A 27 year old female patient came to our department with discharging sinus from proximal part of third metacarpal of left hand and pain. Detailed history revealed that she got minor abrasions by some trivial injury over left hand about 2 months back. These abrasions resolved spontaneously but small nodular swelling developed over the proximal part of third metacarpal bone of left hand. During this period she also had pain at local area and low grade pyrexia. She was given antibiotics and other supportive treatment for one month. After one month there was no improvement and sinus formed with discharging pus in that swelling. There was no past history of antitubercular treatment as well as no history of contact to a known case of tuberculosis.
General examination revealed average built of patient with no significant peripheral lymphadenopathy. Examination of left hand revealed retraction of overlying skin over the proximal part of third metacarpal bone of left hand and pus discharging sinus (figure: 1). Her resting pulse rate was 92/min and blood pressure was 112/68mmHg. Respiratory system examination was within normal limit. Examination of others system was unremarkable. Her Haemoglobin was 14 gm%; Total Leucocyte count was 8,900/cmm; Differential Leucocyte count was Neutrophils 72%, Lymphocytes 17% and Monocytes 7%, eosinophil 4% and Erythrocyte sedimentation rate was 58 mm/hour. Her blood culture was sterile. She was HIV seronegative. Her chest x-ray was normal (Figure: 2). X-ray left hand AP and lateral view revealed osteolytic lesions over neck of third metacarpal bone (fig 3). Her Ultrasonography abdomen revealed no abnormality. Her mantoux test showed 34 mm indurations at 72 hours. Pus from discharging sinus was negative for acid fast bacilli on three occasions. Pus culture was positive for Mycobacterium Tuberculosis by Bactec method.
So the diagnosis of tubercular dactylitis was established and her treatment was began with 4 drugs (Rifampicin, Ethambutol, Isoniazid and Pyrazinamide) for 2 months, followed by 2 drugs (Rifampicin, Isoniazid) for 4 months. Swelling disappeared and sinus healed after six months of institution of antitubercular treatment along with decrement of shadow in radiology (Figure: 4).