A 56-year-old female patient with a history of dermatomyositis diagnosed one year prior to consultation was treated with hydroxychloroquine (Plaquinol®) 200 mg, methotrexate 10 mg and prednisone 30 mg daily.
The patient was hospitalized for 10 days, with fever, malaise and weight loss, and bilateral crackles were found on lung examination.
A chest CT scan showed an extensive bilateral nodular infiltrate with biapical cavitations.
Bronchoalveolar lavage (BAL) smear was positive and polymerase chain reaction (PCR) was positive for Mycobacterium tuberculosis.
The rest of the BAL study was negative (cultivational current, non-existent spp, immunofluorescence PCR for cystisiroveci, viral panel viral, cytomegalovirus j respiratory culture).
The Pathological Department was consulted for ulcers in the thumbs appearing four weeks prior to admission.
Physical examination revealed an ulcer with well-defined borders with a dirty background and necrotic edges, not painful, located in the pulp of the left thumb finger.
Biopsy showed extensive recent necrosis, without evidence of vasculitis or histopathological elements suggestive of TBC, with direct immunofluorescence for C3, IgA, IgG, IgM and fibrin negative.
S. aureus and Candidaparapsilosis grew in the current culture.
Ziehl Neelsen staining in tissue was positive.
Treatment was initiated with isoniazid (INH), rifampicin (RFP), pyrazinamide (PZ), and etambu, plus ceftriaxone and fluconazole.
The accelerated culture of Mycobacterium spp from the thumb ulcer was negative at 60 days; however, the culture obtained in BAL was positive at 30 days.
The patient was admitted to the Thoracic Hospital to continue treatment.
1.
Since this was an immunosuppressed patient with pulmonary tuberculosis (TBC), the thumb ulcer could correspond to a cold abscess.
