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495
GÖNÜL, M et al. Tuberculosis Verrucosa Cutis and Scrofuloderma Turk J Med Sci
(a)
(b)
Figure 1. a. Verrucous plaque with a purplish halo on the left hand.
b. The regressed lesion on the left hand after two months of therapy.
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Vol: 38 No: 5 Tuberculosis Verrucosa Cutis and Scrofuloderma October 2008
Calmette-Guérin (BCG) vaccination in childhood. The administered and regression of the lesions occurred in the
histopathological examination of the lesion on the hand first month of therapy.
revealed granulomas of various sizes on a base of
lymphocytes, which confirmed the diagnosis of TVC
(Figure 3a). No mycobacteria were seen on direct Discussion
microscopic examination of the tissue and culture and TVC is a cutaneous tuberculosis form that is caused by
polymerase chain reaction (PCR) (real time technique) for exogenous re-infection in sensitized individuals (4-9). The
Mycobacterium tuberculosis was negative. The pulmonary morphology of the lesions modifies according to the state
X-ray and abdominopelvic ultrasonography were normal. of innate immunity and the lesions usually start as
A 3 × 2.5 cm lymphadenopathy was detected in the asymptomatic, small papules or papulopustules
superficial ultrasonography of the left axilla. Lymph node surrounded by a purplish halo. They slowly progress to
dissection and histopathological examination were done. verrucous or hyperkeratotic plaques over several months
Although the lymph node maintained its original to years. Superficial scaling and fissuring with subsequent
structure, it was replaced with granulomas of various intermittent purulent discharge may occur. Because of
sizes. Some of the granulomas, which tended to varied morphologic presentation of the lesions, TVC may
coalescence, had caseation necrosis in the center (Figure prove to be a diagnostic dilemma in the absence of a high
3b). The histopathological findings were consistent with degree of suspicion (4,7,9,10). If the disease is left
the diagnosis of tuberculous lymphadenitis. Mycobacterial untreated, it usually runs a prolonged course (4,7,9).
culture and PCR from lymph node could not be done Scrofuloderma is a form of cutaneous tuberculosis
because of the patient’s economic status. TVC and that directly spreads to skin from tissues like lymph nodes
scrofuloderma were diagnosed based on clinical and or bones. Lymph nodes are inflamed, ruptured and
histopathological findings and PPD positivity. No ulcerated. Suppuration, sinuses and bridges may be seen
tuberculous focus could be identified except for the skin in most of the cases. The most frequent localizations are
lesions. Quartet antituberculous therapy was chest, neck and axillary lymph nodes (11).
497
GÖNÜL, M et al. Tuberculosis Verrucosa Cutis and Scrofuloderma Turk J Med Sci
(a)
(b)
Both forms of cutaneous tuberculosis may be examination and positivity of PPD reaction help in the
misdiagnosed as blastomycosis, fixed sporotrichosis, and differential diagnosis (4,9). The presence of mycobacteria
atypical mycobacterial infection, and TVC may be on the tissue by microscopic examination or identification
misdiagnosed as inflammatory diseases such as psoriasis, of mycobacteria on the tissue culture is needed for certain
lichen simplex chronicus, discoid lupus erythematosus and diagnosis but providing both is difficult (4,8,10). PCR for
lichen planus hypertrophicus. Histopathological Mycobacterium tuberculosis can be used in the diagnosis;
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Vol: 38 No: 5 Tuberculosis Verrucosa Cutis and Scrofuloderma October 2008
however, PCR positivity rates are only 55% for TVC and The lymphadenitis associated with TVC is very rare.
PCR results may be negative in TVC (10,13,14). This association was reported in only one case previously
Moreover, PCR is an expensive and labor intensive (8). Coexistence of TVC with scrofuloderma is also rare.
diagnostic test especially for developing countries (10). Sethuraman et al. reported a case with bilateral
This was also true in the current case. Therefore, scrofuloderma on the feet and TVC. TVC developed after
although the cases may have negative laboratory results, the occurrence of scrofuloderma in their case and the
as in our case, if there is a strong suspicion of localization of TVC was near the scrofuloderma lesions
tuberculosis, the antituberculous therapy should be given (5). In our case, the lesion of TVC was located far from
(9). the scrofuloderma lesion. Although the patient said that
both TVC and scrofuloderma had occurred at nearly the
Histopathological findings are characterized with same time, we think that TVC developed secondary to the
tuberculosis granulomas involving caseation necrosis (it scrofuloderma.
does not usually appear). Langhans type giant cells and
We present this case because coexistence of TVC and
epithelioid granulomas with lymphocytes may be seen
scrofuloderma is very rare. We want to stress that the
(9). The histopathological examination of the lesions dermatologist should be aware that a case with a form of
(both on hand and axillary lymph node) in our case cutaneous tuberculosis may also have another form as
revealed granulomas involving caseation necrosis. PPD well. Detailed history and exact physical examination are
was 20 mm. Our patient was diagnosed as cutaneous very important for the diagnosis. We emphasize that
tuberculosis (TVC and scrofuloderma) based on these possibility of determining positive laboratory tests for
findings. The dramatic response to antituberculous tuberculosis is low. We suggest that the antituberculous
therapy confirmed the diagnosis. We think that dramatic therapy should be administered to the case with suspicion
response to antituberculous therapy may be a possible of tuberculosis even if the laboratory tests for
diagnostic criterion, particularly in developing countries. tuberculosis are negative.
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