Monday, November 14, 2011

20 y.o. man with multisystem disease

Presented by Henry B.B. Foong
Foong Skin Clinic, Ipoh, Malaysia

Abstract: 20 yo man with mouth ulcers, arthralgias, skin nodules

HPI: The patient is a 20 yr old student who presented with a 3 year history of recurrent mouth ulcers, polyarthralgia (knee, ankles), fever and tender nodules over the shoulders, elbows and legs. The attacks occur about every 6 months and responded to oral prednisolone. Apparently the nodules run a predictable course - initial erythema, then tender nodule then ulcerate and then subside leaving behind post inflammatory hyperpigmentation – all over 3-4 weeks. There is no photosensitivity, alopecia or cough. There is a family history of similar illness.

O/E: Multiple erythematous tender nodules over the elbows, legs , upper shoulders and scrotum. Those on the scrotum – severe, multiple tender nodules, of which ulcerated with scab formation. Multiple tender ulcers were also noted on the inner mouth.

Clinical Photos: (taken with iPhone)

LAB: (Some pending)
TWBC 11, 700 (N 67% L 18% E 1% M 12% B1%) ESR 44 mm/hr
Mycoplasma serology 1: 160 ( N<1:40)
LFT and renal normal

Pathology: Pending

Dignosis: Behcet’s? PAN? SLE?

Questions: What are your thoughts? Any further studies indicated?


  1. Behcet Disease. Further investigations - Pathergy test, skin biopsy (skin nodules), Ophthalmic examn and systemic examination.

  2. Thoughts that come to mind  are Behcets, inflamm bowel dz (Crohn) PAN, sarcoid, EED, infectious etiologies like fungal or mycobacterium and  brucella serologies.
    Wll need bx for HE , DIF and tissue cultures for fungal and mycobacteria and fungal serologies if available.
    Let us know what the biopsies show
    Rokea elAzahry

  3. I agree. Behcet's would be my # one choice. If dx is Behcet' seeing an ophthalmologist is important. DJE

  4. agree. behcet's was my first thought. less common- cutaneous PAN.
    would be interested to see the f/u on the ANCA.
    biopsy would be very helpful. K. Liao

  5. Behcet's..Agree
    Other thought..
    Is this patient from any place endemic for Leprosy..we do come across patients presenting for the first time with Type 2 reaction without any obvious skin patch or other cardinal signs of Leprosy..If so, it may be worthwhile considering skin smears from earlobes, nose, cheeks, forearms and buttocks..
    Dr Priya


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