A 27-year-old previously healthy African male medical intern sustained a needle-stick injury from a wide bore needle (gauge 18) to his little finger while performing a lumbar puncture on a HIV-infected patient. He sustained a small lesion that bled a little and he immediately washed it with water and soap. He was immediately started on postexposure prophylaxis Anti-Retroviral drugs (ARVs): Zidovudine, Lamivudine and Kaletra for 28 days as per the Kenya National AIDS Control Program protocol. His initial rapid HIV test (Determine) test was negative and so was a PCR done on completion of the ARVs. He had no significant past medical history.
The patient source, an African Female, was WHO clinical stage 4, not on ARVs and was being investigated for meningitis died soon the lumbar puncture and her results were not followed up until several months later.
Two weeks after the injury, the intern had swelling of the little finger associated with a persistent dull ache for which he sought surgical intervention. Pus was aspirated from the finger and incision and drainage were done under local anesthesia. Culture of the pus grew Staphylococcus aureus sensitive to flucloxacillin on which he was started.
His little finger now had an open wound that persisted for several months despite debridement and different antibiotic regimens: levofloxacin, clindamycin, ceftriaxone, and vancomycin. The intern continued to clean and dress his wound daily.
He developed painless axillary lymphadenopathy 6 weeks after the injury. For the next 6 months, there was persistent swelling of the little finger which seemed to be spreading to the hand (Fig.1). This was accompanied with low-grade fever, night sweats, and subjective weight loss. He underwent a surgical debridement 6 months after the injury and was started on levofloxacin. Intraoperatively necrotic debris was found.
Radiographic examinations done during the course of illness showed no bone involvement. Serial blood counts done in the course of illness showed persistently elevated lymphocytes and a raised ESR. Liver function test and renal tests were normal.
Ten months later and with no improvement of symptoms, he underwent yet another surgical debridement. Histological examination of the tissue taken revealed a chronic inflammatory process (Fig.2), granulomatous tubercles with epithelioid cells (Fig.3), giant cells of Langerhans (Fig.4), and a mononuclear infiltrate but no acid-fast bacilli (AFB) were demonstrated on Ziehl-Nelson stain.
He was started on rifampicin, isoniazid, pyrazinamide, and ethambutol for duration of 2 months to be followed by a 4-month course of rifampicin and isoniazid. The intern had complete recovery by the end of the 6 months. A rapid HIV test done at the end of the anti-TB treatment was negative.