Page 79 - SAHCS HIVMed Journal Vol 20 No 1 2019

Page 2 of 3 Case Report

Cases cutaneous TB. He died four weeks after starting treatment

Case 1 from respiratory tract infection, the cause of which was not
determined, as the patient died on arrival at the hospital and
A 34-year-old HIV-infected man, who had been on no autopsy was done.
antiretroviral therapy (ART) for eight months, presented to
hospital with a skin abscess on his lower back of more than 1 Case 3
month’s duration. He had been treated with amoxicillin- A 42-year-old HIV-positive female patient who had never
clavulanic acid at a nearby primary healthcare (PHC) facility been on ART presented to her local hospital with a 2-month
on first presentation. Upon return to the PHC facility one history of a non-healing cold abscess on the right forearm.
month later, the abscess had increased in size, and the patient The patient had been treated with flucloxacillin and
was referred to the hospital. Aspirates were taken from the trimethoprim-sulfamethoxazole by her local GP, whom she
abscess and submitted to the laboratory of medical consulted on three occasions prior to hospital presentation.
microbiology, where both the Xpert® Mycobacterium Incision and drainage was also done by the GP during her
tuberculosis (MTB)/Rif and line probe assay detected M. last visit. Abscess aspirates were collected and submitted to a
tuberculosis. Based on these two tests, the strain was determined microbiology laboratory, where M. tuberculosis was detected
to be resistant to rifampicin and sensitive to isoniazid. Second- by MGIT culture and confirmed by line probe assay. The
line drug susceptibility testing revealed that the strain was patient was initiated on a first-line anti-TB regimen:
sensitive to second-line injectable drugs and fluoroquinolones. rifampicin, isoniazid, pyrazinamide and ethambutol.
Of note is that the patient completed treatment for drug- Pulmonary TB was also diagnosed a month later following
sensitive pulmonary TB 6 months prior to presenting with the new onset of cough, loss of weight and a positive Xpert® test
skin abscess and had no concomitant signs or symptoms of on sputum. Both the cutaneous and pulmonary M. tuberculosis
pulmonary TB when he presented with the skin abscess. It is strains were susceptible to rifampicin and isoniazid; and the
not known if the pulmonary TB was cured. His CD4+ count initial treatment was continued following the diagnosis of
was 122 cells/µL when ART was initiated and 30 cells/µL pulmonary TB. The patient was lost to follow-up and thus
at the time of cutaneous TB diagnosis. He was initiated the outcome is unknown.
on kanamycin, moxifloxacin, ethionamide, terizidone,
ethambutol, isoniazid and pyrazinamide for cutaneous Ethical consideration
rifampicin-resistant TB (regimen used in 2016). The patient
died at home two weeks after TB treatment initiation; cause of Ethical approval was obtained from the Faculty of Health
death could not be determined. Sciences Research Ethics Committee of the University of
Pretoria (ethics reference number: 145/2018).
Case 2 Discussion

A 21-month-old male paediatric patient on ART for eight
months presented with multiple abscesses on the forearms Cutaneous TB can be acquired through direct infection of the
and torso. His mother was on drug-sensitive TB treatment at skin (exogenous TB) or from haematogenous spread of TB
11
the time of the patient’s presentation, and a year prior, the elsewhere in the body. It may not always be obvious how
father had died of pulmonary TB. The patient received the patient acquired the cutaneous TB. Haematogenous
bacillus Calmette-Guérin vaccine at birth. He had first spread of TB may be the most likely cause in the first patient,
presented at the general practitioner (GP) with a week’s as he had recently been treated for pulmonary TB and
history of intermittent cough, papular lesions on the torso presented with low CD4+ count, putting him at increased
and failure to thrive. The treatment given by the GP included risk for disseminated infection. Direct infection of the skin
amoxicillin, trimethoprim-sulfamethoxazole and vitamin B could have occurred in the second patient, although
complex syrup. Gastric aspirates tested negative for TB with haematogenous spread of asymptomatic pulmonary infection
Ziehl-Neelsen and mycobacteria growth indicator tube is more likely because children are more prone to disseminated
(MGIT) culture. The patient returned to the GP a month later, TB. The mode of acquisition is unclear in the third patient.
and the papular lesions had formed abscesses and extended It is clinically important, however, to assess patients with
to the forearms. The patient was transferred to the hospital cutaneous TB for the presence of pulmonary infection,
for further management. Mycobacteria growth indicator tube especially because these infections may be caused by strains
culture of the abscess aspirate grew M. tuberculosis, and line with different resistance profiles. 12
probe assay confirmed the organism as sensitive to rifampicin
and isoniazid. Two respiratory specimens collected at Despite the strong association with HIV, cutaneous TB is
different times after cutaneous TB diagnosis tested negative rarely reported in South Africa, the country with the largest
for M. tuberculosis. Hospital records showed poor adherence HIV–TB epidemic in the world. 11,13 Most likely, under-
to HIV treatment as evident by HIV viral load of diagnosis and under-reporting occur because of the limited
260 000 copies/mL six months after ART initiation and awareness of this condition. The clinical presentation of
missed follow-up appointments. The patient was initiated on cutaneous TB is non-specific and variable. The cases
rifampicin, isoniazid, pyrazinamide and ethambutol for presented illustrate that skin lesions may occur on different

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