A 10-year-old boy came with ulcer in neck and axilla region. The lesion began as papules that gradually developed into nodules, pustules and painless suppurative ulcer (Fig. 1A). Patient also had chronic cough with yellowish sputum since several months along with low grade fever and weight loss.
Physical examination revealed ulcer with suppurative surface in the bottom part, along with nodule measuring 4 cm x 0.5 cm (Fig. 1A). Around his ear, some crusts were found measuring 3 cm x 0.5 cm typical for scrofuloderma (Fig. 1B). In axillary region, there were also painless ulcers with pustulated sinus and purulent discharge, surrounded by bluish and edematous skin surface (Fig. 1C). There was also mobile and painless lymph node enlargement in the left supraclavicular region measuring 2 x 2 cm.
Chest X ray was within normal limit. Tuberculin skin test was positive with 10mm induration. However, direct smear of sputum specimen was negative for acid fast bacilli. Excisional biopsy of the ulcers was performed and the histopathology result showed epidermal necrosis in the central region surrounded by granulomatous tissue peripherally, forming abscess with histiocytic infiltrate around it, confirming the diagnosis of scrofuloderma.
He underwent CT Scan of the cervical region and multiple lymph node enlargement was found, suggestive for tuberculous lymphadenitis (Fig. 2Aand B). Thus, we did FNAB on the lump and the cytology findings showed groups of epitheloid cell with spindle nucleous with chromatin granules spread equally, surrounded with basophilic amorf mass and fibrous tissue. The background staining of the smear was mature lymphocyte, lymphoblast, neutrophil and macrophage, confirming the diagnosis of tuberculous lymphadenitis (Fig. 2C). He was then diagnosed with scrofuloderma with multiple cervical tuberculous lymphadenitis.
He was treated with standard regimen of anti-tuberculosis drugs containing Rifampicin (R), Isoniazid (H), Pyrazinamid (Z), and Ethambutol (E) for 2 months continued by Rifampicin (R), Isoniazid (H) for the next 4 months. In the fourth months, the lymph node enlargement in the cervical region were shrinked (Fig. 3A and B). The ulcers in the neck and axilla began to resolve gradually leaving scar tissue (Fig. 3C). In some spots, some crusts were still found. Overall, he showed a satisfying response to the anti-tuberculosis therapy.