Lesson Learnt of the Management of Bizarre Scrofuloderma Evolving to the Chest Wall in Male Adolescents: A Rare Case Report

Lesson Learnt of the Management of Bizarre Scrofuloderma Evolving to the Chest Wall in Male Adolescents: A Rare Case Report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Lesson Learnt of the Management of Bizarre Scrofuloderma Evolving to the Chest Wall in Male Adolescents: A Rare Case Report Heda Melinda Nataprawira, Ridzky Santiyani Hadi This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6704572/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 16 You are reading this latest preprint version Abstract Background: Cutaneous tuberculosis is a rare manifestation of extrapulmonary tuberculosis in children. Scrofuloderma is the most common form of cutaneous tuberculosis in the developing countries. It typically results from the secondary spread of infection in the lymph node that invade the skin. We report a remarkable case of scrofuloderma evolving to chest wall in an adolescent male. Case Presentation: A 16-year-old adolescent male presented to the Pediatric Respirology Clinic at Hasan Sadikin Hospital with a new lump on the right side of his neck. He had a prior history of bilateral cervical lumps and a mass on the right chest wall. The patient had previously received antituberculosis therapy at inadequate dosages. Fine-needle aspiration biopsy of the cervical lumps confirmed tuberculous lymphadenitis. A thoracic CT scan revealed an abscess, and thoracotomy with aspiration was performed. Histopathological examination confirmed tuberculous inflammation of the chest wall. He was restarted on adult fixed-dose combination anti-tuberculosis therapy at an adequate dose and continued treatment for 12 months. As a result, the lumps resolved, skin lesions healed, and significant weight gain occured. Conclusion: In high TB-burden settings, clinicians must be equipped to recognize the diverse manifestations of lymph node tuberculosis. Scrofuloderma can extend beyond the cervical region to involve the chest wall. Early diagnosis through histopathological examination and molecular testing, along with a combination of surgical intervention and appropriate anti-tuberculosis therapy, is crucial. In adolescents, multidisciplinary management and close monitoring are key to achieving favorable outcomes and preventing recurrence. Tuberculosis Cutaneous TB Scrofuloderma Chest-wall TB Adolescent Figures Figure 1 Figure 2 Figure 3 Background Indonesia is the country with the second highest number of tuberculosis (TB) cases globally. According to the Indonesian Ministry of Health (2022), children under 15 years are estimated at 15.3% of all TB cases in the country [ 1 ]. Extrapulmonary TB (ETB) involves organs other than the lungs, with clinical manifestations varying depending on the organ affected. Symptoms are typically persistent, progressive, and may be accompanied by general features of TB. Cutaneous tuberculosis (CTB) is a rare form of ETB, only 1–2% of all TB cases. CTB is classified based on the route of infection: exogenous, endogenous, or hematogenous [ 2 ]. Scrofuloderma is one of the most common forms of CTB, particularly in developing countries. It spreads via an endogenous route, often from underlying lymph nodes or bone, and frequently affects areas such as the neck, axillae, chest wall, and groin [ 3 ]. Inadequate or improper management can increase the risk of relapse and lead to more extensive disease progression [ 4 ]. Case Presentation A 16-year-old Indonesian adolescent in the six-months inadequate dose of TB treatment, presented to our Pediatric Respirology Clinic with a complaint of an enlarging neck lump (Fig. 1B) and the appearance of a new lump at the level of the right parasternal region between the fourth and fifth intercostal space on the right side of his chest (Fig. 2A). The lump on his neck first appeared one year prior to admission. The lumps beginning small, marble-sized on both sides of the neck, progressively increase in size over time, and gradually evolve into nodules, pustules, and ulcerations. In contrast, the chest mass remained nontender. The patient also reported weight loss within one month. There were no symptoms of cough, fever, or dyspnea. A history of close contact with a pulmonary tuberculosis patient was identified, occurring during a six-month stay at an Islamic boarding school. A lymph node biopsy performed at a previous hospital revealed tuberculous lymphadenitis. Further diagnostic testing via the GeneXpert MTB/RIF assay confirmed the presence of Mycobacterium tuberculosis (M.tb), with no resistance to rifampicin detected. The patient had been receiving antituberculosis treatment via an adult fixed-dose combination (FDC) regimen; however, the dosage was determined to be inadequate for his age and weight. The patient was started on antituberculosis therapy at an adequate dosage based on his weight. Surgical debridement and a repeat biopsy were also performed. After six months of adequate treatment, a new lump reappeared on the neck, accompanied by a nonhealing wound at the previous biopsy site. Physical examination on the admission day, the patient's vital signs were within normal limits. His body weight was 57 kg corresponding to normal nutritional status. The cervical lymph nodes measured 1–1.5 cm in diameter, multiple, soft, bilateral, and nontender. A keloid was noted over the previous biopsy scar (Fig. 1C). Routine blood tests at admission were within normal limits and HIV testing was negative. A tuberculin skin test (TST) was performed, showing 20 mm of induration, indicating a strong positive reaction. GeneXpert MTB/RIF assay examination of a sputum sample did not detect M.tb. A chest X-ray revealed only a minimum pleural effusion. Thoracic computed tomography (CT) scan performed and the results showed a right pectoralis minor intramuscular abscess measuring approx. 3.86 x 9.04 x 6.65cm, multiple partially calcified lymph node enlargement, diameter approximately 0.88-2.67cm, findings were consistent with pulmonary TB, accompanied by multiple loculated empyema in the middle and lower right posterolateral hemithorax (Fig. 2B). The patient underwent excision thoracotomy. Histopathological examination of the excised tissue revealed classic features of tuberculous inflammation, including tubercle formation with epithelioid cell proliferation, Langhans giant cells, and caseous necrosis. The diagnosis was confirmed as tuberculosis involving the lower lobe of the right lung and the right chest wall. Fine-needle aspiration biopsy (FNAB) of the cervical lymph nodes was performed multiple times. Histopathological findings revealed subcapsular stroma and visible lymphoid follicles, with tubercle formation composed of proliferating epithelioid cells, Langhans giant cells, and central caseous necrosis, which is consistent with tuberculous lymphadenitis. A GeneXpert MTB/RIF assay of the cervical mass confirmed the presence of M.tb, with no resistance to rifampicin. At the previous hospital, the patient was treated with an adult FDC regimen consisting of rifampicin (R), isoniazid (H), pyrazinamide (Z), and ethambutol (E) for two months, followed by rifampicin (R) and isoniazid (H) for a four month continuation phase. However, the administered dose was inadequate, an the patient received only three tablets daily when his weight was 49 kg at that time. At our hospital, the patient restarted the regimen, receiving four tablets of the adult FDC, adjusted to his body weight. The treatment was extended to a total duration of 12 months. By the end of therapy, the patient was stable and significantly clinical improvement. No new lumps were observed, the skin lesions had healed, and his weight increased from 57 kg to 63 kg (Fig. 3). The patient completed the full course of TB treatment and was classified as having completed treatment. Discussion and conclusions Extrapulmonary tuberculosis (ETB) can affect various areas, including the skin (cutaneous TB/CTB) and lymph nodes (lymphadenitis TB). Lymphadenitis TB is the most common form of ETB found in children, and is typically located in areas such as the anterior cervical, submandibular, supraclavicular, epitrochlear inguinal, and axillary regions [ 5 ]. CTB occurs in 1–2% of TB patients. The mechanism of CTB can be exogenous, endogenous, or hematogenous. Exogenous infection occurs through direct contact with the skin, endogenous infection is when cutaneous involvement occurs secondarily by contiguity from an already established focus, while a hematogenous route can occur from a distant location [ 2 , 3 , 6 ]. An endogenous infection of TB can occur by hematogenous, lymphatic, or contiguous spread, originating from a primary site of infection [ 3 ]. One of the endogenous types is scrofuloderma which is usually from direct extension of M.tb infected from underlying structural (eg. Lymph node, bone, or joint) to the skin. Scrofuloderma occurs due to lymphadenitis TB invading the skin, often found in the neck, axillae, chest wall, groin, or nearby areas [ 3 ]. The initial lesions in scrofuloderma appear as hard, deep subcutaneous nodules or infiltrates that are reddish-blue and asymptomatic. These infiltrates then expand, harden, undergo liquefaction, become fluctuant, and eventually rupture, opening onto the skin surface to form linear or serpiginous ulcers with irregular, granulated bases, bluish edges, fistulas, and slightly firmer granulomatous nodules. Fibrous scars form, bridging between ulcers or normal skin area. Lesion can heal with scaring and fibrosis [ 3 , 5 ]. Chest wall TB is a very rare condition. There are three mechanisms in the pathophysiology that could lead to the development of chest wall abscess, the first is the direct extension from a pleural or pulmonary condition. The second is a hematogenous spread in a large part of extrapulmonary TB and the third is by direct extension due to tuberculous mediastinal lymphadenitis [ 7 ]. The second and the third mechanism can relate with our case. The symptoms and clinical manifestation of chest wall TB are painless cystic masses without skin inflammation [ 8 ]. In this case, the initial manifestation was a cervical mass, which subsequently extended to involve the overlying skin and chest wall. The mass on the right chest appeared following the development of lumps and abscesses in the neck. This suggests that the chest wall lesion likely resulted from direct extension of tuberculous lymphadenitis. The lumps were non-tender, painless, erythematous, and eventually ruptured, leading to ulceration followed by scar formation. Histopathological examination is essential for establishing the etiological diagnosis. Histopathological findings include a granulomatous inflammatory infiltrate associated with caseous necrosis and the presence of acid-fast bacilli [ 2 , 3 , 5 , 6 ]. In our case, the biopsy results from the right cervical lymph node was tubercle formations composed of proliferating epithelioid cells, Langerhans giant cells, and areas of caseous necrosis. The chest wall biopsy was characterized by the proliferation of epithelioid cells, the presence of Langhans giant cells, and areas of caseous necrosis. In addition to biopsy, the Xpert MTB/RIF assay can be used for the diagnosis of ETB. The Xpert assay is a highly sensitive method for detecting M.tb in lymph node samples [ 9 ]. In our case, M.tb was detected and shown to be rifampicin-sensitive. These findings are consistent with scrofuloderma and tuberculosis as the underlying etiology The treatment for ETB follows the same principles as pulmonary TB. Treatment options for CTB primarily follow systemic treatment regimens, in two phases of treatment. The first phase or intensive phase with 4 types of drugs and the second phase or continuation phase with 2 types of drugs. An adequate dose is needed to minimize the effects and toxicity. Failure to complete anti-TB therapy increases the risks of relapse, acquired drug-resistant TB, treatment failure, disease progression with complications, death, and continued infection transmission [ 2 , 10 ]. Adolescent are at risk for poor adherence in terms of missed doses and lose to follow-up. Predictors of poor treatment adherence for drug-susceptible TB include TB/HIV coinfection, age 15–19 years, prior TB treatment and male gender [ 4 , 11 ]. In this case, the patient had the risk factor to poor treatment which is age 16 years and male gender. The problems of our case is not the adherence of the patient but previously he received anti-tuberculosis treatment at an adequate dose so there was no clinical improvement at the first-time therapy. Therefore, treatment was reinitiated from the beginning. For drug-sensitive TB, the standard 4-drug regimen is rifampicin (R), isoniazid (H), pyrazinamid (Z), and ethambutol (E). The first 2 months of intensive phases consisted of RHZE. This is followed by a continuation phase with RH. The treatment regimen for ETB depends on the affected organ. In CTB, which includes scrofuloderma, the treatment regimen typically consists of a 2-month intensive phase followed by a 4-month continuation phase. However, current guidelines indicate that the continuation phase for CTB may extend between 4 and 12 months, depending on the clinical response and severity of the disease. [ 8 , 12 , 13 ] Chest wall TB typically requires an average treatment duration of 6 months, which may extend to 9–12 months based on clinical presentation, bacterial load, and response to treatment [ 8 , 13 ]. Surgical intervention may be needed for abscess drainage or debridement in advanced cases. A combination of surgical management and antituberculosis therapy is recommended to minimize the risk of recurrence. The surgical approach typically involves obliteration of the residual cavity following decompression of the cold abscess, along with complete excision of the infected tissue [ 8 , 12 ]. In this case, the patient underwent debridement of the abscess on the cervical and chest wall regions. At six-months of therapy, a new lump appeared and we decided to extend the duration of the treatment to 12 months and showed a favorable clinical response with weight gain and no recurrence of new lesions. In conclusion, CTB may present in different clinical forms, depending on the route and extent of M.tb spread beneath the skin. Scrofuloderma is one of the CTB that may result from endogenous spread, affecting the cervical and in rare cases, extending to the chest wall. Early and accurate diagnosis, supported by histopathological examination and molecular assays such as Xpert MTB/RIF, is crucial for appropriate management. A combination of surgical intervention and antituberculosis therapy is often required to achieve optimal outcomes. In adolescents, multidisciplinary collaboration and close monitoring are important to ensure comprehensive care and prevent recurrence in complex and rare presentations of CTB. Abbreviations TB tuberculosis ETB extrapulmonary tuberculosis CTB cutaneous tuberculosis FDC fixed-dose combination FNAB fine-needle aspiration biopsy M.tb Mycobacterium tuberculosis Declarations Acknowledgements Not applicable. Author contributions H.M. advised the case report study. R.S. gathered the patient’s medical and health records. H.M. and R.S. wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript. Funding The authors declare that no funds, grants, or other supports were received during the preparation of this manuscript. Data availability No datasets were generated or analyzed during the current study Declarations Ethics approval and consent to participate The written consent form for conducting procedures, treatment, and publication were signed by the parents Consent for publication Written informed consent was obtained from the patient’s parents for publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing financial interests. References Kementerian Kesehatan Republik Indonesia. Petunjuk teknis tata laksana tuberkulosis anak dan remaja. 2023. Nguyen KH, Alcantara CA, Glassman I, May N, Mundra A, Mukundan A et al. Cutaneous manifestations of Mycobacterium tuberculosis: a literature review. Pathog (Basel). 2023;12(7). Bravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol. 2007;25(2):173–80. Chiang SS, Tanzer JR, Starke JR, Friedman JF, Roman Sinche B, León Ostos K, et al. Identifying adolescents at risk for suboptimal adherence to tuberculosis treatment: a prospective cohort study. PLOS Glob Public Health. 2024;4(2):e0002918. Yadav S. Multiple tubercular cervical, supraclavicular, and pretracheal lymphadenitis with scrofuloderma: a rare case. Cureus. 2023;15(12):e51134. Maloney ME, Cohen B. Cutaneous tuberculosis in the pediatric population: a review. JAAD Int. 2023;12:105–11. Alvarez-Moran A, Avila Sanchez P, Fernández-Lara D. Chest wall soft-tissue tuberculosis: a case report. Rev Med Hosp Gen Mex. 2020;83. Kabiri EH, Alassane EA, Kamdem MK, Bhairis M, Amraoui M, El Oueriachi F, et al. Tuberculous cold abscess of the chest wall: a clinical and surgical experience. Report of 16 cases (case series). Ann Med Surg (Lond). 2020;51:54–8. Denkinger CM, Schumacher SG, Boehme CC, Dendukuri N, Pai M, Steingart KR. Xpert MTB/RIF assay for the diagnosis of extrapulmonary tuberculosis: a systematic review and meta-analysis. Eur Respir J. 2014;44(2):435–46. World Health Organization. WHO consolidated guidelines on tuberculosis: module 4: treatment and care. Geneva: World Health Organization; 2025 Mar. p. 14. World Health Organization. WHO consolidated guidelines on tuberculosis: module 5: management of tuberculosis in children and adolescents: web annex 5: overview of consolidated WHO recommendations. Geneva: World Health Organization; 2022. Hill MK, Sanders CV. Cutaneous tuberculosis. Microbiol Spectr. 2017;5(1). 10.1128/microbiolspec.TNMI7-0010-2016 . Tobin EH, Vadakekut ES. Cutaneous tuberculosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 May 19]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482220/ Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 29 Sep, 2025 Reviews received at journal 18 Jul, 2025 Reviews received at journal 13 Jul, 2025 Reviews received at journal 11 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviewers agreed at journal 09 Jul, 2025 Reviews received at journal 04 Jul, 2025 Reviewers agreed at journal 02 Jul, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers agreed at journal 25 Jun, 2025 Reviewers invited by journal 25 Jun, 2025 Editor invited by journal 28 May, 2025 Editor assigned by journal 24 May, 2025 Submission checks completed at journal 24 May, 2025 First submitted to journal 20 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6704572","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":476592030,"identity":"07641298-a120-406e-b099-97331806295f","order_by":0,"name":"Heda Melinda Nataprawira","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAUlEQVRIiWNgGAWjYBACAzBiYJBhAzE+gMUSQIQEYwMBLTwgLYwzSNICYjPzILQw4NRizt688QNjjg0Pn3Tzxs+2bXfy+NsTGD/8YLCQxaXFsudYsQTjtjQeNpljxdK5bc+KJc48YJbsYZAwxumwGzkGQC2HedgkcgyAWg4nNtxIYJAG+iURp5b7b4x/MG77D9Ji/NsSqGX+jQTm33i13OAxA9pyAKTFTJoRqGXDjQQ2/LacSSuzSNyWDNSSVmbZc+5wseGZh22WPQZ4/HL88OYbH7fZycnPSN5840fZ4Ty548mHb/yoqMMZYmCQgMoGxYgBPvV4tI+CUTAKRsEoAAMAS+FWvA6qpJIAAAAASUVORK5CYII=","orcid":"","institution":"Padjadjaran University","correspondingAuthor":true,"prefix":"","firstName":"Heda","middleName":"Melinda","lastName":"Nataprawira","suffix":""},{"id":476592031,"identity":"fece7666-8e13-4e54-b315-dfcde9c4b359","order_by":1,"name":"Ridzky Santiyani Hadi","email":"","orcid":"","institution":"Padjadjaran University","correspondingAuthor":false,"prefix":"","firstName":"Ridzky","middleName":"Santiyani","lastName":"Hadi","suffix":""}],"badges":[],"createdAt":"2025-05-20 06:53:28","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6704572/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6704572/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":85742054,"identity":"c77139c2-4230-4a57-8cb4-0227b0d0e6b3","added_by":"auto","created_at":"2025-07-01 09:02:19","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":79138,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Ulcer in the cervical region after the first biopsy. (B) Enlargement of the ulcer and cervical lump. (C) Keloid formation and appearance of the new lump in the cervical region after six months of antituberculosis treatment with an inadequate dosage of the adult FDC regimen\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6704572/v1/31dcf2b1fe4a94dd333064f1.jpg"},{"id":85743460,"identity":"56a4845d-fcbf-4a9b-b0ea-3ab158911c6e","added_by":"auto","created_at":"2025-07-01 09:10:19","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":103005,"visible":true,"origin":"","legend":"\u003cp\u003e(A) Lump on the right chest wall (B, C) Thoracic CT-scan revealing an abscess in the right pectoralis minor muscle.\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6704572/v1/fde344fe7e003b2cc6bca1ef.jpg"},{"id":85742055,"identity":"9837bf47-83e5-4b26-a665-ba0ec4f66e52","added_by":"auto","created_at":"2025-07-01 09:02:19","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":84466,"visible":true,"origin":"","legend":"\u003cp\u003eClinical appearance after 12 months of adult FDC\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-6704572/v1/85e052559003031737ccbbc4.jpg"},{"id":85744679,"identity":"bd7459a5-86ee-4e23-9113-783e6ad449a1","added_by":"auto","created_at":"2025-07-01 09:18:24","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":573746,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6704572/v1/09db2114-8639-456c-aec3-05daf392b0d1.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Lesson Learnt of the Management of Bizarre Scrofuloderma Evolving to the Chest Wall in Male Adolescents: A Rare Case Report","fulltext":[{"header":"Background","content":"\u003cp\u003eIndonesia is the country with the second highest number of tuberculosis (TB) cases globally. According to the Indonesian Ministry of Health (2022), children under 15 years are estimated at 15.3% of all TB cases in the country [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Extrapulmonary TB (ETB) involves organs other than the lungs, with clinical manifestations varying depending on the organ affected. Symptoms are typically persistent, progressive, and may be accompanied by general features of TB. Cutaneous tuberculosis (CTB) is a rare form of ETB, only 1\u0026ndash;2% of all TB cases. CTB is classified based on the route of infection: exogenous, endogenous, or hematogenous [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Scrofuloderma is one of the most common forms of CTB, particularly in developing countries. It spreads via an endogenous route, often from underlying lymph nodes or bone, and frequently affects areas such as the neck, axillae, chest wall, and groin [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Inadequate or improper management can increase the risk of relapse and lead to more extensive disease progression [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e"},{"header":"Case Presentation","content":"\u003cp\u003eA 16-year-old Indonesian adolescent in the six-months inadequate dose of TB treatment, presented to our Pediatric Respirology Clinic with a complaint of an enlarging neck lump (Fig.\u0026nbsp;1B) and the appearance of a new lump at the level of the right parasternal region between the fourth and fifth intercostal space on the right side of his chest (Fig.\u0026nbsp;2A). The lump on his neck first appeared one year prior to admission. The lumps beginning small, marble-sized on both sides of the neck, progressively increase in size over time, and gradually evolve into nodules, pustules, and ulcerations. In contrast, the chest mass remained nontender. The patient also reported weight loss within one month. There were no symptoms of cough, fever, or dyspnea. A history of close contact with a pulmonary tuberculosis patient was identified, occurring during a six-month stay at an Islamic boarding school. A lymph node biopsy performed at a previous hospital revealed tuberculous lymphadenitis. Further diagnostic testing via the GeneXpert MTB/RIF assay confirmed the presence of \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e (M.tb), with no resistance to rifampicin detected. The patient had been receiving antituberculosis treatment via an adult fixed-dose combination (FDC) regimen; however, the dosage was determined to be inadequate for his age and weight. The patient was started on antituberculosis therapy at an adequate dosage based on his weight. Surgical debridement and a repeat biopsy were also performed. After six months of adequate treatment, a new lump reappeared on the neck, accompanied by a nonhealing wound at the previous biopsy site.\u003c/p\u003e \u003cp\u003ePhysical examination on the admission day, the patient's vital signs were within normal limits. His body weight was 57 kg corresponding to normal nutritional status. The cervical lymph nodes measured 1\u0026ndash;1.5 cm in diameter, multiple, soft, bilateral, and nontender. A keloid was noted over the previous biopsy scar (Fig.\u0026nbsp;1C). Routine blood tests at admission were within normal limits and HIV testing was negative. A tuberculin skin test (TST) was performed, showing 20 mm of induration, indicating a strong positive reaction. GeneXpert MTB/RIF assay examination of a sputum sample did not detect M.tb. A chest X-ray revealed only a minimum pleural effusion. Thoracic computed tomography (CT) scan performed and the results showed a right pectoralis minor intramuscular abscess measuring approx. 3.86 x 9.04 x 6.65cm, multiple partially calcified lymph node enlargement, diameter approximately 0.88-2.67cm, findings were consistent with pulmonary TB, accompanied by multiple loculated empyema in the middle and lower right posterolateral hemithorax (Fig.\u0026nbsp;2B). The patient underwent excision thoracotomy. Histopathological examination of the excised tissue revealed classic features of tuberculous inflammation, including tubercle formation with epithelioid cell proliferation, Langhans giant cells, and caseous necrosis. The diagnosis was confirmed as tuberculosis involving the lower lobe of the right lung and the right chest wall. Fine-needle aspiration biopsy (FNAB) of the cervical lymph nodes was performed multiple times. Histopathological findings revealed subcapsular stroma and visible lymphoid follicles, with tubercle formation composed of proliferating epithelioid cells, Langhans giant cells, and central caseous necrosis, which is consistent with tuberculous lymphadenitis. A GeneXpert MTB/RIF assay of the cervical mass confirmed the presence of M.tb, with no resistance to rifampicin.\u003c/p\u003e \u003cp\u003eAt the previous hospital, the patient was treated with an adult FDC regimen consisting of rifampicin (R), isoniazid (H), pyrazinamide (Z), and ethambutol (E) for two months, followed by rifampicin (R) and isoniazid (H) for a four month continuation phase. However, the administered dose was inadequate, an the patient received only three tablets daily when his weight was 49 kg at that time. At our hospital, the patient restarted the regimen, receiving four tablets of the adult FDC, adjusted to his body weight. The treatment was extended to a total duration of 12 months. By the end of therapy, the patient was stable and significantly clinical improvement. No new lumps were observed, the skin lesions had healed, and his weight increased from 57 kg to 63 kg (Fig.\u0026nbsp;3). The patient completed the full course of TB treatment and was classified as having completed treatment.\u003c/p\u003e "},{"header":"Discussion and conclusions","content":" \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003cp\u003eExtrapulmonary tuberculosis (ETB) can affect various areas, including the skin (cutaneous TB/CTB) and lymph nodes (lymphadenitis TB). Lymphadenitis TB is the most common form of ETB found in children, and is typically located in areas such as the anterior cervical, submandibular, supraclavicular, epitrochlear inguinal, and axillary regions [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. CTB occurs in 1\u0026ndash;2% of TB patients. The mechanism of CTB can be exogenous, endogenous, or hematogenous. Exogenous infection occurs through direct contact with the skin, endogenous infection is when cutaneous involvement occurs secondarily by contiguity from an already established focus, while a hematogenous route can occur from a distant location [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. An endogenous infection of TB can occur by hematogenous, lymphatic, or contiguous spread, originating from a primary site of infection [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. One of the endogenous types is scrofuloderma which is usually from direct extension of M.tb infected from underlying structural (eg. Lymph node, bone, or joint) to the skin. Scrofuloderma occurs due to lymphadenitis TB invading the skin, often found in the neck, axillae, chest wall, groin, or nearby areas [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The initial lesions in scrofuloderma appear as hard, deep subcutaneous nodules or infiltrates that are reddish-blue and asymptomatic. These infiltrates then expand, harden, undergo liquefaction, become fluctuant, and eventually rupture, opening onto the skin surface to form linear or serpiginous ulcers with irregular, granulated bases, bluish edges, fistulas, and slightly firmer granulomatous nodules. Fibrous scars form, bridging between ulcers or normal skin area. Lesion can heal with scaring and fibrosis [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eChest wall TB is a very rare condition. There are three mechanisms in the pathophysiology that could lead to the development of chest wall abscess, the first is the direct extension from a pleural or pulmonary condition. The second is a hematogenous spread in a large part of extrapulmonary TB and the third is by direct extension due to tuberculous mediastinal lymphadenitis [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. The second and the third mechanism can relate with our case. The symptoms and clinical manifestation of chest wall TB are painless cystic masses without skin inflammation [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. In this case, the initial manifestation was a cervical mass, which subsequently extended to involve the overlying skin and chest wall. The mass on the right chest appeared following the development of lumps and abscesses in the neck. This suggests that the chest wall lesion likely resulted from direct extension of tuberculous lymphadenitis. The lumps were non-tender, painless, erythematous, and eventually ruptured, leading to ulceration followed by scar formation.\u003c/p\u003e \u003cp\u003eHistopathological examination is essential for establishing the etiological diagnosis. Histopathological findings include a granulomatous inflammatory infiltrate associated with caseous necrosis and the presence of acid-fast bacilli [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. In our case, the biopsy results from the right cervical lymph node was tubercle formations composed of proliferating epithelioid cells, Langerhans giant cells, and areas of caseous necrosis. The chest wall biopsy was characterized by the proliferation of epithelioid cells, the presence of Langhans giant cells, and areas of caseous necrosis. In addition to biopsy, the Xpert MTB/RIF assay can be used for the diagnosis of ETB. The Xpert assay is a highly sensitive method for detecting M.tb in lymph node samples [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. In our case, M.tb was detected and shown to be rifampicin-sensitive. These findings are consistent with scrofuloderma and tuberculosis as the underlying etiology\u003c/p\u003e \u003cp\u003eThe treatment for ETB follows the same principles as pulmonary TB. Treatment options for CTB primarily follow systemic treatment regimens, in two phases of treatment. The first phase or intensive phase with 4 types of drugs and the second phase or continuation phase with 2 types of drugs. An adequate dose is needed to minimize the effects and toxicity. Failure to complete anti-TB therapy increases the risks of relapse, acquired drug-resistant TB, treatment failure, disease progression with complications, death, and continued infection transmission [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Adolescent are at risk for poor adherence in terms of missed doses and lose to follow-up. Predictors of poor treatment adherence for drug-susceptible TB include TB/HIV coinfection, age 15\u0026ndash;19 years, prior TB treatment and male gender [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. In this case, the patient had the risk factor to poor treatment which is age 16 years and male gender. The problems of our case is not the adherence of the patient but previously he received anti-tuberculosis treatment at an adequate dose so there was no clinical improvement at the first-time therapy. Therefore, treatment was reinitiated from the beginning.\u003c/p\u003e \u003cp\u003eFor drug-sensitive TB, the standard 4-drug regimen is rifampicin (R), isoniazid (H), pyrazinamid (Z), and ethambutol (E). The first 2 months of intensive phases consisted of RHZE. This is followed by a continuation phase with RH. The treatment regimen for ETB depends on the affected organ. In CTB, which includes scrofuloderma, the treatment regimen typically consists of a 2-month intensive phase followed by a 4-month continuation phase. However, current guidelines indicate that the continuation phase for CTB may extend between 4 and 12 months, depending on the clinical response and severity of the disease. [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] Chest wall TB typically requires an average treatment duration of 6 months, which may extend to 9\u0026ndash;12 months based on clinical presentation, bacterial load, and response to treatment [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSurgical intervention may be needed for abscess drainage or debridement in advanced cases. A combination of surgical management and antituberculosis therapy is recommended to minimize the risk of recurrence. The surgical approach typically involves obliteration of the residual cavity following decompression of the cold abscess, along with complete excision of the infected tissue [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn this case, the patient underwent debridement of the abscess on the cervical and chest wall regions. At six-months of therapy, a new lump appeared and we decided to extend the duration of the treatment to 12 months and showed a favorable clinical response with weight gain and no recurrence of new lesions.\u003c/p\u003e \u003cp\u003eIn conclusion, CTB may present in different clinical forms, depending on the route and extent of M.tb spread beneath the skin. Scrofuloderma is one of the CTB that may result from endogenous spread, affecting the cervical and in rare cases, extending to the chest wall. Early and accurate diagnosis, supported by histopathological examination and molecular assays such as Xpert MTB/RIF, is crucial for appropriate management. A combination of surgical intervention and antituberculosis therapy is often required to achieve optimal outcomes. In adolescents, multidisciplinary collaboration and close monitoring are important to ensure comprehensive care and prevent recurrence in complex and rare presentations of CTB.\u003c/p\u003e \u003c/div\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003etuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eETB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eextrapulmonary tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCTB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ecutaneous tuberculosis\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFDC\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efixed-dose combination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eFNAB\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003efine-needle aspiration biopsy\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eM.tb\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003e \u003cem\u003eMycobacterium tuberculosis\u003c/em\u003e \u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003eAcknowledgements\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAuthor contributions\u003c/p\u003e\n\u003cp\u003eH.M. advised the case report study. R.S. gathered the patient’s medical and health records. H.M. and R.S. wrote the first draft of the manuscript, and all authors commented on previous versions. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003cp\u003eFunding\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that no funds, grants, or other supports were received during the preparation of this manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eData availability\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eNo datasets were generated or analyzed during the current study\u003c/p\u003e\n\u003cp\u003eDeclarations\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEthics approval and consent to participate\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe written consent form for conducting procedures, treatment, and publication were signed by the parents\u003c/p\u003e\n\u003cp\u003eConsent for publication\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient’s parents for publication of this case report and any accompanying images.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eCompeting interests\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing financial interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKementerian Kesehatan Republik Indonesia. Petunjuk teknis tata laksana tuberkulosis anak dan remaja. 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNguyen KH, Alcantara CA, Glassman I, May N, Mundra A, Mukundan A et al. Cutaneous manifestations of Mycobacterium tuberculosis: a literature review. Pathog (Basel). 2023;12(7).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBravo FG, Gotuzzo E. Cutaneous tuberculosis. Clin Dermatol. 2007;25(2):173\u0026ndash;80.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChiang SS, Tanzer JR, Starke JR, Friedman JF, Roman Sinche B, Le\u0026oacute;n Ostos K, et al. Identifying adolescents at risk for suboptimal adherence to tuberculosis treatment: a prospective cohort study. PLOS Glob Public Health. 2024;4(2):e0002918.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYadav S. Multiple tubercular cervical, supraclavicular, and pretracheal lymphadenitis with scrofuloderma: a rare case. Cureus. 2023;15(12):e51134.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMaloney ME, Cohen B. Cutaneous tuberculosis in the pediatric population: a review. JAAD Int. 2023;12:105\u0026ndash;11.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAlvarez-Moran A, Avila Sanchez P, Fern\u0026aacute;ndez-Lara D. Chest wall soft-tissue tuberculosis: a case report. Rev Med Hosp Gen Mex. 2020;83.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKabiri EH, Alassane EA, Kamdem MK, Bhairis M, Amraoui M, El Oueriachi F, et al. Tuberculous cold abscess of the chest wall: a clinical and surgical experience. Report of 16 cases (case series). Ann Med Surg (Lond). 2020;51:54\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eDenkinger CM, Schumacher SG, Boehme CC, Dendukuri N, Pai M, Steingart KR. Xpert MTB/RIF assay for the diagnosis of extrapulmonary tuberculosis: a systematic review and meta-analysis. Eur Respir J. 2014;44(2):435\u0026ndash;46.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO consolidated guidelines on tuberculosis: module 4: treatment and care. Geneva: World Health Organization; 2025 Mar. p. 14.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWorld Health Organization. WHO consolidated guidelines on tuberculosis: module 5: management of tuberculosis in children and adolescents: web annex 5: overview of consolidated WHO recommendations. Geneva: World Health Organization; 2022.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHill MK, Sanders CV. Cutaneous tuberculosis. Microbiol Spectr. 2017;5(1). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1128/microbiolspec.TNMI7-0010-2016\u003c/span\u003e\u003cspan address=\"10.1128/microbiolspec.TNMI7-0010-2016\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTobin EH, Vadakekut ES. Cutaneous tuberculosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 [cited 2025 May 19]. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.ncbi.nlm.nih.gov/books/NBK482220/\u003c/span\u003e\u003cspan address=\"https://www.ncbi.nlm.nih.gov/books/NBK482220/\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tuberculosis, Cutaneous TB, Scrofuloderma, Chest-wall TB, Adolescent","lastPublishedDoi":"10.21203/rs.3.rs-6704572/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6704572/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground:\u003c/h2\u003e \u003cp\u003eCutaneous tuberculosis is a rare manifestation of extrapulmonary tuberculosis in children. Scrofuloderma is the most common form of cutaneous tuberculosis in the developing countries. It typically results from the secondary spread of infection in the lymph node that invade the skin. We report a remarkable case of scrofuloderma evolving to chest wall in an adolescent male.\u003c/p\u003e\u003ch2\u003eCase Presentation:\u003c/h2\u003e \u003cp\u003eA 16-year-old adolescent male presented to the Pediatric Respirology Clinic at Hasan Sadikin Hospital with a new lump on the right side of his neck. He had a prior history of bilateral cervical lumps and a mass on the right chest wall. The patient had previously received antituberculosis therapy at inadequate dosages. Fine-needle aspiration biopsy of the cervical lumps confirmed tuberculous lymphadenitis. A thoracic CT scan revealed an abscess, and thoracotomy with aspiration was performed. Histopathological examination confirmed tuberculous inflammation of the chest wall. He was restarted on adult fixed-dose combination anti-tuberculosis therapy at an adequate dose and continued treatment for 12 months. As a result, the lumps resolved, skin lesions healed, and significant weight gain occured.\u003c/p\u003e\u003ch2\u003eConclusion:\u003c/h2\u003e \u003cp\u003eIn high TB-burden settings, clinicians must be equipped to recognize the diverse manifestations of lymph node tuberculosis. Scrofuloderma can extend beyond the cervical region to involve the chest wall. Early diagnosis through histopathological examination and molecular testing, along with a combination of surgical intervention and appropriate anti-tuberculosis therapy, is crucial. In adolescents, multidisciplinary management and close monitoring are key to achieving favorable outcomes and preventing recurrence.\u003c/p\u003e","manuscriptTitle":"Lesson Learnt of the Management of Bizarre Scrofuloderma Evolving to the Chest Wall in Male Adolescents: A Rare Case Report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-01 09:02:15","doi":"10.21203/rs.3.rs-6704572/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-09-29T10:30:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-18T04:42:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-13T18:04:59+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-12T02:59:24+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"64246846816055083256241020244025596337","date":"2025-07-12T02:34:31+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79216837777582503505150419889912594033","date":"2025-07-11T10:34:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178435166324386722432896343115376329130","date":"2025-07-09T08:38:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-04T10:33:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322750761398811002591300171556024202367","date":"2025-07-02T18:42:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"124203142572951089814159374038116338879","date":"2025-06-25T09:15:18+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"322780198040811638517246131141617882320","date":"2025-06-25T09:01:20+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-06-25T08:43:39+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-28T07:10:19+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-24T06:03:01+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-24T06:01:13+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-05-20T06:51:11+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"e010eae1-7d99-4517-8999-347b751894d1","owner":[],"postedDate":"July 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-03-12T05:38:44+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-01 09:02:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6704572","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6704572","identity":"rs-6704572","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}