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Correspondence to Dr Atanu Chandra; [email protected]
Description
A 21-year-old immunocompetent female hailing from a rural eastern Indian village, farmer and cattle herder by profession, presented with several asymptomatic lumps and bumps over her neck. It had started developing as a solitary pea-sized swelling on the neck which gradually progressed over 2 years to involve the entire front of neck and lower jaw. There was no history of discharge, similar swelling elsewhere or any family history of such lesions. In the same duration, a cow in her farm had been afflicted with a similar nodulocystic cutaneous predicament and died a few weeks prior to present consultation. However, no specific diagnosis could be reached by treating veterinarian. Cutaneous examination revealed a 16×8 cm hyperpigmented plaque studded with skin coloured to brownish-black papules and nodules overlying the anterior neck and submandibular area. Few clear fluid-filled cysts which demonstrated positive transillumination test were also noted (figure 1A). Examination of patient’s other mucocutaneous sites, regional lymph nodes and organ systems did not reveal anything unusual.
Her baseline laboratory investigations revealed mild anaemia. No bony involvement was noted on X-ray of chest and mandible. Skin biopsy from a representative nodule revealed sulphur granules surrounded by neutrophils in an area of granulation tissue, further encased by filamentous gram-negative bacillary structures (figure 1B,C). Fungal staining and modified Ziehl-Neelsen stain (1%) was negative. Culture of fluid aspirate from cyst grew out