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Case Report

Scrofuloderma: A Rare Cutaneous Manifestation of

Tuberculosis
Anuradha Ganesan, Gautham Kumar1
Departments of Oral Medicine and Radiology and 1Periodontics, Madha Dental College and Hospital, Kundrathur, Chennai, India

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

Introduction
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 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
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
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DOI:
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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)]
Address for corresspondence: Dr. Anuradha Ganesan,
Department of Oral Medicine and Radiology, Madha Dental College and
Hospital, Kundrathur, Chennai, India.
E‑mail: anug77@yahoo.com
This is an open access article distributed under the terms of the Creative Commons
Attribution-NonCommercial-ShareAlike 3.0 License, which allows others to remix, tweak,
and build upon the work non-commercially, as long as the author is credited and the new
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For reprints contact: reprints@medknow.com
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.
Received: 21‑03‑2017  Accepted: 08‑11‑2017  Published: 20-11-2017

© 2017 Journal of Indian Academy of Oral Medicine & Radiology | Published by Wolters Kluwer - Medknow 223
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Ganesan and Kumar: A rare cutaneous manifestation of tuberculosis
[Figures 2 and 3], examination of the ulcers, a provisional
diagnosis of cutaneous tuberculosis was given.
On laboratory examination, the Total Leucocyte Count
was 11000/mm3 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.
Discussion
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
Figure 1: Extraoral view of ulcers
Figure 3: OPG showing absence of any odontogenic cause
224 Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 29  ¦  Issue 3  ¦  July‑September 2017
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
Figure 2: IOPA radiograph showing absence of any odontogenic cause
Figure 4: Chest X-ray showing no abnormality
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Ganesan and Kumar: A rare cutaneous manifestation of tuberculosis
Figure 5: Histopathological section of lesion showing Langhan’s giant
cells
differential diagnosis for discharging sinuses can be atypical
mycobacterial infection due to mycobacterium scrofulaceum
and 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
Journal of Indian Academy of Oral Medicine & Radiology  ¦  Volume 29 ¦ Issue 3 ¦ July‑September 2017
Figure 6: Twenty day post treatment photograph showing healing ulcers
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
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.
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Ganesan and Kumar: A rare cutaneous manifestation of tuberculosis

Conflicts of interest 6. Mohanty N, Nayak BB. Cutaneous tuberculosis, tuberculosis verrucosa

There are no conflicts of interest.
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