The immune complex pathogenesis of glomerulonephritis and pulmonary vasculitis in Behçet's disease

[Spontaneous aortic isthmus aneurysm: Exceptional revelation of Behçet's disease]

Arterial involvement in Behçet's disease is rare. The exceptional aortic isthmus location is difficult to treat. We report the case of a young man in whom an aortic isthmus aneurysm revealed Behçet's disease. In this exceptional situation, we opted for classical open surgical repair despite current preference for endovascular treatment.

[False aneurysm of the carotid artery revealing Behçet disease]

Vascular involvement in Behçet's disease often present as venous thrombosis. Arterial damage is rare. We report a case of Behçet's disease occurring in a 40-year-old woman revealed by a false aneurysm of the left common carotid artery. The intervention consisted in a prosthetic graft after endovascular control. After a 2-year follow-up period, the patient did not develop any postoperative complication.

Alveolar Hemorrhage

Alveolar hemorrhage (AH) is a clinical syndrome with diverse etiologies both immune and nonimmune. The defining pathological feature of AH is the presence or absence of pulmonary capillaritis. The antineutrophil cytoplasmic antibody (ANCA) related vasculitis and systemic lupus erythematosus are the commonest causes of immune AH with pulmonary capillaritis, whereas Goodpasture's syndrome and idiopathic pulmonary hemosiderosis are common causes of immune AH without pulmonary capillaritis. The major nonimmune causes of AH are primarily drug induced, or due to hematological malignancy and disorders of coagulation. Clinical features of AH include: dyspnea, fever, hemotypsis, bilateral crackles and pallor. Hypoxemia and bilateral diffuse airspace disease on the chest radiograph with relative sparing of the bases and apices which most often clears within 48 hours after its onset further characterize this syndrome. The major clinical implications of this syndrome are its potential to cause respiratory failure in severe cases and its sequelae of pulmonary fibrosis with associated morbidity and disability. In addition, AH may be the initial manifestation of a systemic immune disorder which can be managed optimally if recognized early. The diagnosis of AH is confirmed by bronchoalveolar lavage by demonstrating a progressively bloody return on successive aliquots of instilled saline or hemosiderin laden macrophages in the bronchoalveolar lavage fluid. The open lung biopsy remains the gold standard for the diagnosis of AH but is reserved for inapparent cases in whom corticosteroids and immunosuppressive therapy may be life saving. Serologic testing and examination of the urine sediment are useful adjuncts to the diagnosis. The treatment of AH is primarily supportive while an attempt is made to determine its etiology and initiate specific therapy. Glucocorticoids and cyclophosphamide are the cornerstones of therapy in immune AH with adjunctive plasmapheresis in life-threatening cases.

Superior Vena Cava Syndrome in Behçet's Disease

Behget's disease was first defined by a Turkish dermatologist of the same name, as a trisymptom syndrome which manifested itself with aphthae in the mouth, genital exul cerations and iridocyclitis with hypopyon. 1 Later, some other features have been attributed to this syndrome, namely skin changes, joint involvement, obstruction of arteries or veins, and infection of sterile injection sites.2-16 Some other rare findings have been also noted in Behqet's disease. Aphthae, genital exulcerations, eye lesions and skin changes are the major lesions. If a patient has three of the major lesions or two major + two minor lesions; the disease is considered to be complete in his case. According to the information we now have, the basic pathological disorder in Behget's disease is vasculitis. Thrombosis in the great veins and arteries, and aneurysms, are frequently noted. The majority of the cases, when they first come to the doctor, suffer from superior vena cava obstruction.

Superior vena cava obstruction is usually diagnosed easily. This causes the appear ance of many collateral veins over the anterior chest wall, the dilation of neck veins, and the growth of edema of the chest, neck and face. In the majority of superior vena cava syndromes noted in the literature, malignancy is pinpointed as the cause, while, occa sionally, benign lesions are also winnowed out to be the culprit.27,31

The aim of this work was to present the review of the last fourteen years' etiology of the superior vena cava syndromes in our hospital, and to attempt to find out how many of them were caused by Behçet's disease. As a result, it was found that Behget's disease is the second cause of superior vena cava syndrome, after malignancy. It is known that Behçet's disease is most frequently diagnosed in Turkey, Japan and Greece, so perhaps this result is not surprising for Turkey. 7,26 What's more, it is also probable that Behçet's disease might be the underlying cause in most of the cases dubbed "due to unknown reasons." To ascertain this properly, a careful case history and complete physical examination are compulsory.

Autoantibodies against complement C1q in patients with Behcet's disease: association with vascular involvement

AIM

The aim of our study was to determine the prevalence of anti-C1q antibodies and their possible association with clinical presentation in Behcet's disease (BD) patients with special emphasis for patients with vascular involvement.

METHODS

Plasma anti-C1q Abs levels were measured using an enzyme-linked immunosorbent assay in 51 BD patients and 25 age- and gender-matched healthy controls.

RESULTS

We found elevated concentrations of anti-C1q more frequently in patients with BD (18 %) than in healthy controls (8 %). The highest prevalence was found in patients with vascular BD (42 %) which was significantly higher than patients without vascular BD and healthy controls (p = 0.025). Furthermore, patients with vascular BD had the highest mean anti-C1q levels when compared to BD patients without vascular involvement or healthy control subjects (p = 0.015). We did not find significant differences in the prevalence of any other organ involvement between BD patients with elevated vs. normal anti-C1q ab levels. Anti-C1q ab levels positively correlated with ESR (r = 0.383, p = 0.006) and negatively with C4 (r = -0.304, p = 0.030).

CONCLUSION

In conclusion, we found an increased prevalence of anti-C1q autoantibodies in BD patients with vascular involvement. Further large scale longitudinal studies are required to assess and clarify the significance and the pathogenic role of anti-C1q antibodies in BD and other autoimmune diseases in which vasculitis is a component.

Autoantibodies against complement C1q in patients with Behcet's disease: association with vascular involvement

AIM: The aim of our study was to determine the prevalence of anti-C1q antibodies and their possible association with clinical presentation in Behcet's disease (BD) patients with special emphasis for patients with vascular involvement. METHODS: Plasma anti-C1q Abs levels were measured using an enzyme-linked immunosorbent assay in 51 BD patients and 25 age- and gender-matched healthy controls. RESULTS: We found elevated concentrations of anti-C1q more frequently in patients with BD (18 %) than in healthy controls (8 %). The highest prevalence was found in patients with vascular BD (42 %) which was significantly higher than patients without vascular BD and healthy controls (p = 0.025). Furthermore, patients with vascular BD had the highest mean anti-C1q levels when compared to BD patients without vascular involvement or healthy control subjects (p = 0.015). We did not find significant differences in the prevalence of any other organ involvement between BD patients with elevated vs. normal anti-C1q ab levels. Anti-C1q ab levels positively correlated with ESR (r = 0.383, p = 0.006) and negatively with C4 (r = -0.304, p = 0.030). CONCLUSION: In conclusion, we found an increased prevalence of anti-C1q autoantibodies in BD patients with vascular involvement. Further large scale longitudinal studies are required to assess and clarify the significance and the pathogenic role of anti-C1q antibodies in BD and other autoimmune diseases in which vasculitis is a component.

Circulating intercellular adhesion molecules in blood and bronchoalveolar lavage in Behçet's disease

The aim of this study was to evaluate circulating intercellular adhesion molecule-1 (cICAM-1) in serum and in bronchoalveolar lavage (BAL), as a marker for the inflammatory process in patients with active Behçet's disease (BD). Circulating ICAM-1 was tested by an enzyme linked immuno-sorbent assay in serum and in BAL of patients with BD. These values were compared to those of patients with tuberculosis and to healthy controls. Increased levels of circulating ICAM-1 were found in serum from patients with active BD compared to healthy controls (p < 0.01). Similar levels of serum cICAM-1 were found in BD and tuberculosis. Additionally, both BD and tuberculosis patients exhibited high levels of cICAM-1 in BAL fluid, suggesting that this increase may be a result of the immune system activation in inflammatory sites. Circulating ICAM-1 seemed to have a good discriminative power in identifying active BD, being elevated in all active stages (p < 0.01) compared to remission BD stage. No differences were found in active BD patients depending upon the clinical manifestations. These results suggest that cICAM-1 may be involved in leucocyte adhesion and migration into the vessel wall of the lung. Circulating forms are derived from molecules expressed on the surface of activated cells, as a result of an inflammatory process.

Pulmonary affectation of vasculitis

Respiratory tract affectation is frequent in some types of vasculitis, fundamentally in those associated with anti-neutrophil cytoplasmic antibodies (ANCA). The clinical, radiological and histopathological presentation is also heterogeneous and conditions the evolution. It is therefore necessary to establish an early diagnosis based on the symptoms because, thanks to new treatments, and despite them being potentially serious diseases, their prognosis has improved considerably in recent years. The present paper updates the diagnosis and the new therapeutic options for pulmonary vasculitis.

The demonstration of serum interleukin 6–8, tumor necrosis factor-alpha, complement, and immunoglobulin levels in Behçet’s disease with ocular involvement

PURPOSE

To investigate whether there are alterations in the humoral immune system in patients with Behçet's disease (BD) with ocular involvement.

METHODS

Twenty-four BD patients with active uveitis and without any other manifestations of the disease were included in Group I-a. The same patients were reassessed during the convalescence period and assigned to Group I-c. Moreover, 24 age- and sex-matched healthy controls (Group II) were included in the study. Serum levels of immunoglobulin (Ig) A, IgM, complement (C) 3, C4, interleukin (IL)-6, IL-8, and tumor necrosis factor-alpha (TNF-alpha) in Groups I-a, I-c, and II were measured and compared.

RESULTS

IgA, C3, C4, IL-6, IL-8, and TNF-alpha levels were higher in Group I-a than in Groups I-c and II.

CONCLUSIONS

IgA-, C3-, C4-, IL6-, IL8-, and TNF-alpha-mediated mechanisms might be responsible for ocular lesions in BD.

Pulmonary alterations in Behcet's disease

PURPOSE

This study aims to demonstrate pulmonary alterations (PA) in patients with Behcet's disease by using CT.

MATERIALS AND METHODS

CTs of 50 patients with Behcet's disease and 20 others in a control group have been evaluated retrospectively for PA (septal, reticular, nodular, atelectatic opacities).

RESULTS

Eight out of 50 patients (16%) with Behcet's disease showed PA. Three out of 20 (15%) in the control group showed PA. No differences were observed between Behcet's disease patients and the control group regarding pulmonary alterations (p=0.917). No differences were observed in the disease duration, ages and sex in either group in those with and without PA.

CONCLUSION

Pulmonary alterations can be seen in patients with Behcet's disease, but these alterations are not significant.

Mucocutaneous lesions of Behcet's disease

Behcet's disease is particularly prevalent in "Silk Route" populations, but it has a global distribution. The diagnosis of the disease is based on clinical criteria as there is as yet no pathognomonic test, and mucocutaneous lesions, which figure prominently in the presentation and diagnosis, may be considered the diagnostic hallmarks. Among the internationally accepted criteria, painful oral and genital ulcers, cutaneous vasculitic lesions and reactivity of the skin to needle prick or injection (the pathergy reaction) are considered hallmarks of Behcet's disease, and often precede other manifestations. Their recognition may permit earlier diagnosis and treatment, with salutary results. This paper describes the various lesions that constitute the syndrome and focuses on those that may be considered characteristic.

Pulmonary involvement in Behçet's disease

BACKGROUND

Behçet's disease (BD) is a multisystem vasculitis and pulmonary involvement in BD is reported to indicate poor prognosis and high mortality.

OBJECTIVES

The aims of this study were to report on patients with pulmonary involvement and to discuss pulmonary artery thrombus and small-sized vasculitis associated with BD, with respect to previously published cases.

METHODS

Fifteen patients with BD and pulmonary involvement were included in this study. Massive hemoptysis was observed in all patients having pulmonary artery aneurysm (PAA).

RESULTS

Eleven patients had macroscopic pulmonary vascular disease (2 PAA, 3 PAA and thrombi and 6 only thrombi) and 3 patients had microscopic pulmonary vascular disease. The remaining patient had pulmonary cryptococcosis.

CONCLUSIONS

Data regarding treatment and outcomes of patients having BD-related pulmonary emboli/infarct and small-sized vasculitis are limited. Pulmonary vasculitis affects different levels of the pulmonary artery in BD and should be classified as macroscopic and microscopic vascular disease. 'Pulmonary artery thrombosis' should be used instead of 'pulmonary emboli'. Spiral CT angiography is the best radiological tool for evaluation of pulmonary problems in BD. Treatment of vasculitis should be based on the type of vascular disease and may vary among different types of vascular disease. Anticoagulation can be used in patients with microscopic vascular disease and nonaneurysmal macroscopic vascular disease. More studies are needed to clarify this issue.

Intestinal perforations in Behçet's disease

Behçet's disease accompanied by intestinal involvement is called intestinal Behçet's disease. The intestinal ulcers of Behçet's disease are usually multiple and scattered and tend to perforate easily, so that many patients require emergency operation. The aim of this study is to determine the extent of surgical resection necessary to prevent reperforation and to point out the findings of concurrent oral and genital ulcers and multiple intestinal perforations in all patients of our series. During a 25-year study period, information of 125 Behçet's disease cases was gathered. Among the 82 patients who were diagnosed with intestinal Behçet's disease, 22 cases had intestinal perforations needing emergency laparotomy. We investigated and analyzed these cases according to the patients' demographic characteristics, clinical presentations, laboratory data, and surgical outcome. There were 14 men and 8 women ranging from 22 to 65 years of age. Nine cases were diagnosed preoperatively, and the diagnoses were confirmed in all 22 cases during the surgical intervention. Surgical resection was performed in every patient, with right hemicolectomy and ileocecal resection in 11 cases, partial ileum resection in 8 cases with two reperforations, and ileocecal resection in 3 cases with one reperforation.

Pulmonary vasculitis in behcet disease: a cumulative analysis

STUDY OBJECTIVES

The aims of this study were to investigate the frequency of pulmonary problems in Behçet disease (BD), and to discuss lesser-known features of pulmonary BD such as clinical characteristics, analysis of prognosis, and evaluation of treatment options with respect to the previously published cases.

DESIGN

We conducted a comprehensive review of the literature to analyze cumulated data about pulmonary involvement in BD.

SETTING

We found 159 articles regarding pulmonary disease associated with BD in May 2003.

PATIENTS

The evaluation of these articles demonstrated 598 pulmonary problems in 585 cases.

RESULTS

Pulmonary artery aneurysms (PAAs) are the most common pulmonary lesion in BD, and these are almost always associated with hemoptysis. Seventy-eight percent of patients with aneurysms have concomitant extrapulmonary venous thrombi or thrombophlebitis. Other pulmonary problems are reported in BD, and these are principally related to vascular lesions and radiologic abnormalities.

CONCLUSIONS

Pulmonary vascular problems, either PAA or involvement of small-sized vessels, are the main pulmonary disorders in BD. Immunopathologic findings indicate that the underlying pathogenesis is pulmonary vasculitis, which may result in thrombosis, infarction, hemorrhage, and PAA formation. Patients with small nonspecific radiologic abnormalities should be followed up closely since early diagnosis of vascular lesions may be life-saving. Immunosuppression is the main therapy for the treatment of a vasculitis. It is important that pulmonary angiitis is not mistaken for pulmonary thromboembolic disease since fatalities have occurred in BD shortly after initiation of anticoagulation/thrombolytic treatment.

Rapidly-progressive glomerulonephritis in a patient with Behcet’s disease: successful treatment with intravenous cyclophosphamide

We report a case of rapidly-progressive glomerulonephritis complicating Behcet's disease (BD). A 44-year-old male has suffered from recurrent oral ulcers and retinal vasculitis developed 2 years ago. He complained of abdominal pain and papulopustular skin lesions. Multiple ulcers were seen on the colon on colonoscopy. Routine renal work-up revealed heavy proteinuria and hematuria. Renal biopsy demonstrated crescentic glomerulonephritis. Most symptoms improved after steroid therapy, except for urinary abnormalities. At this point, intravenous monthly cyclophosphamide pulse therapy was undergone. After the sixth pulse therapy, proteinuria and hematuria were dramatically improved and renal function was well preserved.

Thoracic Manifestations of Behçet Disease at CT

Behçet disease is a multisystemic and chronic inflammatory disorder of unknown cause that is characterized by recurrent oral and genital ulcerations, ocular manifestations, and additional clinical manifestations in multiple organ systems. Behçet disease involving the chest can manifest as a wide spectrum of abnormalities. Although conventional chest radiography is commonly used for initial assessment, spiral computed tomography can demonstrate the entire spectrum of thoracic manifestations of Behçet disease, including abnormalities of the vessel lumen and wall, perivascular tissues, lung parenchyma, pleura, and mediastinal structures. Aneurysms of the pulmonary arteries, with or without thrombosis, are a typical manifestation of Behçet disease. Other manifestations include thrombosis, vasculitis, hemorrhage, infarction, and inflammation. Familiarity with these manifestations can be useful in the diagnosis of Behçet disease, helping to determine the cause of symptoms in patients who present with hemoptysis and guide the choice of appropriate therapy.

[Renal involvement in Behçet's disease. About six cases]

PURPOSE

To analyze anatomoclinic and evolutive aspects of the renal involvement associated to the Behçet's disease through 6 observations collected in the nephrology department from 1985 to 2000 and to make a review of the literature.

METHODS

Retrospective study, diagnosis of Behçet's disease according to the Classification of the International Group Study on the Behçet's disease and renal damage confirmed by histology.

RESULTS

Our patients all male are aged between 25 to 55 years with a mean at 34 years old. The renal damage was revelated by a nephrotic syndrome in 3 cases and by a proteinuria at 1 to 2.7 g/day in 3 cases. Microscopic hematuria was present in 2 cases and arterial hypertension in 2 cases. The renal insufficiency has been noted in 2 cases of which severe in one of them. The renal biopsy showed an amyloidosis AA type in 3 cases, a segmental and focal glomerulonephritis in 2 cases and a thrombotic microangiopathy associated to a moderate tubulo-interstitiel lesions by toxicity of ciclosporine in 1 case. The extrarenal signs were dominated by bipolar aphtosis in all cases, necrotic pseudofolliculitis and the no specific cutaneous hyperreactivity in 5 cases and the erythema nodosum in 1 case. The ocular manifestation has been noted in 4 cases and articular manifestation in 3 cases. The vascular manifestation has been noted in one case. The treatment was colchicine in 4 cases and prednisone and cyclophosphamide in 1 case. Three patients were lost of view and a patient died in hemodialysis. The 2 other patients with amylosis had persistent proteinuria with a normal renal function.

CONCLUSION

The kidney is one of organs that can alter the prognosis of the Behçet's disease; so, its screening must be realised in each patient with this disease.

Renal Behçet's disease: a cumulative analysis

OBJECTIVE

To analyze cumulated data about renal involvement in Behçet's disease (BD) and to report on 6 patients with BD and renal problems.

METHODS

We found reports of 159 patients (including our patients) with BD and specific renal disease (amyloidosis 69, glomerulonephritis [GN] 51, renal vascular disease 35, and interstitial nephritis 4) in our survey.

RESULTS

The frequency of renal problems among BD patients has been reported to vary between 0% to 55%. Male gender is a risk factor for all types of renal BD. Nephrotic syndrome was present in 83% of patients with amyloidosis, and renal failure was common at the time of diagnosis. The mean interval between the initial manifestation of BD and diagnosis of amyloidosis was shorter in men than in women (P =.02). AA-type amyloid fibrils were shown in all cases studied. Vascular involvement was common in the patients with amyloidosis (60%). The renal findings in GN show a wide spectrum, from asymptomatic hematuria and/or proteinuria to rapidly progressive GN. Several types of glomerular lesions ranging from minor glomerular changes to crescentic glomerulonephritis are observed in BD. The common types of glomerular lesions among the reported cases are crescentic GN, proliferative GN, and immunoglobulin A (IgA) nephritis. Aneurysms may be located throughout the renal artery, from the orifice of the main artery to intrarenal microaneurysms. Another type of renal disease (amyloidosis or GN) and other major vascular involvement were present in all cases with renal vein thrombosis. Hypertension is common among patients with renal artery aneurysm or stenosis. Microscopic vascular disease was described in 4 patients.

CONCLUSIONS

Based on data in the literature, we suggest that renal involvement in BD is more frequent than has been recognized, although it is most often mild in nature. Amyloidosis is one of the prognostic factors affecting survival. Patients with vascular involvement carry high risk for amyloidosis, and administration of colchicine to these patients may be beneficial. More evidence is needed to accept interstitial nephritis as a manifestation of BD. In spite of some difficulties, hemodialysis and renal transplantation are safe treatment options in BD-related uremia.

Colonoscopic findings in intestinal Behçet's disease

The aims of this study were to investigate the clinical and colonoscopic characteristics of patients with intestinal Behçet's disease and to compare the findings of typical and atypical intestinal Behçet's disease. Ninety-four patients diagnosed as having intestinal Behçet's disease were included. Of these, we considered 42 patients as having complete or incomplete type; these fulfilled the international criteria as "typical," and the other 52 patients were classified as having "atypical" intestinal Behçet's disease. Abdominal pain was the most common symptom (92%), followed by diarrhea and gastrointestinal bleeding. All of the 22 patients with a history of surgery had ulcers at the anastomotic site. Most of the patients, who had never been operated on, had lesions in the ileocecal area (96%). Sixty-three patients (67%) had a single ulcer. Many (76%) of the ulcers were larger than 1 cm, and the mean size of the ulcers was 2.9 cm. Most (99%) of the ulcers were round/oval or geographic in shape. Usually ulcers were deep (62%), and their margins discrete (80%). There was no difference in the endoscopic findings of typical and atypical intestinal Behçet's disease. Typical colonoscopic findings in intestinal Behçet's disease were single or a few deep ulcers with discrete margins in the ileocecal area or anastomotic site. Endoscopic characteristics of patients with intestinal involvement in the case of "suspect" or "possible" type of Behçet's disease that lack the systemic manifestations of Behçet's disease were in accord with those in "complete" or "incomplete" types of Behçet's disease, who fulfill the International Study Group for Behçet's Disease criteria.

End-stage renal failure due to crescentic glomerulonephritis in a patient with Behçet's syndrome. Review of the literature

We report a rare case of a patient with Behçet's syndrome who developed end-stage renal failure due to crescentic glomerulonephritis (GN). A 20-year-old male patient had suffered from uveitis, aphthous mouth ulcers and genital ulceration for the past 7 years. His renal function rapidly deteriorated and renal biopsy specimens obtained when his serum creatinine level was 3 mg/dl showed diffuse proliferative GN with fibrous crescent formation in 75% of glomeruli excluding totally sclerotic glomeruli. Immune complexes were identified by demonstration of complement and immunoglobulins in the glomeruli. He developed end-stage renal failure during a 1-year course and received maintenance hemodialysis. We reviewed the literature on severe forms of GN in patients with Behçet's syndrome.

Pulmonary capillaritis

Vasculitis, inflammation, and necrosis of blood vessels can involve any size or type of vessel in the pulmonary vasculature, including the capillaries, so-called capillaritis. Although pulmonary capillaritis is a histopathologic diagnosis that is not pathognomonic of a specific disorder, it usually signals the presence of an underlying systemic vasculitis or collagen vascular disease. Patients with pulmonary capillaritis usually present with bilateral infiltrates on chest radiographs and can be acutely ill with diffuse alveolar hemorrhage that may be life threatening. Therapy depends on diagnosis of the underlying disease that gave rise to the capillaritis. Since many of the disorders leading to capillaritis are treated by immunosuppression with corticosteroids and cyclophosphamide or azathioprine, infection must be excluded early in the course of therapy.

Evaluation of diastolic dysfunction and repolarization dispersion in Behcet's disease

Behcet's disease is a generalized chronic inflammatory disease characterized by genital, ocular, and cardiovascular involvement. Recently, left ventricular diastolic dysfunction, ventricular arrhythmia and sudden cardiac death have been documented in Behcet's disease. From January 1996 to May 1998, we investigated left ventricular systolic and diastolic function, valvular heart disease, ischemic heart disease and repolarization dispersion in 71 cases, 40 men and 31 women (mean age, 36.8+/-10.3 years) with Behcet's disease. All of the results were compared with the control group of 33 men and 22 women (mean age, 37.9+/-9.6 years). Exercise stress test or myocardial perfusion scintigraphy was performed for the documentation of ischemia. All the patients and the controls were recorded by M-mode, 2-D and Doppler echocardiography. Ventricular wall thickness, valvular apparatus, left ventricular systolic and diastolic parameters were evaluated. Repolarization dispersion parameters were calculated as the difference between maximal and minimal values of QT from 12-lead electrocardiogram recording at baseline, immediate and end of recovery from the exercise stress tests. The measured parameters were compared with the control group by using statistical methods. In the Behcet's group of 22 patients (31%) E/A ratio was <1. In the control group of five cases (10%) E/A ratio was <1 (P=0.003). In the Behcet's group isovolumic relaxation time (IRT) and mitral deceleration time (MDT) were longer than the control group (P=0.002, P=0.041, respectively). A mean QT of 368+/-30 ms and mean QT dispersion of 73+/-14 ms in the patient group compared with a mean QT of 395+/-39 ms and mean QT dispersion of 38+/-12 ms in the controls. There was no statistical difference between the mean QT values of the patient and control groups however, ventricular dispersion parameters in the Behcet's patients were longer than in the controls (P<0.001). There was also statistical significance for the QT dispersion between the Behcet's patients with and without diastolic dysfunction (P<0.01). In conclusion, the study reveals that the patients with Behcet's disease have a high incidence of increased diastolic dysfunction and repolarization dispersion. A positive correlation may exist between diastolic dysfunction and QT dispersion.

99Tcm-MAA lung scintigraphy in patients with Behçet's disease: its value and correlation with clinical course and other diagnostic modalities

Behçet's disease, initially described as local vasculitis involving the oral, genital mucosa and eyes, can affect many organ systems with a varying clinical course. Pulmonary lesions associated with Behçet's disease are rare and reported to have a prevalence of 1.0-7.7%. In this prospective study, 29 patients aged 16-60 years (mean +/- s: 34 +/- 10.5) were investigated for pulmonary involvement with direct radiography, computerized tomography (CT) and intravenous digital subtraction angiography. Lung scintigraphy was also performed to determine its diagnostic value. In addition, patients had a fibreoptic bronchoscopic examination, spirometric test, carbon monoxide diffusion test and methacholine test. Of the 29 patients with Behçet's disease, 17 had pulmonary involvement. The diagnostic criteria for pulmonary vasculitis and tracheobronchial tree involvement were: (1) hilar vascular prominence or mass, new alveolar and reticulonodular infiltrates on chest X-ray; (2) aphthous lesions, bleeding ulcerations, inflamed mucosal appearance on bronchoscopy; (3) vascular thrombosis or aneurysms on CT; (4) occlusion or aneurysms of the main pulmonary arteries or its branches. The value of lung scintigraphy and its correlation with other imaging modalities were investigated to determine if a lung perfusion scan alone can be used to detect pulmonary involvement in Behçet's disease. Twenty-six patients were investigated with lung scintigraphy. Thirteen of 14 patients with lung involvement were identified. Perfusion lung scintigraphy provided true diagnostic information in 96% of our patients. In eight patients without pulmonary involvement, the lung scans were normal. Although DSA specifically demonstrates pulmonary aneurysms, it involves administration of contrast media and cannot show abnormalities distal to the third pulmonary arterial branches. Although vasculitis caused by collagen disorders is physiologically indistinguishable from pulmonary emboli, most perfusion defects resolve within 3 months, which can be used as a differential diagnostic criterion in the appropriate clinical setting. Therefore, pulmonary perfusion imaging can be used to screen patients suspected of having lung involvement, especially in the absence of thrombophlebitis. In patients with thrombophlebitis, a repeat examination at 3 months is recommended to differentiate pulmonary involvement from pulmonary embolism.

IgA nephropathy and Reiter's syndrome. Report of two cases and review of the literature

Immunoglobulin A (IgA) nephropathy is the commonest type of primary glomerulonephritis worldwide. It has previously been reported in association with the seronegative spondyloarthropathies (ankylosing spondylitis, Behcet's syndrome, psoriatic arthritis, Reiter's syndrome and the postenteritic arthritides). Since this condition was first described in 1968, 5 previous case reports of biopsy-proven IgA nephropathy associated with Reiter's syndrome have been published in the English-language literature. Here we report 2 more such cases, along with a review of the literature describing the association of IgA nephropathy and a number of other immune-complex-mediated glomerulonephritides with the seronegative spondyloarthropathies.

Behçet's disease and complex aphthosis

Behçet's disease is a complex multisystem disease diagnosed by means of clinical criteria. Clinical features include oral and genital aphthae, pustular vasculitic cutaneous lesions, and ocular, gastrointestinal, and vascular manifestations. We believe that complex aphthosis, characterized by oral or oral and genital ulcers, may be a forme fruste of Behçet's disease. Although the pathogenesis of both Behçet's disease and complex aphthosis remain unknown, immune factors, infectious agents, and effector mechanisms are implicated. Treatment is based on the severity of systemic involvement and includes topical therapies as well as colchicine, dapsone, thalidomide, and immunosuppressive agents.

Pulmonary vasculitis

Pulmonary vascular inflammation may be seen in a variety of primary lung diseases and in the setting of numerous systemic illnesses. This article reviews those entities in which pulmonary vasculitis represents a central feature of the pathologic process (Wegener's granulomatosis, Churg-Strauss syndrome, and pulmonary capillaritis). In addition, features of pulmonary involvement in other systemic vasculitides (Giant Cell Arteritis, Takayasu's Arteritis, and Behçet's disease) are described. Finally, general principles for the treatment of vasculitis are reviewed.

Cutaneous vasculitis in Behçet's disease: a clinical and histopathologic study of 20 patients

BACKGROUND

Despite the frequency of small vessel vasculitis in skin lesions of Behçet's disease (BD), BD is classified as a neutrophilic dermatosis.

OBJECTIVE

Our goal was to determine whether the various cutaneous manifestations of BD are secondary to cutaneous vasculitis.

METHODS

Twenty-three specimens with histologically proven necrotizing vasculitis from 20 of 42 patients with BD were investigated.

RESULTS

The cutaneous vasculitic manifestations were characterized as erythema nodosum-like eruptions, palpable purpura, hemorrhagic blisters, infiltrated erythema, Sweet's syndrome-like eruptions, papulopustular lesions, and extragenital ulcerations. Combinations of various skin lesions were commonly seen in the same patient. Venous vessels in the entire dermis to the subcutis were affected with sparing of arterial vessels from middermis to subcutis. Histologic features included leukocytoclastic vasculitis in seven and lymphocytic vasculitis in 13 patients with extensive to focal localized fibrinoid necrosis of vessel walls.

CONCLUSION

Cutaneous vasculitis in BD is predominantly venulitis or phlebitis. Approximately half (48%; 20 of 42) of BD patients with cutaneous lesions had either lymphocytic (31%; 13 of 42) or leukocytoclastic vasculitis (17%; 7 of 42). We suggest that BD be considered as a vasculitis-associated disease separate from the neutrophilic dermatoses.

Hyperreactivity of neutrophils and abnormal T cell homeostasis: a new insight for pathogenesis of Behçet's disease

Neutrophil hyperfunction of Behçet's disease is in part regulated by genetical factors, especially related to HLA-B51 genes and by immunological abnormalities. Regarding the latter points, Behçet's disease worsens with abnormal regulation by gamma delta T cells and alpha beta T cells. Indeed, our own studies and those of other laboratories suggest that human heat shock protein may be one of the triggering factors for activation of both the gamma delta T cells and alpha beta T cells. These activated T cells may produce proinflammatory and/or inflammatory cytokines, and lead to tissue injury possibly via delayed-type hypersensitivity reaction, macrophage activation, and activation and/or recruitment of neutrophils. Here we discuss the crosstalk between the immune system and neutrophils in this disease.

Pulmonary capillaritis and alveolar hemorrhage. Update on diagnosis and management

Pulmonary vascular inflammatory disorders may involve all components of the pulmonary vasculature, including capillaries. The principal histopathologic features of pulmonary capillaritis include capillary wall necrosis with infiltration by neutrophils, interstitial erythrocytes, and/or hemosiderin, and interalveolar septal capillary occlusion by fibrin thrombi. Immune complex deposition is variably present. Patients often present clinically with diffuse alveolar hemorrhage, which is characterized by dyspnea and hemoptysis; diffuse, bilateral, alveolar infiltrates on chest radiograph; and anemia. Pulmonary capillaritis has been reported with variable frequency and severity as a manifestation of Wegener's granulomatosis, microscopic polyarteritis, systemic lupus erythematosus, Goodpasture's syndrome, idiopathic pulmonary renal syndrome, Behçet's syndrome, Henoch-Schönlein purpura, IgA nephropathy, antiphospholipid syndrome, progressive systemic sclerosis, and diphenylhydantoin use. In addition to history, physical examination, and routine laboratory studies, certain ancillary laboratory tests, such as antineutrophil cytoplasmic antibodies, antinuclear antibodies, and antiglomerular basement membrane antibodies, may help diagnose an underlying disease. Diagnosis of pulmonary capillaritis can be made by fiberoptic bronchoscopy with transbronchial biopsy, but thoracoscopic biopsy is often employed. Since many disorders can result in pulmonary capillaritis with diffuse alveolar hemorrhage, it is crucial for clinicians and pathologists to work together when attempting to identify an underlying disease. Therapy depends on the disorder that gave rise to the pulmonary capillaritis and usually includes corticosteroids and cyclophosphamide or azathioprine. Since most diseases that result in pulmonary capillaritis are treated with immunosuppression, infection must be excluded aggressively.

Behçet's syndrome and vesicovaginal fistula: an unusual complication

We present an unusual case of a spontaneous vesicovaginal fistula occurring with Behçet's syndrome. Recommendations and precautions for the management of this situation are briefly discussed.

A case of Behçet's disease combined with pulmonary artery aneurysm in a Korean female patient

Behçet's disease (BD) is a systemic disorder of unknown process resulting from systemic vasculitis. The pulmonary involvements in BD are uncommon. Furthermore, in the female, involvement of the pulmonary artery is quite rare. There were a few cases of female patients with BD with pulmonary artery aneurysm confirmed by pulmonary artery angiogram. In this article, we report a case of BD, combined with pulmonary artery aneurysm, confirmed by pulmonary angiogram and treated by surgery in a Korean female patient.

Pulmonary vasculitis in Behçet's disease

Clinical findings of 12 patients with Behçet's disease and lung involvement are presented. Male to female ratio was 11/1, mean age was 35.3 +/- 8.8 yr. All patients had at least four other organ manifestations of vasculitis, either in their history or during the period of lung involvement. The main complaint was hemoptysis of varying degree in 11 of the 12 patients. The chest X-ray films showed unilateral hilar enlargements in six patients, diaphragm elevation in four, horizontally or obliquely oriented linear opacities in three, diffuse, ill-defined infiltrates in upper and lower zones in three, wedge-shaped peripheral opacities in one, and bilateral pleural effusion in one patient. Computed tomography of the chest performed in nine patients revealed aneurysms, narrowings, and cutoffs of the main, lobar, segmental, or peripheral branches of the pulmonary artery and irregular configuration of other pulmonary vessels. Perfusion scans demonstrated defects of various sizes in all patients. Pulmonary angiography performed in only two patients showed amputation of branches of the pulmonary artery and aneurysmal dilatations. The patients were treated with a combination therapy consisting of corticosteroid, cyclophosphamide, colchicine, and antiaggregants, with very good results in the short term.

Bechet's colitis: a differential diagnosis in inflammations of the large intestine

A previously well 39 year old woman presented with severe localized and painful anorectal ulceration. There were no other associated symptoms apart from arthritis of the hips and fingers. In the absence of definitive tissue diagnosis, a presumptive diagnosis of Crohn's disease was made. After a period of progression, the inflammation and ulceration subsided with conservative therapy. Following a relatively symptom-free period of 7 years, painful ulceration recurred in the same segment of bowel, which was refractory to steroid therapy but responded to defunctioning of the rectum. Upon excision of the defunctioned rectum, multiple discrete ulcers developed in the remaining colon, with a fistula from the distal sigmoid colon to the midline wound. The patient simultaneously developed painful apthous ulceration of the mouth and throat, and pustules appeared on the perianal skin and trunk for the first time. A colectomy was performed, with good results. The pathology of the colonic lesions is described. The characteristic appearance of these lesions, together with associated 'major' and 'minor' clinical criteria, enabled a diagnosis of Bechet's disease to be made. Although there is some overlap, particularly in the distribution of this condition with Crohn's colitis, the pathologic appearances in Bechet's colitis are relatively distinct. A diagnosis of Bechet's colitis should not be excluded in a patient presenting with atypical inflammatory bowel disease, even if associated clinical criteria are not simultaneously present.

Possible Behçet's disease revealed by pulmonary aneurysms

Behçet's disease (BD) is a multisystem disease which may affect many organ systems in addition to the originally described triple symptom complex. Pulmonary aneurysm is one of the rare complications of the disease. We report a case of bilateral pulmonary aneurysm in which usual criteria for the clinical diagnosis of BD were absent and we believe that pulmonary aneurysm could be the first appearance of the disease.

[Arterial manifestations of Behçet's disease. 12 cases]

Out of 196 patients with Behçet's disease, 12 (10 men and 2 women, mean age 34 +/- 7 years) had non-coronary arterial lesions. Behçet's disease was complete in 4 patients. The arterial lesions had appeared 8.6 +/- 8 years on average (20 years at most) after the first sign of the disease. Three patients showed evidence of stenosis or occlusion involving one or several arteries. Eight patients had both stenotic and aneurysmal lesions. One patient had an arteriovenous fistula. Another developed a false aneurysm at the site of introduction of a femoral catheter. Yet another patient developed an anastomotic aneurysm one year after implantation of an abdominal aortic graft. In 2 cases histology showed fragmentation of the media associated with vasculitis of the vasa vasorum. Two patients with pulmonary aneurysm died of massive haemoptysis. In 2 patients combined corticosteroid and cyclophosphamide therapy failed to prevent the development of aneurysmal lesions. Phlebitis was associated with arterial involvement in 7 patients. Comparison between patients with or without arterial lesions showed no significant difference in time of onset of Behçet's disease, sex, main clinical features and presence of HLA B5. Aneurysmal lesions respond poorly to medical treatment, and surgery is mandatory. Since recurrence at the site of anastomosis is possible, prolonged monitoring is required.

Henoch-Schönlein purpura with nephritis in a patient with Behçet's disease

Recently there have been some case reports of Behçet's disease associated with renal lesions. We describe a patient with Behçet's disease who developed Henoch-Schönlein purpura with nephritis. To our knowledge, this is the first such case to be reported.

Pulmonary manifestations in Behçet's syndrome

Among 72 patients with Behçet's syndrome, seven had pulmonary vascular involvement. Additional data from 42 cases in the literature are discussed. Recurrent episodes of dyspnea, cough, chest pain, and hemoptysis were the primary clinical signs, mainly in young men, appearing 3.6 years after the first manifestation of Behçet's syndrome. Fever, elevated ESR, and anemia were common, and chest x-ray films showed pulmonary infiltrates, pleural effusions, and prominent pulmonary arteries. Ventilation-perfusion scans showed perfusion defects even when chest x-ray films were normal. Pulmonary artery aneurysms were seen in 7/13 in whom angiography was done. Of 42 patients, 16 died, 15 from fatal pulmonary hemorrhage, 80 percent within two years from the development of pulmonary disease. Histopathologic study results showed vasculitis of pulmonary vessels of various sizes, leading to thrombosis, destruction of the elastic laminae, aneurysms, and arteriobronchial fistula. In addition, pulmonary emboli and the aphthous lesion of the tracheobronchial tree may aid the clinical picture. Anticoagulant therapy may be hazardous in patients with aneurysmal dilatation of the pulmonary vascular tree, and the beneficial effect of corticosteroid therapy is discussed. Pulmonary vasculitis in Behçet's syndrome is a unique clinical and pathologic picture, differing from other vasculitides affecting the lung, presents a major threat to the patient's life.

Multimodal evoked potentials in neuro-Behçet: a longitudinal study of two cases

Two neuro-Behçet patients have been studied, over a period of several months, by means of peroneal and median somatosensory- (SEP), brainstem auditory- (BAEP), and visual- (VEP) evoked potentials. In both patients, peroneal SEP showed evidence of a pathological reduction in the central conduction velocity without a related deep sensation impairment, while VEP changes were consistent with the visual disorders. Conversely, BAEP and median SEP findings did not show disease-related abnormalities. The observed anomalies were detectable irrespective of the clinical phase of the disease. Thus, evoked potential assessment is useful in providing objective evidence for evaluating and monitoring CNS damage in neuro-Behçet's syndrome.

Neutrophilic vascular reactions

Dermatologic diseases are classified most commonly by morphology, by pathogenesis, or by etiology. Nontraditional classifications may be useful in terms of providing a reassessment of traditional views about disease interrelationships. This review of dermatoses characterized by neutrophilic infiltrates and dermal vessel changes reveals evidence suggesting that these dermatoses result from immune complex-mediated, neutrophil-induced dermal vessel damage. Therapeutic approaches to these heretofore unlinked dermatoses are remarkably similar.