An unusual sore finger...

1 of 3 DESCRIPTION We describe the case of a 75-year-old man with a history of chronic lymphoid leukaemia stage B in Binet system treated by chemotherapy with chlorambucil and prednisolone. The patient was in complete remission with this treatment for 3 years. When he presented to our department, he complained of two painful and indurated swellings in the right fi fth fi nger and in the right wrist that had appeared 7 months before ( fi gures 1A and B ). Blood tests showed increased erythrocyte sedimentation rate and C reactive protein level with a normal white cell count. Tests for rheumatoid arthritis factor, hepatitis B and C viruses, HIV, brucella and Salmonella typhi were negative. Mantoux tuberculin skin test showed an induration of 34 mm after 72 h. A tuberculous infection was suspected but bronchoalveolar lavage and mycobacterium culture was negative. A surgical synovectomy was performed and macroscopic fi ndings revealed numerous white nodules that appeared like scattered grains of boiled rice ( fi gure 2 ). Histopathological examination of the biopsy specimen revealed granulomatous infl ammation with caseous necrosis ( fi gure 3 ). The diagnosis of tuberculous dactylitis was established and treatment was initiated with four drugs (rifampicine, ethambutol, isoniazide and pyrazinamide) for 2 months followed by two drugs (rifampicine and isoniazide) for 6 months. The swelling disappeared and dactylitis was cured 6 months after initiation of antitubercular treatment.