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She CH, Hu D, Zou J, Bao HF, Shen Y, Cai JF, Ye JF, Luo D, Jian LL, Ma HF, Hou CC, Chen Y, Guan JL. Clinical phenotypes of adult-onset Behçet's syndrome: a comprehensive cross-sectional study in China. Clin Rheumatol 2024; 43:2261-2271. [PMID: 38724819 DOI: 10.1007/s10067-024-06995-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 04/13/2024] [Accepted: 05/03/2024] [Indexed: 06/19/2024]
Abstract
Behçet's syndrome (BS) is a variant vasculitis that can involve multiple organs with inflammatory manifestations. This study aimed to provide a more comprehensive analysis of the clinical phenotypes and characteristics of BS patients. We enrolled 2792 BS patients referred from China nationwide to Huadong Hospital Affiliated to Fudan University from October 2012 to December 2022. Detailed assessments of demographic information, clinical manifestations, laboratory results, gastroscopy, and medical imaging were conducted. Cluster analysis was performed based on 13 variables to determine the clinical phenotypes, and each phenotype was characterized according to the features of BS patients. A total of 1834 BS patients were included, while 958 invalid patients were excluded. The median age at onset was 31 years (IQR, 24-40 years), and the median disease duration was 10 years (IQR, 5-15 years). Eight clusters were identified, including mucocutaneous (n = 655, 35.7%), gastrointestinal (n = 363, 19.8%), articular (n = 184, 10%), ocular (n = 223, 12.2%), cardiovascular (n = 119, 6.5%), neurological (n = 118, 6.4%), vascular (n = 114, 6.2%), and hematological phenotype (n = 58, 3.2%). Ocular (RR = 1.672 (95% CI, 1.327-2.106); P < 0.001), gastrointestinal (RR = = 1.194 (95% CI, 1.031-1.383); P = 0.018), cardiovascular (RR = = 2.582 (95% CI, 1.842-3.620); P < 0.001), and vascular (RR = = 2.288 (95% CI, 1.600-3.272); P < 0.001) involvement were more prevalent in male BS patients, while the hematological (RR = 0.528 (95% CI, 0.360-0.776); P = 0.001) involvement was more common among female patients. BS presents significant heterogeneity and gender differences. The eight phenotypes of BS patients we propose hold the potential to assist clinicians in devising more personalized treatment and follow-up strategies. Key Points • This cluster analysis divided adult-onset BS into eight clinical phenotypes. • BS demonstrates a high level of clinical heterogeneity and gender differences. • Hematologic phenotypes of BS present distinctive clinical characteristics.
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Affiliation(s)
- Chun-Hui She
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Dan Hu
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Jun Zou
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Hua-Fang Bao
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Yan Shen
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Jian-Fei Cai
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Jing-Fen Ye
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Dan Luo
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Lei-Lei Jian
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Hai-Fen Ma
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China
| | - Cheng-Cheng Hou
- Department of Rheumatology and Immunology, the First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Yong Chen
- Department of Rheumatology and Immunology, Affiliated Hospital of Zunyi Medical University, Guizhou, China
| | - Jian-Long Guan
- Department of Rheumatology and Immunology, Huadong Hospital Affiliated to Fudan University, #221 Yan'an West Road200040, Shanghai, China.
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Dinler M, Yaşar Bilge NŞ, Arslan AE, Yıldırım R, Kaşifoğlu T. Neurologic manifestations of Behçet disease: rheumatology experience. Z Rheumatol 2024; 83:200-205. [PMID: 37848717 DOI: 10.1007/s00393-023-01436-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/07/2023] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Neurologic involvement in Behçet disease (BD) is a rare manifestation. Herein, we aimed to evaluate the clinical features and treatment choices of neuro-Behçet (NB) patients. METHODS There were records of 800 BD patients between 1998 and 2021. Fifty-five of the BD patients had NB and the files of these patients were retrospectively evaluated. Patients were grouped into three subgroups: 22 (40%) had non-parenchymal, 25 (45%) had parenchymal, and 8 (15%) had both parenchymal and non-parenchymal (mixed) involvement. RESULTS Of the 55 patients, 32 were male. Twenty-six of the NB patients were diagnosed with BD simultaneously. The most common complaint was headache (n = 24, 44%). The most affected site was periventricular white matter (n = 21, 38%). All patients had received corticosteroids. Azathioprine (AZA; n = 39, 71%) was the most common immunosuppressive agent after corticosteroids, followed by cyclophosphamide (n = 16, 29%). CONCLUSION Neurologic involvement is a rare complication of BD but is related to increased mortality and morbidity. Neurologic manifestations may be the initial symptom of BD, thus leading to diagnosis. Both neurology and rheumatology specialists should be aware of this rare condition.
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Affiliation(s)
- Mustafa Dinler
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Nazife Şule Yaşar Bilge
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey.
| | - Ayşe Erçin Arslan
- Department of Internal Medicine, Eskisehir Osmangazi University, Eskisehir, Turkey
| | - Reşit Yıldırım
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
| | - Timuçin Kaşifoğlu
- Division of Rheumatology, Department of Internal Medicine, Faculty of Medicine, Osmangazi University, Eskişehir, Turkey
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Çakan ZK, Yağız B, Pehlivan Y. Clinical features of Behçet's disease and prediction of the use of biologics in 488 cases: a single tertiary center study. Rheumatol Int 2023; 43:2089-2097. [PMID: 37604938 DOI: 10.1007/s00296-023-05416-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/01/2023] [Indexed: 08/23/2023]
Abstract
The objectives are to describe the demographic and clinical properties of Behçet's disease (BD) and investigate their relationship with the use of biological agents. Four hundred-eighty-eight patients, (299 (61.3%) males, 189 (38.7%) females), who fulfilled the ISG classification criteria for BD were included, retrospectively. The patient's demographics, disease onset age (DOA), clinical findings of the disease, and the drugs were determined and analyzed statistically. The means of patient age and DOA were 40.7 ± 9.9 and 30.8 ± 8.8 years, respectively. The most common initial findings were oral ulcer (OU)s (30.1%), genital ulcer (GU) (27.5%), ocular involvement (OI) (12.5%), and papulopustular lesion (PPL)s (10.1%). The most common clinical manifestations were OUs (96.9%), PPLs (70.2%), HLA-B51 (64.4%), positive pathergy reaction (26.4%), GU (58.8%), OI (44.7%), erythema nodosum (29.8%), and vascular involvement (VSI) (27.3%). Although, the frequency of GU was higher in females (p = 0.01), PPLs (p = 0.001) and VSI (p = 0.001) were higher in males. Sixty-three (8.9%) patients used a biological agent. Its frequency was higher in younger patients (< 40 years) (p = 0.006), males (p = 0.012) and patients with OI (p = 0.001). Besides, the DOA (p = 0.012) and the current age (p = 0.001) were lower in biological agent users. The possibility of using biological agent was increased in males (OR = 2.2), patients with OI (OR = 2.7) and young patients (OR = 0.9). Mucocutaneous lesions are distinctive features of BD, especially OUs precede other findings. GU was more common in females and PPLs and VSI were in males. The probability of using biologics is higher in males, patients with OI, and young patients.
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Affiliation(s)
- Zeliha Kübra Çakan
- Division of Oncology, Department of Internal Medicine, Cerrahpasa School of Medicine, Istanbul University-Cerrrahpasa, Istanbul, Turkey.
| | - Burcu Yağız
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Uludağ University, Bursa, Turkey
| | - Yavuz Pehlivan
- Division of Rheumatology, Department of Internal Medicine, School of Medicine, Uludağ University, Bursa, Turkey
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Tamanini JVG, Sabino JV, Cordeiro RA, Mizubuti V, Villarinho LDL, Duarte JÁ, Pereira FV, Appenzeller S, Damasceno A, Reis F. The Role of MRI in Differentiating Demyelinating and Inflammatory (not Infectious) Myelopathies. Semin Ultrasound CT MR 2023; 44:469-488. [PMID: 37555683 DOI: 10.1053/j.sult.2023.03.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2023]
Abstract
Demyelinating and inflammatory myelopathies represent a group of diseases with characteristic patterns in neuroimaging and several differential diagnoses. The main imaging patterns of demyelinating myelopathies (multiple sclerosis, neuromyelitis optica spectrum disorder, acute disseminated encephalomyelitis, and myelin oligodendrocyte glycoprotein antibody-related disorder) and inflammatory myelopathies (systemic lupus erythematosus-myelitis, sarcoidosis-myelitis, Sjögren-myelitis, and Behçet's-myelitis) will be discussed in this article, highlighting key points to the differential diagnosis.
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Affiliation(s)
| | - João Vitor Sabino
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Rafael Alves Cordeiro
- Rheumatology Division, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Sao Paulo University, SP, Brazil
| | - Vanessa Mizubuti
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | | | - Juliana Ávila Duarte
- Department of Radiology and Diagnostic Imaging, HCPA, Porto Alegre, Rio Grande do Sul, Brazil
| | - Fernanda Veloso Pereira
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Simone Appenzeller
- Department of Orthopedics, Rheumatology and Traumatology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Alfredo Damasceno
- Department of Neurology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil
| | - Fabiano Reis
- Department of Anesthesiology, Oncology and Radiology, Faculty of Medical Sciences, State University of Campinas (UNICAMP), Campinas, SP, Brazil.
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Wu Y, Yin W, Liu S, Wang S, Ding Y. Diagnosis and management of Neuro-Behçet disease with isolated intracranial hypertension: a case report and literature review. BMC Neurol 2023; 23:335. [PMID: 37749518 PMCID: PMC10518965 DOI: 10.1186/s12883-023-03392-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 09/12/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUND Neuro-Behçet's disease (NBD), characterized by isolated intracranial hypertension, is a rarely encountered condition, especially in children. In this study, we describe the treatment of a pediatric patient with NBD, who exhibited isolated intracranial pressure elevation as indicated by the initial manifestation of diplopia and physical examination finding of papilledema. CASE PRESENTATION An 8-year-old boy was admitted to the hospital with a confirmed diagnosis of Behçet's disease (BD) over eight months. The patient also presented with the symptom of diplopia for three days. The evaluation of the patient's nervous system did not reveal any apparent abnormalities. The measurement of cerebrospinal fluid pressure yielded a reading of 470 mm H2O. The examination of the fundus indicated papilledema, and imaging scans revealed evidence of focal demyelination. The symptoms of the child showed alleviation after the administration of mannitol, methylprednisolone, and azathioprine. Furthermore, this study involved a comprehensive analysis of 18 cases of NBD with isolated intracranial hypertension, comprising one case reported herein and 17 cases from the literature review. Three cases were children, and an equal distribution of males and females 9:9 was noted. The average age at the onset of symptoms was 24.7 years (8-38 years). Headache (90%) was the most commonly reported clinical manifestation, followed by blurred vision or diplopia (80%). The ocular manifestations included papilledema (100%), abducent nerve paralysis (20%) and local eye hemorrhages in the retina (30%). Notably, 88.9% of these ocular manifestations were relieved or cured after treatment. CONCLUSION This study presents the first reported case of NBD with isolated intracranial hypertension in the pediatric population of China. In a child with Bechet's disease presenting with features of raised intracranial pressure, it is important to be aware of neuro Bechet's presenting with intracranial hypertension without other neurological abnormalities. This will help make early diagnosis, institute treatment and prevent sequelae resulting from untreated raised intracranial pressure.
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Affiliation(s)
- Yali Wu
- Department of Rheumatology and Immunology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430016, China
| | - Wei Yin
- Department of Rheumatology and Immunology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430016, China
| | - Shufang Liu
- Department of Ophthalmology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430016, China
| | - Shasha Wang
- Department of Rheumatology and Immunology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430016, China
| | - Yan Ding
- Department of Rheumatology and Immunology, Wuhan Children's Hospital (Wuhan Maternal and Child Healthcare Hospital), Tongji Medical College, Huazhong University of Science & Technology, Wuhan, 430016, China.
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6
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Silva L, Correia J, Santos E. [Diagnosis and Treatment of Neuro-Behçet: A Clinical Update]. ACTA MEDICA PORT 2023; 36:588-594. [PMID: 37345389 DOI: 10.20344/amp.19734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/03/2023] [Indexed: 06/23/2023]
Abstract
Behçet's disease is a relapsing multisystemic inflammatory syndrome characterized by recurrent oral and/or genital ulcers, uveitis, arthritis, skin lesions, and gastrointestinal and neurological involvement. Neuro-Behçet corresponds to nervous system involvement and is one of the most severe complications of Behçet disease. It occurs in 3% to 30% of cases and is categorized into parenchymal (most common) or non-parenchymal disease. The most common manifestation of parenchymal neuro-Behçet is meningoencephalitis with involvement of the brainstem, where patients present with cranial neuropathies, encephalopathy, sensory-motor syndromes, epilepsy, or myelitis. The main non-parenchymal manifestation is cerebral venous thrombosis. Neuro-Behçet has a predominantly subacute course, with remission within weeks, or clinical progression in one third of the cases. The diagnosis is essentially clinical and diagnostic tests help to corroborate the suspicion, distinguish from differential diagnoses, and exclude complications. Brain magnetic resonance imaging allows the identification of acute lesions (hypointense or isointense on T2-weighted and hypointense on T1-weighted sequences) contrast-enhanced, and chronic lesions characterized by non-contrast enhanced small lesions and brainstem atrophy. If non-parenchymal involvement is suspected, cerebral veno-magnetic resonance imaging /computed tomography should be performed. Cerebrospinal fluid shows elevated proteinorachia and pleocytosis in parenchymal and no changes in non-parenchymal neuro-Behçet (except increased opening pressure). Outbursts of parenchymal disease should be treated with high dose intravenous corticosteroid therapy, with subsequent switch to oral corticoids, followed by biologic therapy, usually an anti-TNF. The treatment of cerebral venous thrombosis is controversial and may consist of a combination of corticosteroids and anticoagulation.
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Affiliation(s)
- Lénia Silva
- Serviço de Neurologia. Centro Hospitalar Universitário de Santo António. Porto. Portugal
| | - João Correia
- Serviço de Medicina Interna. Centro Hospitalar Universitário de Santo António. Porto; Unidade Multidisciplinar de Investigação Biomédica. Instituto Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
| | - Ernestina Santos
- Serviço de Neurologia. Centro Hospitalar Universitário de Santo António. Porto; Unidade Multidisciplinar de Investigação Biomédica. Instituto Ciências Biomédicas Abel Salazar. Universidade do Porto. Porto. Portugal
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Abstract
Behçet's syndrome is a systemic vasculitis affecting arteries and veins of all sizes as well as recurrent oral, genital, and intestinal ulcers, skin lesions, predominantly posterior uveitis, and parenchymal brain lesions. These can be present in various combinations and sequences over time and diagnosis is made by recognizing the manifestations, as there are no diagnostic biomarkers or genetic tests. Treatment modalities include immunomodulatory agents, immunosuppressives and biologics, tailored according to prognostic factors, disease activity, severity, and patients' preferences.
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Affiliation(s)
- Gülen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University - Cerrahpasa, School of Medicine, Istanbul, Turkey; Behçet's Disease Research Center, Istanbul University - Cerrahpasa, Istanbul, Turkey.
| | - Didar Uçar
- Behçet's Disease Research Center, Istanbul University - Cerrahpasa, Istanbul, Turkey; Department of Ophthalmology, Istanbul University - Cerrahpasa, School of Medicine, Istanbul, Turkey
| | - Uğur Uygunoğlu
- Behçet's Disease Research Center, Istanbul University - Cerrahpasa, Istanbul, Turkey; Department of Neurology, Istanbul University - Cerrahpasa, School of Medicine, Istanbul, Turkey
| | - Hasan Yazici
- Rheumatology, Academic Hospital, Istanbul, Turkey
| | - Yusuf Yazici
- Division of Rheumatology, New York University School of Medicine, New York, NY, USA
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Neuro-Behçet - Clinical and radiological findings in a Patient of Sub-saharan African origin. Radiol Case Rep 2022; 17:592-598. [PMID: 34976265 PMCID: PMC8688177 DOI: 10.1016/j.radcr.2021.11.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 11/21/2021] [Indexed: 11/21/2022] Open
Abstract
Behçet's disease is a rare, systemic variable vessel vasculitis mostly seen in patients from the Middle East, Northern Africa and Central Asia. Neuro-Behçet disease (NBD) is often diagnosed in patients with known Behçet's disease who present with neurological symptoms and radiological features of central nervous system involvement. There are very few cases with neuro-Behçet reported from Sub-Saharan Africa in the literature. We report a case of severe parenchymal neuro-Behçet with pseudo-tumoral brainstem lesions in a young male patient of South African origin.
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Hamzaoui K, Borhani-Haghighi A, Dhifallah IB, Hamzaoui A. Elevated levels of IL-32 in cerebrospinal fluid of neuro-Behcet disease: Correlation with NLRP3 inflammasome. J Neuroimmunol 2022; 365:577820. [DOI: 10.1016/j.jneuroim.2022.577820] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 01/10/2022] [Accepted: 01/16/2022] [Indexed: 12/14/2022]
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Hecker C, Welponer T, Herold M, Trinka E, Broussalis E, Killer-Oberpfalzer M. Update on treatment strategies for vasculitis affecting the central nervous system. Drug Discov Today 2021; 27:1142-1155. [PMID: 34838730 DOI: 10.1016/j.drudis.2021.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 10/11/2021] [Accepted: 11/18/2021] [Indexed: 11/16/2022]
Abstract
Vasculitis affecting the nervous system is a rare disease that can not only present with nonspecific initial symptoms, but also run a severe course without accurate treatment. Although improvements have been achieved, diagnosis of vasculitis remains challenging, because many classification criteria are unspecific or inconclusive with regard to central nervous system (CNS) manifestations. Currently, beside an isolated primary CNS vasculitis, several systemic types of vasculitis are known to affect the nervous system. In this review, we provide an overview of the pathophysiology, current therapeutic guidelines, and highlight novel treatment strategies for CNS vasculitis.
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Affiliation(s)
- Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria.
| | - Tobias Welponer
- Department of Dermatology and Allergology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Manfred Herold
- Department of Internal Medicine III with Haematology, Medical Oncology, Haemostaseology, Infectiology, and Rheumatology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Eugen Trinka
- Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria; Neuroscience Institute, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Erasmia Broussalis
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurology, Christian Doppler University Hospital, Centre for Cognitive Neuroscience, Paracelsus Medical University Salzburg, Salzburg, Austria
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Galetta K, Bhattacharyya S. Acute Neurologic Manifestations of Systemic Immune-Mediated Diseases. Semin Neurol 2021; 41:541-553. [PMID: 34619780 DOI: 10.1055/s-0041-1733790] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Systemic autoimmune diseases can affect the peripheral and central nervous system. In this review, we outline the common inpatient consultations for patients with neurological symptoms from rheumatoid arthritis, Sjogren's syndrome, systemic lupus erythematosus, sarcoidosis, immunoglobulin G4-related disease, Behçet's disease, giant cell arteritis, granulomatosis with polyangiitis, microscopic polyangiitis, eosinophilic granulomatosis, polyarteritis nodosa, and ankylosing spondylitis. We discuss the symptoms, diagnostic strategies, and treatment options.
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Affiliation(s)
- Kristin Galetta
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shamik Bhattacharyya
- Division of Hospital Neurology, Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts
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12
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Yazici Y, Hatemi G, Bodaghi B, Cheon JH, Suzuki N, Ambrose N, Yazici H. Behçet syndrome. Nat Rev Dis Primers 2021; 7:67. [PMID: 34531393 DOI: 10.1038/s41572-021-00301-1] [Citation(s) in RCA: 68] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/11/2021] [Indexed: 12/17/2022]
Abstract
Behçet syndrome is a systemic vasculitis with an unknown aetiology affecting the small and large vessels of the venous and arterial systems. The presence of symptom clusters, regional differences in disease expression and similarities with, for example, Crohn's disease suggest that multiple pathological pathways are involved in Behçet syndrome. These disease features also make formulating disease criteria difficult. Genetic studies have identified HLA-B*51 as a genetic risk factor. However, the low prevalence of HLA-B*51 in many patients with bona fide disease, especially in non-endemic regions, suggests that other factors must also be operative in Behçet syndrome. Despite lacking a clear aetiological mechanism and definition, management of manifestations that include major vascular disease, eye disease and central nervous system involvement has improved with the help of new technology. Furthermore, even with our incomplete understanding of disease mechanisms, the prognoses of patients with Behçet syndrome, including those with eye disease, continue to improve. New treatment options and a better understanding of the underlying pathogenesis for various manifestations of this condition are required to further improve the management of the disease, which will improve patient quality of life.
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Affiliation(s)
- Yusuf Yazici
- Division of Rheumatology, New York University School of Medicine, New York, NY, USA.
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine and Behçet's Disease Research Center, Istanbul University - Cerrahpasa, Istanbul, Turkey
| | - Bahram Bodaghi
- Sorbonne University, IHU FOReSIGHT, Pitié-Salpêtrière Hospital UMR 7211 UPMC/CNRS, U972 INSERM, Transimmunom Laboratory of Excellence Sorbonne University, Paris, France
| | - Jae Hee Cheon
- Department of Internal Medicine, Yonsei University College of Medicine, Seodaemun-gu, Seoul, Korea
| | - Noburu Suzuki
- Department of Immunology and Medicine, St. Marianna University School of Medicine, Miyamae-ku, Kawasaki, Japan
| | | | - Hasan Yazici
- (Rheumatology) Academic Hospital Istanbul, Istanbul, Turkey
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13
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Shadmani G, Simkins TJ, Assadsangabi R, Apperson M, Hacein-Bey L, Raslan O, Ivanovic V. Autoimmune diseases of the brain, imaging and clinical review. Neuroradiol J 2021; 35:152-169. [PMID: 34490814 DOI: 10.1177/19714009211042879] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There is an extensive spectrum of autoimmune entities that can involve the central nervous system, which has expanded with the emergence of new imaging modalities and several clinicopathologic entities. Clinical presentation is usually non-specific, and imaging has a critical role in the workup of these diseases. Immune-mediated diseases of the brain are not common in daily practice for radiologists and, except for a few of them such as multiple sclerosis, there is a vague understanding about differentiating them from each other based on the radiological findings. In this review, we aim to provide a practical diagnostic approach based on the unique radiological findings for each disease. We hope our diagnostic approach will help radiologists expand their basic understanding of the discussed disease entities and narrow the differential diagnosis in specific clinical scenarios. An understanding of unique imaging features of these disorders, along with laboratory evaluation, may enable clinicians to decrease the need for tissue biopsy.
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Affiliation(s)
- Ghazal Shadmani
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Tyrell J Simkins
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Reza Assadsangabi
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Michelle Apperson
- Department of Neurology (Neuroimmunulogy), University of California Davis Medical center, USA
| | - Lotfi Hacein-Bey
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Osama Raslan
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
| | - Vladimir Ivanovic
- Department of Radiology, Section of Neuroradiology, University of California Davis Medical Center, USA
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14
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Yalcin Kehribar D, Gunaydin S, Ozgen M. Infliximab therapy in parenchymal neuro-Behçet's disease: A single-center experience. Int J Rheum Dis 2021; 24:1302-1307. [PMID: 34427044 DOI: 10.1111/1756-185x.14209] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/09/2021] [Accepted: 08/14/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Parenchymal neuro-Behçet's disease involvement is the most serious complication of Behçet's disease, and no sufficient data on its treatment exists. This study aims to investigate the efficacy and safety of infliximab treatment in neuro-Behçet's disease patients with parenchymal involvement. MATERIALS AND METHODS Patients who were diagnosed with Behçet's disease with parenchymal neurological involvement and underwent infliximab treatment for at least 12 months were included in the study. Demographic, clinical, and radiological data of the patients were accessed through the electronic database of our hospital. RESULTS This study comprises 19 patients who were diagnosed with neuro-Behçet's disease and used infliximab: 12 male and 7 female patients. The mean age of the patients was 36.5 ± 11.7 years, and the diagnostic age was 26.3 ± 10.8 years. The duration of treatment with infliximab was 32.3 months (minimum 11, max 79). In the 19 patients receiving infliximab treatment, 11 (58%) patients achieved remission (complete disappearance of neurological symptoms) and 7 (37%) patients achieved disease stability (no new neurological findings); steroid treatments were discontinued for these 18 patients. In addition, only 5 patients were concomitantly taking immunosuppressive drugs with the infliximab. Infliximab was discontinued after the development of a new parenchymal attack in the 9th month of infliximab treatment. CONCLUSION In conclusion, parenchymal neurological involvement in Behçet's disease is an important cause of disability, and no sufficient data exists in literature on its treatment. The results of our study suggest that infliximab treatment was effective and safe in neuro-Behçet's disease parenchymal involvement for preventing long-term neurological attacks and discontinuing corticosteroid treatment.
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Affiliation(s)
- Demet Yalcin Kehribar
- Department of Rheumatology, Medical Faculty, Ondokuz Mayıs University, Samsun, Turkey
| | - Serkan Gunaydin
- Department of Rheumatology, Medical Faculty, Ondokuz Mayıs University, Samsun, Turkey
| | - Metin Ozgen
- Department of Rheumatology, Medical Faculty, Ondokuz Mayıs University, Samsun, Turkey
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15
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TUTUNCU M, UYGUNOGLU U, BİNGÖL A, SAİP S, SİVA A. Nöro-Behçet hastalığında kognitif fonksiyon bozukluğunun sıklığı ve örüntüsü: retrospektif bir çalışma. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.871203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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16
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Uygunoglu U, Siva A. An uncommon disease included commonly in the differential diagnosis of neurological diseases: Neuro-Behçet's syndrome. J Neurol Sci 2021; 426:117436. [PMID: 33984547 DOI: 10.1016/j.jns.2021.117436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
Behçet's Syndrome (BS) may present with different neurological problems, related either directly (primary) or indirectly (secondary) to BS. Primary neurological involvement is named as neuro-Behcet's syndrome (NBS), and its two major subtypes that are classified mainly on the clinical and MRI findings are (1) Parenchymal-NBS (p-NBS) and (2) Extra parenchymal neuro-vascular involvement mostly seen as cerebral dural venous sinus thrombosis (CVST). The less commonly seen forms of NBS are cognitive and behavioral syndromes and peripheral nervous system involvement. Parenchymal-NBS is the most common clinical neurological presentation of BS. It is a rare disease with distinct MRI features and is often included in the differential diagnosis of neuro-vascular and neuro-inflammatory disorders. The most commonly affected neuro-anatomical site in p-NBS is the meso-diencephalic junction (MDJ), followed by the ponto-bulbar and thalamic regions, the basal ganglia, and the spinal cord. These varied locations may explain to a certain extent why BS is considered in the differential of so many neurological disorders. The other relatively common form of NBS that results in CVST may also be confused with other conditions resulting in CVST, especially when the systemic clinical features suggestive of BS are missed.
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Affiliation(s)
- Ugur Uygunoglu
- Istanbul University Cerrahpaşa School of Medicine, Department of Neurology, Istanbul, Turkey
| | - Aksel Siva
- Istanbul University Cerrahpaşa School of Medicine, Department of Neurology, Istanbul, Turkey.
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Kötter I, Lötscher F. Behçet's Syndrome Apart From the Triple Symptom Complex: Vascular, Neurologic, Gastrointestinal, and Musculoskeletal Manifestations. A Mini Review. Front Med (Lausanne) 2021; 8:639758. [PMID: 33898481 PMCID: PMC8063110 DOI: 10.3389/fmed.2021.639758] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/12/2021] [Indexed: 12/13/2022] Open
Abstract
Behçet‘s Syndrome (BS) is a variable vessel vasculitis according to the Chapel Hill Consensus Nomenclature (1) and may thus affect any organ, including major and minor arterial and venous vessels to a varying degree and with varying frequency. Although the main features of BS are recurrent oral and genital aphthous ulcers, cutaneous lesions, ocular inflammation and arthritis—major vessel and life—or organ threatening involvement of internal organs and the central and peripheral nervous system occur. In general, BS in Europe appears to form six phenotypes of clinical manifestations (2), which are (1) mucocutaneous only, (2) predominant arthritis/articular involvement, (3) vascular phenotype, (4) ocular manifestations, which are most likely associated with CNS manifestations and HLA-B51, (5) dominant parenchymal CNS manifestations (being associated with the ocular ones), and (6) gastrointestinal involvement. Mucocutaneous manifestations are present in almost all patients/all phenotypes. In the following review, we summarize the current knowledge concerning vascular, neurologic, gastrointestinal and musculoskeletal manifestations of the disease.
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Affiliation(s)
- Ina Kötter
- Division of Rheumatology and Inflammatory Rheumatic Diseases, University Hospital Hamburg Eppendorf and Clinic for Rheumatology and Immunology Bad Bramstedt, Bad Bramstedt, Germany
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital Bern, University of Bern, Bern, Switzerland
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Zou J, Luo JF, Shen Y, Guan JL. Distinct clinical characteristics of pediatric Behçet's syndrome: A study from a referral center in China. Mod Rheumatol 2021; 31:1158-1163. [PMID: 33627024 DOI: 10.1080/14397595.2021.1891670] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES To describe the clinical features and patterns of phenotype aggregation in pediatric Behçet's syndrome (BS) in a tertiary center in China. METHODS This was a cross-sectional study of consecutive BS patients in Huadong Hospital, Fudan University between September 2012 and January 2020. Pediatric BS was defined as diagnosed before 16 years old. We compared clinical variables between pediatric and adult patients. We calculate relative risks (RRs) of clinical variables according to sex. Moreover, a hierarchical cluster analysis was undertaken according to 29 clinical variables to determine homogeneous subgroups. RESULTS From 1596 consecutive BS cases, we identified 69 pediatric BS. Compared with adult-diagnosed BS, pediatric-diagnosed patients had a higher frequency of folliculitis [RR 1.57 (95% CI 1.12, 2.20)], a lower frequency of arthralgia [RR 0.15 (95% CI 0.02, 1.07)] and panuveitis [RR 0.43 (95% CI 0.18, 1.03)], no cardiac lesion. There was an association between male and arterial thrombosis or aneurysms (p = .006). A cluster analysis stratified three sub-clusters (C1-C3): C1 (n = 30) showed a disease type merely affecting skin and mucosa. C2 (n = 20) represented the gastrointestinal type; most patients presented with intestinal involvement, and two cases with esophageal ulcers. In C3 (n = 19), showing a mixture of uveitis, vascular and central nervous system (CNS) involvement, six patients presented with uveitis and nine had vascular lesions, and three cases had CNS lesions. CONCLUSION We conducted a comprehensive statistical analysis in a cohort of pediatric patients with BS in China. Less ocular involvement and no cardiac lesions were observed in childhood-diagnosed patients. For the first time, three distinct phenotype subgroups in pediatric-diagnosed patients were identified by cluster analysis.Key messagesThis study demonstrated the phenotype discrepancy between childhood and adult-diagnosed BS.Three distinct clusters were identified, with skin-mucosa, gastrointestinal, panuveitis, vascular and CNS subgroups.
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Affiliation(s)
- Jun Zou
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jian-Feng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, China
| | - Yan Shen
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
| | - Jian-Long Guan
- Department of Rheumatology and Immunology, Huadong Hospital, Fudan University, Shanghai, China
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Bachhuber A. [Inflammatory spinal cord diseases and transverse myelitis]. Radiologe 2021; 61:251-257. [PMID: 33570678 PMCID: PMC7876978 DOI: 10.1007/s00117-021-00816-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/19/2021] [Indexed: 11/23/2022]
Abstract
Hintergrund Entzündliche Rückenmarkerkrankungen zeigen MR-morphologisch recht einheitliche Bilder, dennoch sind deren richtige Zuordnung zu einer Krankheit für die Therapie und weiteren Verlauf entscheidend. Fragestellung Welche Merkmale der Läsionen erlauben eine richtige Einordnung? Material und Methode Recherche von Artikeln in pubmed.gov, die Myelitiden verschiedener Ätiologie beschreiben. Ergebnisse Die Länge der Läsionen, deren Lokalisation im Rückenmark sowohl bezüglich Höhe als auch im Myelonquerschnitt, und das Kontrastmittelverhalten erlauben in vielen Fällen zumindest eine Eingrenzung der Differenzialdiagnosen. Zum Überblick werden die wichtigsten Charakteristika in einer Tabelle zusammengefasst. Schlussfolgerung Eine sichere Zuordnung ist nur in Ausnahmefällen möglich, da sich viele Entitäten überlappen. Besonders schwierig ist dies bei Erkrankungen, die seltener vorkommen, und deswegen diesbezüglich wenig Erfahrung vorhanden ist.
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Affiliation(s)
- A Bachhuber
- , Kirrberger Str. Geb. 90, 66424, Homburg, Deutschland.
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20
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Zou J, Luo JF, Shen Y, Cai JF, Guan JL. Cluster analysis of phenotypes of patients with Behçet's syndrome: a large cohort study from a referral center in China. Arthritis Res Ther 2021; 23:45. [PMID: 33514418 PMCID: PMC7847001 DOI: 10.1186/s13075-021-02429-7] [Citation(s) in RCA: 53] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Accepted: 01/19/2021] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Behcet's syndrome (BS) is a complex, heterogeneous disorder. However, classification of its subgroups is still debated. The purpose of this study was to investigate the clinical features and aggregation of patients with BS in China, based on manifestations and organ involvements. METHODS This was a cross-sectional study of BS patients in Huadong Hospital of Fudan University between September 2012 and January 2020. We calculated relative risks (RRs) of clinical variables according to sex. Moreover, we conducted a hierarchical cluster analysis applied according to eighteen variables to determine subgroups of patients. RESULTS A total of 860 BS patients were included. Male sex was associated with ocular involvement (RR 2.32, 95% CI 1.67, 3.22, P < 0.0001), vascular involvement (RR 2.00, 95% CI 1.23, 3.23, P = 0.004), cardiac lesion (RR 5.46, 95% CI 2.33, 12.77, P < 0.0001), and central nervous system involvement (RR 2.95, 95% CI 1.07, 6.78, P = 0.007) and was negatively associated with genital ulcers (RR 0.84, 95% CI 0.79, 0.91, P < 0.0001). Five clusters (C1-C5) were observed. C1 (n = 307) showed the skin and mucosa type. In C2 (n = 124), all had articular involvement, barely having major organ involvement except for 18 cases with intestinal lesions. In C3 (n = 156), the gastrointestinal type, 144 patients presented with intestinal involvement, and 36 patients with esophageal ulcers. In C4 (n = 142), all subjects presented with uveitis. C5 (n = 131) consisted of 44 patients with cardiac lesions, 58 with vascular involvement, and 26 cases having central nervous system involvement. CONCLUSION Our analysis confirmed sex differences in phenotypes of BS. Cluster analysis identified gastrointestinal, uveitis, and cardiovascular involvement cluster separately in different subsets, which represents the most commonly involved organs. Further research is required to replicate and clarify the patterns of phenotype in BS.
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Affiliation(s)
- Jun Zou
- Division of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, 200040, Shanghai, People's Republic of China
| | - Jian-Feng Luo
- Department of Biostatistics, School of Public Health, Fudan University, Shanghai, People's Republic of China
| | - Yan Shen
- Division of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, 200040, Shanghai, People's Republic of China
| | - Jian-Fei Cai
- Division of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, 200040, Shanghai, People's Republic of China
| | - Jian-Long Guan
- Division of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, 200040, Shanghai, People's Republic of China.
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Zou J, Luo D, Shen Y, Guan JL. Characteristics and phenotype heterogeneity in late-onset Behçet's syndrome: a cohort from a referral center in China. Clin Rheumatol 2021; 40:2319-2326. [PMID: 33411142 DOI: 10.1007/s10067-020-05536-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2020] [Revised: 11/12/2020] [Accepted: 12/01/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the demographics, clinical aspects, and major organ involvement of patients with late-onset Behçet's syndrome (BS) in a tertiary center in China. METHODS We conducted a cross-sectional study of consecutive BS patients in Huadong Hospital of Fudan University from September 2012 to January 2020. We compared clinical variables between patients with disease onset before and after 40 years of age. The relative risks (RRs) of clinical variables were calculated between the two age groups. Moreover, a hierarchical cluster analysis was conducted according to 29 variables to determine homogeneous subgroups in patients with late-onset BS. RESULTS We enrolled 152 late-onset BS patients, with a median age at onset of 47 years (interquartile range, IQR: 43-52 years). There is a higher prevalence of intestinal ulcers in late-onset BS than in early-onset BS (RR 1.47), but a lower prevalence of ocular involvements (RR 0.54) and folliculitis (RR 0.46). Female sex was associated with genital ulcers, erythema nodosum, and arthritis. Four clusters (C1-C4) were formed. C1 (n = 71), the largest cluster, was defined as the mucocutaneous group, C2 (n = 20) as the arthritis group, C3 (n = 39) as the gastrointestinal group, in which all patients presented with intestinal lesions, and five cases with esophageal ulcers. In C4 (n = 22), showing a mixture of uveitis and vascular lesions, 15 patients presented with uveitis and 8 had vascular lesions, and 1 case had central nervous system lesions. CONCLUSION Four phenotype clusters were identified. Patients with skin lesions comprised the largest cluster, while gastrointestinal, panuveitis, and cardiovascular clusters are the most commonly involved organs in late-onset BS patients. Key Points • Our analysis demonstrated the phenotype discrepancy between early and late onset groups. • Four phenotype clusters were identified, with gastrointestinal, panuveitis and cardiovascular clusters representing commonly involved organs.
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Affiliation(s)
- Jun Zou
- Department of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, No. 221 west Yan'an Road Shanghai, 200040, Shanghai, People's Republic of China
| | - Dan Luo
- Department of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, No. 221 west Yan'an Road Shanghai, 200040, Shanghai, People's Republic of China
| | - Yan Shen
- Department of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, No. 221 west Yan'an Road Shanghai, 200040, Shanghai, People's Republic of China
| | - Jian-Long Guan
- Department of Rheumatology and Immunology, Shanghai Key Laboratory of Clinical Geriatric Medicine, Huadong Hospital, Research Center on Aging and Medicine, Huadong Hospital, Fudan University, No. 221 west Yan'an Road Shanghai, 200040, Shanghai, People's Republic of China.
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22
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Liu J, Yan D, Wang Z, Yang Y, Zhang S, Wu D, Peng L, Liu Z, Zheng W. Tocilizumab in the treatment of severe and refractory parenchymal neuro-Behçet's syndrome: case series and literature review. Ther Adv Musculoskelet Dis 2020; 12:1759720X20971908. [PMID: 33240406 PMCID: PMC7675870 DOI: 10.1177/1759720x20971908] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 09/24/2020] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES This study aimed to investigate the efficacy and safety of tocilizumab (TCZ) in severe and refractory parenchymal neuro-Behçet's syndrome (p-NBS). METHODS We retrospectively analyzed five patients with p-NBS treated with TCZ in our center between 2013 and 2020, and six cases from literature research with the index terms "neuro-Behçet's syndrome" and "tocilizumab" on PubMed NCBI. RESULTS A total of 11 patients with p-NBS were enrolled (5 males, 6 females), with a mean age of 34.5 ± 8.0 years at the onset. All the patients had parenchymal neurological lesions, six patients (54.5%) suffered from multiple lesions, and nine patients (81.8%) were disabled. Before TCZ administration, all the patients had failed conventional therapy, eight patients (72.7%) received two or more immunosuppressants, and five patients showed insufficient response or intolerance to other biologics. TCZ was administrated at 8 mg/kg every 4 weeks, with background glucocorticoids (GCs) and immunosuppressants. After a median follow-up of 13 (interquartile range, 3.5-23.5) months, all the patients achieved both clinical and radiological improvements, and the Behçet's Disease Current Activity Form score improved significantly (3 versus 0, median, p = 0.004), the Rankin score also decreased (4 versus 2, median, p = 0.005). Levels of interleukin-6 in the cerebrospinal fluid decreased significantly in five patients (533.4 ± 389.7 pg/ml versus 34.5 ± 27.1 pg/ml, p = 0.048), after a median of two (interquartile range, 1-4) times of TCZ infusions. Furthermore, the GC dosage (per os) reduced from 69.2 ± 16.9 mg/d to 16.4 ± 16.2 mg/d (p = 0.000), and immunosuppressants were tapered in number and dosage in seven (63.6%) and four (36.3%) patients, respectively. No serious adverse events or deaths were observed during follow-up. CONCLUSIONS TCZ is well tolerated and effective in severe and refractory p-NBS, with a favorable GC- and immunosuppressant-sparing effect. Cerebrospinal fluid interleukin-6 might be used to monitor the effects of TCZ in p-NBS.
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Affiliation(s)
- Jinjing Liu
- Department of Rheumatology and Clinical
Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Key Laboratory of
Rheumatology and Clinical Rheumatology, Ministry of Education, National
Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing,
China
| | - Dong Yan
- Department of Rheumatology and Immunology, The
Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhimian Wang
- Department of Rheumatology and Clinical
Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Key Laboratory of
Rheumatology and Clinical Rheumatology, Ministry of Education, National
Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing,
China
| | - Yunjiao Yang
- Department of Rheumatology and Clinical
Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Key Laboratory of
Rheumatology and Clinical Rheumatology, Ministry of Education, National
Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing,
China
| | - Shangzhu Zhang
- Department of Rheumatology and Clinical
Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Key Laboratory of
Rheumatology and Clinical Rheumatology, Ministry of Education, National
Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing,
China
| | - Di Wu
- Department of Rheumatology and Clinical
Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Key Laboratory of
Rheumatology and Clinical Rheumatology, Ministry of Education, National
Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing,
China
| | - Lingyi Peng
- Department of Rheumatology and Clinical
Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Key Laboratory of
Rheumatology and Clinical Rheumatology, Ministry of Education, National
Clinical Research Center for Dermatologic and Immunologic Diseases, Beijing,
China
| | - Zhichun Liu
- Department of Rheumatology and Immunology, The
Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Wenjie Zheng
- Department of Rheumatology and Clinical
Immunology, Peking Union Medical College Hospital, Chinese Academy of
Medical Sciences & Peking Union Medical College, Key Laboratory of
Rheumatology and Clinical Rheumatology, Ministry of Education, National
Clinical Research Center for Dermatologic and Immunologic Diseases, No. 1
Shuafuyuan, Dongcheng District, Beijing, 100730, China
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Ha-ou-nou F, Essaadouni L. Fréquence et facteurs prédictifs de thrombose veineuse au cours de la maladie de Behçet. Rev Med Interne 2020; 41:578-582. [DOI: 10.1016/j.revmed.2020.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/05/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
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Kardum Ž, Milas Ahić J, Lukinac AM, Ivelj R, Prus V. Optic neuritis as a presenting feature of Behçet's disease: case-based review. Rheumatol Int 2020; 41:189-195. [PMID: 32860521 DOI: 10.1007/s00296-020-04690-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 08/18/2020] [Indexed: 11/28/2022]
Abstract
Behçet's disease (BD) is vasculitis affecting vessels of variable sizes characterized with recurrent oral and/or genital aphthous ulcers accompanied by cutaneous, ocular, articular, gastrointestinal, and/or central nervous system inflammatory lesions. The disease is characterized by recurrent attacks and remissions of different durations, which is one of the reasons why the diagnosis is, in most cases, made several years after the onset of first symptoms. We present a 24-year old male, with South Eastern European heritage, with relapsing bilateral optic neuritis as a first symptom of the disease, followed by aseptic meningitis 2 years, and vascular manifestation 3 years after onset, which finally led to the diagnosis of Behçet's disease. Vascular symptoms were thromboembolism of the right leg and aneurism of the right popliteal artery that due to the size required surgical treatment. The patient was treated with glucocorticoids, azathioprine and anti-tumor necrosis factor-alpha therapy, that proved to be the best treatment options for all manifestations of the disease. Based on our literature review, optic neuritis is a known and rare clinical feature of BD. To our knowledge, there are only several literature reports in which optic neuritis is the initial symptom of BD. Our case report and literature review emphasize the importance of recognizing optic neuritis without inflammatory eye disease as a possible presenting symptom of BD and accentuate detailed medical history review at each patient's visit.
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Affiliation(s)
- Željka Kardum
- Department of Rheumatology, Clinical Immunology and Allergology, Internal Clinic, University Hospital Osijek, J. Huttlera 4, 31000, Osijek, Croatia. .,School of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia.
| | - Jasminka Milas Ahić
- Department of Rheumatology, Clinical Immunology and Allergology, Internal Clinic, University Hospital Osijek, J. Huttlera 4, 31000, Osijek, Croatia.,School of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Ana Marija Lukinac
- Department of Rheumatology, Clinical Immunology and Allergology, Internal Clinic, University Hospital Osijek, J. Huttlera 4, 31000, Osijek, Croatia.,School of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Ružica Ivelj
- Department of Radiology, University Hospital Osijek, J. Huttlera 4, 31000, Osijek, Croatia
| | - Višnja Prus
- Department of Rheumatology, Clinical Immunology and Allergology, Internal Clinic, University Hospital Osijek, J. Huttlera 4, 31000, Osijek, Croatia.,School of Medicine, Josip Juraj Strossmayer University of Osijek, J. Huttlera 4, 31000, Osijek, Croatia
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Kuzu Kumcu M, Bakırarar B, Yücesan C. Quality of life in neuro-Behçet's disease: a cross-sectional study. Neurol Sci 2020; 42:1081-1086. [PMID: 32743747 DOI: 10.1007/s10072-020-04630-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 07/24/2020] [Indexed: 12/24/2022]
Abstract
PURPOSE Behçet's disease (BD) is a multisystemic perivasculitis with recurrent oral aphthous ulcers, genital ulcers, and eye involvement which was first described in 1937. Neurological involvement in BD patients is referred to as neuro-Behçet's disease (NBD). Studies have shown that BD worsens quality of life. However, there is no study that conducts a head-to-head comparison of quality of life between NBD patients and healthy controls. METHODS Forty patients with NBD and 39 age-sex-matched healthy control subjects were included in this study. Sociodemographic data of all participants were recorded; SF-36 was used to assess quality of life. RESULTS NBD patients had significantly lower SF-36 scores of physical functioning, physical difficulty, bodily pain, and general health perception compared with healthy controls. However, there was no significant difference between the groups according to the SF-36 scores of role limitation due to emotional problems, mental health, vitality, and social functioning. There was no significant difference between parenchymal and non-parenchymal NBD groups according to SF-36, Beck's Depression Inventory, and Beck's Anxiety Inventory scores. Patients with cerebellar system involvement had significantly lower physical and social functioning scores compared with those who did not. Patients with brain stem involvement were found to have higher role limitation due to emotional problems, vitality, social functioning, physical pain, and general health perception scores compared with those without brain stem findings. CONCLUSIONS NBD negatively affects many aspects of the quality of life.
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Affiliation(s)
- Müge Kuzu Kumcu
- Department of Neurology, Ankara University School of Medicine, Ankara, Turkey.
| | - Batuhan Bakırarar
- Department of Biostatistic, Ankara University School of Medicine, Ankara, Turkey
| | - Canan Yücesan
- Department of Neurology, Ankara University School of Medicine, Ankara, Turkey
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Lapides DA, McDonald MM. Inflammatory Manifestations of Systemic Diseases in the Central Nervous System. Curr Treat Options Neurol 2020; 22:26. [PMID: 32834714 PMCID: PMC7387810 DOI: 10.1007/s11940-020-00636-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW This review presents the current recommended therapeutic interventions for inflammatory disease in the central nervous system (CNS) secondary to systemic diseases of immune dysregulation. Treatment recommendations for CNS inflammation associated with rheumatologic conditions, immune-related adverse effects from immune checkpoint inhibitors (ICIs), and demyelinating disease from tumor necrosis factor-α (anti-TNFs) are explored. Additional therapeutic options for inflammation related to postviral syndromes and genetic immunodeficiencies are also discussed. RECENT FINDINGS In addition to treatment of mild, moderate, and severe CNS rheumatologic disease as guided by the European League Against Rheumatism (EULAR), early consideration of rituximab for severe IgG4-related disease and induction with anti-TNF therapy for severe neurosarcoidosis should be considered. Although often not first line, treatment options for CNS inflammatory diseases based on disease mechanism are emerging, including tocilizumab for Behcet's disease, natalizumab for ICI associated autoimmune encephalitis, and abatacept for treatment of infiltrative disease secondary to CTLA-4 deficiency. Hematopoietic stem cell treatments represent highly efficacious but risky options for autoimmunity related to genetic immunodeficiency. SUMMARY While early high dose steroids remains first line therapy for most CNS inflammatory conditions, a rapidly expanding arsenal of immune targeted therapies offers clinicians tailored disease specific options for treatment.
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Affiliation(s)
- David A. Lapides
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
| | - Mark M. McDonald
- Division of Neuroimmunology, Department of Neurology, University of Virginia, 1222 Lee Street, Charlottesville, VA 22908 USA
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Partalidou S, Tsiakalou V, Vassilakos I, Kassimos D. Walking Instability in a Patient with Known Neuro-Behçet's Disease. Mediterr J Rheumatol 2020; 31:78-80. [PMID: 32411936 PMCID: PMC7219649 DOI: 10.31138/mjr.31.1.78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 11/06/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023] Open
Abstract
A 53-year-old man with known history of Neuro-Behçet›s Disease (NBD) presented to the Emergency Department with numbness on the left side of the body and the face. The patient was admitted to the Neurological Department and after a thorough investigation, the magnetic resonance imaging (MRI)of the brain revealed a lesion on the brainstem (rhombencephalitis). The case is presented due to rarity of the clinical picture and the good outcome. The therapeutic strategy and the modification of his medication is discussed.
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Borhani-Haghighi A, Kardeh B, Banerjee S, Yadollahikhales G, Safari A, Sahraian MA, Shapiro L. Neuro-Behcet's disease: An update on diagnosis, differential diagnoses, and treatment. Mult Scler Relat Disord 2019; 39:101906. [PMID: 31887565 DOI: 10.1016/j.msard.2019.101906] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Revised: 12/17/2019] [Accepted: 12/21/2019] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
| | - Bahareh Kardeh
- Clinical Neurology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Shubhasree Banerjee
- Division of Rheumatology, Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | | | - Anahid Safari
- Stem Cells Technology Research Center, Shiraz University of Medical Sciences Shiraz, Iran
| | - Mohammad Ali Sahraian
- MS Research Center, Neuroscience Institute, Tehran University of Medical sciences, Tehran, Iran
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Bettiol A, Hatemi G, Vannozzi L, Barilaro A, Prisco D, Emmi G. Treating the Different Phenotypes of Behçet's Syndrome. Front Immunol 2019; 10:2830. [PMID: 31921115 PMCID: PMC6915087 DOI: 10.3389/fimmu.2019.02830] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 11/18/2019] [Indexed: 12/13/2022] Open
Abstract
Behçet's syndrome (BS) is a multisystemic vasculitis, characterized by different clinical involvements, including mucocutaneous, ocular, vascular, neurological, and gastrointestinal manifestations. Based on this heterogeneity, BS can be hardly considered as a single clinical entity. Growing evidence supports that, within BS, different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, three major BS phenotypes have been reported: (a) the mucocutaneous and articular phenotype, (b) the extra-parenchymal neurological and peripheral vascular phenotype, and (c) the parenchymal neurological and ocular phenotype. To date, guidelines for the management of BS have been focused on the pharmacological treatment of each specific BS manifestation. However, tailoring the treatments on patient's specific phenotype, rather than on single disease manifestation, could represent a valid strategy for a personalized therapeutic approach to BS. In the present literature review, we summarize current evidence on the pharmacological treatments for the first-, second-, and third-line treatment of the major BS phenotypes.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy.,Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Florence, Florence, Italy
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Lorenzo Vannozzi
- Eye Clinic, Careggi Teaching Hospital, University of Florence, Florence, Italy
| | - Alessandro Barilaro
- Department of Neurology 2 and Multiple Sclerosis Regional Referral Centre, Careggi University Hospital, Florence, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
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Abstract
Behçet's syndrome (BS) is a complex disease that shows important heterogeneity in clinical findings and physiopathology. Its treatment can be problematic as BS manifestations in different organs may respond differently to the same drug. The cornerstone of therapy for inducing remission is corticosteroids whereas immunomodulatory and immunosuppressive agents such as colchicine, azathioprine, cyclosporine-A, interferon-alpha, and cyclophosphamide are used as steroid-sparing agents and to prevent further relapses. However, a considerable number of patients continue to have mucocutaneous lesions despite therapy, and some patients require more aggressive treatment for refractory major organ involvement. Tumor necrosis factor alpha inhibitors, especially infliximab and adalimumab, are increasingly used for various refractory BS manifestations despite the lack of controlled studies. In this review, we aim to focus on both the traditional and new treatment modalities for BS, with more emphasis on recent data on newer agents.
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Affiliation(s)
- Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, 34098, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, 34098, Istanbul, Turkey.
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Ögün MN, Karabörk Ş, Önerli M, Türkoğlu ŞA, Yildiz S. Cerebrospinal Fluid Levels of Interleukin-17 and Interleukin-34 in Patients with Neuro-Behcet’s Syndrome. NEUROPHYSIOLOGY+ 2019. [DOI: 10.1007/s11062-019-09797-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Han D, Ma B, Liu P, Luo G, Song W. Neuro-Behçet's syndrome with a severe ocular lesion. J Int Med Res 2019; 47:2694-2701. [PMID: 30991870 PMCID: PMC6567698 DOI: 10.1177/0300060519839522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Behçet's syndrome (BS) is an idiopathic, chronic, relapsing, multisystem, vascular-inflammatory disease. Neuro-Behçet's syndrome (NBS) is a subtype of BS that mainly involves the central nervous system. Because of the heterogeneous involvement of NBS and the limited yearly numbers of new cases of NBS, estimating its course, prognosis, and treatment effect is difficult. Therefore, the efficacy of treatment for any form of NBS is unclear. We experienced a male patient with NBS and severe right uveitis. He received high-dose intravenous methylprednisolone (1000 mg/day) pulse therapy for 3 days. Intravenous injection of cyclophosphamide (400 mg, twice a day) and oral administration of prednisone (40 mg in the morning, 20 mg in the evening) were applied. Uveitis was treated with retrobulbar injection of triamcinolone acetonide (40 mg per week). The patient's response was rapid with improved symptoms and signs. The therapeutic regimen of patients with BS has greatly advanced, leading to evidence-based guidelines. Methylprednisolone pulse therapy is important in treatment of BS. Novel therapeutic options are currently being examined to improve the prognosis of BS. These efforts will undoubtedly shed new light on this complex syndrome.
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Affiliation(s)
- Dan Han
- 1 Department of Cardiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Bo Ma
- 3 Department of Ophthalmology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Peng Liu
- 1 Department of Cardiology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Guogang Luo
- 2 Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
| | - Wenfeng Song
- 2 Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, China
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Ertugrul O, Mutlu A, Zindanci I, Cam OH, Ozluoglu L. Audiological and vestibular measurements in Behçet’s disease. Eur Arch Otorhinolaryngol 2019; 276:1625-1632. [DOI: 10.1007/s00405-019-05403-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 03/20/2019] [Indexed: 01/09/2023]
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Affiliation(s)
- Alair Sarmet Santos
- Associate Professor in the Department of Radiology of the Fluminense Federal University School of Medicine, Head of the Radiology Department of the Antônio Pedro University Hospital, Niterói, RJ, Brazil
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