Disseminated miliary tuberculosis with cutaneous involvement in a patient with HIV

A 35-year-old man presented to the hospital with complaints of pain in his left elbow and right knee, persistent cough, weight loss, night sweats, and generalized weakness over the past few months. Recent episodes of recurrent fever and a noticeable decrease in appetite were reported. He was diagnosed with human immunodeficiency virus (HIV) infection 5 years ago and has been on antiretroviral therapy since then. Although his adherence to the therapy was suboptimal, with frequent missed doses, he had not experienced any major opportunistic infections or HIV-related complications.

Skin examination revealed an erythematous papular rash (Figure 1). Ultrasound of the subcutaneous layer showed several hypoechoic nodules of varying sizes (Figure 2). Chest computed tomography showed several small hyperdense nodules compatible with miliary tuberculosis (Figure 3). Ultrasound of the elbow and knee revealed synovial thickening and effusion consistent with arthritis.

FIGURE 1:
Right forearm with an erythematous papular rash.

FIGURE 2:
Ultrasound of the subcutaneous layer of the forearm displaying several granulomas (arrows).

FIGURE 3:
Chest computed tomography; lung window. Diffuse miliary nodules.

Disseminated miliary tuberculosis is a severe form of tuberculosis resulting from Mycobacterium tuberculosis dissemination via the bloodstream, affecting multiple organs¹. Several extrapulmonary manifestations may occur, including arthritis² and a cutaneous form³.

The subcutaneous layer of the affected area may show ill-formed granulomas, which are aggregates of immune cells and necrosis, or micro-abscesses composed of neutrophils and acid-fast bacilli³. The diagnosis of disseminated miliary tuberculosis with cutaneous involvement requires a combination of clinical findings, microbiological tests, and imaging studies.

ACKNOWLEDGMENTS

None.

REFERENCES

• ¹
  Sharma SK, Mohan A. Miliary tuberculosis. Microbiol Spectr. 2017;5(2).
• ²
  Marschall J, Evison J-M, Droz S, Studer UC, Zimmerli S. Disseminated tuberculosis following total knee arthroplasty in an HIV patient. Infection 2008;36(3):274-8.
• ³
  Daikos GL, Uttamchandani RB, Tuda C, Fischl MA, Miller N, Cleary T, et al. Disseminated miliary tuberculosis of the skin in patients with AIDS: report of four cases. Clin Infect Dis. 1998;27(1):205-8.

• Financial Support: None.

Publication Dates

• Publication in this collection
  22 Sept 2023
• Date of issue
  2023

History

• Received
  21 June 2023
• Accepted
  21 July 2023