When Tuberculosis Reaches the Skin: A Teenager’s Chest-Wall Infection Offers Hard Lessons

A sixteen-year-old boy walked into a pediatric respirology clinic in Indonesia with what seemed, at first, to be a routine complaint: a new nodule on his neck. But his medical history told a far more troubling story. Months earlier, he had been diagnosed with tuberculosis and given treatment, yet the therapy he received was underdosed, too weak and too short to fully eradicate the bacteria from his body. Now, the infection was announcing its return in one of the rarest and most visually striking ways tuberculosis can present: as scrofuloderma, a skin lesion formed when the disease beneath the surface literally breaks through to the skin. The case, reported in BMC Pediatrics by Heda Melinda Nataprawira and Ridzky Santiyani Hadi of Universitas Padjadjaran in Bandung, offers clinicians a vivid reminder of what happens when tuberculosis treatment falls short, and how a combination of surgery, histopathology, molecular testing, and a full year of properly dosed drugs can still pull a patient back from the brink.

Scrofuloderma occupies a peculiar place in the spectrum of tuberculosis. Most people imagine the disease as a lung infection marked by cough and fever, but Mycobacterium tuberculosis is a versatile pathogen capable of seeding nearly any organ. When it settles in structures lying just beneath the skin, such as lymph nodes, bones, or joints, the infection can spread by direct extension into the overlying tissue. The result is a chronic, progressive lesion: the skin above the infected node becomes firm, then inflamed, then ulcerated, eventually forming draining sinuses that ooze a mixture of pus and necrotic material. Among the cutaneous forms of tuberculosis, scrofuloderma is the most common in developing countries, precisely because it tracks so closely with untreated or inadequately treated lymph node tuberculosis, which itself remains widespread in high-burden settings. Its rarity in dermatology clinics elsewhere is not a sign that the organism has changed, but that public health systems have, in many places, succeeded in interrupting the chain of infection before it reaches the skin.

The Indonesian adolescent’s story began with bilateral cervical nodules, swollen lymph nodes on both sides of the neck, together with a mass on the right side of his chest wall. These are classic territories for tuberculous lymphadenitis, the most frequent form of extrapulmonary tuberculosis in children and adolescents. He received antituberculosis therapy, but the dose was inadequate, a deceptively simple error with profound consequences. Underdosed treatment fails to achieve the drug concentrations needed to kill the bacteria reliably, and it creates conditions in which partially resistant bacterial populations can flourish. The infection was suppressed but not eliminated. When he presented with a fresh cervical nodule after six months of this insufficient regimen, his clinicians faced a patient whose disease had effectively been given a chance to adapt and to burrow deeper into the tissues of his neck and chest.

Diagnosis in such cases demands a layered approach, and the team proceeded methodically. Fine-needle aspiration biopsy of the cervical nodules, a minimally invasive technique in which a thin needle withdraws cells and fluid from a suspicious mass, confirmed tuberculous lymphadenitis. This mattered enormously, because scrofuloderma can mimic a long list of other conditions, from bacterial abscesses and fungal infections to malignancies, and treating the wrong disease wastes precious time. A thoracic CT scan then revealed an abscess within the chest wall, mapping the hidden anatomy of the infection and showing that the disease had extended well beyond what the skin lesions suggested. Imaging of this kind is essential in suspected chest-wall tuberculosis, because the abscess cavity often communicates with infected ribs, costal cartilage, or pleural space in ways that determine the surgical plan.

With the anatomy defined, the team turned to the operating room. A thoracotomy with aspiration was performed, allowing surgeons to access the chest wall abscess directly, drain its contents, and obtain tissue for examination. Histopathological analysis of that tissue confirmed tuberculous inflammation of the chest wall, closing the diagnostic loop. This dual role of surgery, both therapeutic and diagnostic, is a recurring theme in the management of complicated extrapulmonary tuberculosis. Draining a large abscess removes a reservoir of bacteria and necrotic material that antibiotics penetrate poorly, while the excised tissue provides the histology and culture material that laboratory tests alone cannot always supply. In an era of increasing drug resistance, obtaining organisms directly from the lesion also opens the door to drug susceptibility testing, which identifies which medications will actually work against the specific strain infecting the patient.

Once the diagnosis was secured, the treatment pivoted decisively. The adolescent was restarted on adult fixed-dose combination antituberculosis therapy, this time at an adequate dose, and the course was extended to a full twelve months. Fixed-dose combination pills, which bundle multiple first-line drugs into a single tablet, are a cornerstone of modern tuberculosis control because they simplify adherence and reduce the risk that patients will take some drugs but not others, the exact pattern that breeds resistance. The extended duration reflected the severity and location of the disease: chest-wall and disseminated lymph node involvement generally require longer treatment than uncomplicated pulmonary tuberculosis, and a patient who has already failed one course of therapy warrants a more aggressive and more closely supervised approach.

The outcome vindicated the strategy. The nodules resolved, the skin lesions healed, and the patient experienced significant weight gain, a marker of recovering health in a disease notorious for wasting its hosts. For a teenager who had endured months of ineffective treatment, recurring lesions, and major surgery, the return to normal growth and healing represents more than a clinical success; it is the restoration of an adolescence that tuberculosis had been steadily eroding. The authors emphasize that this favorable result depended on the combination of early diagnosis using histopathology and molecular testing, surgical intervention, and appropriate antituberculosis therapy, with none of these elements sufficient on its own.

Embedded in this single case are lessons that reach far beyond one patient. First, clinicians in high tuberculosis-burden settings must recognize that the disease wears many faces, and that skin lesions, neck masses, and chest-wall swellings in adolescents should always raise the question of tuberculosis, particularly when there is a history of prior treatment. Second, inadequate dosing is not a benign compromise; it is a setup for treatment failure, relapse, and potentially drug resistance, and therapeutic drug monitoring, in which blood levels of antituberculosis drugs are measured and adjusted, is an increasingly available tool to prevent it. Third, diagnosis should never rest on appearance alone. Fine-needle aspiration biopsy, histopathology, and molecular testing each contribute independent confirmation, and together they distinguish tuberculosis from the infections and tumors that imitate it.

The case also underscores the value of multidisciplinary care for adolescents with complicated tuberculosis. A pediatric respirologist, surgeons, pathologists, radiologists, and microbiologists all contributed essential pieces to this patient’s recovery, and the authors argue that close monitoring by such a team is key both to achieving good outcomes and to preventing recurrence. Adolescents occupy an awkward position in tuberculosis programs: too old for straightforward pediatric dosing schemes, too young for the assumptions built into adult care, and often poorly adherent to long medication courses. This patient’s initial underdosing likely reflected exactly that gap, and his eventual cure required deliberately bridging it with adult fixed-dose combination therapy given at full strength under supervision.

For the wider public, the story is a reminder that tuberculosis has not retreated into history. It remains one of the world’s deadliest infectious diseases, and in the regions where it thrives, its reach extends into lymph nodes, bones, joints, and skin, producing presentations that can baffle clinicians who expect only a cough. The sixteen-year-old at the center of this report was fortunate in one respect: his disease, even after inadequate treatment, remained treatable with first-line drugs and responded to a carefully orchestrated combination of surgery and a full year of properly dosed medication. Not every patient with underdosed therapy is so lucky, and the spread of multidrug-resistant tuberculosis means that each treatment failure carries risks for the community as well as the individual. The authors’ closing message is straightforward but urgent: in settings where tuberculosis is common, early recognition of its varied manifestations, rigorous diagnostic workup, adequate dosing from the very first prescription, and sustained multidisciplinary follow-up are the difference between a healed adolescent and a chronic, spreading, drug-resistant infection.

Subject of Research: Cutaneous tuberculosis (scrofuloderma) extending to the chest wall in an adolescent following inadequate antituberculosis therapy

Article Title: Lessons learned from the management of unusual scrofuloderma extending to the chest wall in an adolescent male: case report

Article References: Nataprawira, H. M., & Hadi, R. S. (2026). Lessons learned from the management of unusual scrofuloderma extending to the chest wall in an adolescent male: case report. BMC Pediatrics. https://doi.org/10.1186/s12887-026-07823-1

Image Credits: AI Generated

DOI: 10.1186/s12887-026-07823-1

Keywords: tuberculosis, scrofuloderma, cutaneous tuberculosis, chest-wall tuberculosis, adolescent health, tuberculous lymphadenitis, fine-needle aspiration biopsy, antituberculosis therapy, drug dosing, extrapulmonary tuberculosis, pediatrics, case report