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Picture of the Month Quiz

A 13-year-old girl, born in São Tomé and Príncipe, a country off the western coast of Africa, presented to the hospital with an ulcerated cutaneous lesion measuring 6 x 4.5 cm (Figure). 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.

The patient had an anergic response to the tuberculin skin test. A chest radiograph 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 infection and the results were negative. On the fifth day of admission, cranial and vertebral magnetic resonance imaging was performed, showing destruction of the second thoracic vertebra and a major paravertebral abscess causing cord compression.

Figure

Figure.

What is your diagnosis?

For a complete discussion of this month's case, read next month's Picture of the Month—Quiz Case. For a complete discussion of last month's case, read this month's Picture of the Month—Quiz Case.