{"version":"1.0.0","segments":[{"startTime":0.184,"endTime":3.19,"body":"[upbeat intro music]"},{"startTime":3.19,"endTime":5.6,"body":"[Dr. Handy] Hi, welcome"},{"startTime":3.19,"endTime":5.6,"body":"to Harrison's Podclass,"},{"startTime":5.6,"endTime":8.73,"body":"where we discuss important"},{"startTime":5.6,"endTime":8.73,"body":"concepts in internal medicine."},{"startTime":8.73,"endTime":9.89,"body":"I'm Cathy Handy."},{"startTime":9.89,"endTime":11.64,"body":"[Dr. Wiener] And I'm Charlie"},{"startTime":9.89,"endTime":11.64,"body":"Wiener, and we're coming to you"},{"startTime":11.64,"endTime":14.632,"body":"from the Johns Hopkins School of Medicine."},{"speaker":"[Dr. Handy] Episode 54","startTime":15.81,"endTime":19.94,"body":"A"},{"speaker":"[Dr. Handy] Episode 54","startTime":15.81,"endTime":19.94,"body":"25-Year-Old with Mouth Ulcers."},{"speaker":"[Dr. Handy] Episode 54","startTime":19.94,"endTime":20.9,"body":"[Dr. Wiener] Hi Cathy."},{"speaker":"[Dr. Handy] Episode 54","startTime":20.9,"endTime":23.73,"body":"So, today's case is a 25-year-old woman"},{"speaker":"[Dr. Handy] Episode 54","startTime":23.73,"endTime":27.1,"body":"who presents with a complaint"},{"speaker":"[Dr. Handy] Episode 54","startTime":23.73,"endTime":27.1,"body":"of painful mouth ulcerations."},{"speaker":"[Dr. Handy] Episode 54","startTime":27.1,"endTime":29.877,"body":"She describes these"},{"speaker":"[Dr. Handy] Episode 54","startTime":27.1,"endTime":29.877,"body":"lesions as shallow ulcers"},{"speaker":"[Dr. Handy] Episode 54","startTime":29.877,"endTime":32.08,"body":"that last for one to two weeks."},{"speaker":"[Dr. Handy] Episode 54","startTime":32.08,"endTime":33.55,"body":"They've been appearing and disappearing"},{"speaker":"[Dr. Handy] Episode 54","startTime":33.55,"endTime":35.32,"body":"for the past six months."},{"speaker":"[Dr. Handy] Episode 54","startTime":35.32,"endTime":38.47,"body":"Over the last two days, she's"},{"speaker":"[Dr. Handy] Episode 54","startTime":35.32,"endTime":38.47,"body":"also had a painful red eye,"},{"speaker":"[Dr. Handy] Episode 54","startTime":38.47,"endTime":41.01,"body":"which is why she's coming"},{"speaker":"[Dr. Handy] Episode 54","startTime":38.47,"endTime":41.01,"body":"to the clinic today."},{"speaker":"[Dr. Handy] Episode 54","startTime":41.01,"endTime":42.56,"body":"On further history, she reports"},{"speaker":"[Dr. Handy] Episode 54","startTime":42.56,"endTime":44.84,"body":"that she's had no genital ulcerations,"},{"speaker":"[Dr. Handy] Episode 54","startTime":44.84,"endTime":48.63,"body":"no arthritis, skin rashes,"},{"speaker":"[Dr. Handy] Episode 54","startTime":44.84,"endTime":48.63,"body":"or photo sensitivity."},{"speaker":"[Dr. Handy] Episode 54","startTime":48.63,"endTime":50.29,"body":"So, any thoughts so far?"},{"speaker":"[Dr. Handy] Episode 54","startTime":50.29,"endTime":51.81,"body":"[Dr. Handy] Well, mouth ulcers are common,"},{"speaker":"[Dr. Handy] Episode 54","startTime":51.81,"endTime":54.82,"body":"and often due to a"},{"speaker":"[Dr. Handy] Episode 54","startTime":51.81,"endTime":54.82,"body":"self-limited viral infection."},{"speaker":"[Dr. Handy] Episode 54","startTime":54.82,"endTime":57.24,"body":"The painful red eye has"},{"speaker":"[Dr. Handy] Episode 54","startTime":54.82,"endTime":57.24,"body":"my attention though."},{"speaker":"[Dr. Handy] Episode 54","startTime":57.24,"endTime":58.78,"body":"There are a number of syndromes"},{"speaker":"[Dr. Handy] Episode 54","startTime":58.78,"endTime":61.24,"body":"that can involve the"},{"speaker":"[Dr. Handy] Episode 54","startTime":58.78,"endTime":61.24,"body":"mouth and eye membranes."},{"speaker":"[Dr. Handy] Episode 54","startTime":61.24,"endTime":63.48,"body":"Two big categories are infectious causes"},{"speaker":"[Dr. Handy] Episode 54","startTime":63.48,"endTime":65.36,"body":"or rheumatologic causes."},{"speaker":"[Dr. Handy] Episode 54","startTime":65.36,"endTime":67.48,"body":"What does the physical exam show?"},{"speaker":"[Dr. Handy] Episode 54","startTime":67.48,"endTime":69.08,"body":"[Dr. Wiener] Okay, on"},{"speaker":"[Dr. Handy] Episode 54","startTime":67.48,"endTime":69.08,"body":"physical examination,"},{"speaker":"[Dr. Handy] Episode 54","startTime":69.08,"endTime":72.21,"body":"she appears well-developed"},{"speaker":"[Dr. Handy] Episode 54","startTime":69.08,"endTime":72.21,"body":"and in no distress."},{"speaker":"[Dr. Handy] Episode 54","startTime":72.21,"endTime":75.93,"body":"She has a temperature of"},{"speaker":"[Dr. Handy] Episode 54","startTime":72.21,"endTime":75.93,"body":"37.6, a heart rate of 86,"},{"speaker":"[Dr. Handy] Episode 54","startTime":75.93,"endTime":78.45,"body":"a blood pressure of 126 over 72,"},{"speaker":"[Dr. Handy] Episode 54","startTime":78.45,"endTime":80.5,"body":"and a respiratory rate"},{"speaker":"[Dr. Handy] Episode 54","startTime":78.45,"endTime":80.5,"body":"of 16 breaths per minute,"},{"speaker":"[Dr. Handy] Episode 54","startTime":80.5,"endTime":83.29,"body":"with a normal room-air oxygen saturation."},{"speaker":"[Dr. Handy] Episode 54","startTime":83.29,"endTime":86.88,"body":"Examination of her oral mucosa"},{"speaker":"[Dr. Handy] Episode 54","startTime":83.29,"endTime":86.88,"body":"reveals two shallow ulcers"},{"speaker":"[Dr. Handy] Episode 54","startTime":86.88,"endTime":89.36,"body":"with a yellow base on the buccal mucosa."},{"speaker":"[Dr. Handy] Episode 54","startTime":89.36,"endTime":91.68,"body":"Her neck shows no adenopathy,"},{"speaker":"[Dr. Handy] Episode 54","startTime":91.68,"endTime":94.5,"body":"and her cardiopulmonary"},{"speaker":"[Dr. Handy] Episode 54","startTime":91.68,"endTime":94.5,"body":"examination is normal."},{"speaker":"[Dr. Handy] Episode 54","startTime":94.5,"endTime":95.94,"body":"She has no arthritis,"},{"speaker":"[Dr. Handy] Episode 54","startTime":95.94,"endTime":97.86,"body":"but medially, on the right thigh,"},{"speaker":"[Dr. Handy] Episode 54","startTime":97.86,"endTime":100.82,"body":"there is a palpable cord"},{"speaker":"[Dr. Handy] Episode 54","startTime":97.86,"endTime":100.82,"body":"in the saphenous vein."},{"speaker":"[Dr. Handy] Episode 54","startTime":100.82,"endTime":104.25,"body":"It's not terribly tender, and"},{"speaker":"[Dr. Handy] Episode 54","startTime":100.82,"endTime":104.25,"body":"there's no redness over it."},{"speaker":"[Dr. Handy] Episode 54","startTime":104.25,"endTime":105.76,"body":"She's actually sent urgently"},{"speaker":"[Dr. Handy] Episode 54","startTime":105.76,"endTime":107.97,"body":"for an ophthalmologic examination,"},{"speaker":"[Dr. Handy] Episode 54","startTime":107.97,"endTime":112.2,"body":"and that's consistent, by"},{"speaker":"[Dr. Handy] Episode 54","startTime":107.97,"endTime":112.2,"body":"report, with anterior uveitis."},{"speaker":"[Dr. Handy] Episode 54","startTime":112.2,"endTime":113.88,"body":"So, what do you think?"},{"speaker":"[Dr. Handy] Episode 54","startTime":113.88,"endTime":115.138,"body":"[Dr. Handy] Obviously there is something"},{"speaker":"[Dr. Handy] Episode 54","startTime":115.138,"endTime":116.621,"body":"multisystem going on."},{"speaker":"[Dr. Handy] Episode 54","startTime":116.621,"endTime":119.95,"body":"The most notable findings so"},{"speaker":"[Dr. Handy] Episode 54","startTime":116.621,"endTime":119.95,"body":"far are the anterior uveitis"},{"speaker":"[Dr. Handy] Episode 54","startTime":119.95,"endTime":121.76,"body":"and the venous abnormality."},{"speaker":"[Dr. Handy] Episode 54","startTime":121.76,"endTime":124.29,"body":"[Dr. Wiener] Okay, tell me"},{"speaker":"[Dr. Handy] Episode 54","startTime":121.76,"endTime":124.29,"body":"more about anterior uveitis."},{"speaker":"[Dr. Handy] Episode 54","startTime":124.29,"endTime":125.665,"body":"[Dr. Handy] Remember the eye is structured"},{"speaker":"[Dr. Handy] Episode 54","startTime":125.665,"endTime":128.64,"body":"with three layers, the outer"},{"speaker":"[Dr. Handy] Episode 54","startTime":125.665,"endTime":128.64,"body":"layer includes the sclera"},{"speaker":"[Dr. Handy] Episode 54","startTime":128.64,"endTime":131.832,"body":"and cornea, the inner layer is the retina."},{"speaker":"[Dr. Handy] Episode 54","startTime":131.832,"endTime":134.85,"body":"The middle layer is the uvea,"},{"speaker":"[Dr. Handy] Episode 54","startTime":131.832,"endTime":134.85,"body":"and it consists of the iris,"},{"speaker":"[Dr. Handy] Episode 54","startTime":134.85,"endTime":137.13,"body":"the ciliary body, and the choroid."},{"speaker":"[Dr. Handy] Episode 54","startTime":137.13,"endTime":139.01,"body":"The uvea is a vascular layer"},{"speaker":"[Dr. Handy] Episode 54","startTime":139.01,"endTime":141.8,"body":"involving the anterior"},{"speaker":"[Dr. Handy] Episode 54","startTime":139.01,"endTime":141.8,"body":"structures of the eye."},{"speaker":"[Dr. Handy] Episode 54","startTime":141.8,"endTime":146.35,"body":"Uveitis is also sometimes"},{"speaker":"[Dr. Handy] Episode 54","startTime":141.8,"endTime":146.35,"body":"called iritis or iridocyclitis."},{"speaker":"[Dr. Handy] Episode 54","startTime":146.35,"endTime":148.57,"body":"There are a number of"},{"speaker":"[Dr. Handy] Episode 54","startTime":146.35,"endTime":148.57,"body":"infectious autoimmune"},{"speaker":"[Dr. Handy] Episode 54","startTime":148.57,"endTime":152.28,"body":"and systemic inflammatory"},{"speaker":"[Dr. Handy] Episode 54","startTime":148.57,"endTime":152.28,"body":"causes of anterior uveitis."},{"speaker":"[Dr. Handy] Episode 54","startTime":152.28,"endTime":153.596,"body":"[Dr. Wiener] What are"},{"speaker":"[Dr. Handy] Episode 54","startTime":152.28,"endTime":153.596,"body":"some that come immediately"},{"speaker":"[Dr. Handy] Episode 54","startTime":153.596,"endTime":154.86,"body":"to mind to you?"},{"speaker":"[Dr. Handy] Episode 54","startTime":154.86,"endTime":156.86,"body":"[Dr. Handy] So, some"},{"speaker":"[Dr. Handy] Episode 54","startTime":154.86,"endTime":156.86,"body":"that I always think of,"},{"speaker":"[Dr. Handy] Episode 54","startTime":156.86,"endTime":159.69,"body":"you can get anterior"},{"speaker":"[Dr. Handy] Episode 54","startTime":156.86,"endTime":159.69,"body":"uveitis in sarcoidosis,"},{"speaker":"[Dr. Handy] Episode 54","startTime":159.69,"endTime":163.55,"body":"ankylosing spondylitis, and"},{"speaker":"[Dr. Handy] Episode 54","startTime":159.69,"endTime":163.55,"body":"juvenile rheumatoid arthritis."},{"speaker":"[Dr. Handy] Episode 54","startTime":163.55,"endTime":165.86,"body":"You also see it in"},{"speaker":"[Dr. Handy] Episode 54","startTime":163.55,"endTime":165.86,"body":"inflammatory bowel disease,"},{"speaker":"[Dr. Handy] Episode 54","startTime":165.86,"endTime":169.26,"body":"psoriasis, reactive arthritis,"},{"speaker":"[Dr. Handy] Episode 54","startTime":165.86,"endTime":169.26,"body":"and Behcet's disease."},{"speaker":"[Dr. Handy] Episode 54","startTime":169.26,"endTime":170.51,"body":"On the infectious side,"},{"speaker":"[Dr. Handy] Episode 54","startTime":170.51,"endTime":172.9,"body":"you can see it in herpes"},{"speaker":"[Dr. Handy] Episode 54","startTime":170.51,"endTime":172.9,"body":"infectious, syphilis,"},{"speaker":"[Dr. Handy] Episode 54","startTime":172.9,"endTime":175.99,"body":"Lyme disease, tuberculosis, and leprosy."},{"speaker":"[Dr. Handy] Episode 54","startTime":175.99,"endTime":178.43,"body":"[Dr. Wiener] Okay, so that's"},{"speaker":"[Dr. Handy] Episode 54","startTime":175.99,"endTime":178.43,"body":"a pretty wide differential."},{"speaker":"[Dr. Handy] Episode 54","startTime":178.43,"endTime":180.9,"body":"I assume you'd now like some lab tests."},{"speaker":"[Dr. Handy] Episode 54","startTime":180.9,"endTime":182.62,"body":"[Dr. Handy] Yes, some basic labs,"},{"speaker":"[Dr. Handy] Episode 54","startTime":182.62,"endTime":185.36,"body":"and then also some of"},{"speaker":"[Dr. Handy] Episode 54","startTime":182.62,"endTime":185.36,"body":"the rheumatologic tests."},{"speaker":"[Dr. Handy] Episode 54","startTime":185.36,"endTime":187.29,"body":"[Dr. Wiener] Laboratory"},{"speaker":"[Dr. Handy] Episode 54","startTime":185.36,"endTime":187.29,"body":"studies reveal a sed rate"},{"speaker":"[Dr. Handy] Episode 54","startTime":187.29,"endTime":189.1,"body":"of 68 seconds."},{"speaker":"[Dr. Handy] Episode 54","startTime":189.1,"endTime":191.09,"body":"Her white blood cell count is 10.2,"},{"speaker":"[Dr. Handy] Episode 54","startTime":191.09,"endTime":193.87,"body":"with a differential of 68% neutrophils,"},{"speaker":"[Dr. Handy] Episode 54","startTime":193.87,"endTime":197.28,"body":"28% lymphocytes, and 4% monocytes."},{"speaker":"[Dr. Handy] Episode 54","startTime":197.28,"endTime":201.499,"body":"The ANA and the anti-double-stranded"},{"speaker":"[Dr. Handy] Episode 54","startTime":197.28,"endTime":201.499,"body":"DNA are negative."},{"speaker":"[Dr. Handy] Episode 54","startTime":201.499,"endTime":204.75,"body":"C3 is 89, C4 is 24,"},{"speaker":"[Dr. Handy] Episode 54","startTime":204.75,"endTime":207.55,"body":"and all of her routine"},{"speaker":"[Dr. Handy] Episode 54","startTime":204.75,"endTime":207.55,"body":"chemistries are normal."},{"speaker":"[Dr. Handy] Episode 54","startTime":207.55,"endTime":211.57,"body":"The question now asks, what"},{"speaker":"[Dr. Handy] Episode 54","startTime":207.55,"endTime":211.57,"body":"is the most likely diagnosis?"},{"speaker":"And the options are A","startTime":211.57,"endTime":215.24,"body":"Behcet's syndrome;"},{"speaker":"B","startTime":215.24,"endTime":217.7,"body":"bullous pemphigoid;"},{"speaker":"C","startTime":217.7,"endTime":221.17,"body":"discoid lupus erythematosus;"},{"speaker":"D","startTime":221.17,"endTime":223.7,"body":"Sjogren's syndrome;"},{"speaker":"E","startTime":223.7,"endTime":227.9,"body":"systemic lupus erythematosus, or SLE."},{"speaker":"E","startTime":227.9,"endTime":228.95,"body":"What do you think?"},{"speaker":"E","startTime":228.95,"endTime":230.1,"body":"[Dr. Handy] Well, as I mentioned before,"},{"speaker":"E","startTime":230.1,"endTime":231.48,"body":"the differential is wide."},{"speaker":"E","startTime":231.48,"endTime":233.41,"body":"Infectious diseases aren't listed here,"},{"speaker":"E","startTime":233.41,"endTime":235.6,"body":"so we need to narrow our differential"},{"speaker":"E","startTime":235.6,"endTime":237.64,"body":"to the rheumatologic list."},{"speaker":"E","startTime":237.64,"endTime":239.65,"body":"But with this information"},{"speaker":"E","startTime":237.64,"endTime":239.65,"body":"and these choices,"},{"speaker":"E","startTime":239.65,"endTime":242.4,"body":"the answer is A, Behcet's syndrome."},{"speaker":"E","startTime":242.4,"endTime":244.31,"body":"[Dr. Wiener] Tell me why"},{"speaker":"E","startTime":242.4,"endTime":244.31,"body":"you came to that conclusion."},{"speaker":"E","startTime":244.31,"endTime":246.47,"body":"[Dr. Handy] Behcet's syndrome"},{"speaker":"E","startTime":244.31,"endTime":246.47,"body":"is a multi-system disorder"},{"speaker":"E","startTime":246.47,"endTime":249.15,"body":"that is marked by oral"},{"speaker":"E","startTime":246.47,"endTime":249.15,"body":"and genital ulcerations"},{"speaker":"E","startTime":249.15,"endTime":250.71,"body":"and ocular involvement."},{"speaker":"E","startTime":250.71,"endTime":252.73,"body":"It was named after a Turkish dermatologist"},{"speaker":"E","startTime":252.73,"endTime":254.28,"body":"that described the syndrome."},{"speaker":"E","startTime":254.28,"endTime":256.84,"body":"This disorder affects"},{"speaker":"E","startTime":254.28,"endTime":256.84,"body":"males and females equally,"},{"speaker":"E","startTime":256.84,"endTime":259.41,"body":"and is more common in"},{"speaker":"E","startTime":256.84,"endTime":259.41,"body":"persons of Mediterranean,"},{"speaker":"E","startTime":259.41,"endTime":262.01,"body":"Middle Eastern, or Far Eastern descent."},{"speaker":"E","startTime":262.01,"endTime":264.27,"body":"Approximately 50% of these persons"},{"speaker":"E","startTime":264.27,"endTime":268.3,"body":"have circulating autoantibodies"},{"speaker":"E","startTime":264.27,"endTime":268.3,"body":"to human oral mucosa."},{"speaker":"E","startTime":268.3,"endTime":270.29,"body":"The clinical features are quite varied."},{"speaker":"E","startTime":270.29,"endTime":273.05,"body":"The presence of recurrent"},{"speaker":"E","startTime":270.29,"endTime":273.05,"body":"aphthous ulcerations"},{"speaker":"E","startTime":273.05,"endTime":275.38,"body":"is essential for the diagnosis."},{"speaker":"E","startTime":275.38,"endTime":278.63,"body":"Most of these patients have"},{"speaker":"E","startTime":275.38,"endTime":278.63,"body":"primarily oral ulcerations,"},{"speaker":"E","startTime":278.63,"endTime":281.27,"body":"although genital ulcerations"},{"speaker":"E","startTime":278.63,"endTime":281.27,"body":"are more specific"},{"speaker":"E","startTime":281.27,"endTime":282.97,"body":"for the diagnosis."},{"speaker":"E","startTime":282.97,"endTime":286.5,"body":"The ulcers are generally"},{"speaker":"E","startTime":282.97,"endTime":286.5,"body":"painful, can be shallow or deep,"},{"speaker":"E","startTime":286.5,"endTime":289.59,"body":"and last generally for one to two weeks."},{"speaker":"E","startTime":289.59,"endTime":291.89,"body":"Other skin involvement may occur,"},{"speaker":"E","startTime":291.89,"endTime":295.48,"body":"and other skin findings that"},{"speaker":"E","startTime":291.89,"endTime":295.48,"body":"you might see are folliculitis,"},{"speaker":"E","startTime":295.48,"endTime":298.53,"body":"erythema nodosum, and vasculitis."},{"speaker":"E","startTime":298.53,"endTime":300.67,"body":"Eye involvement is the"},{"speaker":"E","startTime":298.53,"endTime":300.67,"body":"most dreaded complication"},{"speaker":"E","startTime":300.67,"endTime":303.42,"body":"because it may progress"},{"speaker":"E","startTime":300.67,"endTime":303.42,"body":"rapidly to blindness."},{"speaker":"E","startTime":303.42,"endTime":306.63,"body":"It often presents as panuveitis, iritis,"},{"speaker":"E","startTime":306.63,"endTime":309.55,"body":"retinal vessel occlusion,"},{"speaker":"E","startTime":306.63,"endTime":309.55,"body":"or optic neuritis."},{"speaker":"E","startTime":309.55,"endTime":310.63,"body":"[Dr. Wiener] Okay, so the presence"},{"speaker":"E","startTime":310.63,"endTime":314.81,"body":"of the recurrent oral ulcers"},{"speaker":"E","startTime":310.63,"endTime":314.81,"body":"and the anterior uveitis"},{"speaker":"E","startTime":314.81,"endTime":316.49,"body":"is what led you to Behcet's."},{"speaker":"E","startTime":316.49,"endTime":317.96,"body":"[Dr. Handy] Yes. Out of those."},{"speaker":"E","startTime":317.96,"endTime":320.25,"body":"[Dr. Wiener] And do we know"},{"speaker":"E","startTime":317.96,"endTime":320.25,"body":"the cause of Behcet's syndrome?"},{"speaker":"E","startTime":320.25,"endTime":321.19,"body":"[Dr. Handy] Not exactly."},{"speaker":"E","startTime":321.19,"endTime":324.23,"body":"We know that people with HLA-B51 gene"},{"speaker":"E","startTime":324.23,"endTime":326.39,"body":"are at higher risk of developing Behcet's,"},{"speaker":"E","startTime":326.39,"endTime":329.46,"body":"but most people with the gene"},{"speaker":"E","startTime":326.39,"endTime":329.46,"body":"do not develop the disease."},{"speaker":"E","startTime":329.46,"endTime":332.06,"body":"Interestingly, familial"},{"speaker":"E","startTime":329.46,"endTime":332.06,"body":"cases are not the rule,"},{"speaker":"E","startTime":332.06,"endTime":335.01,"body":"consisting only about 5% of cases."},{"speaker":"E","startTime":335.01,"endTime":337.04,"body":"So it's likely that the disease develops"},{"speaker":"E","startTime":337.04,"endTime":338.23,"body":"in at-risk individuals"},{"speaker":"E","startTime":338.23,"endTime":341.699,"body":"exposed to some infectious"},{"speaker":"E","startTime":338.23,"endTime":341.699,"body":"or environmental exposure."},{"speaker":"E","startTime":341.699,"endTime":343.04,"body":"[Dr. Wiener] So, on clinical exam,"},{"speaker":"E","startTime":343.04,"endTime":346.05,"body":"this patient seemed to have"},{"speaker":"E","startTime":343.04,"endTime":346.05,"body":"a saphenous vein thrombosis."},{"speaker":"E","startTime":346.05,"endTime":347.61,"body":"Is that part of the syndrome?"},{"speaker":"E","startTime":347.61,"endTime":348.95,"body":"[Dr. Handy] Yeah, I'm glad"},{"speaker":"E","startTime":347.61,"endTime":348.95,"body":"you brought that up again"},{"speaker":"E","startTime":348.95,"endTime":350.21,"body":"because I forgot to mention that."},{"speaker":"E","startTime":350.21,"endTime":352.48,"body":"So, deep venous thrombosis can be present"},{"speaker":"E","startTime":352.48,"endTime":355.52,"body":"in about a quarter to a"},{"speaker":"E","startTime":352.48,"endTime":355.52,"body":"third of these patients."},{"speaker":"E","startTime":355.52,"endTime":357.86,"body":"And additionally, neurologic"},{"speaker":"E","startTime":355.52,"endTime":357.86,"body":"involvement occurs"},{"speaker":"E","startTime":357.86,"endTime":359.37,"body":"in up to 10%."},{"speaker":"E","startTime":359.37,"endTime":360.4,"body":"[Dr. Wiener] So you said we don't know"},{"speaker":"E","startTime":360.4,"endTime":362.09,"body":"exactly the cause of Behcet's,"},{"speaker":"E","startTime":362.09,"endTime":365.35,"body":"but is there any specific"},{"speaker":"E","startTime":362.09,"endTime":365.35,"body":"diagnostic laboratory test?"},{"speaker":"E","startTime":365.35,"endTime":366.21,"body":"[Dr. Handy] No, not really."},{"speaker":"E","startTime":366.21,"endTime":368.75,"body":"Lab tests are useful to"},{"speaker":"E","startTime":366.21,"endTime":368.75,"body":"rule out other causes,"},{"speaker":"E","startTime":368.75,"endTime":372.5,"body":"but there's no one single"},{"speaker":"E","startTime":368.75,"endTime":372.5,"body":"diagnostic test for Behcet's."},{"speaker":"E","startTime":372.5,"endTime":374.57,"body":"The laboratory findings are nonspecific,"},{"speaker":"E","startTime":374.57,"endTime":377.72,"body":"with elevations in the ESR and"},{"speaker":"E","startTime":374.57,"endTime":377.72,"body":"the white blood cell count."},{"speaker":"E","startTime":377.72,"endTime":381.02,"body":"The ANA and other autoimmune"},{"speaker":"E","startTime":377.72,"endTime":381.02,"body":"tests will be negative."},{"speaker":"E","startTime":381.02,"endTime":383.19,"body":"[Dr. Wiener] So, I've heard"},{"speaker":"E","startTime":381.02,"endTime":383.19,"body":"about the pathergy test"},{"speaker":"E","startTime":383.19,"endTime":386.07,"body":"in Behcet's, tell me about"},{"speaker":"E","startTime":383.19,"endTime":386.07,"body":"that, and is it useful?"},{"speaker":"E","startTime":386.07,"endTime":388.09,"body":"[Dr. Handy] A pathergy"},{"speaker":"E","startTime":386.07,"endTime":388.09,"body":"test is a simple test"},{"speaker":"E","startTime":388.09,"endTime":391.32,"body":"in which the forearm is pricked"},{"speaker":"E","startTime":388.09,"endTime":391.32,"body":"with a small sterile needle."},{"speaker":"E","startTime":391.32,"endTime":393.4,"body":"Occurrence of a small red bump or pustule"},{"speaker":"E","startTime":393.4,"endTime":397.12,"body":"at the site of needle insertion"},{"speaker":"E","startTime":393.4,"endTime":397.12,"body":"constitutes a positive test."},{"speaker":"E","startTime":397.12,"endTime":400.33,"body":"A positive pathergy test can"},{"speaker":"E","startTime":397.12,"endTime":400.33,"body":"be supportive of the diagnosis"},{"speaker":"E","startTime":400.33,"endTime":403.19,"body":"of Behcet's, but it's"},{"speaker":"E","startTime":400.33,"endTime":403.19,"body":"not diagnostic by itself."},{"speaker":"E","startTime":403.19,"endTime":406.54,"body":"However, the test is really"},{"speaker":"E","startTime":403.19,"endTime":406.54,"body":"neither sensitive nor specific."},{"speaker":"E","startTime":406.54,"endTime":408.39,"body":"Only a minority of Behcet's patients"},{"speaker":"E","startTime":408.39,"endTime":410.5,"body":"demonstrate the pathergy phenomenon."},{"speaker":"E","startTime":410.5,"endTime":413.64,"body":"And other diseases may"},{"speaker":"E","startTime":410.5,"endTime":413.64,"body":"cause a pathergy reaction."},{"speaker":"E","startTime":413.64,"endTime":414.473,"body":"[Dr. Wiener] Before we finish,"},{"speaker":"E","startTime":414.473,"endTime":416.37,"body":"why don't you briefly just"},{"speaker":"E","startTime":414.473,"endTime":416.37,"body":"mention the other choices,"},{"speaker":"E","startTime":416.37,"endTime":418.57,"body":"and why they were not"},{"speaker":"E","startTime":416.37,"endTime":418.57,"body":"relevant in this case."},{"speaker":"E","startTime":418.57,"endTime":419.74,"body":"[Dr. Handy] Well, bullous pemphigoid"},{"speaker":"E","startTime":419.74,"endTime":423.13,"body":"is a polymorphic autoimmune"},{"speaker":"E","startTime":419.74,"endTime":423.13,"body":"subepidermal blistering disease"},{"speaker":"E","startTime":423.13,"endTime":425.17,"body":"that's usually seen in the elderly."},{"speaker":"E","startTime":425.17,"endTime":428.51,"body":"Initial lesions may consist"},{"speaker":"E","startTime":425.17,"endTime":428.51,"body":"of urticarial plaques,"},{"speaker":"E","startTime":428.51,"endTime":431.41,"body":"and most patients eventually"},{"speaker":"E","startTime":428.51,"endTime":431.41,"body":"display tense blisters"},{"speaker":"E","startTime":431.41,"endTime":434.64,"body":"on either normal-appearing"},{"speaker":"E","startTime":431.41,"endTime":434.64,"body":"or erythematous skin."},{"speaker":"E","startTime":434.64,"endTime":436.22,"body":"The lesions are usually distributed"},{"speaker":"E","startTime":436.22,"endTime":437.96,"body":"over the lower abdomen and groin,"},{"speaker":"E","startTime":437.96,"endTime":440.63,"body":"and the flexor surfaces"},{"speaker":"E","startTime":437.96,"endTime":440.63,"body":"of the extremities."},{"speaker":"E","startTime":440.63,"endTime":443.77,"body":"Oral mucosal lesions are"},{"speaker":"E","startTime":440.63,"endTime":443.77,"body":"found in some patients."},{"speaker":"E","startTime":443.77,"endTime":447.7,"body":"Discoid lupus erythematosus"},{"speaker":"E","startTime":443.77,"endTime":447.7,"body":"is the cutaneous form of SLE,"},{"speaker":"E","startTime":447.7,"endTime":448.76,"body":"and is characterized"},{"speaker":"E","startTime":448.76,"endTime":451.67,"body":"by atrophic depigmented"},{"speaker":"E","startTime":448.76,"endTime":451.67,"body":"plaques and patches"},{"speaker":"E","startTime":451.67,"endTime":454.44,"body":"that are surrounded by"},{"speaker":"E","startTime":451.67,"endTime":454.44,"body":"hyperpigmentation and erythema,"},{"speaker":"E","startTime":454.44,"endTime":457.06,"body":"in association with scarring and alopecia."},{"speaker":"E","startTime":457.06,"endTime":458.23,"body":"And Sjogren's syndrome"},{"speaker":"E","startTime":458.23,"endTime":460.84,"body":"is a chronic slowly"},{"speaker":"E","startTime":458.23,"endTime":460.84,"body":"progressive autoimmune disease"},{"speaker":"E","startTime":460.84,"endTime":463.15,"body":"characterized by lymphocytic infiltration"},{"speaker":"E","startTime":463.15,"endTime":464.29,"body":"of the exocrine glands"},{"speaker":"E","startTime":464.29,"endTime":467.27,"body":"that results in xerostomia and dry eyes."},{"speaker":"E","startTime":467.27,"endTime":470.16,"body":"So, none of the features of"},{"speaker":"E","startTime":467.27,"endTime":470.16,"body":"those diseases are present here,"},{"speaker":"E","startTime":470.16,"endTime":472.27,"body":"which makes those very unlikely."},{"speaker":"E","startTime":472.27,"endTime":474.31,"body":"[Dr. Wiener] Good, so the"},{"speaker":"E","startTime":472.27,"endTime":474.31,"body":"teaching points in this case"},{"speaker":"E","startTime":474.31,"endTime":476.21,"body":"are that Behcet's disease is characterized"},{"speaker":"E","startTime":476.21,"endTime":478.38,"body":"by recurrent mouth or genital ulcers,"},{"speaker":"E","startTime":478.38,"endTime":481.69,"body":"and may be associated with"},{"speaker":"E","startTime":478.38,"endTime":481.69,"body":"uveitis, venous thrombosis,"},{"speaker":"E","startTime":481.69,"endTime":483.45,"body":"or neurologic findings."},{"speaker":"E","startTime":483.45,"endTime":485.63,"body":"There are no diagnostic"},{"speaker":"E","startTime":483.45,"endTime":485.63,"body":"laboratory findings,"},{"speaker":"E","startTime":485.63,"endTime":489.63,"body":"so it is a syndromic diagnosis,"},{"speaker":"E","startTime":485.63,"endTime":489.63,"body":"or a diagnosis of exclusion."},{"speaker":"E","startTime":489.63,"endTime":492.71,"body":"Individuals with HLA-B51"},{"speaker":"E","startTime":489.63,"endTime":492.71,"body":"are at the highest risk"},{"speaker":"E","startTime":492.71,"endTime":494.15,"body":"of developing the disease,"},{"speaker":"E","startTime":494.15,"endTime":496.53,"body":"but most patients with this HLA complex"},{"speaker":"E","startTime":496.53,"endTime":498.79,"body":"do not develop the disease."},{"speaker":"E","startTime":498.79,"endTime":499.66,"body":"[Dr. Handy] And if you want to learn more,"},{"speaker":"E","startTime":499.66,"endTime":501.41,"body":"you can check out the Harrison's chapter"},{"speaker":"E","startTime":501.41,"endTime":502.97,"body":"on Behcet's disease."},{"speaker":"E","startTime":502.97,"endTime":505.553,"body":"[outro music]"},{"speaker":"E","startTime":507.07,"endTime":508.245,"body":"[Mr. Shanahan] This is Jim Shanahan,"},{"speaker":"E","startTime":508.245,"endTime":510.036,"body":"publisher at McGraw Hill."},{"speaker":"E","startTime":510.036,"endTime":511.55,"body":"Harrison's Podclass is brought to you"},{"speaker":"E","startTime":511.55,"endTime":514.523,"body":"by McGraw Hill's Access"},{"speaker":"E","startTime":511.55,"endTime":514.523,"body":"Medicine, the online medical"},{"speaker":"E","startTime":514.523,"endTime":517.02,"body":"resource that delivers"},{"speaker":"E","startTime":514.523,"endTime":517.02,"body":"the latest trusted content"},{"speaker":"E","startTime":517.02,"endTime":518.87,"body":"from the best minds in medicine."},{"speaker":"E","startTime":518.87,"endTime":521.403,"body":"Go to accessmedicine.com to learn more."}]}