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Abstract
Systemic vasculitides frequently affect the pulmonary vasculature. As the signs and symptoms of pulmonary vasculitis are variable and nonspecific, diagnosis and treatment represent a real challenge. Vasculitides should be given consideration, as these diseases present severe manifestations of rapidly progressing pulmonary disease. Examining other organs usually affected by vasculitides (e.g., the skin and kidneys) and determining autoantibody levels are essential to a better management of the disease. A radiological study would also contribute to establishing a diagnosis. The lungs are commonly involved in small-vessel vasculitis, anti-glomerular basement membrane disease, and vasculitides associated with antineutrophil cytoplasmic antibodies. Associated life-threatening diffuse alveolar haemorrhages and irreversible damage to other organs-usually the kidneys-are severe complications that require early diagnosis. Vasculitides are rare diseases that affect multiple organs. An increasing number of treatments-including biological agent-based therapies-requiring cooperation between specialists and centers have become available in the recent years. In the same way, clinicians should be familiar with the complications associated with immunosuppressive therapies.
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Affiliation(s)
| | | | | | | | | | - Luis Valdés
- Interdisciplinary Research Group in Pneumology, Institute of Sanitary Research of Santiago de Compostela (IDIS), Santiago de Compostela, Spain
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52
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Efficacy of anti-TNF alpha in severe and refractory major vessel involvement of Behcet's disease: A multicenter observational study of 18 patients. Clin Immunol 2018; 197:54-59. [PMID: 30125675 DOI: 10.1016/j.clim.2018.08.004] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 07/16/2018] [Accepted: 08/13/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To describe the outcome and tolerance in patients treated with anti-TNFα in severe and refractory major vessel disease in Behçet's disease (BD). METHODS A multicenter study evaluating 18 refractory BD patients with major vessel involvement [pulmonary artery (n = 4), aorta (n = 4) or peripheral artery aneurysm (n = 1) and/or pulmonary artery (n = 7), inferior vena cava (n = 5), or intra-cardiac (n = 3) thrombosis or Budd Chiari Syndrome (n = 2)] treated with anti-TNFα agents. RESULTS Vascular remission was achieved in 16 (89%) patients. The 9 months risk of relapse was significantly higher with conventional immunosuppressants used prior anti-TNFα agents as compared to anti-TNFα therapy [OR = 8.7 (1.42-62.6), p = 0.03]. The median daily dose of corticosteroids significantly decreased at 12 months. Side effects included infection (n = 4) and pulmonary edema (n = 1). CONCLUSION TNFα-antagonists are safe and might be associated with a decreased risk of relapse at 9 months compared to conventional immunosuppressants in BD patients with major vessels disease.
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53
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Ozguler Y, Leccese P, Christensen R, Esatoglu SN, Bang D, Bodaghi B, Çelik AF, Fortune F, Gaudric J, Gul A, Kötter I, Mahr A, Moots RJ, Richter J, Saadoun D, Salvarani C, Scuderi F, Sfikakis PP, Siva A, Stanford M, Tugal-Tutkun I, West R, Yurdakul S, Olivieri I, Yazici H, Hatemi G. Management of major organ involvement of Behçet’s syndrome: a systematic review for update of the EULAR recommendations. Rheumatology (Oxford) 2018; 57:2200-2212. [DOI: 10.1093/rheumatology/key242] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- Yesim Ozguler
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Pietro Leccese
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza and Matera, Italy
| | - Robin Christensen
- Bispebjerg and Frederiksberg Hospital, Musculoskeletal Statistics Unit, The Parker Institute, Copenhagen, Denmark
- Department of Rheumatology, Odense University Hospital, Copenhagen, Denmark
| | - Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Dongsik Bang
- Department of Dermatology, Catholic Kwandong University International St Mary’s Hospital, Incheon, Korea
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Aykut Ferhat Çelik
- Division of Gastroenterology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Farida Fortune
- Centre for Clinical and Diagnostic Oral Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, London, UK
- The London Behçet’s Centre, Barts Health London, London, UK
| | - Julien Gaudric
- Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Ahmet Gul
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ina Kötter
- Asklepios Clinic Altona, Department of Rheumatology, Immunology and Nephrology, Hamburg, Germany
| | - Alfred Mahr
- Department of Internal Medicine, Hospital Saint-Louis, Paris, France
| | - Robert J Moots
- National Behcet’s Syndrome Centre of Excellence, Aintree University Hospital, Liverpool, UK
| | - Jutta Richter
- Institute for Haematopathology Hamburg, Hamburg, Germany
| | - David Saadoun
- Department of Inflammation-Immunopathology-Biotherapy, Sorbonne Universités, UPMC Univ Paris 06, Paris, France
- INSERM, Paris, France
- CNRS, Paris, France
- Department of Internal Medicine and Clinical Immunology, Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Modena and Reggio Emilia, Italy
| | | | - Petros P Sfikakis
- First Department of Propaedeutic and Internal Medicine & Rheumatology Unit, National Kapodistrian University of Athens Medical School, Athens, Greece
| | - Aksel Siva
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Miles Stanford
- Department of Ophthalmology, St Thomas’ Hospital, London, UK
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Richard West
- Member of the UK Behcet’s Syndrome Society and Director of Behcets International, Patient Research Partner, London, UK
| | - Sebahattin Yurdakul
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ignazio Olivieri
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza and Matera, Italy
- Basilicata Ricerca Biomedica (BRB) Foundation, Potenza and Matera, Italy
| | - Hasan Yazici
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
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54
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Tuzun H, Seyahi E, Guzelant G, Oz B, Batur S, Demirhan O, Hamuryudan V. Surgical Treatment of Pulmonary Complications in Behçet's Syndrome. Semin Thorac Cardiovasc Surg 2018; 30:369-378. [PMID: 30031945 DOI: 10.1053/j.semtcvs.2018.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2018] [Accepted: 07/11/2018] [Indexed: 11/11/2022]
Abstract
We described disease characteristics, management and outcome of a group of Behçet's syndrome (BS) patients who underwent pulmonary lobectomy, segmentectomy or various pleura interventions for complications due to pulmonary artery or descending aorta involvement. There were 9 patients with BS (8 M/1 F; mean age: 24.8 ± 7.5 and mean disease duration: 4.3 ± 3.8 years) who underwent lung surgery from 2000 to 2017. Their medical files including operation details and radiological and pathological studies were reviewed retrospectively. Lobectomy was done in 6 patients, decortications and pleura interventions in the remaining 3. The reason for the surgical procedures were giant pulmonary arterial aneurysms refractory to the medical treatment (n = 4), pneumothorax due to large cavities (n = 2), pleural effusions refractory to the medical treatment (n = 1), a bronchopleural fistula after embolization (n = 1) and bronchiectasis (n = 1). All patients received medical treatment with cyclophosphamide and corticosteroids before the surgical interventions. The histological examination in patients with pseudo-aneurysms showed destruction of medial elastic fibers, inflammatory cell infiltration of adventitial tissues and penetration into the adjacent bronchi with adherent thrombi. Two patients died: one due to Budd-Chiari syndrome 1 year after the surgery, another because of a massive hemoptysis 3 months after lobectomy. The remaining 7 patients are still alive with a median follow-up of 8 years (inter-quartile range [IQR]: 4-11). Lobectomies in BS patients with giant pulmonary aneurysms refractory to medical treatment can be done with favorable outcome. Also, complications such as large cavities causing pneumothorax, refractory pleural effusions, bronchiectasis, and embolization complications can be managed effectively with surgical interventions.
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Affiliation(s)
- Hasan Tuzun
- Department of Cardiovascular Surgery, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey.
| | - Emire Seyahi
- Division of Rheumatology, Department of Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - Gul Guzelant
- Division of Rheumatology, Department of Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - Buge Oz
- Department of Pathology, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - Sebnem Batur
- Department of Pathology, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
| | - Ozkan Demirhan
- Department of Cardiothoracic Surgery, Istanbul Bilim University, Turkey
| | - Vedat Hamuryudan
- Division of Rheumatology, Department of Medicine, Cerrahpasa Medical Faculty, University of Istanbul, Istanbul, Turkey
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55
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Serious Coronary Thrombosis and Pulmonary Artery Thrombosis Revealing Behçet's Disease. Arch Rheumatol 2018; 33:85-88. [PMID: 29900996 DOI: 10.5606/archrheumatol.2018.6383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 05/02/2017] [Indexed: 11/21/2022] Open
Abstract
Behçet's disease is a multisystem inflammatory disorder. Cardiovascular involvement is rare but may present with various manifestations, resulting in high mortality. In this article, we report a young male who had chest pain accompanied by systemic involvement, and was diagnosed of Behçet's disease with serious pulmonary artery and coronary thrombosis by systemic check-up. Finally, the patient was successfully treated with a combination of prednisone and immunosuppressive agents instead of surgery. To our knowledge, this is the first report of concurrent coronary thrombosis and pulmonary artery thrombosis in Behçet's disease patients.
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56
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Voiriot G, Parrot A, Antoine M, Gibelin A, Haddad S, Carette MF, Fartoukh M, Khalil A. Transcatheter embolotherapy of pulmonary artery aneurysms as emergency treatment of hemoptysis in Behcet patients: experience of a referral center and a review of the literature. Intern Emerg Med 2018. [PMID: 29516432 DOI: 10.1007/s11739-018-1817-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Hemoptysis is a life-threatening complication of Behcet's disease that is likely related to pulmonary artery aneurysm (PAA). Vascular interventional radiology may offer effective emergency therapeutic option, but has not been thoroughly investigated in this setting. A case series of a French referral center for hemoptysis combined with a literature review of case reports was conducted. Between 1995 and 2016, 12 patients were referred to our center for hemoptysis revealing or complicating the course of Behcet's disease. Pulmonary artery aneurysm (PAA) was the mechanism of hemoptysis in ten patients, nine of whom were treated by a transcatheter embolotherapy. Combining an additional 8 case reports from the literature, 17 patients treated by transcatheter embolotherapy for PAA were analyzed. The duration of the course of Behcet's disease was 22 months [IQR 3-45] at the time of PAA diagnosis. Transcatheter embolotherapy of PAA was successful for immediately controlling hemoptysis in all patients, without major complication except for one. Hemoptysis recurred in seven patients (41%) within 5 months [IQR 1-12]. The use of coils for transcatheter embolotherapy was associated with hemoptysis recurrence. A bronchosystemic hypervascularization related to the previously occluded PAA was the main mechanism of bleeding recurrence, leading to bronchosystemic artery embolization in four patients and surgery in two patients. Behcet's disease-related hemoptysis is mainly due to PAA. Transcatheter embolotherapy should be considered as the first-line emergency treatment for PAA-related hemoptysis, in association with the immunosuppressive regimen. Hemoptysis may recur in half of the cases, involving preferentially a bronchosystemic arterial mechanism.
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Affiliation(s)
- Guillaume Voiriot
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France.
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est, Créteil, France.
| | - Antoine Parrot
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France
| | - Martine Antoine
- Service d'Anatomie et Cytologie Pathologiques, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Aude Gibelin
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est, Créteil, France
- Faculté de Médecine, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Samuel Haddad
- Service de Radiologie, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Marie-France Carette
- Faculté de Médecine, Université Pierre et Marie Curie Paris VI, Paris, France
- Service de Radiologie, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
| | - Muriel Fartoukh
- Service de Réanimation Médico-chirurgicale, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, 4, rue de la Chine, 75020, Paris, France
- Groupe de Recherche Clinique CARMAS, Faculté de Médecine, Université Paris Est, Créteil, France
- Faculté de Médecine, Université Pierre et Marie Curie Paris VI, Paris, France
| | - Antoine Khalil
- Service de Radiologie, Hôpital Tenon, Hôpitaux Universitaires Est Parisien, Assistance Publique-Hôpitaux de Paris, Paris, France
- Service de Radiologie, Hôpital Bichat Claude Bernard, Hôpitaux Universitaires Paris Nord Val de Seine, Assistance Publique-Hôpitaux de Paris, Paris, France
- Faculté de Médecine, Université Paris Diderot Paris VII, Paris, France
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57
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Salmaninejad A, Gowhari A, Hosseini S, Aslani S, Yousefi M, Bahrami T, Ebrahimi M, Nesaei A, Zal M. Genetics and immunodysfunction underlying Behçet's disease and immunomodulant treatment approaches. J Immunotoxicol 2018; 14:137-151. [PMID: 28693405 DOI: 10.1080/1547691x.2017.1346008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Behçet's disease (BD) is a chronic autoimmune condition primarily prevalent in populations along the Mediterranean Sea. The exact etiology of BD has not been fully explained yet, but the disease occurrence is associated with a genetic factor, human leukocyte antigen (HLA)-B51 antigen. Among the various immunodysfunctions that are found in BD, patients are increased neutrophil motility and superoxide production, as well as elevated production of tumor necrosis factor (TNF)-α and decreased production of interleukin (IL)-10. Elevated levels of inflammatory cytokines like IL-1 and IL-17 in BD have been found associated with aberrant expression of microRNA. Gene polymorphisms in BD patients have been observed in molecules involved in responses to pathogens that can ultimately modulate the host antimicrobial response. Moreover, several single nucleotide polymorphisms (SNPs) have been reported in genes encoding chemokines and adhesion molecules; many of these changes manifest as increases in vascular inflammation and vascular damage. Lastly, genetic and epigenetic changes have been suggested as involved in the pathogenesis of BD. Modifications in DNA methylation have been found in BD patient monocytes and lymphocytes, leading to adverse function of these cells. This review presents a comprehensive compilation of the literature with regard to the immunodysfunction underlying BD, as well as of the genetics, newly described clinical specifications and novel treatment strategies using immunomodulants based on the current understanding of BD.
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Affiliation(s)
- Arash Salmaninejad
- a Drug Applied Research Center , Tabriz University of Medical Sciences , Tabriz , Iran.,b Medical Genetics Research Center, Student Research Committee, Department of Medical Genetics, Faculty of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran.,c Rheumatology Research Center , Tehran University of Medical Sciences , Tehran , Iran
| | - Arezoo Gowhari
- d Department of Immunology, Faculty of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Seyedmojtaba Hosseini
- b Medical Genetics Research Center, Student Research Committee, Department of Medical Genetics, Faculty of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Saeed Aslani
- c Rheumatology Research Center , Tehran University of Medical Sciences , Tehran , Iran
| | - Meysam Yousefi
- b Medical Genetics Research Center, Student Research Committee, Department of Medical Genetics, Faculty of Medicine , Mashhad University of Medical Sciences , Mashhad , Iran
| | - Tayyeb Bahrami
- e Genetics Research Center , University of Social Welfare and Rehabilitation Sciences , Tehran , Iran
| | - Masoume Ebrahimi
- f Department of Biology, Faculty of Sciences , University of Guilan , Rasht , Iran
| | - Abolfazl Nesaei
- g Department of Basic Sciences , Gonabad University of Medical Sciences , Gonabad , Iran
| | - Masoud Zal
- h Department of Medical Genetics , Shahid Beheshti University of Medical Sciences , Tehran , Iran
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58
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Abstract
Behçet's disease (BD) is a chronic, multisystemic, inflammatory disease characterized by recurrent attacks of mucocutaneous, ocular, musculoskeletal, vascular, central nervous system and gastrointestinal manifestations. Treatment of BD changes according to organ involvement, gender and age of the patient with no golden standard therapeutic regimen. Vascular involvement is observed in up to 40% of the patients with BD, especially in young males and is one of the major causes of mortality and morbidity. Glucocorticoids, azathioprine and cyclophosphamide are still recommended as the first-line treatments in vascular BD. However, increasing data with the tumor necrosis factor inhibitors suggest that these agents may also be acceptable options for the management of refractory vascular BD in daily practice. Anticoagulant usage for vascular BD is also still controversial with limited data coming from retrospective studies. There is a clear need for randomized, controlled studies for the management of VBD.
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Affiliation(s)
- Fatma Alibaz-Oner
- Division of Rheumatology, School of Medicine, Marmara University, Istanbul, Turkey
| | - Haner Direskeneli
- Division of Rheumatology, School of Medicine, Marmara University, Istanbul, Turkey
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59
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Farber HW, McDermott S, Witkin AS, Kelly NP, Miloslavsky EM, Stone JR. Case 11-2018: A 48-Year-Old Woman with Recurrent Venous Thromboembolism and Pulmonary Artery Aneurysm. N Engl J Med 2018; 378:1430-1438. [PMID: 29641962 DOI: 10.1056/nejmcpc1800323] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Harrison W Farber
- From the Department of Medicine, Boston Medical Center (H.W.F.), the Department of Medicine, Boston University School of Medicine (H.W.F.), the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Shaunagh McDermott
- From the Department of Medicine, Boston Medical Center (H.W.F.), the Department of Medicine, Boston University School of Medicine (H.W.F.), the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Alison S Witkin
- From the Department of Medicine, Boston Medical Center (H.W.F.), the Department of Medicine, Boston University School of Medicine (H.W.F.), the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Noreen P Kelly
- From the Department of Medicine, Boston Medical Center (H.W.F.), the Department of Medicine, Boston University School of Medicine (H.W.F.), the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - Eli M Miloslavsky
- From the Department of Medicine, Boston Medical Center (H.W.F.), the Department of Medicine, Boston University School of Medicine (H.W.F.), the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
| | - James R Stone
- From the Department of Medicine, Boston Medical Center (H.W.F.), the Department of Medicine, Boston University School of Medicine (H.W.F.), the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Massachusetts General Hospital, and the Departments of Radiology (S.M.), Medicine (A.S.W., N.P.K., E.M.M.), and Pathology (J.R.S.), Harvard Medical School - all in Boston
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60
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Hatemi G, Christensen R, Bang D, Bodaghi B, Celik AF, Fortune F, Gaudric J, Gul A, Kötter I, Leccese P, Mahr A, Moots R, Ozguler Y, Richter J, Saadoun D, Salvarani C, Scuderi F, Sfikakis PP, Siva A, Stanford M, Tugal-Tutkun I, West R, Yurdakul S, Olivieri I, Yazici H. 2018 update of the EULAR recommendations for the management of Behçet's syndrome. Ann Rheum Dis 2018; 77:808-818. [PMID: 29625968 DOI: 10.1136/annrheumdis-2018-213225] [Citation(s) in RCA: 215] [Impact Index Per Article: 35.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2018] [Revised: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 12/14/2022]
Abstract
Several new treatment modalities with different mechanisms of action have been studied in patients with Behçet's syndrome (BS). The aim of the current effort was to update the recommendations in the light of these new data under the auspices of the European League Against Rheumatism (EULAR) Standing Committee for Clinical Affairs. A task force was formed that included BS experts from different specialties including internal medicine, rheumatology, ophthalmology, dermatology, neurology, gastroenterology, oral health medicine and vascular surgery, along with a methodologist, a health professional, two patients and two fellows in charge of the systematic literature search. Research questions were determined using a Delphi approach. EULAR standardised operating procedures was used as the framework. Results of the systematic literature review were presented to the task force during a meeting. The former recommendations were modified or new recommendations were formed after thorough discussions followed by voting. The recommendations on the medical management of mucocutaneous, joint, eye, vascular, neurological and gastrointestinal involvement of BS were modified; five overarching principles and a new recommendation about the surgical management of vascular involvement were added. These updated, evidence-based recommendations are intended to help physicians caring for patients with BS. They also attempt to highlight the shortcomings of the available clinical research with the aim of proposing an agenda for further research priorities.
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Affiliation(s)
- Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Robin Christensen
- Musculoskeletal Statistics Unit, The Parker Institute, Bispebjerg and Frederiksberg Hospital & Department of Rheumatology, Odense University Hospital, Copenhagen, Denmark
| | - Dongsik Bang
- Department of Dermatology, Catholic Kwandong University International St. Mary's Hospital, Incheon, Korea
| | - Bahram Bodaghi
- Department of Ophthalmology, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Aykut Ferhat Celik
- Division of Gastroenterology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Farida Fortune
- Centre for Clinical and Diagnostic Oral Sciences, Barts and the London School of Medicine and Dentistry, Queen Mary University of London, and the London Behçet's Centre, Barts Health London, London, UK
| | - Julien Gaudric
- Department of Vascular Surgery, Pitié-Salpêtrière Hospital, Sorbonne University, Paris, France
| | - Ahmet Gul
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ina Kötter
- Department of Rheumatology, Immunology and Nephrology, Asklepios Clinic Altona, Hamburg, Germany
| | - Pietro Leccese
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza and Matera, Italy
| | - Alfred Mahr
- Department of Internal Medicine, Hospital Saint-Louis, Paris, France
| | - Robert Moots
- National Behcet's Syndrome Centre of Excellence, Aintree University Hospital, Liverpool, UK
| | - Yesim Ozguler
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Jutta Richter
- Institute for Haematopathology Hamburg, Hamburg, Germany
| | - David Saadoun
- Department of Inflammation-Immunopathology-Biotherapy, Sorbonne Universités, UPMC Univ Paris 06, Paris, France.,INSERM, Paris, France.,CNRS, Paris, France.,Department of Internal Medicine and Clinical Immunology, Centre de Référence des Maladies Auto-Immunes et Systémiques Rares, Centre de Référence des Maladies Auto-Inflammatoires, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Carlo Salvarani
- Division of Rheumatology, Azienda USL-IRCCS di Reggio Emilia, University of Modena and Reggio Emilia, Modena and Reggio Emilia, Italy
| | | | - Petros P Sfikakis
- First Department of Propaedeutic and Internal Medicine & Rheumatology Unit, National Kapodistrian University of Athens Medical School, Athens, Greece
| | - Aksel Siva
- Department of Neurology, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Miles Stanford
- Department of Ophthalmology, St. Thomas' Hospital, London, UK
| | - Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Richard West
- Patient Research Partner, Member of the UK Behcet's Syndrome Society and Director of Behcets International, London, UK
| | - Sebahattin Yurdakul
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
| | - Ignazio Olivieri
- Rheumatology Institute of Lucania (IRel) and the Rheumatology Department of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, and the Basilicata Ricerca Biomedica (BRB) Foundation, Potenza and Matera, Italy
| | - Hasan Yazici
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey
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61
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62
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Cardiovascular disease in patients with autoinflammatory syndromes. Rheumatol Int 2017; 38:37-50. [DOI: 10.1007/s00296-017-3854-7] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2017] [Accepted: 10/13/2017] [Indexed: 12/16/2022]
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63
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Zhang SH, Zhang FX. Behcet's disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm: a case report and literature review. J Cardiothorac Surg 2017; 12:79. [PMID: 28874203 PMCID: PMC5585960 DOI: 10.1186/s13019-017-0644-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 08/29/2017] [Indexed: 11/29/2022] Open
Abstract
Background Aneurysm or pseudoaneurysm is the main vascular complication of Behcet’s disease. Most hospitals adopt endovascular treatment. Case presentation We report a case of Behcet’s disease with recurrent thoracic aortic aneurysm combined with femoral artery aneurysm. The patient underwent two rounds of endovascular surgery, but developed new aneurysms immediately after surgery. Eventually, the patient died due to rupture of recurrent aneurysm. Conclusions For vasculo-Behcet’s disease, we suggest performing the operation during the stable period. At the same time, glucocorticoids could be used with immunosuppressants preoperatively and postoperatively.
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Affiliation(s)
- Shi-Huai Zhang
- Department of General surgery, Fuxing Hospital of Captial Medical University, No. 20 of Fuxingmenwai Street, Xicheng District, Beijing, 100038, China.
| | - Fu-Xian Zhang
- Department of Vascular surgery, Shijitan Hospital of Captial Medical University, Beijing, 100038, China
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Esatoglu SN, Kutlubay Z, Ucar D, Hatemi I, Uygunoglu U, Siva A, Hatemi G. Behçet's syndrome: providing integrated care. J Multidiscip Healthc 2017; 10:309-319. [PMID: 28860798 PMCID: PMC5565245 DOI: 10.2147/jmdh.s93681] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Behçet’s syndrome (BS) is a multisystem vasculitis that presents with a variety of mucocutaneous manifestations such as oral and genital ulcers, papulopustular lesions and erythema nodosum as well as ocular, vascular, gastrointestinal and nervous system involvement. Although it occurs worldwide, it is especially prevalent in the Far East and around the Mediterranean Sea. Male gender and younger age at disease onset are associated with a more severe disease course. The management of BS depends on the severity of symptoms. If untreated, morbidity and mortality are considerably high in patients with major organ involvement. Multidisciplinary patient care is essential for the management of BS, as it is for other multisystem diseases. Rheumatologists, dermatologists, ophthalmologists, neurologists, cardiovascular surgeons and gastroenterologists are members of the multidisciplinary team. In this study, we reviewed the epidemiology, etiology, diagnostic criteria sets, clinical findings and treatment of BS and highlighted the importance of the multidisciplinary team in the management of BS.
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Affiliation(s)
| | | | | | - Ibrahim Hatemi
- Division of Gastroenterology, Department of Internal Medicine
| | - Ugur Uygunoglu
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Aksel Siva
- Department of Neurology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine
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65
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Desbois AC, Vallet H, Domont F, Comarmond C, Cacoub P, Saadoun D. Management of severe complications in Behçet’s disease with TNF inhibitors. Expert Opin Biol Ther 2017; 17:853-859. [DOI: 10.1080/14712598.2017.1328496] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- A. C. Desbois
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France
- INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - H. Vallet
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France
- INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - F. Domont
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France
- INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - C. Comarmond
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France
- INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - P. Cacoub
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France
- INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - D. Saadoun
- Inflammation-Immunopathology-Biotherapy Department (DHU i2B), Sorbonne Universités, UPMC Univ Paris 06, UMR 7211, Paris, France
- INSERM, UMR_S 959, Paris, France
- CNRS, FRE3632, Paris, France
- Department of Internal Medicine and Clinical Immunology, AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
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66
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Cinar M, Yilmaz S, Akay S, Bozlar U, Dinc A. Clinical course of Behcet's disease in a patient with delayed diagnosis and radiological follow-up of the thrombi with computed tomography angiography: a five-year follow-up under immunosuppressive treatment. REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:264-269. [PMID: 28535899 DOI: 10.1016/j.rbre.2013.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2013] [Accepted: 08/12/2013] [Indexed: 06/07/2023] Open
Affiliation(s)
- Muhammet Cinar
- Gulhane Military Medical Academy School of Medicine, Division of Rheumatology, Ankara, Turkey.
| | - Sedat Yilmaz
- Gulhane Military Medical Academy School of Medicine, Division of Rheumatology, Ankara, Turkey
| | - Sinan Akay
- Gulhane Military Medical Academy School of Medicine, Department of Radiology, Ankara, Turkey
| | - Ugur Bozlar
- Gulhane Military Medical Academy School of Medicine, Department of Radiology, Ankara, Turkey
| | - Ayhan Dinc
- Gulhane Military Medical Academy School of Medicine, Division of Rheumatology, Ankara, Turkey
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67
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Evolução clínica da doença de Behçet em paciente com atraso do diagnóstico e seguimento radiológico dos trombos com angiotomografia computadorizada: seguimento por 5 anos durante tratamento imunossupressor. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2013.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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68
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Yin H, Li S, Wang M, Hu Z, Wang J, Yao C, Chang G, Wang S. The value of endografts in the surgical management of arterial lesions secondary to Behçet disease. J Vasc Surg 2017; 65:471-477. [DOI: 10.1016/j.jvs.2016.08.109] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 08/21/2016] [Indexed: 10/20/2022]
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69
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Güngen AC, Çoban H, Aydemir Y, Düzenli H. Consider Behcet's disease in young patients with deep vein thrombosis. Respir Med Case Rep 2016; 18:41-4. [PMID: 27144118 PMCID: PMC4840440 DOI: 10.1016/j.rmcr.2016.04.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 03/30/2016] [Accepted: 04/11/2016] [Indexed: 11/22/2022] Open
Abstract
Behcet's disease is a multi-systemic and chronic inflammatory vasculitis of unknown etiology characterized by recurrent oral and genital ulcers, uveitis, arthritis, arterial aneurysms, venous thrombosis, skin lesions and GIS lesions. Although pulmonary artery aneurysms are rare, it is a critical condition due to high risk of rupture. Venous involvement of Behcet's disease primarily occurs in the lower extremities. In the presence of deep vein thrombosis(DVT) and pulmonary embolism, the mainstay of treatment in Behcet's disease is immunosuppressant therapy. Anticoagulants can be used only after initiation of immunosuppressant therapy and suppression of the disease. Anticoagulant therapy alone may lead to fatal hemoptysis. We report the case of a 24 year-old patient who presented to the emergency service with complaints of shortness of breath, general condition disorder and hemoptyhis while using warfarin for DVT and whose thoracic CT angiography showed pulmonary embolism and pulmonary artery aneurysm and diagnosed with Behcet's disease.
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Affiliation(s)
- Adil Can Güngen
- Sakarya University, Research and Training Hospital, Department of Pulmonology, 54100 Sakarya, Turkey
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70
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Behçet's disease: How to diagnose and treat vascular involvement. Best Pract Res Clin Rheumatol 2016; 30:279-295. [DOI: 10.1016/j.berh.2016.08.002] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/27/2016] [Accepted: 07/27/2016] [Indexed: 11/20/2022]
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71
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Seizem Nakiri G, Moretti Monsignore L, Meirelles de Siqueira F, Louzada P, Castro-Afonso LH, Giansante Abud D. Transhepatic Embolization of Bilateral Pulmonary Artery Aneurysm with N-Butyl Cyanoacrylate and Coils in Behçet Disease. J Vasc Interv Radiol 2016; 27:293-5. [DOI: 10.1016/j.jvir.2015.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2015] [Revised: 10/14/2015] [Accepted: 10/15/2015] [Indexed: 11/15/2022] Open
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72
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Chan E, Sangle SR, Coghlan JG, D'Cruz DD. Pulmonary artery aneurysms in Behçet's disease treated with anti-TNFα: A case series and review of the literature. Autoimmun Rev 2016; 15:375-8. [PMID: 26777307 DOI: 10.1016/j.autrev.2016.01.003] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 01/03/2016] [Indexed: 11/25/2022]
Abstract
Behçet's disease (BD) is a systemic inflammatory disorder of unknown aetiology. Pulmonary haemorrhage from ruptured pulmonary artery aneurysms (PAA) in this condition carries a high mortality but treatment has largely been empiric with use of glucocorticoids and cyclophosphamide. Tumour necrosis factor α (TNF-α) was recently recognised as a mediator in the pathogenesis of BD inflammatory lesions. TNFα inhibitors have been shown in various case reports/series to have beneficial effects in uveoretinitis, entero-Behçet's, neuro-Behçet's and BD arthritis. We describe the efficacy and tolerability of infliximab in 2 patients with Behçet's disease complicated by pulmonary vasculitis admitted to our unit during the years 2004-2015, and discuss the previously published data in this area.
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Affiliation(s)
- Estee Chan
- Louise Coote Lupus Unit, Fourth Floor Tower Wing, Guy's Hospital, London SE1 9RT, United Kingdom
| | - Shirish R Sangle
- Louise Coote Lupus Unit, Fourth Floor Tower Wing, Guy's Hospital, London SE1 9RT, United Kingdom
| | - J Gerry Coghlan
- Department of Cardiology, Royal Free Hospital, London NW3 2QG, United Kingdom
| | - David D D'Cruz
- Louise Coote Lupus Unit, Fourth Floor Tower Wing, Guy's Hospital, London SE1 9RT, United Kingdom
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73
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Kage H, Goto Y, Amano Y, Makita K, Isago H, Kobayashi K, Narumoto O, Okudaira R, Tanaka G, Takami K, Ohishi N, Nagase T. Development of Pulmonary Artery Aneurysms Due to Behçet's Disease and Resolution after Treatment. Intern Med 2016; 55:3337-3340. [PMID: 27853079 PMCID: PMC5173504 DOI: 10.2169/internalmedicine.55.6852] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
We herein describe a patient with Behçet's disease in whom we followed the development and resolution of pulmonary artery aneurysms. He presented with intermittent hemoptysis, pulmonary thromboembolism was initially diagnosed, and anticoagulant therapy was started. Over the next several months, the expansion of pulmonary arteries was noted. Five months after his initial admission, he was readmitted for massive hemoptysis, and further examinations revealed that he had Behçet's disease. Corticosteroids and intravenous cyclophosphamide were started. Over the next five months, the pulmonary artery aneurysms and thrombosis resolved. The development of pulmonary artery aneurysms led to the diagnosis of Behçet's disease, and they resolved after immunosuppressive therapy.
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Affiliation(s)
- Hidenori Kage
- Department of Respiratory Medicine, The University of Tokyo, Japan
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74
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Behcet's Disease: Is There Geographical Variation? A Review Far from the Silk Road. Int J Rheumatol 2015; 2015:945262. [PMID: 26798344 PMCID: PMC4698787 DOI: 10.1155/2015/945262] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 11/09/2015] [Accepted: 11/11/2015] [Indexed: 01/18/2023] Open
Abstract
Behcet's Disease (BD) is a systemic vasculitis characterized by the triad of recurrent mouth and genital ulcers with eye involvement. To date there are no laboratory tests specific for the disease and diagnosis continues to remain on clinical grounds. Multiple criteria have been created as guides for diagnosis; however, given the wide spectrum of organ involvement, some cases remain undiagnosed. The diagnosis of Behcet's Disease may only be made over time as the clinical manifestations emerge sometimes separated by months and even years. With an increased recognition of this disease it has become apparent that there is geographical variation in clinical manifestations. In particular cardiac manifestations are not seen commonly in Caucasians compared to Asian and Middle Eastern patients, while neurological manifestations are more common in Caucasians. Use of immunosuppressive and immunomodulatory drugs to suppress inflammation remains the cornerstone of treatment.
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75
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Hamuryudan V, Seyahi E, Ugurlu S, Melikoglu M, Hatemi G, Ozguler Y, Akman C, Tuzun H, Yurdakul S, Yazici H. Pulmonary artery involvement in Behçet׳s syndrome: Effects of anti-Tnf treatment. Semin Arthritis Rheum 2015; 45:369-73. [DOI: 10.1016/j.semarthrit.2015.06.008] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 05/01/2015] [Accepted: 06/12/2015] [Indexed: 01/20/2023]
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76
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Nair JR, Moots RJ. Behçet's disease: Review of management. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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77
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Abstract
Cogan and Behcet syndromes are considered large vessel vasculitides. Both are rare diseases, with varied clinical manifestations affecting multiple organ systems. Although both have hallmark symptoms (ocular and vestibuloauditory inflammation in Cogan syndrome and aphthous ulcers in Behcet syndrome), neither has confirmatory diagnostic testing. Delayed diagnosis can result in poor outcomes. In both syndromes, large vessel arterial inflammation may result in severe morbidity and mortality. Treatment strategies in both syndromes vary based on organ system involvement and severity of manifestations. In this article, the epidemiology, proposed pathogenesis, manifestations, and the most current treatment paradigms for these syndromes are reviewed.
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78
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Bhandari C, Rathi L, Gupta M, Khatri J. Right ventricular thrombus with pulmonary artery aneurysm in a young male: A rare presentation of Behçet's disease. Lung India 2015; 32:274-7. [PMID: 25983417 PMCID: PMC4429393 DOI: 10.4103/0970-2113.156253] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
We describe an adolescent patient presenting with hemoptysis. Detailed clinical work up of the patient showed right ventricular thrombus and bilateral pulmonary artery aneurysms along with the prescribed criteria for the diagnosis of Behcet's disease. Younger age of the patient was another distinctive feature of this case. Six months of therapy with cyclophosphamide and prednisolone resulted in near complete clinicoradiological response.
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Affiliation(s)
- Chand Bhandari
- Department of Chest and TB, SMS Medical College, Jaipur, Rajasthan, India
| | - Lalit Rathi
- Department of Chest and TB, SMS Medical College, Jaipur, Rajasthan, India
| | - Mridul Gupta
- Department of Medicine, RCSM Government Medical College, Kolhapur, Maharashtra, India
| | - Jaikishan Khatri
- Department of Chest and TB, SMS Medical College, Jaipur, Rajasthan, India
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79
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Demirelli S, Degirmenci H, Inci S, Arisoy A. Cardiac manifestations in Behcet's disease. Intractable Rare Dis Res 2015; 4:70-5. [PMID: 25984424 PMCID: PMC4428189 DOI: 10.5582/irdr.2015.01007] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Revised: 03/17/2015] [Accepted: 03/19/2015] [Indexed: 11/05/2022] Open
Abstract
Behcet's disease (BD) is a chronic inflammatory disorder, with vasculitis underlying the pathophysiology of its multisystemic effects. Venous pathology and thrombotic complications are hallmarks of BD. However, it has been increasingly recognised that cardiac involvement and arterial complications are also important aspects of the course of the disease. Cardiac lesions include pericarditis, endocarditis, intracardiac thrombosis, myocardial infarction, endomyocardial fibrosis, and myocardial aneurysm. Treatment of cardiovascular involvement in BD is largely empirical, and is aimed towards suppressing the vasculitis. The most challenging aspect seems to be the treatment of arterial aneurysms and thromboses due to the associated risk of bleeding. When the prognosis of cardiac involvement in BD is not good, recovery can be achieved through oral anticoagulation, immunosuppressive therapy, and colchicine use. In this review, we summarise the cardiovascular involvement, different manifestations, and treatment of BD.
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Affiliation(s)
- Selami Demirelli
- Selami Demirelli, M.D, Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey
- Address correspondence to: Dr. Selami Demirelli, Department of Cardiology, Erzurum Education and Research Hospital, Erzurum, Turkey. E-mail:
| | - Husnu Degirmenci
- Husnu Degirmenci, M.D, Department of Cardiology, Erzincan Universty, Erzincan, Turkey
| | - Sinan Inci
- Sinan Inci, M.D, Department of Cardiology, Aksaray State Hospital, Aksaray, Turkey
| | - Arif Arisoy
- Arif Arisoy, Department of Cardiology, M.D, Gaziosmanpasa Universty, Medical Faculty, Tokat, Turkey
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80
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Tamaki H, Khasnis A. Venous thromboembolism in systemic autoimmune diseases: A narrative review with emphasis on primary systemic vasculitides. Vasc Med 2015; 20:369-76. [DOI: 10.1177/1358863x15573838] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Venous thromboembolism (VTE) is a prevalent multifactorial health condition associated with significant morbidity and mortality. Population-based epidemiological studies have revealed an association between systemic autoimmune diseases and deep venous thrombosis (DVT)/VTE. The etiopathogenesis of increased risk of VTE in systemic autoimmune diseases is not entirely clear but multiple contributors have been explored, especially in the context of systemic inflammation and disordered thrombogenesis. Epidemiologic data on increased risk of VTE in patients with primary systemic vasculitides (PSV) have accumulated in recent years and some of these studies suggest the increased risk while patients have active diseases. This could lead us to hypothesize that venous vascular inflammation has a role to play in this phenomenon, but this is unproven. The role of immunosuppressive agents in modulating the risk of VTE in patients with PSV is not yet clear except for Behçet’s disease, where most of the studies are retrospective. Sensitizing physicians to this complication has implications for prevention and optimal management of patients with these complex diseases. This review will focus on the epidemiology and available evidence regarding pathogenesis, and will attempt to summarize the best available data regarding evaluation and treatment of these patients.
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Affiliation(s)
- Hiromichi Tamaki
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, USA
| | - Atul Khasnis
- Department of Rheumatic and Immunologic Diseases, Cleveland Clinic, USA
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81
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Naguib SM, El Menyawi MM, Nabih MI, Ismail I. Pulmonary manifestations in a group of patients with Behçet’s disease. THE EGYPTIAN JOURNAL OF INTERNAL MEDICINE 2015. [DOI: 10.4103/1110-7782.155827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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82
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Abstract
Pulmonary vasculitis encompasses inflammation in the pulmonary vasculature with involved vessels varying in caliber from large elastic arteries to capillaries. Small pulmonary capillaries are the vessels most commonly involved in vasculitis affecting the lung. The antineutrophil cytoplasmic antibody-associated vasculitides, which include granulomatosis with polyangiitis (formerly Wegener granulomatosis), microscopic polyangiitis, and eosinophilic granulomatosis with polyangiitis (formerly Churg-Strauss syndrome), are the small vessel vasculitides in which pulmonary vasculitis is most frequently observed and are the major focus of this review. Vasculitic involvement of the large pulmonary vessels as may occur in Behçet syndrome and Takayasu arteritis is also discussed.
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Affiliation(s)
- Lindsay Lally
- Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA.
| | - Robert F Spiera
- Division of Rheumatology, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA
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83
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84
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85
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Yurdakul S, Hamuryudan V, Yazici H. Behçet syndrome. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00159-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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86
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Abstract
PURPOSE OF REVIEW There is agreement that the management of Behçet's syndrome has recently improved, especially with the wider use of biologics. The aim of this review is to summarize the current management strategies in Behçet's syndrome. RECENT FINDINGS There is growing experience with tumor necrosis factor-alpha antagonists in the management of eye gastrointestinal and nervous disease in Behçet's syndrome. Interferon-alpha at lower doses may increase its tolerability. Other biologics such as interleukin 1-blocking agents and tocilizumab were used in a small number of patients and also seem to be effective. SUMMARY Although experiences with biologics have expanded and looks promising, this is mostly observational or retrospective. There still is a lack of controlled trials with these agents, especially in patients with major organ involvement.
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87
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Ozguler Y, Yazici H. Behçet's syndrome: New insights into pathogenesis and management. INDIAN JOURNAL OF RHEUMATOLOGY 2014. [DOI: 10.1016/j.injr.2014.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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88
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Abstract
Pulmonary artery aneurysms (PAAs) are the most common type of pulmonary involvement in Behçet's disease. However, the relationships between clinical features and prognosis have not been sufficiently evaluated. This article describes the results of a comprehensive review, revealing that PAAs have a predilection for hemoptysis manifestations, increased dimensions, right lower lobar location, multiplicity and concurrent intramural thrombus formation. Surgical intervention was needed in one third of patients. Patients with massive hemoptysis and PAA rupture warranted emergency operations. Conservatively treated patients were prone to PAA progression; interventional embolization was associated with higher risks of recurrence and reintervention for PAAs; and surgically treated patients exhibited the highest mortality rates. In conclusion, PAAs in Behçet's disease are characterized by a predilection for hemoptysis manifestations, right lower lobar location, multiplicity, and concurrent intramural thrombus formation. Both the condition itself and the surgical operations it warrants are linked with high mortality due to PAA hemorrhage.
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Affiliation(s)
- Shi-Min Yuan
- Fujian Medical University, People's Republic of China
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89
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Caso F, Costa L, Rigante D, Lucherini OM, Caso P, Bascherini V, Frediani B, Cimaz R, Marrani E, Nieves-Martín L, Atteno M, Raffaele CGL, Tarantino G, Galeazzi M, Punzi L, Cantarini L. Biological treatments in Behçet's disease: beyond anti-TNF therapy. Mediators Inflamm 2014; 2014:107421. [PMID: 25061259 PMCID: PMC4100257 DOI: 10.1155/2014/107421] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2014] [Revised: 04/17/2014] [Accepted: 05/01/2014] [Indexed: 12/14/2022] Open
Abstract
Behçet's disease (BD) is universally recognized as a multisystemic inflammatory disease of unknown etiology with chronic course and unpredictable exacerbations: its clinical spectrum varies from pure vasculitic manifestations with thrombotic complications to protean inflammatory involvement of multiple organs and tissues. Treatment has been revolutionized by the progressed knowledge in the pathogenetic mechanisms of BD, involving dysfunction and oversecretion of multiple proinflammatory molecules, chiefly tumor necrosis factor- (TNF-) α, interleukin- (IL-) 1β, and IL-6. However, although biological treatment with anti-TNF-α agents has been largely demonstrated to be effective in BD, not all patients are definite responders, and this beneficial response might drop off over time. Therefore, additional therapies for a subset of refractory patients with BD are inevitably needed. Different agents targeting various cytokines and their receptors or cell surface molecules have been studied: the IL-1 receptor has been targeted by anakinra, the IL-1 by canakinumab and gevokizumab, the IL-6 receptor by tocilizumab, the IL12/23 receptor by ustekinumab, and the B-lymphocyte antigen CD-20 by rituximab. The aim of this review is to summarize all current experiences and the most recent evidence regarding these novel approaches with biological drugs other than TNF-α blockers in BD, providing a valuable addition to the actually available therapeutic armamentarium.
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Affiliation(s)
- Francesco Caso
- Interdepartmental Research Center of Systemic Autoimmune and Autoinflammatory Diseases, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Viale Bracci 1, 53100 Siena, Italy
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Luisa Costa
- Rheumatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Donato Rigante
- Institute of Pediatrics, Cattolica Sacro Cuore University, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Orso Maria Lucherini
- Interdepartmental Research Center of Systemic Autoimmune and Autoinflammatory Diseases, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Paolo Caso
- La Sapienza University, Viale del Policlinico 155, 00161 Rome, Italy
| | - Vittoria Bascherini
- Interdepartmental Research Center of Systemic Autoimmune and Autoinflammatory Diseases, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Bruno Frediani
- Interdepartmental Research Center of Systemic Autoimmune and Autoinflammatory Diseases, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Rolando Cimaz
- Department of Pediatrics, Rheumatology Unit, Anna Meyer Children's Hospital and University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| | - Edoardo Marrani
- Department of Pediatrics, Rheumatology Unit, Anna Meyer Children's Hospital and University of Florence, Viale Pieraccini 24, 50139 Florence, Italy
| | - Laura Nieves-Martín
- Interdepartmental Research Center of Systemic Autoimmune and Autoinflammatory Diseases, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Viale Bracci 1, 53100 Siena, Italy
- Rheumatology Service, Hospital Regional Universitario Carlos Haya, University of Màlaga, Avenida Carlos Haya s/n, 29010 Màlaga, Spain
| | - Mariangela Atteno
- Rheumatology Unit, Department of Clinical Medicine and Surgery, University Federico II, Via S. Pansini 5, 80131 Naples, Italy
| | - Carmela G. L. Raffaele
- Institute of Pediatrics, Cattolica Sacro Cuore University, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Giusyda Tarantino
- Institute of Pediatrics, Cattolica Sacro Cuore University, Largo Agostino Gemelli 8, 00168 Rome, Italy
| | - Mauro Galeazzi
- Interdepartmental Research Center of Systemic Autoimmune and Autoinflammatory Diseases, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Viale Bracci 1, 53100 Siena, Italy
| | - Leonardo Punzi
- Rheumatology Unit, Department of Medicine DIMED, University of Padova, Via Giustiniani 2, 35128 Padova, Italy
| | - Luca Cantarini
- Interdepartmental Research Center of Systemic Autoimmune and Autoinflammatory Diseases, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Viale Bracci 1, 53100 Siena, Italy
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Abstract
Behçet disease is a chronic inflammatory systemic disorder, characterized by a relapsing and remitting course. It manifests with oral and genital ulcerations, skin lesions, uveitis, and vascular, central nervous system and gastrointestinal involvement. The main histopathological finding is a widespread vasculitis of the arteries and veins of any size. The cause of this disease is presumed to be multifactorial involving infectious triggers, genetic predisposition, and dysregulation of the immune system. As the clinical expression of Behçet disease is heterogeneous, pharmacological therapy is variable and depends largely on the severity of the disease and organ involvement. Treatment of Behçet disease continues to be based largely on anecdotal case reports, case series, and a few randomized clinical trials.
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Affiliation(s)
| | - Thurayya Arayssi
- Weill Cornell Medical College-Qatar, Education City, PO Box 24144, Doha, Qatar
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91
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Doss J, England J, Fuchs H. Coughing up blood: Behçet's disease. Am J Med 2014; 127:386-9. [PMID: 24576442 DOI: 10.1016/j.amjmed.2014.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 02/06/2014] [Accepted: 02/06/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Jayanth Doss
- Division of Rheumatology, Vanderbilt University, Nashville, Tenn.
| | - James England
- Department of Medicine, Vanderbilt University, Nashville, Tenn
| | - Howard Fuchs
- Division of Rheumatology, Vanderbilt University, Nashville, Tenn
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92
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93
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Kaieda S, Zaizen Y, Nomura Y, Okabe K, Honda S, Kage M, Ida H, Hoshino T, Fukuda T. An autopsy case of refractory vasculo-Behçet’s disease. Mod Rheumatol 2014; 25:307-11. [DOI: 10.3109/14397595.2013.874755] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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94
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Farouk H. Behçet's disease, echocardiographers, and cardiac surgeons: together is better. Echocardiography 2014; 31:783-7. [PMID: 25041047 DOI: 10.1111/echo.12524] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Behçet's disease is an inflammatory disorder of unknown etiology, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Many abnormal echocardiographic findings have been previously reported in patients with Behçet's disease. Some of these; namely, aortic root dilation, aortic valve regurgitation, intracardiac thrombi, and pulmonary artery aneurysm may precede other manifestations of the disease and occasionally require surgical intervention for proper management. Compared to patients without Behçet's disease, management of these complications in patients with the disease is challenging and requires different treatment strategies. If diagnosis of Behçet's disease is missed prior to surgical intervention, higher incidence of surgical failure, recurrence, and even higher postoperative mortality may occur. In this review, the author discusses these major cardiac complications of Behçet's disease.
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Affiliation(s)
- Heba Farouk
- Lecturer of Cardiovascular Medicine, Cairo University Hospital, Cairo, Egypt
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95
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Desbois AC, Wechsler B, Cluzel P, Helft G, Boutin D, Piette JC, Cacoub P, Saadoun D. [Cardiovascular involvement in Behçet's disease]. Rev Med Interne 2014; 35:103-11. [PMID: 24434015 DOI: 10.1016/j.revmed.2013.12.002] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 12/02/2013] [Indexed: 12/15/2022]
Abstract
Vascular involvement is a common complication of Behçet's disease (BD) and affects up to 40% of BD patients. These complications worsen the prognosis of BD. The concept of vasculo-Behçet has been adopted for cases in which vascular complications dominate the clinical features. Vascular manifestations affect particularly young men, during the first years following onset of the disease. Venous complications are the most frequent vascular complications, affecting 14 to 40% of BD patients. Superficial and deep lower limb thrombosis is the most frequent venous complications but one third of venous thrombosis concern large vessels (such as cerebral venous thrombosis, pulmonary embolism, and inferior or superior vena cava, etc.). Budd-Chiari syndrome is the worst prognostic factor increasing mortality by 9 times. Arterial complications (2 to 17% of BD patients) include aneurysms and occlusions/stenosis. Main locations of arterial lesions are aortic (abdominal and thoracic), femoral, pulmonary and iliac arteries. Aneurysms are the most severe arterial complications, particularly pulmonary aneurysms associated with a high risk of massive bleeding. Cardiac complications (up to 6% of BD patients) include pericarditis, endocardial lesions (aortic regurgitation and less often mitral insufficiency), myocardial lesions (myocardial infarction, myocarditis and endomyocardial fibrosis) and intracardiac thrombosis (right ventricle and atrium). Coronary lesions complicated to myocardial infarction are the most severe cardiac complications. Treatment is based on corticosteroids and immunosuppressive drugs. The use of anticoagulation in venous thrombosis is still controversial.
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Affiliation(s)
- A-C Desbois
- Service de médecine interne, centre de référence des maladies autoimmunes rares, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France; DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, AP-HP, 75013 Paris, France
| | - B Wechsler
- Service de médecine interne, centre de référence des maladies autoimmunes rares, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France
| | - P Cluzel
- Service de radiologie, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France
| | - G Helft
- Service de cardiologie, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France
| | - D Boutin
- Service de médecine interne, centre de référence des maladies autoimmunes rares, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France
| | - J-C Piette
- Service de médecine interne, centre de référence des maladies autoimmunes rares, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France
| | - P Cacoub
- Service de médecine interne, centre de référence des maladies autoimmunes rares, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France; DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, AP-HP, 75013 Paris, France
| | - D Saadoun
- Service de médecine interne, centre de référence des maladies autoimmunes rares, groupe hospitalier Pitié-Salpêtrière, 75013 Paris, France; DHU i2B, immunopathologie, inflammation, biothérapie, université Pierre-et-Marie-Curie, Paris 6, AP-HP, 75013 Paris, France.
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96
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Fioramonti P, Fino P, Ponzo I, Ruggieri M, Onesti MG. Intense pulsed light in the treatment of telangiectasias: case report of Behçet's disease with superficial vascular involvement. J COSMET LASER THER 2013; 16:124-8. [PMID: 24131092 DOI: 10.3109/14764172.2013.854634] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Behçet's disease (BD) is a chronic systemic inflammatory disorder of unknown etiology with variable clinical manifestations. HLA-B51 allele is the most strongly associated known genetic factor. The mucocutaneous lesions (oral aphthae, genital aphthae, skin lesions such as pseudofolliculitis) constitute the hallmark of the disease, but also gastrointestinal, vascular, central nervous systems, and others may be involved. We report a case of a young man affected with Behçet's disease who presented facial telangiectasias and striae rubra in the inner region of his arms and at the level of his hips, as uncommon minor superficial vascular manifestations of BD. To manage them we have subjected the patient to a cycle of Intense Pulsed Light (IPL) therapy. Our findings showed that the use of IPL is a safe and effective treatment for telangiectasias and striae rubra, also in the complex clinical condition of Behçet's disease. In fact, the treatments were well tolerated, no sign of scarring or hyper/hypopigmentation was reported and we obtained a significant improvement of the lesions in terms of color and size of them.
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Affiliation(s)
- Paolo Fioramonti
- Department of Plastic, Reconstructive and Aesthetic Surgery, University of Rome Sapienza , Policlinico Umberto I, Rome , Italy
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97
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Mat C, Yurdakul S, Sevim A, Özyazgan Y, Tüzün Y. Behçet’s syndrome: Facts and controversies. Clin Dermatol 2013; 31:352-361. [DOI: 10.1016/j.clindermatol.2013.01.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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98
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Choose pharmacological therapy for Behçet’s syndrome based on disease severity and organ involvement. DRUGS & THERAPY PERSPECTIVES 2013. [DOI: 10.1007/s40267-013-0030-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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99
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Kanchinadham S, Potikuri D. Multiple pulmonary arterial aneurysms in a young male patient with incomplete Behçet's syndrome. Lung India 2013; 30:76-7. [PMID: 23661925 PMCID: PMC3644843 DOI: 10.4103/0970-2113.106121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Suresh Kanchinadham
- Department of Rheumatology, Nizam's Institute of Medical Sciences, Punjagutta, Hyderabad, India E-mail:
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100
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Kaieda S, Zaizen Y, Nomura Y, Okabe K, Honda S, Kage M, Ida H, Hoshino T, Fukuda T. An autopsy case of refractory vasculo-Behçet’s disease. Mod Rheumatol 2013. [DOI: 10.1007/s10165-013-0873-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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