A 35-year-old male previously healthy surgeon sustained a needlestick injury while performing thoracentesis on a patient with smear-positive pulmonary tuberculosis (PTB) and was suspected of tuberculous pleurisy on November 9, 2012. The source patient was admitted to the local hospital because of respiratory failure, because his sputum detected acid-fast bacilli quickly, PTB was considered and was treated with isoniazid, rifampicin, ethambutol, and pyrazinamide. But his condition deteriorated rapidly and had acute hemopneumothorax. The surgeon in our study gave him an emergency chest puncture and drainage, and he collected the pleural effusion for tuberculosis culture. But he unfortunately sustained a needlestick injury while performing thoracentesis. He immediately disinfected the wound with povidone-iodine and washed it with water and soap. The source patient died the next day because of respiratory failure, it was less than a week before he was admitted to the hospital. Mtb were found in the source patient's hydrothorax culture; however, a susceptibility test was not performed. The surgeon had no history of TB infection or any other health problems. He was vaccinated with Bacillus Calmette-Guerin during childhood. The injury healed normally; however, after 3 weeks, redness, edema erythematous papule, and pain in his thumb at the previously injured site occurred, and then, the papule enlarged and subsequently resulted in abscess formation, which was drained using a needle, Ziehl-Neelsen stain, detecting acid-fast bacilli (AFB). The diagnosis of primary inoculation cutaneous TB was made based on the positive result of Ziehl-Neelsen staining and the source patient's hydrothorax culture. Then, he was treated with isoniazid, rifampicin, ethambutol, and pyrazinamide. After 10 days of treatment, the patient had a mild fever with chest tightness and noted multiple enlarged lymph nodes (LN) in his right axillary region. Then, he was transferred to our hospital.
Physical examination revealed an indurated erythematous plaque at the middle of the thumb, a few clear liquids can be observed when pressed (Figure 1A), and tender multiple right axillary LN. Mild movement limitation of the affected finger's mobility was caused by the presence of a lesion. Laboratory testing revealed an elevated C-reactive protein level and a white blood cell count of 21.6 mg/L and 8800 cells/muL, respectively, with 76.7% neutrophils. Human immunodeficiency virus (HIV) types 1/2 and hepatitis viral panels were negative. A chest computed tomography (CT) scan showed multiple enlarged LN in the right axilla and right pleural effusion (white arrows) (Figure 2A). Magnetic resonance imaging (MRI) of the right hand (conducted 50 days after the needlestick) showed tenosynovitis involvement of the entire flexor tendon of the thumb (Figure 2B). The patient underwent thoracic puncture and drainage in our hospital, the pleural effusion was exudative, and the pleural fluid protein was 37.83 g/L. However, acid-fast staining of the pleural fluid was negative, and the general bacterial culture and TB culture were negative.  
The puncture fluid from the skin lesion was cultured, and Mtb was observed thereafter. Susceptibility was demonstrated against isoniazid and rifampicin. Therefore, the regimen was changed to moxifloxacin (400 mg daily), amikacin (400 mg daily), pyrazinamide (1500 mg daily), prothionamide (600 mg daily), and aminosalicylate (10 g, daily). However, amikacin was discontinued at 5.5 months because the patient complained of tinnitus and aural fullness, then the remaining drugs were continuously administered for 16 months without any other adverse effects. After 4 weeks of treatment, the finger lesion had disappeared (Figure 1B). Axillary adenopathy disappeared approximately 6 months post-treatment. The surgeon completed recovery by the end of the 22-month course of anti-MDR-TB therapy and returned to work afterward and gained normal thumb functions. The patient was maintained in the 8-year follow-up without any relapse.