behcet disease is characterized by recurrent painful oral ulcer and genital ulcer , skin diseases and uveitis . it may involve cardiovascular , gastrointestinal and central nervous system , as well as joints . the diagnosis of behcet disease primarily depends on the patient s history and clinical findings . among the patients who visited the rheumatology division , keimyung university dongsan medical center , taegu , korea from march 1997 to february 1998 , 52 patients were compatible for the diagnosis of behcet disease according to the shimizu criteria . forty seven patients with more than 3 months follow - up were enrolled in this study . forty three patients were referred to the rheumatology division by primary care physicians , two from department of ophthalmology and two from general surgery in keimyung university dongsan medical center . they had been diagnosed as having behcet disease by careful history taking , medical record review and thorough physical examination . on initial visit all patients were followed - up closely and they visited the hospital every two weeks . a direct telephone number was given to the patients and , whenever they felt uncomfortable with ill - defined symptoms , they discussed with the examiner . the shimizu criteria were retrospectively and strictly applied again , and five uncertain patients were excluded . especially , regarding an oral ulcer , only the patients who complained of an evident , recurrent , painful one were included . possible  type of five behcet cases were excluded and two patients , who carried another autoimmune diagnosis(sle ) , were excluded , too . recurrent aphthous ulceration in the mouth , various skin lesions(erythema nodosum - like eruptions , subcutaneous thrombophlebitis , hyper - irritability of the skin ) , eye lesions(recurrent hypopyon iritis or iridocyclitis , chorioretinitis ) and genital ulcerations were evaluated . the presence of joint manifestations , gastrointestinal and vascular lesions , epididymitis and central nervous system involvements were evaluated too . arthropathy was defined as arthralgia with the presence of swelling and/or tenderness . regarding the joint manifestations , the involved joints , tenderness , swelling and the pattern of the articular symptoms were evaluated . the pattern of involvement included the number of involved joints and the duration of arthropathy . basic laboratory tests , including cbc , erythrocyte sedimentation rate ( esr , westergren ) , c - reactive protein ( crp ) , complement , immunoglobulin , rheumatoid factor ( rf ) and antinuclear antibody ( ana ) , were done . synovial fluid analysis was tried whenever the patient had sufficient amount of swelling and agreed to aspirate . the presence and the duration of morning stiffness , which is relieved by exercise , were also evaluated . the involved joints , tenderness , swelling and the number of involved joints were evaluated , as already mentioned above . rf and simple radiologic studies of mainly involved joints were evaluated again , as already mentioned above , for the purpose of comparing the data with those of rheumatoid arthritis . regarding oro - genital ulcers or skin lesions , the author asked whether they were asked of the presence of them by their primary care physicians . among the patients who visited the rheumatology division , keimyung university dongsan medical center , taegu , korea from march 1997 to february 1998 , 52 patients were compatible for the diagnosis of behcet disease according to the shimizu criteria . forty seven patients with more than 3 months follow - up were enrolled in this study . forty three patients were referred to the rheumatology division by primary care physicians , two from department of ophthalmology and two from general surgery in keimyung university dongsan medical center . they had been diagnosed as having behcet disease by careful history taking , medical record review and thorough physical examination . on initial visit all patients were followed - up closely and they visited the hospital every two weeks . a direct telephone number was given to the patients and , whenever they felt uncomfortable with ill - defined symptoms , they discussed with the examiner . the shimizu criteria were retrospectively and strictly applied again , and five uncertain patients were excluded . especially , regarding an oral ulcer , only the patients who complained of an evident , recurrent , painful one were included . possible  type of five behcet cases were excluded and two patients , who carried another autoimmune diagnosis(sle ) , were excluded , too . recurrent aphthous ulceration in the mouth , various skin lesions(erythema nodosum - like eruptions , subcutaneous thrombophlebitis , hyper - irritability of the skin ) , eye lesions(recurrent hypopyon iritis or iridocyclitis , chorioretinitis ) and genital ulcerations were evaluated . the presence of joint manifestations , gastrointestinal and vascular lesions , epididymitis and central nervous system involvements were evaluated too . arthropathy was defined as arthralgia with the presence of swelling and/or tenderness . regarding the joint manifestations , the involved joints , tenderness , swelling and the pattern of the articular symptoms were evaluated . the pattern of involvement included the number of involved joints and the duration of arthropathy . basic laboratory tests , including cbc , erythrocyte sedimentation rate ( esr , westergren ) , c - reactive protein ( crp ) , complement , immunoglobulin , rheumatoid factor ( rf ) and antinuclear antibody ( ana ) , were done . synovial fluid analysis was tried whenever the patient had sufficient amount of swelling and agreed to aspirate . the presence and the duration of morning stiffness , which is relieved by exercise , were also evaluated . the involved joints , tenderness , swelling and the number of involved joints were evaluated , as already mentioned above . rf and simple radiologic studies of mainly involved joints were evaluated again , as already mentioned above , for the purpose of comparing the data with those of rheumatoid arthritis . regarding oro - genital ulcers or skin lesions , the author asked whether they were asked of the presence of them by their primary care physicians . the range of duration between the first clinical manifestation and the diagnosis was from 1 to 25 years . all 35 patients had evident , recurrent , painful oral ulcers by the study definition . in 46% various skin lesions , including erythema nodosum - like eruption , subcutaneous thrombophlebitis and hyper - irritability of the skin were noted in 77% . gastrointestinal ulcerations and vascular manifestations were found only in 6% , respectively . in vascular manifestations , one patient showed three vascular events ( cerebral infarction and carotid , femoral aneurysms ) . other involved joints included wrist , elbow , shoulder , ankle , mtp and dip . tenderness was prominent in 91% and swelling was noted in 44% . in number of affected joints the duration of arthropathy was less than one week in 59% , one to four weeks in 18% , persisting more than 4 weeks in 18% . basic laboratory tests , including cbc , esr , complement and immunoglobulin were nonspecific(data not shown ) except crp . crp was positive in 12 patients and the mean concentration was 2.02 mg / dl ( normal < 0.32 ) . it was also positive in some of suspected type who had very active or advanced manifestations . radiologic studies of mainly involved joints were available in 85% ( 29/34 ) of patients . among these , pip , mcp , wrist , elbow , shoulder , ankle and knee were commonly involved . thirty one patients visited local medical clinics due to their joint problems . in table 5 , initial diagnoses of the patients by their primary care physicians , later found as behcet arthritis , were summarized . sixteen patients out of 31 with joint manifestations were carrying a diagnosis of rheumatoid arthritis . none of them were asked by their primary care physicians whether they had recurrent oro - genital ulcers or erythema nodosum - like skin lesions . no definite answer was obtained from their primary care physicians when the patients asked about the relation of skin lesion and the articular symptoms . the range of duration between the first clinical manifestation and the diagnosis was from 1 to 25 years . all 35 patients had evident , recurrent , painful oral ulcers by the study definition . in 46% various skin lesions , including erythema nodosum - like eruption , subcutaneous thrombophlebitis and hyper - irritability of the skin were noted in 77% . gastrointestinal ulcerations and vascular manifestations were found only in 6% , respectively . in vascular manifestations , one patient showed three vascular events ( cerebral infarction and carotid , femoral aneurysms ) . other involved joints included wrist , elbow , shoulder , ankle , mtp and dip . tenderness was prominent in 91% and swelling was noted in 44% . in number of affected joints the duration of arthropathy was less than one week in 59% , one to four weeks in 18% , persisting more than 4 weeks in 18% . basic laboratory tests , including cbc , esr , complement and immunoglobulin were nonspecific(data not shown ) except crp . crp was positive in 12 patients and the mean concentration was 2.02 mg / dl ( normal < 0.32 ) . it was also positive in some of suspected type who had very active or advanced manifestations . radiologic studies of mainly involved joints were available in 85% ( 29/34 ) of patients . among these , pip , mcp , wrist , elbow , shoulder , ankle and knee were commonly involved . thirty one patients visited local medical clinics due to their joint problems . in table 5 , initial diagnoses of the patients by their primary care physicians , later found as behcet arthritis , were summarized . sixteen patients out of 31 with joint manifestations were carrying a diagnosis of rheumatoid arthritis . none of them were asked by their primary care physicians whether they had recurrent oro - genital ulcers or erythema nodosum - like skin lesions . no definite answer was obtained from their primary care physicians when the patients asked about the relation of skin lesion and the articular symptoms . it is seen mostly in countries along the  silk road  , which include turkey , iran , japan , china and , possibly , korea . behcet disease is diagnosed by a few set of diagnostic criteria , including the shimizu diagnostic criteria and the international study group criteria . in this study , the shimizu criteria were used since they were useful in dealing with minor manifestations , including arthritis . major criteria include recurrent aphthous ulceration in the mouth , skin lesions(erythema nodosum - like eruptions , subcutaneous thrombophlebitis , hyper - irritability of the skin ) , eye lesions(recurrent hypopyon iritis or iridocyclitis , chorioretinitis ) and genital ulcerations . minor criteria include arthritic symptoms and signs(arthralgia , swelling , redness ) , gastrointestinal lesions(appendicitis - like pains , melena , etc . ) , epididymitis , vascular lesions(occlusion of blood vessels , aneurysms ) , and central nervous system involvements(brain stem syndrome , meningo - encephalomyelitic syndrome , confusional type ) . it was proposed by them that if all four of the major symptoms appeared during the clinical course of the disease , the syndrome would be classified as first , in most cases with behcet disease , various clinical manifestations occur in sequence . recurrent oral ulcer is the most common and the earliest symptom , and it is followed by genital and skin lesions . after the skin lesions , arthritis , neurological manifestations and ocular lesions occur which means , although ocular involvement tends to be the most serious problem , it usually does not occur very early in the course of the disease . in other words , although the appearance of uveitis makes the diagnosis of behcet disease complete  , it dose not necessarily mean that we should wait till the patient develops full systemic , lethal manifestations to confirm the diagnosis . second , among the so - called minors , arthritic manifestation is known as the most common manifestation . the purpose of this study is to emphasize the clinical significance of behcet disease , especially when the patients present with arthritic manifestations . in korea , there were two reports focusing arthritic manifestations in behcet disease among 150 papers for behcet disease . however , one of them was done in behcet disease specialty clinic with already known behcet disease patients , and the other did not mention in detail how the patients presented to the doctors . the present study was not conducted at behcet disease specialty clinic , and the author did not intend to collect all behcet patients from other departments . most of them just came to the rheumatology division with arthralgia or arthritis , one among various early manifestations . that is why the arthropathy was the most common manifestation , excluding oral ulcer , since it was prerequisite to be enrolled in this study . since most of them complained of arthritis , the earlier manifestation , the suspected type occupied most of this study group , instead of the clinically more advanced type , such as the incomplete type . it was known that there was an association between the presence of hla b5 and more severe types of behcet disease . frequency of non - arthritic clinical features were similar to those of previous reports , although the size of the present study group was too small to compare with . sixteen patients with joint manifestations were carrying a diagnosis of ra when they were first enrolled in the present study . it is speculative that they are regarded as satisfying the classification criteria for ra by the articular involvement , morning stiffness . it was likely that most doctors were aware of ra and they knew that rheumatoid factor might not be found in some ra patients . to be classified as ra , the joint swelling should be present and persistent , instead of simple tenderness or transient arthritic episode . morning stiffness should be remarkable , instead of brief discomfort . by careful history taking and thorough physical examination , the author could find out quite easily that they had behcet arthritis , after all possible rheumatic diseases had been excluded . with full and careful interpretation of all clinical manifestations , it may not be a problem for an experienced physician to differentiate ra with most of behcet disease . however , for those who do not understand the heterogeneity of rheumatic diseases , behcet disease may pose a diagnostic dilemma , especially when it presents very similar to ra with polyarticular involvement on pip , mcp of hands and with equivocal morning stiffness . it was known that the duration of attacks varied from a few days to a few weeks , and attacks were followed by remissions . joint manifestations were known usually as non - erosive , even after extended periods of time . in the present study , the duration of each attack was less than 4 weeks in 76% , and this result was similar to the previous report . knee , pip , mcp , wrist and shoulder were commonly involved , and the arthritic manifestation was present only for several days in more than half of the patients . in this context , it seemed feasible to say that arthritic manifestations in behcet disease may present as palindromic rheumatism . the joints involved in initial attacks in palindromic rheumatism are mostly knee , wrist , mcp , pip and shoulder . each episode of palindromic rheumatism lasts , not infrequently , for a few weeks , and there is no bone and cartilage destruction even after repeated episodes . it was also positive in some of suspected type who had very active or advanced manifestations , such as widespread erythema nodosum - like skin lesion , crippling arthritis(fig.12 ) , gastrointestinal ulceration or vascular aneurysm . it is likely that crp may be positive in  active  behcet diseases . in korea , even after publication of about 150 papers mentioned above , it seems that behcet disease is still regarded as a very rare disease to primary care physicians and patients , and especially , the arthritic manifestations in behcet disease is usually overlooked . it is likely that many doctors do not completely understand the complex nature of behcet disease , which includes the various clinical spectrum and clinical evolution that was mentioned above in detail . it is speculative that they usually understand behcet disease as  strict  symptom triad which is composed of oral ulcer , genital ulcer and uveitis . since they usually think that all manifestations should appear at the same time , at presentation to them , they will not diagnose a patient as behcet disease if the patient has only one or two manifestations . patients with oro - genital ulcers may not seek help since the clinical manifestation is sometimes tolerable or relieved by topical agents . otherwise , they may feel uncomfortable in visiting a doctor s office with genital problems which are not very urgent . various skin lesions , including erythema nodosum - like eruptions , subcutaneous thrombophlebitis and hyper - irritability of the skin , manifest so diverse and are mostly subclinical . from these contexts , the size of the sample was too small and the duration of follow - up was too short to discuss the entire clinical progression . most patients were the incomplete or suspected type , instead of the complete type , since the author focused on early presenting manifestations and early detection . by the way , recently , there was a report focusing heel pain in behcet disease patients which suggested that arthropathy in behcet disease might be regarded as another entity of seronegative spondyloarthropathy . in the present study , the present study was focused only on articular manifestations and future study , including the enthesopathy , seems to be required . it may present as seronegative rheumatoid arthritis . otherwise , it may present as palindromic rheumatism . much more attention to this disease and a nationwide survey in korea
objectivesto analyze arthritic manifestations in behcet disease , which is one of the most common manifestations of behcet disease.methodsamong the patients who visited the rheumatology division , keimyung university dongsan medical center , taegu , korea from march 1997 to february 1998 , 35 patients , with more than 3 months follow - up , were compatible for the diagnosis of behcet disease according to the shimizu criteria , after exclusion of uncertain or possible behcet cases . 
 the presence of various manifestations was evaluated . regarding the joint manifestations , the involved joint , signs and the pattern of the articular symptoms 
 were examined . 
 basic laboratory tests , hla studies and simple radiologic studies were done.resultsall 35 patients had evident , recurrent , painful oral ulcers by the study definition . 
 genital ulcers were found in 29% , skin lesions in 77% , uveitis in 9% , gastrointestinal ulcerations in 6% and vascular manifestations in 6% . 
 joint manifestations appeared in 97% . 
 knee(91% ) , proximal interphalangeal ( 53% ) and metacarpophalangeal joints(21% ) were the main sites . 
 tenderness was prominent in 91% and swelling in 44% . 
 polyarticular presentation was found in 47% . in most cases ( 76.4% ) , the articular symptom was short - lasting . 
 c - reactive protein was likely to be positive in active behcet disease . 
 hla b51 was positive in 46%.conclusionsin behcet disease , various manifestations can be found . 
 the arthritic manifestation seems quite common , it may present as seronegative rheumatoid arthritis . 
 otherwise , it may present as palindromic rheumatism .