This was a case of a 56-year-old mestizo man from Armenia, department of Quindío, Colombia, who on September 5, 2011 had pain, erythema and heat and reported the occurrence of painful lesions in the right outpatient clinic.
The answer was not the expected, so the patient attended the consultation of the Hospital San Ignacio of Bogotá.
On admission, the patient presented cough with occasional hyaline expectoration of one month of evolution, in addition to reporting febrile episodes.
On physical examination, signs of systemic inflammatory response were found with no apparent painful inflammation adeno43 mm Hg), tachycardia (133 beats per minute), tachypnea (24 breaths per minute), and neurological involvement locomotive septic shock cm.
No alterations were detected in the cardiopulmonary auscultation or in the examination of the abdomen; there was an acuminated lesion in the lumbar region; in the neck region general sarcopenia, grade 1, ulcer, grade 1.
The neurological evaluation showed that the patient obeyed orders, but showed disorientation when asked about his identity, location and time.
Diagnostic support tests were performed, which yielded the following results: in the blood analysis, white blood cell count was 8.300 mEq/L, serum creatinine was 3.74 mEq/L, serum creatinine was 3.74 mEq/L, serum creatinine was 3.37 mEq/L, and 8.3 mEq/L was 4.27 mg/L, blood was 4.
The chest X-ray showed diffusely distributed micronodular opacities (milliary pattern), a finding that was confirmed after performing a high resolution computed tomography in which cervical lymphadenopathy was also observed (AU)
and figure 2).
1.
Based on these clinical and paraclinical findings, it was decided to hospitalize the patient and resuscitation with fluids and vasopressive agents was initiated and extension studies were performed.
Due to the antibiotics administered, it was considered the possibility that the etiological agent of the lesion in the forearm was Staphylococcus aureus resistant to A. aegypti, for which treatment with vancomycin was initiated.
Based on the clinical history, the physical examination and the alterations found in the paraclinical tests, and after signing the informed consent by the patient, on September 6, 2011, we performed the Western blot positive test for HIV.
The following imaging tests were also performed: x-ray of the right hand, in which accentuated and overt bone lesion was observed; ultrasound showed mild ventricular computed tomography, discrete increase of the abdomen and slight hepatic dilatation.
1.
Right lung resection in PCR and left upper lobectomy were performed in order to take samples for pathological, microbiological and molecular studies; in addition, cerebrospinal fluid samples were taken for the detection of M. tuberculosis chain reaction with the technique.
In the histopathological study of the lung, abundant lymphocytic mononuclear inflammatory infiltrate was reported, with formation of histiolinary granulomas, central necrosis and Langhans type cells; similar findings were found in the bone marrow studies.
The staining for acid-fast bacilli was positive in all samples, while those employed for acid-fast bacilli were negative.
1.
Samples of lung and tissue, as well as cerebrospinal fluid for molecular study of tuberculous mycobacteria and osteobacteria National University of Colombia (gene sequences IS6110 and hsp65 ) M were sent to the Laboratory of Mycobacterium.
These analyses confirmed the presence of pulmonary, bone and meningeal infection by a mycobacteria belonging to the M. tuberculosis complex.
Cultures in solid medium were positive and isolates showed sensitivity to first-line antiphymics.
1.
In response to the findings described, antituberculosis therapy was initiated with the tetra-conjugated regimen (rifampicin, isoniazid, and continued anti-tuberculosis therapy); lamivudine was started with antiretroviral therapy (48 months).
The clinical evolution of the patient was satisfactory and, currently, continues to attend outpatient medical controls.
