Abstract
This is a first literature report of a case of uveitis along with severe systemic symptoms following verruca vulgaris treatment with intralesional Candida antigen. We believe the Candida injection was causative.
Introduction
Intralesional immunotherapy with Candida antigen is a commonly used, effective and safe treatment for verruca vulgaris (VV). Stimulation of cell-mediated immunity, via increased production of IL-2 and IFNy, contributes to the immune response against the human papilloma virus.1 Febrile reactions and constitutional symptoms such as chills and aches are reported side effects.1 We report a case of uveitis along with severe systemic symptoms following VV treatment with intralesional Candida antigen.
Case Report
A 47-year-old male with a history of penicillin allergy and narrow angle glaucoma previously treated with laser iridotomy presented to his dermatologist for the treatment of plantar warts. Intralesional Candida antigen was injected into three plantar warts on his left foot. He noted mild discomfort at the injection site. Five days following treatment, he reported generalized fatigue with migratory arthralgias and myalgias in addition to difficulty walking due to swelling and pain of his left foot. He also reported subjective fevers with generalized lymphadenopathy. Two weeks later he presented to an ophthalmologist with redness, pain, blurry vision and photophobia of both eyes. Inflammatory cells and flare were noted in the anterior chamber with no keratic precipitates in either eye. He was diagnosed with bilateral anterior non-granulomatous uveitis and treated with dexamethasone 0.1% eye drops and dilation using cyclopentolate 1% solution.
Nearly three weeks later the patient underwent a second treatment of intralesional Candida antigen on both feet as his warts had improved. After this treatment he developed similar, more severe, earlier onset systemic symptoms including nausea, headache, fever, chills and generalized lymphadenopathy. He again had difficulty walking due to pain and swelling of the treatment sites. He did not report ocular symptoms; however, he was still medicating with a tapering dosage of dexamethasone 0.1% eye drops.
Due to the bilateral nature of his uveitis and his significant systemic symptoms, a second ophthalmologist theorized his uveitis could be related to his treatment with Candida antigen. Testing by ophthalmology revealed elevated antibodies to Candida (Candida IgG 62 U/mL, normal 0–29 U/mL; IgM 43 U/mL, normal 0–9 U/mL; IgA 28 U/mL normal 0–9 U/mL). Additional testing included the following which were normal: CBC, ACE, ESR, ANA, RPR, FTA-Ab, Lyme IgG/IgM Ab, HIV, HLA B-27. His systemic symptoms resolved and his ocular exam normalized. His verruca improved. As this paper went to press he was using duct tape occlusion therapy for residual foot warts.
Example of Verruca Vulgaris
Source: http://www.regionalderm.com/Regional_Derm/RD_Large/Wart33.jpg
Two uveitis experts consulted about the case also suggested the injections were the cause and advocated for its publication. An adverse reaction report was filed with the manufacturer HollisterStier Allergy.
Discussion
This report describes uveitis as a newly recognized side effect of intralesional Candida therapy during treatment of warts. Worsening (and improvement) of uveitis and systemic symptoms following injections of Candida extracts are reported in the ophthalmologic literature, although not in the setting of wart treatment or without a preexisting history of uveitis.2
Previous studies of patients with uveitis noted an abnormal cellular response to Candida antigen with increased circulating levels of CD69 CD4+ T-cells.3 Uveitis following immunotherapy with intravesicular BCG for bladder carcinoma has been reported in patients with HLA-B27 positivity and in one with HLA-B27 negativity.4
The mechanisms of anti-Candida immune responses have been extensively studied. Exposure to Candida antigens triggers pattern recognition receptors of local phagocytes and epithelial cells leading to the production of T cells which then initiate signaling through the IL-17 pathway. In this case it is tempting to speculate that systemic exposure to Candida antigen led to activation of local ocular immune responses resulting in uveitis.5,6
Conclusion
Dermatologists and ophthalmologists should be aware of uveitis as a potential, though apparently rare, side effect of intralesional Candida for the treatment of warts.
Biography
Nicholas J. Crowley, MD, (above), is with the University of Missouri School of Medicine, Department of Dermatology. John C. Hagan III, MD, MSMA member since 1977, and Tyler F. Brundige, MD, MSMA member since 1996, are Ophthalmologists with Discover Vision Centers, Kansas City, Mo. Jonathan A. Dyer, MD, MSMA member since 2006, is with the University of Missouri School of Medicine, Department of Dermatology and Department of Child Health.
Contact: dyerja@health.missouri.edu
References
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