Cranial MRI in Beh�et?s disease: 134�examinations of 98�patients

Clinical Immunology Review Series: an approach to the patient with recurrent orogenital ulceration, including Behçet's syndrome

Patients presenting with recurrent orogenital ulcers may have complex aphthosis, Behçet's disease, secondary complex aphthosis (e.g. Reiter's syndrome, Crohn's disease, cyclical neutropenia) or non-aphthous disease (including bullous disorders, erythema multiforme, erosive lichen planus). Behçet's syndrome is a multi-system vasculitis of unknown aetiology for which there is no diagnostic test. Diagnosis is based on agreed clinical criteria that require recurrent oral ulcers and two of the following: recurrent genital ulcers, ocular inflammation, defined skin lesions and pathergy. The condition can present with a variety of symptoms, hence a high index of suspicion is necessary. The most common presentation is with recurrent mouth ulcers, often with genital ulcers; however, it may take some years before diagnostic criteria are met. All patients with idiopathic orogenital ulcers should be kept under review, with periodic focused assessment to detect evolution into Behçet's disease. There is often a delay of several years between patients fulfilling diagnostic criteria and a diagnosis being made, which may contribute to the morbidity of this condition. Despite considerable research effort, the aetiology and pathogenesis of this condition remains enigmatic.

Cerebral infarct in pediatric neuro-Behçet's disease

Behçet's disease is a multisystem inflammatory vasculitic disorder with a chronic course for which the etiology is unknown. The central nervous system can be affected in 5% to 30% of all Behçet patients, yet it has been rarely reported in children or in Western countries. We describe a 14-year-old girl with Behçet's disease that presented initially as a cerebral infarct without venous sinus thrombosis.

[Acute meningoencephalitis revealing a Behçet's disease]

We report a 69-year-old man admitted in intensive care unit for aseptic meningoencephalitis. Initially, suspicion of an infectious etiology led to introduce an anti-infectious treatment. Behçet's disease was diagnosed during hospitalization incited to screen for noninfectious etiologies. A high dose steroid therapy was rapidly effective. The diagnosis of neuro-Behçet's disease was entertained.

Comparison of the clinical manifestations, brain MRI and prognosis between neuroBeçhet's disease and neuropsychiatric lupus

BACKGROUND

Neuropsychiatric systemic lupus erythematosus (NPSLE) shows some similarities to neuroBeçhet disease (NBD) in that both conditions have some analogous clinical features and they are both pathologically associated cerebral vasculopathy. This study compared the clinical manifestations, brain MRI findings and prognosis of NPSLE and NBD patients.

METHODS

Forty three patients with NPSLE (n = 25) or NBD (n = 18), who were monitored at a single center, were enrolled in this study. We retrospectively analyzed the clinical and brain MRI data. The neuropsychiatric manifestations were classified in both groups according to the new American College of Rheumatology nomenclature for NPSLE.

RESULTS

The diffuse symptoms that included mood disorders, psychosis, confusion, cognitive dysfunctions, generalized seizures and headaches other than migraine or cluster headaches were more commonly observed in the NPSLE patients, while the frequency of focal diseases such as cranial neuropathy tended to be higher in the NBD patients. The brain MRI revealed that the NBD patients had more abnormalities in the brain stem than did the NPSLE patients. Most of the patients improved, at least partially, after being treated with glucocorticoid and/or immune suppressants. However, the disease course differed significantly between the two groups. There were more episodic cases in the NPSLE group of patients, while there were more remittent cases in the NBD group of patients.

CONCLUSION

NPSLE had a tendency to cause diffuse neuropsychiatric manifestations, and it has a different predilection of brain lesions compared with NBD. The NBD patients showed a poorer outcome than did the NPSLE patients, suggesting that different therapeutic strategies for the two diseases need to be considered.

Clinical characteristics and course of spinal cord involvement in Behçet's disease

Parenchymal neurological involvement in Behçet's disease (p-NBD) usually presents with a brainstem syndrome; occasionally spinal cord may also be involved. Files of patients with Behçet's disease and spinal cord involvement were reviewed retrospectively, in comparison with other types of p-NBD. Amongst 216 patients with p-NBD, 24 had spinal cord involvement (11%). Most commonly patients presented with sensory-motor symptoms, sphincter and/or sexual dysfunction evolving over days. Four of 10 patients showed single or multiple cervical and/or dorsal lesions on spinal MRI's and one showed dorsal atrophy. Although the clinical picture was variable, it tended to be severe; seven cases had primary progressive course, 11 cases had a secondary progressive course after initial attack(s), four had attacks with severe residual sequela and two had improvement after attacks. After a median follow-up period of 67 months, eight were independent and 14 were dead or dependent, whereas amongst the remaining patients with p-NBD, 113 patients were independent and 56 patients were dead or dependent (P < 0.05). Our study suggests that spinal cord involvement has even worse prognosis compared with other types of p-NBD. Therefore, recognition of spinal cord involvement in Behçet's patients should prompt early vigorous treatment.

A possible variant of neuro-Behçet disease presenting chronic progressive ataxia without mucocutaneo-ocular symptoms

Behçet disease (BD) is a chronic relapsing multisystem disorder of unknown etiology, which preferentially affects the oral and genital mucous membranes, skin, and eyes. Neurological involvement is one of the most serious manifestations of BD, known as neuro-Behçet disease (NBD). We here describe clinical, radiological, and neuropathological findings for two patients with a possible variant of NBD, who manifested progressive ataxia in the absence of mucocutaneo-ocular signs characteristic for BD. Both patients presented a slowly progressive cerebellar phenotype, accompanied by behavioral changes and sphincter disturbance. Brain MRI scan revealed mild atrophy in pons and cerebellum. Both patients showed a mild CSF pleocytosis, and were positive for HLA-B51. The post-mortem examination performed in one patient, showed widespread foci of chronic encephalitis, consistent with the diagnosis of NBD. Steroid pulse therapy was effective in one patient. Identifying the progressive ataxia phenotype of NBD without mucocutaneo-ocular symptoms is important, because these patients may benefit from early steroid therapy.

Neuro-behçet’s syndrome: Differential diagnosis and management

Behçet's syndrome (BS) is a multisystem disease of unknown etiology, characterized by chronic relapsing cardinal symptoms of orogenital ulcers, uveitis, and different skin lesions. Its major pathologic feature is vasculitis. Neuro-Behçet's syndrome (NBS) is defined as a constellation of neurologic manifestations with characteristic neuropathologic findings, usually confirmed by ancillary investigations, in patients who meet the diagnostic criteria for BS. Neurologic manifestations of the syndrome are more common in male patients and have been reported to occur in anywhere from 5% to 50% of BS patients, depending on their geographical region. NBS primarily affects the central nervous system and includes parenchymal and nonparenchymal involvement. Peripheral neuropathy and myopathy are rare. Immunosuppression is widely used for treatment.

Neurological involvement in North Italian patients with Behçet disease

The aim of this study was to evaluate neurological involvement in a series of 110 North Italian patients with Behçet disease (BD), a multisystemic vasculitis of unknown origin, followed up for a period of 5 years. During this time, 27 (24.5%) patients with neuro-BD were identified. Twenty out of 27 showed at least one acute attack in their clinical course. In 14 of them, a neurological evaluation was carried out during the attack. The other 13 patients were evaluated during a remission phase. The onset of neuro-BD was usually characterized by an acute attack with motor symptoms (66.6%) and behavioural/cognitive changes (47.6%), while headache was more frequent in the remission phase (76.9%). On magnetic resonance imaging, large brain-stem/diencephalon lesions were usually seen during the attack. In the remission phase, they were often located in the white-matter. Aspecific cerebrospinal fluid abnormalities were usually seen during the attacks. Cerebrospinal fluid analysis together with radiological and clinical features seems to be useful for the differential diagnosis in these patients.

Blood-tinged Stools and Blood-shot Eyes

A 37-year-old woman developed red painful eyes, diarrhea, and painful oral and genital ulcerations. Optic disk swelling was noted bilaterally. Colonoscopy was significant for granulomatous lesions consistent with Crohn disease. Epidemiologic factors, diagnostic criteria, and differentiating characteristics for Behcet disease and Crohn disease are discussed.

Central nervous system manifestations of rheumatologic diseases

PURPOSE OF REVIEW

To summarize the current literature on central nervous system manifestations of vasculitides and connective tissue diseases.

RECENT FINDINGS

There have been advances in understanding the mechanisms behind the initiation and perpetuation of inflammatory processes in vasculitic neuropathy. Clinically relevant data have been obtained on the predictive criteria for a positive biopsy result in giant cell arteritis, the imaging characteristics of primary angiitis of the central nervous system, and Behçet disease, and the clinical and radiologic features of neuro-Behçet disease. There is more clarity about the central nervous system syndromes attributable to systemic lupus erythematosus and new insights into the central mechanisms involved in the manifestations of Sjögren syndrome and rheumatoid arthritis. Novel immunomodulatory agents, such as infliximab, have shown some benefit in rheumatoid vasculitis and Sjögren syndrome.

SUMMARY

A better understanding of the clinical, radiographic, and serologic characteristics of various central nervous system complications of rheumatologic diseases has been gained in the past year. Recent advances in understanding the pathophysiology of peripheral nervous system complications and their treatment may affect the management of the central nervous system complications.

Migraine and Cerebral White Matter Lesions

BACKGROUND

Patients with migraine are at an increased risk for white matter lesions, typically multiple, small, punctate hyperintensities in the deep or periventricular white matter, best observed on magnetic resonance imaging utilizing T2-weighted or FLAIR sequences. The underlying pathogenesis of white matter lesions in migraineurs is unknown, and the lesions are usually nonspecific and of unclear clinical significance.

REVIEW SUMMARY

Often the presence of white matter lesions causes uncertainty for physicians and anxiety for patients and may lead to a variety of diagnostic tests and treatments. Occasionally, white matter lesions may represent a secondary cause for headaches such as CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). CADASIL is underrecognized and underdiagnosed; it should be suggested by (i) 1 or more of recurrent subcortical ischemic strokes (especially before age 60 and in the absence of vascular risk factors), migraine (especially with aura, including atypical or prolonged auras) and/or early cognitive decline or subcortical dementia; (ii) bilateral, multifocal, T2/FLAIR hyperintensities in the deep white matter and periventricular white matter with lesions involving the anterior temporal pole, external capsule, basal ganglia, and/or pons; and (iii) an autosomal-dominant family history of migraine, early-onset stroke, or dementia. The clinical spectrum of CADASIL is broad, and there is a poor genotype-phenotype correlation. In certain individuals or families, migraine may be the only clinical manifestation.

CONCLUSIONS

While the prevalence of nonspecific white matter lesions in migraineurs is increased, the white matter lesions may occasionally represent a secondary cause for headache such as CADASIL. Greater awareness of the unique clinical, neuroimaging, and pathologic features, as well as the availability of diagnostic genetic testing, should enhance the recognition and diagnosis of this fascinating condition.