October - LRS Institute of Tuberculosis & Respiratory Diseases

G.S. THIND AND R.S.BEDI
isoniazid and ethambutol in conventional
dosages. There was remarkable clinical
improvement and skin lesions healed by
scarring within one month. He took this
treatment regularly for one month only
and thereafter became
Fig. 1
Showing non-specific cutaneous
abscess (arrow)
irregular and stopped drugs altogether after
another 2 months. He again attended this
hospital after 4 months with complaints of
malaise and recurrence of skin lesions. In
addition, similar skin lesions were also seen
in left axilla and behind left ear. Retreatment
was started with rifampicin, pyrazinamide,
Fig. 2
Tubercular cutaneous granuloma showing
Langhans giant cells and epithdioid cells
PAS and isoniazid. He showed gradual recovery
and skin lesions completely healed with thin
atrophic scars. Anti-T.B. drugs were stopped
after one and a half years and the follow up
was uneventful.
Discussion
In scrofuloderma, the skin lesion usually
starts as a bluish red nodule overlying the
infected gland or bone and soon breaks down
to form undermined ulcers. Progression and
scarring produces irregular adherent masses,
densely fibrous in places and fluctuant or
discharging in others. Excessive granulation
tissue may give rise to fungating tumours
(Wilkinson, 1972). Histologically, necrosis and
abscess formation found in the centre of the
lesion are non-specific. However, the periphery
of the abscesses shows tubercular granulomas
with caseation necrosis. Tubercle bacilli may,
with diligence, be found at the periphery.
The clinical appearance of the skin lesions
in our patient was that of scrofuloderma and
histological appearances were very suggestive
of scrofuloderma. The diagnosis was further
confirmed by clinical improvement with specific
anti-tubercular therapy and worsening when
the patient stopped the drugs. In restrospect,
it appears that cutaneous lesions on medial
aspect of the left elbow, which were now
represented by thin atrophic scars, were also
of tuberculous aetiology which had healed
spontaneously. Spontaneous healing is known
in scrofuloderma, though the usual course
is a protracted one. Kennedy and Knowles
(1975) reported a case of miliary tuberculosis
presenting with cutaneous lesions and emphasized
that cutaneous abormalities may not
only accompany but may even precede the other
evidence of miliary tuberculosis.
Tuberculin test is usually positive both
in miliary tuberculosis and cutaneous tuberculosis.
However, it may be negative in patients
with over-whelming disease. In our patient,
who was not critically ill, the negative reaction
may have reflected temporary specific anergy
to tuberculin as the test became positive subsequently.
Although cutaneous tuberculosis is now
very rare in developed countries, similar
situation may not exist in our country and
one of the purposes of this report is to emphasize
its continued occurrence. Further, more and
more cases of miliary tuberculosis are being
reported in cryptic forms lately, which are
not very easy to diagnose. In such cases,
material from conventional sources in often
not helpful in confirming the tuberculous
aedology. AH cases with suspected miliary
tuberculosis should be carefully examined for
skin lesions, as material obtained from such
lesions provide high diagnostic yield for
miliary tuberculosis. Munt (1972) described
a series of 69 patients of miliary tuberculosis
of which 3 had associated cutaneous lesions