[Progression of Behcet's disease with brain involvement: a case report]

Behcet's disease is a condition characterized by systemic vasculitis liable to thrombosis, and may involve the parenchyma and blood vessels in the brain. We report a case of Behcet's disease that progressed into central neural system involvement rapidly due to failure of tertiary prevention. This case demonstrates the importance of management of the high risk factors of thrombosis and timely prevention of disease progression.

[Clinical features and disease activity index of Behçet's disease]

OBJECTIVE

The clinical features and two disease activity assessment methods of Behçet's disease were evaluated in order to guide clinical management.

METHODS

A total of 116 patients with Behçet's disease from China-Japan Union Hospital of Jilin University in 2007-2014 were analyzed retrospectively for the gender and age distribution as well as clinical features of multisystem involvement. The correlations of Behçet's Disease Current Activity Form (BDCAF) and electronic medical record (EMR)-based activity index (EMRAI) scoring systems with clinical data were compared in Chinese patients for the first time, and clinical suggestion was raised.

RESULTS

Behçet's disease was commonly seen in young adults with age between 21-40 years old with mean course of four years.Males had longer duration than females (9.5 years vs 4.0 years, P<0.05), and vasculopathy was more commonly seen in males (11.9% vs 1.36%, P<0.05), while females had wider age distribution. BDCAF and EMRAI scoring systems were positively correlated with each other; the former was well associated with laboratory inflammatory indices, and the latter was simplified for application.

CONCLUSIONS

The clinical manifestation of Behçet's disease varies with different gender; BDCAF and EMRAI scoring system well correlate with the laboratory inflammatory indices of patients, and can indicate the disease activity.

[Advances in diagnosis and treatment of intestinal Behcet's disease]

Behcet's disease (BD) affects gastrointestinal tract is defined as intestinal BD. The diagnosis and therapeutic efficacy of intestinal BD are still lack of specific diagnostic method and effective treatment. Intestinal BD is diagnosed according to established criteria based on colonoscopic features and biopsy. To date, 5-aminosalicylic acid and systemic corticosteroids are established as the first-line therapy, while immunosuppressants and infliximab are used as second-line therapy for patients with glucocorticoid resistant. In the process of therapy, we need to carefully evaluate the patient's condition and be cautious about surgical treatment. Surgical intervention should only be considered in patients with serious complications. In this review, we summarize the recent advances in diagnosis, disease activity index and treatment of intestinal BD, and provide the theoretic proofs to clinical application.

[Clinical features and misdiagnosis of connective tissue disease plus pulmonary embolism]

OBJECTIVE

To evaluate the clinical features and reasons of misdiagnosis of connective tissue disease plus pulmonary embolism (PE).

METHODS

The clinical data were reviewed retrospectively for 22 hospitalized patients with connective tissue disease and PE from February 2006 to March 2014. And the features of onset, clinical and laboratory characteristics, imaging tests and causes of misdiagnosis were analyzed.

RESULTS

There were 12 males and 10 females with an average age of (36.2 ± 14.2) years. And 12 (54.5%) PE patients had concurrent deep venous thrombosis. Antiphospholipid syndrome and Behcet's disease were the major causes of connective tissue disease. Chest distress, palpitation and extremity swelling were initial symptoms. There were elevated erythrocyte sedimentation rate (n = 11, 50.0%), elevated C-reactive protein (n = 8, 36.4%) and abnormal autoantibody (n = 15, 68.2%) respectively. Computed tomography showed pulmonary arteries stenosis, occlusion and aneurismal dilation. Eighteen (81.8%) patients had pulmonary hypertension with a systolic pulmonary pressure of (72 ± 20) mmHg (1 mmHg = 0.133 kPa). And 3 of them presented severity of pulmonary pressure non-matched to the degree of pulmonary vascular involvement. And 18 (81.8%) patients with connective tissue disease were missed due to a lack of typical symptoms and physician understanding of disease before admission. Three (13.6%) patients had a misdiagnosis of idiopathic pulmonary arterial hypertension. The median time of diagnosis was 12 months.

CONCLUSIONS

Connective tissue disease may develop PE as the initial symptom. And some patients lack typical clinical manifestations of connective tissue disease. It should raise an alert with the physicians.

Evidence-based practice in Behçet's disease: identifying areas of unmet need for 2014

BACKGROUND

Behçet's Disease (BD) is characterized by a relapsing-remitting course, with symptoms of varying severity across almost all organ systems. There is a diverse array of therapeutic options with no universally accepted treatment regime, and it is thus important that clinical practice is evidence-based. We reviewed all currently available literature describing management of BD, and investigated whether evidence-based practice is possible for all disease manifestations, and assessed the range of therapeutic options tested.

METHODS

We conducted an internet search of all literature describing management of BD up to August 2013, including pharmacological and non-pharmacological interventions. We recorded treatment options investigated and disease manifestations reported as primary and secondary study outcomes. Quality of data was assessed according to the Scottish Intercollegiate Guideline Network (SIGN) hierarchy of evidence.

RESULTS

Whilst there is much literature describing treatment of ocular and mucocutaneous disease, there is little to guide management of rheumatoid, cardiovascular and neurological disease. This broadly reflects the prevalence of disease manifestations of BD, but not the severity. Biologic therapies are the most commonly investigated intervention. The proportion of SIGN-1 graded studies is declining, and there are no SIGN-1 graded studies investigating neurological or gastrointestinal manifestations of BD.

CONCLUSIONS

This is the first study to investigate trends in published literature for management of BD over time. It identifies neurological, cardiovascular and gastro-intestinal disease as particular areas of unmet need and suggests that overall quality of evidence is declining. Future research should be designed to address these areas of insufficiency to facilitate evidence-based practice in BD.

[A clinical analysis of ocular involvement in 111 cases of Behcet's disease]

OBJECTIVE

To study the ocular manifestations in patients with Behcet's disease(BD).

METHODS

Medical records at Peking Union Medical College Hospital from 2002 to 2012 were reviewed to identify the patients who were diagnosed as BD with ocular involvement.

RESULTS

One hundred and eleven BD patients developed ocular involvement. Males were more frequently involved, and the male/ female ratio was 2.08: 1. The age at the onset of BD and the time of ocular involvement were (27.6 ± 10.8) and (31.5 ± 10.7) years, respectively. The median interval between the diagnosis of BD and ocular disease was 24 (0, 372) months. Ocular involvement was bilateral in 85.6% patients. About two thirds patients (66.7%) had impaired vision, for example, visual acuity of 0.1 or less was detected in 60.4% patients. Uveitis (90.1%) was the most common findings in BD patients with ocular involvement and the most frequent type of uveitis in both sexes was panuveitis (62.16%). Vision loss, proliferative retinopathy and cataract were more common in men. There was a statistically significantly higher frequency of positive human leukocyte antigen(HLA)-B51 in the male BD with ocular involvement than in the female. All BD patients with uveitis were given systemic corticosteroid or combined immunosuppressive agents. The improvement of visual acuity was seen in 77% BD patients, but the recurrent attacks occurred in 49% patients, resulting in blindness in 25.5% of them. TNFα blockers were given to 19 recurrent uveitis patients, 12 patients improved while two had no response.

CONCLUSIONS

The most common ocular involvement in BD was uveitis. Males were more frequently involved with a more severe disease, higher complications and positive HLA-B51 than in females. Glucocorticoids and immunosuppressants were effective to uveitis, but high rate of recurrent inflammatory ocular attacks led to high risk of blindness. TNFα blockers may improve the outcome of recurrent BD uveitis.

[Chlorambucil treatment of Behçet's syndrome. Retrospective evaluation of two cases]

BACKGROUND

Behçet's syndrome rarely occurs in North America and Central Europe (incidence: 1 : 500,000), whereas it is more frequently seen in Japan and Mediterranean countries (incidence: 1 : 10,000). The diagnosis is based on the detection of symptoms and clinical signs. Orogenital aphthosis, anterior and posterior uveitides that frequently cause loss of vision are considered to be primary symptoms. Dermatologic manifestations, i.e., erythema nodosum, vascular lesions (angio-Behçet's syndrome), gastrointestinal ulcers and neurologic involvement, can be observed. HLA B5 is found in some of the patients with Behçet's syndrome. Administration of chlorambucil, a cytotoxic compound, is an effective form of treatment of symptoms and complications of Behçet's syndrome.

CASE REPORTS

The present article describes the course of a female and a male patient who were 39 and 23 years old when Behçet's syndrome was diagnosed for the first time. Treatment with chlorambucil was started in the early 1990s and continued for a period of 9 1/2 and 3(3/4) years, respectively, with the symptoms remitting during and after this therapy. Approximately 10 years after the start of treatment with chlorambucil, the patients' symptoms changed. The female patient who was first diagnosed having Behçet's syndrome at the age of 39 years developed rheumatoid arthritis with joint destruction. Her symptoms could be controlled in the long term by oral administration of prednisone, at doses below the Cushing threshold combined with methotrexate. The male patient who was first diagnosed having Behçet's syndrome at the age of 23 years developed systemic vasculitis remitting during low-dose treatment with prednisone.

CONCLUSION

Immunosuppressive therapy with chlorambucil administered over several years often induces remission of Behçet's syndrome. However, both case reports indicate that symptoms can change from Behçet's syndrome to systemic vasculitis or rheumatoid arthritis.

Snaring the retrograde wire in the aortic root for chronic total occlusion after Bentall operation in a patient with Behcet's disease

Snaring the retrograde wire in the aortic root was successfully performed for treatment of a chronic total occlusion (CTO) lesion of a saphenous vein graft interposed between a prosthetic graft and the right coronary artery (RCA) ostium in a patient with Behcet's disease after two Bentall operations. Although the coronary guidewire and balloon were able to cross the CTO lesion retrogradely, the coronary guidewire was unable to cross antegradely after ballooning because of intractable engagement of the guiding catheter. A 300 cm guidewire was inserted retrogradely and the guidewire was pulled out of the sheath placed in the right radial artery using a snare. Subsequently, the microcatheter was inserted antegradely into the RCA using the guidewire. The 300 cm guidewire was removed and a standard guidewire was inserted antegradely into the RCA. Finally, a drug-eluting stent was successfully implanted in this difficult-to-treat CTO lesion.

Quality of life and its relation with disease severity in Behçet's disease

OBJECTIVE

Since Behçet's disease (BD) is a systemic vasculitis, it may deteriorate the quality of life of the patients. We aimed to investigate the relationship between the disease severity and the quality of life in patients with BD.

METHODS

We studied 195 BD patients and 195 healthy controls who were matched with regard to age, gender and socio-economic status. Krause score was calculated to assess disease severity, while Short-form-36 (SF-36) and The World Health Organization Quality of Life (WHOQOL-100) were used to evaluate the quality of life in BD.

RESULTS

The overall SF-36 and WHOQOL-100 scale scores, as well as their domains were significantly lower in BD patients. In BD patients, "general health", "role-physical", domains of SF-36, and "psychological", "level of independence", "environment", "environmental-public" domains of WHOQOL-100 showed significantly negative linear correlations with Krause scores. In BD patients with arthritis, the scores of "general health", "physical functioning", "role emotional" domains of SF-36, and the scores of "psychological", "level of independence" and "social relations" domains of WHOQOL-100 were significantly worse than without arthritis. The scores of "pain" domain of SF-36 and "level of independence" domain of WHOQOL-100 were significantly worse in BD patients with vascular involvement, while the scores of "mental health" domain of SF-36 and "psychological" domain of WHOQOL-100 were significantly worse in BD patients with eye involvement.

CONCLUSION

Based on the evaluation of SF-36 and WHOQOL-100 scores, quality of life is impaired and related with disease severity in BD. Arthritis, eye involvement and vascular involvement seem to contribute to this impairment.

[Translational research with experimental autoimmune uveoretinitis (EAU)]

Experimental autoimmune uveoretinitis (EAU) induced by immunization with retinal antigen (Santigen or interphotoreceptor retinoid-binding protein; IRBP) serves as an animal model of human uveoretinitis. As the first stage, we demonstrated the similarities between EAU and ocular inflammation in Behçet's disease by investigating anti-retinal antibodies, leukocyte migration inhibition by retinal antigen, immunogenic antigens, aberrant functions of neutrophils, and dominant Th1 lymphocyte reaction. From these findings, we verified that EAU, which is not associated with the systemic disorders observed in Behçet's disease, is an appropriate model for translational research targeting ocular inflammation. In the second stage, we set 3 therapeutic strategies for uveitis in Behçet's disease to be conducted in the translational research: (1) intraocular administration of an immunosuppressive drug; (2) inhibition of Th1 lymphocytes; and (3) activation of immunoregulatory cells. In strategy 1, our studies indicated that intravitreal injection of 10 microg of tacrolimus (FK 506) was not harmful to the retina and was predominantly effective in suppressing ongoing EAU in rats. In strategy 2, two approaches were adopted to prevent differentiation of Thl cells. One is anti-cytokine antibody therapy using anti-IL-12 monoclonal antibodies(mAb). The other is blockade of co-stimulatory signals, especially the ICOS-B7RP-1 pathway. Administration of anti-IL-12 mAb at the time of IRBP immunization completely inhibited development of EAU, and antagonistic anti B7RP-1 mAb suppressed the severity of EAU even when administered after development of EAU. In strategy 3, adoptive transfer of antigen presenting cells treated with a neuropeptide (vasoactive intestinal peptide or calcitonin gene-related peptide) or CD 4+ CD 25+ regulatory T cells suppressed EAU. We look forward to the day when therapies that are being developed in our translational research using EAU will become available for treating intraocular inflammation in Behçet's disease.

Neuropsychological differences between frontotemporal dementia and Alzheimer's disease: a review

This paper surveys the similarities and differences between frontotemporal dementia (FTD) and Alzheimer's disease (AD). The review covers findings primarily from neuropsychological studies on memory, language, attention/executive function, and visuospatial abilities. However, neuropsychiatric and neuroimaging data are also briefly discussed. Distinguishing features of both FTD and AD are described in order to present a comprehensive clinical picture of these dementing diseases, which is essential for the process of differential diagnosis. The cause of specific cognitive deficits is also considered. Our comprehensive review of the empirical literature reveals that AD is characterized by early memory loss and visuospatial problems, while among the main features of FTD are behavioral abnormalities and executive dysfunctions.