Successful cord blood stem cell transplantation for myelodysplastic syndrome with Behçet disease

A 10-year-old girl who had been treated as an outpatient for neurofibromatosis type 1 was admitted with fever, 10% weight loss, and abdominal pain that had persisted for 1 month. The clinical manifestations and the results of endoscopy led to the diagnosis of intestinal Behçet disease. Blood cell dysplasia appeared during the hospitalization. The patient subsequently developed blast cells, and the diagnosis of myelodysplastic syndrome (MDS) was made. Behçet disease was first controlled with steroids and diet followed by chemotherapy and cord blood stem cell transplantation (SCT). Both the MDS and Behçet disease went into remission after transplantation. The use of hematopoietic SCT has the potential not only to cure but also to help explicate the mechanism of Behçet disease.

Pseudotumor cerebri: etiological factors, presenting features and prognosis in the western part of Turkey

OBJECTIVES

Pseudotumor cerebri (PC) is a clinical condition characterized by signs and symptoms of increased intracranial pressure, such as headache and papilledema.

MATERIAL AND METHOD

A total of 62 patients diagnosed with PC, who were on follow-up for a period ranging from 4 to 60 months, were investigated retrograde from 1990 to 1998 and then anterograde from 1998 to 2001 to find out the etiological factors, symptoms and signs and the prognosis in the western part of Turkey.

RESULTS

There were 47 (76%) women and 15 (24%) men. The age of onset of symptoms was 32.7 +/- 9.9 (range 18-56) years. Obesity was found in only 17 (30%) of them. There were eight patients (13%) with venous sinus thrombosis causing PC. Five patients (8%) had Behçet's disease. The most common symptom was headache, recorded in 93% of the patients, which was followed by transient visual obscurations (60%). Snellen visual acuity was disturbed in 17 patients (27%) at the initial visit. Visual loss determined by automated perimetry was present in 71% of the cases. Three patients (3%) became blind in both eyes. Of the 62 patients, 41 were on follow-up during the study. Twenty-one (51%) showed regression of the visual field grade, nine patients (22%) worsened and 11 (27%) were stationary.

CONCLUSION

Obesity was not as frequent as reported in western countries but Behçet's disease was found to be a frequent cause. Perimetry was the most reliable method to follow-up the patients.

Plasma homocysteine level and uveitis in Behçet's disease

BACKGROUND

Behçet's disease is a chronic relapsing systemic vasculitis of unknown origin in which orogenital ulceration, skin lesions and uveitis are prominent features. Patients with BD have been recognized to be at greater risk for vascular diseases such as thrombosis and aneurysms. Uveitis in BD is usually accompanied by retinal vaso-occlusive disease.

OBJECTIVE

To investigate the possible role of hyperhomocysteinemia as a prethrombotic disorder in the development of uveitis.

METHODS

The study population consisted of 29 patients with BD (13 males and 16 females with a mean age of 32.3 years, range 21-52) and 24 healthy controls. All patients fulfilled the criteria of the International Study Group for BD. The patients were categorized as having active (n = 8) or inactive disease (n = 11) or only uveitis (n = 10). Plasma fasting homocysteine and C-reactive protein levels were studied in all patients and controls. The fasting homocysteine level was significantly higher in patients with only uveitis than in inactive patients and controls (P = 0.029 and P = 0.26 respectively). It was also higher in patients with active disease compared to healthy controls (P = 0.,001). However, no significant difference was found between homocysteine levels of patients with active or inactive disease (P = 0.69). CRP, as a marker of disease activity, was higher in active BD and in patients with only uveitis than in controls (P = 0.01 and P = 0.001 respectively).

CONCLUSION

Homocysteine may play a role in ocular involvement of BD. Chronic inflammation can induce hyperhomocysteinemia, thereby leading to thrombosis in the retinal vascular bed in a way similar to that recently proposed for the pathogenesis of coronary artery disease.

Current management options in Behçet's disease

Behçet's disease (BD) is a multi-system inflammatory disorder, which causes recurrent oral and genital ulceration, intraocular inflammation and skin lesions. Less commonly, locomotor, vascular, neurological and gastro-intestinal manifestations may occur. The pathophysiology of Behçet's disease is not well understood, but may involve a generalised vascular dysfunction. Although rare in Western Europe, BD can cause significant morbidity and mortality to affected individuals. In this article, we review the clinical features and discuss current management options.

The spectrum of vasculitis in children

The common vasculitides of childhood are more self-limited than those in adults. Clinical evidence suggests that infectious agents may have a significant role in the aetiology of these diseases although exact pathogenic mechanisms are not known. One of the most frequent of such diseases in childhood is Henoch-Schönlein purpura. The controversies regarding the management of gastrointestinal and renal disease and suggested treatments are reviewed. The limitations of current definitions for polyarteritis nodosa are discussed and a new classification tree for this disease is introduced. The definitions and classification criteria for the other major vasculitides encountered in children are also presented. Current treatment protocols for polyartertis nodosa, Wegener's granulomatosis and Behcet's disease are summarized.

Opacification of a hydrophilic acrylic intraocular lens with exacerbation of Behçet's uveitis

Behçet's disease is 1 of the most common causes of uveitis in the Eastern world. Its common ocular complications are uveitis, cataract, and obliteration of retinal vessels. Phacoemulsification with intraocular lens (IOL) implantation in patients with Behçet's disease is known to be a safe procedure. We managed a patient with Behçet's disease who had aggravated uveitis and opacification of a hydrophilic acrylic IOL (ACRL-C160, Ophthalmed) 4 months after cataract surgery. Recalcitrant uveitis despite maximum tolerable medication and IOL opacification with vitreous opacity necessitated an IOL exchange and trans pars plana vitrectomy. After the procedure, the eye became quiescent. However, the visual acuity was 20/200 because of the obliteration of retinal vessels.

[Monoclonal antibody therapy for uveitis]

Uveitis, or intraocular inflammation, is caused by various reasons. Since many of the cases are of unknown origin, non-specific anti-inflammatory therapy is often the only choice for the treatment of uveitis. Furthermore, some of the patients are indeed refractory to every available modality and are suffering from severe visual disturbances. Stronger medicine is needed. Monoclonal antibodies against tumor necrosis factor-alpha, TNF-alpha, are one of the candidates in giving us more opportunities to treat such patients more effectively. We are especially hopeful of its application to refractory Behçet's disease. Its unique adverse side effects, though, should be carefully monitored. On balance, this monoclonal antibody therapy may become the last anchor for treating sight-threatening uveitis in the near future.

Identification of alpha-tropomyosin as a target self-antigen in Behçet's syndrome

Behçet's syndrome is a multi-system inflammatory disease affecting mainly the oral and urogenital mucosa and the uveal tract. The etiology and pathogenesis of Behçet's syndrome are unknown, but autoimmune mechanisms are implicated. We initiated this work to identify self-antigens targeted by patients with Behçet's syndrome. We used patient sera to immuno-blot tissue lysates, and we found that some patients manifest antibodies to a 37-kDa band. The 37-kDa band was detected in extracts of skin, tongue, vagina, muscle and heart but not in brain, kidney, lung, liver, intestine and thymus. In-gel digestion and mass spectrometry revealed the band to be alpha-tropomyosin. Autoimmunity to alpha-tropomyosin can be pathogenic; immunized Lewis rats developed lesions in the uveal tract and skin, with features of Behçet's disease.

[Central nervous system involvement in Behçet's disease]

Central nervous system 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 FLAIR images on MRI scans. Cyclosporin A frequently causes acute NB. Acute NB responds to steroid therapy, and is usually self-limiting. By contrast, chronic progressive NB is characterized by intractable slowly progressive dementia, ataxia and dysarthria with persistent elevation of cerebrospinal fluid IL-6 activity (more than 20 pg/ml). In our series, most patients (approximately 90%) with chronic progressive NB were HLA-B51 positive, and had history of attacks of acute NB prior to the development of progressive neurological symptoms. Chronic progressive NB is resistant to conventional treatment with steroid, cyclophosphamide, or azathioprine. However, recent studies suggest the efficacy of low dose methotrexate in chronic progressive NB.

N-acetyltransferase polymorphism in patients with Behçet's disease

OBJECTIVES

The objective of our study was to investigate the possible role of human arylamine N-acetyltransferase 2 (NAT2) polymorphism in susceptibility to Behçet's disease.

METHODS

Eighty-five patients with Behçet's disease gave their written informed consent to participate in the study. Seven point mutations (G191A, C282T, T341C, C481T, A803G, G590A, G857A) in the NAT2 gene were analysed using polymerase chain reaction/restriction fragment length polymorphism techniques. In addition, each patient received 100 mg dapsone orally to determine their NAT2 phenotype. Dapsone and its metabolite monoacetyl-dapsone were measured in 3-h plasma samples using high-performance liquid chromatography. Subjects with an acetylation ratio (monoacetyl-dapsone/dapsone) less than 0.4 were defined as slow acetylators.

RESULTS

Of 85 patients with Behçet's disease, 54 (63.5%) were identified as genotypically slow acetylators. However, 60% (51 of 85) of patients were diagnosed as slow acetylators according to monoacetyl-dapsone/dapsone ratio. Thus, a low incidence of genotype/phenotype discrepancy (3.5%) was observed in Turkish patients with Behcet's disease. When we compared our results with previous phenotyping and genotyping studies in the Turkish population, frequencies of slow and rapid acetylators were not statistically different in patients with Behçet's disease. The frequency of the *5B allele was found to be slightly higher in patients with Behçet's disease than historic controls (44.7 vs 35.6%, P = 0.039). However, there was no significant difference in the frequency of the overall genotypes and alleles of NAT2 between patients and controls.

CONCLUSION

Although the frequency of the NAT2*5B allele, responsible for slow acetylation, was slightly higher in patients than historic controls, our results failed to show an association between NAT2-acetylator status and risk for developing Behçet's disease.

Atypical Behçet's syndrome in a patient with myelodysplastic syndrome

We report the case of a 67-year-old man with myelodysplastic syndrome (MDS), who presented with fever, painless penile and groin ulcers, as well as oral and esophageal ulcerations, all of which were exquisitely responsive to corticosteroids. Some cases of Behçet's syndrome and MDS have been reported in association with trisomy 8 and HLA B51, with the pathology varying from vasculitis to acute neutrophilic inflammation. Our patient with orogenital ulcers had neither trisomy 8 nor HLA B51. Also lacking were other features typical of Behçet's syndrome, such as uveitis, vasculitis, and central nervous system abnormalities. However, his response to corticosteroids on the initial presentation and subsequent episodes was dramatic. Esophageal ulcerations have not been described in Behçet's syndrome. In this respect, our patient was unique.

Behçet's disease: an update on the pathogenesis

Behçet's disease is a chronic inflammatory disorder of unknown etiology. It has long been postulated that immunological abnormalities, which are possibly induced by microbial pathogens in genetically susceptible individuals, are important in its pathogenesis. Recent findings have both supported the significance of genetic factors and better defined the nature of inflammation in Behçet's disease. Molecular genetic studies have strengthened the primary association of HLA-B51 with Behçet's disease. The exact pathogenic mechanism of the HLA-B51 molecule is still unknown, and its contribution to the overall genetic susceptibility to Behçet's disease is estimated to be less than 20%. Spontaneous and/or induced overexpression of pro-inflammatory cytokines (mainly Th1 type) from various cellular sources seems responsible for the enhanced inflammatory reaction in Behçet's disease, and it may be associated with the genetic susceptibility. An antigen-driven immune response superimposed on this primed-state and induced by heat shock proteins or other peptides from different strains of streptoccocci or other microbial agents has been suggested to trigger manifestations of Behçet's disease. Endothelial activation/injury and the resultant occlusive vasculopathy may also contribute to the tissue damage.

Trisomy 8 involved in myelodysplastic syndromes as a risk factor for intestinal ulcers and thrombosis--Behçet's syndrome

Only 12 myelodysplastic syndrome (MDS) cases with Behçet's syndrome have been previously reported and trisomy 8 was found to have accumulated in all these patients. Five of the cases had complications in the form of multiple intestinal ulcers, which is one of the symptoms of Behçet's syndrome. To investigate the relationship between trisomy 8 and multiple intestinal ulcers in MDS patients, we analyzed 46 MDS cases treated in our hospital over the last decade, and trisomy 8 was observed in eight of them. Three of these cases had complications of both multiple intestinal ulcers and thrombosis, and two cases showed episodes of thrombosis without intestinal ulcers. All these five cases featured trisomy 8, while the other 38 MDS patients without trisomy 8 had no episode of either intestinal ulcer or thrombosis. Two of the three cases suffering from multiple intestinal ulcers were treated with granulocyte-colony stimulating factor (G-CSF), which resulted in aggravation of the symptoms. Although the influence of G-CSF on such symptoms in MDS patients with trisomy 8 remains unclear, it seems advisable to exercise caution in the use of G-CSF when an MDS patient with trisomy 8 has intestinal ulcers or thrombosis.

Ocular attacks after phacoemulsification and intraocular lens implantation in patients with Behçet disease

PURPOSE

To elucidate factors related to ocular inflammatory attacks after cataract surgery, limited to a single procedure of phacoemulsification and intraocular lens implantation, in patients with Behçet disease.

METHODS

This retrospective study included 12 consecutive patients (16 eyes) with Behçet disease, who underwent phacoemulsification and intraocular lens implantation during 4 years from January 1995 to December 1998 at three institutions. Their medical records were reviewed, and factors related to the ocular attacks were analyzed.

RESULTS

Four eyes of 3 patients experienced ocular attacks during 1 year before cataract surgery, while 4 eyes of 4 patients developed ocular attacks during 1 year after the surgery. The development of ocular attacks after cataract surgery was significantly related with the presence of ocular attacks during 1 year before the surgery (p = 0.0286, chi(2) test). The patients' age or gender, the duration of Behçet disease or oral medications for Behçet disease did not show any relationship with the presence or absence of ocular attacks after cataract surgery. The visual acuity improved in all patients after the surgery, including those who developed ocular attacks.

CONCLUSIONS

The experience of ocular attacks during 1 year before cataract surgery is related to postoperative ocular attacks. Despite postoperative ocular attacks, phacoemulsification with intraocular lens implantation is a safe procedure to expect a good visual outcome in patients with Behçet disease.

Behçet disease

Behçet's disease is a multisystem inflammatory disorder of unknown origin, characterized by recurrent oral and genital ulcerations, ocular and cutaneous lesions, arthritis, central nervous system, and vascular disease. There is no pathognomonic laboratory test, but there are clinical criteria to assist in establishing the diagnosis. Behçet's is most common along the Silk Road. It is particularly common among persons who have the HLA-B51 major histocompatibility type. Cutaneous lesions include pustules, erythema nodosum-like lesions, Sweet's-like lesions, pyoderma gangrenosum-ike lesions, and pathergy. The major cutaneous findings may be classified as neutrophilic vascular reactions. There is considerable morbidity resulting from Behçet's disease, most notably a high risk of blindness from ocular involvement. Mortality may occur as a result of neurologic or vascular disease or gastrointestinal perforation.

Intestinal Behçet's disease associated with myelodysplastic syndrome with chromosomal trisomy 8--a report of two cases and a review of the literature

Two cases of intestinal Behçet's disease, which developed in the state of myelodysplastic syndrome with trisomy 8, are presented. Both cases are included in the incomplete type of Behçet's disease, with recurrent aphthous stomatitis, skin lesions, genital ulcers or vascular involvement and punched-out ulcers in the cecum, without ocular involvement. The chromosomal analyses revealed chromosomal abnormalities, including trisomy 8, in both cases. Chromosomal trisomy 8 was shown in all 6 cases with the intestinal Behçet's disease associated with myelodysplastic syndrome reported previously, including our patients. Their histories indicated that myelodysplastic syndrome might have started before the development of intestinal Beçet's disease. Theses findings suggested that chromosomal trisomy 8 might play an important role in the pathogenesis, at least in some groups, of intestinal Behçet's disease.

Behçet's disease

Behçet's disease is a systemic vasculitis of unknown aetiology characteristically affecting venules. Onset is typically in young adults with recurrent oral and genital ulceration, uveitis, skin manifestations, arthritis, neurological involvement, and a tendency to thrombosis. It has a worldwide distribution but is prevalent in Japan, the Middle East, and some Mediterranean countries. International diagnostic criteria have been proposed, however diagnosis can be problematical, particularly if the typical ulcers are not obvious at presentation. Treatment is challenging, must be tailored to the pattern of organ involvement for each patient and often requires combination therapies.

[Behçet's disease: recent findings. Review of the literature]

In this work the author reviews the clinical literature and the pathogenetic hypotheses, with particular attention to the correlations of the HLA, for Behçet disease. Behçet's syndrome is a multisystem disorder presenting with recurrent oral and/or genital ulcerations, chronic relapsing uveitis that may cause blindness, and neurologic impairments. Although it has a worldwide distribution, the Behçet's disease is rare in the Americas and Europe and is more prevalent in Turkey and the Middle and Far East. It affects mainly young adults, with men having more severe disease than women. Behçet syndrome is often diagnosed in late age for the lack of a correct diagnostic protocol and for the different symptoms that can be present. The need to follow the criteria made by the International Group of study on the disease of Behçet is underlined.

Behçet's syndrome

We report our clinical experience of 230 patients referred to the Hammersmith hospital with a working diagnosis of Behçet's syndrome. The pathogenesis, diagnosis and management of the syndrome are discussed.