Radiological Neuro-BehçEt'S Associated with Bipolar Disorder: First Presentation of a Multisystem Disease

Abstract

Behçet's disease is a chronic, relapsing, systemic inflammatory disease affecting the orogenital mucosa, eyes, joints, blood vessels, nervous system and intestines. The prevalence of neurological involvement varies geographically and can include psychiatric manifestations. Current evidence for a causal association between Behçet's disease and bipolar disorder is limited to a small number of case reports. We report a case of a patient with a recent diagnosis of bipolar disorder who was subsequently diagnosed with Behçet's disease. The 38-year-old male presented with a 6-month history of right eye visual blurring, 5-month history of mouth ulcers and 3 months of genital ulceration. His inflammatory markers were raised. An MRI of the brain was conducted in the absence of any focal neurological signs or symptoms owing to his past psychiatric history. The MRI showed changes in the medial aspect of the right temporal lobe highly suspicious of neuro-Behçet's disease. His inpatient care was coordinated with neurology, rheumatology, ophthalmology and psychiatry teams, and he was later discharged with outpatient follow up owing to a clinical improvement on high-dose steroids. This case shows that, although widely unrecognised, neuro-Behçet's can occur in the absence of focal neurology. Additionally, neuro-Behçet's should be considered in patients with bipolar disorder presenting with symptoms suggestive of Behçet's disease. The case emphasises how patients presenting with ulceration, mood disorder and visual changes should not have these symptoms considered in isolation and multisystem disease should be considered. Furthermore, the coordinated multidisciplinary approach required for the care of patients with Behçet's disease is demonstrated.

Behçet Disease and Bipolar Disorder: A Case Report and Review

“…Nonetheless, bipolar disorder can occur in BD in the absence of NBD, and bipolar disorder can precede the somatic symptoms of BD. 2,8,12 In our case, the patient had a history of bipolar disorder with onset at age 17 with a manic episode. This was followed by numerous depressive episodes and manic episodes.…”

“…Hibberd et al 2 reported a male with a history of bipolar disorder, who was diagnosed with NBD after admission to a psychiatry ward for suicidal ideation. 2 The precise links between BD and bipolar disorder remain elusive, but possible explanatory theories have been posited. Psychiatric symptoms can be secondary to neurological involvement, namely parenchymal lesions affecting subcortical structures.…”

“…(Journal of Psychiatric Practice 2023;29;421-425) KEY WORDS: Behçet disease, Behçet syndrome, bipolar disorder, comorbidity, mood disorders Behçet disease (BD) is a rare inflammatory disease with multifactorial etiology and a relapsing course. 1,2 It was first described by Hulusi Behçet in 1937, as a triad of recurrent oral and genital ulcers on mucous membranes (aphthous ulcers) and inflammation of parts of the eye (eg, relapsing anterior uveitis with hypopyon). [3][4][5] Currently, it is known to affect almost any tissue or organ, causing skin lesions, neurological symptoms, gastrointestinal manifestations, and articular complaints in addition to the classic orogenital and ocular involvement.…”

“…3,6 NBD can present as lesions of functional or nonfunctional (parenchymal or nonparenchymal) cells. 2,6,7 Parenchymal lesions have been associated with psychiatric manifestations, such as anxiety disorders, mood disorders, psychosis, and cognitive impairment. 2,3,6,8 Psychiatric disorders are common in individuals with BD, with a prevalence that may reach 41.1%, and they can exist even in the absence of NBD.…”

“…2,6,7 Parenchymal lesions have been associated with psychiatric manifestations, such as anxiety disorders, mood disorders, psychosis, and cognitive impairment. 2,3,6,8 Psychiatric disorders are common in individuals with BD, with a prevalence that may reach 41.1%, and they can exist even in the absence of NBD. 4,8 The epidemiology of bipolar disorder in BD and NBD remains unknown and case reports are scarce, even though a significantly higher frequency of bipolar disorder in BD and NBD has been reported.…”