45 yr old man present this lesion from 2 monthtook treatment for chicken pox but not get relief. This case is posted to me by my friend.& I have only this information can any one help me in diagnosis


Thank u Dr Mayur for tagging me. Ur line of thinking is rational. Such florid lesions an imune defficiency like HIV/ AIDS should be kept in mind. Miliary TB and Sy 2 are also reasonable options. Ut there seems more to it. As for as TB is concernedd it could be dissiminaton ( hematogenous) qualifying for miliary Cutaneous TB. Or might be an allergic response to tubercular bacillus protein- the tuberculids of which there r varieties. Dissiminated or miliary TB is a seriou nearly fatal disease not to be seen in isolation with complete picture of miliary spread to other organs. Look for milliary nodules in lung, choroidal tubercles in eye, clinical and csf investigation for menigitis, hepato-splnomegaly and anergy by Tubeculin test. If proved we have played with time andd life of the pt. In isolation hence miliary TB cannot be confirmed.Investigation in this direction is warrented. Regarding its being a tubeculid the possibilities r equally grim. Papulonecrotic tuberculid is unlikely because of abscent simultaneous pitted scars and varioliform distribution. Lichen scrufulosorum is unlkely as the presentatation would have been grouped , discrete, folliclar papules. Other forms lack exanthematous oresentation Since TB is strongly associated with and immunosuppressio is suspected here, the option should be kept open without any dogma till proved. Secondery syphilus is a possibility as it is seen 6 weeks to 6 months after primary. But h/o exposure , presence of primary syphilituc sore b 4 are prerequusites. Positive VDRL and associated sec.sy. fearutes r mandatory..especially the mucus membrane of mouth and genetalia and generalised lymphadenopathy etc. Personally tI feel that the look of lesions don't qualify for SY2, as SY 2 lesions have infiltrated look shotty and in theskin than upon the skin. Here the lesions appear more duperficial ( upon the skin). Investigate to its logical ebd. Could they ne related t pilosebacious units ? Possible becase of wide distribution on haity region, closel set and appear follicular .some of the lesions show depigmentation around, syggesting involvement if melanocytes which are in close associatuon with pilosebacious units. Now acneform look adds another point in its favout. The fundamental lesion of pilosebaceous unitit is folliculitus which may be inflamatory or non inflomatory. Lack of (ac ) inflamatory look, noninflamatory cause is a possibility. In the brader context oh back ground immunodeficiency, how rational is considering esonophylic folliculitis where esonophils cause immunological damage to the unit whose expression is the rash. Ofcourse immunodefficiebcy is to be establushed first. But EF classic variety, can occur in abscence of imunosuppression also. Next objection is that the name contsins ' pustular' implying the basic lesion to be pustular . Papular presentation without pustule is also reported in varities other than the classic type first discribed. Now biopsy will only settle the issue- presence of esonophilic infiltrate around the pilo sebacious unit. Hyper ig E Syndtome is also some times associated which may add a point in fsvour. This is just an analysis- not a conclusion.
Thank you Sir. Yes i think the sec syphilis doesnt fit in. Your well describing answers keep encouraging me and improving my approach towards the case.

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Considering the generalised distribution of rashes and persistence since last 2 months, and h/o mild fever, patient must be screened for immunodeficiency status. Must screen for HIV. Ddx: #generalised miliary cutaneous TB # secondary syphilis Sir please lead me in right direction@Dr. Asv Prasad
DD :1) Deep fungal infections-cryptococcosis,penicilliosis,histoplasmosis 2)Histoid Hansen 3)Papulonecrotic tuberculid.First should rule out immunosuppression like HIV..Can do a biopsy to confirm the diagnosis.let us know once the diagnosis is made
I thought on similar lines. Generalised involvement with molluscoid lesions and such closely spaced lesions. I agree with miliary TB.
A little more of history pls. Taken acyclovir? Any lesions prior to these fluid filled lesions? Any preceding drug intake? Are limbs involved?
Thx doctor for answer .actually this pic was sent me for diagnosis.pt is taking tt for chicken pox ; but not getting relief. Rash is spreading not fluid filled .itching & mild fever is present
I thought on similar lines. Generalised involvement with molluscoid lesions and so closely spaced lesions. I agree with miliary TB
Kindly look for additional cause and skin disease.
This is not the picture of miliary tuberculosis
@s dhara - can u help me in diagnosis
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