Tuberculosis cutis miliaris disseminata

Cutaneous miliary tuberculosis.

Miliar tuberculosis of the skin due to haematogenous seeding. This occurs mainly in immunosuppressed patients or children or old people.

In particular, infants, young children, the elderly and immunocompromised people are affected.

• After haematogenous seeding of tubercle bacilli, miliary tuberculosis occurs.
• Abundant pathogens are found in the cutaneous lesions.

• Partially ulcerating, densely standing erythematous-brownish, haemorrhagic papules.
• Enoral involvement is possible.

• Travel history.
• Clinical.
• Tuberculin test (Mendel-Mantoux) often negative.
• Quantiferone test.
• Biopsy.

To exclude systemic involvement:

• Thoracic X-ray or CT- thorax.
• Sonography of the abdomen and kidneys.
• In the morning (fasting up to 4h) on 3 consecutive days, sputum must be collected.
• Pass urine in the morning on 3 consecutive days (fluid restriction the evening before!).
• Bronchoalveolar lavage (BAL).

Most often, disseminated organ infestation occurs.

Therapy regimen:

• The initial phase should last for 8 weeks/2 months. During this time, the majority of the bacteria are killed. In the subsequent phase of therapy (lasting for months), attempts are made to eliminate the remaining bacteria. Antituberculous therapy should be continued for at least 2 months after the skin is free of symptoms.

Therapy should last individually between 12-24, but at least 6 months!

Induction phase (2 months):

• Rifampicin p.o. 10 mg/kg bw/d
• Isoniazide p.o. 5 mg/kg bw. (with Vit B 6)
• Pyrazinamide p.o. 35 mg/ bw/ d if necessary combination with allopurinol!
• Ethambutol p.o. 15 mg/kg bw/ d
• A clear improvement can be seen in the vast majority of cases after 1 ½ months.

Consolidation phase:

• Induction phase (2 months):
• Rifampicin p.o. 10 mg/kg bw/ d
• Isoniazide p.o. 5 mg/kg bw. (with Vit B 6)
• Ethambutol p.o. 15 mg/kg bw/d (can also be omitted if isoniazid resistance has been ruled out)
• HIV patients: therapy must last ≥ 7 months. Ethambutol should be replaced by streptomycin p.o. 15-20 mg/kg bw/d (from > 60 y. max 750 mg) in case of additional therapy with NNRTI.

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2. Rietbroek RC, Dahlmans RP, Smedts F, Frantzen PJ, Koopman RJ , van der Meer JW. Tuberculosis cutis miliaris disseminata as a manifestation of miliary tuberculosis: literature review and report of a case of recurrent skin lesions. Rev Infect Dis 1991;13:265-9.
3. Libraty DH , Byrd TF. Cutaneous miliary tuberculosis in the AIDS era: case report and review. Clin Infect Dis 1996;23:706-10.
4. Handog, E. (2016). Cutaneous manifestations of tuberculosis. Uptodate.com. Retrieved 24 May 2016, from http://www.uptodate.com/contents/cutaneous-manifestations-of-tuberculosis?source=search_result&search=tuberkulosis+skin&selectedTitle=1~16
5. Haas, W. (2016). RKI - RKI-Ratgeber für Ärzte - Tuberkulose. Rki.de. Retrieved 24 May 2016, from https://www.rki.de/DE/Content/Infekt/EpidBull/Merkblaetter/Ratgeber_Tuberkulose.html#doc2374486bodyText3