|Year : 2014 | Volume
| Issue : 1 | Page : 34-36
Lupus vulgaris associated with Scrofuloderma
Isha Preet Tuli1, Shikha Verma2, Binod Kumar Thakur2, Deepti Joshi3
1 Department of ENT and HNS, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
2 Department of Dermatology, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
3 Department of Pathology, Sikkim Manipal Institute of Medical Sciences, Gangtok, Sikkim, India
|Date of Web Publication||20-Mar-2014|
Isha Preet Tuli
Department of ENT and HNS, Sikkim Manipal Institute of Medical Sciences, 5th Mile, Tadong, Gangtok, Sikkim - 737 102
Source of Support: None, Conflict of Interest: None
Lupus vulgaris is a rare manifestation of tuberculosis. It is even rarer for it to complicate scrofuloderma. We report a case of a 27-year-old man who had undergone a successful treatment for pulmonary tuberculosis presenting with scrofuloderma with lesions of lupus on the overlying skin. The Mantoux test was positive and initial chest X-ray did not show any active features of tuberculosis. Discharge from the lesion stained positive for acid fast bacilli. Multiple fine needle aspirations were inconclusive. However the histopathology of biopsied lesion revealed tuberculoid granuloma with Langhans giant cells. TThe patient improved with antitubercular therapy. We are presenting this case as a rare coexistence of scrofuloderma with lupus vulgaris.
Keywords: Lupus vulgaris, Mycobacterium tuberculosis, scrofuloderma
|How to cite this article:|
Tuli IP, Verma S, Thakur BK, Joshi D. Lupus vulgaris associated with Scrofuloderma. Sahel Med J 2014;17:34-6
| Introduction|| |
Cutaneous tuberculosis is an uncommon form of extrapulmonary tuberculosis largely occurring in developing countries. The recent rise in the incidence of tuberculosis, especially due to human immunodeficiency virus infections, has led to a resurgence of its extrapulmonary forms.  Lupus vulgaris and scrofuloderma lie at opposite ends of the clinical spectrum of cutaneous tuberculosis in terms of bacillary load.  We are reporting a rare case of lupus vulgaris developing in the vicinity of cervical scrofuloderma.
| Case Report|| |
A 27-year-old male, a primary school teacher, presented to the ENT outpatient department of the Central Referral Hospital, Gangtok, India with an insidious onset, slow-growing, tender, right-sided neck swelling for 1 month. There was no history of weight loss, fever, cough, diabetes and hypertension. There was a history of treatment for primary pulmonary tuberculosis 5 years previously. Examination revealed right-sided, tender, multiple, matted cervical lymph nodes of various sizes, free from overlying skin and underlying structures. He was prescribed a course of broad-spectrum antibiotics, to which he responded and was advised for follow-up. The patient then presented 5 months later with a large nonhealing painless ulcer on the right side and two similar, smaller ulcers on the left side of the neck for 2 months, after which he was referred to the dermatology department. General and systemic examinations findings were insignificant, except for bilateral cervical lymphadenopathy.
The body mass index was 16.6 Kg/m 2 . Local examination revealed a 2 cm ×3 cm large nontender ulcer on the base of the right side of the neck with bluish undermined margins and necrotic debris on the floor. Similar smaller ulcers were present on the left side of the neck. An erythematous, well-defined, indurated plaque 4 cm ×1.5 cm, with psoriasiform scaling [Figure 1], was present inferiorly to the left-sided ulcers. Bilateral cervical lymph nodes were palpable, matted and nontender. Sputum for the AFB was negative. Mantoux test (1 TU) was positive (14 mm) and chest X-ray showed widespread patchy ill-defined opacities throughout both lung fields. Ziehl-Neelsen staining of discharge from the ulcers showed numerous acid fast bacilli (AFB). Fine needle aspiration of the right cervical lymph node showed reactive lymphadenitis.Excision biopsy of the lymph node was performed, and it demonstrated multiple caseating tuberculoid granulomas. Histopathological examination from the plaque also revealed tuberculoid granulomas [Figure 2]. The enzyme-linked immunosorbent assay for HIV was negative. Hemogram and liver and renal function tests were within normal range, except for raised ESR. A diagnosis of scrofuloderma with lupus vulgaris, with reactivation of pulmonary tuberculosis, was made. Regimen for previously treated case of tuberculosis using direct observed therapy short course (DOTS)  was started with significant improvement after 2 months of therapy [Figure 3].
|Figure 1: Erythematous, well-defined, indurated plaque with psoriasiform scaling (pretreatment)|
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|Figure 2: Histopathological examination of plaque revealing tuberculoid granulomas|
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| Discussion|| |
Cutaneous tuberculosis remains one of the more elusive and difficult diagnoses to make for clinicians practicing in developing countries. The cutaneous form of extrapulmonary tuberculosis has varied clinical presentations, which is determined by both route of infection and status of cellular immunity of the host. 
Scrofuloderma results from contiguous tubercular involvement of the skin from an underlying infected structure  while lupus vulgaris is acquired either exogenously by direct inoculation or endogenously by hematogenous or lymphatic spread of AFB. ,
Our patient developed a cold abscess, consequent to a cervical adenitis, with secondary breakdown of overlying skin. The tubercular bacilli from the discharge got inoculated into the surrounding skin to form a lesion of lupus vulgaris. In addition, there was reactivation of pulmonary tuberculosis in the patient.
The lesion of lupus vulgaris is characterized by plaque with an apple-jelly nodule that extends irregularly with scar formation and tissue destruction, as was seen in our case. , Lupus vulgaris developing in the vicinity of scrofuloderma is rarely seen ,, and may be misdiagnosed.  In our case, the patient was diagnosed to have cutaneous tuberculosis only when he presented to the dermatology department with the lesion of lupus vulgaris. Scrofuloderma has been reported as the most common form of cutaneous tuberculosis in a study from Northeast India.  However, lupus vulgaris accompanying scrofuloderma has not been reported from the North East region of India.  This is probably the first case of lupus vulgaris with scrofuloderma reported from Sikkim, India. Cases of simultaneous occurrence of scrofuloderma and lupus vulgaris, although rare, are seen and may be missed if the clinician is not aware enough of this entity, leading to a delay in the diagnosis and initiation of treatment, as in our case. All specialties must be made aware of such a co-existence to obviate any delay in timely treatment and to prevent morbidity and complications.
| Acknowledgment|| |
The authors would like to acknowledge Dr. R.L. Sharma, MD (Dermatology), Professor and Head, Department of Dermatology, SMIMS and CRH, Gangtok, Sikkim, for his help with the photographs of the patient.
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[Figure 1], [Figure 2], [Figure 3]