CAMEO SCROFULODERMA AND CARIES SPINE VIRENDRA N. SEHGAL, M.D., SANJIV JAIN, M.D., DEVINDER M. THAl'PA, M.D., AND KULBHUSHAN LOGANI, M.D. A 27-year-old woman was apparently well until 2 years ago, when she developed asymptomatic small, firm swellings in the neck. The swellings were mobile. In a few months, the overlying skin developed bluish discoloration and was ad- herent to the swellings. The swellings burst through the overlying skin discharging mucopurulent material. Ever since, the discharge oozed out intermittently through the si- nuses. A few months later she developed backache; she also had difficulty in walking and bending. The practitioner prescribed medicine to which the response was poor. The skin over the cervical region was marked by small ir- regular sinuses arranged in linear fashion. The margins of these sinuses were undermined and bluish in color, Seropu- rulent discharge was exuding from some of the sinuses, while others were covered with crust (Fig, 1), Spinal exami- nation revealed tenderness over the dorsolumbar region. Hemoglobin was 11 g%. Blood sedimentation rate was 62 mm at the end of the first hour (Westergren), Total and differ- ential leukocyte counts were within normal limits and so was the roentgenogram of the chest. Roentogenographic exami- nation of the thoracolumbar spine showed decreased inter- vertebral disc space between L2 and L3, with osteolytic lesion at L3 near the upper surface (Fig. 2). The changes were sug- gestive of caries of the spine at L2 and L3, Ziehl-Neelsen stained smear of the discharge oozing out of cervical sinuses was negative for acid-fast bacilli, Lowenstein-Jensen medium did not yield growth after 6 weeks. Accordingly, niacin and pigment tests to exclude atypical mycobacteria were not. possible. Mantoux test was 16 mm after 48 hours, ELISA and Western blot tests for mv infection were negative. The hematoxylin-eosin stained section of the affected skin revealed ulceration in the center. At the periphery was a tuberculous granuloma located in the lower dermis. It was marked by caseation necrosis in the center surrounded by epithelioid cells, lymphocytes, and giant cells. Tubercle bacilli were demonstrated in the tissue section using Fites stain (Fig. 3). Short course intensive chemotherapy comprising isoni- azid 300 mg, rifampin 600 mg, and streptomycin Ig IM was initiated and continued for 2 months. Subsequently, strepto- mycin was withdrawn, and the treatment with the remaining two drugs was continued to complete 9 months. The patient From the Departments of Dermatology & STD and Pathology, Lady Hardinge Medical College and Associated S.K. & K.S.C. Hospitals, New Delhi, India. Address for correspondence: Professor Virendra N. Sehgai, M.D., A/6, Panchwati, Opp. Azadpur Suhzi Mandi, Delhi-110 033, India. Figure 1. Small, irregular, linearly arranged tuberculous si- nuses over the cervical region. Figure 2. Caries of the spine with decreased intervertebral disc space between L2 and L3 with osteolytic lesion at the upper surface of L3. SOS