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CASE REPORT
Year : 2016  |  Volume : 17  |  Issue : 2  |  Page : 117-120

Scrofuloderma associated with lupus vulgaris and tuberculosis verrucosa cutis in an immunocompetent boy


Department of Dermatology, SVS Medical College, Yenugonda, Mahbubnagar, Telangana, India

Date of Web Publication30-Mar-2016

Correspondence Address:
Angoori Gnaneshwar Rao
F12, B8, HIG-2 APHB, Baghlingampally, Hyderabad - 500 044, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-7250.175662

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  Abstract 

Cutaneous tuberculosis is protean and diverse in its clinical manifestations, it usually manifests as a single clinical morphological form. However, three different morphological forms of cutaneous tuberculosis such as scrofuloderma (SFD), lupus vulgaris (LV), and tuberculosis verrucosa cutis (TVC) may coexist in the same patient. Herein, we present coexistence of SFD, LV, and TVC in a 14-year-old boy, initially developed SFD in the left axilla and subsequently developed LV of the left elbow followed by TVC involving pubic region. Typical clinical morphology and epithelioid cell granuloma with Langhans giant cells on histopathological examination of the biopsy taken from the plaque of elbow and pubic region corroborated in establishing the diagnosis of SFD, LV, and TVC. The considerable clinical improvement was observed after 12 weeks of instituting four drugs antitubercular treatment.

Keywords: Langhans giant cell, Lowenstein–Jensen's medium, lupus vulgaris, scrofuloderma, tuberculosis verrucosa cutis


How to cite this article:
Rao AG. Scrofuloderma associated with lupus vulgaris and tuberculosis verrucosa cutis in an immunocompetent boy. Indian J Paediatr Dermatol 2016;17:117-20

How to cite this URL:
Rao AG. Scrofuloderma associated with lupus vulgaris and tuberculosis verrucosa cutis in an immunocompetent boy. Indian J Paediatr Dermatol [serial online] 2016 [cited 2019 Nov 19];17:117-20. Available from: http://www.ijpd.in/text.asp?2016/17/2/117/175662


  Introduction Top


Tuberculosis is a chronic infectious disease caused by Mycobacterium tuberculosis, known to cause morbidity and mortality among millions of people each year. There are nearly 9 million new cases and 1.4 million deaths reported in 2011.[1] The World Health Organization estimates that nearly one-third of the global population is at the risk of developing the disease.[2]


  Case Report Top


A 14-year-old boy came to us with ulcers in the left armpit, left elbow, and scars in the left groin of 7–8 years duration. He was apparently asymptomatic 8 years back then he noticed a swelling in the left groin which subsequently resulted in ulceration with recurrent discharge and ultimately healed with scaring. Two years later developed an ulcer on the inner side of the elbow which gradually spread to involve the arm above and forearm below. Then he subsequently developed ulcers in the left axilla which intermittently discharged serosanguinous fluid. Family history was negative for tuberculosis. Both cervical and inguinal group of lymph nodes on the left side were found enlarged and matted. Bacille de Calmette et Guérin (BCG) scar was noted on the left arm.

On examination, a crusted plaque with multiple sinuses was noted in the left axilla (6 cm × 2cm). Left elbow had contracture of the skin with a limited range of movement and surrounding atrophic scaly plaque [Figure 1]. Single horizontal verrucous plaque of 3 cm × 4 cm size was noted in the pubic region along with two atrophic plaques in the left groin [Figure 2]. The axillary plaque was provisionally diagnosed as scrofuloderma (SFD) and elbow plaque as lupus vulgaris (LV) and plaque in the pubic region as tuberculosis verrucosa cutis (TVC). Actinomycosis and sporotrichosis were considered in the differential diagnosis of SFD, while blastomycosis, pyoderma gangrenosum in the differential diagnosis of LV, and chromoblastomycosis was considered in the differential diagnosis of TVC.
Figure 1: Ulcerated crusted plaque with multiple sinuses in the left axilla and atrophic scaly plaque involving the left elbow

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Figure 2: Horizontal verrucous plaque in the pubic region and two atrophic plaques in the left groin

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Routine laboratory investigations were within normal limits except for raised erythrocyte sedimentation rate. Mantoux's test was negative. Smear taken from crusted plaque in left axilla was negative for both M. tuberculosis and fungus. The culture was also negative on Lowenstein–Jensen's medium and sabouraud's dextrose agar. Fine needle aspiration cytology from left axillary and left inguinal lymph node was noncontributory. Serology for human immunodeficiency virus I and II was nonreactive. X-ray chest, X-ray left elbow, and ultrasonography of abdomen was unremarkable. Skin biopsy from the plaque on the elbow and pubic region revealed epithelioid cell granuloma with Langhans giant cells and dense collection of lymphocytes and plasma cells [Figure 3] and [Figure 4]. Fite stain for acid-fast bacillus was negative. Biopsy tissue for polymerase chain reaction (PCR) was negative for M. tuberculosis. Characteristic clinical morphology and histopathological examination of the biopsy corroborated in establishing the diagnosis of SFD with LV and TVC. He was administered four drugs antitubercular regimen (rifampicin 450 mg daily, isoniazid 300 mg daily, ethambutol 800 mg daily, and pyrazinamide 750 mg twice daily) which resulted in considerable regression of all the three lesions within 12 weeks of treatment.
Figure 3: Microphotograph of skin. H and E stain ×100: Showing epithelioid cell granuloma with Langhans giant cells (black arrow)

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Figure 4: Microphotograph of skin. H and E stain ×400: Showing granuloma consisting of epithelioid and Langhans giant cells (black arrow) and lymphocytes

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  Discussion Top


Cutaneous tuberculosis, caused by M. tuberculosis and Mycobacterium bovis, constitutes 1.5% of all cases of extrapulmonary tuberculosis.[3] The prevalence of cutaneous tuberculosis among various dermatology outpatient departments in India ranges between 0.1% and 0.5%.[4],[5] The most common sites of SFD are the chest, neck, and axilla. Involvement of left axilla in the index case concurs with the observation. Although the face is the common site of involvement for LV, in a small percentage lesions occur on the extremities as manifested in the index case. TVC occurs on the areas prone to friction and trauma. However, the involvement of pubic area in the index case is noteworthy.

There is no evidence of systemic involvement in the index case. However, systemic involvement was reported in 21.3% of children with cutaneous tuberculosis.[6] It has been observed that BCG-vaccinated patients are less likely to develop disseminated tuberculosis. However, the development of disseminated tuberculosis (SFD, LV, and TVC) in the index case in the backdrop of BCG vaccination is inexplicable. Smear and culture (from SFD lesion) for M. tuberculosis were negative in the reported case. Notably, tuberculous bacilli could be demonstrated in only 22.5% of children with SFD.[6] In a study, using culture on Lowenstein–Jensen's medium, researchers observed positive cultures in 51.05% of patients with SFD, 42.85% with TVC, and 13.3% with (LV).[7] Histopathology of skin biopsy confirmed the diagnosis of tuberculosis in the index case. In a study, classical tubercular histology was observed in 47.5% of patients with SFD and 100% patients with TVC.[6] PCR for M. tuberculosis in the biopsy tissues was negative for the reported case. However, in a study on the utility of PCR for cutaneous tuberculosis, it was found positive in 50% of cases of SFD and 62.2% cases of TVC.[8]

Coexistence of SFD with LV and TVC in the same patient, as seen in the index case, is very rare. All the three types of cutaneous tuberculosis have diverse underlying immunity as evidenced by CD4 ± CD8 + ratio in the granuloma: LV with strong immunity, TVC with intermediate immunity, and SFD with low-level immunity.[9] It may be due to the overall dominance of decreased cellular immunity to M. tuberculosis leading to dissemination of tuberculosis resulting in different forms of cutaneous tuberculosis as seen in the index case. Nonetheless, the authors have reported coexistence of SFD with TVC in an 11-year-old boy who developed initially SFD in left groin and later developed TVC on the dorsum of the left foot.[10] Furthermore, there have been few reports of coexistence SFD with TVC and LV with TVC in the literature [Table 1].[10],[11],[12],[13] These patients must be counseled regarding prolonged treatment and nutritious diet.
Table 1: Published reports of coexistence of different cutaneous tuberculosis with time gap between development

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  Conclusion Top


It may be said that coexistence of SFD with LV and TVC in the same patient is possible when other combinations such as SFD with LV and LV with TVC have been described. As chances of laboratory confirmation of cutaneous tuberculosis are less, it may be worthwhile to institute antitubercular therapy on clinical suspicion, even if the laboratory confirmation is unsupportive.[14] Moreover, the ensuing therapeutic response to antitubercular therapy may be considered as a diagnostic criterion, particularly in developing countries such as India.

Financial Support and Sponsorship

Nil.

Conflicts of Interest

There are no conflicts of interest.

 
  References Top

1.
Global Tuberculosis Control; 2011. p. 11. Available from: http://www.who.int/publications/global. [Last accessed on 2015 Aug 18].  Back to cited text no. 1
    
2.
Vashisht P, Sahoo B, Khurana N, Reddy BS. Cutaneous tuberculosis in children and adolescents: A clinicohistological study. J Eur Acad Dermatol Venereol 2007;21:40-7.  Back to cited text no. 2
    
3.
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. 3
    
4.
Ramesh V, Misra RS, Jain RK. Secondary tuberculosis of the skin. Clinical features and problems in laboratory diagnosis. Int J Dermatol 1987;26:578-81.  Back to cited text no. 4
    
5.
Kumar B, Kaur S. Pattern of cutaneous tuberculosis in North India. Indian J Dermatol Venereol Leprol 1986;52:203-7.  Back to cited text no. 5
    
6.
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. 6
    
7.
Sehgal VN, Jain MK, Srivastava G. Changing pattern of cutaneous tuberculosis. A prospective study. Int J Dermatol 1989;28:231-6.  Back to cited text no. 7
    
8.
Padmavathy L, Rao L, Veliath A. Utility of polymerase chain reaction as a diagnostic tool in cutaneous tuberculosis. Indian J Dermatol Venereol Leprol 2003;69:214-6.  Back to cited text no. 8
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9.
Sehgal VN, Gupta R, Bose M, Saha K. Immuno histopathological spectrum in cutaneous tuberculosis. Clin Exp Dermatol 1993;18:309-13.  Back to cited text no. 9
    
10.
Rao AG. Scrofuloderma associated with tuberculosis verrucosa cutis. Indian J Dermatol Venereol Leprol 2014;80:76-8.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Gul U, Kilic A, Soylu, S, Demiriz M, Kubar A. Coexistence of tuberculosis verrucosa cutis with scrofuloderma – A case report. Turk J Med Sci 2008;38:495-9.  Back to cited text no. 11
    
12.
Pramatarov K, Balabanova M, Miteva L, Gantcheva M. Tuberculosis verrucosa cutis associated with lupus vulgaris. Int J Dermatol 1993;32:815-7.  Back to cited text no. 12
    
13.
Sethuraman G, Kaur J, Nag HL, Khaitan BK, Sharma VK, Singh MK. Symmetrical scrofuloderma with tuberculosis verrucosa cutis. Clin Exp Dermatol 2006;31:452-82.  Back to cited text no. 13
    
14.
Gruber PC, Whittam LR, du Vivier A. Tuberculosis verrucosa cutis on the sole of the foot. Clin Exp Dermatol 2002;27:188-91.  Back to cited text no. 14
    


    Figures

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