Recurrent Oral Ulcers: Are They Horses or Zebras?

Oral ulcers are one of the most common complaints seen by general practitioners in their offices. Recurrent aphthous stomatitis affects roughly 20% of the general population. When ulcers persist despite conventional treatment, it is crucial to consider systemic diseases such as Behçet's disease to prevent delays in care. Early recognition and appropriate management of underlying conditions are essential for improving patient outcomes and quality of life. We present a case of a 41-year-old Scottish male who came in with complaints of recurrent oral ulcers and oral thrush. Initial treatment by an infectious disease specialist resolved the oral thrush but not the ulcers. Despite further treatment attempts for three years, including biopsy and antiviral therapy, ulcers persisted. Finally, referral to rheumatology led to comprehensive autoimmune testing, revealing positive HLA B51 and a diagnosis of Behçet's disease. Treatment with topical steroids and colchicine yielded significant improvement.

Behcet's-like disease induced by secukinumab in a patient with psoriasis: a case report and literature review.

Purpose: The incidence of cutaneous paradoxical reactions associated with IL-17 inhibitors has gained attention in recent literature. Our report aims to investigate the characteristics of one rare paradoxical reaction, presenting as Behcet's disease.Methods: We reported one case of Behcet's-like disease induced by secukinumab in a patient with psoriasis. This patient, a young woman with a long history of psoriasis, showed significant improvement in her psoriatic condition after receiving four doses of secukinumab. Unexpectedly, she developed symptoms such as high fever, painful oral and genital ulcers, facial maculopapules, and erythema nodosum-like lesions on her lower limbs. Despite neutrophilia, there was no evidence of infection found in her laboratory tests. Histological analysis of a skin biopsy highlighted subcutaneous panniculitis and a mixed inflammatory cell infiltrate in the dermis. The patient was consequently diagnosed with secukinumab-induced Behcet's-like disease. Additionally, we have reviewed nine other documented cases of Behcet's-like disease triggered by IL-17 inhibitors.Results: This group showed no significant gender preference, suffering from conditions such as psoriasis, ankylosing spondylitis, and hidradenitis suppurativa. Oral and genital ulcers were prevalent among the paradoxical reactions noted. Marked improvement was observed in all patients upon discontinuation of the IL-17 inhibitors.Conclusions: Our report serves to alert physicians to this uncommon but significant paradoxical effect that may arise with anti-IL-17 treatment.

COVID 19 vaccination as a trigger of acute genital ulcers in an immunocompromised adolescent-case study and literature review.

Acute genital ulcers can affect females of all ages. In children, they often appear as an emergency and remain a diagnostic challenge for pediatricians, gynecologists and dermatologists. Prompt diagnosis and identification of disease- related factors help to implement appropriate treatment. Firstly, it is crucial to properly compile the past medical history of the patient. Past infectious, autoimmune, malignant or traumatic conditions, as well as vaccinations may contribute to the occurrence of acute genital ulcers. Moreover, new infectious agents, such as severe acute respiratory syndrome coronavirus 2 and vaccinations against Coronavirus disease of 2019, may play a significant role in the development of atypical clinical symptoms. Here we present a case of a 12-year-old girl with acute genital ulcers. Additional symptoms accompanying the ulcer included: abdominal pain, nausea, vomiting, dysuria, vulvar pain and fever. Blood test showed leukocytosis, especially neutrophilia and monocytosis and increased levels of c-reactive protein and procalcitonin. Serological tests for the most common infections were negative. Moreover, the patient had a history of autoimmune diseases. She had periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, and IgA vasculitis, also known as Henoch-Schönlein purpura in her past medical history. Additionally, she was vaccinated against SARS-CoV-2 shortly before the lesions appeared.

Lipschütz ulcers due to SARS-CoV-2 infection: a neglected diagnosis in emergency room.

Background: Primary acute genital ulcers, or Lipschütz ulcers (LU), are nonsexually transmitted, painful, self-limiting, nonrecurrent vulvar ulcers with unclear pathogenesis, representing a challenging diagnosis in emergency setting. LU have recently been described in association with severe acute respiratory syndrome coronaVirus 2 (SARS-CoV-2) infection and vaccination. Objective: The aim of this study is to describe 2 cases of LU due to SARS-CoV-2 infection, highlighting the diagnostic process, differential diagnosis, disease course, and management options. Methods: We describe 2 young females (12 and 9 years old) who presented to pediatric emergency room with the sudden onset of well-demarcated, painful, vulvar ulcers with fibrinous necrotic center. Results: Both patients tested positive to SARS-CoV-2 nasal swab, and, at physical examination, no other lesions were found in other cutaneous or mucosal sites. Sexual abuse was excluded in both cases, as well as infectious and autoimmune diseases. Supportive analgesic therapy was administered, and complete remission of lesions was observed at follow-up visits without evidence of scarring. Limitations: The main limitation of this work is represented by the small number of cases described. Conclusion: Even though extremely rare, LU related to COVID-19 are an emerging entity to be considered in the diagnosis of acute genital ulcerations. Multidisciplinary diagnostic workup of genital ulcers must be established in order to exclude sexual child abuse, to ensure patient safety, and to avoid unnecessary treatment and familial anxiety.

Acute Genital Ulcers in a Woman Secondary to COVID-19 Infection: A Case Report.

Acute genital ulcers (AGU) have been associated with various pathogens, such as Epstein-Barr virus (EBV) and cytomegalovirus (CMV). However, cases of AGU associated with coronavirus disease 2019 (COVID-19) are rare, and this disease significantly impairs human quality of life. In this case, we report a 37-year-old woman who presented with a five-day history of a painful genital ulcer and fever. A month earlier, she had experienced a COVID-19 infection that resolved without medical therapy. Physical examination revealed that multiple asymmetric ulcers presented on labia minora covered with whitish exudates. The patient, without any high-risk sexual behavior, or a personal or family history of autoimmune disorders or inflammatory bowel disease, was diagnosed with COVID-19-related AGU after ruling out other infectious and immune diseases. Following a two-week treatment of oral prednisone, her vulvar edema, ulcers, and fever improved significantly. This case suggests that AGU may be triggered by a COVID-19 infection.

Manejo en atención primaria de las infecciones de transmisión sexual (II). Lesión ulcerada genital. Vulvovaginitis. Virus del papiloma humano / Management of sexually transmitted diseases in primary care (II). Genital ulcers. Vulvovaginitis. Human papilloma virus

En el presente artículo abordamos tres síndromes clínicos infecciosos con diferentes gérmenes como causantes, pero tienen en común que las manifestaciones que presentan son a nivel genital. Algunos son estrictamente originados por gérmenes de transmisión sexual, pero otros no. Hablaremos en este capítulo de las vulvovaginitis, de la lesión ulcerada genital y del virus del papiloma humano, tres grandes entidades que presentan una tasa no menospreciable de consulta en atención primaria, en aumento en los últimos años, y que como profesionales de salud debemos saber abordar por completo, desde su manejo diagnóstico, pasando por su correcto tratamiento y finalizando con los posteriores controles. En estas entidades es tan importante el correcto abordaje como el saber recomendar la prevención, el estudio de contactos y los cribados de otras infecciones que pueden presentarse concomitantemente.(AU)

In this paper we approach three clinical syndromes with different microbial agents that cause sexually transmitted diseases (STD) with a common condition: the symptomatology is in the genital area. Some of these microbial agents are transmitted strictly sexually, but not all. In this section we will discuss about vulvovaginitis, genital ulcers and human papilloma virus, three syndromes which have increased their incidence in recent years and primary care must know its management: diagnosis, correct treatment, controls, and study of sexual contacts. The optimal approach is as important as knowing how to recommend prevention of STD, contact study and screening for other infections that can be present at the same time although asymptomatically.(AU)

[Management of sexually transmitted diseases in primary care (II). Genital ulcers. Vulvovaginitis. Human papilloma virus]. / Manejo en atención primaria de las infecciones de transmisión sexual (II). Lesión ulcerada genital. Vulvovaginitis. Virus del papiloma humano.

In this paper we approach three clinical syndromes with different microbial agents that cause sexually transmitted diseases (STD) with a common condition: the symptomatology is in the genital area. Some of these microbial agents are transmitted strictly sexually, but not all. In this section we will discuss about vulvovaginitis, genital ulcers and human papilloma virus, three syndromes which have increased their incidence in recent years and primary care must know its management: diagnosis, correct treatment, controls, and study of sexual contacts. The optimal approach is as important as knowing how to recommend prevention of STD, contact study and screening for other infections that can be present at the same time although asymptomatically.

A rare case of Behcet's disease in Nepal: multisystem manifestations and diagnostic challenges.

Behcet's disease (BD) is a chronic inflammatory disorder characterized by a relapsing and remitting course and multisystem involvement. The authors present a case report of a 20-year-old male who presented with bilateral knee joint pain, oral and genital ulcers, and papulopustular skin lesions. The patient's clinical history, physical examination, laboratory findings, and biopsy results were consistent with the diagnosis of BD. The patient tested positive for the HLA-B51 allele, confirming a genetic predisposition. The diagnosis was supported by a positive pathergy test and a skin biopsy showing vasculitis. The diagnostic criteria established by the international study group and the International Criteria for Behcet's Disease were fulfilled. Treatment consisted of colchicine, azathioprine, and topical corticosteroids. This case highlights the importance of recognizing the varied clinical presentations of BD and the need for a multidisciplinary approach to diagnosis and management. Early and accurate diagnosis is crucial to prevent severe complications and improve patient outcomes.

Inferior Vena Cava Thrombosis and Pulmonary Embolism in a Patient With Behcet Disease: A Rare Presentation.

Behcet syndrome is a systemic vasculitic syndrome. Vascular involvement in Behcet syndrome affects both arterial and venous vascular systems, contributing to significant morbidity and mortality. However, diagnosing vascular lesions can be challenging due to their resemblance to common vascular diseases, leading to potential misdiagnoses. This case report emphasizes the importance of recognizing atypical manifestations of this disease to ensure a prompt and accurate diagnosis. This case report describes a unique presentation of Behcet syndrome in a 23-year-old male patient who presented with per rectal bleeding, abdominal distension, right quadrant abdominal pain, pleuritic chest pain, and fever. The patient also reported a history of recurrent oral and genital ulcers, skin lesions, and a previous episode of dural venous sinus thrombosis. Extensive investigations revealed the involvement of the inferior vena cava and right hepatic vein, representing an atypical vascular manifestation of Behcet syndrome. Prompt diagnosis by a multidisciplinary team led to appropriate treatment with cyclophosphamide and steroids, resulting in the resolution of vascular thrombosis. In this particular case, the patient presented with involvement of the inferior vena cava and right hepatic vein, a rare and unusual manifestation of the disease. This case highlights the diverse nature of vascular complications in Behcet syndrome and underscores the importance of considering this diagnosis in patients with unexplained vascular abnormalities. Overall, this case report highlights the importance of considering Behcet syndrome in the differential diagnosis of patients with unexplained vascular manifestations. It also emphasizes the need for a comprehensive clinical evaluation and collaborative approach to ensure timely and effective management.

Genital Ulcers Associated with Systemic Lupus Erythematosus - What are the Possible Causes? A Case Report.

Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune disease that affects many organs. In this report, we discuss the case of a patient with SLE who presented to an out-hospital clinic, complaining of fever and pain with genital ulcers. Negative evaluations for other causes of genital ulcers, indicated these ulcers as related to SLE. This case highlights the importance of including SLE ulcers in the differential diagnosis of genital ulcers. LEARNING POINTS: Determining the cause of genital ulceration is a clinical challenge, especially in sexually active individuals.Genital ulcers associated with SLE are often underdiagnosed. Any patient with a history of SLE presenting with genital discomfort and/or pain must be evaluated for genital ulcers without delay.

Recurrent Genital Herpes Triggering Ulcerative Pyoderma Gangrenosum.

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis that presents as painful, rapidly growing skin ulcers with undermined edges and a violaceous, ragged border at the periphery and is non-responsive to conventional treatments. The average onset age is in the fourth decade, with a female preponderance. Genital PG is uncommon and may present singly or coexist with common sexually transmitted genital ulcerative diseases, which causes delays in the diagnosis and treatment of genital PG, thereby adding to the morbidity. Here, we highlight a case of non-healing genital ulcers that did not respond to conventional antibiotic treatment and aggravated each month with menstruation. In this case, menstruation acted as a trigger factor for the development of a herpes genital infection. The latter acts as a pathergy for the monthly aggravation of genital PG. The patient responded to treatment with anti-viral medications and immunosuppressive medications.

Genital ulcers following all-trans-retinoic acid therapy: A case series with review of literature.

All-trans-retinoic acid (ATRA) has transformed the treatment of acute promyelocytic leukemia. Most of the adverse effects associated with this drug are minor barring differentiation syndromes. Genital ulcers feature among the underreported adverse effects of ATRA which needs to be kept in mind to avoid life-threatening complications. We describe two cases who developed genital ulcers while treated with ATRA.

Lipschütz Ulcers: Classic Presentation of an Uncommon Condition.

We describe the case of a 17-year-old female who presented with the acute onset of painful genital ulcers after experiencing a week of flu-like symptoms. A physical exam revealed two 1 cm necrotic ulcers on the right vulva with an erythematous margin and overlying exudate. A diagnosis of Lipschütz ulcers was made based on the classic signs and symptoms, in addition to ruling out relevant infectious and inflammatory diseases. Our goal in presenting this case is to add to the literature and increase awareness regarding this uncommon condition. The differential diagnosis and workup for genital ulcers can be extensive, but when diagnosed correctly, treatment and reassurance can provide great comfort for the patient.

Recurrent endobronchial occlusion and aorto-bronchial fistula formation in Behcet's disease.

BACKGROUND: Behcet's disease is a multi-system inflammatory disorder. A small subset of patients with Behcet's develop relapsing polychondritis which is classified as a separate disease known as Mouth and Genital ulcers with inflamed cartilage (MAGIC syndrome). It has previously been observed that this condition can also affect the cartilaginous tissue in the tracheobronchial tree. CASE PRESENTATION: We present the case of a 44-year-old lady with Behcet's Disease, Mouth and Genital ulcers with inflamed cartilage (MAGIC) syndrome and an aortic Frozen Elephant Trunk (FET) who presented to hospital with recurrent episodes of left lobar collapse of the lung. During bronchoscopy, we found the presence of multiple inflammatory endobronchial webs occluding segments of the left bronchial tree. Repeated examinations showed evidence that these inflammatory webs were progressing in size, density and location. Furthermore, we noticed herniation of her descending aortic FET into her left bronchial tree forming an aorto-bronchial fistula which was complicated by a graft infection. Her descending aortic FET section was surgically replaced with an open procedure and bronchoscopic interventions attempted to remove the occlusions in her bronchial tree. Despite optimisation of medical management and surgical correction, this patient continued to develop progressive occlusion of her left bronchial tree, resulting in a chronically collapsed left lung. CONCLUSIONS: A multi-disciplinary team approach is of paramount importance in order to optimally manage patients with Behcet's disease, balancing immunosuppressive regimens that need close monitoring and titration in the context of potential surgical intervention and the risk for intercurrent infection.

Behcet disease: an undifferentiating and complex vasculitis.

Behçet Disease is a relapsing and remitting variable vessel vasculitis characterized by recurrent mucocutaneous ulcers that can involve almost every organ system in the body. Indeed, the presence of recurrent oral or genital ulcers with other auto-inflammatory symptoms should raise suspicion for this elusive disease. It is unique among the vasculitides in that it can affect vessels of small, medium, and large size and tends to involve venous rather than arterial circulation, and its effects on the pulmonary venous circulation are particularly notable for their role in disease mortality. Classically seen in Mediterranean, Middle-Eastern, and eastern Asian countries, and relatively rare in the United States, prevalence has been increasing, prompting an increased need for internists to be aware of Behcet's clinical presentation and treatment. As early recognition and diagnosis of the disease is key to successful treatment and better prognosis, this review provides a brief summary of the current etiological theories, important clinical manifestations, and treatments including newer biologic alternatives.

Lipschutz Ulcers in an Adolescent After Sars-CoV-2 Infection.

This case report describes a 15-year-old female who presented with acute onset of painful genital ulcers. She denied being sexually active and tested positive for severe acute respiratory coronavirus 2 five days prior. Associated symptoms on days 1 to 3 included fatigue, nausea, headaches, and fever. Lipschutz ulcers (LUs), also known as aphthous ulcers, acute genital ulcers, and acquired genital ulcerations; are an uncommon, self-limiting, nonsexually transmitted condition characterized by the rapid onset of painful, necrotic ulcerations of the vulva or lower vagina. The pathogenesis of LUs is unclear, and the diagnosis is one of exclusion.

The first case of monkeypox virus and acute HIV infection: Should we consider monkeypox a new possible sexually transmitted infection?

Since May 2022, a Monkeypox virus (MPXV) outbreak has been ongoing in several non-endemic countries. MPXV is usually transmitted after intimate contact, through body fluids, close contact from active lesions or through respiratory droplets. The recent outbreak occurrent in people with multiple recent sexual intercourse suggests the sexual route as the main way of transmission. However, there is no sufficient evidence to consider MPXV as a new sexually transmitted infection (STI), even though we believe that a link between MPXV and other STIs may exist with a possible facilitating action on their spreading. Herein, we illustrate the first case described during the current outbreak of a young man with both MPXV and acute HIV infection in a non-endemic country.

Sexual history of human monkeypox patients seen at a tertiary hospital in Bayelsa, Nigeria.

Background: Human monkeypox (HMPX) is currently spreading outside endemic countries in Africa and the majority of those affected are gay and bisexual men within interconnected sexual networks. We investigated the sexual history of HMPX cases seen at a tertiary hospital in Bayelsa State during the 2017-2018 outbreak in Nigeria.Method: A cross-sectional study was conducted between 20 October 2017 and 2 January 2019 among adult confirmed/probable HMPX cases. A questionnaire was used to collect data on the sexual history of participants, including sexual contact in relation to the first symptom, and high-risk behaviours (HRB) such as a history of condomless casual sex, multiple sexual partners, and transactional sex.Results: Of 21 patients, 16 (76.2%) gave consent to participate in the study: age range of 22-43 years, 75% males, three (18.8%) HIV-1 positive, and 13 (81.2%) with genital ulcers. Nine (56.2%) of participants reported HRB, and all were male heterosexuals. Eight of the 16 participants (50%) reported having sex within a month before their first symptom, and five (62.5%) of this number reported HRB. There were two cases of sex with a partner with a non-genital rash, and a spouse who developed a vulval ulcer four days after sex with her husband.Conclusion: Our results support the role of sexual contact in the transmission of monkeypox among some confirmed cases from Nigeria. However, future elaborate studies are required to confirm if sexual behaviour and sexual transmission are associated with HMPX in Nigeria.