The patient was started on piperacillin-tazobactam, assuming bacterial abscess. Complete needle aspiration of the collection plus axillary core biopsies were performed, and Mycobacterium tuberculosis (Mt) was actively sought, due to the scrofulous appearance of the skin. The serohematic aspirate was negative for acid-fast bacteria in the Ziehl-Neelsen stain, as were culture and polymerase chain reaction (PCR) with cartridge-based nucleic acid amplification test for Mt. The biopsy showed fibroadipose tissue and necrotic material without granulomas. The biopsy's culture was positive for Mt in both Lowenstein-Jensen medium and BACTECTM MGITTM, showing no drug resistance in Middlebrook 7H10, thereby indicating a diagnosis of BTB. Lung TB was ruled out, with bronchial secretions and bronchoalveolar lavage being negative for Mt in Lowenstein-Jensen, BACTECTM MGITTM, and PCR. The patient's four-year-old son, whom she had breastfed for one year, had a negative TB screening.
The patient was started on daily weight-adjusted isoniazid (H) 300 mg, rifampin (R) 600 mg, pyrazinamide (Z) 1000 mg, and ethambutol (E) 800 mg, plus pyridoxine 40 mg. After consulting with the surgery team, we prioritized minimally invasive procedures, to reduce additional trauma to an already severe keloid scarring process, reserving surgery in case of refractoriness.
Her condition significantly improved in the first month of treatment with HRZE, with remission of fever and night sweats, ceasing of fistula drainage, and breast size reduction. Her anemia improved and ESR and CRP returned to normal levels (9 mm/h and 0.17 mg/dL, respectively). She completed 12 months of antituberculosis regimen (two months of HRZE followed by 10 months of HR), with complete resolution of symptoms, the disappearance of liver lesions, and the return of spleen size to normal; her lymph nodes decreased in size, despite maintaining a necrotic center.