Multiple Discharging Sinuses with Disseminated Dactylitis

Department of Pediatrics, Maulana Azad Medical College & Associated Chacha Nehru Bal Chikitsalya, 
Geeta Colony, Delhi, India.
Email: [email protected]
 

A 10-year-old male presented with fever, cough, poor oral acceptance, weight loss, and multiple painless swellings associated with serosanguineous discharge for last six weeks. He had already received multiple courses of antibiotics before presenting to us. On examination, four spindle shaped swellings with discharging sinuses were present over right index, middle and ring fingers. There were two discharging sinuses present over the dorsum of left hand and on the medial aspect of left thigh. An ulcer with discharging sinus was present over lateral aspect of left ankle (Fig. 1). He was severely wasted. Hands X-ray revealed multiple lytic lesions with little periosteal reaction in underlying respective phalanges and metacarpal bones. Chest X-ray showed nodular miliary shadows. The Ziehl-Neelsen staining of the discharges taken separately from all discharging sinuses, demonstrated acid fast bacilli. After one month of antitubercular treatment, all discharging sinuses completely healed.

Fig.1 (a)Spindle shaped swellings with discharging sinuses over index, middle and ring fingers of right hand, (b) Discharging sinus present over the dorsum of left hand, (c) Discharging sinus present over left thigh, (d) An ulcer with discharging sinus over left ankle.

Tuberculosis (TB) of metatarsals, metacarpals and phalanges is usually associated with active pulmonary involvement, as observed in present case. TB of phalanges results in characteristic spindle shaped swelling of fingers, a condition known as spina ventosa. Spina is a latin word for "short bone" and ventosa is a latin word for "inflated with air". The differential diagnosis of such a swelling includes syphilis and sickle cell dactylitis. Disseminated tubercular dactylitis, as seen in this case has been reported very rarely. Differentials for multiple discharging sinuses in children include staphylococcal infection and mucormycosis, both are rapidly progressive in nature, and later is associated with necrosis of skin and subcutaneous tissue leading to eschar formation. Other gradually progressive diseases presenting as discharging sin-uses in children are actinomycosis, botryomycosis, nocardiosis, and sporotrichosis. Sinus tracts of actinomycosis and nocardiosis usually discharge granules; botryomycosis is associated with subcutaneous nodules and large verrucous (wart-like) lesions; and in sporotrichosis an ascending chain of nodules develops along skin lymphatic channels (nodular angiitis).