SHM Converge Scientific Abstract ePoster Gallery-Tubercular Dactylitis Following Tocilizumab Therapy for Severe Covid-19 Infection

Pdf Summary

A 77-year-old Russian-speaking woman with coronary disease, hypothyroidism, hypertension, and severe COVID-19 infection four months earlier developed progressive right thumb pain. Her COVID-19 treatment had included steroids, fluvoxamine, and tocilizumab; pre-treatment TB screening with a T-spot IGRA was negative. She also had additional TB risk factors, including prior residence in an endemic region and occupational exposure in a microbiology lab.<br /><br />Initial urgent care evaluation showed only soft tissue swelling on X-ray, and she was diagnosed with synovitis. Because pain worsened, MRI later revealed an abscess around the first proximal phalanx and interphalangeal joint, with cellulitis and osteomyelitis of the first proximal and distal phalanges. She underwent incision and drainage, but early cultures were negative. Pathology from inpatient surgery showed necrotizing granulomatous inflammation, raising suspicion for atypical infection. After five days of negative cultures, she was discharged on broad-spectrum antibiotics.<br /><br />On day 25, acid-fast cultures grew Mycobacterium tuberculosis, confirming tubercular dactylitis with osteomyelitis/septic arthritis of the thumb. Antibiotics were stopped, and she was started on standard RIPE therapy and referred to public health. Follow-up imaging showed ongoing joint instability, pain, septic arthritis of the first IP joint, osteomyelitis, and a nondisplaced fracture.<br /><br />This case highlights that tocilizumab and corticosteroids used during COVID-19 can increase vulnerability to opportunistic infections even in patients without classic immunosuppression. It also emphasizes that IGRA testing may not reliably exclude active TB, that extrapulmonary TB can present with nonspecific musculoskeletal findings, and that a high index of suspicion is needed to ensure appropriate isolation and timely diagnosis.

Asset Subtitle

Julie C. Kielt

Meta Tag

Author List Claire Sevov, Julie C. Kielt

Category Clinical Vignettes

Concept Tuberculous Dactylitis

Concept Active Tuberculosis

Concept Necrotizing Granulomatous Inflammation

Concept Skeletal Tuberculosis

Concept RIPE Therapy

Distinguished Non-Finalist

Presenter Organization The Ohio State University Wexner Medical Center

Presenting Author Julie C. Kielt

Track Adult

Keywords

tubercular dactylitis

Mycobacterium tuberculosis

osteomyelitis

septic arthritis

thumb abscess

tocilizumab

corticosteroids

COVID-19

IGRA negative

extrapulmonary tuberculosis

Tuberculous Dactylitis

Active Tuberculosis

Necrotizing Granulomatous Inflammation

Skeletal Tuberculosis

RIPE Therapy