October - LRS Institute of Tuberculosis & Respiratory Diseases

Ind.J.Tub,, 1986, 33, 185
MltlARY TUBERCULOSIS IN ASSOCIATION WITH SCROFULODERMA
G.S. THIND* AND R.S. BEDI**
Summary : A rare association of miliary tuberculosis with scrofuloderma is reported. Attention is
drawn to the diagnostic importance of skin involvement in cases with suspected miliary tuberculosis.
Introduction
Before the introduction of anti-tubercolosis
chemotherapy, various cutaneous lesions were
seen during the course of miliary tuberculosis,
but such lesions did not occur very often.
These lesions used to be macular, papular,
vesicular, purpuric and haemorrhagic bullous
eruptions (Wilkinson, 1972). In developed
countries, due to the advent of anti-TB drugs,
improved living conditions and nutrition, overall
prevalence of tuberculosis including miliary
and cutaneous forms has declined and their
association has become still rarer. Now-a-days,
one may occassionally come across a case report
describing miliary tuberculosis in association
with solitary skin lesions usually related
to underlying suppurative foci (Sahn and
Neff, 1974; Bateman et al, 1980). However,
in developing countries, prevalance of all
forms of tuberculosis is still high.
Scrofuloderma is a subcutaneous tuberculous
process, secondary to underlying lymph
node, bone or joint tuberculosis leading to
cold abscess formation and a secondary breakdown
of the overlying skin.
This case report describes a patient of
miliary tuberculosis along with scrofuloderma,
a rare association, which prompted us to
present this case
Case Report
A 20 year old male farmer was admitted
with complaints of low grade fever, cough
and malaise of two months’ duration. He also
complained of ulcers in groins and left thigh
of the same duration. Skin lesions had started
as small reddish papules with slight itching,
gradually increasing in size and ultimately
breaking down within a month to form ulcers
with dirty white discharge. The patient also
gave a history of having had papular lesions
on the medial aspect of the left upper arm
near the elbow 2 months prior to this ailment,
which also ulcerated but healed with some
indigenous treatment.
On examination, he was moderate in built
and nourishment and was febrile. Chest
examination revealed no abnormal physical
signs and choroidal tubercles were not seen.
Dermatological examination was as follows:
Left inguinal region showed ulcerated, warty
red out-growths covered with dirty white
slightly foul smelling discharge. The ulcer
had inverted undermined edges and the floor
has covered with soft, uneven granulation
tissue which did not bleed on touch. There was
no sinus formation and three inguinal glands
were moderately enlarged but non-tender.
Adjoining area of the thigh revealed areas of
scarring and hyperpigmentation. Scarring was
present in the right groin also and one tender,
pedunculated flesh-colored outgrowth was seen
in the central area. In addition, one sinus
was seen on the right side. Thin atrophic
scars, not adherent to underlying structures,
were present on the medial aspect of the left
elbow. The skin lesions were suggestive of
clinical diagnosis of scrofuloderma.
Haemoglobin was 12 gm% and total and
differential white cell counts were within normal
limits. Mantoux test with PPD ITU was
negative. Chest X-ray showed miliary mottling
throughout both lung fields. His sputum and
discharge from ulcers were negative for acid
fast bacilli. Biopsy taken from left groin
lesions revealed destruction of skin with evidence
of non-specific abscess formation in the centre
(Fig I). In peripheral portion, tubercular
granulomas of varying size consisting of caseation,
lymphocytes, epithelioid cells and giant
cells of Langhans type were seen (Fig. 2).
Acid fast bacilli were not found. The findings
were consistent with histopathological diagnosis
of scrofuloderma.
Treatment was started with streptomycin,
*Assistant Professor **Medical Officer
Deptt. of T.B. and Chest Diseases, Govt. Medical College, Patiala-147001.
Correspondence : Dr. G.S. Thind, Assistant Professor and Head, Deptt. of T.B. and Chest Diseases,
S.G.G.S. Medical College, Kotkapura (Faridkot).