Behçet's disease and pregnancy

BACKGROUND

Behçet's disease (BD) is a multisystem inflammatory chronic disorder, which is characterized by relapsing oral and genital ulceration and iridocyclitis. While being of unknown etiology, vasculitic changes of possible autoimmune origin are common to all involved organs, and thrombotic complications, which may adversely affect gestation, are frequently seen. Very little is known to date about the reciprocal influence of BD and pregnancy. We have undertaken to explore the mutual effect of BD and pregnancy with emphasis on maternal and fetal complications.

METHODS

In this case-control study, we have evaluated pregnancies that occurred in women suffering from BD, who were treated in our institution during the last 25 years. All records were reviewed, and data were confirmed by a telephone interview and compared with a matched control group. To review the current knowledge, a Medline search together with a manual search of selected articles was performed.

RESULTS

Thirty-one Behçet's patients who had 135 pregnancies were studied. Remissions were significantly more frequent during both pregnancy and postpartum periods, while exacerbations were observed only in one-sixth of the patients (P < 0.001). Pregnancy complications (P < 0.001), cesarean section (P < 0.001), and miscarriage (P < 0.02) rates, however, were significantly higher in the study group.

CONCLUSIONS

Our study suggests that pregnancy does not have a deleterious effect on the course of BD and may possibly ameliorate its course. However, it seems that BD may adversely affect pregnancy. The miscarriage rate was higher, and the pregnancy complications and cesarean section rates were significantly elevated.

Synovial proinflammatory cytokines and their correlation with matrix metalloproteinase-3 expression in Behçet's disease. Does interleukin-1beta play a major role in Behçet's synovitis?

The objective of this study has been the well established fact that proinflammatory cytokines and metalloproteinases play a crucial role in the pathogenesis of chronic arthritis as well as the development of pannus, with the eventual erosive changes. Among the proinflammatory cytokines, interleukin-18 (IL-18) has been shown to contribute to the pathogenesis of chronic synovitis by increasing the secretion of interleukin-1beta (IL-1beta) and the tumor necrosis factor-alpha (TNF-alpha) and also stimulating angiogenesis. The aim of this study is to investigate the synovial IL-18, IL-1beta, TNF-alpha and matrix metalloproteinase-3 (MMP-3) levels in patients with Behçet's disease (BD), and compare them with the levels of patients with rheumatoid arthritis (RA) and osteoarthritis (OA). 30 patients with BD, 20 with RA, and 20 with OA were included in the study. The synovial levels of IL-18, IL-1beta, TNF-alpha and MMP-3 were detected using the two-step sandwich ELISA method. The synovial IL-18, TNF-alpha and MMP-3 levels were significantly higher in RA patients than patients with BD (P=0.004, 0.019, 0.025, respectively) and with OA (P=0.004, 0.045, 0.032, respectively). There were no differences, with respect to the cytokine levels, when patients with BD were compared with those with OA. Patients with RA and BD had higher IL-1beta levels than patients with OA (P=0.017, 0.013, respectively). However, no such difference was found for IL-1beta between BD and RA patients. Among patients with RA, positive correlations were found between TNF-alpha and MMP-3 (r=0.683, P=0.001). Our results showed that MMP-3 and proinflammatory cytokines, except IL-1beta, were expressed in relatively small quantities in Behçet's synovitis. Detection of the lower levels of these cytokines and metalloproteinases might explain the non-erosive character of Behçet's arthritis. We suggest that IL-1beta may be involved in the pathogenesis of Behçet's synovitis.

Angiotensin-converting enzyme I/D polymorphism in Behçet's disease

OBJECTIVE

To investigate a potential relationship between I/D polymorphism within intron 16 of the angiotensin-converting enzyme (ACE) gene located on human chromosome 17 and Behçet's disease.

MATERIALS AND METHODS

Genomic DNA was obtained from 35 Turkish patients diagnosed with Behçet's disease according to the International Study Group criteria and 150 healthy individuals. Polymerase chain reaction was used to detect the presence of I and D (insertion and deletion) alleles in intron 16 of the ACE gene in these DNA samples.

RESULTS

We found differences in ACE I/D polymorphism between Behçet's disease and healthy controls (chi2=4.61, d.f.=1, p=0.044). In Behçet's disease patients, the D allele frequency was 84.3% and I allele frequency 15.7%.

CONCLUSION

An association between Behçet's disease and ACE polymorphism may provide a useful basis for future molecular studies and therapeutic approaches in this complex disease.

Morbus Adamantiades-Beh�et

Adamantiades-Behcet's disease (ABD) is a chronic recurrent vasculitis whose aetiology is still unclear. The first description goes back to B. Adamantiades und H. Behcet. The disease mainly occurs in Mediterranean, Middle and Far Eastern countries. However, it is not limited to these regions and can be found worldwide, and, as a result of increasing human mobility, is steadily becoming more significant. Clinical findings reveal recurrent oral and/or genital ulcers, arthritis and skin involvement in the form of erythema nodosum and superficial thrombophlebitis. Relapsing ocular involvement is one of the major manifestations in ABD and can be found in 60-80% of patients, resulting in retinal vasculitis, neuropathy or panuveitis. Eye involvement can lead to blindness in the affected eye in 20-50% of cases. Steroids, cyclosporin A und azathioprin are available to treat affected eyes. Studies of new treatment modalities including interferon-alpha or TNF antibodies are under way.

Behcet's disease

Behcet's disease (BD) is a systemic disorder of recurrent acute inflammation, characterized by major symptoms of oral aphthous ulcers, uveitis, skin lesions and genital ulcers. Involvement of intestines, vessels, and central nervous system (CNS) sometimes leads to a poor prognosis. Patients with BD are known to distribute along the ancient Silk Road. The incidence is relatively higher from eastern Asia to the Mediterranean area as roughly 1-10 patients in 10,000 people, whereas only 1-2 patients in 1,000,000 people in UK and North America. Although etiology of the disease is still unknown, high prevalence of HLA-B51, increased expression of heat shock protein 60 and Th1 dominant immune responses in the patients are considered important in its pathogenesis. Non-infectious neutrophil activation and infection with Streptococcus sanguis and herpes simplex virus would also be associated. Because BD lacks any pathognomonic symptoms and laboratory findings, the diagnosis relies largely upon the criteria proposed by the International Study Group for Behcet's disease in 1990. In Japan, the diagnosis was also made according to the Japanese criteria revised in 1987. Recently, the Behcet's Disease Research Committee of Japan again revised the Japanese criteria in 2003 to avoid overdiagnosis. The new Japanese criteria are introduced in this review. Differential diagnosis excluding Sweet's disease, pemphigus, erythema nodosum and Crohn's disease is important, and positive laboratory data for pathergy test, prick test for dead Streptococci and HLA-B51 are emphasized to make appropriate diagnosis in these criteria. Pathological findings of the disease-affected site such as erythematous nodosum is also stressed. Treatment for the disease has been chosen according to the clinical symptoms. Non-steroidal anti-inflammatory drugs, immunosuppressants, corticosteroids and colchicine are basically introduced. Recently, effects of interferon-alpha/beta, anti-tumor necrosis factor antibody and thalidomide are encouraging, specifically in treatment for the cases with poor prognosis including eye, intestine, vessel and CNS involvement. Low dose weekly administration of methotraxate looks effective for the cases with CNS involvement. Further studies for elucidation of the etiology, improvement of the diagnostic criteria and development of new therapy are needed to conquer the disease.

Involvement of Th1 cells and heat shock protein 60 in the pathogenesis of intestinal Behcet's disease

Involvement of excessive Th1 cell functions and heat shock protein expression in the pathogenesis of Behcet's disease (BD) has been reported. In this study we have characterized immune responses in intestinal lesions of BD. Peripheral blood lymphocytes (PBL) of BD and healthy controls (HC) and tissue specimens of intestinal Behcet's disease (intestinal BD), Crohn's disease (CD) and ulcerative colitis (UC) were analysed for mRNA and protein expression by reverse transcriptase-polymerase chain reaction (PCR) and immunohistochemistry, respectively. PBL of BD patients expressed the Th1-related chemokine receptor, CCR5 and CXCR3 preferentially compared with those of healthy controls. Intestinal lesions of BD expressed interferon (IFN)-gamma, tumour necrosis factor (TNF)-alpha and interleukin (IL)-12 mRNA, indicating Th1 skewed responses in vivo. mRNA of Txk, a Tec family tyrosine kinase specific to Th1 cells, was expressed in the lesions, suggesting its contribution to the Th1-dominant responses. In the intestinal samples, CCR5 was detected in all the cases with BD, whereas Th2-related CCR3 and CCR4 were detected randomly, mainly in the cases with inactive BD and those receiving large amounts of prednisolone, indicating the Th1-dominant immune responses in the intestinal lesions. As the ligands of CCR5, MIP1alpha and MIP1beta were detected, whereas RANTES was not. Heat shock protein (HSP) 60 was expressed in PBL and intestinal tissues of BD. Th1-dominant immune responses and HSP60 expression may induce the inflammatory responses and thus be associated with the pathogenesis of intestinal BD.

Decreased erythrocyte deformability in Behçet's disease

Behçet's disease (BD) is a chronic recurrent systemic vasculitis of unknown cause. Thrombotic tendency is another characteristics of BD. While hemorheological changes play crucial role in thrombosis, erythrocyte deformability (ED), which is one of the main determinants of microcirculation and blood viscosity, has not been studied before in BD. ED was measured by the filtration method in 13 active BD patients diagnosed according to the criteria proposed by International Study Group for BD (ISG-BD) and in 13 age-, sex-, weight-, smoking habit-, and blood pressure-matched healthy controls. ED was decreased in active BD patients compared to the healthy control subjects. The median deformability indices (DIs) in BD patients and healthy controls were 3.19 and 2.08 (p<0.001), respectively. The decrease in ED may be one of the reasons for increased thrombotic tendency in BD. Alteration in ED possibly plays a crucial role in the etiopathogenesis of thrombotic complications in BD and thus may be a target for treatment. Drugs increasing ED, such as pentoxifylline, have already been shown to be beneficial in the treatment of BD. Therefore, we propose that the therapeutic mechanism underlying the beneficial effect of this drug in BD is likely to be the correction of impaired ED.

Behçet's disease

Behçet's disease is a systemic vasculitis characterized by recurrent oral and genital ulcers, and ocular inflammation, and which may involve the joints, skin, central nervous system and gastrointestinal tract. It is most common in those of Mediterranean and Eastern origin, although it also affects Caucasians. The aetiology of the disease remains unknown, but the most widely held hypothesis of disease pathogenesis is that of a profound inflammatory response triggered by an infectious agent in a genetically susceptible host. Supporting this is the consistent association of disease susceptibility with polymorphisms in the human leukocyte antigen complex, particularly HLA-B*51. The diagnosis is a clinical one, and although there is no single laboratory test specific for the diagnosis of Behçet's disease, the 1990 classification criteria perform well in a clinical context. Whereas many favoured treatments for single or multisystem disease still lack a sound evidential base, cyclosporin and azathioprine perform well in clinical trials, and evidence is accumulating for the efficacy of anti-tumour necrosis factor therapy in particular clinical situations. This review will focus on recent developments in the understanding of disease pathogenesis and clinical diagnosis, and review the evidence base for both established and new agents in the therapeutic strategy.

Evidence of chronic Chlamydia pneumoniae infection in patients with Behçet's disease

Behçet's disease is a chronic vasculitis of unknown aetiology. Particular viral and bacterial pathogens have long been suspected of playing a role in the pathogenesis of the disease. Chlamydia pneumoniae is an intracellular bacterium capable of causing chronic infections. Some reports have suggested that the microorganism might be involved in the pathogenesis of vasculitis. The purpose of the present study was to investigate a possible correlation between C. pneumoniae infection and Behçet's disease. For this purpose, 90 consecutive patients with Behçet's disease and 50 healthy controls were enrolled. Immunoglobulin A (IgA) and IgG antibodies to C. pneumoniae were determined by 2 different techniques, namely indirect fluorescent antibody assay (IFA) and enzyme linked immunosorbent assay (ELISA). IgA antibodies to C. pneumoniae were detected in 17 (18.9%) patients with Behçet's disease and in 1 (2%) healthy control by IFA. By ELISA 27 patients (30.0%) and 6 controls (12.0%) had C. pneumoniae IgA. A significant difference was observed for IgA seropositivity between the 2 groups. Although IgG seropositivity between the 2 groups did not differ significantly, the number of individuals with IgG titres of > or = 1:1000 was significantly higher in the patient group (43.1%) compared with the control group (13.9%). These finding provide serological evidence of chronic C. pneumoniae infection in association with Behçet's disease.

[Myelodysplastic syndrome associated with intestinal tract-type Behçet disease characterized by an esophageal ulcer]

A 55-year-old man with advanced myelodysplastic syndrome was hospitalized prior to undergoing an allogeneic bone marrow transplantation. Immediately before hospitalization, he had suffered from phlegmon in both lower extremities and right forearm as well as genital and oral ulcers. After admission, he developed an esophageal ulcer and was thus diagnosed as having intestinal tract-type Behçet disease. HLA-B51 was not present. Within a month, he died of pulmonary hemorrhage associated with pneumonia, possibly because of a low platelet count, and vasculoendothelial damage related to Behçet disease. This is a rare case of myelodysplastic syndrome that developed Behçet disease with a severe esophageal ulcer.

T and NK cell subset changes with microbial extracts and human HSP60-derived peptides in Behçet's disease

OBJECTIVE

Microorganisms such as streptococcus and autoantigens such as 60 kD heat-shock protein (HSP60) are implicated in the etiopathogenesis of Behçet's disease (BD).

METHODS

Peripheral blood mononuclear cells from patients with BD (n = 16) and healthy controls (HC) (n = 11) were cultured for 5 days with extracts of S. sanguis-KTH-1 (SS), E. coli (EC) and a mixed peptide combination from human HSP60 (aa 136-50, 179-97, 224-58 and 336-51) reported to be associated with BD. T and NK cell subset changes were determined by flow cytometry.

RESULTS

In unstimulated 5-day cultures gammadelta+ (both CD4+gammadelta+ and CD8+gammadelta+), CD8+alphabeta+, CD4+CD56+ and CD8+CD11b+ cells were increased in BD compared to HC. In antigen-stimulated cultures of BD patients CD3+ and alphabeta+ T cells responded to HSP60 peptides whereas EC stimulated only CD16/ CD56+ NK cells. In the control group, similar to BD, alphabeta+ and CD4+ T cells responded to HSP60 peptides, however SS and EC mainly activated cytotoxic T cell subsets (CD8+CD11b and CD4+CD56+ T cells).

CONCLUSION

Significant increases in unstimulated T cell subsets suggest the presence of an in vivo T cell activation in BD. In both patients and controls similar patterns of responses were observed against different microorganisms, however the role of human HSP60 peptides as immunodominant, crossreactive antigens could not be demonstrated.

An unusual case of Behçet's syndrome: triggered by typhoid vaccination?

A case of Behçet's syndrome in a 32-year-old woman occurring shortly after her third vaccination against typhoid fever is described. Scleritis and pyoderma gangrenosum were unusual manifestations of BS that occurred in this case. Treatment benefit was provided by mycophenolate mofetil and etanercept. As bacterial antigens have been proposed as potential triggers for the onset of BS, it is possible that the syndrome was precipitated by typhoid vaccination in this patient.

New insights into the pathogenesis and therapy of Behçet's disease

Behçet's disease is a chronic multisystem inflammatory disease characterized by the predominance of Th1 cytokines. The human leukocyte antigen-B 51 gene is associated with the disease in several ethnic groups, but it is not certain whether it is the susceptibility gene or if it is in linkage disequilibrium with other genes. Recent studies of polymorphisms of neighboring, as well as distant, genes to human leukocyte antigen-B 51 are helpful in elucidating the pathogenesis of the disease and could have therapeutic implications.

Central nervous system involvement in connective tissue diseases

Neuropsychiatric manifestations are relatively common and serious complications in systemic lupus erythematosus (CNS lupus). Overall, in patients with CNS lupus, CSF IgM, IgA, IgG indexes (indicators of intrathecal Ig synthesis) as well as CSF IL-6 activities were significantly elevated. Of note, especially in patients lupus psychosis, but not in those with focal CNS lesions, anti-ribosomal P antibody (anti-P) in the sera as well as anti-neuronal antibody (anti-N) in the CSF was significantly elevated in relation to their CNS disease activities. These data indicate that the immune system activation within the CNS, possibly resulting in the elevation of CSF anti-N, plays an important role in the pathogenesis of CNS lupus, including lupus psychosis. CNS involvement in Behçet's disease, usually called neuro-Behçet's syndrome (NB), includes acute type and chronic progressive type. Acute NB is characterized by acute meningoencephalitis with focal lesions, presenting high intensity areas in T2-weightened images or Flare images on MRI scans, whereas chronic progressive NB is characterized by intractable slowly progressive dementia, ataxia and dysarthria with persistent elevation of CSF IL-6 activity. Chronic progressive NB is resistant to conventional treatment with steroid, cyclophosphamide, or azathioprine, but responds to low dose methotrexate. As for ANCA-related vasculitis, pachymeningitis has been found to be associated with P-ANCA as well as C-ANCA.

Review article: oral ulceration--aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic

Oral ulceration is a common complaint of patients attending out-patient clinics. The aim of this review is to provide the gastroenterologist with a differential diagnosis of oral ulceration, and a practical guide for the management of recurrent aphthous stomatitis, including topical and systemic therapy. The association of recurrent aphthous stomatitis with Behçet's disease and other systemic disorders, including coeliac disease, is discussed. Recent evidence concerning the immunopathogenesis of Behçet's disease is reviewed, including renewed interest in the role of Streptococcus sanguis and possible infectious triggering of an inappropriate immunoinflammatory response, resulting in tissue damage. The efficacy and limitations of conventional treatment for this mutisystem disorder are outlined together with the potential role of novel biological agents, such as anti-tumour necrosis factor-alpha therapy. Oral ulceration, as a manifestation of inflammatory bowel disease and a complication of drug therapy, is described. Guidance is given concerning indications for referral of patients with oral ulceration to an oral physician/surgeon for further investigations, including biopsy if appropriate.

Pathogenesis of Adamantiades-Behçet's disease

The aetiology of Adamantiades-Behçet's disease remains unknown and its pathogenesis is not fully understood. Linked intrinsic and extrinsic factors are thought to contribute to the development of the disease, which probably occurs by environmental triggering of a genetically determined disorder. Transmission is solely vertical, indicating that the disease is not contagious. Genetic factors have been investigated and a significant link of HLA-B51, especially of HLA-B5101, has been identified. However, none of the functional correlates of the disease appear to be restricted by HLA-B51. Recently, the role of the genes encoding TNF, Tap proteins and MICA has been emphasised. Extrinsic pathogenetic candidates have been identified, including bacterial ( Streptococcus sanguis, Mycoplasma fermentas) and viral (human herpes virus) antigens and environmental pollution, which may cross-react with oral mucosal antigens and induce immunological mechanisms. A common factor linking some of the possible pathogenetic agents is extrinsically induced tissue stress or heat shock proteins, which react with host tissues and elicit significant Th1 cell responses. Neutrophils may also play a role in the pathogenesis of the disease, as they are attracted by macrophages and activated endothelial cells, which release cytokines and chemokines (especially IL-8) at the site of the lesions, and thus contribute to tissue damage and self maintenance of inflammation. Endothelial activation leading to a chronic local inflammation process together with platelet and serum factors enhance coagulation and thrombosis.

[Prevalence of extrahepatic illnesses in patients with chronic hepatitis b and hepatitis c: retrospective study of 435 patients]

Chronic infections that caused by hepatitis B and C viruses, are important all of the world as a public health problem. Despite intensive control measurements, the incidences of chronic hepatitis B and C virus infections in our country are estimated as 5-7% and 3%, respectively. There are accumulating data of especially autoimmune mediated extrahepatic manifestations of hepatitis B and C virus infections, such as Diabetes Mellitus (DM), Behçet's Disease (BD), hypo- or hyper-thyroiditis and autoimmune diseases. The aim of this study was the retrospective evaluation of 400 chronic B hepatitis (CBH) and 35 C hepatitis (CCH) patients by means of the presence of extrahepatic manifestations. As a result, the positivity rates of extrahepatic manifestations detected in CBH and CCH patients were as follows respectively; 1.5% and 8.5% for DM, 1.5% and 5.7% for hypothyroiditis, 0.75% and 2.8% for hyperthyroiditis, 2% and 20% for nodular goitre, 0.25% and 5.7% for BD, 1% and 0% for systemic lupus, 1% and 5.7% for Rheumatoid Arthritis (RA), and 22% and 11.4% for iron deficiency anemia. DM, thyroid diseases and RA were the most common extrahepatic manifestations detected in both of the patient groups, while the rates of DM, BD and nodular goitre were found higher in CCH patients than CBH patients (p < 0.05). As a result, the extrahepatic manifestations should be carefully followed in patients with chronic hepatitis B and C infections, for an early diagnosis and appropriate treatment.