The patient was a 19-year-old girl, inhabitant of urban area of Hamadan Province, West Iran. She presented to Sina Hospital at the end of 2017, with complaints of pain, redness, and blurred vision of both the eyes since 2 months ago. Examination of her eyes by an ophthalmologist revealed panuveitis. The patient denied other complaints such as cough, weight loss, fever, and chills or perspiration.
Physical examination revealed some nodular erythematous lesions with an approximate size of 2 cm x 2 cm on the anterior and posterior aspects of both the lower legs, which was treated as eczema for 1 year [Figure 1]. Furthermore, some condyloma acuminata were seen on her genitalia and perianal area, persistent over the past 2 years despite numerous medical and electrosurgical therapies.
She had a history of smear-positive pulmonary TB 10 years ago with good response to standard treatment. Her brother had a history of disseminated TB as well, with simultaneous involvement of the brain, omentum, and gastrointestinal tract. The patient's brother had been successfully treated with anti-TB treatment and interferon-gamma (IFN-gamma).
Results of laboratory tests and imaging studies were as follows: white blood cell = 7000, hemoglobin = 10.4 g/dl, erythrocyte sedimentation rate = 29 mm/h, C-reactive protein = +1, angiotensin-converting enzyme = 34, tuberculin skin test (TST) =25 mm, HIV test (fourth-generation enzyme-linked immunosorbent assay): negative, venereal disease research laboratory: negative, and chest X-ray: normal. Histopathologic examination of skin biopsies obtained from lower leg and perianal lesions confirmed the diagnosis of erythema induratum and condyloma acuminatum, respectively. With respect to familial history of disseminated TB, personal history of pulmonary TB, existence of erythema induratum, and persistent genital warts, we decided to evaluate the patient's immune system by laboratory tests including C3, C4, CH50, immunoglobulin G (IgG), IgM, IgA, CD3, CD4, CD8, CD16, and CD56. However, these tests were all normal.
Based on the result of TST, past TB history, presence of erythema induratum, and exclusion of other causes of panuveitis, anti-TB drugs as well as short course of oral prednisolone were started. Uveitis responded dramatically to this medical treatment, but the improvement of erythema induratum was slow and took a few months to appear.
After 3 weeks, the patient was admitted again to the infectious ward with drug hepatotoxicity. Chief complaints of the patient were nausea, vomiting, and abdominal discomfort concomitant with abnormal laboratory tests (aspartate aminotransferase = 134 U/L, alanine aminotransferase = 157 U/L, alkaline phosphatase = 418 U/L, total bilirubin = 1.99 mg/dL, direct bilirubin = 1.66 mg/dl, and international normalized ratio = 1.1). After normalization of liver function tests, anti-TB treatment was restarted and continued without any problem. Taking into consideration, the role of stimulation of immune system on improvement of her genital warts, along with an unfavorable response of her condyloma to previous electrosurgical treatments, we started intralesional and systemic IFN-gamma twice a week for 2 months. This treatment resulted in disappearance of all her genital lesions.