Sarcoidal (non-caseating) or tuberculoid
granulomas are cutaneous manifestations of
common variable immunodeficiency (CVID). In this case report, we describe a patient with CVID but with non-sarcoidal, non-tuberculoid
granuloma. The 29-year-old Egyptian male patient presented with a vitiliginous patch on the chin of 1 year duration and multiple recurrent
warts on the hands and feet of 8 years duration. He is a known case of CVID with chronic
diarrhea, recurrent
otitis media,
pneumonia,
purulent conjunctivitis,
septic arthritis, hepato-
splenomegaly, and generalized
lymphadenopathy. In addition, he had evidence of multiple non-tender subcutaneous nodules predominantly juxta-articular and recurrent rheumatoid-like
arthritis. The skin overlying the nodules was either normal or slightly erythematous. Laboratory findings revealed markedly reduced serum
immunoglobulins (
IgG 3.4, n = 7.2-16.9 g/l;
IgA 0.1, n = 0.69-3.82 g/l and
IgM 0.1, n = 0.63-2.77 g/l) and deficient T cell function. Histopathologic examination of a skin nodule showed well demarcated areas of fibrinoid degeneration of
collagen that
stain homogeneously and are surrounded by histiocytes in a palisading arrangement, suggestive of
granuloma annulare. No microorganisms could be detected. Serology for
rheumatoid factor and
HIV infection has been persistently negative. Although most
infections, including common
warts responded well to
intravenous immunoglobulin replacement
therapy (12 g/i.v., every 2 weeks) and oral broad spectrum
antibiotic therapy, the subcutaneous nodules persisted. The vitiliginous patch responded favorably and disappeared within 24 local PUVA sessions. Since skin nodules are asymptomatic, no further treatment was given.