Oral aphthous ulcers after difficult intubation in a patient with Behcet's disease.

Abstract

Behcet's disease (BD), first described in 1937, is known to be a complex multisystem disease, characterised by oral and genital aphthous ulcers, pustular vasculitic cutaneous lesions and ocular, gastrointestinal and vascular manifestations [1]. This disease is most commonly encountered in Japan, the Middle East and eastern Mediterranean countries [2]. We describe a patient who developed multiple oral aphthous ulcers after a difficult orotracheal intubation. A 26-year-old woman weighing 49 kg was scheduled for hemicolectomy because of BD with gastrointestinal involvement, which was unresponsive to medical treatment. She had been taking colchicine for 14 years. Pre-operative examination and laboratory workup were within normal limits. One healing aphthous ulcer was the only detectable lesion on the tongue. In the operating room, standard monitoring and anaesthetic induction were performed, but the anaesthetists were faced with an unpredicted difficult intubation. The tracheal tube was successfully inserted on the fourth attempt. A laparoscopic-assisted right hemicolectomy was performed and the trachea was extubated after completion of surgery. The operation and the recovery period were uncomplicated and the patient was sent to the surgical ward. On the first postoperative day, aphthous lesions began to appear on the lips, gums, tongue, oral mucosa, tonsils and larynx (Fig. 5). These lesions caused considerable discomfort to the patient and prevented oral intake. The lesions healed in 7 days with thalidomide and azathioprine therapy. The pathogenesis of BD and complex aphthosis is not completely understood but is probably mediated by some factors including immune dysregulation, inflammatory mediators and infection. Circulating immune complex damage, together with enhanced neutrophil migration, may be involved in the mucocutaneous effects of BD [3]. Trauma may lead to major reactions and cause recurrences of cutaneous or mucosal lesions in these patients [4]. The oral ulcers in BD are typically painful and may last between 1 and 4 weeks. These lesions generally heal without scarring [5]. In the anaesthetic literature, there is only a single case of a patient with BD who developed oral aphthous ulcers after anaesthesia [6]. In these patients it is impossible to rule out the contribution of the immune response following surgical trauma or the unpredictable nature of BD itself in which oral lesions may develop spontaneously. Tracheal intubation was difficult in our patient, and laryngoscopy and intubation attempts inevitably caused tissue trauma, which may have led to the generation of aphthous ulcers. It is important to appreciate that any trauma may cause painful cutaneous or mucosal lesions and these contribute to the postoperative morbidity in patients with Behcet's disease.