A 35 yo M of Turkish descent presents to clinic with oral ulcers.

History & Physical Exam

Patient Reports
  • Oral ulcers started about 1 year ago and have been recurring every 2-3 months since then. 
  • He has had one genital ulcer during this time. He is sexually active with one partner and uses barrier protection. 
  • He had laboratory work drawn about 4 months ago and noticed increased redness at the site of the needlestick, which persisted for about 48 hours (he notes this has been occurring since childhood). 
  • Does not take any medications other than occasional OTC ibuprofen for headaches.
  • The ulcers have started to become more bothersome, and he would like to see if there is anything he can do to help with their recurrence. 
Physical Exam
  • Two ulcers in his mouth
  • Vital signs are normal
  • Labs are unremarkable
Differential Diagnosis

Next Steps & Treatment

  • The report of pathergy would need to be verified and visualized by a physician.
  • At this time, no treatment should be started until infectious etiology is ruled out. 
  • If no other cause is identified, consider a topical steroid (for his oral ulcers a dexamethasone elixir, for genital ulcers a topical steroid) and if uncontrolled, then a systemic immunosuppressant such as colchicine can be considered, and rheumatology follow-up is warranted. 

A 45 yo Japanese M with history of Crohn’s disease had recent colonoscopy, which revealed increasing and worsening ulcers in his colon.

Clinical Presentation & History

  • Biopsy of the new ulcers revealed nonspecific inflammation with no granulomas.  
  • Currently on treatment with anti-TNF alpha inhibitor and had good control of his symptoms until last year. 
  • He has noticed occasional oral ulcers, which he attributed to his history of oral herpes and that have increased while he has been on immunosuppressives. 
  • He was diagnosed with Crohn’s disease at 25 yo, which was confirmed with bx with granulomas. 
  • Persistent redness in the area of needle sticks as child and adult.  
  • He recently had evaluation by an ophthalmologist; diagnosed with uveitis and treated with topical eye drops.

Physical Exam & Tests

  • His vital signs today are normal.
  • Physical exam is unremarkable. 
  • CBC, CMP, ESR, and CRP are all within normal limits.
Differential Diagnosis

Treatment

  • Most likely would consist of adding another systemic immunosuppressant to control Behcet’s ulcers in his colon, in addition to continuing treatment anti-TNF-inhibitor therapy for his Crohn’s disease.