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    Scrofuloderma: Images in Dermatology

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    Akira Masumi
    Tuber

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    Scrofuloderma: Images in Dermatology

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    Akira Masumi
    45 views1 page
    Tuber

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    Tuber

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    Scrofuloderma: Images in Dermatology

    Uploaded by

    Akira Masumi
    Tuber

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    © All Rights Reserved
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    of 1

    Clinical Review & Education

    Images in Dermatology

    Scrofuloderma
    Sarah Oberhelman, BS; Jacqueline Watchmaker, MD; Tania Phillips, MD

    A 24-year-old woman presented to her primary care physician with


    Figure. Clinical Image at Presentation
    a 1-month history of nonproductive cough and shortness of breath
    followed by 2 weeks of fevers, chills, night sweats, and left neck pain
    and swelling. Her only noteworthy medical history was asthma
    treated with albuterol. She worked as a server and had immigrated
    to the United States from El Salvador with her parents more than a
    decade prior to presentation. She had not left the United States since
    she immigrated. On physical examination, she had mild, tender left
    anterior cervical lymphadenopathy without erythema or drainage.
    Results from tuberculosis screening with interferon-gamma re-
    lease assay were positive. Additional laboratory tests, including tests
    for white blood cell count, HIV, Epstein-Barr virus, cytomegalovi-
    rus, Lyme disease, bartonella, toxoplasma, and rapid streptococ-
    cus, were unremarkable except for positive results for rhinovirus/
    enterovirus on respiratory panel. Tests of sputum acid-fast bacilli
    stain, Mycobacterium tuberculosis complex polymerase chain reac-
    tion, and chest x-ray showed no evidence of active pulmonary tu-
    berculosis. Results of a lymph node biopsy showed necrotic tissue Cutaneous tuberculosis is a rare entity that occurs in 1% to 2%
    and no evidence of malignancy. Tissue acid-fast bacilli stain from the of all patients with tuberculosis.1 Scrofuloderma, as seen in this case,
    lymph node was negative, and a mycobacterial culture was sent. is a manifestation of endogenous tuberculosis infection caused by
    A diagnosis of tuberculous lymphadenitis was suspected. M tuberculosis or, less commonly, M bovis.1 The disease originates from
    The patient was started on a trial of antituberculosis treatment contiguous spread of a tuberculous focus to the overlying skin owing
    consisting of rifampin, isoniazid, ethambutol, and pyrazinamide. Soon to local tissue destruction. This results in the formation of a painless
    after treatment was initiated, red-brown plaques formed on the skin subcutaneous nodule that breaks down and expresses purulent
    and overlaid multiple enlarged nodes, which subsequently ulcerated discharge.1,2 Because scrofuloderma can appear similar to a bacterial
    and began draining pale yellow fluid (Figure). Tests for M tuberculo- abscess or malignancy both clinically and radiographically, a high in-
    sis complex polymerase chain reaction and acid-fast bacilli stain of the dex of suspicion is necessary for diagnosis.2 Although culture is the
    drainage yielded positive results. After 9 weeks of incubation, the pre- gold standard for diagnosis, smear for acid-fast bacilli and molecular
    vious lymph node culture grew M tuberculosis complex. The patient techniques, such as polymerase chain reaction, can aid in diagnosis.1,2
    was diagnosed with tuberculous lymphadenitis with scrofuloderma. Standard treatment consists of 2 months of a 4-drug antituberculo-
    Through the National Tuberculosis Genotyping Service offered by the sis treatment followed by 4 months of isoniazid and rifampin use.2
    Centers for Disease Control and Prevention, the specific strain of My- If M bovis is identified, pyrazinamide should be discontinued owing
    cobacterium was found to be Mycobacterium bovis after region of de- to resistance, and a longer duration of treatment may be required.3
    letion analysis. Antibiotic treatment was adjusted accordingly. Fur- As seen in the present patient, a paradoxical worsening of symp-
    ther imaging investigations, including neck and chest computed toms may be seen in 20% to 23% of immunocompetent patients with
    tomography, showed only cervical lymph node involvement. tuberculous lymphadenitis on initiation of treatment.4

    ARTICLE INFORMATION Conflict of Interest Disclosures: None reported. bacterial abscess. Ann Dermatol. 2012;24(1):70-73.
    Author Affiliations: Tulane University School of Additional Contributions: We thank the patient for doi:10.5021/ad.2012.24.1.70
    Medicine, New Orleans, Louisiana (Oberhelman); granting permission to publish this information. 3. Han PS, Orta P, Kwon DI, Inman JC.
    Boston University School of Medicine, Boston, Mycobacterium bovis cervical lymphadenitis:
    Massachusetts (Watchmaker, Phillips). REFERENCES a representative case and review. Int J Pediatr
    Corresponding Author: Sarah Oberhelman, BS, 1. Franco-Paredes C, Marcos LA, Henao-Martínez Otorhinolaryngol. 2015;79(11):1798-1801. doi:10.1016/
    Tulane University School of Medicine, 1430 Tulane AF, et al. Cutaneous mycobacterial infections. Clin j.ijporl.2015.09.007
    Ave, New Orleans, LA 70112 (soberhel@tulane. Microbiol Rev. 2018;32(1):e00069-e18. doi:10.1128/ 4. Fontanilla JM, Barnes A, von Reyn CF. Current
    edu). CMR.00069-18 diagnosis and management of peripheral
    Published Online: April 3, 2019. 2. Kim GW, Park HJ, Kim HS, et al. Delayed tuberculous lymphadenitis. Clin Infect Dis. 2011;53
    doi:10.1001/jamadermatol.2018.5651 diagnosis of scrofuloderma misdiagnosed as a (6):555-562. doi:10.1093/cid/cir454

    jamadermatology.com (Reprinted) JAMA Dermatology Published online April 3, 2019 E1

    © 2019 American Medical Association. All rights reserved.

    Downloaded From: https://jamanetwork.com/ by a Idaho State University User on 04/03/2019

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