A 46-year-old female refugee from the Dominican Republic with a history of hypertension presented at our outpatient clinic for management of left axillary HS, previously diagnosed 4 years ago in her country. Her HS nodules were confined to her left axilla and first presented four years prior. She denied ever having lesions in other folds. She had previously received courses of antibiotics in her country with limited improvement.
She was initially treated with intralesional triamcinolone, topical clindamycine, and oral doxycycline. At her 2-month follow-up, the nodules had progressed, and she now presented two subcutaneous fluctuant masses underlying the HS nodules.
On examination, three tender erythematous nodules with friable granulation tissue and sinus tracts were visible in the left axilla. On both the superior-lateral quadrant of the left breast and pectoral region, two large subcutaneous fluctuant masses were palpated. A solitary left cervical adenopathy was also palpated. No double comedones or HS nodules were visible in her axilla or other folds.
Basic laboratory workup was unremarkable. The patient was referred to radiology for a surface ultrasound of the axilla, which demonstrated three heterogenous fluid collections in the left deltopectoral groove (5 x 2 x 3 cm), left subclavian space (1.8 x 1.6 cm and 2.8 x 2.4 cm), and supero-lateral quadrant of left breast (4.5 x 3.4 x 3.7 cm), all suggestive of suppurative adenitis. At this time, an ultrasound-guided aspiration of the fluid was conducted, which was positive for M. tuberculosis by polymerase chain reaction (PCR). Additional mycobacterial, bacterial, and fungal cultures of the fluid were negative. Chest X-ray and cervicothoracic computed tomography (CT)-scan showed normal pulmonary parenchyma and were negative for extra-axillary abnormalities. Cultures of sputum for M. tuberculosis were negative. She was not tested for HIV antibodies.
A diagnosis of scrofuloderma of the left axilla without pulmonary involvement was made. Infectious diseases were consulted, and the patient was treated with a combination of isoniazid, rifampicin, pyrazinamide, ethambutol, and vitamin B6. She was asked to self-isolate until the results of her sputum cultures were confirmed negative.
After 6 months of treatment, the patient demonstrated a near-complete resolution of the adenitis on follow-up CT-scan.