PMC9643053_01
(a) Right hallux non-healing ulcer, (b) chest radiograph, and (c) magnetic resonance imaging (MRI) of the thoracic spine.
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His first contact with our institute was via the vascular surgery outpatient clinic, where he was referred for the nonhealing ulcer on his right hallux (Figure 1(a)).  On dipsticks, he had 3+ leucocytes and 3+ red blood cells, while urine microscopy revealed granular casts with no bacterial culture growth.  Figure 1(b) shows a chest radiograph demonstrating bilateral reticular-nodular opacities. A biopsy of the right hallux ulcer (Figure 1(a)) revealed necrotising granulomatous inflammation with a solitary acid-fast bacillus seen on microscopy. Magnetic resonance imaging (MRI) of his spine (Figure 1(c)) revealed multi-level contiguous spondylitis at levels T6 to T10 with discitis and an epidural and paraspinal collection complicated by spinal cord compression but no oedema, in keeping with spinal MTB.
(a) Periodic acid-Schiff stained paraffin sections showing mesangial hypercellularity (arrow) and a focal cellular crescent (star) (x 100). (b) Higher magnification of glomerulus exhibiting mesangial hypercellularity (arrow) (x 400). (C) and (D) Immunohistochemical staining for IgA-strong mesangial and focal paramesangial staining, early subendothelial deposits are also appreciated (C). Strong mesangial staining was noted in occasional glomeruli which did not exhibit mesangial hypercellularity (D).
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Haematoxylin and eosin (H&E) showed glomeruli with diffuse mesangial hypercellularity with no evidence of endocapillary hypercellularity (Figure 2(a) and 2(b)). Immunohistochemical stains revealed diffuse strong IgA (3+) staining within the mesangium with lesser amounts noted within the paramesangium region (Figure 2(c) and 2(d)).