Recurrent Abscesses of The Neck: Scrofuloderma: Bacterium Tuberculosis PCR Were Negative. A Culture Was Not
Recurrent Abscesses of The Neck: Scrofuloderma: Bacterium Tuberculosis PCR Were Negative. A Culture Was Not
Recurrent Abscesses of The Neck: Scrofuloderma: Bacterium Tuberculosis PCR Were Negative. A Culture Was Not
B
Report of a Case | A woman in her 80s was referred for surgical
treatment of a cervical abscess. Similar abscesses erupted in
the cervical region over the course of 2 years (Figure 1A).
A needle aspiration biopsy was performed on a node at the
left side of the neck, which measured 2 cm. The histopatho-
logic report described a minor nonspecific inflammatory
reaction, not suggestive of infection. Findings of the Myco-
bacterium tuberculosis PCR were negative. A culture was not
performed. Two months later, the whole nodule was
excised, including the adjacent inflamed skin. The resulting
defect, with a diameter of 7 cm, was closed with a rotary-
transposition flap. During this intervention, the thoracic
nerve was injured resulting in an elevation palsy of the left
arm. The histopathologic report of the excised tissue again
showed a nonspecific inflammatory reaction; no microbio-
logical analysis was conducted. A, Multiple cervical abscesses recurred in the 2 years prior to presenting for
care. B, A cold abscess at the neck was opened and drained to gain a specimen
At presentation, the patient had puckered scars scattered for histologic and microbiological analysis; multiple puckered scars are visible on
over the neck in addition to an unusual “cold abscess” the neck.
(Figure 1B). The clinical appearance was suggestive of scrofu-
loderma. Results of the Mendel-Mantoux test were positive (di-
ameter, 20 mm), as were those from the interferon-γ release picin, 600 mg/d, was initiated. After 2 months, the regimen was
assay. However, PCR findings from the skin biopsy specimen reduced to isoniazid and rifampicin. After 4 months of the re-
and abscess material were negative for M tuberculosis. Histo- duced regimen, all skin lesions had healed completely, leav-
logically, no acid-fast bacilli could be detected by Ziehl- ing scars, and sonography revealed no remaining abscesses.
Neelsen staining. Treatment was well tolerated, and at 24-month follow-up, no
Cervical sonography and magnetic resonance tomogra- new nodules had evolved.
phy revealed multiple abscesses in the lateral muscle loge.
Chest radiography excluded pulmonary tuberculosis. Labo- Discussion | From 1% to 2% of tuberculosis cases are cutane-
ratory work showed an elevated level of C-reactive protein (115 ous tuberculosis (CTB).1 Tuberculosis cutis colliquativa, also
mg/L; normal, <5 mg/L) but no other pathological findings. (To known as scrofuloderma, is the most common CTB subtype
convert C-reactive protein to nanomoles per liter, multiply by in Europe.2 Scrofuloderma is a subcutaneous form of CTB
9.524.) manifesting with cold abscesses most commonly on the
After 19 days, M tuberculosis was cultivated from the skin neck that spreads from underlying lymph nodes. Infection
specimen (Figure 2). The strain was sensitive to isoniazid, rif- can also involve joints, bones, and epididymis.3 The same
ampicin, pyrazinamide, ethambutol, and streptomycin. quadruple antibiotic therapy is used as in pulmonary tuber-
Classic quadruple treatment with isoniazid, 300 mg/d; culosis. Before treatment is begun, possible multidrug resis-
pyrazinamide, 1500 mg/d; ethambutol, 1200 mg/d; and rifam- tance should be excluded.