When Pulmonary TB Gets Under Your Skin: A Case Pulmonary Tuberculosis Causing Cutaneous Fistula With Lung Collapse

Abstract Introduction:Tuberculosis (TB) continues to be a major global health issue, particularly in under-sourced regions. Although TB primarily affects the lungs, extra-pulmonary tuberculosis with cutaneous manifestations can occur and serve as important diagnostic clues, especially in atypical cases. Herein, we present a 24-year-old male from Micronesia, an area with high TB incidence, who developed a cutaneous lesion following blunt trauma to the chest, ultimately found to have a cutaneous fistula to the lung cavity caused by TB. This case emphasizes the importance of considering TB in the differential diagnosis of unusual skin lesions in high-risk populations.Case Presentation:The patient presented with a 10-day history of right lower chest wall pain and swelling, which periodically drained white fluid following blunt chest trauma. He had a one-year history of nonproductive cough, night sweats, and unintentional weight loss. On admission, he was tachycardic, afebrile, and had tenderness over the chest wall with an oozing ulcerated lesion. Laboratory tests showed leukocytosis, anemia, and elevated inflammatory markers. A CT scan revealed a complex pleural effusion, and bronchoscopy confirmed TB infection via positive polymerase chain reaction (PCR) from bronchoalveolar lavage fluid. The patient was started on RIPE therapy (rifampin, isoniazid, pyrazinamide, and ethambutol) and managed conservatively for empyema, allowing auto-drainage through the pulmocutaneous fistula that was collected via an ostomy bag that was placed on the chest wall for ease and infection control. Consultation with regional TB experts advised against aggressive interventions such as intrapleural antibiotics/lytics or chest tube placement. The patient was discharged after 14 days, with outpatient follow-up for continuation of RIPE therapy through the local county TB program.Discussion:Cutaneous TB can result from exogenous, endogenous, or hematogenous spread. Trauma-associated reactivation, as seen in this case, is rare but important to recognize. We suspect our patient experienced reactivation of latent TB after trauma, leading to disseminated disease with pulmocutaneous fistulization. Despite improvements in global TB control, including in Micronesia, certain regions continue to experience high TB incidence, underscoring the need for ongoing vigilance and multidisciplinary care.This case highlights the complexity of TB presentations and its potential reactivation following trauma. It also emphasizes the critical role of coordinated care among infectious disease specialists, pulmonologists, radiologists, and surgeons in managing both typical and atypical TB manifestations.