ISSN: 2378-3656 Amar et al. Clin Med Rev Case Rep 2020, 7:330 DOI: 10.23937/2378-3656/1410330 Volume 7 | Issue 12 Clinical Medical Reviews Open Access and Case Reports CASE REPORT Scrofuloderma: A Rare Case Report on Cutaneous Tuberculosis Taksande Amar, MD, FIAE1*, Zeeshan Patel, MBBS2 and Meshram Rewat, MD3 1Professor, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, India 2 Resident, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Check for Medical Sciences, India updates 3Associate Professor, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, India *Corresponding author: Dr. Amar Taksande, Department of Paediatrics, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences, Sawangi Meghe, Wardha, Maharashtra State 442004, India nodes are most often involved followed by axillary, in- Abstract guinal group of lymph nodes [2]. Scrofuloderma begins Globally, India has one of the highest burdens of tuber- as firm, deep seated nodule adherent to skin followed culosis (TB). The diagnosis of tuberculosis is challenging, particularly in young children due to a high rate of extra-pul- by softening, suppuration, perforation and then, lastly monary and meningeal disease. Scrofuloderma is cuta- formsan ulcer or sinus. Later on, a scarred tract devel- neous tuberculosis, accounting for approximately 1.5% of ops and bridges the ulcerative areas [2,3]. Here we re- extra-pulmonary cases. Mycobacterium tuberculosis is the port a rare case of scrofuloderma in pediatric patient. main etiological agent and, rarely, by Mycobacterium bo- vis. The cutaneous variants of tuberculosis have a variable Case Report clinical appearance, significance and prognosis. Here, we describe the case of a 9-year-old boy presenting with mul- A 9-year-old boy, presented with complains of mul- tiple abscesses and discharging sinuses over neck since 1 tiple abscesses and discharging sinus over neck for du- year. Skin punch biopsy from anterior aspect of lesion was ration of 1 year. He also complained of swelling in the suggestive of scrofuloderma. It constitutes very small per- centage of extra-pulmonary tuberculosis and rarely seen in right axillary region since 1 week. There was no history pediatric age group. of any respiratory, urinary or gastro-intestinal symp- toms. General examination revealed mild pallor. Mul- Keywords tiple bilateral cervical lymph nodes were palpable.Vital Scrofuloderma, Tuberculosis, Lymphadenopathy signs showed that body temperature was 36.7 °C, blood pressure was 104/60 mmHg, heart rate was 88 beats/ Introduction min, respiratory rate was 20/min, and pulse oximetry Cutaneous tuberculosis or Scrofuloderma is caused was 96%. On local examination, multiple undermined by Mycobacterium tuberculosis, M. bovis and rarely black colored ulcerative lesions were present with dis- Calmette-Guerin bacillus. Scrofuloderma is also known charging pus sinuses with puckered scar marks over the as “tuberculosis cutis colliquativa”, a commonly used anterior aspect of the neck (Figure 1). In the right axilla, term for cutaneous tuberculosis in children and young a single soft, non-tender, fluctuant swelling measuring adults. The introduction of the organism may be by ex- 1.5 × 1.5 cm was present (Figure 2). On abdominal exa- ogenous inoculation, hematogenous route or by direct mination, spleen was just palpable and liver was pal- spread through underlying foci. The immune status of pable 2 cm below the right costal margin with normal an individual determines the clinical presentation of consistency. Respiratory and cardiovascular systems cutaneous tuberculosis [1]. Cervical group of lymph were normal. Investigations revealed a hemoglobin of 8.3 g/dl, total leukocyte count of 6100 cells per cumm Citation: Amar T, Patel Z, Rewat M (2020) Scrofuloderma: A Rare Case Report on Cutaneous Tubercu- losis. Clin Med Rev Case Rep 7:330. doi.org/10.23937/2378-3656/1410330 Accepted: December 02, 2020: Published: December 04, 2020 Copyright: © 2020 Amar T, et al. This is an open-access article distributed under the terms of the Cre- ative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Amar et al. Clin Med Rev Case Rep 2020, 7:330 • Page 1 of 3 • DOI: 10.23937/2378-3656/1410330 ISSN: 2378-3656 Figure 2: It shows single soft swelling over left axillary region. Figure 1: It shows multiple undermined black colored ulcerative lesions present with pus discharging sinuses with affected are adolescents belonging to 10-14 years age- puckered scar marks on the neck. group [3,5]. Shrestha SB, et al. [6] observed that scrof- uloderma was the most common form of cutaneous tu- with normal differential count, and platelet count of berculosis accounting for 47% (8/17) of total cases of cu- 5,60,000 per cumm. Peripheral smear showed a normo- taneous tuberculosis in children. Scrofuloderma results cytic moderately hypochromic with few microcytes and from the contiguous spread to the overlying skin from occasional pencil cells. Erythrocyte sedimentation rate adjacent structures such as lymph node, joint, bone or was 65 mm/hr. Mantoux test done showed an indura- the epididymis. Most commonly neck, axillae or groin tion measuring 30 mm at 72 hours. Biochemical param- are involved. Clinically, it presents as a firm subcuta- eters were normal. Serologic testing for human immu- neous nodule that enlarges, becomes confluent, ulcer- nodeficiency virus (HIV) was negative. Sputum for acid ates and forms draining sinus tracts of caseous material fast bacilli (AFB) was negative. Chest X-ray was normal. [7]. Histopathologically, ulcerated dermal abscess with Ultrasonography of abdomen showed borderline sple- scattered histiocytes with few lymphocytes and marked nomegaly. Skin punch biopsy from anterior aspect of le- caseative necrosis containing abundant bacilli can be sion present over neck region was taken which showed seen [8]. A study by Kar, et al. [9] described two pedi- atrophied epidermal lining with loss of rete pegs and atric cases, one with ulcerated lesion with undermined islands of epidermis trapped in the dermis. Underlying edges over upper chest with axillary lymphadenopathy the dermis, chronic inflammatory infiltrate composed while the other case presented with multiple pustular predominantly of lymphocytes and few polymorphs lesion over right post auricular, right supraclavicular re- with multinucleated giant cells at places were present. gion and right axillary region. Our patient also present- No areas of congestion, edema, hemorrhage or ne- ed similarly with multiple abscess and discharging sinus crosis were seen. The histopathological features were from the cervical nodes. Scrofuloderma may also be a suggestive of cutaneous tuberculosis or scrofuloderma. manifestation of systemic tubercular disease and can On the basis of local examination of ulcer, skin biopsy result from direct extension or hematogeneous spread findings and a positive mantoux test, a diagnosis of ex- of the infection. Systemic involvement has been report- tra-pulmonary tuberculosis of cutaneous tuberculosis ed to be associated with 21.3% of children with cutane- (Scrofuloderma) was made. Patient was started on four ous tuberculosis [10]. However, there was no evidence druganti-tuberculosis treatment (ATT) with isoniazid, of systemic involvement in the index case. Diagnosis of rifampicin, pyrazinamide and ethambutol daily under scrofuloderma is complicated and requires a full work- category I according to Revised National Tuberculosis up, including a detailed history and physical examina- Control Program (RNTCP) -Directly Observed Treatment tion, clinical presentation, blood investigation including Short-course (DOTS) strategy. The condition of the pa- complete blood count, ESR, skin biopsy with histological tient has improved after treatment with ATT. analysis and special staining methods for identification of AFB. Mantoux test is a good screening test for tuber- Discussion cular infection. The use of other diagnostic tests, such Tuberculosis is one of the biggest health crisis in In- as chest X-ray and culture for Mycobacterial culture re- dia accounting for 2.2 million cases each year [4]. Cuta- mains the most reliable method [11]. Differential diag- neous tuberculosis accounts for only 0.1-0.9% of total nosis of discharging sinuses are atypical mycobacterium out-patients in dermatology in India. Most commonly due to M. scrofulaceum and M. avium, actinomycosis, Amar et al. Clin Med Rev Case Rep 2020, 7:330 • Page 2 of 3 • DOI: 10.23937/2378-3656/1410330 ISSN: 2378-3656 sporotriciasis, botyomycocsis, nocardiosis, hidradenitis taneous tuberculosis in children and adolescents: a clinico- suppurativea [9,11-13]. histological study. J Eur Acad Dermatol Venereol 21: 40-47. 2. Sehgal VN, Wagh SA (1990) Cutaneous tuberculosis. Cur- Treatment of scrofuloderma follows similar recom- rent concepts. Int J Dermatol 29: 237-252. mendations as other forms of TB with multi-drug thera- py (MDT) and ideally adjusted as the culture and suscep- 3. Singal A, Sonthalia S (2010) Cutaneous tuberculosis in children: The Indian perspective. Indian J Dermatol Vene- tibility data. Our patient was started on ATT with four reol Leprol 76: 494-503. drug intensive phase comprising of Isoniazid (H), Rifam- 4. Udwadia ZF, Mehra C (2015) Tuberculosis in India. BMJ