Chronic Osteomyelitis of Humerus Presenting as Scrofuloderma
A 22 year old female presented with discharging sinuses and swelling over the right arm of 18 months duration. She received courses of antibiotics at a local clinic. The nodulo-ulcerative discharging sinuses were initially small sized but failed to heal and continued to increase in size. On local examination multiple crater like ulcers with few papulo-pustular lesions on the dorso-lateral aspect of the lower two-third of right arm were seen []. The ulcer had indurated margin surrounded by a zone of hyperpigmentation with mild seropurulent discharge and crust formation at the base of the ulcer [Figrue 2]. Features of eczematization were seen on the surrounding margins of the ulcer. There was local rise of temperature on the overlying skin. No regional lymphadenopathy was detected. Systemic examination did not reveal any abnormalities. There was no history of recent loss of weight and night sweats. There was no history of trauma or immune suppressive therapy. But the family history revealed a treated case of pulmonary tuberculosis in one of the family members. Routine investigations showed normal blood counts with raised Erythrocyte sedimentation rate (ESR) which was 58 mm/after 1 hr and raised C-reactive protein (CRP). Routine urine tests and blood biochemistry were within normal limits. HIV, VDRL tests were negative and Mantoux test showed positive reaction. Primary staining of discharge was negative for bacteria, fungi and mycobacteria. Skin biopsy from the lesion was subjected to culture on LJ media and histopathological examination. On culture there was yellowish, rough colony which grew after 21 days of inoculation which was confirmed as Mycobacterium tuberculosis by PCR []. Histopathology study of skin biopsy revealed epithelioid granuloma with inflammatory cell infiltrates in the dermis []. The chest X-ray of anterior-posterior (AP) and lateral view showed no infiltration. X-ray of the right humerus AP/lateral view showed features of periosteal reaction with new bone formation and soft tissue showed irregular radiolucent areas in the margin []. These findings were suggestive of chronic osteomyelitis. Basing on the above positive findings the case was diagnosed as scrofuloderma associated with chronic osteomyelitis of the right arm.\nPatient was put on anti tubercular therapy showed improvement and complete cure occurred after one year.