A 41 year old male, with a past medical history of HIV with no recent CD4 count, was admitted with a several month history of fatigue, night sweats, anorexia, painful swallowing with ulcers over the upper lip, and painful draining ulcers in inter-gluteal fold. On physical exam, these ulcers were noted to have a purulent discharge, with erythema of the surrounding skin. He was also found to have painful pretibial nodules and oral thrush. Chest examination included normal breath sounds and regular heart sounds. The abdominal examination was non-tender and soft with normal bowel sounds. The initial impression was cutaneous herpes involving perianal skin and lips, with a bacterial superinfection. Odynophagia was attributed to possible candidal esophagitis versus herpes esophagitis. Accordingly, treatment with acyclovir, fluconazole, vancomycin and piperacillin/tazobactam was initiated.
Serologies for FTA-ABS for syphilis were found to be positive, with an RPR titer of 1:4, and weekly treatment for latent syphilis with benzathine penicillin was started for duration of three weeks. Empiric treatment for Lymphogranuloma venereum (LGV) was begun with doxycycline. CD4 count was 78, and therefore, prophylaxis for PCP was initiated with atovaquone, as the patient had an allergy to trimethoprim/sulfamethoxazole. At this time HAART therapy was initiated as well. Eventually serologies for Chlamydia trachomatis, Neisseria gonorrhoeae, LGV serology, and acid fast smear for TB were negative.
Our patient's condition improved with antibiotics and the patient was discharged with antiretroviral therapy and scheduled for a follow up as outpatient. Two months later the patient was readmitted with perianal ulcers, and multiple painful oral ulcers. The largest ulcer was measured at 10 mm x 7 mm in diameter; at this time a differential diagnosis of ulcers secondary to an HSV infection and oral thrush was considered. The patient was noncompliant with the antiretroviral medications since discharge from the hospital. His CD4 count at this time was less than 20, HAART medications were resumed during at admission. The patient was started on fluconazole for possible candidal esophagitis, acyclovir for cutaneous herpes, and primary antimicrobial prophylaxis for pneumocystosis and toxoplasmosis. Upper endoscopy was done, and showed a large 5 cm deep ulcer in the lower esophagus.
The patient went for colonoscopy that showed active GI bleed from the descending colon. Patient had technetium-labeled red blood cell bleeding scan which was negative. Angiography was performed which did not reveal any actively bleeding vessel but during the procedure the patient developed massive lower gastrointestinal bleeding, requiring 20 units of transfused blood. He underwent subtotal colectomy with ileostomy and a PEG tube was placed for feeding.
Biopsy of esophagus showed mild acute and chronic inflammation. Biopsy from duodenum, stomach and esophagus was negative for fungal elements, HSV1, HSV2, and CMV PCR. Colon biopsy showed punched out ulcers, associated with monocytic inflammation, vasculitis with thrombi, mural necrosis with histiocytes and lymphocytes in the vascular wall. A diagnosis of Behcet's disease, along with Behcet's colitis was made based on the histopathology findings and the correlating clinical history. Subsequently treatment with colchicine twice a day was initiated for mucocutaneous manifestations of Behcet's disease until resolution of symptoms.