Thanks to Colin Purmal for presenting the case of a 26F presenting with diffuse abdominal pain, bloody diarrhea and oral ulcers, who was diagnosed with Behcet’s disease.
1. Oral ulcers have a fascinating differential, including infection, autoimmune disease, malignancy, medication-induced, and vitamin deficiencies. But the most common cause is the aphthous ulcer!
2. Consider treating severe infectious bloody diarrhea (e.g. systemically ill, immunocompromised or elderly) with ciprofloxacin. The benefits outweigh the risks except in cases with high concern for EHEC or Salmonella typhi.
3. Behcet’s disease is a key “Crohn’s disease mimicker.”
- Pocket reference Ddx:
Infection– primary HSV, HIV,TB, CMV, EBV, coxsackie, GC/CT, syphilis, fungal
Autoimmune– Behcet’s, SLE, Crohn’s, blistering skin disease (Pemphigus)
Malignant– SCC, lymphoma
Meds- DIHS, SJS
- More complete Ddx: https://www.evernote.com/l/AGKI9qP23mxDTriAN3stshZa7aDjPcMQ5wE
Antibiotics in infectious bloody diarrhea
- Most acute infectious diarrhea does not require antibiotic therapy.
- 2001 IDSA guidelines for dysentery (to use the Oregon Trail-approved terminology) recommend obtaining stool cultures and treating empirically for 3 days in 3 cases: 1) toxic-appearing, 2) elderly, 3) immunocompromise.
- The main benefit of antibiotic therapy is reduced duration of symptoms.
- Ciprofloxacin is first-line, but Azithromycin can be used in pregnancy or if high suspicion for resistant Campylobacter (e.g. recent SE Asia travel).
- Contraindications: 1) high concern for enterohemorrhagic E. coli (concern for precipitating HUS), 2) high concern for Salmonella typhi (concern for promoting carrier state and relapse)
IDSA Guidelines: http://www.uphs.upenn.edu/bugdrug/antibiotic_manual/idsadiarrhea.pdf
Crohn’s disease mimickers
- Thinking about Crohn’s disease?
- Consider Behcet’s disease in…patients from eastern Asia or the Middle East (the Silk Road!) with oral ulcerations (more frequent and more severe); genital ulcerations (more specific but less sensitive); systemic symptoms, including ocular symptoms, rashes, pan-vasculitis, weird clots (Budd-Chiari or cerebral venous thrombosis), pathergy (a 20G needle prick causes a papule or pustule within 48 hours).
- International Study Group for Behcet’s Disease Diagnostic Criteria:
|Recurrent oral ulceration:||Aphthous (idiopathic) ulceration, observed by physician or patient, with at least three episodes in any 12-month period|
|Plus any 2 of the following:|
|Recurrent genital ulceration||Aphthous ulceration or scarring, observed by physician or patient|
|Eye lesions||Anterior or posterior uveitis cells in vitreous in slit-lamp examination; or retinal vasculitis documented by ophthalmologist|
|Skin lesions||Erythema nodosum-like lesions observed by physician or patient; papulopustular skin lesions or pseudofolliculitis with characteristic acnelform nodules observed by physician|
|Pathergy test||Interpreted at 24 to 48 hours by physician|