Multiple abscesses and ax...

A 9-year-old boy, presented with multiple abscesses and discharging sinus over the neck for a duration of 1 year. He also complained of swelling in the right axillary region for 1 week. There was no history of any respiratory, urinary, or gastro-intestinal symptoms. General examination revealed mild pallor. Multiple bilateral cervical lymph nodes were palpable. Vital signs showed that body temperature was 36.7 °C, blood pressure was 104/60 mmHg, heart rate was 88 beats/min, respiratory rate was 20/min, and pulse oximetry was 96%. On local examination, multiple undermined, black-coloured ulcerative lesions were present with discharging pus sinuses with puckered scar marks over the anterior aspect of the neck (Figure 1). In the right axilla, a single soft, non-tender, fluctuant swelling measuring 1.5 × 1.5 cm was present (Figure 2). 

Examination

On abdominal examination, the spleen was just palpable, and the liver was palpable 2 cm below the right costal margin with normal consistency. Respiratory and cardiovascular systems were normal. Investigations revealed a haemoglobin of 8.3 g/dl, total leukocyte count of 6100 cells per mm3 with normal differential count, and platelet count of 5,60,000 per mm3. Peripheral smear showed a normocytic moderately hypochromic with few microcytes and occasional pencil cells. Erythrocyte sedimentation rate was 65 mm/hr. Mantoux test done showed an induration measuring 30 mm at 72 hours. Biochemical parameters were normal. Serologic testing for human immunodeficiency virus (HIV) was negative. Sputum for acid fast bacilli (AFB) was negative. Chest X-ray was normal. Ultrasonography of abdomen showed borderline splenomegaly. 

Skin punch biopsy from anterior aspect of lesion present over neck region was taken which showed atrophied epidermal lining with loss of rete pegs and islands of epidermis trapped in the dermis. Underlying the dermis, chronic inflammatory infiltrate composed predominantly of lymphocytes and few polymorphs with multinucleated giant cells at places were present. No areas of congestion, oedema, haemorrhage, or necrosis were seen.