A 28-year-old woman with previously untreated HIV infection, born in Ecuador and residing in Spain from one month before the onset of symptoms.
Established on October 14, 2006 for a four-day history of fever of up to 40.8oC, pleuritic pain in the right hemithorax, irritative cough and appearance of a painful mass in the left third
Investigations revealed significant cachexia with a weight of 38 kg (BMI 16.4 kg/m2), temperature of 37.4 ° C, basal oxygen saturation of 97%, clearance of the following third vesicular hairy cell in the right side 127 mg
The CD4 lymphocyte count was 137/μL and the HIV viral load was 278,000 copies/mL.
The chest X-ray showed a right pleural effusion accompanied by condensation in the ipsilateral midfield.
The chest CT scan showed hiliar and mediastinal lymphadenopathy, together with atelectasis of the middle lobe, a right pleural effusion of moderate magnitude and a bilateral nodullary pattern.
Plain radiography of the left side revealed a lytic lesion in the fibula diaphysis with cortical and medullary destruction, peripherical interruption and presence of a soft tissue mass adjacent to the bone lesion.
Median ultrasound study of this mass was found its cystic appearance and the existence of septa inside.
Magnetic resonance imaging confirmed the radiological diagnosis of osteomyelitis of the middle third of the perineum with cortical rupture and adjacent soft tissue abscess.
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An aspiration puncture of the mass of the left lower extremity was performed, obtaining a purulent material that was sent to the Microbiology Service.
Ziehl-Neelsen staining and detection of Mycobacterium tuberculosis-specific RNA (MTD-Gen Probe) performed on this material and on three previously obtained sputum samples were positive.
The strain of Mycobacterum tuberculosis isolated in culture from these samples was sensitive to all anti-tuberculosis agents of first line.
The pleural fluid obtained by puncture was exudate with high levels of adenosine deaminase (47.4 U/L) and Ziehl-Neelsen staining and culture negative.
No detection of Mycobacterium tuberculosis RNA was performed in pleural fluid.
Conventional bacterial cultures of all samples discussed and blood cultures were negative.
On October 24, 2006, isoniazid treatment with rifampicin, pyrazinamide and isoniazid was started, and 15 days later, antiretroviral treatment with Tenofovir + 3TC + Nevirapine was started.
On November 19, the patient developed a generalized and intensely pruritic rash that disappeared within 48 hours after the withdrawal of rifampicin and its replacement with etambu bag.
On November 30, with the persistence of fever and fluctuating mass at the level of the left lower extremity, surgical drainage of the abscess was performed.
Thereafter the thermal curve was modified, and the fever disappeared completely with the addition of prednisone to the therapeutic regimen.
The subsequent evolution was favorable, being discharged after sixty days of hospitalization.
In the first outpatient review, performed on January 12 2007, the patient had gained 7 kilos of weight and correctly fulfilled all the treatment with good clinical tolerance.
The chest X-ray showed almost complete disappearance of the right lesions, persisting only a minimal residual paracardiac infiltrate.
The CD4 lymphocyte count was 119/μL and the HIV viral load was undetectable (<40 copies/ml).
