Case 2:
An eight-month-old girl was presented due to a left thigh swelling since birth. There was erythema on the site for the first 40 days after birth and then it was healed spontaneously but the swelling remained for eight months and was exacerbated in the last three days before referral. The patient’s past medical history was unremarkable except for pneumonia when she was one month old. At the time of admission, the patient had an appropriate general condition; there was no fever, and other vital signs were stable. On general physical examination, there was no abnormal finding including no lymphadenopathy. There was a swelling mass sized 7*7 (cm) on the lateral side of the left thigh. There was no erythema or inflammation on the site and it was not tender on palpation. Laboratory findings showed WBC: 19900/μl (PMN: 20% and Lymphocyte: 80%), Hemoglobin: 12.3 mg/dl, Platelet: 335000/μl, and ESR: 5 mm/h. BUN, Cr, and liver function tests were within normal ranges. The ultrasound examination of thigh soft tissue and X-ray of left femoral bone were requested. Ultrasound results demonstrated an echo-free zone with a thick wall (41*65*39 mm, approximately 57 ml, 6 mm under the skin) containing faint debris in the depth of the left thigh muscle. The X-ray was normal. The patient underwent surgical drainage and debridement of the lesion. Before the surgery, needle aspiration of the lesion was done and samples were sent for gram staining, acid-fast staining, culture, and PCR examination of various mycobacterium types. Gram staining and routine culture were negative. Acid-fast staining and culture on Loewenstein Jensen culture media were both positive for Mycobacterium Tuberculosis. The PCR test result was positive for Mycobacterium Bovis (the subtype of Mycobacterium in the BCG vaccine). Also, Tuberculin Skin Test (TST) was done and the result showed 0 mm induration. The patient received Clindamycin after admission to cover possible causes of the abscess. After a confirmed diagnosis of tubercular cold abscess, clindamycin was discontinued and Isoniazid, Rifampin were started and continued for the next six months. The patient had good growth and development with no further re-accumulation of pus or any other remarkable health problem during the follow-up.