Chair, Department of Rehabilitation Medicine NYU Rusk Rehabilitation New York, New York, United States
Case Diagnosis: Neuro-Behcet’s Disease
Case Description: Patient is a 29 yo male with history of migraines and right corona radiata cerebrovascular accident (CVA) who presented for botox injection to treat left upper extremity spasticity. Two weeks after injection, he reported a 3x4cm area of non-erythematous swelling over the left pronator teres. On examination, no redness or warmth was noted. MRI of the elbow was ordered, but prior to completing, the patient developed a second stroke of the left thalamus, left pons and right caudate. At that time, he was diagnosed with Behcet’s disease and placed on chronic oral methylprednisolone. He has since started Renflexis therapy.
Discussions: Behcet’s disease is a multisystem, autoimmune vasculitis that typically presents with recurrent aphthous ulcers, genital ulcers and uveitis. Neurological symptoms present in less than 10% of cases, and this small subsection is referred to as Neuro-Behcet’s Disease. Due to its overlapping symptoms with other disease processes, Neuro-Behcet’s can be difficult to initially diagnose. In this case, the patient’s first CVA was reported to be of unclear etiology. When treated with botox, he experienced swelling to the needle stick. We theorize that this reaction to botox was an exaggerated inflammatory response, similar to that seen in a pathergy test. Such a response can be an important sign to consider Behcet’s disease.
Conclusions: Neuro-Behcet’s disease is a rare, autoimmune vasculitis that can be a potential cause for stroke. It is an important differential to keep in mind for stroke in young patients. Abnormal inflammatory reactions in such patients may be an important indicator to further explore this diagnosis. Early identification and intervention with immunosuppressive therapy is essential to prevent further devastating neurological consequences.
