Pustular skin lesions in a patient with advanced HIV infection and pneumonia.

Diagnosis: Tuberculosis cutis miliaris acuta generalisata in the context of advanced human immunodeficiency virus (HIV) infection. Histopathological findings on the skin biopsy (Figure 1) revealed superficial dermal granulomatous inflammation (Figure 2) and acid-fast bacilli (Figure 3). Empirical treatment for tuberculosis and Mycobacterium avium complex (MAC) infection was commenced with rifampicin, isoniazid, pyrazinamide, ethambutol, and clarithromycin. Mycobacterium tuberculosis complex (MTB) polymerase chain reaction (PCR) performed on the skin biopsy specimen was positive and clarithromycin was discontinued. The fever defervesced within 48 hours. Over the subsequent weeks, fully sensitive MTB was cultured from blood cultures, sputum, bronchoalveolar lavage fluid, and urine from the acute admission. Cutaneous tuberculosis has long been recognized as a clinical syndrome having been first described by Laennec in 1826. It continues to be an important but rare clinical manifestation of tuberculosis in a resource-rich setting [1] with highly variable skin findings. Direct inoculation from an exogenous source, Figure 1. Multiple pustular skin lesions on upper limb (arrows). Figure 2. Hematoxylin-eosin stain of skin biopsy (×100 magnification) showing superficial dermal granulomatous inflammation (arrow).