Serum homocysteine level is increased and correlated with endothelin-1 and nitric oxide in Behçet's disease

Risk and prognostic factors of poor visual outcome in Behcet's disease with ocular involvement

PURPOSE

The purpose of the study was to determine factors correlated with the progression of irreversible visual disturbance in Behcet's disease (BD) with ocular involvement.

METHODS

Forty-seven BD patients with ocular inflammation, who presented with the first ocular episode, and who had been followed continuously for 5-10 years in our hospital, were studied. Charts were reviewed for gender, onset age of uveitis, complete or incomplete type BD, HLA-B51 status, final visual acuity at the last remission period, mean number of ocular attacks per year, and clinical findings of iridocyclitis with profuse hypopyon, strong vitreous opacity blocking the observation of retinal vessels, diffuse retinal vasculitis, and exudates with hemorrhage within the retinal vascular arcade.

RESULTS

Patients with a visual acuity of < or =20/200 and those with >20/200 differed significantly in the mean number of ocular attacks per year and clinical findings of strong vitreous opacity and exudates within the retinal vascular arcade, but not with regard to the other factors. In addition, the frequency of ocular attacks showed a significant negative correlation with the outcome of visual acuity. Logistic regression analysis indicated a significant association of an average of more than three ocular attacks per year, strong vitreous opacity, and exudates within the retinal vascular arcade with poor visual outcome.

CONCLUSIONS

This study indicates that more than three ocular attacks per year, strong vitreous opacity, and exudates within the retinal vascular arcade are the risk and prognostic factors for a poor outcome of visual acuity in BD patients.

Synovial nitric oxide concentrations are increased and correlated with serum levels in patients with active Behçet's disease: a pilot study

Behçet's disease (BD) is a relapsing immunoinflammatory vasculitis of unknown etiology characterized by endothelial dysfunction. Articular symptoms and signs are present in about 75% of cases and characterized by seronegative arthritis and nonspecific synovitis. We demonstrated that both serum and erythrocyte nitric oxide (NO(.)) levels, the most abundant free radical in the body, were elevated in BD and associated with disease activity. This study further investigated NO(.) levels in the synovial fluid and serum from patients with active and inactive BD. A total of 23 BD patients with articular involvement (14 men and 9 women) satisfying International Study Group criteria and 15 age- and sex-matched healthy control subjects (9 men and 6 women) undergoing elective arthroscopy were included in this case-control investigation. The synovial fluid and serum were obtained from BD patients and controls. Clinical and laboratory findings including neutrophil count and erythrocyte sedimentation rate (ESR) were used to classify BD patients as active (n = 11) or inactive (n = 12). Synovial as well as serum NO(.) levels were compared between the groups and correlation analysis was performed. Acute phase reactant levels were significantly higher (for each, p < 0.01) in BD patients than control subjects in the active period. The mean synovial NO(.) level in active Behçet's patients (mean +/- SD 76.61 +/- 11.95 micromol/l) was significantly higher than in inactive patients (46.16 +/- 8.89 micromol/l, p < 0.001) and healthy control subjects (39.60 +/-8.03 micromol/l, p < 0.001). The difference between inactive patients and controls was not significant (p > 0.05). Active BD patients had significantly higher serum NO(.) levels (38.84 +/- 9.15 micromol/l) than inactive patients (30.91 +/- 5.88 micromol/l, p = 0.018) and control subjects (28.86 +/- 5.91 micromol/l, p = 0.002). In addition, synovial NO(.) levels were positively correlated with serum levels (r(2) = 0.621, p < 0.001). Increased synovial NO(.) levels in active BD patients probably reflect a nonspecific inflammatory process of the synovium and, therefore, arthralgia and arthritis as a common finding of BD.

Pseudotumeur cardiaque révélant une maladie de Behçet

INTRODUCTION

Cardiac thrombosis is a rare complication of Behçet's disease (BD), which may present as a cardiac tumor. Its discovery precedes, in half of the cases, the diagnosis of BD. The high mortality may be associated to postsurgical complications and/or an associated involvement of pulmonary arteries.

CASE REPORT

We present the case of a 31 years old Caucasian French woman, with a history of venous thromboembolic disease, who had surgery after the discovery of a right ventricle tumor. That was an organised thrombus with endomyocardial fibrosis and a diagnosis of Behçet's disease was made after the surgery. The outcome was favourable under medical treatment associating corticosteroids, colchicine and antivitamin K (AVK), without relapse four years later.

CONCLUSION

The discovery of an intracardiac mass in a young patient must evoke the diagnosis of cardiac thrombus and Behçet's disease, even in the absence of predisposing ethnic or geographic factor.

Vascular endothelial function and plasma homocysteine levels in Behcet's disease

The purpose of the present study was to test endothelial function and to determine if plasma homocysteine levels are associated with endothelial injury in patients with Behcet's disease (BD). Flow-mediated dilation in patients with BD was smaller than that of control subjects (p = 0.001), and mean plasma homocysteine levels in patients with BD were significantly higher (p = 0.0001). On regression analysis, only mean plasma homocysteine concentration was independently related to flow-mediated dilation (F = 5.7, p = 0.001).

Beh??et??s syndrome and the nervous system

PURPOSE OF REVIEW

Behçet's syndrome (BS) is a multi-system, vascular-inflammatory disease of unknown origin, involving the nervous system in a subgroup of patients. The syndrome is rare, but as patients with BS are young and frequently present with an acute or subacute brainstem syndrome or hemiparesis, as well as with other various neurological manifestations, the syndrome is often included in the differential diagnosis of multiple sclerosis, stroke of the young adult, and another wide range of neurological disorders. The present review summarizes the neurological involvement in BS, and emphasizes recent clinical concepts and ethiopathogenetic findings.

RECENT FINDINGS

Over the last years the growing clinical and imaging evidence had suggested that neurological involvement in BS may be subclassified into two major forms: one, which is seen in the majority of patients, may be characterized as a vascular-inflammatory CNS disease, with focal or multifocal parenchymal involvement; the other, which has few symptoms and a better neurological prognosis, may be caused by isolated cerebral venous sinus thrombosis and intracranial hypertension. These two types rarely occur in the same individual, and their pathogenesis is likely to be different. A nonstructural vascular type headache is relatively common, whereas isolated behavioral syndromes and peripheral nervous system involvement are rare.

SUMMARY

The involvement of the nervous system in BS is heterogeneous as clinical and imaging data reveal. Currently it is unknown which factors determine or have a role in the development of neurological involvement, but some progress has been achieved in understanding the neurological spectrum of the syndrome, which may lead to a better management of these patients.

Endothelial cell activation and hypercoagulability in ocular Behçet's disease

PURPOSE

To investigate the presence of a hypercoagulable state and vascular endothelial dysfunction in patients with ocular Behçet's disease and relate the results to the activity of ocular and systemic involvement.

DESIGN

Cross-sectional laboratory and clinical study.

METHODS

Prospective study of blood samples of 24 patients diagnosed with ocular Behçet's disease, which were analyzed for factor VIII, factor XI, von Willebrand factor antigen and ristocetin (vWF ag and risto), antithrombin III (ATIII), protein C and S, fibrinogen and activated protein C (APC) resistance. The results were compared with 40 healthy controls and analyzed for association with ocular and systemic clinical features.

RESULTS

The mean values of factor VIII, factor XI, vWF ag, vWF risto, ATIII, and fibrinogen were significantly raised compared to healthy population (for all: P <.001). Most striking were factor VIII activity levels above 130% in 79% (19 of 24) of our patients. 67% (16 of 24) had levels of factor VIII above 150%, which correlates with a fivefold increase in risk of thrombosis. Other prothrombogenic factors were negative in all but 2 patients (1 protein C deficiency, 1 factor V Leiden mutation). Endothelial cell activation, measured by vWF activity, revealed elevated levels in 42% (10/24). Complete/incomplete Behçet's disease patients with present or previous macular edema had significantly higher FVIII levels than complete/incomplete Behçet's disease patients who had never shown any signs of macular edema (P =.04). Further correlations between the laboratory results and clinical symptoms were not found.

CONCLUSIONS

We found a generalized hypercoagulable state with endothelial cell activation in ocular Behçet's disease, irrespectively of current ocular disease activity.

Hyperhomocysteinemia in patients with Behçet’s disease: is it due to inflammation or therapy?

Considerable discrepancies exist in the literature with respect to plasma total homocysteine (tHcy) levels in Behçet's disease (BD). The aim of this study was to evaluate tHcy concentrations in these patients. Thirty-two patients with BD and 20 age- and body mass index-matched healthy volunteers were enrolled. Plasma tHcy concentrations were significantly higher, while vitamin B12 and folate levels were significantly lower in patients with thrombosis and eye involvement than those without. C-reactive protein levels also correlated significantly in a negative manner with vitamin B12 and folate but positively with tHcy. In conclusion, increased use or accelerated catabolism of folate and vitamin B12 due to chronic inflammation and moderately increased tHcy concentrations related with deficiency of these cofactors, and immunosuppressive drug administration might be potential threats of vascular disease in BD.

Hyperhomocysteinaemia is associated with uveitis but not with deep venous thrombosis in Behçet's disease

Plasma homocysteine was assessed in Behçet's disease (BD) patients in order to determine the prevalence of hyperhomocysteinaemia in BD and to test its association with clinical manifestations of the disease. The study included 59 patients with BD and 118 age- and sex-matched healthy subjects. Plasma homocysteine, vitamin B

Endothelial nitric oxide synthase gene polymorphisms in Behçet's disease and rheumatic diseases with vasculitis

OBJECTIVE

To assess potential associations between Korean Behçet's disease (BD) or other rheumatic diseases with vasculitis and two polymorphisms of the endothelial nitric oxide synthase (eNOS) gene, which include the Glu298Asp polymorphism in exon 7 and a variable number of tandem repeats (VNTR) polymorphism in intron 4.

METHODS

65 patients with BD, 27 with rheumatic diseases with vasculitis, and 80 controls were studied. Analyses of the Glu298Asp polymorphism in exon 7 and VNTR polymorphism in intron 4 of the eNOS gene were made by the polymerase chain reaction (PCR)-restriction fragment length polymorphism technique and PCR genotyping, respectively. Additionally, HLA-B51 typing was performed in the BD group and controls by a two step PCR sequence-specific primers method.

RESULTS

Significant differences in Glu298Asp genotype frequencies were found between the BD or vasculitis groups and the controls (BD group v controls: p(corr)=0.006; vasculitis group v controls: p<0.001). The Asp298 frequency was much higher in the BD and vasculitis groups than in the controls. Even after stratification of the BD group based on the results of HLA-B51 testing, a significant association of the Glu298Asp polymorphism was still found (p=0.002, Mantel-Haenszel weighted odds ratio 4.3, 95% confidence interval 1.7 to 10.9). Distribution of the genotype frequencies in two eNOS gene polymorphisms was similar in connective tissue diseases-associated vasculitis and primary vasculitic syndromes. In contrast, distribution of alleles and genotypes of VNTR polymorphism did not differ between BD or vasculitis groups and the controls.

CONCLUSION

The Glu298Asp polymorphism in exon 7 of the eNOS gene seems to be a susceptibility gene for Korean BD and other rheumatic diseases.

Vascular endothelial growth factor levels are increased and associated with disease activity in patients with Behçet's syndrome

BACKGROUND/AIMS

Vascular endothelial growth factor (VEGF) is a cytokine participating in inflammation with potent endothelial cell effects. It is produced by macrophages, neutrophils and vascular endothelial cells and can alter vessel permeability. Behçet's syndrome is a systemic inflammatory disorder with unknown etiology. Vascular endothelial dysfunction is one of the prominent features of the disease. We previously demonstrated the possible involvement of proinflammatory cytokines [tumor necrosis factor (TNF)-alpha, soluble interleukin-2 receptor (sIL-2R), interleukin (IL)-6 and IL-8], nitric oxide (NO) and adrenomedullin in the etiopathogenesis of Behçet's syndrome. Since VEGF expression is induced by these cytokines and VEGF itself is a potent stimulator of NO production with endothelial cell effects, this study aimed to investigate whether VEGF was affected during the course of Behçet's syndrome. We also assessed the possible involvement of VEGF in ocular Behçet's syndrome or in disease activity.

METHODS

This multicenter case-control study included a total of 39 patients with active (n = 22) or inactive (n = 17) Behçet's syndrome (mean age, 38.1 +/- 10.4 years; 21 men and 18 women) satisfying International Study Group criteria, and 15 healthy hospital-based control volunteers (mean age, 39.2 +/- 9.3 years; eight men and seven women) matched for age and gender from a similar ethnic background. Patients were examined by a dermatologist and an ophthalmologist with an interest in Behçet's syndrome. Plasma VEGF concentrations were measured using a newly established enzyme-linked immunosorbent assay. Clinical findings and acute-phase reactant parameters such as erythrocyte sedimentation rate, alpha1-antitrypsin, alpha2-macroglobulin, and neutrophil count were used to classify the disease in Behçet's patients as active or inactive. The Wilcoxon test or the Mann-Whitney U-test was used for statistical analysis as indicated and the results were expressed as mean +/- SD, with range.

RESULTS

The mean plasma VEGF level in patients with Behçet's syndrome (291.9 +/- 97.1 pg/mL; range 121-532 pg/mL) was higher than that in control subjects (103.0 +/- 43.6 pg/mL; range 25-187 pg/mL) and the difference was significant (P < 0.001). Patients with active disease had significantly (P < 0.001) higher VEGF levels than patients with inactive disease (347.6 +/- 87.1 vs. 219.9 +/- 51.6 pg/mL). In addition, ocular Behçet's patients (n = 23) had higher VEGF levels (315.7 +/- 92.1 pg/mL) than nonocular patients (n = 16, 257.8 +/- 96.6 pg/mL) and the difference was of borderline significance (P = 0.041). The levels of all acute-phase reactant parameters were significantly higher in the active stage than in the inactive stage (for each, P < 0.01) or in control subjects (for each, P < 0.001).

CONCLUSIONS

VEGF may participate in the course of Behçet's syndrome, especially in the active stage, and elevated levels of VEGF may be an additional risk factor for the development of ocular disease, contributing to poor visual outcome.

Adenosine deaminase enzyme activity is increased and negatively correlates with catalase, superoxide dismutase and glutathione peroxidase in patients with Behçet's disease: original contributions/clinical and laboratory investigations

AIM

Behçet's disease (BD) is an inflammatory vasculitis with immunologic, endothelial and neutrophil alterations. Adenosine deaminase (AD) is a marker of T-cell activation and is related to the production of reactive oxygen species by neutrophils with the production of NO(*), O(2)(*-), H(2)O(2) and OH(*). We reported increased tumour necrosis factor-alpha, soluble interleukin-2 receptor, interleukin-6, interleukin-8 and NO(*) in active BD. As there is a relation between cytokines, T cells and oxidative stress in inflammatory diseases, this study further evaluated: (1) plasma AD activity and its correlation with acute phase reactants; (2) thiobarbituric acid-reactive substances (TBARS) as an indicator for lipid peroxidation; and (3) antioxidant enzymes superoxide dismutase (SOD), glutathione peroxidase (GSHPx) and catalase in patients with BD. The effect of disease activity and correlations between the measured parameters were explored.

METHODS

A total of 35 active (n=17) or inactive (n=18) patients with BD (16 men, 19 women) satisfying International Study Group criteria, and 20 age-matched and sex-matched controls (nine men, 11 women) were included in this cross-sectional case-control study. AD and TBARS were measured in plasma, catalase in red blood cells (RBC), and SOD and GSHPx in both plasma and RBC in both groups. Acute phase reactants (alpha(1)-antitrypsin, alpha(2)-macroglobulin, neutrophils, erythrocyte sedimentation rate) were used to classify patients as active or inactive.

RESULTS

Plasma AD (mean+/-standard error of the mean, 36.1+/-0.7 U/l) and TBARS (4.2+/-0.1 nmol/ml) levels were significantly (for each, p<0.001) higher in BD than in controls (24.1+/-0.8 U/l and 1.6+/-0.1 nmol/ml, respectively). RBC catalase activity was significantly (p<0.001) lower in BD than in controls (120.9+/-3.8 versus 160.3+/-4.1 k/g haemoglobin). SOD and GSHPx activities were significantly lower in both plasma and erythrocytes of patients with BD than in controls (plasma SOD, 442.4+/-8.6 versus 636.4+/-9.2 U/ml, p<0.001; RBC SOD, 3719.2+/-66.0 versus 4849.7+/-49.0 U/g haemoglobin, p<0.001; plasma GSHPx, 73.1+/-1.5 versus 90.6+/-2.9 U/ml, p<0.001; RBC GSHPx, 600.7+/-8.0 versus 670.6+/-10.1 U/g haemoglobin, p<0.001). Active BD patients had significantly lower antioxidant enzymes (except RBC catalase) and higher AD and TBARS levels than inactive subjects (for each, p<0.01). When considering all BD patients, a significant positive correlation was present between AD and TBARS (p<0.001) whereas both AD and TBARS were negatively correlated with antioxidant enzymes (for each, p<0.05).

CONCLUSIONS

AD and lipid peroxidation are increased and associated with defective antioxidants in BD, suggesting interactions between activated T cells and neutrophil hyperfunction. Measures of pro-oxidative stress and antioxidative defence with AD activity as an indicator of T-cell activation can be considered as significant supportive diagnostic indicators, especially in active disease. In addition, strengthening the antioxidant defence may contribute to treatment modalities.