Diagnostic challenge

Abstract

A 10-year-old female patient, with a history of severe combined immunodeficiency (SCID), hospitalized a month ago with daily fever, with peaks up to 40.0ºC and generalized lymphadenopathy. Treated with broad-spectrum antibiotics without improvement and managed with empirical first-line antituberculosis treatment on previous occasions due to similar symptoms.

Physical examination:

Patient is stable, listless and feverish . Cardiopulmonary is well, the abdomen is slightly globose, with hepatosplenomegaly. Generalized lymphadenopathy. On the skin, a necrotic-looking crusted lesion is observed at the edge of the left nostril and in the central submandibular area, and in the facial area adjacent to the eye, there is a small umbilicated lesion with adjacent erythema.

The blood count showed pancytopenia.

Thoracic-abdominal CT: mediastinal, axillary, retroperitoneal and mesenteric lymphadenopathy. Diffuse hepatosplenomegaly. Bibasal atelectasis.

What is your diagnosis?

1. Ecthyma gangrenosum
2. Disseminated histoplasmosis
3. Resistant multidrug skin tuberculosis
4. Chromoblastomycosis