Clinical Immunology Review Series: an approach to the patient with recurrent orogenital ulceration, including Behçet's syndrome

Oral and vulval disease: prevalence, associations, and management recommendations for the oral medicine clinician

OBJECTIVE

The oral cavity is a common site for mucosal conditions which may be confined to the mouth, or may manifest as mucocutaneous involvement at other sites, including the anogenital region. This retrospective analysis aimed to assess the appropriateness of oral medicine referrals to a specialized vulval clinic and review the prevalence of oral disease associated with vulval involvement of the same condition.

STUDY DESIGN

One hundred thirty-six patients referred from oral medicine to the vulval service at Guy's Hospital were analyzed. Retrospective data collated included: reason(s) for referral, onset of oral and genital symptoms, oral diagnosis, vulval diagnosis, correlation between the oral and vulval diagnosis, and discharge at first appointment.

RESULTS

Forty-nine percent (n = 67) of the patients had oral and vulval manifestations of the same disease. The majority of these patients (n = 63) were diagnosed with vulval lichen planus, of whom 61 had concomitant oral lichen planus involvement (97%). Other associated oral and vulval diseases included aphthous ulceration, Behçet's disease, dryness secondary to Sjögren's disease, Crohn's disease, and mucous membrane pemphigoid. The remaining 51% (n = 69) of the patients presented with independent vulval conditions unrelated to their oral disease.

CONCLUSION

Clinicians should recognize the association between genital symptoms and oral disease and refer to specialist allied services, as appropriate.

Diagnostic Methods and Management Strategies of Herpes Simplex and Herpes Zoster Infections

Herpesviruses are medium-sized double-stranded DNA viruses. Of more than 80 herpesviruses identified, only 9 human herpesviruses have been found to cause infection in humans. These include herpes simplex viruses 1 and 2 (HSV-1 and HSV-2), varicella-zoster virus (VZV), human cyto-megalovirus (HCMV), Epstein-Barr virus (EBV), and human herpesvirus (HHV-6A, HHV-6B, HHV-7, HHV-8). HSV-1, HSV-2, and VZV can be problematic given their characteristic neurotropism which is the ability to invade via fusion of its plasma membrane and reside within neural tissue. HSV and VZV primarily infect mucocutaneous surfaces and remain latent in the dorsal root ganglia for a host's entire life. Reactivation causes either asymptomatic shedding of virus or clinical manifestation of vesicular lesions. The clinical presentation is influenced by the portal of entry, the immune status of the host, and whether the infection is primary or recurrent. Affecting 60% to 95% of adults, herpesvirus-associated infections include gingivostomatitis, orofacial and genital herpes,and primary varicella and herpes zoster. Symptomatology, treatment, and potential complications vary based on primary and recurrent infections as well as the patient's immune status.

Chronic Oro-Genital Ulcerations as a Presenting Feature of Chronic Eosinophilic Leukemia: A Case Report

Hypereosinophilia can be primary, including idiopathic hypereosinophilic syndrome (HES) and chronic eosinophilic leukemia, or secondary/reactive to various infective and non-infective stimuli. Chronic oro-genital ulcerations can occur due to various dermatological and non-dermatological disorders, and many times it serves as a useful indicator of an underlying systemic disorder. Hence, a case presenting with chronic oro-genital ulcerations needs a thorough evaluation. We are reporting an interesting case of a middle-aged male who had chronic oro-genital ulcerations as a presenting feature of chronic eosinophilic leukemia with FIP1L1-PDGFRA fusion (FIP1-like 1/platelet-derived growth factor receptor alpha). The patient's oro-genital ulcerations responded excellently to imatinib.

Vulval Aphthous Ulcers in Adolescents Following COVID-19 Vaccination - Analysis of an international case series

STUDY OBJECTIVE

To review and characterise reports of vulval aphthous ulcers (VAU) following COVID-19 vaccination in VigiBase, the World Health Organization global database of reported potential side effects of medicinal products, to demonstrate the importance and power of case reports for rare suspected adverse reactions and to investigate whether they suggest a potential for COVID-19 vaccination to be a trigger.

METHODS

Cases reporting the Medical Dictionary for Regulatory Activities' (MedDRA) Preferred Term (PT) "Vulvovaginal ulceration" and related PTs in adolescent patients aged 12 to 17 years in association with any COVID-19 vaccine were extracted from VigiBase. The cases were clinically reviewed, and causality was assessed by applying the Bradford Hill criteria to the obtained case series.

RESULTS

As of June 30^th, 2022, there were 444 reports for the selected MedDRA PTs following COVID-19 vaccination in VigiBase. Ninety-four de-duplicated reports concerned adolescent female patients. Thirty-seven cases were clinically consistent with the diagnosis of VAU. Upon causality assessment, the analysed case series fulfilled six of the nine Austen Bradford Hill criteria supporting a potential causal relationship.

CONCLUSION

VAU can be perceived as a traumatic experience, especially in adolescent patients. There is, furthermore, a risk that the ulcers will be misdiagnosed resulting in avoidable investigation and treatment burdens for patients. We communicate our findings to support the small number of published case reports and raise awareness of VAU occurring in a temporal association with COVID-19 vaccination. Furthermore, our analysis supports observations about the value of case reports for the recognition and assessment of rare adverse events.

Recurrent Aphthous Stomatitis – An Overview

Recurrent aphthous ulcers are common painful mucosal conditions affecting the oral cavity. Despite their high prevalence and knowledge of many etiological factors, the exact mechanism of disease is still not fully understood. There are three different clinical forms of recurrent aphthous stomatitis and the therapy differs depending on it.

The aim of this article is to provide an overview of current knowledge about the possible causes and treatment of recurrent aphthous stomatitis. We discuss its pathogenesis which is currently the least explained in the literature. This review offers scientists and clinicians useful information about clinical presentation, diagnosis, predisposing aetiological factors and recent trends in the management of recurrent aphthous stomatitis.

Recurrent reactive non-sexually related acute genital ulcers: a risk factor for Behcet's disease?

BACKGROUND AND AIM

Lipschutz ulcers (LU) are idiopathic genital lesions characterized by the sudden appearance of painful, usually symmetric vulvar ulcers, typically occurring in sexually inactive adolescents. LU is a diagnosis of exclusion. As these lesions heal spontaneously, in the absence of tissue scarring, the therapy is mainly symptomatic and focuses on pain relief. Recurrence of LU associated with oral ulcers describes the clinical picture of complex aphthosis, which belongs to Behçet's disease (BD) pathological spectrum. Our work aims to analyze the correct diagnostic approach to recurrent aphthous, focusing on the importance of a multidisciplinary assessment and immunogenetic investigation to identify the subjects at risk of progression towards BD.   Methods: We present the case of a 12-year-old non sexually active Italian girl who was diagnosed with LU. After 15 months, she presented recurrent reactive non sexually related acute genital ulcer associated with a history of oral aphthous. According to clinical features and anamnesis, complex aphthosis was diagnosed. For diagnostic purposes, she underwent an immunogenetic analysis that showed HLA-B51 positivity.

RESULTS

In the absence of clinical and laboratory criteria to define the risk of progression of complex aphtosis towards BD, we think that besides a strict follow-up, in pediatric patients with a suggestive clinical history, it is crucial to adopt a multidisciplinary approach, comprehensive of HLA investigation, in order to guarantee an early diagnosis and a prompt therapeutic intervention.

CONCLUSIONS

In children and adolescents with genital ulcers, it is essential to consider all the possible differential diagnoses to undertake a timely and correct course of treatment.

Interesting Presentation of Oral Herpes Simplex Virus in a High-Risk Patient

Orolabial and genital herpes are common conditions caused by herpes simplex virus (HSV) that affect many individuals. Although skin findings may mimic other conditions, an HSV infection may still be diagnosed clinically. We present a case of polymerase chain reaction (PCR) negative orolabial herpes in a young male with a high-risk social history. Although testing was negative, oral HSV was clinically diagnosed and the patient was adequately treated with IV acyclovir. Both clinical history and physical examination are essential to provide an accurate diagnosis even in cases presenting with a negative diagnostic test result.

An evaluation of apremilast for the treatment of adult patients with oral ulcers associated with Behçet's syndrome

INTRODUCTION

Behçet's syndrome is a chronic, multi-system, variable vasculitis of unknown etiology that can result in significant morbidity and mortality. Mucocutaneous lesions such as oral ulcers and genital ulcers are common manifestations that can affect the quality of life of patients significantly. Treatment for mucocutaneous lesions in Behçet's syndrome continues to be critical, and an unmet need remains a significant issue.

AREAS COVERED

This review evaluates the mechanism of action of apremilast, its effect on the number and pain of oral ulcers, other manifestations, such as genital ulcers, disease activity, quality of life and safety profile in Behçet's syndrome patients. Data from clinical trials as well as observational studies were included.

EXPERT OPINION

Two randomized placebo-controlled trials and real-world observational data suggest that apremilast is an effective and well-tolerated treatment modality for oral and genital ulcers in Behçet's syndrome. Observational studies additionally showed beneficial results for skin lesions, arthritis, and intestinal involvement.

Subclinical ocular inflammation in patients with recurrent aphthous stomatitis

OBJECTIVE

Recurrent aphthous stomatitis (RAS) is the major finding of Behçet's disease as well as an inflammatory disease. We compared the choroidal thickness (CT) in patients with RAS with healthy volunteers.

METHODS

Patients with RAS (n = 34) and age- and sex-matched controls (n = 34) were evaluated using spectral-domain optical coherence tomography (OCT). CT measurements were executed at 3 different points (subfoveal, nasal, and temporal). Laboratory parameters were determined for patients and controls.

RESULTS

The mean subfoveal CT in the RAS and control groups were 356.7 ± 91.7 μm and 326.3 ± 86.6 μm, respectively. The RAS group demonstrated significantly higher subfoveal CT than the control group (p = 0.008).

CONCLUSION

This was the first reported study demonstrating a significantly higher subfoveal CT in patients with RAS. Further studies investigating the risk for subclinical ocular inflammation in this patient population are warranted.

Herpetiform aphthous genital ulcers misdiagnosed as herpes genitalis in a young male and their effective response to colchicine therapy

Genital ulceration can be a source of tremendous stress to the patient, as well as to the family members, and poses a difficult and sensitive diagnostic conundrum for the clinician. Cultural taboos and social stigmas related with the disease often result in the clinician not believing the patient’s version of history and basing the diagnosis entirely upon the clinical picture, aided by diagnostic tests. The clinicians should keep in mind that sexually transmitted infections (STIs), which can cause genital ulceration are very common, but there is a long list of non-sexually acquired causes of genital ulceration, which can lead to a diagnostic dilemma, and these should be considered before labelling the patient as suffering from a STI. We present a rare case of herpetiform genital aphthous ulcers mimicking herpes genitalis and chancroid, which was misdiagnosed repeatedly, and their effective response to treatment with colchicine on subsequent identification of the correct diagnosis.

Vasculitis

Vasculitis, characterized by inflammation and necrosis, manifests a wide spectrum of presentation by involving a vasculature of various sizes and locations. A definitive diagnosis of vasculitis invariably requires histologic confirmation since there are no diagnostic clinical, imaging, or laboratory findings. The most widely adopted vasculitis classification is the Chapel Hill Consensus Conference (CHCC) nomenclature of systemic vasculitis which integrated clinical symptoms, histopathologic features, and laboratory findings. This classification accounts for the size of the involved vessels. This chapter outlines the clinical and histologic features of the small-vessel vasculitis including the immune complex vasculitis and antineutrophil cytoplasmic antibody-associated vasculitis; medium-vessel vasculitis such as polyarteritis nodosa and Kawasaki disease; large-vessel vasculitis, namely, giant cell arteritis and Takayasu arteritis; variable-vessel vasculitis such as Behcet disease and Cogan syndrome; and vasculitis associated with systemic diseases including rheumatoid arthritis, lupus vasculitis, and sarcoid vasculitis. Vasculitis can also be secondary to drugs, infection, underlying systemic disease, or trauma. Therefore, a diagnosis of vasculitis cannot be based on histologic ground alone. Clinical pathologic correlation is necessary.

Vascular suture line wrapping for Aortoiliac anastomoses following open surgical repair of Infrarenal Behçet's Aortoiliac aneurysms

Background

This study was conducted to evaluate our local experiences of adjunctive mechanical prosthetic wrapping for aortoiliac vascular anastomoses as a prophylactic measure following surgical repair of Behçet’s aortoiliac aneurysms. The goal of prosthetic wrapping to reinforce the vascular anastomoses by mechanical protection to reduce the bleeding complications, and consequently pseudoaneurysm formation. This was aided by the administration of pre- and postoperative immunosuppressive therapy as an adjuvant treatment.

Methods

A seven-year retrospective study was conducted between January 2006 and December 2012, retrieving data of patients with Behçet’s aortoiliac aneurysms. All patients underwent open surgical repair using a heparin-bonded synthetic Dacron® graft. Data for all patients were retrieved and analyzed for diagnostic procedures, graft selection, as well as, different methods of surgical repair. Graft-related complications such as anastomotic pseudoaneurysms, occlusion, and thrombosis were also reported.

Results

Sixteen patients were recruited in this study. There were  11 (69%) males and 5 (31%) females with the male to female ratio 2:1. The patients’ age ranged between 25 and 47 years with the mean of 36.4 ± 7.3. All Behçet’s aortic/aortoiliac aneurysms were repaired by the application of heparin-bonded Dacron® tube and bifurcated grafts. The anastomotic wrapping technique was performed for both the proximal and the distal vascular anastomoses. The technical success of aortoiliac aneurysm and wrapping techniques was achieved in 100% of patients. All patients were given pre- and postoperative systemic immunosuppressive therapy. No graft-related complications were reported except for only one anastomotic pseudoaneurysm that developed at one of the right iliac anastomoses, that developed within 24 months after follow up.

Conclusions

Mechanical prosthetic wrapping for vascular anastomoses in patients with Behçet’s aortic/aortoiliac aneurysms is a feasible, simple, and reliable technique with low morbidity and mortality. It was performed as a prophylactic measure to avoid the development of postoperative anastomotic pseudoaneurysms. It must be performed for all patients with Behçet’s arterial aneurysms whenever possible. Furthermore, the supplemental administration of pre- and postoperative systemic immunosuppressive therapy should be considered as an important factor for the prophylaxis and prevention of anastomotic pseudoaneurysms and other graft-related complications.

Cutaneous Polyarteritis Nodosa Presenting Atypically with Severe Pharyngeal Ulceration

Polyarteritis nodosa (PAN) is a multisystem, necrotising vasculitis of small- and medium-sized arteries with a predilection for the visceral vessels. Cutaneous PAN is a rare variant with symptomatic vasculitis limited to the skin, typically presenting as nodular lesions on the extremities with a propensity to ulcerate. We describe a rare case of histologically confirmed cutaneous PAN presenting in a 55-year-old Ghanaian woman with severe oropharyngeal ulceration. This was associated with dysphagia and significant weight loss. Oesophagoduodenoscopy showed that the ulceration extended throughout the oropharynx. Systemic polyarteritis nodosa was ruled out with magnetic resonance angiography. Our patient was treated successfully with corticosteroids and methotrexate. This case suggests that cutaneous PAN should be considered in the differential diagnosis of patients with oropharyngeal ulceration and that histological assessment is pivotal in establishing the diagnosis early in order to instigate appropriate therapy.

Clinical Significance of Serum Bilirubin in Behçet's Disease

Background and Objective

Bilirubin (Bb) is the product of the intravascular compartment of catabolic pathway. In a small number of clinical trials, it has been shown that Bb molecules are associated with cardiovascular diseases, diabetes, cancer, autoimmune (lupus, rheumatoid arthritis) diseases and schizophrenia. Behçet's disease is a chronic, multisystemic, inflammatory vasculitis that was first described by Hulusi Behçet in 1937, which affects almost all organs and systems without any known aetiology. Here, we investigated the clinical significance of serum Bb as a biomarker in the patients with Behçet's disease.

Methods

Seventy-one (N = 71) patients with Behcet's diagnosis within the last 1 year were included retrospectively. Control group consisted of 75 subjects with similar age and sex distribution. Serum Bb, indirect Bb, total Bb, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) data were recorded from the hospital records.

Results

In the Behçet group, direct Bb was significantly lower (P = 0.011), ESR and CRP were significantly higher (P = 0.00). No significant differences were observed in other parameters. In the whole group, total Bb and indirect Bb were negatively correlated with ESR (P = 0.025, P = 0.01). Direct Bb was negatively correlated with CRP (P = 0.002). For the diagnosis of Behçet, direct Bb with a threshold of < 0.14 can be used as a diagnostic test (P = 0.000) with 70% sensitivity, 68% specificity (area under the curve = 0.69; 95% confidence interval 0.59–0.80) in ROC curve analysis.

Conclusion

According to our study, we found that inflammatory markers were high and direct Bb values were low in patients with Behcet's disease. In addition, Bb parameters were negatively associated with acute phase reactants. As a practical biomarker with anti-oxidative properties, the direct Bb can be used to diagnose and clinical follow-up in cases with Behçet's disease.

The influence of oral health and psycho-social well-being on clinical outcomes in Behçet's disease

This study was designed to investigate the association of oral ulceration and oral health factors, together with psycho-social well-being in Behçet's disease (BD), and to clarify the importance of psycho-social support of patients in the overall management of BD. The study comprised of a cohort of 146 BD patients (mean age ± SD = 39.65 ± 13.20) and 20 recurrent aphthous stomatitis (RAS) patients (mean age ± SD = 42.32 ± 11.32). Oral ulcer severity score (OUSS), Behçet's disease current activities form (BDCAF), hospital anxiety and depression scale (HADS), and the work and social adjustment scale (WSAS) were investigated. Oral health risk factors were also included. The analysis of variance, regression, and factor analysis were used to scrutinise the data. Almost 73% of patients were at high caries risk in BD and RAS groups. Thirty-nine percent of BD and forty percent of RAS had a score of BPE3 (probing depth 3.5-5.5 mm). Regression analysis revealed that OUSS and WSAS had a positive impact to increase the BDCAF score in BD patients (β = 0.395, P = 0.001; β = 0.240, P = 0.019), respectively. Dental health, periodontal health, anxiety, depression, and WSAS variables had strong loadings by factor analysis based on gender and at the time of present and absent of oral ulceration. The main oral ulcer characteristics that had significant influences on the total of oral health quality of life by 68.6% were: size, duration, ulcer-free period, and pain. The results highlighted the significant influence of oral ulceration, patients' oral health, diet, and psycho-social well-being as multi-factorial causes on increasing disease activity in BD patients.

Trends in the relative prevalence of genital ulcer disease pathogens and association with HIV infection in Johannesburg, South Africa, 2007-2015

Background

In South Africa, treatment of genital ulcer disease (GUD) occurs in the context of syndromic management. GUD aetiological studies have been conducted in Johannesburg since 2007. We report on GUD pathogen prevalence, sero-prevalence of STI co-infections and aetiological trends among GUD patients presenting to a community-based primary healthcare facility in Johannesburg over a 9-year period.

Methods and findings

GUD surveys were conducted from January to April each year. Consecutive genital ulcers were sampled from consenting adults. Swab-extracted DNA was tested by multiplex real-time PCR assays for herpes simplex virus (HSV), Treponema pallidum (TP), Haemophilus ducreyi (HD) and Chlamydia trachomatis (CT). HSV-positive DNA extracts were further subtyped into HSV-1 and HSV-2 using a commercial PCR assay; CT-positive extracts were tested with an in-house PCR assay specific for serovars L1-L3 (lymphogranuloma venereum). Sera were tested for HIV, HSV-2, and syphilis co-infections. Giemsa-stained ulcer smears were screened for Klebsiella granulomatis by microscopy. Data were analysed with STATA^TM version 14. Of 771 GUD specimens, 503 (65.2%) had a detectable pathogen: HSV 468 (60.7%); TP 30 (3.9%); CT L1-3 7 (0.9%); HD 4 (0.5%). No aetiological agents were detected in 270 (34.8%) ulcer specimens. Seroprevalence rates were as follows: HIV 61.7%; HSV-2 80.2% and syphilis 5.8%. There was a strong association between GUD pathogen detection and HIV seropositivity (p < 0.001); 68% of cases caused by HSV were co-infected with HIV. There was a significant decline in the relative prevalence of ulcer-derived HSV over time, predominantly from 2013–2015 (p-value for trend = 0.023); and a trend towards a decrease in the HIV seropositivity rate (p-value for trend = 0.209).

Conclusions

HSV remains the leading cause of pathogen-detectable GUD in South Africa. The prevalence of HIV co-infection among GUD patients is high, underlining the importance of linkage to universal HIV testing and treatment in primary healthcare settings.

Genital ulcer severity score and genital health quality of life in Behçet's disease

Background

Behçet’s Disease (BD) is a chronic auto-inflammatory, multisystem relapsing/remitting disorder of unknown aetiology. Oro-genital ulceration is a key feature of the disease and has a major impact on the patients’ quality of life. Other clinical manifestations include ocular inflammation, rheumatologic and skin involvement, while CNS and vascular complications can lead to considerable morbidity. The availability of a valid monitoring tool for BD activity is crucial in evaluating the impact of the disease on daily life activity. The aims of this study were to validate a novel tool for monitoring genital ulceration severity in BD and to assess the impact of genital ulcers on the Genital Health Quality of Life (GHQoL).

Methods

Genital Ulcer Severity Score (GUSS) was developed using six genital ulcer characteristics: number, size, duration, ulcer-free period, pain and site. A total of 207 BD patients were examined, (137 females: mean age ± SD: 39.83 ± 13.42 and 70 males: mean age ± SD: 39.98 ± 11.95) from the multidisciplinary Behçet’s Centre of Excellence at Barts Health NHS Trust. GUSS was used in conjunction with Behçet’s Disease Current Activity Form (BDCAF).

Results

The over-all score of GUSS showed a strong correlation with all genital ulcer characteristics, and the strongest correlation was with the pain domain (r = 0.936; P < 0.0001). Ulcer average size and ulcer pain were the major predicting factors in GUSS (β = 0.284; β = 0.275) respectively, and P-values were significant. Multivariate regression analysis indicated that the ulcer pain, size and site are the main ulcer characteristics having an influence on the GHQoL (R²: 0.600; P < 0.0001).

Conclusions

This study established the practicality of GUSS as a severity monitoring tool for BD genital ulcers and validated its use in 207 patients. Genital ulcers of BD have a considerable impact on the patients GHQoL.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-015-0341-7) contains supplementary material, which is available to authorized users.

Recurrent Oral and Genital Ulcers in an Infant: Neonatal Presentation of Pediatric Behçet Disease

Behçet disease is a complex, multisystem disease characterized by recurrent oral and genital ulcerations. It rarely occurs in infants or children. Neonatal Behçet disease has been reported in infants whose ulcers resolve at or before 9 weeks of age. Few cases of neonatal Behçet disease persisting into childhood have previously been reported. We report the case of a 1-month-old infant who presented with severe recurrent genital ulcerations and at 6 months developed recurrent oral ulcerations. Her orogenital ulcerations continue to recur. Human leukocyte antigen testing revealed HLA-B51 and B44 positivity. This is a case of pediatric Behçet disease in the neonatal period. Behçet disease should be considered in the differential diagnosis of recurrent genital and oral ulcerations in infants and children.

Recurrent Aphthous Stomatitis in Childhood and Adolescence: A Single-Center Experience

BACKGROUND

Recurrent aphthous stomatitis (RAS) is a common oral ulcerative condition in children. The objective was to describe the clinical features of RAS in children with accompanying clinical and laboratory findings.

METHODS

The study included 120 patients younger than 18 years of age (mean age 9.6 ± 4.3 years) with three or more oral aphthous ulcers per year between August 2008 and February 2014. Demographic characteristics of the patients, clinical features of the ulcers, and associated clinical and laboratory findings were evaluated.

RESULTS

The mean number of aphthae per year was 12.8 ± 8.5 and the mean duration of the disease was 3.6 ± 2.9 years. Minor aphthae were the most common type (87%), papulopustules were the most common accompanying cutaneous lesions (13.3%), and family history of RAS was the most common associated factor (35.8%). Genital scarring (p = 0.04) and pathergy (p = 0.01) were significantly more common in the adolescent group. Pathergy was significantly related to genital scarring (p = 0.04) and Behçet's disease (p = 0.02). There was no association between the number of aphthae per year and the duration of the disease and hematologic and immunologic abnormalities.

CONCLUSION

Our study is consistent with previous reports in terms of clinical features of aphthous ulcers, related diseases, and family history of RAS, but no associated laboratory abnormalities were noted.

Update on the therapy of Behçet disease

Behçet disease is a chronic inflammatory systemic disorder, characterized by a relapsing and remitting course. It manifests with oral and genital ulcerations, skin lesions, uveitis, and vascular, central nervous system and gastrointestinal involvement. The main histopathological finding is a widespread vasculitis of the arteries and veins of any size. The cause of this disease is presumed to be multifactorial involving infectious triggers, genetic predisposition, and dysregulation of the immune system. As the clinical expression of Behçet disease is heterogeneous, pharmacological therapy is variable and depends largely on the severity of the disease and organ involvement. Treatment of Behçet disease continues to be based largely on anecdotal case reports, case series, and a few randomized clinical trials.

Genital aphthosis in Behçet's disease: is it associated with less eye involvement?

Behçet's disease (BD) is a multisystem disease classified among the vasculitides with various clinical features. Genital aphthosis (GA) is one of the major manifestations of BD. The aim of this study was to evaluate the characteristics of BD patients with GA. A cross-sectional sample of BD patients registered in 37 years was selected. We determined clinical and laboratory features of BD patients with GA (GA cases) and compared them with the patients who never developed GA (non-GA cases). The comparisons were performed by the chi-square test and logistic regression analysis. Odds ratios (ORs) with 95 % confidence intervals were calculated to estimate the precision of ORs. Among 6,935 BD patients, 4,489 cases (64.7 %) were ascribed to GA cases. Male to female ratio (1.11:1.00 vs. 1.48:1.00 OR 0.753, P value <0.001) and mean age of disease onset (OR = 0.9, P value <0.001) were lower in GA subset. In GA cases, oral aphthosis (OA) was a more common onset manifestation (OR 2.250, P value <0.001), while uveitis (OR 0.140, P value <0.001) and retinal vasculitis (OR 0.077, P value <0.001) were less common at the disease onset. In the whole course of disease, eye involvement was less common in GA cases (OR 0.215, P value <0.001). On the contrary, OA (OR 19.698, P value <0.001), skin (OR 1.762, P value <0.001), joint (OR 1.257, P value = 0.001), gastrointestinal (OR 1.302, P value = 0.009), neurological (OR 1.624, P value <0.001) and vascular involvements (OR 1.362, P value <0.001), epididymitis (OR 1.596, P value <0.001), positive pathergy test (OR 1.209, P value <0.001) and positive familial history of OA (OR 1.325, P value <0.001) were more common in GA subset. This study showed that GA subset of BD is associated with less eye involvement but higher rates of other BD manifestations.

Association of Rho-kinase 1 (ROCK1) gene polymorphisms with Behçet's disease

BACKGROUND AND OBJECTIVE

Behçet's disease (BD) is a chronic inflammatory vasculitis presenting with flares and silent periods usually between 15 and 40 years of age. The aim of this study was to evaluate the possible association between Rho-kinase 1 (ROCK1) gene polymorphisms and patients with BD in a Turkish population.

METHODS

A total of 192 BD patients and 255 healthy controls of similar age and sex were enrolled in this study. Polymorphisms were analyzed in genomic DNA using a BioMark HD dynamic array system.

RESULTS

In the presence of CC genotype for rs73963110, CT genotype for rs111874856 (Val355Ile), and TC genotype for rs112130712 (Lys1054Arg) polymorphisms, the risk of BD increased 12.13-, 15.05-, and 16.28-fold, respectively (p < 0.0001). There was a lower frequency of the GA genotype of the rs112108028 (Pro1164Leu) polymorphisms in BD (10.3 %) compared with controls (39.7 %; p < 0.0001). Marked associations between these polymorphisms and the manifestations of BD were recorded.

CONCLUSION

This is the first study to show that ROCK1 gene polymorphisms may have a significant impact on susceptibility to BD.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common ulcerative disease affecting the oral mucosa. RAS occurs mostly in healthy individuals and has an atypical clinical presentation in immunocompromised individuals. The etiology of RAS is still unknown, but several local, systemic, immunologic, genetic, allergic, nutritional, and microbial factors, as well as immunosuppressive drugs, have been proposed as causative agents. Clinical management of RAS using topical and systemic therapies is based on severity of symptoms and the frequency, size, and number of lesions. The goals of therapy are to decrease pain and ulcer size, promote healing, and decrease the frequency of recurrence.

In pursuit of excellence: an integrated care pathway for C1 inhibitor deficiency

There are estimated to be approximately 1500 people in the United Kingdom with C1 inhibitor (C1INH) deficiency. At BartsHealth National Health Service (NHS) Trust we manage 133 patients with this condition and we believe that this represents one of the largest cohorts in the United Kingdom. C1INH deficiency may be hereditary or acquired. It is characterized by unpredictable episodic swellings, which may affect any part of the body, but are potentially fatal if they involve the larynx and cause significant morbidity if they involve the viscera. The last few years have seen a revolution in the treatment options that are available for C1 inhibitor deficiency. However, this occurs at a time when there are increased spending restraints in the NHS and the commissioning structure is being overhauled. Integrated care pathways (ICP) are a tool for disseminating best practice, for facilitating clinical audit, enabling multi-disciplinary working and for reducing health-care costs. Here we present an ICP for managing C1 inhibitor deficiency.

Oral manifestations of systemic autoimmune and inflammatory diseases: diagnosis and clinical management

CONTEXT

Systemic autoimmune and inflammatory diseases often manifest oral lesions in their earliest stages, and early diagnosis, which may be spurred by a dental examination, is key for improved outcomes. After systemic diagnosis, oral lesions benefit from specialized care by dentists in collaboration with the medical team. This review aims to educate dental clinicians about the most relevant systemic autoimmune and inflammatory conditions with accompanying oral lesions, their implications for health, and management strategies supported by the biomedical literature and clinical experience. Ulcerative conditions including Behcet and Crohn diseases are discussed, along with rheumatic conditions including Sjögren syndrome, lupus erythematosus, and rheumatoid arthritis.

EVIDENCE ACQUISITION

Evidence was accumulated through PubMed searches using pertinent keywords for each subsection. References were reviewed and original publications examined to verify the accuracy of the information. We focused on evidence included in current reviews and randomized trials. Recommendations were supported by multiple studies and consensus expert opinion.

EVIDENCE SYNTHESIS

Disease phenotypes described and clinical recommendations were synthesized from best-quality evidence available for each disease. Efforts were made to describe evidence selection within each disease section.

CONCLUSIONS

Dentists play an important role in the early detection and multidisciplinary medical management of complex autoimmune diseases. It is important to recognize prevalent medical and dental issues and special needs of patients with autoimmune conditions. The management of many inflammatory conditions is similar, and often begins with the use of topical steroids, analgesics, and antimicrobial treatments, in addition to careful attention to oral hygiene and appropriate fluoride usage. In this brief review, we aim to discuss the presentation/prevalence, diagnosis, and treatment of oral manifestations encountered in autoimmune, autoinflammatory and systemic chronic inflammatory diseases. Systemic autoimmune conditions are estimated to affect 5% to 8% of Americans.(1) Oral manifestations are encountered with high frequency, and are often the first clinical signs or symptoms of the general disease. Optimal management of complex autoimmune diseases requires a multidisciplinary medical team including dentists to care for lesions of the oral cavity. The dental practitioner may be asked to play a primary role in the diagnosis of such conditions and to participate with other health professionals working together to achieve effective clinical management. To aid in this process, we discuss in this article the current general knowledge of systemic autoimmune conditions that present with prevalent oral manifestations. The focus is on the diagnosis and management of the oral component of each disease. Importantly, whereas the etiology and pathogenesis and systemic clinical presentation may vary, presentation in the oral cavity is often similar and many conditions involve oral ulcerations. For this reason, we discuss the differential diagnosis and management of the most common oral ulcerations in a general section and subsequently address individual conditions that present with oral ulcerations. Similarly, treatment of various autoimmune/inflammatory oral conditions is often common and involves modulation or suppression of the immune response locally and/or systemically and will be therefore addressed in a common section as well as individually for each disease when unique treatment regimens are recommended. We present here our general treatment recommendations based on clinical experience and literature review; however, it is critical that good clinical judgment and specifics of an individual case should determine the appropriate dental/oral medicine intervention for a specific patient.

Fournier's Gangrene Associated with Local Cutaneous HPV Lesions in a Previously Healthy Girl

A case of an 11-year-old prepubertal girl with Fournier's gangrene is presented. The diagnosis was posed after the disease had progressed to the typical clinical picture of frank gangrene. A benign viral infection, common warts, possibly represents the initiating event of the development of this necrotizing soft tissue infection. The development of childhood Fournier's gangrene in association with viral infections has been reported in the past. An optimal outcome was achieved by aggressive antibiotic and surgical treatment despite the late diagnosis. In children, Fournier's gangrene develops in previously healthy individuals with benign diseases often representing the initiating events; thus, high index of suspicion is necessary for an early diagnosis that will lead to the optimal outcome.

A young girl with refractory intestinal Behçet's disease: a case report and review of literatures on pediatric cases who received an anti-tumor necrosis factor agent

Behçet's disease (BD) is a chronic, relapsing, multisystem inflammatory disorder classified as vasculitis and characterized by recurrent oral and genital ulcerations, uveitis, and protean clinical signs of skin, central nervous system, musculoskeletal, and gastrointestinal involvements. Among the protean manifestations due to BD, intestinal BD is often intractable, but effective treatment for intestinal BD has not been fully established. Tumor necrosis factor (TNF)-α plays a central role in inflammation in BD patients; however, there are very few reports on the successful treatment of pediatric-onset cases of intestinal BD using anti-TNF-α agents. We report the case of a 6-year-old Japanese girl with refractory intestinal BD who was successfully treated with multidrug therapy including etanercept (ETN). Also, we performed a review of literatures on pediatric cases who received an anti-TNF-α agent. To our knowledge, this is the youngest patient with intestinal BD who was successfully treated using ETN. Although further studies are needed to determine the efficacy and safety of anti-TNF-α agents in the treatment for pediatric-onset BD, we believe that even in very young patients with refractory BD, an anti-TNF-α agent may be beneficial.

Association between Rho-kinase (ROCK2) gene polymorphisms and Behçet's disease

Behçet's disease (BD) is a multi-systemic vasculitis. The aim of this study was to investigate the association between Rho-kinase (ROCK2) gene polymorphisms and patients with BD in a Turkish population. A total of 194 BD patients and 276 healthy controls with similar age and sex were included to this study. Polymorphisms were analyzed in genomic DNA using a BioMark 96.96 dynamic array system. mRNA from blood samples was extracted, and real-time polymerase chain reaction was performed for ROCK2 gene expression. There were marked changes in both genotype (TT, 41.8%; TA, 30.3%) and allele (T, 57%; A, 43%) frequencies for the rs35768389 (Asp601Val) polymorphism in patients compared with controls (TT, 64.6%; TA, 9.4%, P < 0.0001; T, 69.3%; A, 30.7%, P = 0.0004). Although CC genotype (52.0%) of rs1515219 polymorphism were more frequent, CT genotype (27.7%) were less frequent among the patients than controls (CC, 31.7%, CT, 44.6%, P = 0.0001). There was an increase in C allele (65.8% vs 54.0%) and decrease in T allele frequencies (34.2% vs 46.0%, P = 0.001) in patients. However, no associations were found with rs726843, rs2290156, rs965665, rs10178332, rs2230774, rs6755196, rs10929732, and rs34945852 polymorphisms. There was an increase in peripheral blood mRNA ROCK2 expressions in patients. This is the first study to examine the involvement of ROCK2 gene variation in the risk of incident BD. The results strongly suggest that ROCK2 gene polymorphisms may modify individual susceptibility to BD in the Turkish population.

Oral Aphthosis: Management Gaps and Recent Advances

Introduction: Though oral aphthosis is common, it has a significant impact on the quality of life in the patients. It is the most common oral ulcerative condition encountered in clinical practice. This study describes the characteristics and patterns of oral aphthosis seen at a tertiary dermatological centre in Singapore, with emphasis in evaluating the management gaps and in identifying underlying systemic diseases and nutritional deficiencies. Materials and Methods: This is a retrospective review of medical records over a 10-year period between June 2000 and June 2010. Two hundred and thirteen patients were identified using the search terms ‘oral ulcers’, ‘aphthous ulcers’, ‘oral aphthosis’, and ‘Behcet’s disease’. Patients with Behcet’s disease without oral ulcers and other diagnoses such as pemphigus vulgaris, lichen planus and herpes simplex were excluded. The remaining patients were evaluated with regard to demographic characteristics, characteristics of oral ulcers, associated connective tissue disorders and nutritional deficiencies, diagnostic tests results, treatment response as well as follow-up duration. Results: One hundred and seventy-five patients were included in this study. One hundred and one patients had recurrent oral aphthosis, with 77 having simple aphthosis and 24 having complex aphthosis. Fourteen patients (8%) fulfilled the International Study Criteria (ISG) for Behcet’s disease, of which, 85.71% had complex aphthosis. The therapeutic ladder for such patients ranged from topical steroids and colchicine through to oral corticosteroids and/or dapsone therapy. Conclusion: Recurrent oral aphthosis is a niche condition in which dermatologists are well-poised to manage. This study demonstrates that a more definitive management and therapeutic algorithm for oral aphthosis are needed for better management patients in the future. In particular, complex aphthosis needs to be monitored for progression onto Behcet’s disease. Key words: Behcet’s disease, Oral ulcers, Recurrent aphthosis

Jugulodigastric Lymph Node Inflammation Derived from Chronic Atypical Oropharyngeal Phlogosis Recurring Annually after Flu Virus Vaccination: A Holistic Vision and a Clinical Case Solved after Chlamydicidal Antibiotic Therapy

In this report, we evaluated the case history of a patient with longstanding chronic pharyngitis who had periodic clinical manifestation for three years after a flu vaccine administration, and after various treatments tried to resolve the chronic pharyngitis with unsuccessful antibiotic and anti-inflammatory therapies. The patient occasionally presented a slight ocular inflammation, while dysuria occurred after sexual activity. The search for common pathogens by use of pharyngeal swabs resulted only in Corynebacterium ulcerans growth. After this first result, we focused our investigations on ocular and uro-genital infections of Chlamydiaceae (Ct and Cp) and Mycoplasmataceae (Mh and Uu) families. We examined the patient's pharynx using molecular and culture techniques from three different sites. Although several infectious agents, including viruses and bacteria, causing chronic pharyngitis are reported in the literature, these ocular and uro-genital pathogens are seldomly routinely investigated in the same patient in ORL. Furthermore, while episodes of chronic pharyngitis is one of the most common clinical manifestation in ENT patients, these atypical pharyngitis represent ever-increasing infections which must always be considered and researched by suitable instruments such as PCR. Only from the collection of detailed medical history and careful observations of clinical manifestation, indicative of an oral chronic pathologic phenomenon of low intensity initiated several years previously, starting with sudden outbreak and relapse like a bout of flu', we suggest to study these atypical infecting agents frequently localized in the urogenital human area, awhich would allow to highlight and to recognize these clinical cases that manifest themselves as chronic inflammation of jugulodigastric lymph nodes, remaining still unrecognized and rarely associated to chlamydial infection, confused with the response to flu vaccination. After several specific cycles of antibiotic therapy, the patient's health improved considerably and showed almost complete regression of jugulodigastric lymph node inflammation.

Comparing the Effect of Phenytoin Syrup and Triamcinolone Acetonide Ointment on Aphthous Ulcers in Patients with Behcet's Syndrome

BACKGROUND

Recurrent aphthous stomatitis (RAS) appears to be the most common type of oral ulcers. The lesion is usually self limited but its painful presentation results in some difficulties. Therefore, an efficient therapeutic strategy is required and currently existing therapies seem to be inadequate because of its unclear etiology. Here the therapeutic effect of triamcinolone acetonide ointment as a relatively expensive medication has been compared with phenytoin syrup on aphthous ulcers in patients with Behcet's syndrome.

METHODS

Thirty out of 60 our patients with Behcet's syndrome were randomly treated by phenytoin syrup and the remaining were advised to use 0.1% triamcinolone acetonide ointment. After a week, they were visited again to determine the status of aphthous ulcers.

RESULT

Positive response in the triamcinolone acetonide group and phenytoin group was 86.7% and 53.3%, respectively.

CONCLUSION

The effectiveness of triamcinolone acetonide ointment was more than phenytoin on aphthous ulcers in patients with Behcet's syndrome.

Clinical and Pathological Manifestations with Differential Diagnosis in Behçet's Disease

Behçet's disease is a multisystemic inflammatory disease of unknown etiology which usually occurs as a trait of symptoms: aphthous stomatitis, genital ulcerations, and ocular disease. At the beginning of the disease the diagnosis is uncertain because of various clinical manifestations and a long period up to the full clinical picture manifestation. Since neither the laboratory data nor the histopathological signs are truly pathognomonic in Behçet's disease, the differential diagnosis depends on a careful evaluation of the medical history and meticulous physical examination to detect concomitant systemic manifestations. Sometimes, some laboratory test may help establish the diagnosis. Subspecialty referral to ophthalmology, rheumatology, neurology, and gastroenterology should be considered when indicated.

Use of Lozenges Containing Lactobacillus brevis CD2 in Recurrent Aphthous Stomatitis: A Double-Blind Placebo-Controlled Trial

Recurrent aphthous stomatitis is a common disorder of the oral cavity, affecting mainly young people. It is characterized by small ulcers which can be very painful and generally heal spontaneously within 7–14 days. There is currently no therapy that can provide rapid healing. This study evaluated the efficacy and rapidity of response of a lozenge containing Lactobacillus brevis CD2. 30 patients were randomized to take 4 lozenges a day of active product or placebo for 7 days. Signs and symptoms as well as laboratory parameters in the saliva were assessed at the start of the study and after 7 days of treatment. The study demonstrated the efficacy and the rapidity of response of the Lactobacillus brevis CD2 lozenges in resolving the clinical signs and symptoms of aphthous stomatitis, with a significantly rapid improvement of pain. This is the first study confirming the efficacy of a probiotic product in this pathology.

Lipschutz ulcers: evaluation and management of acute genital ulcers in women

Acute genital ulcers are painful and distressing to women and perplexing to the providers who care for them. The differential diagnosis includes sexually and nonsexually transmitted infections, autoimmune conditions, drug reactions, and local manifestations of systemic illness. However, in many cases, no causative agent is identified, and lesions are classified as idiopathic aphthosis. In the setting of fever and acute onset of genital ulcers in girls and women, the term Lipschutz ulcers has been used to describe ulcers associated with an immunologic reaction to a distant source of infection or inflammation. The aims of this article are to review the differential diagnosis and pathogenesis of acute genital ulcers, to offer an evaluation and classification scheme, and to discuss treatment options for the dermatologist who cares for women and girls with vulvar ulcers.

[Behçet's disease in obstetrics and gynecology]

Behçet's disease is a multisystemic disease of unknown origin characterized by a recurrent bipolar aphtosis (oral and genital) associated with vascular, digestive or articular symptoms. Gynecologists can be faced to this disease at any time of the life of their patients, including during the pregnancy. Given that the first demonstrations of the disease can be genital, they are in the front line to evoke this diagnosis. They thus have to know the main characteristics of the disease to make the diagnosis and to organize a multidisciplinary management. During pregnancy, the treatment of the disease is to be adapted to avoid teratogenic drugs, and adapt the doses of the treatment.