Dear editor, We read with great interest the article by Go ZL et al., which was published in your esteemed journal1. The authors had reported an unusual and yet important case of cutaneous manifestations of malignancy. Being the only and initial presentation of Hodgkin’s lymphoma, prurigo nodularis can manifest as a benign dermatological appearance in the underlying sinister condition. We want to again highlight the importance of this bizarre cutaneous presentation which can counterfeit the actual and occult villain.
Introduction: Tuberculosis (TB) of the elbow joint is uncommon. Prompt diagnosis and treatment are important to prevent joint destruction and preserve function. We present a case of TB synovitis of the elbow joint in a patient with active rheumatoid arthritis (RA). Case description: A 56-year-old woman with a known seropositive RA on metho-trexate and Leflunomide was seen in the outpatient rheumatology clinic as part of her monthly follow-up. She com-plained of persistent bilateral elbow pain and swelling, despite optimisation of her disease-modifying antirheumatic drugs (DMARD) and steroid therapy. The suspicion for another diagnosis for her elbow symptoms stems from the persistent pain and swelling amidst increased titration of methotrexate and prednisolone dosages. Ultrasound scan of her elbows revealed bilateral complex olecranon bursitis with active synovitis. The left elbow aspiration yielded cloudy yellowish synovial fluid and the sample was sent for fluid culture, acid-fast bacilli (AFB) stain, and GeneXpert. No AFB was seen but the GeneXpert test confirmed the presence of Mycobacterium Tuberculosis. Thus, a diagnosis of TB synovitis of the left elbow was made, and she was promptly started on anti-tubercular therapy (ATT) consisting of Rifampicin, Isoniazid, Ethambutol and Pyrazinamide with the aim to complete 9 months of ATT. Conclusion: The diagnosis of tuberculous synovitis is challenging. In the absence of constitutional or respiratory symptoms, joint TB is usually low on the initial differential diagnosis in patients presenting with joint pain and swelling. The diagnosis is made even more difficult in patients with concomitant rheumatoid arthritis. This case demonstrates the importance of a high index of suspicion for TB, particularly when evaluating patients in high TB prevalence area with an underlying immunosuppressive state.
Introduction:Light’s criteria for pleural fluid analysis has long been the standard for distinguishing transudates from exudates. In pleural tuberculosis, the resulting pleural fluids are usually exudates. We present a case of presumed transudative effusion which was eventually diagnosed as pleural tuberculosis. Case description: A 59-year-old man with end-stage renal failure (ESRF) on regular haemodialysis presented with a one-day history of acute onset dys-pnoea associated with pleuritic chest pain and cough. Chest radiograph revealed bilateral pleural effusions and thoracentesis was done. The pleural fluid result was interpreted as transudative effusion according to Light’s criteria because his pleural fluid to serum protein ratio was less than 0.5. AFB 1+ was seen in the pleural fluid with negative gram stain and culture. This resulted in conflicting opinions on whether to start this patient on anti-tuberculous ther-apy (ATT) and there was even a suggestion to get a second opinion for the possibility of AFB fluid contamination. The initial diagnosis was written as fluid overload secondary to ESRF but ATT was started anyway to cover for pleural TB. On further analysis of his pleural fluid, the pleural protein 32 g/L which on its own is a marker of exudative effusion. Subsequent investigations revealed the presence of exudative ascitic fluid which further raised the suspicion for a concomitant peritoneal TB. Conclusion: Premature conclusion that the pleural fluid was transudative occurred prob-ably due to the bilateral nature of the pleural effusion associated with a known tendency for the patient to develop pulmonary overload secondary to his ESRF. This case is a reminder that Light’s criteria also requires serum and fluid LDH measurement for the diagnosis of transudative pleural effusion. More importantly, a high level of suspicion for TB is important when evaluating patients from areas where TB is prevalent and a positive AFB result should not be taken lightly.