Case Number : Case 2069 - 11 May 2018 Posted By: Dr. Richard Carr

Excellent quality clinical photographs of unilateral “cold abscesses” in someone with a probable RA.

Suppurative and granulomatous dermatitis with a probable dermal abscess.

An infective cause needs to be considered first through appropriate stains and triple tissue cultures. In the UK most of these cases is related to Non-Tubeculous Mycobacterial (NTM) infections especially Mycobacterium Chelonae. Usually the latter is isolated in those on immunosuppresives especially oral Prednisolone, CPC is essential including history of trauma/fish tank etc.

Leishmaniasis. 

Chronic granulomatous inflammation either due to atypical mycobacterial infection or deep fungal infection.

Agree with Anil

Please see final two images for an extra clue!

Solid staining acid fast bacilli. - M chelonae or M fortuitum infection.

Very well done and Saman in particular. I had not told you this patient was on prednisolone for bullous pemphigoid. This was also culture +ve for M. chelonae.

Great case Richard and thanks for the feedback on final diagnosis.