Presentation
A priority face-to-face review was arranged for a 40-year-old Caucasian female with known Behcet’s disease (BD) after receiving smartphone images showing well-demarcated ulcerated lesions on her intestinal stoma (Fig. 1). At review, she described 5 days of malaise, nonspecific abdominal pain, and concurrent painful orogenital ulceration. Inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) were unremarkable. Intramuscular triamcinolone 80 mg resolved symptoms within 1 week, with no recurrence at 6 months.
Fig. 1.
Smartphone photographs taken by the patient of the ileostomy site. a and b Yellow arrows show two discrete, painful ulcerated lesions with concurrent orogenital ulceration noted
Prior to her BD diagnosis, she experienced a non-ST-elevation myocardial infarction requiring coronary stenting at age 33. At 35, she presented with fulminant colitis, which was attributed to Crohn’s disease. This required emergency subtotal colectomy and conversion proctectomy; remission was achieved with short-term oral glucocorticoids. Alongside a history of recurrent non-herpetic orogenital ulceration, a national centre confirmed her BD diagnosis at age 37. Treatment of her BD with daily azathioprine (100 mg) and colchicine (as required) maintained a near disease-free status.
A review of histopathological specimens, prompted by her Behcet’s diagnosis, showed no obvious granulomatous disease, vasculitis, or pathognomonic Crohn’s features. Alongside her most recent flare with concurrent orogenital and stomal ulceration, the team reconsidered their initial diagnosis of Crohn’s disease. The previous episode of colitis is now attributed to BD only.
Discussion
Differentiating Crohn’s and Behcet’s diseases from histopathological specimens is challenging [1, 2]. Although drugs, including infliximab, can treat both conditions, it is important to distinguish between them [2, 3]. Here, concurrent orogenital and stomal ulceration supports that this patient does not have Crohn’s disease, with Behcet’s being the unifying diagnosis.
BD classically affects the ileocecal area, but stoma disease is not widely described [3, 4]. This case presents a rare visible manifestation of Behcet’s intestinal disease, with identification and review facilitated by telemedicine. Telemedicine developments will be increasingly important in managing rheumatic diseases in the post-COVID-19 era [5].
Acknowledgements
We would like to acknowledge and thank the patient for their kind permission to present this case and share these images.
Author contribution
AA and NH prepared the first draft of the manuscript and contributed equally. JB critically reviewed and revised the manuscript. All authors reviewed and approved the final manuscript prior to submission. JB is the consultant physician caring for the patient.
Declarations
Ethical standards
Written, informed consent was obtained from the patient to publish this case and related clinical image.
Conflict of interest
The authors declare no competing interests.
Footnotes
Aditya Adiga and Naveed Hussain are co-first authors.
Publisher's note
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Contributor Information
Aditya Adiga, Email: adiadiga10@gmail.com.
Naveed Hussain, Email: naveed195@hotmail.co.uk.
James Bateman, Email: jamesbateman@nhs.net.
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