Fibrinolytic activity and d-dimer levels in Behçet's syndrome

OBJECTIVE

Thrombophlebitis occurs in a third of patients with Behçet's syndrome (BS). The thrombotic tendency in BS has been studied with inconclusive results perhaps due to the inadequate numbers of patients studied during the acute phase of the thrombosis as well as the lack of appropriate diseased controls. We have studied tissue-type plasminogen activator (t-PA) and its inhibitor (PAI-1), and d-dimer levels in BS patients with and without thrombosis both in the acute and chronic phases along with suitable diseased and healthy controls.

METHODS

t-PA and PAI-1 were studied by ELISA and d-dimer by semiquantitative latex agglutination slide test in 30 BS patients without deep vein thrombosis (DVT), 10 BS with acute DVT (ADVT), 25 BS with chronic DVT, 27 with ankylosing spondylitis, 26 diffuse systemic sclerosis, 15 patients with ADVT due to other causes, 10 patients with sepsis, and 23 healthy controls.

RESULTS

The t-PA levels in BS with ADVT were significantly lower than those in patients with ADVT due to other causes (7.4 +/- 6.2 vs. 13.4 +/- 6.3, P = 0.027) while PAI-1 levels did not show significant differences between the groups (P = 0.60). The numbers of patients with d-dimer levels of > or = 0.5 microg/ml in BS with ADVT were similar to those found in patients with ADVT due to other causes (9/10 vs. 14/14).

CONCLUSION

The relatively low t-PA levels point to a defect in fibrinolysis in BS. d-dimer levels are increased in the acute phase of thrombosis in BS.

Anti-Saccharomyces cerevisiae antibodies (ASCA) in Behçet's syndrome

OBJECTIVES

Anti-Saccharomyces cerevisiae antibodies (ASCA) are found in 50-60% of patients with Crohn's disease. Increased as well as normal levels have been reported in Behçet's syndrome (BS). We reassessed the level of IgG and IgA ASCA antibodies in BS and in a group of diseased and healthy controls.

METHODS

Eighty-five patients with BS were studied along with 20 patients with ankylosing spondylitis (AS), 24 with Crohn's disease (CD), 25 with ulcerative colitis (UC) and 21 healthy volunteers. A commercial ELISA kit was used (Inova Diagnostics).

RESULTS

It was only the patients with CD who had significantly higher levels of antibodies compared with the rest of the group (ANOVA: ASCA IgG, p = 0.0001; ASCA IgA, p = 0.0001). 42% of CD, 4% of BS, 4% of UC and 15% of AS patients had a positive IgG+IgA ASCA. There was a significant trend for patients with gastrointestinal (GI) involvement with BS (n = 8) to be more positive for IgG and IgG+IgA ASCA compared to the rest of the patients with BS (n = 77) (Chi-square, IgG, p = 0.02, IgG+IgA, p = 0.001).

CONCLUSION

The rate of positivity of ASCA in BS is comparable to that observed among patients with UC and AS. Patients with BS who have GI involvement may have higher levels of ASCA and this needs to be further studied.

Secondary amyloidosis in progressive systemic sclerosis

Progressive systemic sclerosis (PSS) is a connective tissue disease that may affect many organs, including the kidneys. It is quite rare to see secondary amyloidosis due to PSS. We present a patient with a 9-year history of PSS who developed nephrotic syndrome, and whose renal biopsy was compatible with secondary amyloidosis. He died from massive upper gastrointestinal bleeding caused by oesophageal telangiectasia.

Papulopustular skin lesions are seen more frequently in patients with Behçet's syndrome who have arthritis: a controlled and masked study

OBJECTIVE

To determine the prevalence of acneiform skin lesions (comedones, papules, and pustules) in patients with Behçet's syndrome (BS) with arthritis.

METHODS

Study groups included 44 patients with BS with arthritis (32 men, 12 women, mean (SD) age 37.8 (8.9)), 42 patients with BS without arthritis (31 men, 11 women, mean age 35.5 (6.4)), 21 patients with active rheumatoid arthritis (five men, 16 women, mean age 48.8 (14)), and 33 healthy volunteers (28 men, five women, mean age 40.1 (8.1)). All probands and controls were examined by a rheumatologist and a dermatologist, in a prospective and masked protocol. An ophthalmological evaluation was performed if necessary. Skin lesions, including comedones, papules, and pustules, were counted and scored as 0: absent, 1: 1-5, 2: 6-10, 3: 11-15, 4: 16-20, and 5: >20.

RESULTS

Although there was no significant difference between the four groups in the prevalence of comedones, the number of papules and pustules was significantly higher in patients with BS with arthritis (p=0.0037 for papules and p<0.0001 for pustules) than in the remaining three groups.

CONCLUSION

Acneiform skin lesions (papules and pustules) seem to be more frequent in patients with BS with arthritis. This suggest that the arthritis seen in BS may possibly be related to acne associated arthritis.

A double-blind trial of colchicine in Behçet's syndrome

OBJECTIVE

Colchicine is a widely used treatment for Behçet's syndrome, even though in a previous 6-month controlled study, it was shown to be effective only in controlling erythema nodosum and arthralgias. We reassessed the effect of colchicine in Behçet's syndrome in a study conducted among a larger group of patients for 2 years.

METHODS

We randomized 116 patients with Behçet's syndrome (60 male/56 female), who had active mucocutaneous disease without eye or major organ involvement, to receive either placebo or colchicine (1-2 mg/day, adjusted to body weight) in a double-blind trial for 2 years. The primary outcome measure was the sustained absence of any lesions during treatment (complete response). The secondary outcome measure was the difference in the number of mucocutaneous lesions or arthritic joints between the active drug and placebo arms. Women and men were analyzed separately.

RESULTS

Eighty-four patients (72%; 45 male, 39 female) completed the 24-month study. Kaplan-Meier analyses showed significantly more complete responses in the colchicine treatment group in terms of reduced occurrence of genital ulcers (P = 0.004), erythema nodosum (P = 0.004), and arthritis (P = 0.033) among the women, and reduced occurrence of arthritis (P = 0.012) among the men. The mean numbers of genital ulcers (P = 0.001), erythema nodosum lesions (P = 0.002), and arthritic joints (P = 0.014) among the women were less in the colchicine group, and the mean number of arthritic joints (P = 0.026) among the men was less in the colchicine group. Adverse effects were similar in both groups.

CONCLUSION

Colchicine may be useful for treating some of the manifestations of Behçet's syndrome, especially among women. This might be a reflection of less severe disease among the women.

Anticardiolipin antibodies in Behçet's disease: a reassessment

OBJECTIVE

To assess the frequency and clinical relevance of anticardiolipin antibodies (aCL) in Behçet's disease (BD).

METHODS

IgG, IgM and IgA aCL isotypes were investigated by ELISA in 128 patients with BD, 143 healthy controls and 20 systemic lupus erythematosus (SLE) patients.

RESULTS

The IgA binding index (BI) was slightly elevated in BD compared with healthy controls (120+/-53 vs 107+/-46, P=0.02), whereas IgG and IgM aCL levels were not significantly different (IgG, BD 2.5+/-2.4 G phospholipid (GPL), healthy controls 2.8+/-3.6 GPL, P=0.6; IgM, BD 0.7+/-0.9 M phospholipid (MPL), healthy controls 0.9+/-1.3 MPL, P=0.6). The frequency of aCL positivity was 7% in BD (IgG 0.8%, IgM 1.6%, IgA 4.6%), 50% in SLE and 5.6% in healthy controls. IgA BI was elevated in the HLA-B5-negative group compared with HLA-B5-positive patients (P<0.005). In a literature review, the frequency of aCL was found to be 9.5% in studies from Turkey compared with 25.5% in other series (P<0.0001).

CONCLUSION

These results do not suggest a primary role for aCL in BD. A significantly lower frequency of aCL in Turkish BD patients than in other series indicate that regional determinants, whether environmental or genetic, might also play a role in controlling aCL production in BD.

A reappraisal of amyloidosis in Behçet's syndrome

OBJECTIVE

To evaluate the clinical features and outcome of patients with Behçet's syndrome (BS) and amyloidosis and to assess the associated risk factors.

METHOD

A chart review was done to determine the frequency of amyloidosis in BS among 4000 patients. Data from 14 BS patients with amyloidosis were compared with data obtained from 718 patients with BS without amyloidosis. Multiple stepwise logistic regression analysis was used to assess the risk factors.

RESULTS

All patients with amyloidosis presented with the nephrotic syndrome or significant proteinuria. The mean time to the onset of amyloidosis was 8.1 yr (range 3-15 yr). The mean duration of follow-up after amyloidosis was 3.4 yr (range 1-11 yr). Seven out of 14 patients were alive at the time of the evaluation. Peripheral and pulmonary arterial involvement and arthritis were associated with amyloidosis (P<0.05).

CONCLUSION

Amyloidosis in BS is rare and has a 50% mortality rate at 3.4 yr (range 1-11 yr). Peripheral and pulmonary arterial involvement and arthritis seem to be the strongest predictors of amyloidosis in BS.

Behçet disease

Central nervous system involvement in Behçet disease (BD) may be either parenchymal or nonparenchymal. Abnormal cerebrospinal fluid findings and parenchymal involvement are associated with a poorer prognosis. A self-antigenic role for HLA B51 has been postulated in the pathogenesis of BD. The sibling occurrence rate is 3.6%. Familial aggregation may be more pronounced among pediatric cases compared with adult cases. The importance of inherited coagulation abnormalities in the pathogenesis of BD is not clear. Vasculitis of the vasa vasorum seems to be the major site of pathology in large vessel disease. Even among experts, no consensus exists regarding the optimal approach to treatment. Low-dose thalidomide is effective for the mucocutaneous lesions, but polyneuropathy complicates its prolonged use. Neurologic side effects of cyclosporine A should preclude its use in patients with central nervous system involvement except in unusual circumstances. The heightened inflammatory response of BD patients to simple trauma may lead to postoperative complications, but should not be regarded as a contraindication to surgery.

Intestinal permeability in Behçet's syndrome

OBJECTIVE

To measure the intestinal permeability in patients with Behçet's syndrome (BS) and to compare the results with those obtained from healthy and diseased controls.

METHOD

The study group comprised 34 patients with BS without known gastrointestinal disease. Ten patients with ankylosing spondylitis (AS), 6 with inflammatory bowel diseases (IBD), 17 with systemic lupus erythematosus (SLE), and 15 healthy subjects (HC) constituted the controls. All patients received 100 microCi (3.7 MBq) of chromium-51 EDTA ((51)Cr-EDTA) as a radioactive tracer after a 72 hour abstinence from all drugs. The percentage of the isotope excreted in a 24 hour urinary specimen was the measure of permeability.

RESULTS

The percentage (SD) rate of excretion of (51)Cr-EDTA was 4.6 (2.6) in BS, 6 (2.4) in AS, 5.2 (1. 9) in IBD, 5.56 (1.78) in SLE, and 2.3 (1) in healthy controls. (Analysis of variance: f=6.4, p=0.0002. BS v HC, AS v HC, SLE v HC significant.)

CONCLUSION

The intestinal permeability in BS was significantly more than that seen among the healthy controls. Similar results in all the diseased controls cast doubt on its specificity.

[Effect of levodopa therapy on visual evoked potentials and visual acuity in amblyopia]

Amblyopia represents the most common form of visual impairment in children, affecting approximately 2% of the population. To determine the efficacy of the dopamine agonist levodopa for childhood amblyopia, a double-masked, placebo-controlled randomised study was performed on 32 amblyopic children with central fixation between 4 and 17 years. Subjects received 2 mg/kg levodopa benzeraside or placebo 3 times per day over a 1 week period. Estimates of visual acuity for each eye (Snellen visual acuity) were obtained, and pattern-shift visually evoked potentials (VEP) were examined by an opthalmologist and a neurologist. At the end of dosing regimens, the levodopa group was significantly improved in visual acuity by 1.4 lines and pattern VEP amplitudes. No changes could be detected after placebo administration. One week after the termination of the treatment, Snellen line acuity and pattern VEP amplitude were decreased to pretreatment levels. The transient effect of levodopa points to a long-term treatment with the substance. Our results should therefore encourage further long-term clinical trials investigating the therapeutic potential of levodopa in amblyopia.

Behçet's syndrome. The Cerrahpasa experience. Members of the Behçet's Syndrome Research Centre

Behçet's syndrome (BS) is a systemic vasculitis of unknown etiology. There are several reasons for doubting a primary autoimmune pathogenesis of this condition. Recent information suggests evidence for genetic anticipation. Although there is heightened inflammatory activity, as exemplified by the pathergy reaction, wound healing in BS is normal. BS also runs a more stormy course in adults and in the young. However, the amount of androgen receptors in scrotal skin have not found to be increased. Another unsolved problem is the nature of acne-like lesions and how they differ from acne vulgaris (AV). Only lesions in "non-acne" areas were compared between the two conditions, and no differences were detected. Mortality is increased in BS, especially among males. Azathioprine proved to be effective in disease control after 8 years of follow-up. We have also recently finished a 24 week controlled trial of two doses of thalidomide, 100 mg and 300 mg per day. Both doses were superior to placebo, with no real differences in efficacy, in controlling the oral and genital ulcers.

The management of Behçet's syndrome

Behçet's syndrome (BS), originally described as a triad of oral aphthae, genital ulcerations and uveitis, is a systemic vasculitis that is prevalent in the Middle east, Far East and in the Mediterranean basin. It is characterized by a heightened state of inflammation although the main drive that initiates and sustains this is not yet elucidated. Suppression of this inflammatory state constitutes the major goal of treatment and therapy is tailored according to the specific manifestations observed. We now have considerable more insight on drug management of BS compared to 20 years ago. Particularly, within the recent past we have learned to use more rationally the agents that were already available to us. This is especially true for azathioprine, cyclosporin A, thalidomide and colchicine. Promising data are also being collected with alpha-interferon. With these agents, significant progress has been achieved in the management of uveitis and mucocutaneous symptoms but treatment issues related to thrombotic problems, major vessel involvement and neurological disease have not yet been resolved.

Evaluation of the Turkish translation of a disease activity form for Behçet's syndrome

OBJECTIVE

This study examined the interobserver and intra-observer reliability of the Turkish version of the Behçet's Disease Current Activity Form (BDCAF), which was obtained by a translation and back-translation process.

METHODS

Fifty Behçet's syndrome (BS) patients were assessed by four rheumatologists in separate morning and afternoon sessions.

RESULTS

The results showed good intra- and interobserver agreement for the oro-genital ulcers and eye involvement of BS, but there was poor agreement between (kappa score = 0.14) and within observers (range for kappa scores 0.09-0.25) for their overall impression of disease activity. Individual low kappa scores were also noted for erythema nodosum, vascular involvement, central nervous system involvement and gastrointestinal involvement.

CONCLUSION

These results suggest that the Turkish version of BDCAF may be useful for assessing the classic triad of BS (oro-genital ulceration and eye involvement), but more experience is needed for its other parts.

Masked assessment of MRI findings: is it possible to differentiate neuro-Behçet's disease from other central nervous system diseases? [corrected]

Two neuroradiologists reviewed MRI studies of 34 patients with neuro-Behcet's disease (NBD), 22 with multiple sclerosis (MS) and 7 with systemic lupus erythematosus (SLE) with central nervous system involvement, masked to the clinical diagnosis, age and sex of the patients. Of the patients with NBD 12 were in an acute attack; the others had chronic disease. MRI was assessed using a set of criteria, looking at atrophy, the site of discrete parenchymal lesions, regions of predominant involvement and the extent of the lesion(s). The observers also made a guess at the clinical diagnosis. The brain stem and/or basal ganglia were the most predominantly involved sites in all patients with acute NBD; 75% of these lesions were large and confluent, mainly extending from the brain stem to the diencephalon and basal ganglia. However, in chronic cases, the predominant involvement was in the brain stem and/or basal ganglia in only 36%, and in cerebral hemisphere white matter in another 36%; 27% of these patients showed no parenchymal lesion. Hemisphere white-matter lesions were equally distributed between periventricular and other areas in NBD, while in MS more were periventricular, and in SLE more were nonperiventricular. Brain-stem atrophy was seen in 21% of patients with NBD, with a specificity of 96.5%. In the absence of cortical atrophy, its specificity was 100%. The attempt at making a radiological diagnosis was successful in all cases of acute NBD and 95.5% of patients with MS, but in only 40% of patients with chronic NBD. Most of this latter groups MRI studies were interpreted as MS. An extensive lesion involving the brain stem and basal ganglia seemed to be diagnostic of acute NBD. However, hemisphere white-matter lesions could not be differentiated from those in MS.

Phenotypic characteristics of B cells in Behçet's disease: increased activity in B cell subsets

OBJECTIVE

Increased numbers of spontaneous Ig secreting B cells and elevated immunoglobulin levels have been described in Behçet's disease (BD), in addition to changes in numbers and activities of T cells, natural killer cells, and monocyte-macrophages. We investigated other characteristics of B cells in BD.

METHODS

B lymphocyte subsets (CD19+CD5+, CD19+CD13+, CD19+CD28+, CD19+CD33+, CD19+CD80+, CD5+CD19+CD45RA+, CD5+CD19+CD45RO+) were phenotypically evaluated in 50 patients with BD, 80 healthy subjects, and 20 other patients with rheumatoid arthritis (RA), systemic lupus erythematosus (SLE), and sepsis.

RESULTS

Although the B cell number (CD19+) was normal, CD13 and CD33 positive B cells were more numerous in BD and sepsis compared to healthy controls and patients with RA and SLE. The percentage of CD45RO positive B cells was higher in both BD and sepsis, while the percentage of CD80 positive B cells was high only in BD. There was no increase in the CD5+CD19+ B cell subset, previously shown to be increased in several autoimmune diseases. Naive (CD45RA) and memory (CD45RO) status of CD5+CD19+ and CD5-CD19+ B cells showed that CD45RA expression was higher in CD5+CD19+ B cells, whereas expression of both CD45RA and CD45RO was higher in the CD5-CD19+ B cell group compared with healthy controls.

CONCLUSION

Although the total B cell number was normal, increased levels of activated and memory B cell subsets suggest a modified B cell function in BD, which may be related to a weak stimulus by an unknown external antigen.

Behçet's syndrome

There have not been any breakthroughs in understanding of the pathogenesis of Behçet's syndrome within the past year. We still do not know the meaning of the HLA-B51 association. The role of T cells in pathogenesis is still undefined, and it is not yet clear whether an extrinsic antigen or antigens produces the disease. Likewise the role of the neutrophil in pathogenesis is under scrutiny. More pediatric cases are being described. We are beginning to have a better understanding of central nervous system involvement, the prime pathology of which might not be vasculitis. Azathioprine, not a panacea, is nevertheless effective for long-term management. Thalidomide has clearly been shown to be effective in mucocutaneous disease even at a dose of 100 mg/d. However, relapses are seen with cessation of therapy.

Fibromyalgia in Behçet's syndrome

OBJECTIVE

To ascertain the frequency of fibromyalgia (FM) in Behçet's syndrome (BS) and to evaluate the relationship of FM to Behçet's disease activity.

METHOD

Self-questionnaires were completed by 108 patients with BS. Each patient was evaluated by an observer blinded to diagnosis; evaluation included assessment of tender points by palpation. Another observer determined the disease activity of patients at that time.

RESULTS

Ten of 108 patients (9.2%) met the American College of Rheumatology criteria for FM. Nine of the patients who met the criteria for FM were women. In contrast to patients without FM, patients with FM had mild to moderate disease activity in which musculoskeletal complaints were common.

CONCLUSION

There is a trend for an increased frequency of FM in female BS patients.

A case of rapidly progressive pulmonary aneurysm as a rare complication of Behçet's syndrome--a case report

One of the severe complications of Behçet's syndrome is pulmonary arterial involvement. The authors report a patient with Behçet's syndrome who had the complications of multiple pulmonary arterial aneurysms presenting with hemoptysis and right ventricular thrombus. He underwent emergency surgery because of failure of intensive immunotherapy and died 2 months after the surgery.

Clinical features of Behçet's disease in children: an international collaborative study of 86 cases

OBJECTIVES

The objective of this study was to characterize the clinical picture of Behçet's disease (BD) in children.

STUDY DESIGN

A questionnaire was completed by five BD specialists from Turkey, France, Iran, or Saudi Arabia. We first reviewed 86 cases retrospectively with a specially designed computerized database and then selected 65 who met the criteria of the International Study Group for BD, which include buccal aphthosis plus at least two among recurrent genital aphthosis, eye lesions, skin lesions, and positive pathergy test. The remaining 21 patients, who had features suggestive of BD but did not fulfill the international criteria, were analyzed separately and then compared with the other 65 patients.

RESULTS

BD affected boys and girls equally. The clinical picture frequently included mucocutaneous lesions. Uveitis was less frequent than in adults but carried a poor prognosis, especially in male patients (p < 0.001). The mortality rate (3%) was related to large vessel involvement. Familial cases were particularly frequent (15%). Erythema nodosum and skin hypersensitivity were common in Turkish patients, whereas neuro-BD was more frequent in French and Saudi Arabian patients. Patients who did not fulfill the international criteria had significantly less genital aphthosis (p < 0.01), less skin lesions or hypersensitivity (p < 0.01), and less uveitis (p < 0.01).

CONCLUSION

BD in children is similar to BD in adults. The high frequency of familial cases calls for further investigation of the immunogenetic factors that may favor early expression of the disease.

Thalidomide in the treatment of the mucocutaneous lesions of the Behçet syndrome. A randomized, double-blind, placebo-controlled trial

BACKGROUND

Recurrent oral and genital ulcers are the most frequent problem in the management of the Behçet syndrome. Uncontrolled experience suggests that thalidomide may help prevent recurrences of these ulcers.

OBJECTIVE

To determine the efficacy of two thalidomide dosages in the treatment of mucocutaneous lesions of the Behçet syndrome.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Specialist outpatient clinic for the Behçet syndrome in Turkey.

PATIENTS

96 male patients with the Behçet syndrome who primarily had mucocutaneous lesions without major organ involvement.

INTERVENTION

Thalidomide, 100 mg/d or 300 mg/d, or placebo for 24 weeks.

MEASUREMENTS

Sustained absence of any oral and genital ulceration during treatment (complete response) and changes in the number of mucocutaneous lesions. An additional evaluation was done 4 weeks after treatment ended.

RESULTS

A complete response occurred in 2 of the 32 patients (6% [95% CI, 0.8% to 20.8%]) receiving thalidomide, 100 mg/d; in 5 of the 31 patients (16% [CI, 5.5% to 33.7%]) receiving thalidomide, 300 mg/d; and in none of the 32 patients (0% [CI, 0% to 10.9%]) receiving placebo (P = 0.031). The suppressive effect of thalidomide with either dosage was evident at 4 weeks for oral ulcers (P < 0.001) and at 8 weeks for genital ulcers (P < 0.001) and follicular lesions (P = 0.008). This effect persisted during treatment but diminished rapidly after treatment was discontinued. Both thalidomide dosages led to significant increases in the number of erythema nodosum lesions during the first 8 weeks of treatment (P = 0.03). Polyneuropathy developed in 4 patients (1 in the 100-mg/d group and 3 in the 300-mg/d group); in 3 of these patients, the condition was diagnosed after the trial had ended.

CONCLUSIONS

Thalidomide is effective for treating the oral and genital ulcers and follicular lesions of the Behçet syndrome. A dosage of 100 mg/d is as effective as a dosage of 300 mg/day.

Wound healing in Behçet's syndrome

BACKGROUND

Because there is an increased inflammatory response to trauma, particularly of the skin, in patients with Behçet's syndrome (BS), an alteration in wound healing in BS is expected. The aim of this study was to investigate the healing features of punch biopsy wounds in BS and acne vulgaris (AV) patients used as controls.

METHOD

Full-thickness skin punch biopsies (4 mm) were taken from the hairless sites of the non-dominant forearms in 20 BS and 20 AV patients. Each patient was examined on days 1, 2, 3, 4, 5, 8, and 10, and the biopsy wound area and induration were marked on sterile glass slides. Other inflammatory changes, such as suppuration and pain, were also recorded. No antiseptic solutions or ointment, except saline, were used.

RESULTS

The wound area healed similarly in both groups (p > 0.05). Thirteen (65%) BS patients had erythematous haloes around the wound on the first day. The number of patients presenting inflammatory changes reached 18 (90%) on the second day in the BS group. The area of erythema around the wound in BS patients was significantly greater than that in AV patients (5; 25%). It gradually decreased day by day. Purulent changes were observed in four BS patients on day 1, and induration around the biopsy wound in six patients on day 2. Only one patient with AV had suppuration, which appeared on the second day, while no AV patient displayed induration.

CONCLUSION

Biopsy-induced trauma may cause increased inflammation in BS, but wound healing is not altered.