Belated Intern report pearls 4/7: Hand foot mouth disease and Behcet’s disease

A few misc pearls:

  • In the outpatient world, when you see acute issues repeatedly, consider: does the patient need to go to the ED for expedited eval? Or early f/u? Expedited specialty referrals?
  • For HSV, Valtrex is most helpful for symptoms in the first 72 hours
  • IBD:
    • Crohn’s classically has “skip lesions” and has transmural inflammation on pathology. Can involve the entire GI tract from mouth to perianal area. Remember extraintestinal manifestations as well (including eye, skin, joints!)
    • UC classically starts in the rectum, extending proximally in a continuous and circumferential pattern. Biopsies show crypt abscesses.
  • Thanks to Micki for sharing a few OBGYN pearls:
    • If you are concerned about genital HSV, do a pelvic exam and look for cervical vesicles too!
    • Young women with persistent tachycardia is concerning. It takes a lot to become tachycardic, and they can maintain hemodynamic stability for a long time!


Hand foot mouth disease (HFMD)

  • Epi: commonly in young children (<5-7yo) but can be seen in adults; commonly in summer and early fall but can occur anytime.
  • Transmission: fecal-oral
  • Microbiology: coxsackie, echovirus, and enterovirus
  • Clinical presentation: low-grade fevers (<38.3oC), oral lesions usually in isolation, begin as macules then progress to vesicles then superficial painful ulcers
    • But there is also atypical HFMD with a specific coxsackievirus A6 genotype – more severe: higher fevers, wider distribution of lesions, longer duration
  • Diagnosis: clinical diagnosis
    • If need confirmation, can perform PCR/cx on throat, stool and vesicular fluid samples
  • Treatment: supportive
  • Complications: poor po from oral pain leading to dehydration, viral “aseptic” meningoencephalitis, myocarditis, conjunctival ulceration


Behcet’s disease

  • Epi: very rare! Often in 20-40yo, most common in east Asia, Mediterranean areas, lower prevalence in North America and Europe
  • Rare vasculitic disease, can affect small, medium and large vessels – both arteries and veins!
  • Diagnosis of exclusion! There are criteria for diagnosis, primarily used for research:
    • Oral ulcers – at least 3x in 12 mos
    • Any 2 of the following
      • Recurrent genital sores/ulcers
      • Uveitis or retinal vasculitis
      • Characteristic skin lesions – erythema nodosum, pseudofolliculitis, papulopustular lesions, acneiform nodules
      • Positive pathergy test (though can be negative in some patients!)
        • What is this?! A prick in the forearm with a small gauge needle à test is positive if there is a small red bump or pustule 24-48h after the prick!
      • Interestingly, renal and peripheral nervous system involvement is rare!
    • Treatment: ibuprofen, colchicine, steroids, immunomodulators
    • Complications to be on the lookout for: pulmonary artery aneurysms, vascular thrombosis
    • A short handout is attached!




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