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.
Ultrasound of the subcutaneous layer of the forearm displaying several granulomas (arrows).
Disseminated miliary tuberculosis is a severe form of tuberculosis resulting from Mycobacterium tuberculosis dissemination via the bloodstream, affecting multiple organs11. Sharma SK, Mohan A. Miliary tuberculosis. Microbiol Spectr. 2017;5(2).. Several extrapulmonary manifestations may occur, including arthritis22. 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. and a cutaneous form33. 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..
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 bacilli33. 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.. The diagnosis of disseminated miliary tuberculosis with cutaneous involvement requires a combination of clinical findings, microbiological tests, and imaging studies.
ACKNOWLEDGMENTS
None.
REFERENCES
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1Sharma SK, Mohan A. Miliary tuberculosis. Microbiol Spectr. 2017;5(2).
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2Marschall 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.
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3Daikos 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.
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Financial Support: None.
Publication Dates
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Publication in this collection
22 Sept 2023 -
Date of issue
2023
History
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Received
21 June 2023 -
Accepted
21 July 2023