Concurrent Behcet’sDisease with Deep Venous Thrombosis of The Lower Extremity Alone: A Case Report

Deep Venous of The Lower Extremity


Introduction
It is well known that deep vein thrombosis of the lower limbs is a common condition with a high incidence. Behcet's disease, on the other hand, is a rare disorder with a low incidence [1]. The author reviewed a patient who visited an outpatient clinic for follow-up of deep vein thrombosis in the lower extremities. After physical examination, detailed history acquisition and further testing, it was found that the patient suffered from a primary disorder, Behcet's disease, which presented with only deep vein thrombosis of the lower limbs, without involvement of the neurological, respiratory or digestive systems and vascular lesions elsewhere. After targeted treatment of rheumatology and immunology, the patient's condition showed marked improvement. Here, we present a summary of this case.

Patient Description
A 31-year-old man with the diagnosis of deep vein thrombosis in the lower extremities in June 2017 after a colour Doppler ultrasound examination revealed thrombosis of the lower femoral vein in both lower limbs. Blood tests showed a D-dimer level of 921.20ng/ml, and a fibrinogen of 5.50g/L. After the diagnosis of deep vein thrombosis in both lower extremities was made, a therapeutic dose of rivaroxaban (15 mg, twice a day) was given for limbs, and anticoagulant therapy did not achieve a satisfactory result, we delved deeper into the patient's medical history. It was found that the patient had 20-year history of recurrent oral ulcers with no clear cause and also history of ocular foreign body sensation. There was also 6-year history of nodular erythema in the lower limbs. Some of the nodules had become purulent and formed ulcers and crusts. The patient did not seek diagnosis and treatment for these symptoms, and the nodules healed by themselves, leaving behind pigmentation and scars. Superficial scrotal ulcers developed 5 years ago. These healed with the use of topical medication and did not recur. Intermittent interphalangeal joint pain in both hands as well as pain in the first metatarsophalangeal joint developed 3 years ago.  (Table 1).  Since the incidence of this disease is higher in Asian countries than Western countries, particularly in those along the old silk trading routes such as Turkey, Iran, China, and Japan, Behcet's disease is also known as "Silk Road Disease". The diagnosis of Behcet's disease is based mainly on clinical symptoms. As such, it is important to obtain detailed history and pay special attention to typical clinical signs and symptoms. The presence of damage to large blood vessels or to the nervous system is highly suggestive of the diagnosis of Behcet's disease [1,2].
At present, the diagnostic criteria for Behcet's disease were proposed by the International Study Group for Behcet's Disease in 1989 , which were as follows: repeated oral ulcers are a necessary condition, along with two or more out of the following four clinical features: recurrent genital ulcers, eye lesions, skin lesions, and a positive pathergy response [3]. Other signs and symptoms that are highly associated with a diagnosis of the disease include gastrointestinal ulcers, joint pain, and epididymal inflammation.
In the case presented in this report, there were recurrent oral ulcers, genital ulcers, and eye lesions combined with skin lesions, vascular involvement, and joint pain, which were all indicative of and complex. Due to factors such as insufficient understanding of the disease as well as its low incidence, it is easy to overlook the diagnosis and treatment of the primary condition [4,5].
When clinicians are faced with the common presentation of deep vein thrombosis in the lower limbs, the patient's past history should be paid attention to and a thorough examination is recommended if the cause of thrombosis is unknown, and there is history of skin lesions, long-term oral ulcers, and a poor response to anticoagulant treatment. Thrombophilia should be investigated, and a biopsy of skin lesions carried out. A comprehensive analysis, appropriate consideration of this condition, and a review by rheumatology/immunology specialists are required to avoid a missed or incorrect diagnosis.

Conclusion
In this case report we demonstrated that BD combined with LEDVT can lead to reduced efficacy of the anticoagulation therapy against LEDVT and inclination to relapse. Early discovery and treatment of BD can improve the treatment effect of LEDVT. Besides, the possibility of concurrent BD should be considered in those with LEDVT to reduce missed diagnosis and missed treatment.