Correspondence Address:
Sushruta Kathuria
Department of Dermatology and STD, Safdarjung Hospital and Vardhaman Mahavir Medical College, Ansari Nagar, New Delhi
India

Full Text



Sir,

Scrofuloderma is a form of multi-bacillary cutaneous tuberculosis, which occurs due to the direct invasion of the skin by tubercle bacilli from an underlying focus. Scrofuloderma classically heals with puckered scarring. Here, we report an unusual case of scrofuloderma of the neck in an 18-year-old male healing with scarring and multiple acrochordon formation.

An 18-year-old male presented with plaques with scarring on the neck for the past 8 months. He had a history of intermittent evening rise of temperature and night sweats without cough or weight loss. There was no family history of tuberculosis. On examination, four erythematous crusted plaques with scarring and two soft pedunculated papules in the midline of the anterior neck were seen [Figure 1]a and [Figure 1]b. Submandibular lymph nodes were palpable, tender, mobile, not matted, and 2 × 1.5 cm in size. The rest of the examination was normal. FNAC from the left submandibular lymph node showed epithelioid cell granulomas and necrosis, with Ziehl–Neelsen stain for AFB positive. A histological examination of the pedunculated papule showed fibrovascular tissue covered by squamous epithelium and composed of collagenous tissue with blood vessels suggestive of acrochordon. Deeper sections showed well-formed epithelioid cell granulomas within the collagenous tissue surrounded by a rim of lymphohistiocytes [Figure 2]a and [Figure 2]b, consistent with scrofuloderma. Tissue culture and polymerase chain reaction for Mycobacterium tuberculosis were negative from the biopsy specimen. On routine blood tests, his hemoglobin was 9.9 g/dl and a peripheral smear showed microcytic and hypochromic anemia. Liver and kidney function tests were normal. Mantoux reaction at 48 hours was 23 × 24 mm. Blood sugar, lipid profile, and serum insulin levels were normal. Human immunodeficiency virus serology and venereal disease research laboratory test were non-reactive. The chest radiograph and ultrasound of the abdomen were normal. The patient was started on 6 months of antitubercular treatment (ATT) comprising 2 months of isoniazid, rifampicin, ethambutol, and pyrazinamide and 4 months of isoniazid, rifampicin, and ethambutol. After a month of ATT, the lesions had started healing with a progressive increase in the number of acrochordons [Figure 1]c and [Figure 1]d.{Figure 1}{Figure 2}

Scrofuloderma occurs due to the contiguous spread of infection from an underlying focus into the skin.[1] The evolution of scrofuloderma is slow and can form chronic ulcers and fistulae with persistent purulent discharge or can lead to atrophy or scarring, characteristically described as puckered scarring.[2] Healing of scrofuloderma with acrochordon formation is till now, an unreported occurrence. The pathogenesis of acrochordons has not been fully elucidated yet. Acrochordons are associated with type 2 diabetes mellitus, hyperinsulinemia, obesity, pregnancy, acromegaly, aging, and genetic predisposition.[3] Insulin-like growth factor (IGF) 1 and 2 are anabolic proteins involved in growth and have been found to mediate the association of hyperinsulinemia and acrochordon development through the stimulation of the growth of epithelial and fibroblastic cells.[4] IGF-1 also plays an important role in wound epithelialization by promoting the migration of keratinocytes and enabling wound bed contraction, as well as stimulating hyaluronan synthesis.[4] IGF-1 may thus be the common link in the healing of our case of scrofuloderma and acrochordon formation. Here, we have reported a case of scrofuloderma involving submandibular LN healing with progressive acrochordon formation.

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Informed consent from the patient was taken.

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Nil.

Conflicts of interest

There are no conflicts of interest.

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