Genitourin Med 1995;71:308-310

Disseminated cutaneous Mycobacteriumtuberculosis infection in a patient with AIDS

E L Corbett, I Crossley, K M De Cock, R F Miller

Individuals infected with the humanimmunodeficiency virus (HIV) are at anincreased risk of both pulmonary andextrapulmonary tuberculosis.' Dissemi-nated cutaneous tuberculosis is rare, buthas been reported in four HIV-positivepatients, all ofwhom also had pulmonaryinfection.2-5 In this report we describe anHIV-infected patient with a febrile illnessand an abnormal chest radiograph whodeveloped widespread cutaneous tuber-culous pustules following a lymph nodebiopsy on the previous day.

(Genitourin Med 1995;71:308-3 10)

HIVIAIDS Unit,Camden and IslingtonCommunity HealthServices NHS Trust,The MiddlesexHospital, MortimerStreet, LondonW1N 8AA, UKE L CorbettI CrossleyKM De CockR F MillerAccepted for publication15 June 1995

Keywords: tuberculosis; AIDs; cutaneous

Case reportA 40 year old Caucasian homosexual man wasadmitted complaining of a three week historyof fatigue, myalgia and fever with nightsweats. He had been HIV-1 antibody positivefor two years and had had Pneumocystis cariniipneumonia seven months before this admis-sion. He had been taking 600 mg per day ofAZT for the previous two years, otherwise he

had been well. He recalled BCG vaccinationas a school child, but had no apparent scar.On admission he was noted to have a smallpalpable right supraclavicular lymphnode, apalpable liver edge and splenic tip and waspyrexial, with temperature 39 7°C. Investi-gations showed that he was anaemic (haemo-globin = 9 4 g dl- 1), and had a low white cellcount, 3-4 x 109 ml -', CD4+ lymphocytecount = 030 x 109 ml-l (normal range =0-35-2-2 x 109 ml-'). Liver function testswere normal apart from an albumin of 31 gl- 1(normal range = 35-33 gl- '). A chest radio-graph showed right hilar enlargement and leftupper zone interstitial shadowing compatiblewith his previous P carinii pneumonia. Atfibreoptic bronchoscopy, no anatomicalabnormality was noted. Auramine and methe-namine staining of bronchoalveolar lavagefluid from the left upper lobe were negative.Samples of blood, stool, urine and broncho-alveolar fluid were cultured for mycobacteria.

Over the course of the next two weeks thepatient's condition deteriorated markedlywith loss of 7 kg in weight, increase in size ofthe supraclavicular lymph node to 3 x 2 cmand clinical and radiographic evidence of aright middle lobe collapse/consolidation.Spiral computed tomography (CT) of the

Figure 1 CT scan of thethorax showing hilar andmediastinallymphadenopathy. A massis seen arising at the righthilum extending into themiddle lobe.

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Disseminated cutaneous Mycobacterium tuberculosis infection in a patient with AIDS

chest showed marked and inhomogeneoushilar and mediastinal lymphadenopathy withperipheral contrast enhancement, compres-sion of the right main bronchus and a massextending from the right hilum into the rightmiddle lobe (fig 1). An abdominal ultrasoundscan showed a 16 cm spleen and no retroperi-toneal lymphadenopathy. The time course ofthe illness and the CT scan appearances werefelt to be most consistent with an aggressivelymphoma. A bone marrow aspirate andtrephine were nondiagnostic. On the 16th dayof admission the enlarged supraclavicularlymph node was biopsied. On the morningfollowing surgery the patient developed a rashwhich consisted of sparse 2-3 mm pustules onan erythematous base distributed over thetrunk and thighs (fig 2). Microscopy of anauramine stained sample of pus from the skinlesions showed mycobacteria and histologicalexamination of the lymph node biopsy alsoshowed mycobacteria, which were present inlarge numbers. Culture from lavage fluid,sputum, stool, urine, bone marrow, skin andlymphnode grew Mycobacterium tuberculosiswhich was subsequently found to be isoniazidresistant.

Treatment was begun with isoniazid,rifampicin, ethambutol and pyrazinamide inconventional doses and the patient was iso-lated and notified to the Director of Public

Figure 2 Pustular rashover the trunk.

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Health. Isoniazid was discontinued whenresistance was demonstrated. He made anuneventful recovery with resolution of thepustules into dry scabs over 7-10 days, and amore gradual improvement of the chest radio-graphic abnormalities. He was dischargedhome two weeks after the start of anti-tuberculous treatment and remains well withsustained weight gain four months later.

DiscussionThe clinical and radiographic presentation oftuberculosis is frequently atypical in patientswith HIV. 1 67 Clinically apparent extrapul-monary disease is more common, and chestradiograph appearances are often nonspecific.' 6 Tuberculosis may present as arapidly progressive disease in immunosup-pressed patients.' Haematogenous spread oftuberculosis to the skin resulting in a gener-alised eruption, which is known as tuberculosiscutis miliaris acuta generalisata, is a rare con-dition that has been described in the contextof both primary infection and following reacti-vation of an endogenous focus.8 Prior to theHIV epidemic, acute milary tuberculosis ofthe skin was most commonly seen in children,occurred most often following a viral exan-tham or severe bacterial infection, and had ahigh short term mortality rate.89 The rash oftuberculosis cutis miliaris acuta generalisata isquite different from other more commonforms of cutaneous tuberculosis, such as scro-fuloderma or lupus vulgaris, and consists ofmultiple pustules with a centripetal distri-bution.8 9 10

Recently four published cases of cutaneousmilary tuberculosis have been described inpatients with AIDS.2 5 The presentation ofthese patients have several features in com-mon with that of our own case. All thesepatients were profoundly immunosuppressedwith CD4+ lymphocyte counts rangingbetween 0.16 to 0.2 x 109 ml- ' and all fourpatients were anaemic. In three of these casespatients were admitted with a febrile illness,without a clinically obvious source, and nor-mal initial chest radiographs apart from mildcardiomegaly in one patient and questionablemediastinal lymphadenopathy in another.The initial working diagnoses in these patientswere bacterial endocarditis in two cases andP carinii pneumonia in the third. The fourthpatient had miliary shadowing on the admis-sion chest radiograph and was sputum smearpositive for mycobacteria, although micro-scopy of bronchoalveolar lavage fluidobtained two weeks earlier had been negativefor acid-fast bacilli. In each of the four casesthe cutaneous lesions developed suddenlywhile the patients were in hospital and theappearances and distribution were similar tothose in our patient. All four patients werecritically ill and two died; in one of the twofatal cases tuberculosis was diagnosed only atpost mortem examination and in the other thediagnosis was made from a skin biopsyobtained two days before the patient's death.Diagnosis in the two surviving patients was

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Corbett, Crossley, De Cock, Miller

made by microscopy of sputum and lavagefluid respectively.The temporal relationship between the

lymph node biopsy and the appearance of therash in our patient suggests that haemato-genous spread may have been exacerbated byhandling of the node at the time of surgery,although subsequent positive cultures ofM tuberculosis from urine collected prior tosurgery indicate that dissemination hadalready occurred.The thoracic CT appearances in our

patient were compatible with tuberculosis inadvanced HIV disease, with massive medias-tinal and hilar lymphadenopathy togetherwith a parenchymal infiltrate.7 Surprisingly,despite the marked radiographic abnormali-ties, microscopy of the lavage fluid wasnegative for acid-fast bacilli. HIV positivepatients with culture positive pulmonarytuberculosis are less likely to be smear positiveon microscopy for acid-fast bacilli than arenon-HIV infected patients, even in thepresence of extensive chest radiograph abnor-malities.' '

In conclusion, although our case is notunique, it illustrates the need to maintain ahigh index of suspicion for disseminatedtuberculosis in HIV-infected patients, and

also underlines the high diagnostic yield frommicroscopy and culture of any unusual rashesin this patient group.

1 Foley NM and Miller RF. Tuberculosis and HIV infec-tion: is "the white plague" up and coming? Jf Infect 1993;26:39-43.

2 Stack RJ, Bickley LK, Coppel IG. Miliary tuberculosispresenting as skin lesions in a patient with acquiredimmunodeficiency syndrome.3Am Acad Dermatol 1990;23:1031-5.

3 Rohatgi PK, Palazzolo JV, Saini NB. Acute miliary tuber-culosis of the skin in acquired immunodeficiency syn-drome. J Am Acad Dermatol 1992;26:356-9.

4 Bassiri A, Chan NB, McLeod A, et al. Disseminated cuta-neous infection due to Mycobacterium tuberculosis in aperson with AIDS. Can MedAssocJ 1993;148:577-8.

5 Inwald D, Nelson M, Cramp M, et al. Cutaneous manifes-tations of mycobacterial infection in patients with AIDS.BrJfDermatol 1994;130:111-14.

6 Greenberg SD, Frager D, Suster B, Walker S, et al. Activepulmonary tuberculosis in patients with AIDS; spectrumof radiographic findings (including a normal appear-ance). Radiology 1994;193:115-9.

7 Pastores SM, Naidich DP, Aranda CP, et al. Intrathoracicadenopathy associated with pulmonary tuberculosis inpatients with human immunodeficiency virus infection.Chest 1993;103:1433-7.

8 Schermer DR, Simpson CG, Haserick JR, et al.Tuberculosis cutis miliaris acuta generalisata. Report ofa case in an adult and a review of the literature. ArchDermatol 1969;99:64-9.

9 Beyt BE, Ortbals DW, Cruz DJS, et al. Cutaneousmycobacteriosis: analysis of 34 cases with a new classifi-cation of the disease. Medicine 1980;60:95-109.

10 Seghal VN, Bhattacharya SN, Jain S, et al. Cutaneoustuberculosis: the evolving scenario. Int Jf Dermatol 1994;33:97-104.

11 Klein NC, Duncanson FP, Lenox TH, et al. Use ofmycobacterial smears in the diagnosis of pulmonarytuberculosis in AIDS/ARC patients. Chest 1989;95:1190-2.

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