is granulomatous and fibrotic lesions, which tend to always required in TB endemic areas. break down and form abscesses that drain through multiple sinuses.11 Typical “sulphur granules” REFERENCES occur in these abscesses.11 The disease is caused by actinomycesisraelii, the anaerobicorganism [1] Tappeiner g. Tuberculosis and infections With atypical producing filamentous branching hyphae. The mycobacteria. In: wolff k, Goldsmith la, katzsi, et al., eds. Fitzpatrick‟s dermatology in general Medicine, 7th edn. lesions occur primarily on the face and neck, New york: mcgraw-hill; 2008. p. 1768-78. especially on the lateral surfaces of neck beneath [2] Yates vm, rook gaw. Mycobacterial Infections. In: burns t, the jaw, less often on the chest wall or lower breathnach s, cox N, griffiths c, eds. Rook‟s textbook of abdomen. The absence of sulphur granules and Dermatology, 7th edn. London: blackwell Science; 2004. p.28.1-28.39. negative culture report for actinomycetes helped to [3] Meltzer sm, nacy ca. Cutaneous Tuberculosis. Jan 28, delineate this condition. Where sporotrichosis is 2009. Available from endemic, it must also be excluded.12The clinical Http://emedicine.medscape.com/artical/1105 317- features of this condition are similar to overview. [4] Ngan v. Cutaneous tuberculosis [internet] Online scrofuloderma but a negative report for fungal december, 2006. Available from: hyphae and histopathology led to exclusion of this Http://www.dermnetnz.org/becterial/tubercul Osis.html condition.Botryomycosis Is a chronic inflammatory [5] Rajakumar d, rosenberg am. Mycobacterium tuberculosis condition due to a bacterial infection.13 The monoarthritisIn a child. Pediatrrheumatol 2008; 6: 2-10 [6] Tan wp, tang mby, tan hh. Scrofuloderma from the infection is more common in immunocompromised acromioclavicularJoint presenting as a chronic ulcer in an patients. The disease presents as nodules, sinuses, Immunocompetent host. Singapore med j 2007; 48: 243-5. fistulae, abscesses and ulcers, leading to scarring. [7] Dye c, scheele s, dolin p et al. Consensus Statement. The lesion usually occurs on the extremities but Global burden of tuberculosis, Estimated incidence, prevalence, and Mortality by country.Who global less commonly affected sites are head, neck and Surveillance and monitoring project.Jama 1999; 282: 677- buttocks. The granules (like sulphur granules) are 86. formed and discharged from the lesions which on [8] Gopinathan r, pandit d,
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