GW Kim, et al caused by a lesion in the lymph node, bone, muscle or tendon that continuously spreads to the skin2-4. The skin lesion first presents as painless, subcutaneous nodules, which is called a cold abscess. Then, the reddish- blue induration suppurates and breaks down, forming an ulcer with granulating tissue at the base. Sometimes sinu- ses may develop and communicate directly with areas of deep infection. Progression and scarring produce irregular adherent masses, densely fibrous in places, and fluctuant or discharging in others2-4. The disease is usually slow- growing, and has an insidious course and an unusual pre- sentation; a chronically discharging sinus or a non-healing ulcer are possible4. Scrofuloderma remains a diagnostic and therapeutic chal- lenge because the clinical appearance of the lesions is not always characteristic, and a positive culture result is not always obtained1,7. This case highlights delayed diagnosis of scrofuloderma presenting as a bacterial abscess. Al- though our case presents typical features of scrofuloderma, the presence of purulent discharge, prominent ulceration, or features suggestive of a carbuncle can cause further confusion and misdiagnosis as a bacterial abscess7. More- over, radiologic evaluation on CT also led to the possi- bility of secondary lesions from an abscess or malignancy. The delay in the diagnosis emphasizes the importance of maintaining a high level of suspicion. In our case, scrofuloderma was confirmed by the presence of acid fast bacilli on AFB staining and a positive culture for Mycobacterium tuberculosis. Supportive evidence in- cluded the presence of epithelioid granulomas on histo- pathologic examination and a positive result on PCR for mycobacteria. Scrofuloderma may be a manifestation of systemic tuber- culous disease and can result from direct extension or 72 Ann Dermatol Fig. 4. 1 cm small calcified nodules on the right upper pulmonary lobe (A), and peripheral enhancing low density lesions (arrow) on the left neck (B). hematogeneous spread of the infection6. The incidence of systemic involvement in adults with scrofuloderma has been reported to be as high as 35%6. Of note, using PCR to identify the infectious agents has increased the sensi- tivity and improved the overall detection rate among those with a diagnosis of cutaneous tuberculosis7,8. A further advantage of PCR is the possibility of earlier initiation of treatment7,8. Histology may show marked caseation necrosis, with numerous bacteria usually in the deeper structures2,9. The center of the lesion is dominated by necrosis and abscess material with inflammatory infiltrates. In the epidermis, scarring and atrophic changes often predominate. Tuber- cle bacilli are usually easy to identify in the purulent discharge or biopsy tissue3. Chemotherapy still remains the treatment of choice2,10. It aims to cure the disease as rapidly as possible in order to prevent relapses and the emergence of resistant strains. The standard 6-month regimen for adults includes isonia- zid, rifampin, pyrazinamide, and ethambutol for the initial 2 months followed by isoniazid and rifampin for a further 4 months in the continuation phase2,10. When a therapeu- tic trial is undertaken in a case of cutaneous tuberculosis, 6 weeks of therapy with four drugs appears adequate to confirm the diagnosis11. The response to anti-tuberculous treatment alone as a primary therapy is usually good, but some authors have recommended wide surgical removal of all diseased tissue, combined with pharmacologic anti- tuberculous treatment2,3. Our case serves as a reminder that chronic neck ulcers may be due to cutaneous tuberculosis and that pulmonary tuberculosis may be a focus for tuberculous infection. A chronic, non-healing ulcer is a common presentation of scrofuloderma. Nevertheless, scrofuloderma with concomi-