Journal of Pakistan Association of Dermatologists 2011; 21: 61-65.
Case Report
Scrofuloderma: a common type of cutaneous
tuberculosis. A case report
Usma Iftikhar, Muhammad Nadeem, Shahbaz Aman, Atif Hasnain Kazmi
Department of Dermatology Unit-I, KEMU/ Mayo Hospital, Lahore
Abstract Scrofuloderma is a common type of cutaneous tuberculosis characterized by a bluish-red nodule
overlying an infected lymph gland, bone or joint that breaks down to form an undermined ulcer
with a granulating tissue at the base. Progression of the disease leads to irregular adherent masses,
densely fibrous at some places while fluctuant and discharging at others. It heals with a
characteristic puckered scarring at the site of infection. The disease is caused by Mycobacterium
tuberculosis and common anti-tuberculous drugs are recommended for treatment. Many similar
cases with additional features have been reported in foreign literature. We describe a case of this
disorder along with review of literature.
Key words
Scrofuloderma, tuberculosis, Mycobacterium, anti-tuberculous drugs
Introduction and sinus tracts with undermined edges and
ultimately puckered scars.1 Diagnosis is usually
Cutaneous tuberculosis has a worldwide performed by needle aspiration biopsy or
distribution.1 Though, human disease with excisional biopsy of the mass and the
Mycobacterium tuberculosis and M. bovis microbiological demonstration of stainable acid-
usually spreads by droplets, and the portal of fast bacteria.3 PCR has a low sensitivity but high
entry is often the respiratory tract, skin can also specificity.5,6
be involved primarily.2,3 Many types of
cutaneous tuberculosis like lupus vulgaris, The best approach for treatment of this disorder
scrofuloderma, tuberculosis verrucosa cutis, is with conventional anti-tubercular drugs while
tuberculous gumma, orificial tuberculosis etc. people in close contact with the patient, such as
are seen in our population.1,2,4 family members, should undergo testing for
tuberculosis.3 The role of surgery cannot be
Scrofuloderma, also called ‘tuberculosis denied.2 The affected nodes can be treated with
colliquativa cutis’ is a common form of electrosurgery, cryosurgery and curettage with
cutaneous tuberculosis affecting children and electrodessication as an adjunct measure, with
young adults in which there is breakdown of pharmacological therapy as the primary method
skin overlying a tuberculous focus in the lymph of treatment.3 We report a case of
node, bone or joint.1,4 Initially, there are firm scrofuloderma, a commonly seen variety of
painless, subcutaneous nodules that gradually cutaneous tuberculosis in our society.
enlarge and suppurate.1,3,4 These lead to ulcers
Case report
Address for correspondence
Dr. Usma Iftikhar A 25-year-old male, unemployed, resident of
357-AA, Phase-IV, DHA, Lahore Cantt.
Fatehgarh, Lahore, presented at the Department
E-mail: usma_iftikhar@hotmail.com
61
Journal of Pakistan Association of Dermatologists 2011; 21: 61-65.
of Dermatology Unit-I, King Edward Medical
University/ Mayo Hospital, Lahore with
complaints of multiple discharging sinuses on
his left shoulder and scapular region and right
upper arm for the last 6 months. Initially, the
lesions started as papules that progressed to
nodules and pustules leading to draining sinuses.
He also had a history of low grade fever with
evening rise, associated with rigors and chills.
There was no history of trauma, cough, Figure 1Multiple discharging sinuses & swelling
haemoptysis, anorexia and weight loss or similar over right little finger
disease in his family.
The patient was diagnosed as a case of
cutaneous tuberculosis in another hospital at
Lahore and was put on anti-tubercular therapy
but he discontinued the treatment after 2-3
weeks. When he presented to us, he had
swellings and redness on right little finger, left
wrist and left elbow for the last 3 months. The
discharge from the lesions was initially serous
Figure 2Discharging sinus (left elbow joint)
and then purulent in nature. He had generalized
aches and pains with joint stiffness. He also had
swellings on the dorsal and ventral surface of
left hand, right elbow and left foot. There was no
history of contact with a tubercular patient and
nothing was positive on systemic enquiry. In
family history, his parents, 5 brothers and 3
sisters, were all alive and healthy. He was non-
smoker, non-addict and belonged to a poor class.
Physical examination revealed a young man
with normal built and pale complexion. Lymph
nodes examination showed a palpable left Figure 3 Swelling and discharging sinus (palmar
aspect of left hand). Swelling on right little finger as
epitrochlear node, single, mobile, non-tender, shown in Figure 1.
2cm in size with a firm consistency while no
other nodes were palpable. Cutaneous ventral and dorsal aspect of left hand (Figure 3),
examination revealed discharging sinuses on the right elbow and dorsal aspect of left foot near
right little finger, left wrist and left elbow the lateral border. The right elbow and ankle
(Figures 1 and 2). There were soft, fluctuant, joint were also found to be swollen. Multiple
erythematous swellings around the sinuses with depressed atrophic scars were also present on the
a purulent discharge while firm, tender, right arm and anterior aspect of right shoulder
erythematous subcutaneous nodules on the with striae distensae.
Journal of Pakistan Association of Dermatologists 2011; 21: 61-65.
There was tenderness and difficulty in flexion/ infiltration of medullary cavity in the 5th
extension of all joints in the vicinity of affected metatarsal while X-ray right foot revealed
areas. Respiratory system examination showed a irregularity at the medial aspect of shaft of 1st
decreased expansion in the upper chest while metatarsal. Abdominal ultrasonography revealed
vocal fremitus was increased and the percussion hepatomegaly with a fatty liver. Histopathology
note dull in the right upper chest. Auscultation of skin revealed chronic non-specific
revealed diminished breath sounds and an inflammation while bone curettage showed
increased vocal resonance in the right upper granulomata composed of epithelioid cells with
zone. No significant finding was noted in Langhan’s giant cells and caseation necrosis. No
gastrointestinal, cardiovascular and nervous malignancy was seen and the final report was
system. suggestive of tuberculosis.
On laboratory investigations, the blood complete Currently, the patient is under observation with
examination revealed TLC: 9800/mm3, Hb: continued treatment on oral isoniazid,
10gm/dl, ESR: 70 mm and a microcytic rifampicin, ethambutol, pyrazinamide,
hypochromic picture while urine and stool pyridoxine and injection streptomycin 1gm
examination had no abnormal finding. Gram intramuscular daily for the last 6 months with
staining and smear for Leishman-Donovan some improvement.
bodies were negative. The bacteriological
examination of pus showed no acid-fast bacilli Discussion
or other micro-organisms. Hepatitis B surface
antigen, anti-HCV and HIV screening were One-third of the world’s population is infected
negative. Mycodot test revealed negative IgG with M. tuberculosis and global burden of the
and IgM result. Microscopy for fungal spores disease continues to grow.1,5,7 The organism
was also negative. Sputum for AFB was positive responsible for tuberculosis was identified more
and polymerase chain amplification showed a than 100 years ago while a tuberculosis vaccine
positive result with mycobacteria. Chest X-ray has been in use for over 60 years and
showed non-homogeneous shadowing in the chemotherapy for over 30 years.8 Despite all
right upper lobe, bordered by horizontal fissure these, the disease still remains a major
with upward pull of hila due to chronic international health problem.3,5,7 The reasons
inflammatory process, most probably may be malnutrition, low socioeconomic
tuberculosis. X-ray left elbow joint revealed conditions and multidrug resistant strains of M.
subtle critical erosion around medial epicondyle, tuberculosis.3,9 In our case, swellings with
with overlying mild soft tissue swelling. X-ray draining sinuses, histopathology report, positive
of right hand showed destructive changes, with result on PCR testing and a good response to
ill-defined sclerosis and lucencies and overlying ATT favoured the diagnosis of scrofoluderma.
soft tissue swelling at the proximal phalanx of
little finger while x-ray of left hand revealed The condition has to be differentiated from some
sclerosis with cortical thickening and infiltration other similar clinical entities (Table 1). Atypical
of medullary cavity of third metacarpal and mycobacterial infections clinically mimic
overlying soft tissue swelling. X-ray left foot scrofuloderma.1 M. scrofulaceum produces only
showed cortical thickness with sclerosis and a benign, self-limiting lymphadenopathy with no
organ involvement.
Journal of Pakistan Association of Dermatologists 2011; 21: 61-65.
Table 1 Differential diagnosis of discharging sinuses are similar to scrofuloderma but a negative
[1-3,6,10] report for fungal hyphae and histopathology led
Atypical mycobacterial infection due to
Mycobacterium scrofulaceum and M.
to exclusion of this condition.
avium-intracellulare
Actinomycosis Botryomycosis is a chronic inflammatory
Sporotrichosis condition due to a bacterial infection.13 The
Botryomycosis
infection is more common in
Nocardiosis
Syphilitic gumma immunocompromised patients. The disease
Hidradenitis suppurativa presents as nodules, sinuses, fistulae, abscesses
and ulcers, leading to scarring. The lesion
The infection is seen in children, mainly usually occurs on the extremities but less
between the ages of 1 and 3 years. commonly affected sites are head, neck and
Submandibular and submaxillary nodes are buttocks.13 The granules (like sulphur granules)
typically involved and there are no constitutional are formed and discharged from the lesions
symptoms. Primary skin disease caused by M. which on histologic examination are proven to
avium-intracellulare1 has been reported in rare be masses of cocci, mostly Staphylococci.13 The
instances, presenting as single or multiple, condition can be ruled out on the basis of
painless, scaly yellowish plaques or absence of bacteria from pus or biopsy
subcutaneous nodules with a tendency to specimen. In nocardiosis, papulo-nodular
ulceration and a slowly progressive, chronic lesions occur on the limbs and trunk leading to
course. This infection also causes lung disease draining sinuses and the organisms are detected
or, less frequently, osteomyelitis and may as gram-positive branched-filaments and
produce a cervical lymphadenitis with sinus branching at right angle is confirmatory.11,12
formation that is clinically indistinguishable
from scrofuloderma. Both of these conditions Syphilitic gumma is a typical granulomatous
were ruled out on the basis of histopathology lesion of tertiary syphilis mainly found in the
and positive PCR report for M. tuberculosis.2,5,6 skin and bone.12,14 Cutaneous lesions are
rounded, red to flesh-coloured nodules which
Actinomycosis is characterized by can occur anywhere. The nodules may break
granulomatous and fibrotic lesions, which tend down to form punched-out ulcers leading to
to break down and form abscesses that drain atrophic scars or can heal with no residue.12,14 In
through multiple sinuses.11 Typical “sulphur our case, there was no neurological or
granules” occur in these abscesses.11 The disease cardiovascular involvement and serological tests
is caused by Actinomyces israelii, the anaerobic for syphilis were also negative.
organism producing filamentous branching
hyphae. The lesions occur primarily on the face The earliest lesion of hidradenitis suppurativa is
and neck, especially on the lateral surfaces of a painful erythematous nodule in an apocrine
neck beneath the jaw, less often on the chest gland-bearing site such as axilla, inguinal,
wall or lower abdomen.11 The absence of sulphur perianal and even the areolar skin leading to
granules and negative culture report for abscess formation.15 Rupture and drainage of the
Actinomycetes helped to delineate this condition. abscesses soon occurs, with healing by deep
Where sporotrichosis is endemic, it must also be fibrosis.15 As the process recurs again and again,
excluded.12 The clinical features of this condition there is an increase in scarring and sinus tract
Journal of Pakistan Association of Dermatologists 2011; 21: 61-65.
formation with restriction of movement of the 6. Tan WP, Tang MBY, Tan HH.
affected limb. Many patients with severe chronic Scrofuloderma from the acromioclavicular
joint presenting as a chronic ulcer in an
disease show open comedones or blackheads, in immunocompetent host. Singapore Med J
the affected areas. The clinical picture and 2007; 48: 243-5.
negative report for micro-organisms 7. Dye C, Scheele S, Dolin P et al. Consensus
statement. Global burden of tuberculosis,
differentiated the condition from scrofuloderma. estimated incidence, prevalence, and
mortality by country. WHO Global
The key elements in the diagnosis of this Surveillance and Monitoring Project. JAMA
1999; 282: 677-86.
infection are a high index of suspicion, taking a 8. Gopinathan R, Pandit D, Joshi J et al.
history with an emphasis on exposure to any Clinical and morphological variants of
sufferer in the family or other potential sources cutaneous tuberculosis and its relation to
mycobacterium species. Indian J Med
and tissue biopsy for culture & histopathology.3
Microbiol 2001; 19: 193-6.
Therapeutic regimens include anti-tubercular 9. Padmavathy L, Rao L, Ethirajan N et al.
treatment with four drugs for initial 2 months Scrofuloderma: A clinicopathological and
epidemiological study. Indian J Dermatol
and then combination of two drugs regularly for
Venereol Leprol 1963; 29: 25-42
a sufficient period up to 12-18 months, 10. Karabudak O, Dogan B, Harmanyeri Y.
depending upon the clinical picture and Long-lasting scrofuloderma of hands and
investigations.3,4,6 foot. Acta Derm Venereol 2007; 87: 91-2.
11. Bravo FG, Arenas R, Sigall DA.
Actinomycosis, nocardiosis and
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