SCROFULODERMA (TUBERCULOSIS CUTIS)

1. AIN NURSALLI BINTI ZABUDIN C11107354

2. NUR HAZIERAH BINTI MOHAMAD RASHID C11107279

3. NUGRAHA T. PALIN C11107142

PATIENT IDENTITYName: Tuan A

Gender: Male

Age: 19 years old

Occupation: Salon worker

Address: Jalan Pa’bentengan

First admitted to hospital: 12 january 2011

HISTORY TAKINGA man, 19 years old came to the hospital with the

main complaint of bumps at the lateral neck accompanied by mild pain since + 5 months ago and variant lesions at the dextra supraclavicular region. Nausea-, Vomit -, Loss body weight -, Malaise +, Chill at night +, Night sweat +, Eating appetite loss + .

Fever since + 1 week ago.Job History is currently working at a salon.Past medications consumptions prior to the symptoms.Past medical history is dyspepsia.Family history with the father continuous coughing.

PRESENT STATUS1. GENERAL STATUS :

Mild sickness Compos mentis Moderate nutritional status

2. VITAL SIGNS : Blood Pressure: 110/80 Pulse: 80 x/minutes Respiratory Rate: 24 x/minutesTemperature: 37 ⁰C

DERMATOLOGY STATUS1. Dermatology status

Efflorescence: Skin-bridge, crusts, violaceous plaques, papules

erythema, fistula.

Location: Dextra supraclavicular region

2. Skin diagnose: Scrofuloderma (Tuberculosis cutis)

PICTURES

Pictures of scrofuloderma with appearance of papule erythematous, fistula, crusts and skin bridge

Skin-bridge

Fistula

Papule erythematosus

RESUMEA man, 19 years old came to the hospital with

the main complaint of palpable node enlargement at the lateral neck accompanied by mild pain since + 5 months ago and variant lesions at the dextra supraclavicular region. Nausea-, Vomit -, Body weight decrease in one month -, Malaise +, Chill at night +, Night sweat +, Anorexia +. Fever since 1 week ago.

Job History is currently working at a salon. Past medications consumptions prior to the symptoms. Past medical history is dyspepsia. Family history with father suspected TB.

On physical examinations, variant lesions could be found

at the supraclavicular region. Enlargement of the lymph node around the lateral neck region could be felt andpalpated. General status and vital signs are under normal circumstances. The skin efflorescence's are

skin-bridge, crusts, violaceous plaques, papules erythema, fistula located at the supraclavicular region. The clinical diagnosis is Scrofuloderma ( Tuberculosis cutis)

DIFFERENTIAL DIAGNOSIS1. Leprosy

2. Syphilis Tertier

3. Lupus Erythematous Discoid (LED)

PICTURES1. Leprosy 2. Syphilis

3. LED

DISCUSSIONScrofula : result of an infection in the lymph nodes,

known as lymphadenitis and is most often observed in immunocompromised). About 95% of the scrofula are caused by Mycobacterium tuberculosis. The rest are caused by atypical mycobacterium (Mycobacterium scrofulaceum) or nontuberculous mycobacterium (NTM). Scrofuloderma results from breakdown of skin overlying a tuberculous focus, usually at a lymph node but also at the skin over infected bones or joints.

DISCUSSIONLesions present as firm, pain or painless,

subcutaneous nodules that gradually enlarge and suppurate and then form ulcers and sinus tracts in overlying skin. Typical ulcers have undermined edges and a floor of granulation tissue. Typical tubercles with acid-fast bacilli are found in the lower dermis and walls of the ulcer or abscess. Tubercle bacilli usually can be isolated from the purulent discharge. Tuberculin sensitivity usually is marked. Spontaneous healing can occur but often takes years and is accompanied by the formation of hypertrophic scars

DIAGNOSEMedical history:

Symptoms of the disease, TB exposure or infection, past TB treatment, demographic risk factors for TB, and medical conditions that increase risk for TB.

Physical examination: Palpate all lymph nodes that might infected -> Enlargement of

lymph nodes

Tuberculin skin test: Positive (+) : strong -> causes by M.tuberculosis

weak -> causes by atypical microbacteria

SUPPORTING EXAMINATIONSImaging Studies:

Obtain a posteroanterior chest radiograph.

Bacteriologic examination: 3 sputum specimens on each of 3 consecutive days.

Histologic examination: Acid-fast bacilli in stained tissue or nucleic acid amplification of bacterial DNA and RNA.

THERAPYConventional treatment with antibiotics ( 4-drug treatment) for 2 months:

IsoniazidRifampinPyrazinamideEthambutol

Compress Nacl 0.9%.

Scrofula caused by NTM: responds well to surgery, but is usually resistant to antibiotics.

The affected nodes can be removed either by repeated aspiration, curettage or total excision.

PROGNOSISWith adequate treatment, clinical remission is practically

100%. In NTM infections, with adequate surgical treatment, clinical remission is greater than 95%.

It is recommended that persons in close contact with the diseased person, such as family members, be tested for tuberculosis.