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Scrofuloderma: a diagnostic challenge*

Scrofuloderma: a diagnostic challenge* t ropiCAl / i nfeCtopArAsitAry d ermAtology 1 1 2 Renan Bernardes de Mello , Everton Carlos Siviero do Vale , Isabela Guimarães Ribeiro Baeta DOI: http://dx.doi.org/10.1590/abd1806-4841.20188560 Abstract: Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis, comprising 1-2% of cases. Caused by Mycobacterium tuberculosis or related strains, it presents a wide range of clinical manifestations, mimicking other chronic dermatoses and leading to delayed diagnosis. A case of scrofuloderma is reported, whose diagnosis and treatment were only made six years after onset of the disease. Keywords: Delayed diagnosis; Diagnosis, differential; Mycobacterium tuberculosis; Tuberculosis, cutaneous; Tuberculosis, lymph node In Brazil, an average of 10,800 cases per year of extrapul- immune status, exogenous or endogenous acquisition pathway, and 1 5 monary tuberculosis were reported from 2012 to 2015. An average tissue response to infection. The described clinical forms are: tuber- of 227 cases of cutaneous tuberculosis are reported annually. Cu- culosis verrucosa cutis, tuberculous chancre, lupus vulgaris, scrofu- taneous tuberculosis can be caused by Mycobacterium tuberculosis, loderma, orificial tuberculosis, metastatic tuberculosis abscess, and M. bovis, or the Calmette-Guérin bacillus (BCG). Scrofuloderma and miliary tuberculosis. lupus vulgaris are the most prevalent forms, but the occurrence os- Scrofuloderma is the result of cutaneous infection adjacent 2-4 cillates according to geographic location and age group. The clini- to a tuberculous focus, which may correspond to peripheral gan- cal presentations vary according to the bacterial load (multibacillary glionar tuberculosis (the most common form of extrapulmonary or paucibacillary), PPD reactivity, previous host sensitization and tuberculosis in HIV-positive patients and in children), or to bone, Received 21 June 2018. Accepted 13 September 2018. * Work conducted at the Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil. Financial support: None. Conflict of interest: None. Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil. Discipline of Dermatology, Medicine Course, Universidade Federal de São João del-Rei, Divinópolis (MG), Brazil. Mailing a ddress : Renan Bernardes de Mello E-mail: bernardesrenan@yahoo.com.br ©2019 by Anais Brasileiros de Dermatologia An Bras Dermatol. 2019;94(1):102-4. s Scrofuloderma: a diagnostic challenge 103 joint, or testicular tuberculosis. The clinical picture is characterized We report a case of a 25-year-old man who complained of by the presence of subcutaneous, painless, slowly growing nodules a painless erythematous nodule in the right supraclavicular region that evolve to ulcers and fistulous tracts with drainage of serous, with onset six years previously that ulcerated after approximately 30 4,5 purulent, or caseous content. The evolution is insidious and can days and evolved with the persistence of a secreting fistula. Anoth- evolve with persistent purulent discharge, chronic ulcers, atrophic er similar nodule appeared in the right infraclavicular region after sequelae, or spontaneous cure. Cervical lymph nodes are the most three months. The diagnosis of pyoderma gangrenosum was made, frequently compromised, but there may be involvement of the axil- but treatment with prednisone and dapsone was unsuccessful. After lary, inguinal and pre- and post-auricular, submandibular, epithro- four months, other nodules and fistulae appeared in the axillae, left clear and occipital lymph nodes. The differential diagnosis includes supraclavicular region, and right parasternal region, with persistent bacterial abscesses, hidradenitis suppurativa, atypical mycobacte- purulent secretion (Figures 1 and 2A). The case was treated as hi- riosis, sporotrichosis, gummatous syphilis and actinomycosis. Al- dradenitis suppurativa with antiseptics and oral tetracycline, but though traditionally classified as a multibacillary form, the oldest without improvement. Patient was admitted to our service due to lesions may be paucibacillary and the tuberculin skin test is usually the appearance of a fluctuating erythematous tumoral mass without strongly reactive. Histopathological findings include granuloma- local heat, measuring approximately 4cm x 3cm in the left cervi- tous inflammatory infiltrate associated with caseous necrosis and cal region (Figure 2B). The patient did not present chronic cough, the detection of acid-fast bacilli. weight loss, fever or other complaints. Complementary exams re- FIgure 3: FIgure 1: Atrophic scars in the supraclavicular regions bilaterally Tuberculin and in the right axilla. Purulent fistulae in the right parasternal re- skin test gion and right axilla result, 25mm x 24mm FIgure 2: A - Purulent fistula in the left axilla. B. Erythematous tumoral mass measuring appro- ximately 4cm x 3cm in A B the left cervical region An Bras Dermatol. 2019;94(1):102-4. 104 Mello RB, Vale ECS, Baeta IGR FIgure 4: A - Absence of purulent secretion and healed fistula in the left axilla following treat- ment B. Involution of the tumoral mass after six B months of treatment vealed no abnormalities in the front and lateral view chest X-rays, ACKNOWLEDGMENTS a PPD skin test measuring 25mm x 24mm (Figure 3), and positive The authors wish to thank the Pulmonology Service of Hos- secretion smear for acid-fast bacilli in a cervical mass obtained by pital das Clínicas (Universidade Federal de Minas Gerais) for col- puncture. Bacterioscopy and fungal and aerobic bacterial cultures laborative follow-up of the case. were negative. A treatment regimen consisting of two months of ri- fampicin, isoniazid, pyrazinamide, and ethambutol was proposed, followed by rifampicin and isoniazid for another four months, with clinical remission (Figure 4).q REFERENCES 1. Tabnet.datasus.gov.br [Internet]. Tuberculose - casos confirmados notificados no 4. Santos JB, Figueiredo AR, Ferraz CE, Oliveira MH, Silva PG, Medeiros VL. sistema de informação de agravos de notificação - Brasil, 2012 - 2015 [cited 2017 Cutaneous tuberculosis: epidemiologic, etiopathogenic and clinical aspects - par t Oct 29]. Available from: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinannet/cnv/ I. An Bras Dermatol. 2014;89:219-28. tubercbr.def. 5. Frankel A, Penrose C, Emer J. Cutaneous tuberculosis: a practical case repor t and 2. Bhutto AM, Solangi A, Khaskhely NM, Arakaki H, Nonaka S. Clinical and review for the dermatologist. J Clin Aesthet Dermatol. 2009;2:19-27. epidemiological observations of cutaneous tuberculosis in Larkana, Pakistan. Int 6. Sethuraman G, Ramesh V. Cutaneous tuberculosis in children. Pediatr Dermatol. J Dermatol. 2002;41:159-65. 2013;30:7-16. 3. Dwari BC, Ghosh A, Paudel R, Kishore P. A clinicoepidemiological study of 50 7. Hill MK, Sanders CV. Cutaneous tuberculosis. Microbiol Spectr. 2017;5:TNMI7- cases of cutaneous tuberculosis in a tertiary care teaching hospital in Pokhara, 0010-2016. Nepal. Indian J Dermatol. 2010;55:233-7. AUTHORS’CONTRIBUTIONS Renan Bernardes de Mello 0000-0002-7586-0799 Conception and planning of the study; Intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; Critical review of the literature; Elaboration and writing of the manuscript; Critical review of the manuscript; Approval of the final version for publication Everton Carlos Siviero do Vale 0000-0002-9172-3639 Conception and planning of the study; Effective participation in research orientation; Intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; Critical review of the literature; Elaboration and writing of the manuscript; Critical review of the manuscript; Approval of the final version for publication Isabela Guimarães Ribeiro Baeta 0000-0002-1243-7870 Intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; Approval of the final version for publication How to cite this article: Mello RB, Vale ECS, Baeta IGR. Scrofuloderma: a diagnostic challenge. An Bras Dermatol. 2019;94(1):102-4. An Bras Dermatol. 2019;94(1):102-4. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Anais Brasileiros de Dermatologia Pubmed Central

Scrofuloderma: a diagnostic challenge*

Anais Brasileiros de Dermatologia , Volume 94 (1) – Feb 1, 2019

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Pubmed Central
ISSN
0365-0596
eISSN
1806-4841
DOI
10.1590/abd1806-4841.20188560
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Abstract

t ropiCAl / i nfeCtopArAsitAry d ermAtology 1 1 2 Renan Bernardes de Mello , Everton Carlos Siviero do Vale , Isabela Guimarães Ribeiro Baeta DOI: http://dx.doi.org/10.1590/abd1806-4841.20188560 Abstract: Cutaneous tuberculosis is a rare form of extrapulmonary tuberculosis, comprising 1-2% of cases. Caused by Mycobacterium tuberculosis or related strains, it presents a wide range of clinical manifestations, mimicking other chronic dermatoses and leading to delayed diagnosis. A case of scrofuloderma is reported, whose diagnosis and treatment were only made six years after onset of the disease. Keywords: Delayed diagnosis; Diagnosis, differential; Mycobacterium tuberculosis; Tuberculosis, cutaneous; Tuberculosis, lymph node In Brazil, an average of 10,800 cases per year of extrapul- immune status, exogenous or endogenous acquisition pathway, and 1 5 monary tuberculosis were reported from 2012 to 2015. An average tissue response to infection. The described clinical forms are: tuber- of 227 cases of cutaneous tuberculosis are reported annually. Cu- culosis verrucosa cutis, tuberculous chancre, lupus vulgaris, scrofu- taneous tuberculosis can be caused by Mycobacterium tuberculosis, loderma, orificial tuberculosis, metastatic tuberculosis abscess, and M. bovis, or the Calmette-Guérin bacillus (BCG). Scrofuloderma and miliary tuberculosis. lupus vulgaris are the most prevalent forms, but the occurrence os- Scrofuloderma is the result of cutaneous infection adjacent 2-4 cillates according to geographic location and age group. The clini- to a tuberculous focus, which may correspond to peripheral gan- cal presentations vary according to the bacterial load (multibacillary glionar tuberculosis (the most common form of extrapulmonary or paucibacillary), PPD reactivity, previous host sensitization and tuberculosis in HIV-positive patients and in children), or to bone, Received 21 June 2018. Accepted 13 September 2018. * Work conducted at the Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil. Financial support: None. Conflict of interest: None. Dermatology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte (MG), Brazil. Discipline of Dermatology, Medicine Course, Universidade Federal de São João del-Rei, Divinópolis (MG), Brazil. Mailing a ddress : Renan Bernardes de Mello E-mail: bernardesrenan@yahoo.com.br ©2019 by Anais Brasileiros de Dermatologia An Bras Dermatol. 2019;94(1):102-4. s Scrofuloderma: a diagnostic challenge 103 joint, or testicular tuberculosis. The clinical picture is characterized We report a case of a 25-year-old man who complained of by the presence of subcutaneous, painless, slowly growing nodules a painless erythematous nodule in the right supraclavicular region that evolve to ulcers and fistulous tracts with drainage of serous, with onset six years previously that ulcerated after approximately 30 4,5 purulent, or caseous content. The evolution is insidious and can days and evolved with the persistence of a secreting fistula. Anoth- evolve with persistent purulent discharge, chronic ulcers, atrophic er similar nodule appeared in the right infraclavicular region after sequelae, or spontaneous cure. Cervical lymph nodes are the most three months. The diagnosis of pyoderma gangrenosum was made, frequently compromised, but there may be involvement of the axil- but treatment with prednisone and dapsone was unsuccessful. After lary, inguinal and pre- and post-auricular, submandibular, epithro- four months, other nodules and fistulae appeared in the axillae, left clear and occipital lymph nodes. The differential diagnosis includes supraclavicular region, and right parasternal region, with persistent bacterial abscesses, hidradenitis suppurativa, atypical mycobacte- purulent secretion (Figures 1 and 2A). The case was treated as hi- riosis, sporotrichosis, gummatous syphilis and actinomycosis. Al- dradenitis suppurativa with antiseptics and oral tetracycline, but though traditionally classified as a multibacillary form, the oldest without improvement. Patient was admitted to our service due to lesions may be paucibacillary and the tuberculin skin test is usually the appearance of a fluctuating erythematous tumoral mass without strongly reactive. Histopathological findings include granuloma- local heat, measuring approximately 4cm x 3cm in the left cervi- tous inflammatory infiltrate associated with caseous necrosis and cal region (Figure 2B). The patient did not present chronic cough, the detection of acid-fast bacilli. weight loss, fever or other complaints. Complementary exams re- FIgure 3: FIgure 1: Atrophic scars in the supraclavicular regions bilaterally Tuberculin and in the right axilla. Purulent fistulae in the right parasternal re- skin test gion and right axilla result, 25mm x 24mm FIgure 2: A - Purulent fistula in the left axilla. B. Erythematous tumoral mass measuring appro- ximately 4cm x 3cm in A B the left cervical region An Bras Dermatol. 2019;94(1):102-4. 104 Mello RB, Vale ECS, Baeta IGR FIgure 4: A - Absence of purulent secretion and healed fistula in the left axilla following treat- ment B. Involution of the tumoral mass after six B months of treatment vealed no abnormalities in the front and lateral view chest X-rays, ACKNOWLEDGMENTS a PPD skin test measuring 25mm x 24mm (Figure 3), and positive The authors wish to thank the Pulmonology Service of Hos- secretion smear for acid-fast bacilli in a cervical mass obtained by pital das Clínicas (Universidade Federal de Minas Gerais) for col- puncture. Bacterioscopy and fungal and aerobic bacterial cultures laborative follow-up of the case. were negative. A treatment regimen consisting of two months of ri- fampicin, isoniazid, pyrazinamide, and ethambutol was proposed, followed by rifampicin and isoniazid for another four months, with clinical remission (Figure 4).q REFERENCES 1. Tabnet.datasus.gov.br [Internet]. Tuberculose - casos confirmados notificados no 4. Santos JB, Figueiredo AR, Ferraz CE, Oliveira MH, Silva PG, Medeiros VL. sistema de informação de agravos de notificação - Brasil, 2012 - 2015 [cited 2017 Cutaneous tuberculosis: epidemiologic, etiopathogenic and clinical aspects - par t Oct 29]. Available from: http://tabnet.datasus.gov.br/cgi/tabcgi.exe?sinannet/cnv/ I. An Bras Dermatol. 2014;89:219-28. tubercbr.def. 5. Frankel A, Penrose C, Emer J. Cutaneous tuberculosis: a practical case repor t and 2. Bhutto AM, Solangi A, Khaskhely NM, Arakaki H, Nonaka S. Clinical and review for the dermatologist. J Clin Aesthet Dermatol. 2009;2:19-27. epidemiological observations of cutaneous tuberculosis in Larkana, Pakistan. Int 6. Sethuraman G, Ramesh V. Cutaneous tuberculosis in children. Pediatr Dermatol. J Dermatol. 2002;41:159-65. 2013;30:7-16. 3. Dwari BC, Ghosh A, Paudel R, Kishore P. A clinicoepidemiological study of 50 7. Hill MK, Sanders CV. Cutaneous tuberculosis. Microbiol Spectr. 2017;5:TNMI7- cases of cutaneous tuberculosis in a tertiary care teaching hospital in Pokhara, 0010-2016. Nepal. Indian J Dermatol. 2010;55:233-7. AUTHORS’CONTRIBUTIONS Renan Bernardes de Mello 0000-0002-7586-0799 Conception and planning of the study; Intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; Critical review of the literature; Elaboration and writing of the manuscript; Critical review of the manuscript; Approval of the final version for publication Everton Carlos Siviero do Vale 0000-0002-9172-3639 Conception and planning of the study; Effective participation in research orientation; Intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; Critical review of the literature; Elaboration and writing of the manuscript; Critical review of the manuscript; Approval of the final version for publication Isabela Guimarães Ribeiro Baeta 0000-0002-1243-7870 Intellectual participation in propaedeutic and/or therapeutic conduct of the cases studied; Approval of the final version for publication How to cite this article: Mello RB, Vale ECS, Baeta IGR. Scrofuloderma: a diagnostic challenge. An Bras Dermatol. 2019;94(1):102-4. An Bras Dermatol. 2019;94(1):102-4.

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Published: Feb 1, 2019

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