Case Presentation: A 25 year old Ethiopian female presented with a four week history of painful genital ulcer, oral lesions and intermittent back pain with dysuria. Ulcer initially started as painless bumps that progressively became painful and ulcerated. She reported no prior history of genital ulcers or sexually transmitted diseases and denied any sexual encounter in the past 4 years. Past history was significant for recurrent oral apthous ulcers. On presentation, she was febrile and tachycardic. Physical exam revealed a 4 x 2 cm foul-smelling right labial majora ulcer which was tender to palpate. She was also noted to have four oral apthous ulcers. No inguinal lymphadenopathy, costovertebral or abdominal tenderness was noted. With concerns of secondary bacterial infection, antibiotics were started. An ultrasound of the groin showed no abscess. Blood, labial and urine cultures showed no growth. With minimal relief in symptoms for two days, she underwent examination under anesthesia which showed two ulcers in the cervix. HSV, RPR, EBV, Donovan bodies, C. trichomatis L1-L3 and rapid HIV were all negative. A computed tomography of abdomen/pelvis done for intermittent back pain revealed bilateral vasculitic changes in the kidneys. Pathology from the lesions showed necrotic tissue consistent with vasculitis. Rheumatology was consulted and a diagnosis of Behçet’s disease was made. She was started on prednisone which improved her symptoms. ANA, C3, C4, CH50 panel, ANCA and pathergy test were all negative. All antibiotics were discontinued and she was discharged on prednisone and colchicine. In a subsequent follow up, she had recovered fully.
Discussion: There are close to 20 million cases of genital ulcers seen globally. When it comes to diagnosing genital ulcers, it is imperative to take a stepwise approach that differentiates infectious from non-infectious causes. A proper history and physical exam with laboratory evaluation can help. Of the many infectious causes, genital herpes is the most diagnosed in United States and hence should always be investigated. Non-infectious causes are rare, include multiple etiologies and may need a multidisciplinary approach. Of these, Behçet’s disease is rare with its prevalence being 0.33%. It is a multisystem disease that has a predominant incidence in the Mediterranean, Middle East and Far East. There are only a few cases reported in the Ethiopian population, making our case unique. Diagnosis is clinical and treatment includes steroids, colchicine and immunosuppressive agents.
Conclusions: Genital ulcers can be due to infectious or non-infectious causes; the latter being rare, often misdiagnosed and needing a high degree of clinical suspicion. We presented an uncommon case of genital ulcer caused by Behçet’s disease rarely seen in the Ethiopian and American populations.