Clinical Tropical Medicine 
Christian Medical College, Vellore, Tamilnadu, India

History:

Mrs  Mariya Magdalena, a diabetic for 9 years developed multiple nodular lesions at the left lateral aspect of the trunk 3 year ago. Lesions ulcerated and discharged pus. There was no associated fever, joint pains or oral ulcers. She was started on antibiotics but swelling did not resolve. Biopsy done outside showed ulcerated skin tissue with granulation in the dermis. No evidence of vasculitis. Soon the sinuses spread to the anterior chest wall. She now presents with low grade intermittent fever for 1 month with no chills or rigors. There was no weight or appetite loss, cough, hemoptysis, dyspnea, night sweats or evening rise of temperature. 8 years ago she had a cholecystectomy but following the operation she developed secondary infection which resolved but a discharging sinus persisted. Four years ago she developed a symptomatic left pleural effusion which settled with antituberculous treatment.

On examination she had normal vital signs.

On abdominal examination she had a palpable liver 2 cm below costal margin. There were multiple healed sinuses in the left back. There was one tender nodular lesion 5 x 4 cm in the left mammary area with an ulcer and actively discharging sinus.

On Examination

Patient is conscious and co-operative.

There was  pallor but no icterus, cyanosis, clubbing, or pedal edema.

2 left axillary lymph nodes were tender & significantly enlarged.

Pulse - 88/min: Blood pressure - 120/80 mm Hg.

Cardiovascular system: S1, S2 heard normally with no murmurs.

Respiratory system: Normal vesicular breath sounds heard, no added sounds.

Abdomen: Soft, no masses palpable, Liver was palpable 2 cm below right costal margin, spleen was palpable 3 cm below left costal margin, no evidence of free fluid. There were multiple, healed sinuses in the left back. One tender, nodular indurated lesion 5x4 cm in the left inframammary area with an ulcer, with an actively discharging sinus present.

Central nervous system: No focal neurological deficits.

Musculoskeletal system: Normal.

Skin: Normal.

Investigations:

Hb - 8.3 GM%  (Hypochromia Present,)

Platelet Count-  539000 CC.MM         

 WBC Total – 15800  /CU MM        

WBC DIFFERENTIAL : Neutrophils -  73 % ; Eosinophils - 3 % ; Basophils - 1 % ; Lymphocytes - 17 % ;             Monocytes – 6 %             

Creatinine - 1.0 mg%           

HBA1c (Glycosylated Hb)  - 8.5 %             

Blood Borne Virus Screen                 

            HIV     - Negative      

            HbsAg - Negative      

            HCV   -  Negative      

 

                       

Chest X-Ray  -           Left pleural effusion with trachea deviated to the right

CT  Thorax  &  Abdomen  /  Pelvis

  1. Large  ill-defined  diffuse  soft  tissue  lesion  noted  involving  the  parietal  abdominal  wall  muscles  in  left  hypochondriac  and  left  lumbar  region,  measuring  approximately  12x7cm  with  destruction  of  anterior  end  of  left  lower  rib. Intraabdominal  extension  of  the  soft  tissue  lesion  which  is  seen  encasing  the  spleen  with  loss  of  plane  of  cleavage  with  spleen. Multiple  hypodense  lesions  in  spleen  with  few  peripheral  wedge  shaped  lesions. Soft  tissue  extending  along  the  gastrosplenic  ligament  and  extending  along  left  lobe  of  liver  and  body  of  stomach and seen  in  close  relation  to  splenic  flexure  -  likely  to  be  involved.
  2. Sinusogram  shows  irregular  branching  sinus  tract  in  left  parietal  abdominal  wall
  3. Multiple  hypodense  lesions  in  spleen  with  few  peripheral  wedge  shaped  lesions  -  s/o  fungal  /  granulomatous  lesions  with  splenic  infarcts
  4.  Multiple  periportal,  paraaortic  and  left  axillary  adenopathy
  5.  Thrombosis  of  intrahepatic  IVC  with  multiple  abdominal  wall  collaterals  and  dilated  azygous  vein 
  6. Collapse  consolidation  of  left  lower  lobe  with  associated  minimal  pleural  thickening 

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