The subclinic autonomic dysfunction in patients with Behçet disease: an electrophysiological study

Therapeutic approach to central nervous system involvement of Behçet's disease

BACKGROUND

Neurologic involvement in Behçet's disease (BD) represents a major cause of disease morbidity and mortality. Early recognition and timely treatment represent crucial aspects that aim at preventing long-term disability. The absence of robust and evidence-based studies further complicates the management of neuro-BD (NBD). In this review we aim at collecting the best available evidence and suggest a treatment algorithm for an optimal and personalized management of NBD.

EVIDENCE ACQUISITION

PubMed (NLM) database for papers written in English language was used to retrieve relevant articles for this review.

RESULTS AND CONCLUSIONS

Neurologic involvement in BD is one of the most serious and challenging aspects to manage, particularly in its chronic progressive form. It is important to distinguish between acute and chronic progressive NBD, as treatment may vary considerably. Currently, no standardized treatment guidelines support physicians in the decision-making process that therefore relies on low-level evidence. High dose corticosteroids remain the cornerstone for managing acute phase both in the parenchymal and non-parenchymal involvement. Prevention of relapses and control of disease progression represent crucial goals for acute and chronic progressive NBD respectively. In this regard, mycophenolate mofetil and azathioprine are valuable options in the acute NBD. On the other hand, low weekly dose methotrexate has been suggested for chronic progressive NBD. Refractory cases or intolerant patients to conventional therapies may benefit from biologic agents, particularly infliximab. First-line infliximab may be preferred in severe patients with high risk of damage. Other agents including tocilizumab, interleukin-1 inhibitors, B-cell depletion therapy and to a lesser extent, interferon-α and intravenous immunoglobulins are potential options in severe and multidrug resistant cases. Due to multiple organ involvement in BD, long-term treatment should be determined by a multidisciplinary approach. Therefore, multicenter collaborations in the context of international registry-based projects could promote data sharing, standardization of more clinical outcomes and knowledge diffusion that hopefully may optimize therapy and personalize the management of patients with such a complex syndrome.

Cutaneous manifestations of orthostatic intolerance syndromes

Dysautonomia refers to a group of autonomic nervous system disorders that affect nearly 70 million people worldwide. One subset of dysautonomia includes syndromes of orthostatic intolerance (OI), which primarily affect adolescents and women of childbearing age. Due to the variability in disease presentation, the average time from symptom onset to diagnosis of dysautonomia is 6 years. In general, there is a paucity of dermatological research articles describing patients with dysautonomia. The objective of this review is to summarize the existing literature on cutaneous manifestations in dysautonomia, with an emphasis on syndromes of OI. A PubMed database of the English-language literature (1970–2020) was searched using the terms “dysautonomia”, “orthostatic intolerance”, “cutaneous”, “skin”, “hyperhidrosis”, “hypohidrosis”, “sweat”, and other synonyms. Results showed that cutaneous manifestations of orthostatic intolerance are common and varied, with one paper citing up to 85% of patients with OI having at least one cutaneous symptom. Recognition of dermatological complaints may lead to an earlier diagnosis of orthostatic intolerance, as well as other comorbid conditions.

Heart Rate Variability as an Indicator of Autonomic Nervous System Disturbance in Behcet's Disease

Background

Behçet’s disease (BD) is a multisystemic vasculiti where cardiac involvement is not common. Previous studies have shown that the incidence of ventricular arrhythmia and sudden cardiac death (SCD) is higher in patients with BD than in the healthy population. Among various possible explanations, autonomic nervous system (ANS) dysfunction has been suggested. Few studies have evaluated ANS function in patients with BD, and the results obtained are controversial.

Objective

We aimed to assess cardiac autonomic function by heart rate variability (HRV) in patients with BD; to evaluate circadian changes in HRV; and to study the relationship between HRV parameters and disease parameters.

Methods

Thirty-six patients with Behçet’s disease (median age 42 years, 28 men) and 36 age- and sex-matched healthy volunteers were included. HRV analyses were performed in the time and frequency domains for the entire 24-hour period and for the daytime and nighttime periods. BD activity was studied with Behcet’s disease current activity form (BDCAF).

Results

Patients with BD had significantly lower values of SDNN compared to controls. PNN50, RMSSD, and HF components mean values were significantly reduced in patients than in controls implying parasympathetic impairment. LF was comparable between the two groups, whereas LF/HF ratio was significantly higher in BD group. The circadian rhythm of HRV was preserved in patient group. There was no significant correlation of CRP or disease duration with HRV indices in Behçet’s subjects. BDCAF score was found to be negatively correlated with LF/HF.

Conclusion

Patients with BD, despite no cardiovascular involvement, have reduced parasympathetic activity compared with controls. However, circadian rhythms of autonomic function were preserved. As known, there is strong evidence for the role of the ANS in the pathogenesis of ventricular arrhythmias. Thus, being a practical tool, HRV can be an interesting approach for the rhythmic follow-up of BD patients.

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Myocardial involvement in Behçet's disease may be higher in patients with Neuro-Behçet's disease: a speckle tracking echocardiographic study

BACKGROUND

Behcet's disease (BD) may present with life threating complications including neurological and cardiovascular involvement. Neuro-Behcet's disease (NBD) is one of the most important causes of morbidity and mortality in patients with BD. The aim of the present study is to investigate whether patients with NBD are different than BD patients with other manifestations in terms of subclinical myocardial dysfunction.

METHODS

Forty patients with NBD (23 female, mean age: 42.4 ± 9.4 years), 40 patients with BD (9 female, mean age: 39.7 ± 9.0 years) and 40 controls (20 male, mean age: 41.8 ± 6.5 years) were consecutively included in the study. All subjects underwent a transthoracic echocardiography for evaluation of left ventricular (LV) and atrial (LA) functions with two-dimensional (2D) speckle tracking echocardiography (STE).

RESULTS

Baseline characteristics, clinical data, LV dimensions, systolic and diastolic functions were all in normal range among the groups. LV global longitudinal strain (LV-GLS) was significantly lower in patients with NBD and BD patients without neurologic involvement compared to controls. LA conduit strain was significantly lower in patients with NBD compared to controls. Patients with both parenchymal NBD and vascular NBD manifestations had significantly lower LV-GLS and LA conduit strain compared to controls. Linear regression analysis demonstrated that among cardiovascular risk factors only presence of NBD was the independent predictor of LV-GLS.

CONCLUSIONS

BD is associated with impaired LV and LA functions. LV-GLS and LA conduit strains of the patients with NBD were lower. NBD was an independent predictor of LV-GLS, suggesting a link between neurological manifestations and cardiac dysfunction in BD patients.

Behçet's Disease with Severe Autonomic Disorders Developing after Herpes Zoster

A 58-year-old Japanese woman with herpes zoster developed Behçet's disease (BD) with symptoms including orthostatic intolerance as an autonomic disorder. Multiple immune-suppressive therapies and a β-blocker successfully controlled both the disease activity of BD and the autonomic disorders. A cytokine multiplex analysis of her serum revealed the elevation of proinflammatory cytokines [interleukin (IL)-1, IL-6, IL-12, tumor necrosis factor alfa (TNFα), and interferon gamma (IFN-γ)] and a low IL-10 concentration. IL-10 production is reported to be important for defense against herpes zoster virus (VZV). Insufficient IL-10 production is reported in BD. The reactivation of VZV with this cytokine profile suggests that BD will develop with various symptoms, including severe autonomic disorders.

Neuro-Behcet's disease: An update on diagnosis, differential diagnoses, and treatment

Neuro-Behcet's disease (NBD) is defined as a combination of neurologic symptoms and/or signs in a patient with Behcet's disease (BD). Relevant syndromes include brainstem syndrome, multiple-sclerosis like presentations, movement disorders, meningoencephalitic syndrome, myelopathic syndrome, cerebral venous sinus thrombosis (CVST), and intracranial hypertension. Central nervous involvement falls into parenchymal and non-parenchymal subtypes. The parenchymal type is more prevalent and presents as brainstem, hemispheric, spinal, and meningoencephalitic manifestations. Non-parenchymal type includes CVST and arterial involvement. Perivascular infiltration of polymorphonuclear and mononuclear cells is seen in most histo-pathologic reports. In parenchymal NBD, cerebrospinal fluid (CSF) generally exhibits pleocytosis, increased protein and normal glucose. In NBD and CVST, CSF pressure is increased but content is usually normal. The typical acute NBD lesions in brain magnetic resonance imaging (MRI) are mesodiencephalic lesions. The pattern of extension from thalamus to midbrain provides a cascade sign. Brain MRI in chronic NBD usually shows brain or brainstem atrophy and/or black holes. The spinal MRI in the acute or subacute myelopathies reveals noncontiguous multifocal lesions mostly in cervical and thoracic lesions. In chronic patients, cord atrophy can also be seen. Brain MRI (particularly susceptibility-weighted images), MR venography (MRV) and computerized tomographic venography (CTV) can be used to diagnose CVST. Parenchymal NBD attacks can be treated with glucocorticoids alone or in combination with azathioprine. For patients with relapsing-remitting or progressive courses, shifting to more potent immunosuppressive drugs such as mycophenolate, methotrexate, cyclophosphamide, or targeted therapy is warranted. For NBD and CVST, immunosuppressive drugs with or without anticoagulation are suggested.

Measurement of Contrast Sensitivity in Patients with Behçet's Disease without Ocular Involvement

Purpose

To evaluate contrast sensitivity in patients with Behçet's disease (BD) without ocular involvement.

Methods

The study group was composed of 47 BD patients (20 to 50 years of age) who did not have ocular involvement. The control group was composed of 47 normal volunteers who were similar to the study group in terms of age and gender. No participants in this study had any ocular or systemic pathologies except for BD. The contrast sensitivity measurements were performed using the Functional Acuity Contrast Test under photopic conditions, and the results were compared between the two groups.

Results

The mean age of the BD patients and control subjects was 34.5 ± 9.7 and 33.2 ± 7.6 years, respectively. The mean disease duration of the BD patients was 5.5 ± 6.4 years. There was a statistically significant decrease at five spatial frequencies (A, 1.5; B, 3; C, 6; D, 2; and E, 18 cycles per degree) in patients with BD compared with control subjects (p < 0.001, p = 0.004, p = 0.002, p < 0.001, and p = 0.001, respectively).

Conclusions

The contrast sensitivity of BD patients without ocular involvement was lower than that of the control group. Further studies seem mandatory to confirm our results.

The autonomic dysfunction in patients with lupus disease: An electrophysiological study

Background:

The aim of this study was to investigate autonomic nervous system (ANS) function by using electrophysiological tests in patients with systemic lupus erythematosus (SLE).

Materials and Methods:

This descriptive analytical study was done on 28 individuals with a history of lupus and ten age- and sex-matched healthy objects were being selected randomly. The autonomy questionnaire has been used to determine clinical symptom of ANS involvement. The electrophysiological assessments of ANS function were performed by sympathetic skin response (SSR). The mean values of sympathetic (SSR latency and amplitude) parameters were compared to determine any correlations between SSR parameters and clinical characteristics of ANS.

Results:

28 SLE patients (3 males, 25 females) with a mean age of 34.6 ± 9.74 years and 10 control subjects (4 males, 6 females) with a mean age of 36.8 ± 6.43 years were included in the study. Among patients 17 (60.7%) exhibited autonomic symptoms. Headache was the most common issue with the highest percentage rate (41.17%). The mean latency and amplitude of SSR were increased (1.52 ± 0.16 vs. 1.39 ± 0.16 and 107 ± 15.6 vs. 110 ± 15.6, respectively), compared to control. A significant difference was observed between the SSR test results of patients with lupus compared to normal healthy objects (P < 0.05). R = 0.43 correlation was found between autonomy questionnaire scores and SSR (P < 0.05).

Conclusion:

It could be concluded that latency measures in SSR test can be used as a valuable and accurate evaluation guideline for autonomic system assessment.

Calprotectin in rheumatic diseases

Calprotectin is a heterodimer formed by two proteins, S100A8 and S100A9, which are mainly produced by activated monocytes and neutrophils in the circulation and in inflamed tissues. The implication of calprotectin in the inflammatory process has already been demonstrated, but its role in the pathogenesis, diagnosis, and monitoring of rheumatic diseases has gained great attention in recent years. Calprotectin, being stable at room temperature, is a candidate biomarker for the follow-up of disease activity in many autoimmune disorders, where it can predict response to treatment or disease relapse. There is evidence that a number of immunomodulators, including TNF-α inhibitors, may reduce calprotectin expression. S100A8 and S100A9 have a potential role as a target of treatment in murine models of autoimmune disorders, since the direct or indirect blockade of these proteins results in amelioration of the disease process. In this review, we will go over the biologic functions of calprotectin which might be involved in the etiology of rheumatic disorders. We will also report evidence of its potential use as a disease biomarker. Impact statement Calprotectin is an acute-phase protein produced by monocytes and neutrophils in the circulation and inflamed tissues. Calprotectin seems to be more sensitive than CRP, being able to detect minimal residual inflammation and is a candidate biomarker in inflammatory diseases. High serum levels are associated with some severe manifestations of rheumatic diseases, such as glomerulonephritis and lung fibrosis. Calprotectin levels in other fluids, such as saliva and synovial fluid, might be helpful in the diagnosis of rheumatic diseases. Of interest is also the potential role of calprotectin as a target of treatment.

Epidemiology and management of neuropsychiatric disorders in Behçet's syndrome

Behçet's syndrome (BS) is a systemic, chronic, relapsing vasculitis, typically characterized by recurrent orogenital ulcers, ocular inflammation and skin manifestations; articular, vascular, gastroenteric and neurological involvement may also occur. Besides the other clinical features of BS, it seems relatively frequent that patients with BS develop a neurobehavioural syndrome, characterized by euphoria, bipolar disorders and paranoid attitudes, loss of insight/disinhibition, and indifference to their disease, defined as 'neuro-psycho-BS'. To date, the pathogenetic mechanism underlying neuro-psycho-BS has not been determined. It may be secondary to organic neurological involvement, or it may be related to poor quality of life and the relapsing course of the disease. Another engaging theory suggests that it could be related to the frequent observation of psychiatric symptoms during relapses or, in some cases, in the phases preceding reactivation of the disease; these elements suggest that psychiatric disorders in BS could represent a crucial element, whether a psychiatric subset or a distinct clinical feature of the disease. Moreover, it has been reported that cognitive impairment in BS can be seen with or without central nervous system involvement. Globally, psychiatric symptoms have been described as being multifaceted, ranging from anxiety disorders to depressive-bipolar disorders or to psychotic ones. In addition, some psychological characteristics of BS patients seem to predispose them to maladaptive stress management, which may lead to stress-related disorders, including anxiety and depression. Therefore, the aims of this review are to explore the epidemiology of neuro-psycho-BS by evaluating the relationship between the stress system and the multifaceted psychiatric manifestations in BS, and to summarize the therapeutic strategy used.

Elevated serum levels of calprotectin (MRP8/MRP14) in patients with Behçet's disease and its association with disease activity and quality of life

BACKGROUND

Behçet's disease (BD) is an inflammatory disease with multisystem chronic vasculitis. The disease is characterized by attacks of oral and genital ulcerations, skin lesions, arthritis, uveitis and deep vein thrombosis. The main histopathological feature is known to be vascular inflammatory change. Calprotectin (MRP8/MRP14) has been identified as an important alarmin that is expressed by activated phagocytes, granulocytes, monocytes and vascular endothelial cells, recognized by toll-like receptors, and induces a thrombogenic and inflammatory response in human microvascular endothelial cells.

AIM

We aimed to investigate the serum levels of calprotectin in patients with BD and its association with disease activity and quality of life.

MATERIALS AND METHODS

Forty-eight patients (25 males and 23 females) and 47 healthy controls (29 males and 18 females) were included to study. BD Current Activity Form (BDCAF) was used to assess the disease activity of patients with BD. Quality of life was assessed by using the Nottingham Health Profile (NHP). Depression and anxiety symptoms were assessed by using the Hospital Anxiety and Depression Scale (HADS). Serum level of calprotectin was determined using an ELISA kit. Results. Serum levels of calprotectin was significantly higher in patients with BD compared to healthy controls (p = 0.001). Serum levels of calprotectin did not correlate with the sores of BDCAF, NHP and HADS.

CONCLUSION

Calprotectin may play a significant role in the pathogenetic mechanisms of BD. Further insight into this area of research might provide opportunities to develop novel treatment strategies.

Does Behcet's disease associate with neuropathic pain syndrome and impaired well-being?

Previously peripheral neuropathy signs have been reported in inflammatory chronic diseases but the presence of neuropathic pain syndrome (NPS) in Behcet's disease (BD) is unclear. The aim of this study was to investigate the association of BD with NPS and impaired quality of life and sleep quality. A total of 111 patients diagnosed as BD and 52 healthy controls were included. Pain severity was assessed by visual analogue scale (VAS) in rest and during activity. The NPS was diagnosed according to the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) index. The well-being and sleep disturbances of the groups were evaluated with Psychological General Well-Being (PGWB) Scale and Pittsburg Sleep Quality Index (PSQI). Although there were no one with NPS in healthy controls, the proportion of NPS in patients with BD was 19.8 % (p = 0.001). The VAS scores both in activity and at rest were higher in BD (p < 0.001). There was statistically significant decrease in total PGWB score in BD patients compared to healthy controls (p < 0.001). And significant increase in LANSS score was observed in patients with BD compared to healthy controls (p = 0.000). The total LANSS scores showed significant positive correlation with PSQI scores (r = 0.322) and negative correlation with total PGWB scores (r = -0.672) in patients with BD. We observed a positive correlation between LANSS and VAS (rest and activity) scores (r = 0.44, r = 0.42 respectively). The NPS seems to be associated with BD which should be taken into consideration in patients with neuropathic signs. The quality of life (QoL) and quality of sleep of the patients with BD were found to be impaired and this may be due to the presence of NPS.