Picture of the Month—Quiz Case

A 13-year-old girl, born in São Tomé and Príncipe, a country off the western coast of Africa, presented to our hospital with an ulcerated cutaneous lesion measuring 6 × 4.5 cm below her chest (Figure, A). The ulcer was first noted 8 months earlier. She underwent surgical drainage and several courses of intravenous antibiotics, without improvement. In addition to the cutaneous ulcer, physical examination revealed mild kyphosis and mild lower extremity weakness, which prompted gait discoordination attributable to decreased strength, as there was no other evidence of ataxia in the neurologic examination.

Figure. 

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A, Photograph showing initial ulcer beneath the patient's chest on the left side. B, The chest radiograph demonstrated erosion of the superior border of the left fifth rib (white arrow), mild enlargement of the superior mediastinum, and decreased second thoracic vertebral height (black arrow). C, Digitally enhanced image of vertebral magnetic resonance imaging at the second thoracic vertebra showing extensive vertebral destruction and a major paravertebral abscess (arrow) with significant intervertebral foramina and epidural extension causing cord compression. D, Digitally enhanced image of vertebral magnetic resonance imaging (long axis, sagittal plane) showing another view of the second thoracic vertebra destruction and paravertebral abscess.

The patient had an anergic response to the tuberculin skin test. A chest radiograph (Figure, B) showed erosion of the superior border of the left fifth rib and mild enlargement of the superior mediastinum. The patient was tested for human immunodeficiency virus (HIV) infection (using enzyme-linked immunosorbent assay) and the results were negative. On the fifth day of admission, cranial and vertebral magnetic resonance imaging was performed (Figure, C and D).

What is your diagnosis?