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Behcet Disease Workup

  • Author: Fatima A Alnaimat, MBBS; Chief Editor: Herbert S Diamond, MD  more...
 
Updated: Apr 26, 2016
 

Approach Considerations

Specific diagnostic tests for Behcet disease are lacking. Suggestive features of the disease can be obtained from laboratory evaluations, imaging studies, and histopathologic evaluation in the right clinical context. However, development of those features may take several months to years, leaving the diagnosis of Behcet disease rather suggestive in many cases. 

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Imaging Studies

Imaging study findings are as follows:

  • Sacroiliitis may be observed on a radiograph, magnetic resonance imaging (MRI) scan, or computed tomography (CT) scan
  • Radiographs of peripheral joints may show soft-tissue swelling and/or effusions
  • Brain CT scanning may identify areas of acute ischemia
  • Brain MRI/magnetic resonance angiography (MRA) can identify cerebral vasculopathy and areas of acute/subacute ischemia
  • Single-photon emission computed tomography (SPECT) has been used to identify areas of cerebral hypoperfusion.
  • Angiography may be used to evaluate for aneurysms

In a study of lower-extremity vein thrombosis, patients with Behçet disease demonstrated the following findings on Doppler ultrasonography, compared with patients with thrombosis from other causes[35] :

  • Significantly more bilateral involvement
  • Less complete recanalization
  • More frequent collateral formation
  • Contiguous and symmetric pattern of venous involvement, affecting all deep and superficial veins of the lower extremities, with less affinity for crural veins
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Other Tests

Pathergy test

For the pathergy test, a sterile blunt needle is inserted into the skin of the forearm. The development of an inflammatory papule or pustule within 24-48 hours constitutes a positive result. This finding reflects an overactive immune response to minor injuries. Histologic studies of these lesions reveals mononuclear cell infiltrates and keratinocytes.

The pathergy test is helpful but is not sensitive or specific for the diagnosis of Behcet disease. Positive results tend to be more common in Mediterranean patients. 

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Procedures

Arthrocentesis and lumbar puncture may be used to rule out alternate causes of disease presentation, as they normally demonstrate nonspecific inflammatory findings.

Synovial fluid

Synovial fluid usually is cloudy with variable viscosity, and the white blood cell (WBC) counts are 300-36,000/µL (either noninflammatory or inflammatory). Polymorphonuclear leukocytes and protein elevations are the predominant findings, and glucose levels are near normal. Thus, because synovial fluid merely demonstrates general inflammation, examination serves only to rule out the presence of aseptic joint, crystal-induced arthropathy, or other alternative identifiable cause in patients with Behçet disease.

Cerebrospinal fluid

Analysis may indicate local inflammation with increased WBC counts, lymphocyte predominance, and elevated protein levels, as well as Ig levels and Ig index that reflect local production of Ig. Opening pressures are very high in some patients.

 

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Histologic Findings

Although no specific histologic findings characterize Behçet disease, biopsy samples of affected tissue often reveal widespread vasculitis of the arteries and veins of any size.Thrombosis commonly develops in affected areas and must be distinguished from vasculitis as a precipitating cause for organ-specific symptoms. 

Other organ-system findings include the following:

  • Skin -Skin biopsy results often reflect nondiagnostic findings but can be used to differentiate alternate disease entities. Erythema nodosum lesions with characteristic findings and occasional granulomas; folliculitis; leukocytoclastic vasculitis; dermal inflammation and perivascular infiltrates; fibrosis; and mucosal lesions, including aggregated intravascular conglomerates of neutrophils, endothelial cell swelling, fibrinoid necrosis, and a mixed perivascular infiltrate (Eye - Cataracts, posterior and anterior uveitis, retinal vasculitis and thrombosis, cytoid macular degeneration, retinal detachment, and lymphocytic infiltrates in the iris (even during clinical remissions)
  • Brain - Infarctions due to vasculitis or thrombosis, meningoencephalitis, lymphocytic meningeal infiltration, or demyelinization
  • Joint - Superficial inflammatory synovial infiltrates, mainly polymorphonuclear lymphocytes, and deposition of IgG in the synovium
  • GI tract - Ulcerations from the buccal mucosa to the anus, intestinal perforation, peritonitis, infiltration with polymorphonuclear leukocytes and lymphocytes, hepatitis, cholecystitis, and pancreatitis
  • Heart - Pericarditis, myocarditis, endocarditis, coronary arteritis, and myocardial fibrosis
  • Lung - Serositis and vasculitis
  • Kidneys - Glomerulonephritis
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Laboratory Studies

Laboratory findings

Laboratory findings are nonspecific and reflect the inflammatory state.

C-reactive protein levels, erythrocyte sedimentation rate (ESR), leukocyte count, complement components, and acute-phase reactants may all be elevated during an acute attack.

levels of IgA, IgG, alpha-2 globulin, IgM, and immune complexes are occasionally elevated.

In a study of 48 patients with Behçet disease and 47 healthy controls, serum levels of calprotectin were significantly elevated in the Behçet disease group. Serum calprotectin levels did not correlate with scores on the Behçet Disease Current Activity Form or with measures of depression and anxiety or quality of life.[36]

None of these findings is specific for the diagnosis of Behçet disease, but such findings can corroborate active disease.

Antiphospholipid antibodies

These include lupus anticoagulant, dilute Russell viper venom test (DRVVT), and anticardiolipin antibodies. Although uncommon in Behçet disease, they are worth pursuing to rule out alternate causes of thrombosis.

Up to one third of patients with Behçet disease who have thrombosis are found to have factor V Leiden–deficiency mutations. Therefore, this, APL antibody, and other causes of hypercoagulability should be ruled out as contributing factors to thrombosis formation.

Antineutrophil cytoplasmic antibody

Occasionally, patients are found with positive test results for perinuclear antineutrophil cytoplasmic (p-ANCA) antibody. However, positive or negative results on this test do not change prognosis or therapy.

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Contributor Information and Disclosures
Author

Fatima A Alnaimat, MBBS Rheumatologist, Essentia Health

Fatima A Alnaimat, MBBS is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Nothing to disclose.

Coauthor(s)

Jeffrey R Lisse, MD, FACP Professor, Department of Internal Medicine, Chief, Section of Rheumatology, University of Arizona School of Medicine

Jeffrey R Lisse, MD, FACP is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians-American Society of Internal Medicine, American College of Rheumatology, American Geriatrics Society, Sigma Xi

Disclosure: Received consulting fee from Genentech for consulting; Received consulting fee from Centacor for consulting; Received consulting fee from Novartis for review panel membership.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Lawrence H Brent, MD Associate Professor of Medicine, Jefferson Medical College of Thomas Jefferson University; Chair, Program Director, Department of Medicine, Division of Rheumatology, Albert Einstein Medical Center

Lawrence H Brent, MD is a member of the following medical societies: American Association for the Advancement of Science, American Association of Immunologists, American College of Physicians, American College of Rheumatology

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Janssen<br/>Serve(d) as a speaker or a member of a speakers bureau for: Abbvie; Genentech; Pfizer; Questcor.

Chief Editor

Herbert S Diamond, MD Visiting Professor of Medicine, Division of Rheumatology, State University of New York Downstate Medical Center; Chairman Emeritus, Department of Internal Medicine, Western Pennsylvania Hospital

Herbert S Diamond, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Physicians, American College of Rheumatology, American Medical Association, Phi Beta Kappa

Disclosure: Nothing to disclose.

Additional Contributors

Kristine M Lohr, MD, MS Professor, Department of Internal Medicine, Interim Chief, Division of Rheumatology, Director, Rheumatology Training Program, University of Kentucky College of Medicine

Kristine M Lohr, MD, MS is a member of the following medical societies: American College of Physicians, American College of Rheumatology

Disclosure: Nothing to disclose.

Acknowledgements

Augusto C Posadas, MD Rheumatologist, Saguaro Physician Group, Tucson, AZ

Disclosure: Abbott Honoraria Speaking and teaching

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Oral aphthous ulcers secondary to Behçet disease.
 
 
 
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