A 38-year-old woman with advanced HIV disease (antiretroviral treatment experienced with treatment interruption) presented to Khayelitsha District Hospital with multiple cutaneous abscesses and associated constitutional symptoms of loss of appetite, loss of weight and night sweats. She reported a 3-month history of subcutaneous swellings with overlying hyperpigmentation affecting the arms, legs and buttocks, which subsequently formed spontaneous sinuses with drainage of purulent discharge.
The patient had a history of three previous episodes of drug-sensitive TB and had completed anti-TB treatment on all occasions (Table 1). She had recently been admitted to the surgical department where she was diagnosed with lower limb cellulitis complicated by soft tissue collections. During that admission, an incision and drainage procedure was performed, and the patient received an oral course of amoxicillin and clavulanic acid. Routine microscopy, culture and sensitivity of the pus did not identify any bacterial pathogen; however, a specific mycobacterial culture was not requested.
On admission to the internal medicine department, the patient had a tachycardia and a documented fever. She was cachectic with pallor and generalised lymphadenopathy. She had multiple skin lesions with a widespread distribution, affecting predominantly the lower limbs, perianal area, hands and face. The lower limb and perianal lesions involved subcutaneous collections with overlying hyperpigmented patches and central fluctuance. Certain of these collections had ulcerated with draining sinuses (Figure 1). Her facial lesions were hyperpigmented papules and plaques predominantly affecting the nasal area and associated with crusting suggestive of lupus vulgaris (Figure 2). Initial blood results showed acute kidney impairment, normocytic anaemia and an elevated C-reactive protein (Table 2).