A 34 year old man with bilateral anterior uveitis and a rash

A 34 year old railway engineer of south Indian descent was under the care of the ophthalmology team. He was being treated for bilateral anterior uveitis with topical steroids and mydriatics after a one month history of decreasing visual acuity, photophobia, and ocular pain. He also had a four month history of irritation over his tattoo sites that his general practitioner had suspected was dermatitis related to ultraviolet radiation. He was also having severe night sweats. In view of these symptoms, he was referred to the medical team.

His medical history included well controlled asthma and two hospital admissions for lower respiratory tract infections in the past five years. He had no known allergies and the only drug that he took regularly was budesonide/formoterol 200/6. He was an ex-smoker, having stopped two months previously.

On admission, his observations were normal. Abnormalities over his tattoo sites were noted (fig 1⇓) and his visual acuity was reduced to 6/18 bilaterally. All other systems examinations were normal. Full blood count, electrolytes, liver function tests, and bone profile tests were within normal ranges. C reactive protein was 13 mg/L (reference range 0-5) and his erythrocyte sedimentation rate was 14 mm in the first hour (0-10). Autoimmune serologies, VDRL, and HLA B27 were negative. Serum angiotensin converting enzyme was 154 mg/L (20-90). A chest radiograph was performed (fig 2⇓).