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 Table of Contents  
CASE REPORT
Year : 2021  |  Volume : 10  |  Issue : 4  |  Page : 469-471

Lichen scrofulosorum: Cutaneous manifestation of tuberculous lymphadenitis


1 Department of Dermatology, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
2 Department of Paediatrics, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
3 Department of Pathology, Iqraa International Hospital and Research Centre, Calicut, Kerala, India
4 Department of Health Research, Iqraa International Hospital and Research Centre, Calicut, Kerala, India

Date of Submission08-Sep-2021
Date of Decision22-Sep-2021
Date of Acceptance22-Oct-2021
Date of Web Publication14-Dec-2021

Correspondence Address:
Nalakath Arakkal Uvais
Department of Health Research, Iqraa International Hospital and Research Centre, Calicut, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmy.ijmy_183_21

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  Abstract 


Cutaneous tuberculosis (TB) known as tuberculid forms 1%–1.5% of all extrapulmonary manifestation of TB. Tuberculids result from a hypersensitivity reaction to an extracutaneous source of Mycobacterium tuberculosis in individuals with high immunity and can be difficult to diagnose. Lichen scrofulosorum (LS) is a rare form of tuberculid predominantly seen in children and young adults; we report a case of an 8-year-old boy evaluated for fever and mediastinal lymphadenopathy in whom the skin lesions, LS, served as an important clue for the diagnosis of tuberculous lymphadenitis.

Keywords: Lichen scrofulosorum, tuberculid, tuberculous lymphadenitis


How to cite this article:
Rakhesh SV, Moideen Hidayathullah PK, Khader A, Uvais NA. Lichen scrofulosorum: Cutaneous manifestation of tuberculous lymphadenitis. Int J Mycobacteriol 2021;10:469-71

How to cite this URL:
Rakhesh SV, Moideen Hidayathullah PK, Khader A, Uvais NA. Lichen scrofulosorum: Cutaneous manifestation of tuberculous lymphadenitis. Int J Mycobacteriol [serial online] 2021 [cited 2022 Aug 16];10:469-71. Available from: https://www.ijmyco.org/text.asp?2021/10/4/469/332353




  Introduction Top


Lichen scrofulosorum (LS) is rare form of tuberculid, presenting as asymptomatic lichenoid or skin colored papules predominantly in children and young adults. Cutaneous tuberculosis (TB) forms 1%–1.5% of all extrapulmonary manifestation of TB, which forms about 8.4%–13.7% of all TB cases.[1] Tuberculids are a group of cutaneous TB (CTB) resulting from a hypersensitivity reaction to an extracutaneous source of Mycobacterium tuberculosis usually in individuals with high immunity. The various forms of tuberculids include LS, papulonecrotic tuberculids, erythema induratum of Bazin, and erythema nodosum. A newly described variant is nodular tuberculid.[2] We describe an 8-year-old boy evaluated for fever and mediastinal lymphadenopathy in whom the skin lesions served as an important diagnostic clue.


  Case Report Top


An 8-year-old boy admitted in the department of pediatrics for the evaluation of recurrent fever during the past 2 months was referred to the dermatology OPD for an asymptomatic rash of 1 month duration over the trunk and both lower legs. There was a history of evening rise of temperature, loss of weight during the past 6 months, and occasional nonproductive cough. He had no past or family history of TB. General examination was unremarkable except for cervical lymphadenopathy. Cutaneous examination revealed multiple discrete and few coalescent erythematous and skin-colored papules of 1–3 mm distributed bilaterally over the lower anterior and posterior trunk [Figure 1]. The lesions on the lower legs showed scaly papules coalescing to form psoriasiform plaques [Figure 2]. Bacillus Calmette–Guérin (BCG) scar was visible on the left deltoid region. Systemic examination of the respiratory, cardiovascular, abdominal, and central nervous system did not reveal any abnormalities. His hemoglobin level was 10.1 g%, erythrocyte sedimentation rate was 85 mm, and Mantoux test was strongly positive, 35 mm with blistering [Figure 1]. COVID-19 reverse transcription polymerase chain reaction (PCR) Truenat was negative. His chest X-ray showed mediastinal shadows, and spiral computed tomography scan of the thorax (plain and contrast) study revealed a large mediastinal conglomerate lymph node mass with areas of necrosis involving the right upper paratracheal, right and left lower paratracheal, and right hilar and subcarinal nodes. Similar enlarged lymph nodes with necrosis were also seen in bilateral supraclavicular region and left gastric region. In view of the asymptomatic papular eruption with cervical and mediastinal lymphadenopathy, the clinical differentials considered at this juncture were LS, papular sarcoidosis, and lymphoma.
Figure 1: Multiple discrete, and few coalescent erythematous and skin-colored papules of 1–3 mm distributed bilaterally over the lower anterior and posterior trunk with strong Mantoux positivity

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Figure 2: Scaly papules coalescing to form psoriasiform plaques

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Histopathological examination of skin biopsy revealed focal granulomatous inflammation without caseation in the upper dermis [Figure 3], indicating a diagnosis of LS. Cervical lymph node biopsy revealed large areas of necrosis surrounded by poorly formed epithelioid granulomas with few multinucleated giant cells [Figure 4]. The histopathological finding was consistent with a diagnosis of tuberculous lymphadenitis. Thus, a diagnosis of LS arising from a focus of tuberculous lymphadenitis could be confirmed. The child was started on a standard 6-month regimen of anti-TB therapy (ATT) and is currently on follow-up.
Figure 3: Skin biopsy showing focal granulomatous inflammation without caseation in the upper dermis

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Figure 4: Cervical lymph node biopsy showing large areas of necrosis surrounded by poorly formed epithelioid granulomas with few multinucleated giant cells

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  Discussion Top


LS also known as TB cutis lichenoides is a rare form of tuberculid that occurs predominantly in children and young adults. A recent report, however, has reported LS to be the second most common form of CTB.[3] Seven percent of CTB patients were found to have LS in a prospective study in India.[3] LS is clinically characterized by the asymptomatic clusters of tiny follicular and perifollicular skin colored or lichenoid grouped papules of 0.5 mm to 3 mm, sometimes topped by tiny micropustules or spiny scales, predominantly located over the trunk and the proximal part of the limbs. The lesions may coalesce to form annular or discoid plaques. Psoriasiform plaques have also been described rarely.[4] Our patient exhibited this rare psoriasiform presentation of LS over the lower extremities in addition to the classical clustered papular lesions of LS over the trunk. Differential diagnosis of LS includes all asymptomatic grouped papules predominantly affecting the trunk, including lichen nitidus, papular pityriasis rosea, papular or lichenoid sarcoidosis, etc., Lichen nitidus presents with shiny skin-colored papules predominantly involving the extensor extremities and characteristically involves the male genitalia. Papular pityriasis rosea have a noticeably short duration of onset and are arranged along the longitudinal axis of the ribs. Lichenoid sarcoidosis is quite rare in children and can be easily differentiated by their characteristic histopathology. Histopathology of LS demonstrates superficial noncaseating epithelioid granulomas around hair follicles and sweat ducts. The tubercle bacilli can neither be demonstrated by staining nor can they be cultured from the skin specimens.

Tuberculids are thought to occur because of hypersensitivity response to the hematogenous dissemination of bacilli in a person with moderate or high degree of immunity against M. tuberculosis. It is usually associated with strongly positive tuberculin reaction. Mycobacterial DNA can also be detected in some lesion using the PCR technique.[5] However, Tan et al. have not found PCR to be a useful test for the diagnosis of CTB.[6]

The most frequent extracutaneous involvement of TB in association with LS is lymphadenopathy (cervical, hilar, axillary, or mediastinal) followed by foci in bone.[3] Pulmonary involvement has also been reported.[3] Our patient had concomitant involvement of the supraclavicular, mediastinal, and gastric lymph nodes without any pulmonary involvement. In a prospective study of 39 patients of LS by Singal and Bhattacharya, 72% had an underlying focus of TV whereas no identifiable focus could be demonstrated in 28%.[7]


  Conclusion Top


Asymptomatic grouped papular eruption in a child could serve as an important clue to a potentially treatable but serious condition like TB. Awareness of this entity among pediatricians and a high index of suspicion is required to diagnose and treat this condition to prevent disease spread and avoid complications. Lack of awareness about this subtle asymptomatic skin lesions, which may also be ignored by the patients or their wards may be the reason why this uncommon condition has been considered rare. The concomitant presence of psoriasiform skin lesions in our patient, although an unusual and rarer presentation of LS signifies the deeper diagnostic challenges this condition can put forth. The clinical suspicion of LS should also prompt the physician to screen extensively for a possible occult tubercular focus leaving no stones unturned.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parents have given their consent for the patient's images and other clinical information to be reported in the journal. The patient's parents understand that the patient's name and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest



 
  References Top

1.
Kajal NC, Prasanth P, Dadra R. Lichen scrofulosorum: An uncommon manifestation of a common disease. Lung India 2020;37:461-3.  Back to cited text no. 1
[PUBMED]  [Full text]  
2.
Friedman PC, Husain S, Grossman ME. Nodular tuberculid in a patient with HIV. J Am Acad Dermatol 2005;53 2 Suppl 1:S154-6.  Back to cited text no. 2
    
3.
Yates VM. Mycobacterial Infections. In: Burns T, Breathnach S, Cox N, Griffith C, editors. Rook's Textbook of Dermatology. 8th ed. Massachusettes: Wiley-Blackwell; 2010. p. 21-2.  Back to cited text no. 3
    
4.
Kumar U, Sethuraman G, Verma P, Das P, Sharma VK. Psoriasiform type of lichen scrofulosorum: Clue to disseminated tuberculosis. Pediatr Dermatol 2011;28:532-4.  Back to cited text no. 4
    
5.
Padmavathy L, Rao L, Veliath A. Utility of polymerase chain reaction as a diagnostic tool in cutaneous tuberculosis. Indian J Dermatol Venereol Leprol 2003;69:214-6.  Back to cited text no. 5
[PUBMED]  [Full text]  
6.
Tan SH, Tan BH, Goh CL, Tan KC, Tan MF, Ng WC, et al. Detection of mycobacterium tuberculosis DNA using polymerase chain reaction in cutaneous tuberculosis and tuberculids. Int J Dermatol 1999;38:122-7.  Back to cited text no. 6
    
7.
Singal A, Bhattacharya SN. Lichen scrofulosorum: A prospective study of 39 patients. Int J Dermatol 2005;44:489-93.  Back to cited text no. 7
    


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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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