An 11-year-old girl was admitted in the pediatric infectious department of Imam Hossein Children's Hospital, Isfahan University of Medical Sciences, due to pain and swelling around the left eye (Figure 1).
The patient developed redness and photophobia a week before admission, then gradually developed pain in the eye movements, swelling, and redness around the left eye. She had normal vital signs on examination. On physical examination, she had redness and swelling around the left eye. Globe movements were associated with pain and limitation. Visual acuity was 5/10 in the left and 10/10 in the right eye. Cranial nerve examination and other physical examinations were normal.
The patient was diagnosed with preseptal cellulitis and treated with clindamycin intravenous infusion. The computed tomography (CT) scan orbit was normal, and no signs of orbital cellulitis were found. After 3 days of treatment, the patient's condition did not improve. Therefore, an ophthalmology consultation was done for the patient
In ophthalmology consultation, posterior uveitis (diffuse choroiditis) was reported on the left eye with an ophthalmic examination. In the ultrasonography of the left eye, the thickness of the wall of the globe in the posterior pole was increased (2.4 mm), and the appearance of scleral edema with Classic view of T- sign Was seen, which confirmed episcleritis (Figure 2). Episcleritis and posterior uveitis were reported, and rheumatology consultation was recommended. Finally, the patient was transferred to the pediatric rheumatology department. A full history was taken there. The patient had a history of recurrent oral aphthous ulcers (5-6 times a year), genital ulcers, and chronic and vague abdominal pain. The results of laboratory tests including complete blood count, erythrocyte sedimentation rate, C-reactive protein, and serum electrolytes were normal. Serology tests for cytomegalovirus, toxoplasmosis, parvovirus B19, tuberculosis, and rheumatologic tests including angiotensin-converting enzyme, antinuclear antibody, and antiphospholipid antibodies were negative. The patient did not meet the laboratory and clinical criteria for lupus and granulomatosis with polyangiitis (GPA).
Both human leukocyte antigen (HLA) B5 and HLA-B51 tests were positive. The result of the pathergy skin test was positive (Figure 3).
According to the criteria of the International Study Group for Behcet Disease, the patient was recognized as a case of BD-related episcleritis and posterior uveitis, and the treatment started by prescribing pulse methylprednisolone and intravenous infliximab. Treatment was continued with oral prednisolone 2 mg/kg/d, azathioprine 2 mg/kg/d, and colchicine 1 mg/d.
After a 1-month follow-up, the patient had no symptoms and ocular exam through slit lamp and funduscopy was normal. Infusion of infliximab 8 mg/kg was given, and oral prednisolone 1 mg/kg/d with azathioprine and colchicine was continued. Three months after discharge, the patient did not have any complaints about aphthous ulcers and GI system visual acuity of both eyes was 10/10, and ocular exam was normal.