A 26-year-old man surgical resident at a tertiary care hospital in Lima, Peru with no relevant medical history, developed a cutaneous lesion one week after sustaining a needlestick injury in his third left hand finger while performing a cervical lymphadenopathy aspiration. Source patient had been admitted to the hospital with a known diagnosis of HIV infection, failing HAART and cervical lymphadenopathy. He received prompt HIV post-exposure prophylaxis with tenofovir/emtricitabine and raltegravir with negative baseline and follow up HIV test.
One week after accident swelling and erythema developed in the site of puncture (Fig. 1A). Lesion progressed to ulceration with sero-purulent discharge despite receiving oral and parenteral antimicrobials for 3 weeks. He was admitted for diagnostic work up and surgical management of wound. On examination: He was in good overall condition and vital signs within normal range, throughout the course of illness. A cutaneous skin ulcer was noted in his third finger of left hand with erythema of the ulcer margins and yellowish secretion (Fig. 1B) and limitation of affected finger mobility secondary to presence of the lesion. There were no enlarged regional lymph nodes and the rest of exam unremarkable. Blood-work including complete cell count, liver and renal function and chest and finger radiographs were normal.
A surgical exploration and debridement of the finger lesion was performed and tissue for biopsy and bacterial, fungi and mycobacterial cultures were sent. Histopathologic findings revealed an acute and chronic inflammation, with epithelioid granulomas, Langhan's giant cells and foci of caseous necrosis (Fig. 2A). Ziehl-Neelsen (ZN) stain detected the presence of acid-fast bacilli (Fig. 2B). Six weeks later, tissue culture grew one colony of Mycobacterium tuberculosis and Genotype   MTBDR Plus showed isoniazid and rifampicin sensitivity.
The patient was treated with weight-adjusted doses of four-drug tuberculosis treatment (isoniazid, rifampin, pyrazinamide and ethambutol) for 2 months followed by 6 months of a two-drug regimen with gradual resolution of lesion (Fig. 1C) and full functional recovery.
Additional management included restriction to perform procedures and direct patient care until complete healing of ulcer.