[Therapy-resistant tuberculous skin abscesses after methylprednisolone therapy]

Systemic lupus erythematodes was suspected in a 55-year-old patient with arthralgias, secondary Raynaud's syndrome with acral necroses and increased antinuclear antibodies. Treatment with methylprednisolone was started but despite initial improvement of symptoms, the fever, weight loss and nocturnal sweating continued and the patient developed a progressive erythema on his left thigh. Skin biopsy revealed Mycobacterium tuberculosis.

Drug sensitivity tests of the initial culture isolate from the skin biopsy indicated response to all tested first-line drugs. The initial chest-x-ray showed only posttubercular lesions in both upper lobes. Computed tomography revealed a progressive infiltration in the right upper lobe and multiple disseminated lesions in both lungs. Mycobacteria were cultured from sputum. A fluorescence-activated cell analysis of peripheral leucocytes showed a decreased total T-cell-count of 173/microl.

Tuberculostatic treatment with five first-line drugs led to a temporary improvement of the patient's general condition and of the inflammatory signs. But the initially small cutaneous erythema expanded and developed into a large abscess, which could not be controlled even with surgery. Multiple necrotic lesions then developed rapidly in different areas of the skin without any response to various tuberculostatic drugs. Despite of several months of treatment the patient died of septic multi-organ-failure.

A possible explanation for the treatment-failure may have been the state of low immunity, either as a result of an underlying disease or after the methylprednisolone therapy. An alternative reason could be the insufficient penetration of the antibiotics into the necrotic abscesses.