Behcet's Disease in an Behcet's Disease in an Indian Patient Indian Patient

Dr. Rathinam SivakumarDr. Rathinam Sivakumar HOD - Uveitis Services HOD - Uveitis Services

Dr. Radhika. TDr. Radhika. TConsultant, Uveitis ServiceConsultant, Uveitis Service Dr. Vedhanayaki RajeshDr. Vedhanayaki RajeshConsultant, Uveitis Service Consultant, Uveitis Service

HistoryHistory

22 year old male22 year old male OU:OU:

defective vision since 3 monthsdefective vision since 3 months photophobia since 3 monthsphotophobia since 3 months H/o oral and genital ulcersH/o oral and genital ulcers H/o joint painH/o joint pain painful skin lesionspainful skin lesions

First Presentation First Presentation VA: OD 6/6, OS 6/6VA: OD 6/6, OS 6/6 IOP: OD 10mm Hg; OS 14mm HgIOP: OD 10mm Hg; OS 14mm Hg OU: OU:

non-granulomatous KP's non-granulomatous KP's AC 2+ cells; flare 2+; AVF occ. cells AC 2+ cells; flare 2+; AVF occ. cells fundus: disc edema with hyperaemia fundus: disc edema with hyperaemia

Skin lesionsSkin lesions multiple, discharging pustules over the bodymultiple, discharging pustules over the body multiple pigmented, excavated scars on the back, face and multiple pigmented, excavated scars on the back, face and

limbslimbs

Mouth and Genital lesionsMouth and Genital lesions

Nodular lesions Nodular lesions over penis and over penis and scrotumscrotumMouth ulcer

PolyarthritisPolyarthritis H/o multiple joint H/o multiple joint

swelling and painswelling and pain Swelling of left ankleSwelling of left ankle

Swelling of finger joints

OU: non-granulomatous KP's AC 2+ cells; flare 2+; vitreous cells 2+ in the

lower quadrant fundus: disc edema with

hyperaemia, retinal infiltrates

First Presentation – Ocular Findings

InvestigationsInvestigations

Routine baseline investigations within Routine baseline investigations within normal limitsnormal limits

ESR – 50mm – 1st hrESR – 50mm – 1st hr Mantoux & TPHA -veMantoux & TPHA -ve LFT - normal LFT - normal

DiagnosisDiagnosis

Bilateral Panuveitis in Bilateral Panuveitis in Behcet's DiseaseBehcet's Disease

TreatmentTreatment

Prednisolone e/d (OU) - tapering therapyPrednisolone e/d (OU) - tapering therapy Oral Prednisolone tapered weekly from Oral Prednisolone tapered weekly from

40mg/week to 10mg (4 weeks)40mg/week to 10mg (4 weeks) Methotrexate 20mg/week Methotrexate 20mg/week Folic acid 6 days/weekFolic acid 6 days/week

Follow Up – After 6 weeksFollow Up – After 6 weeks

No oral ulcerNo oral ulcer VA: OD 6/6, OS 6/12VA: OD 6/6, OS 6/12 IOP: OD 17mm Hg; OS 17mm Hg IOP: OD 17mm Hg; OS 17mm Hg OU:OU:

quiet eye, resolution of uveitis quiet eye, resolution of uveitis patient was continued on oral therapypatient was continued on oral therapy

Follow-up – After 8 MonthsFollow-up – After 8 Months OU: recurrence of panuveitis with oral ulcer and joint OU: recurrence of panuveitis with oral ulcer and joint

painpain VA: OD 6/6, OS 6/12VA: OD 6/6, OS 6/12 IOP: OD 13mm Hg; OS 18mm HgIOP: OD 13mm Hg; OS 18mm Hg OU: AC – 1+ cells; AVF 2+ cellsOU: AC – 1+ cells; AVF 2+ cells fundus: fundus:

OU: disc hyperaemia OU: disc hyperaemia OD:intense vitreous cell reaction in lower OD:intense vitreous cell reaction in lower

quaderant quaderant

Treatment for both EyesTreatment for both Eyes

Prednisolone e/d - tapering therapyPrednisolone e/d - tapering therapy oral Prednisolone tapered weekly from oral Prednisolone tapered weekly from

40mg/week to 10mg (4 weeks)40mg/week to 10mg (4 weeks) Methotrexate 20mg/week (a day)Methotrexate 20mg/week (a day) Folic acid 6 days/weekFolic acid 6 days/week intravitreal Triamcinolone acetonide intravitreal Triamcinolone acetonide

(20 mg)(20 mg) biologicals were not available for himbiologicals were not available for him

Final Presentation - findings Final Presentation - findings Aug 2010 – Jul 2014:Aug 2010 – Jul 2014: recurrence of panuveitis with Behcet´s Diseaserecurrence of panuveitis with Behcet´s Disease oral therapy (Steroids and oral therapy (Steroids and

Immunosuppresants)Immunosuppresants) Intravitreal Triamcinolone acetonideIntravitreal Triamcinolone acetonide VA: OD 6/6 OS 6/18 no active inflammationVA: OD 6/6 OS 6/18 no active inflammation Diminished vision (OU) due to ERM at Diminished vision (OU) due to ERM at

Macula (OS>OD)Macula (OS>OD)

Complications during TreatmentComplications during Treatment

due to concomitant medications:due to concomitant medications: fungal ulcerfungal ulcer skin ulcer (lumbar region) skin ulcer (lumbar region) methotrexate stopped during drug methotrexate stopped during drug

associated complication period(s)associated complication period(s)

ConclusionConclusion Bilateral Panuveitis in Behçet's DiseaseBilateral Panuveitis in Behçet's Disease systemic disease affecting young males of 2.-3. decade systemic disease affecting young males of 2.-3. decade presents with oral and genital ulcer, ocularpresents with oral and genital ulcer, ocular

involvement, skin lesions and + pathergy testinvolvement, skin lesions and + pathergy test early diagnosis and appropriate treatment with early diagnosis and appropriate treatment with

systemic steroids, immunosuppressants, but better systemic steroids, immunosuppressants, but better biologicals help to preserve visionbiologicals help to preserve vision

recurrences are often without biologicalsrecurrences are often without biologicals