Turk J Med Sci
2008; 38 (5): 495-499
Müzeyyen GÖNÜL1
Ülker GÜL1
Arzu KILIÇ1
Seçil SOYLU1
Murat DEMİRİZ2
Ayhan KUBAR3
1
Department of 2nd Dermatology
Clinic, Ankara Numune Education
and Research Hospital,
Sıhhiye, Ankara - TURKEY
2
Department of Pathology,
Gülhane Military Medical Academy,
Etlik, Ankara - TURKEY
3
Department of Microbiology,
Gülhane Military Medical Academy,
Etlik Ankara - TURKEY
Received: December 31, 2007
Accepted: July 08, 2008
Correspondence
Müzeyyen GÖNÜL
Barış Mah. Güzelyaka Cad.
Demetkent sit. B-2 Blok
No: 44 Yenimahalle,
Ankara - TURKEY
muzeyyengonul@yahoo.com
CASE REPORT © TÜBİTAK
E-mail: medsci@tubitak.gov.tr
Coexistence of Tuberculosis Verrucosa Cutis with
Scrofuloderma
Abstract: Although cutaneous tuberculosis is rarely seen in developed countries, it is still commonly seen in
developing countries. Tuberculosis verrucosa cutis (TVC) is a form of cutaneous tuberculosis that is caused by
direct inoculation of Mycobacterium tuberculosis into the skin through open wounds or abrasions in sensitized
individuals and is rarely seen in our country. Scrofuloderma is a form of cutaneous tuberculosis that occurs by
direct spread of Mycobacterium tuberculosis from a contiguous structure. Coexistence of TVC and
scrofuloderma is extremely rare.
A 35-year-old woman presented to our clinic with a lesion on the dorsum of her left hand. Dermatological
examination revealed verrucous, hyperkeratotic plaque on the dorsum of the left hand and fluctuating,
purplish nodules and sinuses on the left axilla. The granulomas with caseation necrosis and Langhans type giant
cells were seen in the histopathological examination of biopsy specimens obtained from the lesions on both the
dorsum of the left hand and the left axillary lymphadenopathy. PPD was 20 mm. No tuberculous focus was
detected in the patient.
We present this case because coexistence of TVC and scrofuloderma is very rare.
Key Words: Tuberculosis verrucosa cutis, scrofuloderma, cutaneous tuberculosis
Tüberkülozis Verrükoza Kutis ve Skrofuloderma Birlikteliği
Özet: Kutanöz tüberküloz gelişmiş ülkelerde nadir görülmesine rağmen, gelişmekte olan ülkelerde hala sık
olarak görülmektedir. Tüberkülozis verrükoza kutis (TVK) Mycobacterium tuberculosis’in duyarlı bireylerde
derdeki açık yara ve abrazyonlardan direkt inokülasyonu ile oluşan kutanöz tüberkülozun ülkemizde nadir
görülen bir formudur. Skrofuloderma ise Mycobacterium tuberculosis’in komşu dokulardan direkt yayılımı ile
oluşan kutanöz tüberküloz formudur. TVK ve skrofulodermanın bir arada görülmesi oldukça nadirdir.
Otuz beş yaşında kadın hasta el sırtındaki lezyonla kliniğimize başvurdu. Dermatolojik muayenesinde sol el
sırtında verrüköz hiperkeratotik plak ve sol aksillada fluktuasyon veren, morumsu nodüller ve sinüsler
saptandı. Sol el sırtındaki lezyondan ve sol aksilladaki lenf nodundan alınan biyopsilerin histopatolojik
incelemesinde kazeasyon nekrozu ve Langhans tipi dev hücrelerin izlendiği granülomlar görüldü. PPD 20 mm
idi. Hastada başka bir tüberküloz odağı saptanmadı.
TVK ve skrofuloderma birlikteliğinin çok nadir olması nedeni ile bu olguyu sunuyoruz.
Anahtar Sözcükler: Tüberkulozis verrükoza kutis, skrofuloderma, kutanöz tüberküloz
Introduction
Today, tuberculosis is a major public health problem for both developed and
developing countries. The World Health Organization estimates that nearly one-third of
the global population is at risk of developing the disease (1). Cutaneous tuberculosis
constitutes 1.5% of all cases of extrapulmonary tuberculosis (2). Cutaneous
tuberculoses are divided into two groups according to the patient’s sensitization:
primary (in unsensitized individuals) and secondary (in sensitized individuals). Secondary
cutaneous tuberculosis shows a spectrum based on the immunity of the individual: lupus
vulgaris (high immunity), tuberculosis verrucosa cutis (TVC) (middle immunity),
scrofuloderma, tuberculosis cutis orificialis and tuberculous gummas (low immunity) (3).
TVC is a rare form of cutaneous tuberculosis (4). Coexistence of TVC and scrofuloderma
in the same case is very rare (5).
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GÖNÜL, M et al. Tuberculosis Verrucosa Cutis and Scrofuloderma Turk J Med Sci

Case Report questioned in detail, it was ascertained that she had a

A 35-year-old woman presented to our clinic with a
lesion on the dorsum of her left hand. The lesion had
developed as a small papule one year ago and enlarged
progressively. She had received nonspecific antibiotic
therapies but the lesion showed no change. She was a
housewife and did not have any remarkable feature in her
personal or family history. When the patient was
tumor and discharge on the left axilla that occurred at
nearly the same time as the lesion on the left hand
(Figures 1 a-b, 2). Dermatological examination revealed a
6 × 4 cm verrucous plaque with surrounding violet halo
on the dorsum of the left hand and fluctuating nodules
and sinuses on the left axilla. Routine laboratory tests
were normal. PPD was 20 mm and she had Bacillus

(a)

(b)
Figure 1. a. Verrucous plaque with a purplish halo on the left hand.
b. The regressed lesion on the left hand after two months of therapy.

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Calmette-Guérin (BCG) vaccination in childhood. The
histopathological examination of the lesion on the hand
revealed granulomas of various sizes on a base of
lymphocytes, which confirmed the diagnosis of TVC
(Figure 3a). No mycobacteria were seen on direct
microscopic examination of the tissue and culture and
polymerase chain reaction (PCR) (real time technique) for
Mycobacterium tuberculosis was negative. The pulmonary
X-ray and abdominopelvic ultrasonography were normal.
A 3 × 2.5 cm lymphadenopathy was detected in the
superficial ultrasonography of the left axilla. Lymph node
dissection and histopathological examination were done.
Although the lymph node maintained its original
structure, it was replaced with granulomas of various
sizes. Some of the granulomas, which tended to
coalescence, had caseation necrosis in the center (Figure
3b). The histopathological findings were consistent with
the diagnosis of tuberculous lymphadenitis. Mycobacterial
culture and PCR from lymph node could not be done
because of the patient’s economic status. TVC and
scrofuloderma were diagnosed based on clinical and
histopathological findings and PPD positivity. No
tuberculous focus could be identified except for the skin
lesions. Quartet antituberculous therapy was
Figure 2. Purplish nodular lesion and fistula on left axilla.
October 2008
administered and regression of the lesions occurred in the
first month of therapy.
Discussion
TVC is a cutaneous tuberculosis form that is caused by
exogenous re-infection in sensitized individuals (4-9). The
morphology of the lesions modifies according to the state
of innate immunity and the lesions usually start as
asymptomatic, small papules or papulopustules
surrounded by a purplish halo. They slowly progress to
verrucous or hyperkeratotic plaques over several months
to years. Superficial scaling and fissuring with subsequent
intermittent purulent discharge may occur. Because of
varied morphologic presentation of the lesions, TVC may
prove to be a diagnostic dilemma in the absence of a high
degree of suspicion (4,7,9,10). If the disease is left
untreated, it usually runs a prolonged course (4,7,9).
Scrofuloderma is a form of cutaneous tuberculosis
that directly spreads to skin from tissues like lymph nodes
or bones. Lymph nodes are inflamed, ruptured and
ulcerated. Suppuration, sinuses and bridges may be seen
in most of the cases. The most frequent localizations are
chest, neck and axillary lymph nodes (11).
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GÖNÜL, M et al. Tuberculosis Verrucosa Cutis and Scrofuloderma Turk J Med Sci

(a)

(b)

Figure 3. a. Granulomas of various sizes on a base of lymphocytes in the dermis (hematoxylin

and eosin [H&E] x50).
b. Granulomas of various sizes with caseation necrosis in the center of the lymph
node (H&E x25).

Both forms of cutaneous tuberculosis may be
misdiagnosed as blastomycosis, fixed sporotrichosis, and
atypical mycobacterial infection, and TVC may be
misdiagnosed as inflammatory diseases such as psoriasis,
lichen simplex chronicus, discoid lupus erythematosus and
lichen planus hypertrophicus. Histopathological
examination and positivity of PPD reaction help in the
differential diagnosis (4,9). The presence of mycobacteria
on the tissue by microscopic examination or identification
of mycobacteria on the tissue culture is needed for certain
diagnosis but providing both is difficult (4,8,10). PCR for
Mycobacterium tuberculosis can be used in the diagnosis;

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however, PCR positivity rates are only 55% for TVC and
PCR results may be negative in TVC (10,13,14).
Moreover, PCR is an expensive and labor intensive
diagnostic test especially for developing countries (10).
This was also true in the current case. Therefore,
although the cases may have negative laboratory results,
as in our case, if there is a strong suspicion of
tuberculosis, the antituberculous therapy should be given
(9).
Histopathological findings are characterized with
tuberculosis granulomas involving caseation necrosis (it
does not usually appear). Langhans type giant cells and
epithelioid granulomas with lymphocytes may be seen
(9). The histopathological examination of the lesions
(both on hand and axillary lymph node) in our case
revealed granulomas involving caseation necrosis. PPD
was 20 mm. Our patient was diagnosed as cutaneous
tuberculosis (TVC and scrofuloderma) based on these
findings. The dramatic response to antituberculous
therapy confirmed the diagnosis. We think that dramatic
response to antituberculous therapy may be a possible
diagnostic criterion, particularly in developing countries.
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October 2008
The lymphadenitis associated with TVC is very rare.
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the scrofuloderma lesion. Although the patient said that
both TVC and scrofuloderma had occurred at nearly the
same time, we think that TVC developed secondary to the
scrofuloderma.
We present this case because coexistence of TVC and
scrofuloderma is very rare. We want to stress that the
dermatologist should be aware that a case with a form of
cutaneous tuberculosis may also have another form as
well. Detailed history and exact physical examination are
very important for the diagnosis. We emphasize that
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