Silent central nervous system involvement in Egyptian Behçet's disease patients: clinical, psychiatric, and neuroimaging evaluation

Neurological involvement by Behçet's syndrome: clinical features, diagnosis, treatment and outcome

Neurological involvement in Behçet's syndrome arises predominately through an inflammatory meningoencephalitis characterised by perivenular inflammation due to activation of Th-17 immunological pathways. The brainstem is involved in 50% of cases, the diencephalon and other areas of the brain in 30%, and the spinal cord in 10%. Movement disorders and epilepsy may occur. Psychiatric syndromes may arise with brain and brainstem involvement, and cognitive disorders relate to the brain disease, to circulating inflammatory factors, and to fatigue and despondency. Eighty per cent of cases begin with a relapsing disease course, of whom 70% have only one attack, and 30% have a progressive disease course either from onset or following an initially relapsing course. Venous thrombosis leading to intracranial hypertension and cerebral venous infarction is less common and caused by inflammation in affected veins and a circulating prothrombotic state. Arterial involvement is rare and relates to an arteritis affecting large-sized and medium-sized vessels within the brain leading to infarction, subarachnoid and parenchymal haemorrhage, aneurysm formation and arterial dissection. There is a newly recognised disorder of cerebral cortical hypoperfusion. Cranial neuropathy, peripheral neuropathy and myositis are rare. There has been significant progress in understanding the pathophysiology and treatment of the systemic disease, leading to improved outcomes, but there has been no randomised trial of treatment in the neurological disorder.

Psychiatric Symptoms and Cognitive Disorders in Behçet's Disease: A Single-Center, Cross-Sectional Study

BACKGROUND

Behçet's disease (BD) is a rare form of vasculitis involving both veins and arteries of all calibers. Psychological symptoms and cognitive impairment appear to be frequent, but few data are available.

METHODS

All consecutive patients in our center fulfilling the 2013 BD criteria underwent a psychometric evaluation with auto- (SCL-90-R and Modified Fatigue Index) and hetero-questionnaires (MINI). A standardized test battery assessed cognitive dysfunction. Data were correlated with BD activity as well as quality of life (SF-36).

RESULTS

We included 20 consecutive patients (16 men, four women) with a median [IQR] age of 38 (30.0-45.5) and a median disease duration of 7 years (1.8-11.0). Five patients had an abnormal brain MRI. The SCL-90-R questionnaire highlighted eight psychopathological profiles (42.1%) that correlated with altered quality of life and more severe fatigue. The most frequent symptoms were anxiety (9/19, 47.4%), somatization (8/19, 42.1%) and phobia (5/19, 26.3%). Psychopathological symptoms appeared to be more severe, but not more frequent, in neuro-Behçet's patients. Based on standardized cognitive evaluation, nine patients had cognitive impairment defined by three or more altered tests. Notably, 6/9 patients did not have any complaint of memory loss and were thus considered ansognostic.

CONCLUSION

Cognitive involvement was significantly associated with BD activity score (BSAS) but not with brain MRI abnormalities.

A Systematic Review of Neurocognitive Functioning in Behçet's Disease

Behçet's disease (BD) is a vascular, inflammatory multisystem disorder with neuro-Behçet's (NBD) diagnosed in a subset of patients with neurological manifestations. The objective of this review was to determine whether neurocognitive dysfunction is observed in BD, in which neurocognitive domains, and whether there are differences in rates of dysfunction observed between BD and NBD groups. Studies of any methodology were included that reported results from standardized neurocognitive assessment measures in participants with BD or NBD. Twelve group comparison studies met the criteria for inclusion in the review (totalling 284 BD and 157 NBD participants), as well as 17 case study/series papers (11 BD, 35 NBD). Issues with blinding, incomplete data reporting and selective reporting bias were found across the group and case study/series papers, as well as inadequate statistical adjustment for multiple comparisons in the group studies, and the lack of the use of appropriate norms or adjustment for premorbid ability in the case series/studies papers. These quality issues impacted on the conclusions that could be drawn from the current literature. Neurocognitive dysfunction was found in NBD compared to health controls (HC) in a higher proportion of results across studies, than in comparisons between BD and HC groups. The domains in which neurocognitive attenuation was most often reported were visual spatial ability, working memory and acquired knowledge, with more than 25% of these results showing significantly lower functioning in both the BD and NBD groups compared to HC. More than 25% of the processing speed and long-term memory encoding and retrieval results were also lower for the NBD group, compared to HC. Group comparisons between NBD and multiple sclerosis participants indicated few significant differences in neurocognitive test results. The majority of case study/series participants were found to have some degree of attenuated neurocognitive functioning, as defined by case study/series authors.

Psychiatric and functional neuroimaging abnormalities in chronic hepatitis C virus patients: Is vasculitis a contributing factor?

BACKGROUND AND STUDY AIMS

Central nervous system (CNS) involvement in hepatitis C virus (HCV) infection has different facets such as anxiety, depression, cognitive impairment and vasculitis. We were interested in detecting subclinical CNS involvement in chronic HCV infected subjects with and without systemic vasculitis.

PATIENTS AND METHODS

Nineteen patients (15 females and 4 males) with chronic HCV infection (mean age 46.5 ± 7 and mean duration since diagnosis of HCV infection 4.7 ± 4 years, including 6 (32%) Child-Pugh class A cirrhotic patients) and 30 age, sex and education matched healthy control subjects were studied. Thirteen patients had associated vasculitis. Patients and control subjects were assessed using the block design and comprehension subtests of Wechsler Bellevue Adult Intelligence Scale, Wechsler Memory scale (WMS), Beck Anxiety Inventory (BAI) and Beck Depression Inventory (BDI). Brain HMPAO Single Photon Emission Computed Tomography (SPECT) was performed for HCV patients.

RESULTS

Patients with HCV had lower scores on the block design test compared to control subjects (8.37 ± 1.89 versus 10.37 ± 1.47, p < 0.001), lower total WMS scores (43.15 ± 10.49 versus 60.27 ± 8.08, p < 0.001) and higher anxiety and depression scores (16.94 ± 10.46 and 37.17 ± 10.38 versus 10.3 ± 4.67 and 28.9 ± 5.99, p = 0.004 and 0.001, respectively). Total WMS were lower in HCV patients with vasculitis compared to those without vasculitis (39.14 ± 9.3 versus 51.17 ± 8.3, p = 0.019) while the block design and comprehension tests, BAI and BDI were not significantly different between both groups. The block design and comprehension tests, WMS, BAI and BDI were not significantly different between cirrhotic and non-cirrhotic patients. Seven patients had different patterns of cerebral hypoperfusion on SPECT, and all of them had associated vasculitis. Abnormal SPECT was associated with lower total WMS scores (35.87 ± 10.8 versus 46.79 ± 8.6 in those with normal SPECT, p = 0.049).

CONCLUSIONS

Vasculitis may contribute to the development of neuropsychiatric involvement in HCV patients.

Chronic behavior disturbance and neurocognitive deficits in neuro-Behcet's disease: a case study

Behcet's disease is a vasculitis and multisystem inflammatory syndrome. Neurological abnormalities occur in a subset of patients. This report presents a case of neuro-Behcet's disease characterized by an initial onset of behavior changes prior to diagnosis, which evolved into a chronic behavioral syndrome. Neuroimaging investigations revealed progressive periventricular white matter and brainstem atrophy and lesions in the basal ganglia and deep white matter tracts, while neuropsychological investigations revealed reductions in information processing, executive functioning, and memory. The case indicates that behavior changes may be the first symptoms to emerge in Behcet's, before other defining features of the disease.

[Neurological and psychiatric disorders in Behҫet's disease]

The data of the literature on epidemiology, clinical manifestations, diagnosis and treatment of Behcet's disease are presented. Particular attention is paid to international recommendations (2014) on the classification, diagnostic criteria and treatment of neurological symptoms of Behҫet disease.

Headache in Behçet's syndrome: review of literature and NYU Behçet's syndrome center experience

Headache, a common and disabling symptom in Behçet's syndrome, may be associated with a variety of neurologic syndromes and ocular inflammation, or may present as an isolated feature. Our objective is to describe the various neurologic and ocular syndromes of Behçet's syndrome of which headache is a symptom, and to review the features of isolated headaches in Behçet's. We also report results of a study of headache in Behçet's syndrome patients who are followed at NYU Hospital for Joint Diseases, the first study of its kind in North American patients, and the first to document prevalence of both episodic and chronic daily headache in Behçet's.

Role of Brain Perfusion SPECT with 99mTc HMPAO in the Assessment of Response to Drug Therapy in Patients with Autoimmune Vasculitis: A Prospective Study

BACKGROUND

The diagnosis of vasculitis in the brain remains a quite difficult achievement. To the best of our knowledge, there is no imaging method reported in literature which is capable of reaching to a diagnosis of vasculitis with very high sensitivity.

AIM

The aim of this study was to determine whether perfusion brain single photon emission computed tomography (SPECT) can be usefully employed in monitoring the treatment of vasculitis, allowing treating only potentially responder patients and avoiding the side effects on patients who do not respond.

MATERIALS AND METHODS

Twenty patients (two males and 18 females) suffering from systemic lupus erythematosus (SLE; n = 5), Behcet's disease (BD; n = 5), undifferentiated vasculitis (UV; n = 5), and Sjogren's syndrome (SS; n = 5) were included in the study. All patients underwent a wide neurological anamnestic investigation, a complete objective neurological examination and SPECT of the brain with 99mTc-hexamethyl-propylene-aminoxime (HMPAO). The brain SPECT was then repeated after appropriate medical treatment. The neurological and neuropsychiatric follow-up was performed at 6 months after the start of the treatment.

RESULTS

Overall, the differences between the scintigraphic results obtained after and before the medical treatment indicated a statistically significant increase of the cerebral perfusion (CP). In 19 out of 200 regions of interest (ROI) studied, the difference between pre- and post treatment percentages had negative sign, indicating a worsening of CP. This latter event has occurred six times (five in the same patients) in the UV, 10 times (eight in the same patients) in the SLE, never in BD, and three times (two in the same patient) in the SS.

CONCLUSION

The reported results seem to indicate the possibility of identifying, by the means of a brain SPECT, responder and nonresponder (unchanged or worsened CP) patients, affected by autoimmune vasculitis, to the therapy.

Kleptomania in patients with neuro-Behçet's disease

OBJECTIVE

This study was conducted to characterize the prevalence and clinical features of kleptomania, an impulse control disorder, in patients with Behçet's disease involving the central nervous system.

SUBJECTS AND METHODS

Medical records of 350 patients with neuro-Behçet's disease were evaluated, and clinical and neuropsychological features of patients with kleptomania were noted.

RESULTS

Of the 350 neuro-Behçet's disease patients 6 (1.7%) had presented with symptoms that fulfilled the criteria of kleptomania according to the revised 4th version of the Diagnostic and Statistical Manual of Mental Disorders. The 6 patients (5 men, 1 woman) had parenchymal lesions and had developed kleptomania during remission. Magnetic resonance imaging done on the 6 patients before the onset of kleptomania mostly revealed brainstem lesions. Psychiatric assessment did not show any comorbid psychiatric disorders and neuropsychological evaluation showed executive dysfunction in all patients.

CONCLUSION

The 6 patients with kleptomania had developed a frontal lobe syndrome.

Cognitive impairment in neuro-Behcet's disease and multiple sclerosis: a comparative study

Both multiple sclerosis (MS) and neuro-Behcet's disease (NBD) can cause a cognitive dysfunction mainly involving the executive functions. We conducted this study to clarify the probable differential cognitive/behavioral profiles of MS and NBD. Twenty consecutive cases with parenchymal NBD (13 male, seven female), and 20 cases with MS (five male, 15 female) were evaluated. Both groups had a thorough neurological examination; an evaluation for Expanded Disability Status Scale (EDSS), Multiple Sclerosis Functional Composite (MSFC), and Beck's Depression Scale; and a detailed neuropsychological evaluation masked to the diagnosis. Among the two groups, male/female ratio differed significantly while other demographic and clinical features were not different. In California Verbal Learning Test, both short- and long-term delayed recall and cued recognition were worse in neuro-Behcet's cases. They had impaired semantic clustering and increased false positives. Stroop Test was also more impaired in neuro-Behcet's cases. They needed significantly more trials to complete the first category of the Wisconsin Card Sorting Test and had a poorer total Frontal Behavioral Inventory Score. Our results suggest that neuro-Behcet's patients have a more severe "frontal"-executive dysfunction than MS patients.