Miliary tuberculosis and central nervous system infection caused by hematogenous transmission from a primary subcutaneous tuberculous abscess: A case report

Rationale We report an extremely rare case in which delayed diagnosis and treatment of Mycobacterium tuberculosis infection primarily involving the subcutaneous tissues of an extremity led to hematogenous dissemination of the infection and subsequent deterioration of the patient. Patient concerns An 82-year-old man presented to our hospital with a painful mass on the right ankle for over a year, as well as persistent fever and shortness of breath for >14 days. He received piperacillin/tazobactam followed by meropenem, which failed to decrease his peak temperature. Diagnoses After performing chest computed tomography, acid-fast staining of the abscess specimen, GeneXpert M tuberculosis/rifampin assay, and cerebrospinal fluid tests, the patient was diagnosed with miliary pulmonary tuberculosis and tuberculous meningitis hematogenously transmitted from a primary subcutaneous tuberculous abscess. Interventions Isoniazid, rifampin, levofloxacin, linezolid, and ethambutol were administered through a nasogastric tube to treat the tuberculosis, and 5 mg of dexamethasone was administered to reduce the inflammatory response. Outcomes The treatment was halted because of poor compliance, and the patient died of respiratory failure within 1 month of returning home. Lessons We suggest tuberculosis screening or biopsy recommendations for chronic soft tissue swellings in high tuberculosis-burden areas, to avoid missed or delayed diagnosis.