A 28-year-old man from Turkey presents with recurrent painful oral ulcers (>3 per year), genital ulcers with scarring, and recurrent episodes of eye inflammation. On slit-lamp examination, the anterior chamber shows the finding marked **D** in the diagram. Which of the following is the most appropriate systemic management to prevent vision-threatening complications in this patient?

Explanation

## Why Systemic azathioprine or infliximab with aggressive immunosuppression is right The finding marked **D** (hypopyon — sterile pus in the anterior chamber) is a hallmark of anterior uveitis in Behçet disease. The clinical presentation (recurrent oral ulcers >3/year, genital ulcers with scarring, ocular involvement) meets international diagnostic criteria for Behçet disease. Hypopyon in Behçet disease signals aggressive inflammation and high risk of vision-threatening posterior uveitis, retinal vasculitis, and chronic recurrent inflammation leading to blindness. Harrison 21e and Khurana emphasize that ocular involvement (~50–70% of Behçet patients) is the major cause of morbidity and requires aggressive systemic immunosuppression — azathioprine, cyclosporine, or infliximab (anti-TNF, preferred for refractory ocular disease) — to preserve vision and prevent atrophy. Topical therapy alone is insufficient for systemic Behçet disease with anterior uveitis. ## Why each distractor is wrong - **Topical corticosteroids and colchicine alone**: Colchicine is first-line for mucocutaneous manifestations (ulcers, erythema nodosum), but topical steroids alone cannot control systemic Behçet uveitis. Hypopyon indicates need for systemic immunosuppression to prevent posterior segment involvement and vision loss. - **Oral antibiotics and topical NSAIDs**: Behçet disease is a sterile vasculitis, not an infection. Antibiotics are not indicated. NSAIDs and topical therapy are insufficient for aggressive anterior uveitis with hypopyon. - **Anticoagulation therapy with warfarin**: Anticoagulation is reserved for venous thrombotic complications in Behçet disease (cerebral venous sinus thrombosis, DVT), not for ocular inflammation. Hypopyon is inflammatory, not thrombotic, and does not require anticoagulation. **High-Yield:** Hypopyon in Behçet disease = aggressive anterior uveitis → systemic immunosuppression (azathioprine, infliximab) mandatory to prevent vision loss; topical therapy alone is insufficient. [cite: Harrison 21e Ch 363; AK Khurana 7e]