Ocular Involvement of Behçet's Syndrome: a Comprehensive Review

Integrated analysis of genetic, proteinic, and metabolomic alterations in Behcet's disease

Numerous studies have investigated the alterations of genes, proteins, and metabolites in Behcet's disease (BD). By far, little is known about the depiction of panoramic changes underlying this disease. This study purposed to assess the consistently dysregulated genes, proteins, and metabolites in BD across publications using the vote-counting approach. This study was based on 745 studies that identified a collection of 2354 differential molecules with 3574 molecule entries in blood, peripheral blood mononuclear cells, CD4+T cells, and aqueous humor samples from patients with BD. In this study, the results of binomial analysis showed that the circulating levels of 38 molecules, including interferon-γ and interleukin 17, were consistently upregulated, whereas high density lipoprotein cholesterol, apolipoprotein A, hemoglobin, and glutathione were consistently downregulated. The levels of interferon-γ, tumor necrosis factor-α and toll like receptor 4 in peripheral blood mononuclear cells, and interferon-γ and interleukin-17 in CD4+T cells were consistently upregulated. Additionally, the levels of interferon-γ, tumor necrosis factor-α and C-X-C motif chemokine ligand 8 in aqueous humor were consistently upregulated. Collectively, this study showed that the hyperactivity of Th1 and Th17 responses played an essential role in the pathogenesis of BD, and the progression of this disease was associated with enhanced neutrophil chemotaxis, vascular endothelial injury, activation of haemostatic system, and oxidative stress.

Behçet syndrome with eye involvement

Behçet's uveitis (BU) is a significant form of major organ involvement in Behçet syndrome and is associated with considerable morbidity. Ocular examination is crucial for diagnosing BS and detecting vitreous cells, even in asymptomatic patients. The primary goals in managing BU are to rapidly suppress ocular inflammation and prevent relapses. Initial treatment for posterior segment involvement in BU typically involves immunosuppressive agents combined with glucocorticoids. Biologic agents are increasingly used in BU management, including as first-line treatments for patients with poor prognostic risk factors or sight-threatening uveitis. There is no established consensus on when to discontinue or taper immunosuppressive therapy. Once remission is achieved, the absence of retinal vasculitis should be confirmed with fluorescein angiography, which should be utilized throughout the process of tapering immunosuppressive therapy. In addition to monoclonal tumor necrosis factor-alpha antagonists and tocilizumab, Janus kinase inhibitors may offer the potential for managing BU in the future.

Does microperimetry have a role in monitoring visual function in patients with Behçet uveitis?

BACKGROUND

To evaluate the change in time in visual acuity, central macular thickness (CMT), and microperimetry (MP) findings in Behçet uveitis (BU) patients who were in remission with maintenance therapy.

METHODS

This single center, retrospective, observational cohort study included twenty-five eyes of 25 patients with BU who were in remission during maintenance therapy. Best corrected visual acuity (BCVA), CMT, macular integrity index, average threshold, and fixation stabilities (P1 and P2) evaluated at six-month intervals were recorded. The changes in time were statistically analyzed. Paired samples t-test was used for normally distributed data and Wilcoxon rank test was performed for non-normally distributed data.

RESULTS

The mean BCVA and CMT showed no significant changes after six months. Although the mean macular integrity index decreased and the mean fixation stabilities increased after six months, these findings were not statistically significant. The mean average threshold was 16.8 dB at baseline and it increased significantly to 19.3 dB in the sixth month (p < 0.001).

CONCLUSIONS

The results of our study suggest that although visual acuity and CMT showed no change in patients with Behçet uveitis receiving maintenance therapy, MP could detect an improvement in macular function.

Cyclosporin A as an adjunct may enhance the therapeutic effect of interferon alpha-2a in patients with refractory Behcet's uveitis: a retrospective cohort study

Background

The application of biologic agents has benefited patients with Behcet's uveitis (BU) who do not respond to conventional treatment regimens. However, there is currently no consensus on the optimal treatment regimen of interferon alpha-2a (IFN-α2a) for refractory BU.

Objectives

To evaluate treatment outcomes and safety of IFN-α2a in a large series of refractory BU patients and to explore whether nonbiologic immunomodulatory agents (cyclosporin A) other than corticosteroids should be concomitantly used.

Design

We conducted a retrospective cohort study, which included 153 BU patients who received IFN-α2a treatment between December 2012 and September 2023 with a minimum duration of 6 months.

Methods

Best-corrected visual acuity (BCVA), the frequency of uveitis relapse, corticosteroid-sparing effect, and side effects were evaluated.

Results

Of the 153 patients enrolled, 87 patients were treated with IFN-α2a plus corticosteroids (IC), and 66 patients were treated with IFN-α2a plus corticosteroids and cyclosporin A (ICC). Both IFN-α2a treatment regimens significantly improved BCVA as early as 2 months following treatment, and the improvement was maintained over at least a 2-year follow-up. At the final visit, 86.8% and 73.1% of the affected eyes in the ICC and IC groups achieved improved or stable vision, respectively. The ICC regimen was more effective at improving vision (p = 0.01). Overall, the frequency of uveitis relapse and the dose of oral prednisolone were significantly reduced in both groups after treatment (all p < 0.0001). However, there were no statistically significant differences in these parameters between the two groups. None of the included patients experienced serious side effects that led to the discontinuation of IFN-α2a therapy.

Conclusion

IFN-α2a treatment is a promising option for patients with refractory BU. Our results showed that cyclosporin A as an adjunct could enhance the therapeutic effect of IFN-α2a.

Comparative Study of Adalimumab, Infliximab and Certolizumab Pegol in the Treatment of Cystoid Macular Edema Due to Behçet's Disease

Background: The leading cause of blindness due to non-infectious uveitis is cystoid macular edema (CME). Behçet's disease (BD) is one of the most commonly conditions related to CME. Objectives: To compare the effectiveness and safety of adalimumab (ADA), infliximab (IFX) and certolizumab (CZP) in refractory CME due to BD. Methods: Multicenter study of BD-CME patients with no response to glucocorticoids (GCs) and at least one conventional immunosuppressive drug. At baseline, all patients presented CME, defined by OCT > 300 µ. The effectiveness of ADA, IFX and CZP was assessed over a 2-year period from baseline using the following ocular parameters: macular thickness (µm), visual acuity (BCVA), anterior chamber (AC) cells and vitritis. Mixed-effects regression models were applied. Results: a total of 50 patients (75 eyes) were studied (ADA = 25; IFX = 15 and CZP = 10). No significant differences in demographic parameters were found among the three groups. However, individuals in the CZP group had a significantly extended time from diagnosis to treatment onset (72 (36-120) months, p = 0.03) and had received a higher number of biological therapies (1.7 ± 1.1) compared to the ADA and IFX groups. Within the CZP group, ADA and IFX were previously administrated in seven patients. After 2 years of follow-up, a rapid and sustained reduction in macular thickness was noted in all three groups with no significant differences between them. Additionally, enhancements in BCVA, AC cells and vitritis were also observed. No serious adverse events were reported in the CZP group, although one isolated case of bacteremia was documented in the ADA group. ADA, IFX and CZP appear to be effective and safe treatments for refractory CME in BD. CZP seems to remain effective even in patients with an insufficient response to ADA and/or IFX. Conclusions: ADA, IFX and CZP appear to be effective and safe treatments for refractory CME in BD. CZP seems to remain effective even in patients with an insufficient response to ADA and/or IFX.

A Proposal of a New Tool for the Assessment of Damage in Behçet Syndrome Uveitis: Cerrahpasa Ocular Damage Grading System

INTRODUCTION/OBJECTIVE

There is currently no tool available to assess the severity of damage in uveitis due to Behçet's syndrome (BS). In this preliminary study, we developed a new grading system to evaluate ocular damage and assessed it in a prospective cohort.

METHODS

A specialist in BS uveitis (YO) developed a grading system for ocular damage with five grades based on the extent of damage in the posterior segment. YO trained a senior and general ophthalmologist with sample fundus images. BS patients who had undergone color fundus photography during their routine visits in attack-free periods were included in the study. The color fundus photos of this prospective cohort were evaluated blindly by YO and his trainees using the new grading tool. Inter and intra-observer agreement between the graders were assessed by Cohen's kappa analysis. The evaluation of YO was considered as the gold standard.

RESULTS

One hundred eighty-five eyes of 108 (29 F/79 M) patients with BS uveitis were graded for damage by two investigators. Their mean age was 38,58 years and their median ocular disease duration was 13 years. The gold standard and the two investigators exhibited substantial concordance with the ocular damage grading system. The inter- and intra-observer agreement were also almost perfect.

CONCLUSION

The newly developed ocular damage grading system enables the standardization of damage severity in BS uveitis. It is imperative to conduct internal and external validations across diverse cohorts. Furthermore, future studies should investigate its correlation with other multimodal imaging methods such as fluorescein angiography and optical coherence tomography.

Mycophenolate mofetil may be an alternative for maintenance therapy of Behçet syndrome uveitis: a single-center retrospective analysis

Experience with mycophenolate in uveitis due to Behçet syndrome (BS) is limited. Twelve patients with panuveitis or posterior uveitis who were started mycophenolate were included. Data on demographic characteristics, therapies, ocular attacks, and adverse events were extracted from patient charts. Seven patients with BS uveitis were prescribed mycophenolate for remission induction, of which 6 were refractory/intolerant to conventional immunosuppressives. Mycophenolate was combined with anti-TNFs in 3 patients, resulting in no further ocular attacks. Mycophenolate had to be stopped in the fourth patient due to adverse events. The remaining 3 patients continued to have ocular attacks and were switched to other agents without any drop in visual acuity. Among the 5 patients who were prescribed mycophenolate for maintenance, 2 were relapse free, but 3 experienced ocular attacks. One patient had an exacerbation of mucocutaneous lesions, and 2 experienced adverse events. Mycophenolate monotherapy may not be adequate for remission induction of refractory BS uveitis, but it can be a safe and effective alternative when combined with a biologic agent. It may also be an option for maintenance therapy.

Risk factors, clinical features and treatment of Behçet's disease uveitis

Behçet's disease is a systemic vasculitis frequently associated with intraocular inflammation. Recent findings identified independent clinical clusters in Behçet's disease, each involving distinct combinations of affected organs. Ocular Behçet's disease, mainly manifested as uveitis, is characterized as an independent cluster with a low likelihood of association with other system involvements, such as intestinal, cardiovascular, or central nervous system. A prevailing theory suggests that the pathogenesis of the disease is multifactorial, where a variety of genetic and infectious agents may interact with each other to cause the disease. Among sporadic cases, the human leukocyte antigen (HLA) genes, including HLA-B51, HLA-A26, HLA-B15, and HLA-B5701, have been found to be a key component conferring genetic susceptibility. Outside the HLA region, a set of susceptibility variants are identified, closely related to interleukin (IL)-23/IL-17 pathway, tumor necrosis factor (TNF) signaling, and pattern recognition receptor systems. Microbial infections, such as Streptococcus sanguinis, Mycobacterium tuberculosis, and Herpes simplex virus (HSV), are linked to play the triggering of disease in immunogenetically predisposed individuals. Clinically, due to the notable relapsing-remitting course of ocular Behçet's disease, the prevention of recurrent attack would be the primary treatment goal. Combination of corticosteroids and immunomodulatory drugs, such as anti-TNF agents, interferon, and conventional immunosuppressants (e.g. cyclosporine, azathioprine), have been the mainstream regimen for the disease. Future research may focus on comparing the effectiveness of immunomodulatory drugs and identifying the most suitable subgroups for a specific drug on the basis of the knowledge of the molecular heterogeneity of the disease.

Protective effect of early immunomodulatory treatment on ocular involvement in Behcet's disease: Historical cohort of 1166 patients

Objectives

Eye involvement is a main presentation of Behcet's disease. This study was performed to evaluate possible determinants affecting the occurrence of eye involvement, especially the role of early systemic treatment with immunomodulatory drugs on the incidence of ocular involvement.

Methods

This is a retrospective cohort study performed on 1166 Behcet's patients in the Behcet's Clinic of Rheumatology Research Center. All patients were followed up for at least 10 years and a maximum of 15 years. Data analysis was performed using survival analysis models including Kaplan-Meier Survival analysis, Logrank test, and Cox's proportional hazards regression.

Results

1166 Behcet's patients were evaluated. 80 patients who had eye involvement as the first manifestation of the disease were excluded and 1086 participants entered the analysis. Among them, 647 patients (59.6%) developed ocular involvement 7.8 ± 6.7 years after the first symptom. Immunomodulatory treatment before ocular involvement reduced the risk by 3 times (P-value <0.001).

Conclusion

This study demonstrated that the initiation of immunomodulatory treatment prior to eye involvement can reduce the risk of eye involvement in Behcet's patients. Therefore, reducing the onset time of disease symptoms and providing appropriate treatment can reduce Behcet's disease ocular complications.

Behçet Syndrome

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.

Anti-TNF vs tocilizumab in refractory uveitic cystoid macular edema due to Behcet's disease. Multicenter study of 49 patients

OBJECTIVE

To compare the efficacy of TNF inhibitors (adalimumab (ADA) and infliximab (IFX)) vs tocilizumab (TCZ) in patients with refractory cystoid macular edema (CME) due to Behçet's disease (BD).

METHODS

Multicenter study of patients with BD-associated CME refractory to conventional and/or biological immunosuppressive drugs. From a cohort of 177 patients treated with anti-TNF and 14 patients treated with TCZ, we selected those with CME at baseline. We analyzed the evolution of macular thickness (main outcome), best-corrected visual acuity (BCVA) and intraocular inflammation (Tyndall and vitritis) from baseline up to 4 years in the 3 groups mentioned.

RESULTS

49 patients and 72 eyes with CME were included. ADA was used in 25 patients (40 eyes), IFX in 15 (21 eyes) and TCZ in 9 (11 eyes). No statistically significant baseline differences were observed between the 3 groups except for a lower basal BCVA in TCZ group and a higher basal degree of intraocular inflammation in ADA group. Most patients from all groups had received several conventional immunosuppressive drugs. In addition, most patients in the group of TCZ had also received anti-TNF agents. Biological therapy was used in monotherapy (n=8) or combined with conventional immunosuppressive drugs (n=41). Macular thickness progressively decreased in the 3 groups, with no signs of CME after 1 year of treatment. Similarly, BCVA improvement and inflammatory intraocular remission was achieved in all groups.

CONCLUSION

Refractory CME associated with BD uveitis can be effectively treated either with ADA, IFX or TCZ. Furthermore, TCZ is effective in patients resistant to anti-TNF therapy.

Current pharmacological solutions for Behçet's syndrome

INTRODUCTION

Behçet's syndrome (BS) has a heterogeneous clinical phenotype, and its clinical manifestations may respond differently to drugs commonly used to treat BS. The type, dose, and duration of immunomodulatory, immunosuppressive, and biologic agents should be tailored individually.

AREAS COVERED

We reviewed the literature for articles on BS management that were published until June 2022 and summarized the management options in BS for each type of organ involvement. We aimed to cover all currently available pharmacological agents used in BS, as well as surgical and interventional options, focusing on recent evidence.

EXPERT OPINION

The management aims in BS are to preserve function and quality of life and to avoid damage. The choice of treatment modalities depends on the organs that are actively involved, the severity of that involvement, and prognostic factors. A treat-to-attack strategy would help improve long-term outcomes in BS.

Biological Agent Use in Behçet's Patients Who Are Resistant to Conventional Treatments: A Multidisciplinary Retrospective Study

Background Comparing treatment modalities is difficult in Behcet's syndrome, even if tumour necrosis factor-alpha (TNF-α) inhibitors are a treatment option for all involvements resistant to conventional therapy. This study evaluated how different departments dealt with treatment, particularly with TNF-α inhibitors. Material and Methods The study comprised 111 patients from our Behcet's syndrome cohort who were treated with TNF-α inhibitors between 2010 and 2019. Data on patients were retrieved retrospectively from the rheumatology, ophthalmology, and dermatology clinics' patient records. Results Patients followed up in rheumatology (n: 40) were classified as Group 1, and patients followed up in ophthalmology (n: 49) and dermatology (n: 5) as Group 2. In Group 1, genital ulcers, erythema nodosum (p=0.009, p=0.003, respectively), lower extremity deep vein thrombosis, arterial aneurysm and neurological involvement were more common (p=0.005, p=0.008, p=0.001, respectively). In Group 2, the use of cyclosporine and interferon-α before the anti-TNF agent was higher (p

Quantitative changes in peripapillary, macular, and choriocapillaris microvasculatures of patients with non-ocular Behçet's disease and relationship with systemic vascular involvement, an optical coherence tomography angiography study

BACKGROUND

To evaluate the changes in the peripapillary, macular and choriocapillaris microvasculatures in the eyes of patients with Behçet's disease (BD) without ocular involvement by optical coherence tomography angiography (OCT-A) and to investigate the relationship with systemic vascular involvement (SVI).

METHODS

The study included 56 eyes of 33 patients with non-ocular BD and 61 eyes of 33 healthy subjects. The macular microvascular (MMV) vessel densities (VDs), FAZ parameters, Choriocapillaris flow area (CCFA), radial peripapillary capillary (RPC) VDs and optic nerve head (ONH) analyses were performed with OCT-A. MMV, RPC, ONH, and CCFA measurements were compared between the non-ocular BD patients and healthy controls. Then, the patient group was divided into two subgroups according to the presence of SVI. MMV, RPC, and CCFA measurements of these subgroups were compared with the healthy controls.

RESULTS

While deep capillary plexus VD and foveal density decreased in MMV analysis in the BD group compared to the control group, CCFA was not different. In the RPC and ONH analysis, the VDs of the inside-disc small vessels and the VDs of the inside-disc all vessels were decreased while the cup/disk area ratio and cup volume were increased in the BD group compared to the healthy controls. Furthermore, the VDs of the inside-disc vessels were reduced in patients without SVI compared to those with SVI and healthy controls.

CONCLUSIONS

The RPC network, ONH and MMV architecture analysis by OCT-A revealed changes in the MMV, RPC, and ONH structures in non-ocular BD patients. Moreover, the decrease in RPC VDs and MMV VDs in patients without SVI suggested that the patients with BD without SVI had subclinical ocular involvement even in the absence of clinical ocular findings.

Retinal microvasculature features in patients with Behcet's disease: a systematic review and meta-analysis

This meta-analysis aimed to analyze retinal microvasculature features in eyes with Behçet's disease (BD) using optical coherence tomography angiography (OCTA). Electronic databases, including PubMed, Web of Science, Embase, and Cochrane Library, were comprehensively searched for published studies comparing retinal microvasculature characteristics between eyes with BD and controls. Continuous variables were calculated using the mean difference (MD) with 95% confidence interval (CI). Review Manager software (version 5.30) was used to conduct statistical analysis. A total of 13 eligible studies involving 599 eyes with BD and 622 control eyes were included in the meta-analysis. The pooled results showed that the macular whole enface superficial and deep vessel density (VD) values measured by OCTA were significantly lower in eyes with BD than in control eyes (superficial VD: MD = - 3.05, P < 0.00001; deep VD: MD = - 4.05, P = 0.0004). The foveal superficial and deep VD values were also significantly lower in the BD group than in the control group (superficial VD: MD = - 1.50, P = 0.009; deep VD: MD = - 4.25, -  = 0.03). Similarly, the analysis revealed a significant reduction in the parafoveal superficial and deep VD in eyes with BD than in control eyes (superficial VD: MD =  - 3.68, P < 0.00001; deep VD: MD = - 4.95, P = 0.0007). In addition, the superficial and deep foveal avascular zones (FAZs) were significantly larger in patients with BD than in controls (superficial FAZ: MD = 0.06, P = 0.02; deep FAZ: MD = 0.12, P = 0.03). The present meta-analysis found that macular whole enface VD, foveal VD, and parafoveal VD were lower in eyes with BD, and the FAZ was larger in patients with BD. The findings suggest that OCTA can assist clinicians in diagnosing and monitoring the status of patients with BD.

[Behçet's disease and uveitis]

This literature review is dedicated to the Behçet's disease - a multi-symptom, severe autoimmune condition, relatively rare among the population of the former Soviet republics, and to one of its three most frequent manifestations - uveitis.

Clinical profile and evolution of patients with juvenile-onset Behçet's syndrome over a 25-year period: insights from the AIDA network

Behçet's syndrome (BS) represents an understudied topic in pediatrics: the main aims of our study were to characterize demographic and clinical features of a cohort of BS patients with juvenile-onset managed in three tertiary referral centers in Italy, evaluate their evolution in the long-term, and detect any potential differences with BS patients having an adult-onset. Medical records of 64 juvenile-onset and 332 adult-onset BS followed-up over a 2-year period were retrospectively analyzed and compared. Mean age ± SD of first symptom-appearance was 10.92 ± 4.34 years with a female-to-male ratio of 1.06:1. Mucocutaneous signs were the most frequent initial manifestations, followed by uveitis. Throughout the disease course, genital aphthae (76.56%) and pseudofolliculitis (40.63%) prevailed among the mucocutaneous signs, while major organ involvement was represented by gastrointestinal and ocular involvement (43.75 and 34.38%, respectively). No significant differences emerged for both mucocutaneous signs and specific major organ involvement between juvenile-onset and adult BS patients. After excluding nonspecific abdominal pain, juvenile-onset BS patients were less frequently characterized by the development of major organ involvement (p = 0.027). Logistic regression detected the juvenile-onset as a variable associated with reduced risk of long-term major organ involvement (OR 0.495 [0.263-0.932], p = 0.029). In our cohort, juvenile-onset BS resembled the clinical spectrum of adult-onset patients. Pediatric patients with a full-blown disease at onset showed a more frequent mucocutaneous involvement. In addition, patients with juvenile-onset seemed to develop less frequently major organ involvement and had an overall less severe disease course.

Preclinical ocular features in patients with Behçet's disease detected by optical coherence tomography angiography

OBJECTIVE

The aim of this study was to evaluate the perifoveal and peripapillary microvascular structure in patients with Behçet's disease (BD) without clinically ocular involvement.

METHODS

Fifty-six eyes of 28 patients with Behçet's disease without clinically ocular involvement and 50 age-matched healthy eyes were included in this prospective study. Vessel densities (VD) of macula and optic nerve head, foveal avascular zone (FAZ), choroid capillary plexus (CCP) flow area, perifoveal capillary nonperfusion, capillary dilatation and/or telangiectasia and perifoveal capillary arcade disruption were analyzed with optical coherence tomography angiography (OCTA). The relationship between duration of disease and vessel densities was also evaluated.

RESULTS

The FAZ was significantly higher in the BD group (p < 0.001). VD of the foveal and parafoveal region in deep capillary plexus (DCP) were significantly lower in the BD group than in the control group (p < 0.001, p < 0.001). Total disc, peripapillary and inside-disc VD were significantly lower in BD group (p = 0.001, p = 0.002, p = 0.004). Perifoveal morphological changes in DCP were significantly higher in nonocular BD (p < 0.001, p < 0.001, p < 0.001). There was a mild negative correlation between disease duration and whole VD in DCP, total disc VD, peripapillary VD was determined (For whole VD in DCP, r = -0.400, p = 0.035; for total disc VD r = -0.396, p = 0.037; for peripapillary VD r = -0.442, p = 0.018).

DISCUSSION

Perifoveal and peripapillary microvascular changes that can be detected by OCTA may occur in Behçet's patients without clinically ocular involvement.

Behçet Disease: An Update for Dermatologists

Behçet disease (BD) is a chronic, relapsing, systemic vasculitis of unknown etiology with the clinical features of oral and genital ulcers, cutaneous vasculitic lesions, ocular, articular, vascular, gastrointestinal, neurologic, urogenital and cardiac involvement. BD usually appears around the third or fourth decade of life. Gender distribution is roughly equal. The disease is much more frequent in populations along the ancient 'Silk Road', extending from Eastern Asia to countries in the Middle East and the Mediterranean, compared with Western countries, but has universal distribution. Mucocutaneous manifestations are the clinical hallmarks of BD. The diagnostic criteria widely used in the disease's diagnosis are based on mucocutaneous manifestations because of their high sensitivity and/or specificity. Genetic factors are the key driver of BD pathogenesis, and HLA-B51 antigen is the strongest genetic susceptibility factor. Streptococcus sanguinis (S. sanguinis) or microbiome change can trigger innate immune system-mediated inflammation sustained by adaptive immune responses. Epistatic interaction between HLA-B51 and endoplasmic reticulum aminopeptidase 1 (ERAP1) in antigen-presenting cells disrupt T-cell homeostasis leading to downregulation of Tregs and expansion of Th1 and Th17. Thus, neutrophil activation and intense neutrophil infiltration of the affected organs develop in the early stage of inflammation. BD has a variable clinical course with unpredictable exacerbations and remissions. The disease is associated with a high mortality rate, especially in young male patients, and large-vessel, neurological, gastrointestinal system and cardiac involvement are the most important causes of death. The principal aim of treatment should be to prevent irreversible organ damage, especially during the disease's early, active phase. A better understanding of the disease's pathogenesis has provided important information on its management. New drugs, especially apremilast and anti-TNF-α agents are effective in the management of BD and have the potential to improve patients' quality of life, prognosis and survival.

The Efficacy of Adalimumab as an Initial Treatment in Patients with Behçet's Retinal Vasculitis

Background: No study has evaluated the effectiveness of Adalimumab (ADA) as first-line in treatment-naïve patients with retinal vasculitis due to Behçet’s Uveitis (BU).

Objective: To compare the efficacy of ADA plus conventional therapy and conventional therapy alone as initial treatments in naïve BU patients characterized by retinal vasculitis.

Methods: Medical records of BU patients characterized by retinal vasculitis treated with conventional therapy (CT, refers to glucocorticoid and immunosuppressive agents) alone or ADA plus conventional therapy with at least 6 months of follow-up between February 2015 and June 2020 were analyzed. Only patients who were first diagnosed with BU without previous systemic treatment were reviewed. The retinal vasculitis score based on fluorescein angiography (FA), best-corrected visual acuity, glucocorticoid-sparing effect, the number of relapses and ocular complications were evaluated.

Results: A total of 45 patients (87 eyes) were included. Twenty-four patients (55.33%) in the CT group were treated with conventional therapy and 21 patients (46.67%) in the ADA group were treated with ADA plus conventional therapy. The inflammatory parameters improved in both groups. FA scores showed significantly greater improvement in ADA group than CT group (p < 0.001). The median number of relapses was significantly lower, and the duration of remission was longer in ADA group than CT group (p < 0.001). At the last visit, a significantly better BCVA improvement (p = 0.024), better inflammation control (anterior chamber inflammation p = 0.017 and vitritis p < 0.001) and lower daily glucocorticoid dosage (p = 0.005) were identified in patients received ADA therapy. In CT group, 1 patient suffered hepatitis B and tuberculosis, 1 had growth retardation, 1 patient had with osteoporosis, then followed by other mild AEs (mostly respiratory upper tract infections); while in ADA group, 1 patient experienced a mild pneumonia (n = 1) while milder AEs were represented mostly by respiratory upper tract infections followed by gastrointestinal discomfort.

Conclusion: ADA plus conventional therapy achieved superiority over conventional therapy as initial treatment in naïve BU patients with retinal vasculitis.

Reperfusion of retinal ischemia in retinal occlusive vasculitis with nicotinic acid and infliximab in Adamantiades-Behçet's disease

To describe a case of ischemic retinal vasculitis in Adamantiades-Behçet disease (ABD) that demonstrated significant resolution of retinal ischemia following treatment with nicotinic acid and infliximab.Observations: A 12-year-old male with a history of recurrent oral ulcers, fevers, and failure to thrive was admitted to the hospital with fever, oral and perirectal mucositis, and poor oral intake one month before presentation to uveitis clinic. He was suspected to have ABD and was treated with three doses of intravenous (IV) methylprednisolone (30 mg/kg/day) which led to improvement in his systemic symptoms. One week after admission, he complained of decreased vision in both eyes (OU), during which he was found to have anterior uveitis in OU and was referred to the Uveitis Clinic. Upon examination, his visual acuity was 20/80 in OU. Intraocular pressures were within normal limits. Anterior chamber evaluation revealed 0.5+ cells and 1.5+ flare in OU. Posterior examination revealed pale optic nerve, sclerosis and vascular sheathing of retinal arteries, and collateral vessels in OU. Fluorescein angiography (FA) showed optic disc leakage and widespread retinal ischemia in OU. The patient was diagnosed with retinal occlusive vasculitis associated with ABD. He was initially treated with infliximab (5 mg/kg), systemic methylprednisolone, and mycophenolate mofetil. Three months later, his BCVA improved to 20/70 OU with slight improvement of retinal ischemia on FA. Nicotinic acid was added to his treatment regimen. Due to logistic challenges, he did not receive infliximab treatment during the subsequent three months. However, three months after beginning nicotinic acid therapy, FA revealed significant improvement of his retinal ischemia OU. Conclusion: To our knowledge, the index report is the first to show that nicotinic acid may improve retinal ischemia in vaso-occlusive retinal vasculitis and be an integral part of the treatment regimen of this sight-threatening condition.

Uveitis as an Open Window to Systemic Inflammatory Diseases

Spondyloarthritis (Spa), Behçet's disease (BD) and sarcoidosis are major systemic inflammatory diseases worldwide. They are all multisystem pathologies and share a possible ocular involvement, especially uveitis. We hereby describe selected cases who were referred by ophthalmologists to our internal medicine department for unexplained uveitis. Physical examination and/or the use of laboratory and imaging investigations allowed to make a diagnosis of a systemic inflammatory disease in a large proportion of patients. In our tertiary referral center, 75 patients have been diagnosed with Spa (n = 20), BD (n = 9), or sarcoidosis (n = 46) in the last two years. There was a significant delay in the diagnosis of Spa-associated uveitis. Screening strategies using Human Leukocyte Antigen (HLA)-B27 determination and sacroiliac magnetic resonance imaging in patients suffering from chronic low back pain and/or psoriasis helped in the diagnosis. BD's uveitis affects young people from both sexes and all origins and usually presents with panuveitis and retinal vasculitis. The high proportion of sarcoidosis in our population is explained by the use of chest computed tomography (CT) and 18F-fluorodeoxyglucose positron emission tomography CT that helped to identify smaller hilar or mediastinal involvement and allowed to further investigate those patients, especially in the elderly. Our results confirm how in these sight- and potentially life-threatening diseases a prompt diagnosis is mandatory and benefits from a multidisciplinary approach.

Correlation of clinical signs and symptoms of Behçet's disease with mean platelet volume (MPV) and red cell distribution width (RDW)

Background

A strong correlation was previously found between mean platelet volume (MPV), red blood cell distribution width (RDW), and the severity of signs and symptoms in patients suffering from inflammatory and autoimmune diseases. The current study evaluated these correlations in patients with Behçet’s disease (BD) as well the relationship between MPV and RDW and disease activity score on the Iranian Behçet’s Disease Dynamic Activity Measurement (IBDDAM).

Methods

This cross-sectional study included 319 patients with BD for whom demographic and epidemiological data, IBDDAM scores, and duration of illness was recorded. Blood samples were then obtained and the relationships between their disease status and manifestations and their laboratory parameters were evaluated with statistical models to find possible correlations.

Results

Our analysis showed a significantly higher RDW in patients with BD who had ocular manifestations (p < 0.001) and oral aphthae (p = 0.004). Patients with active BD had higher RDW (p < 0.001) and MPV (p < 0.001) in comparison to those with currently inactive BD. Similarly, patients who had any type of ocular manifestation had higher RDW (p < 0.001) and MPV (p < 0.001). Regression analyses identified a statistically significant model for the effect of RDW and MPV in predicting active BD status (p < 0.001), as well as its significant relationship with active ocular manifestations (p < 0.001).

Conclusion

BD was found to be associated with an increase in MPV and RDW, particularly during active phases. RDW and MPV were also found to have predictive value for screening to detect BD activity and its ocular complications.

Risk factors of disease activity in patients with Behçet's syndrome

OBJECTIVES

To investigate the clinical characteristics and laboratory data in Behçet's syndrome (BS) patients in China and analyze the risk factors of disease activity.

METHOD

A retrospective analysis method was used and the demographic data and laboratory results were collected from 174 BS patients. Univariate and multivariate logistic regression analyses were used to analyze the demographic data and laboratory indexes whether that are risk factors or not of disease activity.

RESULTS

The most common clinical manifestations of BS patients enrolled were mouth ulceration (48.85%), followed by erythema nodosum (20.69%), and eye involvement (13.75%), while the least common was headache (0%). Most active BS patients (96.55%) used 2 or ≥ 3 immunosuppressants to control disease, while most inactive patients (75%) used 0 or 1 immunosuppressant. The associated risk factors of disease activity consisted of disease duration, neutrophil-to-lymphocyte ratio (NLR), white blood cells, red blood cells, hemoglobin, platelets, fibrin degradation products, IgG, IgM, complement 3, complement 4, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), albumin, albumin-to-globulin ratio (AGR), and high-density lipoprotein (HDL) (P < 0.05 or P = 0.00). Disease duration (≤ 60 months) (OR 8.49, 95% CI 2.09-34.49, P = 0.003), NLR (≥ 2) (OR 8.68, 95% CI 2.12-35.49, P = 0.003), CRP (≥ 10 mg/L) (OR 41.12, 95% CI 8.43-200.70, P = 0.000), ESR (≥ 20 mm/H) (OR 9.60, 95% CI 2.41-38.18, P = 0.001), and AGR (< 1.5) (OR 12.42, 95% CI 2.92-52.80, P = 0.001) were the independent risk factors of disease activity in BS patients.

CONCLUSIONS

Attention should be paid to the risk factors of disease activity and the medicine should be adjusted correspondingly. Key Points • The current diagnosis and efficacy evaluation of Behçet's syndrome (BS) mainly relied on clinical symptoms, while there are no specific laboratory biomarkers for reference. • In this study, we found that disease duration (≤ 60 months), neutrophil-to-lymphocyte ratio (≥ 2), C-reactive protein (≥ 10 mg/L), erythrocyte sedimentation rate (≥ 20 mm/H), and albumin-to-globulin ratio (< 1.5) were the independent risk factors of disease activity in BS patients. • In the ROC curve analysis, we found that erythrocyte sedimentation rate, C-reactive protein, and neutrophil-to-lymphocyte ratio could predict whether BS patients were active.

Higher 25-hydroxyvitamin D level is associated with increased risk for Behçet's disease

BACKGROUND & AIM

Previous studies showed a vitamin D deficiency in patients with Behçet's disease, suggesting potential benefits of vitamin D supplementation in the prevention and treatment of Behçet's disease. Interpretation of these studies may be limited by reverse causality or confounding bias. We aim to determine the causal association between serum 25-hydroxyvitamin D [25(OH)D] and the risk of Behçet's disease by Mendelian randomization.

METHODS

An allele score formed by four variants (rs2282679, rs10741657, rs12785878 and rs6013897) that were associated with serum 25(OH)D level, was examined using data of genome-wide association study (GWAS) on 999 Behçet's disease and 4417 healthy individuals of Chinese ancestry and validated using data of GWAS on 1215 Behçet's disease and 1278 controls of Turkish ancestry. The primary outcome was the risk of Behçet's disease, evaluated by an inverse variance weighted average of the associations with genetically determined 25(OH)D levels.

RESULTS

The inverse variance weighted estimate showed that genetically increased 25(OH)D level was associated with a higher risk of Behçet's disease. In the Chinese cohort, the odds ratio for Behçet's disease in one standard deviation increase of natural log-transformed 25(OH)D level was 3.82 (95% CI: 1.27-11.42). Data from Turkish cohort confirmed the association with Behçet's disease (OR, 95% CI: 4.18, 1.15-15.12). In overall combination of Chinese and Turkish cohorts, the odds ratio for Behçet's disease per standard deviation increase of natural log-transformed 25(OH)D level was estimated to be 3.96 (95% CI: 1.72-9.13; P = 0.001). No significant evidence of pleiotropy and heterogeneity was detected.

CONCLUSIONS

On the basis of evidence in 7909 human beings, this study provides the newest indication that a lifelong higher 25(OH)D level is associated with an increased risk of Behçet's disease. Special attention should be paid to the potential harm of long-term or high-dose use of vitamin D supplements in clinical practice.

Long-Term Outcomes of Behçet's Syndrome-Related Uveitis: A Monocentric Italian Experience

Objectives

To examine demographic and clinical characteristics and long-term visual outcome in a cohort of Italian patients affected by Behçet's uveitis (BU).

Materials and Methods

Retrospective chart review of 47 patients with BU attending our unit between January 2018 and December 2019. Ophthalmologic manifestations, best-corrected visual acuity (BCVA), fluoroangiography and optical coherence tomography findings, and ocular complications were recorded. Predictive factors of a poor visual outcome and long-term complications were also investigated.

Results

Forty-seven patients (23 males and 24 females) for a total of 84 eyes were enrolled. Uveitis was bilateral in 37 (78.7%) patients with panuveitis being the most frequent anatomical pattern (40 out of 84 eyes), whereas 27 eyes presented a posterior uveitis. Isolated anterior uveitis was detected in 16 eyes. A significant improvement of median BCVA between baseline and last follow-up values was detected (p = 0.042). A higher risk of poor visual prognosis was observed in patients with uveitis duration greater than 15 years (p = 0.019). A significant resolution of retinal vasculitis was detected between baseline and last follow-up evaluation (p < 0.0001) whereas the mean ± SD macular thickness did not decrease significantly between baseline (376.00 ± 97.45 μm) and last follow-up evaluation (338.08 ± 55.81 μm). Forty-two eyes developed 57 complications during the disease course. Cataract was the most frequent (n = 12), followed by epiretinal membranes (n = 11) and cystoid macular edema (n = 6). The following variables were identified as predictors of long-term complications: human leukocyte antigen- (HLA-) B51 (p = 0.006), panuveitis (p = 0.037), and a uveitis duration of more than 15 years (p = 0.049).

Conclusions

In Italian patients, BU typically arises in the third decade and predominantly manifests as a bilateral posterior uveitis or panuveitis. Its duration is associated with a poor visual prognosis. Uveitis duration, the presence of HLA-B51, and panuveitis are predictors of long-term structural complications, thus representing main drivers in the treatment decision-making.

Treating the Different Phenotypes of Behçet's Syndrome

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.

Behçet's disease; A rare refractory patient with vena cava superior syndrome treated with infliximab: a case report and review of the literature

Objectives: Behçet's disease (BD) is a multi-systemic inflammatory disorder which can affect all types and sizes of vessels.The usage of TNF-α antagonists is increasing in different involvements of BD that is inadequately controlled by standard immunosuppressive regimens. Methods: Here we reported a rare BD case that is controlled by only infliximab (IFX) treatment. Results: A 24-years-old male patient was diagnosed as BD with recurrent oral and genital ulcerations,uveitis,femoral vein thrombosis and HLA-B5 positivity.He had had terminal ileitis,epididymitis,bilateral internal iliac artery aneurysm and superior sagittal sinus thrombosis after the diagnosis.He admitted to our outpatient clinic with dyspnea,orthopnea,chest pain and facial swelling.We detected facial edema,plethora,venous distention on neck and chest.We suspected vena cava superior syndrome(VCSS) and performed CT angiography that demonstrated high-grade vena cava superior stenosis and thrombus where SVC opens to the right atrium.Patient was anticoagulated with warfarin and a shunt was implanted between the left brachiocephalic vein and right atrium.Colchicine and interferon-alfa treatment were continued and 1mg/kg steroid was added.But the patients' symptoms relapsed one month later and his shunt was revised with balloon angioplasty.5mg/kg IFX was started.We  performed a CT-angiography annually for two years.VCSS and other symptoms of BD are resolved and have not relapsed yet. Conclusions: Vascular involvement of BD are generally treated with immunosuppressive agents such as steroids and immunomodulators.IFX was found effective and well tolerated in the treatment of intestinal,neurological and vascular involvement of BD especially in patients with poor response or intolerance to conventional therapy.This case report supports IFX as a new therapeutic option for patients with vascular BD.

Retinal vasculitis with Chronic Recurrent Multifocal Osteomyelitis: a case report and review of the literature

Background

Concurrent presentation of retinal vasculitis with mixed sclerotic and lytic bone lesions is rare.

Case presentation

We present the case of a 37-year old woman with a several year history of episodic sternoclavicular pain who presented for rheumatologic evaluation due to a recent diagnosis of retinal vasculitis. We review the differential diagnosis of retinal vasculitis, along with the differential diagnosis of mixed sclerotic and lytic bone lesions. Ultimately, bone marrow biopsy confirmed diagnosis of chronic recurrent multifocal osteomyelitis (CRMO). Concurrent presentation of CRMO with retinal vasculitis is extremely rare but important to recognize. The patient demonstrated clinical response to prednisone and tumor necrosis factor-alpha inhibition (TNF-i).

Conclusion

This case reports and unusual presentation of CRMO spectrum disease involving the sternum and sternoclavicular joint with concurrent retinal vasculitis.

Update on the treatment of Behçet's syndrome

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.

Evaluation of tear osmolarity and tear function in patients with Behçet's syndrome

OBJECTIVE

To evaluate the effects of Behçet's syndrome (BS) on tear osmolarity and tear film function tests.

METHODS

Thirty patients with BS and 41 control subjects were enrolled in this study. Tear osmolarity was measured with an osmometer. Tear film function tests involved corneal fluorescein staining, tear film breakup time (TBUT), Schirmer's 1 test, and an Ocular Surface Disease Index (OSDI) Questionnaire.

RESULTS

The patients with BS had significantly higher tear osmolarity (p = 0.000) and OSDI scores (p = 0.000) than the healthy controls. The TBUT (p = 0.000) and Schirmer's 1 test (p = 0.033) results were significantly lower in the BS group, but the fluorescein staining results were not statistically different. A significant correlation was found between tear osmolarity, OSDI, and the activity of BS.

CONCLUSIONS

BS is associated with hyperosmolarity of the tear film, which can damage the ocular surface and affect tear functions.

Quantitative analysis of retinal microcirculation in optical coherence tomography angiography in cases with Behçet's disease without ocular involvement

PURPOSE

To evaluate the retinal vascular plexus and choriocapillaris structures in patients with non-ocular Behçet's disease (BD) using optical coherence tomography angiography (OCTA).

METHODS

The study included 42 eyes of non-ocular BD patients (study group) and 40 eyes of 20 healthy subjects (control group). Flow area (mm²), mean vascular density (VD) (%) and foveal avascular zone (FAZ) (mm²) were measured using OCTA (Optovue Inc., Fremont, CA, USA). Subfoveal choroidal thickness (CT) (μm) and central macular thickness (CMT) (μm) measurements were also performed.

RESULTS

The mean superficial capillary plexus, deep capillary plexus and choriocapillaris flow area values were found to be significantly lower in the study group than in the control group (p < 0.001, p < 0.001, p = 0.008, respectively). In respect of mean VD, a statistically significant difference was determined between the study and control groups in both superficial and deep VD (p < 0.001). No statistically significant difference was found out between the groups in respect of superficial FAZ, deep FAZ and CMT (p = 0.165, p = 0.477, p = 0.457, respectively). The subfoveal CT was also measured to be significantly thicker in the study group than in the control group (p < 0.001).

CONCLUSION

The results obtained with OCTA revealed that there could be both retinal and choroidal involvement in non-ocular BD patients before the emergence of evident clinical findings.

Anti-interleukin 6 receptor tocilizumab in refractory uveitis associated with Behçet's disease: multicentre retrospective study

Objective

To assess the efficacy of tocilizumab (TCZ) in refractory uveitis of Behçet's disease (BD).

Methods

Multicentre study of patients with BD-associated uveitis. Patients were refractory to conventional and biologic immunosuppressive drugs. The main outcome measures were intraocular inflammation, macular thickness, visual acuity and corticosteroid-sparing effects.

Results

We studied 11 patients (7 men) (20 affected eyes); median age 35 years. Uveitis was bilateral in nine patients. The patterns of ocular involvement were panuveitis (n = 8, with retinal vasculitis in 4), anterior uveitis (n = 2) and posterior uveitis (n = 1). Cystoid macular oedema was present in seven patients. The clinical course was recurrent (n = 7) or chronic (n = 4). Before TCZ, patients had received systemic corticosteroids, conventional immunosuppressants and the following biologic agents: adalimumab (n = 8), infliximab (n = 4), canakimumab (n = 1), golimumab (n = 3), etanercept (n = 1). TCZ was used as monotherapy or combined with conventional immunosuppressants at 8 mg/kg/i.v./4 weeks (n = 10) or 162 mg/s.c./week (n = 1). At TCZ onset the following extraocular manifestations were present: oral and/or genital ulcers (n = 7), arthritis (n = 4), folliculitis/pseudofolliculitis (n = 4), erythema nodosum (n = 2), livedo reticularis (n = 1) and neurological involvement (n = 2). TCZ yielded rapid and maintained improvement in all ocular parameters of the patients, with complete remission in eight of them. However, this was not the case for the extraocular manifestations, since TCZ was only effective in three of them. After a mean (s.d.) follow-up of 9.5 (8.05) months, TCZ was withdrawn in two cases, due to a severe infusion reaction and arthritis impairment, respectively.

Conclusion

TCZ could be a therapeutic option in patients with BD and refractory uveitis.

Frequency of Behçet's disease among a group of visually impaired adults

BACKGROUND

Behçet's disease (BD) is one of the reasons of acquired visual impairment among young adults. Ocular involvement is a significant cause of disability in BD. The objective of this study is to assess the prevalence of BD among a group of adults who has visual impairment.

METHODS

Ankara Metropolitan Municipality Education and Technology Center is one of the official institutions which records and follows the demographic data of visually impaired people in Turkey. In November 2014, there were 675 visually impaired people recorded at this center. Medical history was taken from 294 adults by phone in November and December of 2014. Participants were asked if the visual impairment had been either acquired or congenital. If the patients had BD or suspicious BD, they were recalled for detailed investigation which would be carried out by an internist, a rheumatologist and an ophthalmologist.

RESULTS

Two hundred thirteen of 294 (72.4%) visually impaired adults were male. One hundred nine of 294 (37.1%) had acquired visual impairment. Six (5.5%) of those 109 patients had BD. Overall prevalence of BD among study group was 2.04%.The median age of people with BD was 35 years. The median age at BD diagnosis was 16.5 years and the median duration from diagnosis to visual loss was 2.5 years.

CONCLUSION

BD is still one of the causes of acquired visual impairment in Turkey. In this study, BD prevalence among a visually impaired adult group was 2.04%. BD accounted for 5.5% among adults who had acquired visual impairment. In a study of 1965, BD prevalence among people with acquired blindness was 12%. However, this study was conducted at pre-immunosuppressive period. Our prevalence is obviously lower than those studies. Extended population-based studies are needed for population estimations.

Multiple aneurysms and gastrointestinal involvement in Behcet's disease: A case report

RATIONALE

Behcet's disease (BD) is a rare systemic vasculitis disorder that can involve vessels of any size.

PATIENT CONCERNS

A 60-year-old female had recurrent painful mouth ulcers about 30 years ago and recently presented with abdominal distension, conjunctival congestion, and chest pain in sequence.

DIAGNOSES

The patient was diagnosed with BD according to the International Criteria for Behcet's Disease (ICBD).

INTERVENTIONS

A therapy of glucocorticoids and cyclophosphamide was administered.

OUTCOMES

After a 3-month treatment, follow-up examination showed a depression of the inflammation and a slight decrease of the arterial aneurysms.

LESSONS

BD patients may get a delayed diagnosis because of the long duration between the first and subsequent manifestations. Suspect patients should be followed-up and the diagnosis of BD should be considered when multiple tissues or organs are involved.

Behçet's syndrome: providing integrated care

Behçet’s syndrome (BS) is a multisystem vasculitis that presents with a variety of mucocutaneous manifestations such as oral and genital ulcers, papulopustular lesions and erythema nodosum as well as ocular, vascular, gastrointestinal and nervous system involvement. Although it occurs worldwide, it is especially prevalent in the Far East and around the Mediterranean Sea. Male gender and younger age at disease onset are associated with a more severe disease course. The management of BS depends on the severity of symptoms. If untreated, morbidity and mortality are considerably high in patients with major organ involvement. Multidisciplinary patient care is essential for the management of BS, as it is for other multisystem diseases. Rheumatologists, dermatologists, ophthalmologists, neurologists, cardiovascular surgeons and gastroenterologists are members of the multidisciplinary team. In this study, we reviewed the epidemiology, etiology, diagnostic criteria sets, clinical findings and treatment of BS and highlighted the importance of the multidisciplinary team in the management of BS.

Systemic vasculitis and the eye

PURPOSE OF REVIEW

The primary systemic vasculitides represent a spectrum of rare but life-threatening conditions that may also affect the eye in various forms. This article reviews recently published data on ocular manifestations of systemic vasculitis.

RECENT FINDINGS

Early diagnosis and timely treatment has led to better visual outcomes in giant cell arteritis (GCA). Gene expression from orbital tissues could distinguish granulomatosis with polyangiitis (GPA) from sarcoidosis and Graves disease, but not from idiopathic orbital inflammation. Rituximab was an effective therapeutic option in ocular GPA. An ocular attack severity scoring system, flare levels, fluorescein angiography and optical coherence tomography parameters have been suggested as predictors of visual prognosis in Behçet disease. Efficacy of tumor necrosis factor-alpha inhibitors, interferon α and anti-interleukin-1 agents was shown in noncontrolled studies of ocular Behçet disease.

SUMMARY

Widely used fast-track pathway care as well as ocular imaging to detect subclinical involvement may enable earlier diagnosis of GCA and prevention of permanent visual loss. Orbital inflammation may not remain idiopathic with advances in gene expression profiling of orbital tissues. With an increased availability and the use of biologic agents, visual prognosis will improve in patients with severe ocular complications of systemic vasculitides.

The Immune Response and the Pathogenesis of Idiopathic Inflammatory Myositis: a Critical Review

The pathogenesis of idiopathic inflammatory myositis (IIMs, including polymyositis and dermatomyositis) remains largely enigmatic, despite advances in the study of the role played by innate immunity, adaptive immunity, genetic predisposition, and environmental factors in an orchestrated response. Several factors are involved in the inflammatory state that characterizes the different forms of IIMs which share features and mechanisms but are clearly different with respect to the involved sites and characteristics of the inflammation. Cellular and non-cellular mechanisms of both the immune and non-immune systems have been identified as key regulators of inflammation in polymyositis/dermatomyositis, particularly at different stages of disease, leading to the fibrotic state that characterizes the end stage. Among these, a special role is played by an interferon signature and complement cascade with different mechanisms in polymyositis and dermatomyositis; these differences can be identified also histologically in muscle biopsies. Numerous cellular components of the adaptive and innate immune response are present in the site of tissue inflammation, and the complexity of idiopathic inflammatory myositis is further supported by the involvement of non-immune mechanisms such as hypoxia and autophagy. The aim of this comprehensive review is to describe the major pathogenic mechanisms involved in the onset of idiopathic inflammatory myositis and to report on the major working hypothesis with therapeutic implications.

Ocular Involvement in Systemic Autoimmune Diseases

Eye involvement represents a common finding in patients with systemic autoimmune diseases, particularly rheumatoid arthritis, Sjogren syndrome, seronegative spondyloarthropathy, and antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis. The eye is a privileged immune site but commensal bacteria are found on the ocular surface. The eye injury may be inflammatory, vascular or infectious, as well as iatrogenic, as in the case of hydroxychloroquine, chloroquine, corticosteroids, and bisphosphonates. Manifestations may affect different components of the eye, with episcleritis involving the episclera, a thin layer of tissue covering the sclera; scleritis being an inflammation of the sclera potentially leading to blindness; keratitis, referring to corneal inflammation frequently associated with scleritis; and uveitis as the inflammation of the uvea, including the iris, ciliary body, and choroid, subdivided into anterior, posterior, or panuveitis. As blindness may result from the eye involvement, clinicians should be aware of the possible manifestations and their management also independent of the ophthalmologist opinion as the therapeutic approach generally points to the underlying diseases. In some cases, the eye involvement may have a diagnostic implication, as for episcleritis in rheumatoid arthritis, or acute anterior uveitis in seronegative spondyloarthritis. Nonetheless, some conditions lack specificity, as in the case of dry eye which affects nearly 30 % of the general population. The aim of this review is to elucidate to non-ophthalmologists the major ocular complications of rheumatic diseases and their specific management and treatment options.

Autoimmunity in 2014

Our PubMed search for peer-reviewed articles published in the 2014 solar year retrieved a significantly higher number of hits compared to 2013 with a net 28 % increase. Importantly, full articles related to autoimmunity constitute approximately 5 % of immunology articles. We confirm that our understanding of autoimmunity is becoming a translational paradigm with pathogenetic elements rapidly followed by new treatment options. Furthermore, numerous clinical and pathogenetic elements and features are shared among autoimmune diseases, and this is well illustrated in the recent literature. More specifically, the past year witnessed critical revisions of our understanding and management of antiphospholipid syndrome with new exciting data on the pathogenicity of the serum anti-beta2 glycoprotein autoantibody, a better understanding of the current and new treatments for rheumatoid arthritis, and new position papers on important clinical questions such as vaccinations in patients with autoimmune disease, comorbidities, or new classification criteria. Furthermore, data confirming the important connections between innate immunity and autoimmunity via toll-like receptors or the critical role of T regulatory cells in tolerance breakdown and autoimmunity perpetuation were also reported. Lastly, genetic and epigenetic data were provided to confirm that the mosaic of autoimmunity warrants a susceptible individual background which may be geographically determined and contribute to the geoepidemiology of diseases. The 2014 literature in the autoimmunity world should be cumulatively regarded as part of an annus mirabilis in which, on a different level, the 2014 Annual Meeting of the American College of Rheumatology in Boston was attended by over 16,000 participants with over selected 3000 abstracts.

Autoimmunity in visual loss

There are a number of autoimmune disorders which can affect visual function. There are a very large number of mechanisms in the visual pathway which could potentially be the targets of autoimmune attack. In practice it is the retina and the anterior visual pathway (optic nerve and chiasm) that are recognised as being affected in autoimmune disorders. Multiple Sclerosis is one of the commonest causes of visual loss in young adults because of the frequency of attacks of optic neuritis in that condition, however the basis of the inflammation in Multiple Sclerosis and the confirmation of autoimmunity is lacking. The immune process is known to be highly unusual in that it is not systemic and confined to the CNS compartment. Previously an enigmatic partner to Multiple Sclerosis, Neuromyelitis Optica is now established to be autoimmune and two antibodies - to Aquaporin4 and to Myelin Oligodendrocyte Glycoprotein - have been implicated in the pathogenesis. The term Chronic Relapsing Inflammatory Optic Neuropathy is applied to those cases of optic neuritis which require long term immunosuppression and hence are presumed to be autoimmune but where no autoimmune pathogenesis has been confirmed. Optic neuritis occurring post-infection and post vaccination and conditions such as Systemic Lupus Erythematosus and various vasculitides may cause direct autoimmune attack to visual structures or indirect damage through occlusive vasculopathy. Chronic granulomatous disorders such as Sarcoidosis affect vision commonly by a variety of mechanisms, whether and how these are placed in the autoimmune panoply is unknown. As far as the retina is concerned Cancer Associated Retinopathy and Melanoma Associated Retinopathy are well characterised clinically but a candidate autoantibody (recoverin) is only described in the former disorder. Other, usually monophasic, focal retinal inflammatory disorders (Idiopathic Big Blind Spot Syndrome, Acute Zonal Occult Outer Retinopathy and Acute Macular Neuroretinitis) are of obscure pathogenesis but an autoimmune disorder of the post-infectious type is plausible. Visual loss in autoimmunity is an expanding field: the most significant advances in research have resulted from taking a well characterised phenotype and making educated guesses at the possible molecular targets of autoimmune attack.

A Clinical Picture of the Visual Outcome in Adamantiades-Behçet's Disease

Adamantiades-Behçet's disease is a multisystemic vasculitis with multiorgan involvement. Ocular disorders occur often in this syndrome typically in the form of a relapsing-remitting panuveitis and vasculitis and can lead to blindness as one of its most disabling complications if left untreated. There are known risk factors related with the worst visual prognosis, which require early and intensive treatment in order to obtain a rapid suppression of inflammation and to prevent future relapses. The management strategy to avoid vision loss and blindness currently involves the use of local and systemic drugs including steroids and immunosuppressive and biologic agents. This review aims to demonstrate how the introduction and the use of biologic agents improves the visual outcome of patients with Adamantiades-Behçet's disease.