Journal of Dermatological Treatment.

2011; 22: 52–54

CASE REPORT

Pott’s disease with scrofuloderma and psoas abscess misdiagnosed

and treated as hidradenitis suppurativa

AYLIN 
_ TÜREL ERMERTCAN1, FERDI_ ÖZTÜRK1, GÜLSÜM GENÇOGLAN 1
,
_
IŞ IL INANIR1
, NURI_ ÖZKÜTÜK2 & PEYKER TEMIZ
_ 3
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1
Department of Dermatology, 2Department of Microbiology, and 3Department of Pathology, Faculty of Medicine,
Celal Bayar University, Manisa, Turkey

Abstract
A 29-year-old man with painless ulcers on the lumbar and inguinal regions associated with purulent discharge of 1.5 years’
duration presented to our outpatient clinic. Dermatological examination revealed palpable nodules, discharging sinuses and
scars on the left lumbar, gluteal and inguinal regions. According to the clinical, histopathological, scintigraphy, and magnetic
resonance imaging findings as well as mycobacteriological examinations, the patient was diagnosed with Pott’s disease with
For personal use only.

scrofuloderma and psoas abscess. Herein, we present an interesting case of Pott’s disease with scrofuloderma and psoas abscess
mistreated as hidradenitis suppurativa for a long time.

Key words: Pott’s disease, psoas abscess, scrofuloderma, skin, tuberculosis

Introduction his lesions had been misdiagnosed as hidradenitis

Scrofuloderma is tuberculous involvement of the skin
by direct extension, usually from underlying tuber-
culous lymphadenitis (1). Pott’s disease is the most
common and dangerous form of skeletal tuberculosis.
It may be complicated with local complications, such
as psoas abscess (2).
Herein, we present a rare and interesting case
report of Pott’s disease with scrofuloderma and psoas
abscess misdiagnosed and mistreated as hidradenitis
suppurativa.
Case report
A 29-year-old man with painless ulcers on the lumbar
and inguinal regions associated with purulent dis-
charge presented to our outpatient clinic. He
explained that his lesions appeared 1.5 years ago
and showed progression gradually. Incision and
drainage had been performed by surgeons and then
suppurativa, and multiple courses of local and sys-
temic antibiotics had been applied.
Dermatological examination revealed palpable
nodules, discharging sinuses and scars on the left
lumbar, gluteal and inguinal regions (Figure 1).
A general physical examination revealed no other
abnormality except paleness, lethargy and lumbar
pain. There was a history of progressive weight loss
for 1 year. There were no palpable lymph nodes.
Laboratory examinations showed no abnormal find-
ings except for a raised erythrocyte sedimentation
rate. A tuberculin skin test was positive. Chest radio-
graphy, thorax CT, abdominal ultrasound, CT and
bronchoscopy did not show any abnormality. An
incisional skin biopsy was performed from a lesion
on the inguinal region for histological examination,
mycobacteriological culture and molecular examina-
tions. Histopathological findings revealed dermal
granuloma formation and lymphoplasmocytic inflam-
mation consisting of epithelioid and Langhans’ giant
cells on the basis of the ulceration (Figure 2). The

Correspondence: A. Türel Ermertcan, Celal Bayar Üniversitesi Tip Fakültesi, Dermatoloji Anabilim Dali, 45010 Manisa, Türkiye. Fax: 90 236 2370213.
E-mail: draylinturel@hotmail.com

(Received 15 October 2009; accepted 19 October 2009)

ISSN 0954-6634 print/ISSN 1471-1753 online  2011 Informa Healthcare USA on behalf of Informa UK Ltd.
DOI: 10.3109/09546630903443365
 Pott’s disease with scrofuloderma and psoas abscess
A.
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Figure 1. (A and B) Nodules, sinuses and scars on the left lumbar, gluteal and inguinal regions.
responsible microorganism was detected as Myco-
bacterium tuberculosis with mycobacteriological culture
and molecular examinations (Lowenstein-Jensen
medium and Bactec 460 TB culture system). An
abdominal magnetic resonance imaging (MRI) study
showed L1–L5 spondylitis and a large psoas abscess
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on the left (Figure 3). A Tc-99m methylene di phos-
phonate (MDP) bone scintigraphy showed Pott’s
disease. So, the patient was diagnosed with Pott’s
disease with scrofuloderma and psoas abscess.
Although CT-guided percutaneous aspiration of
the psoas abscess had been planned, it could
not be performed because the abscess was multi-
locular and very close to the colon and iliac artery.
Antituberculous therapy was started, consisting of
isoniazid 300 mg/day, rifampicin 600 mg/day,
Figure 2. Granuloma formation (H&E 40).
53
B.
ethambutol 1000 mg/day, and pyrazinamide 2500 mg/
day. On the second month of the therapy, his lesions
showed marked improvement and he is still being
followed-up.
Discussion
Cutaneous tuberculosis remains a rare infection, with
an incidence of 3.5% reported among patients with
organ tuberculosis (3). The presence of purulent
discharge or features suggestive of a carbuncle can
cause further confusion and misdiagnosis as a bacte-
rial abscess. The differential diagnosis includes acti-
nomicosis, granuloma inguinale, lymphogranuloma
venerum, and hidradenitis suppurativa (4). Our
patient had been misdiagnosed with a bacterial
abscess, and incision and drainage had been per-
formed by a surgeon. Then he had been misdiagnosed
with hidradenitis suppurativa and he had used mul-
tiple courses of local and systemic antibiotics.
Spinal tuberculosis is the most common and dan-
gerous form of skeletal tuberculosis. The major site of
Figure 3. Abdominal MRI axial T2-weighted image showing left
psoas abscess (arrowhead).
 54 A. Türel Ermertcan et al.
infection is the vertebral body at the thoracolumbar
junction. The management of spinal tuberculosis in
different parts of the world ranges from immobiliza-
tion with antituberculous chemotherapy to various
forms of operative treatment combined with drug
therapy (5). Psoas and iliopsoas abscesses are rare
complications of spinal tuberculosis and are fre-
quently diagnosed late because of the non-specific
symptoms they produce (6). When performed by an
experienced physician, percutaneous drainage is a
low-risk and easily performed procedure for the
management of psoas compartment abscesses (5).
In our patient, antituberculous therapy was started,
consisting of isoniazid, rifampicin, ethambutol, and
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pyrazinamide. Since his abscess was multilocular and
very close to the colon and iliac artery, CT-guided
aspiration of the psoas abscess could not be per-
formed. We decided to continue antituberculous
therapy for 12 months. On the second month of
the therapy the lesions showed marked improvement.
He gained weight and his symptoms, such as paleness,
lethargy and lumbar pain had regressed. He is still
being followed-up in our clinic.
With this rare and interesting case report we suggest
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that scrofuloderma should be considered in the
differential diagnosis of hidradenitis suppurativa
showing an atypical clinical course and resistance to
the conventional treatments.
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
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