Case Report: Anesthesia Management in a patient with Behcet

Faris Suleiman Saleh Aldobekhi^*

^*Correspondence: Faris Suleiman Saleh Aldobekhi, Department of Anesthesia, College of Medicine, Majmaah University, Al Majmaah, 11952, Saudi Arabia, Email:

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Introduction

Behcet's disease is characterized by moth ulcers, genital ulcers, and multisystem involvement. Ulcers of the mouth affect every patient at some point throughout their treatment. They frequently recur, can be painful, and are experienced by every individual diagnosed with Behcet disease. The lesions appear like a typical canker sore but are far more numerous, severe, and frequent. They are frequently the first complaint a person notices, and they may manifest themselves a significant amount of time before any other symptoms do. The mouth's ulcers can appear anywhere, including the lips, tongue, and inside of the cheeks. Genital sores have a similar appearance to mouth sores and can also cause discomfort. They do not occur as frequently as mouth sores do. In men, they can be found on the scrotum, while in women, they can be found on the vulva. Pain, hazy vision, lightheadedness, tears, and eye redness can all result from eye inflammation. Behcet's disease patients have a significantly increased risk of developing an interatrial septal aneurysm, mitral regurgitation, aneurysmal dilatation of the sinus Valsalva, and aneurysmal dilatation of the ascending aorta. This is in comparison to normal subjects. Despite the significant prevalence of MVP in patients suffering from Behcet's disease, its underlying pathophysiology remains obscure [1].

Vision loss could eventually result from Behçet's disease. In the Arab World and Japan, severe eye diseases that might result in blindness are more prevalent than in the United States. Skin issues are a typical sign. They could resemble nodules or tender, coin-shaped pimples. Meninges, the coating of the brain, in particular, may be impacted. Fever, headaches, stiff necks, and difficulty coordinating movement are signs of brain inflammation. Another possibility is a stroke, which happens when arteries in the brain are either clogged or burst. Abdominal discomfort or blood in your stool is a GI tract symptom brought on by lesions resembling those in the mouth and genitalia [2].

Case

A woman in her 38^th year presented to the emergency room with symptoms that she had been experiencing something coming out of the anus for the past three months. Behcet's syndrome, one of the symptoms of blindness in the right eye, has already been identified as her condition. Behcet's disease affects multiple body systems, and the patient in question has a very advanced case of the situation. The ready sickness involved the patient's eye and other parts of their body, such as their joints. Therefore, the patient is scheduled to meet with a rheumatologist, cardiology, and neurological specialists. The prolapse is the patient's primary issue, and we intend to do surgery on her to treat it. It has been decided to put out a call for anesthesia fitness. The patient has been evaluated and found to be in good health. Following the evaluation, the internal medicine team concluded that the patient is typical, except for Behcet disease, which requires her to take steroids. Because the patient is taking steroids, there is an increase in the number of white blood cells in the body. They have determined that the patient is healthy enough to undergo anesthesia, but they will need to raise the patient's dose of steroids following the operation.

The patient family history is positive for stroke that is the father of the patient died of a stroke. The family history is also positive for diabetes. The mother undergoes amputation due to under-controlled diabetes. The patient mother also has an episode of intestinal obstruction. The patient’s aunt has thrombosis and another aunt has multiple sclerosis.

An examination of the young adult's physical state revealed they were somewhat wasted, fully aware, and afebrile. She had discharge from both of his eyes, which was pus. Additionally, she suffered from significant labial oral ulcers in addition to thrush patches on the throat. There were no signs of Kaposi's sarcoma or lymphadenopathy on the patient's body. An examination by an ophthalmologist revealed that the patient had bilateral conjunctivitis, normal visual acuity in one eye but no vision in the other eye, and normal optic nerves. However, a slit lamp examination revealed signs of uveitis on the normal side of the patient's eye.

The oxygen level in the room air was 95%, the systolic vs. diastolic pressure was 120/60 mmHg, the heart rate was consistent at 78 beats per minute, the breathing rate was 19 cycles per minute, and the oxygen level in the blood was 95%. An examination of the urinary system found that the patient had typical female genitalia, but there were some wet ulcerations on the scrotum. According to the physical examination results, the remaining systems are in basically normal condition.

Complete blood count was found to be the result of the lab study that was done. The mean corpuscular volume was 93 fl., the count of other cells was within the normal range, and the Venereal Disease Research Laboratory tested the serum for syphilis antibodies. The Hb level was average, and the white blood cell count was high— it was 14k—but this was thought to be the result of the medication because there were no signs of infection. The HIV fast serological test returned negative, the scrotal and ocular ulcers' swabs for Gram staining detected no bacteria, the kidney function test was within normal range, and the random blood glucose was 4.8 mmol/L. The pathergy test came back negative (negative). In addition, an oesophago-gastroduodenoscopy was done, and the results were normal. The presence of reoccurring oral aphthae, recurrent vaginal aphthae, and posterior uveitis with eye infections led to the conclusion that the patient was suffering from BD. The ISGBD 9 criteria reached this conclusion [3](Figure 1).

Figure 1: Behcet’s disease

The examination did not reveal any signs of anemia. With Mallampati class IV, the mouth aperture was around one finger's width. This patient's examination observed oral mucosal ulceration, acneiform skin lesions, and vaginal scarring. Both the echocardiogram and the magnetic resonance imaging of the brain came back negative for any abnormalities. It was decided to keep administering the oral prednisolone dose in the morning, and the NPO status and written informed consent were verified. Under general anesthesia, the prolapse in the patient's pelvic organ was surgically repaired. After a single puncture, an intravenous (IV) line was established with a cannula of 20 gauges, and a solution of Ringer lactate was administered. Injections of 50 milligrams of hydrocortisone and 4 milligrams of Ondansetron were given via the intravenous route. After administering 3 milliliters of bupivacaine with a concentration of 0.5% and 30 micrograms of injectable clonidine, a block up to T6 was achieved. The patient's heart rate, blood pressure, breathing rate, ECG, and oxygen saturation were taken throughout. The operation was successful but without any complications.

Diagnosis and treatment

Diagnose factors for Behcet's disease, as proposed by Mason and Barnes, include major and minor criteria. Our patient was on tablet prednisone 10mg daily and tablet azathioprine 50mg daily. In infections of skin lesions, acute conjunctivitis, and neurologic illness, corticosteroids are a practical choice that should be considered. They may be administered alone or with azathioprine as a monotherapy or combination therapy. However, in a recent randomized and placebo-controlled research of 86 patients who had active infections of the skin lesions without eye and central organ participation, it was found that low dose depot steroid was only helpful in controlling EN, particularly in females. This was the case regardless of whether the patients had an eye and major organ involvement. This conclusion does not, however, imply that the substance is not efficacious in dosages taken on a daily basis or higher [4].

On the other hand, their usage over the long run is restricted due to the well-known adverse impact profile, and administering more corticosteroids does not enhance the outcome over the long term. It is essential to remember that even though some of the adverse reactions could be rather serious, measures will be taken to recognize and treat problems before they become dangerous. If any of the following adverse reactions occur, you should get in touch with your healthcare provider: a worsening discomfort in the stomach and abdominal pain. Symptoms of nausea and vomiting Alterations in hair color and texture, in addition to thinning of the hair. (Most of the time, these alterations are just transitory. a decrease in appetite, Blood found in the feces or the pee, unusual bruising, Fatigue, and The formation of sores and ulcers inside the mouth. As a result of the patient's use of these medications, the white blood cell count of the patient has increased, and the patient is also much more susceptible to infections and gastrointestinal ulcers [5].

Regional anesthesia is not as effective as general anesthesia because it increases the risk of inflammation and the formation of nodules whenever it is administered through a needle that is inserted through the skin or any mucous membranes. A dangerous parenchymal CNS involvement that impacts the brainstem, spinal cord, and cerebral sides of the brain is one of the contraindications for the neuraxial block. Other non-parenchymal occurrences, like intracranial hypertension, aseptic meningitis, skull neuropathy, and ischemic stroke disorders are also among the list of contraindications. These conditions have the potential to endanger one's life. On the other hand, we decided to go with spinal anesthesia rather than general anesthesia since it eliminated the risk of the central nervous system being involved, and the challenges associated with a problematic airway were far more challenging. Clonidine was administered in order to ensure that the neuraxial block would continue to be effective for an extended period of time [5].

Because the penetration of the skin or mucous membranes is highly likely to result in inflammation and the creation of nodules, regional anesthesia is less suitable than general anesthesia. Contraindications for the neuraxial block include dangerous parenchymal CNS involvement that affects the brainstem, spinal cord, and cerebral hemispheres, as well as non-parenchymal manifestations such as intracranial hypertension, aseptic meningitis, cranial neuropathy, and cerebrovascular disorders. These conditions can be life-threatening. On the other hand, we opted for spinal anesthesia because it excluded the possibility of central nervous system involvement, and the difficulties connected with a difficult airway were far more severe. Clonidine was added in order to make the neuraxial block last for a more extended period [1].

Behçet disease-related genital ulcers are frequently found in the vulva and are typically painful; however, if they are found in the vagina, they may not be unpleasant. A vaginal examination should be carried out if Behçet disease is suspected based on other symptoms since it is required for an accurate diagnosis of the condition, particularly in patients who have vaginal bleeding without vulval ulcers. On examination, it was discovered that our patient had uterine prolapse, which was repaired [6].

The patient was made to lie down. The antibiotic infusion was initiated. The sound of the uterus suggests that the cervix has become longer. To make it easier for the sutures used to cover the severed cervix with vaginal flaps to pass through the cervical canal, the cervical canal is widened. Additionally, it guarantees sufficient uterine drainage and avoids cervical stenosis while the external os is healing. To remove the diseased endometrium, curettage is performed [7].

Cervical amputation when future reproduction is necessary, a low amputation must be performed. The Mackenrodt ligaments are plicated in front of the cervix. This makes it easier for them to shorten and raise the cervix to its usual position. Anterior cleft surgery. Colpoperineorrhaphy done [8].

Discussion and Conclusion

Behcet symptom is a disease known to be uncommon, persistent, and relapsing. Three clinical manifestations characterize this disease: stomatitis aphthous, genital mutilation, the conjunctiva, and iridocyclitis in the eye, as well as accompanying symptoms in all the other organs. Pemphigus Vulgaris, erythema exudative multiform, and ulcus acutum vulvae have all been considered possible diagnoses based on the patient's medical history as well as the clinical appearance. Following talks with experts in the fields of history and literature, as well as the results of our case-based analysis report, we have concluded that we are dealing with oculo-Bucco- genital Behcet syndrome. Because there is a chance that the condition will also affect the joints, we are going to get some professional advice about it. Because of the potential involvement of the neurological and cardiovascular systems, we are equally concerned about these systems. The ECG of the heart is expected according to the standards of the field of internal medicine. And the consultation with the neurology team is still being prepared [9].

The Behcet disease is a diverse and, at the same time, fascinating condition. Despite the great progress that has been made in research, there are still a lot of holes to fill. New information regarding the disease's Immuno pathogenesis, genetics, and epidemiology will significantly assist in creating diagnostic criteria, laboratory tests, activity indexes, and, most importantly, selecting the most effective treatment [10].

Acknowledgement

I would like to thank the Deanship of Scientific Research, Majmaah University, Majmaah for supporting this study with project number R-XXXX-XXX.

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