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LETTERS Behcet’s syndrome and palate perforation To the Editor: Behcet described the relapsing symptom triad of aphthous stomatitis, genital ulcerations, and iridocyclitis (1). This syndrome also produces the histopathologic changes of vasculitis in other areas, thus it is a systemic disease (2). Herein we report a patient with Behcet’s syndrome and an unusual complication. In April, 1975 a 26-year-old male had fever and oral ulcerations lasting 5 days. Four months later the same symptoms were observed and in April 1976, conjunctivitis and diplopia with paralysis of the right lateral rectus muscle were noted. In January 1977 the patient had a new flareup, losing 15 kg of body weight as a consequence of multiple and painful oral ulcers that discouraged eating. Results of the ophthalmologic examination were normal. Laboratory tests showed: leukopenia of 2,900/mm3 and 1,298 lymphocytes/mm3. Forty-six percent of the lymphocytes formed E rosettes (normal 66.37 f 1.89). EAC rosettes were within normal limits. Skin tests (PPD, coccidioidin, histoplasmin, SIC-SD) were negative, as were bacterial and fungal cultures; cryoglobulins, antiDNA antibodies (Farr), and antinuclear antibodies by indirect immunofluorescence were not found. Radiologic and scintiscan studies of sacroiliac joints and paranasal sinuses were normal. Biopsy from oral ulcers disclosed perivascular infiltration of lymphocytes and polymorphonuclear leukocytes; immunofluorescent staining failed to identify deposits of immunoglobulins. HLA-B5 was demonstrated by microlymphocytotoxicity. In May 1977 the patient had fever, headache, paresthesias in the legs and hands, ulcers of the penis foreskin, conjunctivitis, and regurgitation of food into the nasal cavity. An ulcer perforating the soft palate was observed. Prednisone was increased to 60 mg daily and 10 mg of chlorambucil were started. The diagnosis of Behcet’s syndrome was established by the presence of the three major criteria: oral ulcers, genital ulcers, and ocular lesions, plus other systemic manifestations, all of which have been reported in this condition. Mucocutaneous and colonic ulcerations in general are shallow and not larger than 1 to 1.5 cm; no report is known describing perforation. The complication Arthritis and Rheumatism, Vol. 22, No. 3 (March 1979)
of soft palate perforation is important in the differential diagnosis, since this has been described in systemic lupus erythematosus, Wegener’s granulomatosis, lethal midline granuloma, mycotic infections, and neoplasia. All these diseases were ruled out in our case by clinical and laboratory parameters. CARLOS LAVALLE, M.D. JESUSGUDINO,M.D. SERGIOR. REINOSO, M.D. JORGEALCOCER,M.D. ANTONIO FRAGA,M.D. Servicio de Reumatologia, Hospital General, Centro Medico La Raza IMSS A venida Vallejo y Jacarandas Mexico, I S , DF
REFERENCES 1. Behcet H: Uber rezidivierende, aphthose, durch einen Virus verursachte Geschwure am Mund, am Auge und anden Genitalien. Derm Wschr 105:1152-1157, 1937 2. ODuffy JD, Canney JA, Deodhar S: Behcet’s disease. Ann Intern Med 7556 1-570, 1971 3. Mason RM, Barnes CG: Behcet’s syndrome with arthritis. Ann Rheum Dis 28:95-103, 1969
Cost of nerve conduction studies in carpal tunnel syndrome To the Editor: Dr. Joseph Rogoff s letter (1) is indicative of the thinking that has caused health care costs to soar in this country. He objects to the fact that Drs. Ahmed and Braun treated 4 of their 5 patients with carpal tunnel syndrome and polymyalgia rheumatica with corticosteroid injections into the carpal tunnel without bothering to obtain nerve conduction studies. All of the patients responded, although 1 or 2 needed later repeat injections (2). Dr. Rogoff evidently feels that any ambulatory patient with carpal tunnel symptoms should be dispatched from the office without treatment and scheduled for nerve conduction studies at a cost of $75 or more. When these results are obtained, the patient should return to the rheumatologist’s office to pay another office visit fee and possibly have an injection into
LETTERS Behcet’s syndrome and palate perforation To the Editor: Behcet described the relapsing symptom triad of aphthous stomatitis, genital ulcerations, and iridocyclitis (1). This syndrome also produces the histopathologic changes of vasculitis in other areas, thus it is a systemic disease (2). Herein we report a patient with Behcet’s syndrome and an unusual complication. In April, 1975 a 26-year-old male had fever and oral ulcerations lasting 5 days. Four months later the same symptoms were observed and in April 1976, conjunctivitis and diplopia with paralysis of the right lateral rectus muscle were noted. In January 1977 the patient had a new flareup, losing 15 kg of body weight as a consequence of multiple and painful oral ulcers that discouraged eating. Results of the ophthalmologic examination were normal. Laboratory tests showed: leukopenia of 2,900/mm3 and 1,298 lymphocytes/mm3. Forty-six percent of the lymphocytes formed E rosettes (normal 66.37 f 1.89). EAC rosettes were within normal limits. Skin tests (PPD, coccidioidin, histoplasmin, SIC-SD) were negative, as were bacterial and fungal cultures; cryoglobulins, antiDNA antibodies (Farr), and antinuclear antibodies by indirect immunofluorescence were not found. Radiologic and scintiscan studies of sacroiliac joints and paranasal sinuses were normal. Biopsy from oral ulcers disclosed perivascular infiltration of lymphocytes and polymorphonuclear leukocytes; immunofluorescent staining failed to identify deposits of immunoglobulins. HLA-B5 was demonstrated by microlymphocytotoxicity. In May 1977 the patient had fever, headache, paresthesias in the legs and hands, ulcers of the penis foreskin, conjunctivitis, and regurgitation of food into the nasal cavity. An ulcer perforating the soft palate was observed. Prednisone was increased to 60 mg daily and 10 mg of chlorambucil were started. The diagnosis of Behcet’s syndrome was established by the presence of the three major criteria: oral ulcers, genital ulcers, and ocular lesions, plus other systemic manifestations, all of which have been reported in this condition. Mucocutaneous and colonic ulcerations in general are shallow and not larger than 1 to 1.5 cm; no report is known describing perforation. The complication Arthritis and Rheumatism, Vol. 22, No. 3 (March 1979)
of soft palate perforation is important in the differential diagnosis, since this has been described in systemic lupus erythematosus, Wegener’s granulomatosis, lethal midline granuloma, mycotic infections, and neoplasia. All these diseases were ruled out in our case by clinical and laboratory parameters. CARLOS LAVALLE, M.D. JESUSGUDINO,M.D. SERGIOR. REINOSO, M.D. JORGEALCOCER,M.D. ANTONIO FRAGA,M.D. Servicio de Reumatologia, Hospital General, Centro Medico La Raza IMSS A venida Vallejo y Jacarandas Mexico, I S , DF
REFERENCES 1. Behcet H: Uber rezidivierende, aphthose, durch einen Virus verursachte Geschwure am Mund, am Auge und anden Genitalien. Derm Wschr 105:1152-1157, 1937 2. ODuffy JD, Canney JA, Deodhar S: Behcet’s disease. Ann Intern Med 7556 1-570, 1971 3. Mason RM, Barnes CG: Behcet’s syndrome with arthritis. Ann Rheum Dis 28:95-103, 1969
Cost of nerve conduction studies in carpal tunnel syndrome To the Editor: Dr. Joseph Rogoff s letter (1) is indicative of the thinking that has caused health care costs to soar in this country. He objects to the fact that Drs. Ahmed and Braun treated 4 of their 5 patients with carpal tunnel syndrome and polymyalgia rheumatica with corticosteroid injections into the carpal tunnel without bothering to obtain nerve conduction studies. All of the patients responded, although 1 or 2 needed later repeat injections (2). Dr. Rogoff evidently feels that any ambulatory patient with carpal tunnel symptoms should be dispatched from the office without treatment and scheduled for nerve conduction studies at a cost of $75 or more. When these results are obtained, the patient should return to the rheumatologist’s office to pay another office visit fee and possibly have an injection into
