Dermatological window to a disseminated disease.

A 14 year old boy presented with fever and respiratory distress for four days. In view of moderate acute respiratory distress syndrome (ARDS), he was mechanically ventilated. Blood and bronchoalveolar lavage cultures for bacterial and fungal pathogens were sterile. His workup for tropical infections came out to be positive for chikungunya by IgM enzyme linked immunosorbent assay (ELISA). He was initially managed conservatively but his hospital stay became complicated with development of ventilator acquired pneumonia (Acinetobacter baumanni) and catheter related blood stream infection (Escherichia coli). He also developed an abscess in the right middle finger. It was thought to be a complication of bacteremia and was incised and drained. He improved with imipenem and was discharged on a tracheostomy tube.

Three weeks later, he presented with recurrence of fever and generalized tonic clonic seizures for two days. Anti-epileptics were given in the emergency room. The abscess on middle finger had recurred with development of maculo-papular eruptions on the medial aspect of right hand. (Fig. 1) MRI of the brain revealed altered signal intensity with nodular enhancement in left parietal and occipital lobes. Cerebrospinal fluid was acellular with raised protein, low sugar and normal adenosine deaminase levels. Auto-immune markers including ANA, ANCA and anti dsDNA were negative. A skin biopsy showed presence of acid fast bacilli. Trans-tracheal aspirate using liquid culture of Mycobacterium tuberculosis was also positive. Treatment was initiated with isoniazid, rifampin, pyrazinamide, ethambutol and corticosteroids. The skin lesions began to resolve and he became afebrile in two weeks. The follow up after one year of anti-tubercular therapy revealed complete clinical and radiological resolution.

Fig. 1

Photograph showing maculo-papular eruptions on the medial aspect of right hand.

Acute pulmonary tuberculosis is not an unknown entity in endemic settings with 1–5% cases presenting with acute respiratory distress syndrome [[1], [2]]. During the monsoon season, there is an outbreak of vector borne diseases (mostly viral) in many parts of India. Many of these cases can have pulmonary complications such as ARDS. Our patient was prematurely diagnosed with chikungunya infection because of the positive result on ELISA. This result could have been either a false positive or persistent positive from a past asymptomatic infection. His initial partial recovery may have been due to the anti-tubercular activity of imipenem. The correct and final diagnosis was made through analysis of the skin lesions. These seemingly innocuous lesions are often the most accessible site in establishing an otherwise difficult microbiological diagnosis and should be properly evaluated.

Declarations of interest

None.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.