Behcet's Disease: Causes, Symptoms, Diagnosis And Treatment

Behcet's Disease: Causes, Symptoms, Diagnosis And Treatment

What Is Behcet's Disease?

The disease was first described in 1937 by Dr. Helusi Behcet, a professor of dermatology in Istanbul. Behcet's disease is now recognized as a chronic condition that causes sores or ulcers in the mouth and on the genitals, and inflammation in parts of the eye. In some people, the disease also results in arthritis (swollen, painful, stiff joints) and inflammation of the digestive tract, brain, and spinal cord.

What Causes Behcet's Disease?

The exact cause of Behcet's disease is unknown. Most of the symptoms are caused by inflammation of the blood vessels, particularly veins. Inflammation is the body’s characteristic reaction to injury or disease and is marked by four signs: swelling, redness, heat, and pain. Doctors think that an autoimmune reaction may cause blood vessels to become inflamed, but they do not know what triggers this reaction. In an autoimmune reaction, the immune system mistakenly attacks and harms the body’s own tissues. Under normal conditions, the immune system protects the body from diseases and infections by killing harmful foreign substances, such as germs, that enter the body.

Behcet's disease is not contagious and does not spread from one person to another. Researchers think that two factors are probably important in its development. First, it is believed that abnormalities of the immune system make some people susceptible to the disease. Researchers think that this problem may be inherited; that is, it may be due to one or more specific genes. Second, something in the environment, possibly a bacterium or virus, might trigger or activate the disease in susceptible people. Researchers have found that people who have frequent strep infections (caused by Streptococcus bacteria) are more likely to develop Behcet's disease.

What Are the Symptoms of Behcet's Disease?

Behcet's disease affects each person differently. Some people have only mild symptoms, such as skin sores or ulcers in the mouth or on the genitals. Others have more severe disease, such as meningitis or inflammation of the membranes that cover the brain and spinal cord. Meningitis can cause fever, a stiff neck, and headaches. More severe symptoms usually appear months or years after a person notices the first signs of Behcet's disease. Symptoms can last for a long time or can come and go in a few weeks. Typically, symptoms appear, disappear, then reappear. The times when a person is having symptoms are called flares. To help the doctor diagnose Behcet's disease and monitor its course, patients may want to keep a record of the symptoms that occur and when they occur. Because many conditions mimic Behcet's disease, physicians must observe symptoms to make an accurate diagnosis. The four most common symptoms of Behcet's disease are mouth sores, genital sores, inflammation of parts of the eye, and arthritis.

  • Mouth sores: Mouth sores (known as oral aphthosis and aphthous stomatitis) affect almost all patients with Behcet's disease. They are often the first symptom that a person notices and may occur long before any other symptoms appear. The sores usually have a red border and several may appear at the same time. They can be painful and make eating difficult. Mouth sores go away in 10 to 14 days but often come back. Small sores usually heal without scarring, but larger ones may scar.
  • Genital sores: Affecting more that half of all people with Behcet's disease, most genital sores appear on the scrotum in men and vulva in women. The sores look similar to mouth sores and may be painful. After several outbreaks, they may cause scarring.
  • Uveitis (yoo.vee.EYE.tis): Inflammation of the middle part of the eye (the uvea), including the iris, occurs in more than half of all people with Behcet's disease. This symptom is more common among men than women and typically begins within 2 years of the first symptoms. Eye inflammation can cause blurred vision and, rarely, pain and redness. Because partial loss of vision or blindness can result if the eye frequently becomes inflamed, patients should report these symptoms to their doctor immediately.
  • Arthritis: Inflammation of the joints occurs in more than half of all patients with Behcet's disease. Arthritis causes pain, swelling, and stiffness in the joints, especially the knees, ankles, wrists, and elbows. Arthritis that results from Behcet's disease usually lasts a few weeks and does not cause permanent damage to the joints.
In addition to mouth and genital sores, eye inflammation, and arthritis, Behcet's disease may cause other skin problems, blood clots, and inflammation in the central nervous system and digestive organs.

Behcet's disease causes various skin sores that look like red bumps on a black-and-blue mark. The sores are red, raised, and typically appear on the legs and upper torso. In some people, sores or lesions may appear when the skin is scratched or pricked. When doctors suspect that a person may have Behcet's disease, they may perform a test called pathergy in which they prick the skin with a small needle: 1 to 2 days after the test, people with Behcet's disease may develop a bump where the doctor pricked the skin. Doctors disagree about the usefulness of a pathergy test because Behcet's patients in the United States rarely have a skin reaction. However, more than half of the patients in Middle Eastern countries and Japan do have a reaction.

About 10 percent of patients with Behcet's disease have blood clots resulting from inflammation in the veins (thrombophlebitis), usually in the legs. Symptoms include pain and tenderness in the affected area, which may also be swollen and warm. Because thrombophlebitis can have severe complications, people should report symptoms to their doctor immediately. A few patients may experience artery problems such as aneurysms (a stretching or expanding of a weakened blood vessel).

Behcet's disease affects the central nervous system in about 10 percent of all patients with the disease. The central nervous system includes the brain and spinal cord and helps the body to coordinate movements and process information. Behcet's disease can cause meningoencephalitis inflammation of the brain and the thin membrane that covers and protects it. People with meningoencephalitis may have fever, headache, stiff neck, and difficulty coordinating movement, and should report any of these symptoms to their doctor immediately. If this condition is left untreated, a stroke can result.

Only rarely does Behcet's disease cause inflammation and ulceration (sores) in the digestive tract and lead to stomach pain, diarrhea, constipation, and vomiting. Because these symptoms are very similar to symptoms of other diseases of the digestive tract, such as a peptic ulcer, ulcerative colitis, and especially Crohn's disease, careful evaluation is essential.

How Is Behcet's Disease Diagnosed?

Diagnosing Behcet's disease is very difficult because no specific test confirms it. Less than half of the patients initially thought to have Behcet's disease actually have it. The doctor must examine a patient with symptoms and rule out other conditions with similar symptoms. Because it may take several months or even years for all the common symptoms to appear, the diagnosis may not be made for a long time. A patient may even visit several different kinds of doctors before the diagnosis is made.

These symptoms are key to diagnosing Behcet's disease:

  • Mouth sores at least three times in 12 months
  • Any two of the following symptoms: recurring genital sores, eye inflammation with loss of vision, skin lesions, or positive pathergy (skin prick test).
Besides finding these signs, the doctor must rule out other conditions with similar symptoms, such as Crohn's disease and Reiter's syndrome. The doctor may also recommend that the patient see an eye specialist to identify possible complications related to eye inflammation.

Who Gets Behcet's Disease?

Behcet's disease is common in the Middle East, Asia, and Japan, but rare in the United States. In Middle Eastern and Asian countries, the disease affects more men than women. In the United States, the opposite is true. Behcet's disease tends to develop in people in their twenties or thirties, but people of all ages can develop it.

How Is Behcet's Disease Treated?

Although there is no cure for Behcet's disease, people can usually control their symptoms with proper medication, rest, and exercise. Treatment goals are to reduce discomfort and prevent serious complications such as disability from arthritis or blindness. The type of medicine and the length of treatment depend on the person's symptoms and their severity.

It is likely that a combination of treatments will be needed to relieve specific symptoms. Patients should tell each of their doctors about all of the medicines they are taking so that the doctors can coordinate treatment.

Topical medicine is applied directly on the sores to relieve pain and discomfort. For example, doctors prescribe rinses to treat mouth sores. Creams are used to treat skin and genital sores. The medicine usually contains corticosteroids, which reduce inflammation, or an anesthetic, which relieves pain.

Doctors also prescribe medicines taken by mouth to reduce inflammation throughout the body, suppress the overactive immune system, and relieve symptoms. Doctors may prescribe one or more of the medicines described below to treat the various symptoms of Behcet's disease.

  • Corticosteroids Prednisone is a corticosteroid prescribed to reduce pain and swelling throughout the body in people with severe joint pain and inflammation, skin sores, eye disease, or central nervous system symptoms. Patients must carefully follow the doctor's instructions about when to take prednisone and how much to take. It is also important not to stop taking the medicine suddenly because it alters the body's production of the natural corticosteroid hormones. Long-term use of prednisone can have side effects such as osteoporosis, weight gain, delayed wound healing, persistent heartburn, and elevated blood pressure. However, these side effects are rare when prednisone is taken at low doses for a short time. It is important that patients see their doctor regularly to monitor possible side effects.

  • Immunosuppressive drugs Medicines (including corticosteriods) that help control an overactive immune system, such as is the case in people with Behcet's disease, reduce inflammation throughout the body and can lessen the number of flares. Doctors may use immunosuppressive drugs when a person has eye disease or central nervous system involvement. These medicines are very strong and can have serious side effects. Patients must see their doctor regularly for blood tests to detect and monitor side effects.

Depending on the person's specific symptoms, doctors may use one or more of the following immunosuppressive drugs:

  • Azathioprine Most commonly prescribed for people with organ transplants because it suppresses the immune system, azathioprine is now used to treat uveitis and central nervous system involvement in Behcet's disease. This medicine can upset the stomach and may reduce the production of new blood cells by the bone marrow.
  • Chlorambucil Doctors use chlorambucil to treat uveitis and meningoencephalitis. People taking chlorambucil must see their doctor frequently because it can have serious side effects, such as permanent sterility and cancers of the blood. Patients need regular blood tests to monitor blood counts of white cells and platelets.
  • Cyclosporine Like azathioprine, doctors prescribe this medicine for people with organ transplants. When used by patients with Behcet's disease, cyclosporine reduces uveitis and central nervous system involvement. To reduce the risk of side effects, such as kidney and liver disease, the doctor can adjust the dose. Patients must tell their doctor if they take any other medicines, because some affect the way the body uses cyclosporine.
  • Colchicine Commonly used to treat gout, which is a form of arthritis, colchicine reduces inflammation throughout the body. The medicine is sometimes used to treat eye inflammation and skin symptoms in patients with Behcet's disease. Common side effects of colchicine include nausea, vomiting, and diarrhea. The doctor can decrease the dose to relieve these side effects.
If these medicines do not reduce symptoms, doctors may use other drugs such as cyclophosphamide and methotrexate. Cyclophosphamide is similar to chlorambucil. Methotrexate, which is also used to treat various kinds of cancer as well as rheumatoid arthritis, can relieve Behcet's symptoms because it suppresses the immune system and reduces inflammation throughout the body.

Although rest is important during flares, doctors usually recommend moderate exercise, such as swimming or walking, when the symptoms have improved or disappeared. Exercise can help people with Behcet's disease keep their joints strong and flexible.