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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 29  |  Issue : 3  |  Page : 223-226

Scrofuloderma: A rare cutaneous manifestation of tuberculosis


1 Department of Oral Medicine and Radiology, Madha Dental College and Hospital, Kundrathur, Chennai, India
2 Department of Periodontics, Madha Dental College and Hospital, Kundrathur, Chennai, India

Date of Submission21-Mar-2017
Date of Acceptance08-Nov-2017
Date of Web Publication20-Nov-2017

Correspondence Address:
Anuradha Ganesan
Department of Oral Medicine and Radiology, Madha Dental College and Hospital, Kundrathur, Chennai
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_33_17

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   Abstract 

Scrofuloderma, cutaneous tuberculosis in the orofacial region, is rare and is often a confusing and challenging diagnosis for a dental physician. Here, we present a case report of a 7-year-old girl who had two ulcers in the right side of the face. Only with a proper history, general, and local examination and along with various investigative findings, the diagnosis was confirmed.

Keywords: Cutaneous tuberculosis, scrofuloderma, tuberculosis


How to cite this article:
Ganesan A, Kumar G. Scrofuloderma: A rare cutaneous manifestation of tuberculosis. J Indian Acad Oral Med Radiol 2017;29:223-6

How to cite this URL:
Ganesan A, Kumar G. Scrofuloderma: A rare cutaneous manifestation of tuberculosis. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2020 Dec 3];29:223-6. Available from: https://www.jiaomr.in/text.asp?2017/29/3/223/218718


   Introduction Top


One of the most life threatening but treatable infectious diseases with high mortality is tuberculosis (TB).[1] Tuberculosis is a chronic granulomatous infectious disease caused by Mycobacterium tuberculosis, an acid fast bacillus whose route of spread is through the inhalation of airborne droplets. Rarely, mycobacterium bovis Scientific Name Search  or other atypical mycobacteria can also lead to the development of tuberculosis.[2] Tuberculosis most commonly affects the lungs; however, the disease can also occur in other tissues/organs such as the meninges, kidney, bone, lymph nodes, skin, and oral cavity. About 1.5% of tuberculous manifestations are cutaneous and accounts for 0.1–0.9% of total dermatological out patients in India.[3] Scrofuloderma is a type of cutaneous tuberculosis affecting children and young adults. Also called tuberculosis colliquativa cutis, in this condition there is breakdown of skin overlying a tuberculous focus in the lymph node, bone, or joints.[4] Here, in this article, we present a case of scrofuloderma on the skin of the right side of the face.


   Case Report Top


A 7-year-old female child presented herself to the Department of Oral Medicine and Radiology of our institution with a complaint of ulcers on the skin of the right side of the face since two weeks. History revealed that there were two lesions, which started as papules, initially increased in size and progressed to pustules leading to ulcerations with drainage of pus. She also gave a history of low grade fever with weight loss and loss of appetite since one month. There was no history of haemoptysis, cough, trauma, or any similar complaints among family members. On examination, there was a single matted lymph node less than 2 cm in size present in the right submandibular region. There were no other palpable lymph nodes.

On extraoral examination, there were two ulcers present on the right side of the face, one at the angle of the mandible, and the other one 1 cm anterior to it. The first ulcer was 3 × 2 cm in size and the other one was 2 × 1 cm in size. Both the ulcers had ill-defined borders and the surrounding skin was edematous and pigmented. The floor of the ulcer was covered with slough and there was discharge of pus from both the ulcers. The edges of the ulcers were undermined and non tender [Figure 1]. Intraorally, there were no carious lesions or any odontogenic cause leading to the ulcers. So, correlating the history, duration, palpable matted submandibular nodes, absence of any odontogenic cause [ruled out with intraoral periapical radiograph (IOPA) and orthopantomograph (OPG)] [Figure 2] and [Figure 3], examination of the ulcers, a provisional diagnosis of cutaneous tuberculosis was given.
Figure 1: Extraoral view of ulcers

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Figure 2: IOPA radiograph showing absence of any odontogenic cause

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Figure 3: OPG showing absence of any odontogenic cause

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On laboratory examination, the Total Leucocyte Count was 11000/mm 3 with a raised erythrocyte sedimentation rate (ESR) of 42 mm/hr (Wintrobe). The other values were within normal limits. A Mantoux test was performed and was positive (18 mm/72 hrs). Chest X-ray did not reveal any abnormality [Figure 4]. The swabs from the discharging fluid were tested positive for acid fast bacilli. Analysis for human deficiency virus was negative. An incisional biopsy of the skin was performed and the histological picture revealed a granulomatous lesion with Langhan's type of giant cells with peripherally arranged nuclei. The stroma had lymphocytic infiltration with epitheloid cells distributed throughout [Figure 5]. Once the final diagnosis of scrofuloderma was established, TB regimen consisting of rifampicin, isoniazid, pyrazinamide, and ethambutol was started for 2 months. After 20 days, the patient was recalled and the ulcers had started to heal and there was no discharge present [Figure 6]. The patient is presently under medication and observation.
Figure 4: Chest X-ray showing no abnormality

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Figure 5: Histopathological section of lesion showing Langhan's giant cells

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Figure 6: Twenty day post treatment photograph showing healing ulcers

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   Discussion Top


TB cases are estimated to be around 9.6 million with around 1 million of them in children.[5] The diagnosis of cutaneous TB may pose a challenge to the clinician because of its resemblance to other skin lesions and varied clinical manifestations.[6] Cutaneous tuberculosis was classified in 1981 by Beyt et al. and is accepted with some modifications.[7] Among all the types, the most common clinical presentation seen in children is scrofuloderma.[8],[9] The most common sites of scrofuloderma are the chest, neck, and axilla. Our case presents scrofuloderma in a rare site. The lesions start as firm, painless subcutaneous nodules that eventually suppurate and form ulcers and sinus tracts in the overlying skin. Acid fast bacilli may be demonstrated in lesions and cultures may show positive for mycobacteria as compared with other types of cutaneous TB.[10]

Chest X-rays are mandatory to rule out systemic TB and also a screening test for HIV (Western blot) should be performed. Tuberculin sensitivity usually is marked, but it has a very low specificity. Polymerase chain reaction (PCR) has low sensitivity but high specificity. Histopathological examination is confirmatory, which reveals the presence of tubercular granulomas with epitheloidal cells, Langhan's giant cells and lymphocytes. According to various reports, only a small percentage of histopathological specimens stain positive for acid fast bacilli.

Various other conditions can clinically mimic scrofuloderma and should be correctly identified and differentiated. Various differential diagnosis for discharging sinuses can be atypical mycobacterial infection due to  Mycobacterium scrofulaceum Scientific Name Search d M. avium-intracellulare, actinomycosis, sporotrichosis, botryomycosis, nocardiosis.[4]

Atypical mycobacterial infection is also seen in children involving submandibular and submaxillary nodes with no constitutional symptoms. Even though clinically indistinguishable from scrofuloderma, it can be differentiated on the basis of histopathology and positive PCR report for M. tuberculosis. Actinomycosis also presents with multiple draining sinuses with typical sulphur granules. The absence of sulphur granules and negative culture report for actinomycetes help to differentiate this condition.

Absence of fungal hyphae in histopathology leads to exclusion of sporotrichosis. Botryomycosis is more common in immunocompromised patients and usually occurs on extremities and is less common in head, neck, and buttocks. Absence of bacteria from pus or biopsy rules out this condition from scrofuloderma. Rarely, syphilitic gummas and nocardiosis can also lead to draining sinuses, which should be differentiated by serological test for syphilis and branched filaments at right angles typically seen in organisms in nocardiosis.

The treatment of cutaneous TB is very crucial and general measures should be taken to treat the malnutrition, any concomitant illness causing immunosuppression, and also people in close contact with the patient such as the family members should undergo testing for TB. Anti-TB treatment as per the recommendation of therapy for extrapulmonary TB should be started. WHO recommends treatment of cutaneous TB in HIV negative individuals using directly observed treatment short course (DOTS) chemotherapy consisting of four drugs, Isoniazid (H), Rifampicin (R), Pyrizinamide (Z), and Ethambutol (E) given for 2 months (intensive phase) followed by isoniazid and rifampicin given for the next four months (continuation phase) (2RHZE/4RH). The pharmacological presentation of this scheme is a fixed dose tablet with a combination of four drugs (RHZE), in the following dosages R150mg, M75mg, Z400mg, and E275mg. This medication should be taken once daily. For newly diagnosed cases of cutaneous TB children less than 10 years, 2RHZ/4RH scheme is followed. Ethambutol in children younger than 5 years needs proper monitoring. As children approach a body weight of 25 kg, adult dosages can be used.[11]

The role of surgery also should be considered, even though pharmacotherapy is the primary method of treatment. Electrosurgery, cryosurgery, and curettage with electrodessication are the modes of treatment of affected nodes as an adjunctive measure.[12]


   Conclusion Top


According to WHO, 1/3rd of the world's population is infected with tuberculosis bacilli. Even though various measures have been taken to tackle this menace like improving the hygiene, living conditions of people, introduction of BCG vaccine, and other effective therapeutic measures, TB is estimated to increase in the next five years due to emergence of multidrug-resistant mycobacterium tuberculosis. Also, rare manifestations of TB-like scrofuloderma may be misdiagnosed. Hence, a thorough history, complete examination and various investigations should be carried out for early diagnosis and initiation of treatment for complete recovery. In addition, the importance of completing the treatment should be made aware to the patient so as to ensure successful therapy.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
Kapoor S, Gandhi S, Gandhi N, Singh I. Oral manifestations of tuberculosis. CHRISMED J Health Res 2004;1:11-4.  Back to cited text no. 1
    
2.
Kolokotronis A, Antoniadis D, Trigonidis G, Papanagioutou P. Oral tuberculosis. Oral Dis 1996;2:242-3.  Back to cited text no. 2
    
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Kumar B, Muralidhar S. Cutaneous tuberculosis: A twenty year prospective study. Int J Tuberc Lung Dis 1999;3:494-500.  Back to cited text no. 3
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4.
Tappeiner G. Tuberculosis and infections with atypical mycobacteria. In: Wolff K, Goldsmith LA, Katz SI, et al., editors. Fitz Patrick's Dermatology in General Medicine. 7th ed. NewYork: McGraw-Hill; 2008. p. 1768-78.  Back to cited text no. 4
    
5.
World Health Organization. Global tuberculosis report 2017. Geneva, Switzerland. Available from: http://www.who.int/tb/publications/global_report/en/. [Last accessed on 2017 Feb 25].  Back to cited text no. 5
    
6.
Mohanty N, Nayak BB. Cutaneous tuberculosis, tuberculosis verrucosa cutis. Med J DY Patil Univ 2014;7:53-5.  Back to cited text no. 6
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7.
Beyt Jr BE, Ortbals DW, Santa Cruz DJ, Kobayashi GS, Eisen AZ, Medoff G. Cutaneous mycobacteriosis: Analysis of 34 cases with a new classification of the disease. Medicine (Baltimore) 1981;60:95-109.  Back to cited text no. 7
    
8.
Kumar B, Rai R, Kaur I, Sahoo B, Muralidhar S, Radotra BD. Childhood cutaneous tuberculosis: A study over 25 years from northern India. Int J Dermatol 2001;40:26-32.  Back to cited text no. 8
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Ramesh V, Misra RS, Beena KR, Mukherjee A. A study of cutaneous tuberculosis in children. Pediatr Dermatol 1999;16:264-9.  Back to cited text no. 9
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Pandhi D, Reddy BS, Chowdhary S, Khurana N. Cutaneous tuberculosis in Indian children. The importance of screening for involvement of internal organs. J Eur Acad Dermatol Venereol 2004;18:546-51.  Back to cited text no. 10
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11.
Dias MF, Bernardes Filho F, Quaresma MV, Nascimento LV, Nery JA, Azulay DR. Update on cutaneous tuberculosis. An Bras Dermatol 2014;89:925-38.  Back to cited text no. 11
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12.
Yates VM, Rook GA. Mycobacterial infection. In: Burns T, Breathnach S, Cox N, Griffiths C, editors. Rook's Textbook of Dermatology. 7th ed. London: Blackwell Science; 2004. p. 28.  Back to cited text no. 12
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]



 

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