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Kharge JL, M. UK, M.L. J, Newaskar AA, Shetty AU, Sridhar SL. Percutaneous Closure of Bilateral Pulmonary Artery Aneurysms in Behcet's Disease. JACC Case Rep 2024; 29:102341. [PMID: 38680129 PMCID: PMC11047295 DOI: 10.1016/j.jaccas.2024.102341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2024] [Revised: 03/12/2024] [Accepted: 03/20/2024] [Indexed: 05/01/2024]
Abstract
Behcet's disease is a multisystemic vasculitis. It can affect the pulmonary artery in 2% to 5% cases. We discuss a case of a young male diagnosed with Behcet's disease on immunosuppressive therapy who presented with bilateral pulmonary artery aneurysms which were closed with covered stent and other devices.
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Affiliation(s)
- Jayashree L. Kharge
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - Usha K. M.
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - Jayranganath M.L.
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - Aditi A. Newaskar
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - Ananya U. Shetty
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
| | - Sastry L. Sridhar
- Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Jayanagar, Bengaluru, Karnataka, India
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Aksoy A, Kocakaya D, Demircioglu O, Cimsit NC, Yildizeli B, Karakurt S, Direskeneli H, Alibaz-Oner F. Angiographic findings of pulmonary arterial involvement in Behcet's Disease: Do they correlate with symptoms and acute phase response? Respir Med 2024; 221:107481. [PMID: 38035945 DOI: 10.1016/j.rmed.2023.107481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 11/08/2023] [Accepted: 11/24/2023] [Indexed: 12/02/2023]
Abstract
INTRODUCTION Behcet's disease (BD) is a chronic inflammatory disorder with arterial vasculitis. Although, pulmonary artery aneurysm (PAA) is accepted as the prototypic arterial disorder, an increasing presence of pulmonary artery thrombosis (PAT) with or without aneurysms was also reported in recent studies. In this study, we aimed to describe computed tomography pulmonary angiography (CTPA) findings of pulmonary involvement and its correlation with symptoms and acute phase response in BD. METHOD In this retrospective study, 153 CTPA of BD patients were assessed by two radiologists. Clinical and laboratory data were collected from the patient files. Pulmonary artery involvement (PAI) was defined as thrombus or aneurysm in CT angiography. RESULTS Most of (85.6 %) our patients were male and median age was 33.7 ± 10 years during angiographic assessments. Sixty-two (40.5 %) angiographies presented a thrombus: 14 subsegmental, 29 segmental, 13 lobar and 6 main branches. Among these, 82.3 % (n = 51) had bilateral involvement. Isolated PAT was present in 58 (93.5 %) angiographies with only 4 (2.6 %) angiographies displaying an aneurysm together with a thrombus. Pulmonary infarction was detected in 9 angiographies. Forty-four (29.3 %) patients, almost all of them under immunosuppressive treatments for other indications, were screened for asymptomatic pulmonary involvement (without any symptoms or increased acute-phase response (APR)), and one fourth of these were diagnosed as having a segmental or subsegmental PAT. CONCLUSION Our results show that isolated pulmonary thrombosis is the main form of PAI, and isolated pulmonary aneurysm formation is rare in our BD cases. In the presence of pulmonary symptoms with or without increased APRs, involvement of segmental or more proximal parts of pulmonary arteries is most commonly detected. We also observed that PAI may be seen in about one fourth of especially male BD patients without symptoms or increased APR. Our results suggest that BD patients with pulmonary symptoms should be screened by CTPA for PAI, however, further research is needed to clarify the role of routine CTPA screening in asymptomatic BD patients.
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Affiliation(s)
- Aysun Aksoy
- Department of Internal Medicine Division of Rheumatology, Faculty of Medicine, Marmara University, İstanbul, Turkey.
| | - Derya Kocakaya
- Department of Pulmonary Medicine and Critical Care, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Ozlem Demircioglu
- Department of Radiology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Nuri Cagatay Cimsit
- Department of Radiology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Bedrettin Yildizeli
- Department of Chest Surgery, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Sait Karakurt
- Department of Pulmonary Medicine and Critical Care, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Haner Direskeneli
- Department of Internal Medicine Division of Rheumatology, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Fatma Alibaz-Oner
- Department of Internal Medicine Division of Rheumatology, Faculty of Medicine, Marmara University, İstanbul, Turkey
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Esatoglu SN, Ozguler Y, Hatemi G. Disease and Treatment-Specific Complications of Behçet Syndrome. Curr Rheumatol Rep 2024; 26:1-11. [PMID: 37995045 DOI: 10.1007/s11926-023-01124-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2023] [Indexed: 11/24/2023]
Abstract
PURPOSE OF REVIEW We aimed to highlight disease-related and treatment-related complications of Behçet syndrome (BS) based on previous and recent studies and our own experience. RECENT FINDINGS The Behçet's Disease Overall Damage Index is a newly developed instrument to assess damage in BS. Validation studies showed that damage is already present in some patients at diagnosis and continues to progress during the follow-up, mainly related to treatment complications. Nervous system and eye involvement are important causes of long-term disability. Cyclophosphamide seems to be associated with infertility and an increased risk of malignancies among BS patients, prompting the consideration of shortening the treatment duration. Flares in mucocutaneous manifestations have been reported with tocilizumab, and de novo BS manifestations with secukinumab therapy. Earlier diagnosis and treatment are essential to prevent disease-related damage in BS. Treatment-related complications seem to be the leading cause of damage during the disease course.
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Affiliation(s)
- Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
- Behçet's Disease Center, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Yesim Ozguler
- Division of Rheumatology, Department of Internal Medicine, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey
- Behçet's Disease Center, Istanbul University-Cerrahpaşa, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
- Behçet's Disease Center, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
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Nagafuchi H, Kikuchi H, Ishibash H, Maeda H, Ogino H, Kirino Y, Sawada T, Saito K, Kuwana M, Hirohata S, Ishigatsubo Y, Niimi M, Okita Y, Miyata T, Shigematsu H, Takeno M. Recommendations for the management of the vascular involvement in Behçet's disease by the Japanese National Research Committee for Behçet's disease-secondary publication. Mod Rheumatol 2023; 34:182-193. [PMID: 36658731 DOI: 10.1093/mr/road002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 12/18/2022] [Accepted: 12/25/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVES This study aimed to develop clinical guidelines for the management of vascular Behçet's disease (BD) by the Behçet's Disease Research Committee of the Ministry of Health, Labour and Welfare of the Japanese Government. METHODS A task force proposed clinical questions (CQs) concerning vascular BD based on a literature search. After screening, draft recommendations were developed for each CQ and brushed up in three blinded Delphi rounds, leading to the final recommendations. RESULTS This study provides recommendations for 17 CQs concerning diagnosis and differential diagnoses, assessment of disease activity, and treatment. The guidelines recommend immunosuppressive treatments, for both arterial and venous involvement with active inflammation. Anticoagulation is also recommended for deep vein thrombosis except in high-risk patients. Surgical and endovascular therapies can be optional, particularly in patients with urgent arterial lesions undergoing immunosuppression. In addition, two sets of algorithms for diagnosis and treatment are shown for arterial and venous involvement. CONCLUSIONS These recommendations are expected to serve as useful tools in the daily clinical practice of BD. This content has already been published in Japanese in the Guideline for the Management of Behçet's Disease 2020 and is submitted with permission from both the primary and secondary publishers.
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Affiliation(s)
- Hiroko Nagafuchi
- Division of Rheumatology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hirotoshi Kikuchi
- General Medical Education and Research Center, Teikyo University, Tokyo, Japan
| | - Hiroyuki Ishibash
- Department of Vascular Surgery, Aichi Medical University, Nagakute, Aichi, Japan
| | - Hideaki Maeda
- Department of Cardiovascular Center, Ukima Central Hospital, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Tetsuji Sawada
- Department of Rheumatology, Tokyo Medical University Hospital, Tokyo, Japan
| | - Kazuyoshi Saito
- The First Department of Internal Medicine, University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masataka Kuwana
- Department of Allergy and Rheumatology, Nippon Medical School Graduate School of Medicine, Tokyo, Japan
| | - Shunsei Hirohata
- Department of Internal Medicine, Teikyo University School of Medicine, Tokyo, Japan
| | - Yoshiaki Ishigatsubo
- Department of Internal Medicine and Clinical Immunology, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
| | | | - Yutaka Okita
- Cardio-Aortic Center, Takatsuki General Hospital, Osaka, Japan
| | - Tetsuro Miyata
- Office of Medical Education, International University of Health and Welfare, Narita, Japan
| | - Hiroshi Shigematsu
- Clinical Research Center for Medicine, International University of Health and Welfare, Narita, Japan
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School, Musashi Kosugi Hospital, Kawasaki, Japan
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Samreen I, Darji P, Genobaga S, Doosetty S, Mohta T, Maity G, Vue C, Nakka S, Umeh C. Pulmonary Artery Aneurysm in Behcet Disease: Medical, Endovascular or Surgical Intervention. Cureus 2023; 15:e49368. [PMID: 38146562 PMCID: PMC10749288 DOI: 10.7759/cureus.49368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/22/2023] [Indexed: 12/27/2023] Open
Abstract
Behçet's disease is a chronic inflammatory condition that predominantly affects the body's blood vessels, exhibiting various clinical manifestations and complications. The exact cause remains unclear, but genetic predisposition, immune responses, and vascular activation are believed to contribute to its development. This disease is more prevalent in certain geographic regions and primarily affects young adults, particularly males. Pulmonary aneurysm, a complication of Behçet's disease, is the leading cause of mortality in Behcet disease. In this review, we summarize the complications of Behcet disease with a focus on pulmonary artery aneurysms. We discussed the medical, endovascular, and surgical management of pulmonary aneurysms in Behcet disease and the indications and outcomes of the different treatment options. Corticosteroids and cyclophosphamide remain the preferred first-line therapy. However, clinical improvement with infliximab or adalimumab, tumor necrosis factor-alpha (TNFα) blocking agents, have been reported after treatment failure with recommended first-line agents. In patients who fail medical therapy or those with life-threatening hemoptysis, endovascular or surgical intervention is the next option. Endovascular interventions include pulmonary artery embolization with coils or acrylic glue and using plugs, occluders, or stents. Endovascular interventions usually have fewer adverse effects than surgery. Although the risk of surgical procedures is high in pulmonary artery aneurysms, it could be a life-saving procedure in patients with life-threatening hemoptysis. Surgical options, including pulmonary artery ligation, aneurysmorrhaphy, segmentectomy, lobectomy, or pneumonectomy are available. However, the results of surgical therapy for Behçet aneurysms are often disappointing.
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Affiliation(s)
- Isha Samreen
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
| | - Puja Darji
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
| | | | | | - Tamanna Mohta
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
| | - Gargi Maity
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
| | - Chong Vue
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
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Atalar E, Erten S, Dogan I, Konak HE. Vascular Involvement in Behcet's Disease: An Evaluation of 147 Cases and Literature Review. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:380-386. [PMID: 37900329 PMCID: PMC10600606 DOI: 10.14744/semb.2023.89083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 08/16/2023] [Accepted: 08/20/2023] [Indexed: 10/31/2023]
Abstract
Objectives Behcet's disease (BD) is characterized by systemic vasculitis with inflammation that can affect various body organs. In BD, vasculitis primarily manifests with venous involvement, distinguishing it from other forms of systemic vasculitis. Methods We retrospectively analyzed the demographic and clinical characteristics of 147 patients diagnosed with vascular BD in our center. Results Vascular BD cases accounted for 25.0% (147 out of 589) of all BD patients. A statistically significant correlation was found between gender and vascular involvement that was seen predominantly in males (76.9%). In 71 patients, a vascular event developed during follow-up for BD, while in 76 patients the disease was diagnosed after the occurrence of a vascular event (51.7%). The most common vascular event was deep vein thrombosis in the lower extremities (69.4%). Arterial involvement was primarily observed in the pulmonary arteries (12.9%). Patients with lower extremity deep vein thrombosis tended to be younger, while those with pulmonary artery involvement were typically older. Overall, veins were affected 4.5 times more frequently than arteries. Conclusion The prevalent type of venous involvement was deep vein thrombosis in the lower extremities. Thrombotic events in BD cannot be solely attributed to abnormalities in thrombotic factors. The treatment of thrombotic events in BD remains contentious, with anticoagulant efficacy being debated and immunosuppressive therapy representing the primary treatment approach. Behcet's disease should be considered when a young male patient presents with an arterial or venous vascular event, especially if it is recurrent.
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Affiliation(s)
- Ebru Atalar
- Division of Rheumatology, Department of Internal Medicine, Ankara City Hospital, Ankara, Türkiye
| | - Sukran Erten
- Division of Rheumatology, Department of Internal Medicine, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara, Türkiye
| | - Ismail Dogan
- Division of Rheumatology, Department of Internal Medicine, Ankara Yildirim Beyazit University Faculty of Medicine, Ankara, Türkiye
| | - Hatice Ecem Konak
- Division of Rheumatology, Department of Internal Medicine, Ankara City Hospital, Ankara, Türkiye
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Alagha OA, Abu ElQomboz AY, Alsarafandi SF. Concurrent Pulmonary Artery Aneurysm, Pulmonary Thrombosis, and Intracardiac Thrombus in Behçet's Disease: A Case Report. Cureus 2023; 15:e43993. [PMID: 37746357 PMCID: PMC10516585 DOI: 10.7759/cureus.43993] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Behçet's disease is a systematic, inflammatory disorder affecting vessels of all sizes. It affects both venous and arterial systems. Vascular involvement carries a high risk of morbidity and mortality. Knowing that Behçet's disease is the most common vasculitides that causes pulmonary artery aneurysms, with a mortality rate of around 25%, makes early detection crucial. Thrombosis in Behçet's disease is mainly caused by an inflammatory process rather than a thrombophilic state, thus vascular thrombosis control is achieved with immunosuppressant medications rather than anticoagulants. An exception to the use of anticoagulants in Behçet's disease appears to be due to cerebral venous thrombosis. The occurrence of multiple site thrombosis and aneurysm simultaneously makes the management very challenging, as we will highlight in our case. We present a case of a 31-year-old female patient with many prior hospitalizations due to cerebral venous thrombosis, bilateral pulmonary thrombi, right ventricular thrombus, and right pulmonary artery aneurysm. The patient was diagnosed with Behçet's disease according to the Behçet's Syndrome International Study Group criteria and then managed with the prophylactic low molecular weight heparin, cyclophosphamide, and prednisolone, resulting in significant improvement in the patient's symptoms. Presentation with cerebral venous thrombosis, pulmonary thrombosis, and aneurysm simultaneously is very rare in Behçet's disease. This made this case distinct and challenging in achieving good control of thrombosis and aneurysm simultaneously, which needs close monitoring and a multidisciplinary team to deal with the case.
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Thouil A, Rhazari M, Alaoui H, Serraj K, Kouismi H. Bronchial Fissuring: A Severe Complication of Arterial Aneurysm. Cureus 2023; 15:e43029. [PMID: 37674955 PMCID: PMC10479719 DOI: 10.7759/cureus.43029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/06/2023] [Indexed: 09/08/2023] Open
Abstract
Arterial aneurysms are rare and may occur in the context of Behçet's disease. The natural progression of these aneurysms can lead to an increase in their size and eventual rupture into the bronchi, causing life-threatening hemoptysis. We report a case of a subclavian artery aneurysm in a 30-year-old female patient with Behçet's disease who presented with moderate hemoptysis caused by a fistulized left subclavian artery aneurysm into the left main bronchus. The patient was treated with a bolus of corticosteroids followed by oral therapy, and six boluses of cyclophosphamide were scheduled. Unfortunately, the patient's condition deteriorated, and she died after her second cycle of cyclophosphamide following fulminant hemoptysis. The management of aneurysms in Behçet's disease is not standardized, but embolization appears to be the most promising conservative therapy.
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Affiliation(s)
- Afaf Thouil
- Laboratory of Research and Medical Sciences, Department of Respiratory Diseases, Faculty of Medicine and Pharmacy of Oujda, Mohammed VI University Hospital, Mohammed First University, Oujda, MAR
| | - Meriem Rhazari
- Department of Pulmonology, Mohammed VI University Hospital, Oujda, MAR
| | - Habiba Alaoui
- Laboratory of Immunohematology and Cellular Therapy, Department of Internal Medicine, Mohammed First University, Oujda, MAR
| | - Khalid Serraj
- Department of Internal Medicine, Mohammed First University, Oujda, MAR
| | - Hatim Kouismi
- Department of Pulmonology, Mohammed VI University Hospital, Oujda, MAR
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Kurada BRV, Umeh CA, Gupta RC, Onyi SC, Penaherrera J. Pulmonary Arterial Aneurysms and Thrombosis in a Young Male: A Rare Presentation of Behcet's Disease. Cureus 2023; 15:e41928. [PMID: 37583732 PMCID: PMC10424765 DOI: 10.7759/cureus.41928] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2023] [Indexed: 08/17/2023] Open
Abstract
Behcet's disease (BD) is a chronic systemic inflammatory vasculitis with a relapsing and remitting course. The disease predominantly affects males between the ages of 20 and 40 years. The disease is more prevalent in Middle Eastern and Asian countries but is less common in North American countries. BD typically presents as recurrent oro-genital ulcers and ocular inflammation. Pulmonary vasculitis with pulmonary arterial involvement is a unique manifestation, with most pulmonary manifestations occurring later in the disease course. Here, we report a case with pulmonary arterial aneurysms and variable arterial-venous thrombosis in a young African American Male diagnosed with BD after he presented with pulmonary manifestations. This report emphasizes that a high index of suspicion is needed to diagnose a rare condition with such variable manifestations as Behcet's disease and that early detection and immunosuppression therapy can confer improved prognosis.
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Affiliation(s)
- Bapi Raju V Kurada
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
- Medicine, St. George's University School of Medicine, Grenada, GRD
| | - Chukwuemeka A Umeh
- Internal Medicine, Hemet Global Medical Center, Hemet, USA
- Medicine, St. George's University School of Medicine, Grenada, GRD
| | - Rakesh C Gupta
- Pulmonary and Critical Care Medicine, Hemet Global Medical Center, Hemet, USA
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Coşkun S, Ekici Tekin Z, Güngörer V, Çelikel E, Kurt T, Polat MC, Tekgöz PN, Sezer M, Karagöl C, Kaplan MM, Öner N, Gürsu HA, Kavurt AV, Güzelküçük Z, Özbek NY, Çelikel Acar B. A case series of intracardiac thrombi and vascular involvement in pediatric Behçet's disease. Rheumatol Int 2023; 43:1161-1171. [PMID: 36890395 DOI: 10.1007/s00296-023-05292-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 02/21/2023] [Indexed: 03/10/2023]
Abstract
To evaluate the general characteristics of pediatric Behçet's disease (BD) patients with thrombus and to present the clinical features, treatment responses and prognosis of patients with intracardiac thrombus. The clinical characteristics and outcomes of 15 patients with thrombus among 85 pediatric BD patients followed in the Department of Pediatric Rheumatology were evaluated retrospectively. Of the 15 BD patients with thrombus, 12 (80%) were male, 3 (20%) were female. The mean age at diagnosis was 12.9 ± 1.1 years. Thrombus was present at the time of diagnosis in 12 patients (80%), while thrombus developed in three patients within the first three months after diagnosis. The most common site of thrombus was the central nervous system (n = 9, 60%), followed by deep vein thrombus (n = 6, 40%) and pulmonary artery thrombus (n = 4, 26.6%). Three male patients (20%) developed intracardiac thrombus. The overall intracardiac thrombus rate in the 85 patients was 3.5%. Two of the three patients had thrombus in the right, and one had thrombus in the left heart cavity. In addition to steroids, 2 of the 3 patients received cyclophosphamide, while the patient with thrombus localized in the left heart cavity was given infliximab. In the follow-up, the two patients with thrombus in the right heart cavity were switched to infliximab because of resistance to cyclophosphamide. Complete resolution was observed in 2 of the 3 patients on infliximab; a significant reduction in the thrombus of the other patient was achieved. Intracardiac thrombus is a rare presentation of cardiac involvement in BD. It is usually observed in males and in the right heart. Although steroids and immunosuppressive agents such as cyclophosphamide are recommended as first-line treatment, favorable outcomes can be achieved with anti-TNFs in resistant cases.
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Affiliation(s)
- Serkan Coşkun
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey.
| | - Zahide Ekici Tekin
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Vildan Güngörer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Elif Çelikel
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Tuba Kurt
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Merve Cansu Polat
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Pakize Nilüfer Tekgöz
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Müge Sezer
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Cüneyt Karagöl
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Melike Mehveş Kaplan
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Nimet Öner
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Hazım Alper Gürsu
- Division of Pediatric Cardiology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Ahmet Vedat Kavurt
- Division of Pediatric Cardiology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Zeliha Güzelküçük
- Division of Pediatric Hematology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Namık Yaşar Özbek
- Division of Pediatric Hematology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
| | - Banu Çelikel Acar
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Health Sciences, Ankara City Hospital, 06800, Ankara, Turkey
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Zhang Z, Driskill E, Chi J, Duensing I, Cui Q. The impact of Behcet syndrome on total knee arthroplasty outcomes: a retrospective matched cohort study. INTERNATIONAL ORTHOPAEDICS 2023:10.1007/s00264-023-05850-6. [PMID: 37249630 DOI: 10.1007/s00264-023-05850-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/18/2023] [Indexed: 05/31/2023]
Abstract
PURPOSE Articu lar involvement is a common manifestation of Behcet syndrome (BS), which can eventually result in significant arthralgia and necessitate total knee arthroplasty (TKA). However, outcomes of BS patients after TKA are still poorly documented in the literature. The purpose of this study was to evaluate BS as a potential risk factor for complications after TKA. METHODS BS patients undergoing primary TKA were identified from the PearlDiver Mariner database from 2010 to 2021 and compared to 10:1 matched controls. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to two years. Ninety-day emergency department (ED) visit and inpatient readmission were also documented. RESULTS A total of 4286 patients undergoing primary TKA were queried, of which 390 had BS. Patients with BS demonstrated significantly higher rates of medical complications, including deep venous thrombosis. The rates of surgical complications were similar between the two groups with the exception of periprosthetic instability, aseptic loosening, and wound complications in BS patients. Additionally, a significantly higher rate of ED visits but markedly lower rates of 90-day readmissions were noted in patients with BS. CONCLUSION Patients with BS undergoing TKA are at higher risks of medical and surgical complications. Special considerations for a unique postoperative course with the higher complications should be made. It is crucial for orthopedic surgeons and patients alike to consider these risks when determining the expected course after TKA for patients with BS.
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Affiliation(s)
- Zhichang Zhang
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, 22908, USA
- Department of Orthopaedic Surgery, The First Affiliated Hospital of Xinxiang Medical University, Weihui, 453100, Henan, China
| | - Elizabeth Driskill
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | - Jialun Chi
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | - Ian Duensing
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, 22908, USA
| | - Quanjun Cui
- Department of Orthopaedic Surgery, University of Virginia, Charlottesville, VA, 22908, USA.
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Bettiol A, Alibaz-Oner F, Direskeneli H, Hatemi G, Saadoun D, Seyahi E, Prisco D, Emmi G. Vascular Behçet syndrome: from pathogenesis to treatment. Nat Rev Rheumatol 2023; 19:111-126. [PMID: 36544027 DOI: 10.1038/s41584-022-00880-7] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
Behçet syndrome is a rare, chronic inflammatory disease of unknown aetiopathogenesis, most commonly presenting with mucocutaneous and ocular manifestations. Vascular involvement, most frequently superficial vein and deep vein thrombosis, can occur in up to 50% of patients with Behçet syndrome. Venous thrombosis at atypical sites (inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right atrium and/or ventricle) and arterial involvement (mostly in situ thrombosis and aneurysms of the pulmonary arteries, as well as aneurysms of the abdominal aorta, and peripheral and visceral arteries) are also unique features of Behçet syndrome. Behçet syndrome is considered a natural model of inflammation-induced thrombosis in humans, with an impaired immune-inflammatory response rather than traditional cardiovascular risk factors contributing to thrombogenesis. Specifically, neutrophil hyperactivation and neutrophil-mediated mechanisms of damage directly promote endothelial dysfunction, platelet activation and thrombogenesis in Behçet syndrome. This unusual pathogenesis directly determines the treatment approach, which relies mostly on immunosuppressants rather than anticoagulants for treatment of thrombosis and for secondary prevention. This Review discusses the main histopathological, pathogenetic and clinical aspects of vascular Behçet syndrome, addressing their implications for therapeutic management. Future perspectives in terms of pathogenetic studies, disease monitoring and treatment strategies are also discussed.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy.,Internal Interdisciplinary Medicine Unit, Behçet Center, Careggi University Hospital, Firenze, Italy
| | - Fatma Alibaz-Oner
- Vasculitis Clinic, Marmara University, School of Medicine, Department of Internal Medicine, Division of Rheumatology, Istanbul, Turkey
| | - Haner Direskeneli
- Vasculitis Clinic, Marmara University, School of Medicine, Department of Internal Medicine, Division of Rheumatology, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University-Cerrahpasa, School of Medicine, Istanbul, Turkey.,Behçet's Disease Research Centre, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - David Saadoun
- Sorbonne Universités AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département de Médecine Interne et Immunologie Clinique, F-75013, Paris, France.,Centre National de Références Maladies Autoimmunes Systémiques Rares, Centre National de Références Maladies Autoinflammatoires et Amylose Inflammatoire; Inflammation-Immunopathology-Biotherapy Department (DMU 3iD); INSERM 959, Groupe Hospitalier Pitie-Salpetriere, AP-HP, Paris, France
| | - Emire Seyahi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University-Cerrahpasa, School of Medicine, Istanbul, Turkey.,Behçet's Disease Research Centre, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy.,Internal Interdisciplinary Medicine Unit, Behçet Center, Careggi University Hospital, Firenze, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy. .,Internal Interdisciplinary Medicine Unit, Behçet Center, Careggi University Hospital, Firenze, Italy. .,Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia.
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13
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Wang Z, Zu X, Xiong S, Mao R, Qiu Y, Chen B, Zeng Z, Chen M, He Y. The Role of Colchicine in Different Clinical Phenotypes of Behcet Disease. Clin Ther 2023; 45:162-176. [PMID: 36732153 DOI: 10.1016/j.clinthera.2023.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Revised: 12/29/2022] [Accepted: 01/11/2023] [Indexed: 02/04/2023]
Abstract
PURPOSE Behcet disease (BD) is a multisystemic disorder characterized by variable clinical manifestations that affect nearly all systems and organs. Colchicine, an alkaloid plant extract, is considered as the first-line therapy for gout, pericarditis, and familial Mediterranean fever. However, the role of colchicine in the treatment of different clinical phenotypes of BD has not been clearly described. This narrative review summarizes the clinical use of colchicine in BD. METHODS All relevant literature from 1980 to March 2021 was searched in PubMed, MEDLINE, and Cochrane Library. The Medical Subject Heading terms and related words that were searched are as follows: Behcet's disease, Behcet's syndrome, BD, colchicine, management, treatment, and therapy. FINDINGS BD is an autoimmune systemic vasculitis with various clinical phenotypes, with involvement of skin mucosa, joints, eyes, and gastrointestinal, vascular, and neurologic systems. Colchicine has been used for centuries, acts by binding to tubulin to prevent the mitotic process, and has anti-inflammatory, antitumor, and antifibrotic properties. Colchicine has been reported to be an effective option for the treatment of skin, mucosal, and joint involvement in patients with certain BD clinical phenotypes. IMPLICATIONS Colchicine reduces the severity of certain clinical phenotypes and may improve the overall disease activity index in patients with BD. More randomized clinical trials are needed to confirm the value of colchicine in the treatment of BD, and further elucidation of the mechanisms is also needed, which may reveal new application of colchicine that has been used for centuries.
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Affiliation(s)
- Zeyuan Wang
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China; Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College & Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaoman Zu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Shanshan Xiong
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Ren Mao
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yun Qiu
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Baili Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhirong Zeng
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Minhu Chen
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yao He
- Department of Gastroenterology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China.
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Abstract
Behçet Disease is a relapsing and remitting variable vessel vasculitis characterized by recurrent mucocutaneous ulcers that can involve almost every organ system in the body. Indeed, the presence of recurrent oral or genital ulcers with other auto-inflammatory symptoms should raise suspicion for this elusive disease. It is unique among the vasculitides in that it can affect vessels of small, medium, and large size and tends to involve venous rather than arterial circulation, and its effects on the pulmonary venous circulation are particularly notable for their role in disease mortality. Classically seen in Mediterranean, Middle-Eastern, and eastern Asian countries, and relatively rare in the United States, prevalence has been increasing, prompting an increased need for internists to be aware of Behcet's clinical presentation and treatment. As early recognition and diagnosis of the disease is key to successful treatment and better prognosis, this review provides a brief summary of the current etiological theories, important clinical manifestations, and treatments including newer biologic alternatives.
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Affiliation(s)
- Daniel Pak
- Internal Medicine, St Mary Medical Center, Langhorne, Pennsylvania, USA
| | - Hyon Ju Park
- Internal Medicine, Lankenau Medical Center, Wynnewood, Pennsylvania, USA
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15
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Behçet's Disease: A Radiological Review of Vascular and Parenchymal Pulmonary Involvement. Diagnostics (Basel) 2022; 12:diagnostics12112868. [PMID: 36428928 PMCID: PMC9689730 DOI: 10.3390/diagnostics12112868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 11/13/2022] [Accepted: 11/15/2022] [Indexed: 11/22/2022] Open
Abstract
Behcet's disease (BD) is a chronic systemic inflammatory disorder characterized by underlying chronic vasculitis of both large- and small-caliber vessels. Thoracic involvement in BD can occur with various types of manifestations, which can be detected with contrast-enhanced MSCT scanning. In addition, MR can be useful in diagnosis. Characteristic features are aneurysms of the pulmonary arteries that can cause severe hemoptysis and SVC thrombosis that manifests as SVC syndrome. Other manifestations are aortic and bronchial artery aneurysms, alveolar hemorrhage, pulmonary infarction, and rarely pleural effusion. Achieving the right diagnosis of these manifestations is important for setting the correct therapy and improving the patient's outcome.
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16
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Law N, Quencer K, Kaufman C, Iravani A, Hardman R, Smith T. Embolization of pulmonary artery aneurysms in a patient with Behçet’s disease complicated by coil erosion into the airway. J Vasc Surg Cases Innov Tech 2022; 8:193-195. [PMID: 35402753 PMCID: PMC8989708 DOI: 10.1016/j.jvscit.2022.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 02/04/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Nicole Law
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT
| | - Keith Quencer
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT
| | - Claire Kaufman
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT
| | - Aidin Iravani
- Department of Pulmonology, University of Utah, Salt Lake City, UT
| | | | - Tyler Smith
- Department of Interventional Radiology, University of Utah, Salt Lake City, UT
- Correspondence: Tyler Smith, MD, Department of Interventional Radiology, University of Utah, 30 North 1900 East #1A071, Salt Lake City, UT 84132-2140
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17
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Ghembaza A, Boussouar S, Saadoun D. [Thoracic manifestations of Behcet's disease]. Rev Mal Respir 2022; 39:523-533. [PMID: 35659162 DOI: 10.1016/j.rmr.2022.04.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Accepted: 04/29/2022] [Indexed: 10/18/2022]
Abstract
Behcet's disease (BD) is a multisystemic vasculitis involving arteries and veins of all sizes. While joint and dermatological manifestations are the most common features of BD and are associated with a good prognosis; vascular involvement, remains the principal cause of death. Arterial manifestations occur in 5-10% of cases and manifest as occlusion/thrombosis or aneurysms. Arterial aneurysms are likely multiple and the most common sites are pulmonary arteries, aorta and arteries of lower limbs. Parenchymal involvement is less frequent and may manifest as consolidation or nodules, which may evolve to excavation. Aneurysms may occur at the sites of arterial puncture; then, non-traumatic techniques are favored. Patients with arterial manifestations may present with fever and increased inflammatory markers. Artery damage is rare, serious, and may result in massive hemoptysis. The prognosis of pulmonary artery aneurysms is severe (mortality estimated up to 26%) but has been improved by earlier diagnosis and the introduction of immunosuppressants. Treatment of severe arterial manifestations is based on high-dose corticosteroids along with cyclophosphamide or anti-TNF antagonists. Anticoagulation could be added to immunosuppressants in case of venous thrombosis if a coexisting pulmonary aneurysm is ruled out. Endovascular treatment should be performed in case of severe symptomatic pulmonary aneurysms, along with an adequate medical management. Long-term maintenance therapy of these severe forms is of paramount importance because of relapse risk (40% at five years).
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Affiliation(s)
- A Ghembaza
- Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France; Department of Internal Medicine and Clinical Immunology, Paris, France; Centre de référence des maladies auto-immunes systémiques rares, centre de référence des maladies auto-inflammatoires et de l'amylose inflammatoire, AP-HP, 75013 Paris, France; Institut national de la santé et de la recherche médicale, Paris, France; Inserm, UMR_S 959, 75013, Paris, France; RHU IMAP, CNRS, FRE3632, 75005 Paris, France
| | - S Boussouar
- Cardiovascular and Thoracic Imaging Unit, hôpital Pitié Salpêtrière, AP-HP, Paris, France; Inserm, laboratoire d'imagerie biomédicale, CNRS, Institute of Cardiometabolism and Nutrition, Sorbonne Université, Paris, France
| | - D Saadoun
- Sorbonne Université, Pitié-Salpêtrière University Hospital, Paris, France; Department of Internal Medicine and Clinical Immunology, Paris, France; Centre de référence des maladies auto-immunes systémiques rares, centre de référence des maladies auto-inflammatoires et de l'amylose inflammatoire, AP-HP, 75013 Paris, France; Institut national de la santé et de la recherche médicale, Paris, France; Inserm, UMR_S 959, 75013, Paris, France; RHU IMAP, CNRS, FRE3632, 75005 Paris, France.
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18
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Weiss EH, Ko CJ, Leung TH, Micheletti RG, Mostaghimi A, Ramachandran SM, Rosenbach M, Nelson CA. Neutrophilic Dermatoses: a Clinical Update. CURRENT DERMATOLOGY REPORTS 2022; 11:89-102. [PMID: 35310367 PMCID: PMC8924564 DOI: 10.1007/s13671-022-00355-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/15/2022] [Indexed: 11/13/2022]
Abstract
Purpose of Review Neutrophilic dermatoses are defined by the presence of a sterile neutrophilic infiltrate on histopathology. This review focuses on the pathogenesis, epidemiology, clinicopathological features, diagnosis, and management of four disorders: Sweet syndrome, pyoderma gangrenosum, Behçet syndrome, and neutrophilic eccrine hidradenitis. Recent Findings Recent studies have provided insight into the complex pathogenesis of neutrophilic dermatoses. Evidence supports an intricate interplay of abnormal neutrophil function and inflammasome activation, malignant transformation into dermal infiltrating neutrophils, and genetic predisposition. Summary Neutrophilic dermatoses have diverse cutaneous and extracutaneous manifestations and may be associated with significant morbidity and mortality. Common underlying associations include infectious, inflammatory, and neoplastic disorders, as well as drug reactions. Emerging diagnostic and therapeutic frameworks identify an expanding role for biologic and targeted anti-inflammatory therapies.
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Abstract
Behçet syndrome (BS) is a unique type of vasculitis that affects veins and arteries of all sizes, leading to recurrent vascular events, mostly venous thrombosis. The prevalence of venous thromboembolism in BS patients ranges between 15 and 40%. Thrombosis is usually an early manifestation leading to diagnosis of BS in up to 40% of patients. BS is per se a model of inflammation-induced thrombosis. The primary autoimmune response activates lymphocytes that in turn produce a cytokine cascade that activates neutrophils, which modify the secondary structure of fibrinogen making it less susceptible to plasmin-induced lysis. This leads to endothelial dysfunction, platelet activation and overexpression of tissue factor leading to inflammatory thrombi, usually attached to the wall. The pathogenesis of thrombosis is especially relevant to direct the specific treatment, that is based on immunosuppression rather than anticoagulation. Superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) are the most common form of thrombosis in BS, but thrombosis in atypical sites (cava vein, suprahepatic veins, intracardiac thrombus) and arterial involvement can also occur. We assessed the latest update of the European League Against Rheumatism recommendations for the management of BS. Vascular Behçet treatment is usually based of immunosuppressants, and the role of anticoagulation remains controversial. The use of interventional and surgical procedures should be carefully evaluated, due to the risk of triggering a vascular pathergy phenomenon.
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20
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Tazi Mezalek Z, Khibri H, Chadli S, El Fari S, Ammouri W, Harmouche H, Maamar M, Adnaoui M. Vascular complications of Behçet disease. Minerva Med 2022; 112:767-778. [PMID: 35168306 DOI: 10.23736/s0026-4806.21.07490-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological, and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. Venous involvement is significantly more common than arterial disease, and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressants are the recommended first-line treatments in vasculo-Behçet. Furthermore, controlled trials are still needed to assess the role of adding anticoagulation to the treatment regimen, with an accent on new oral anticoagulants. Treatment with anti-TNF alpha agents seems promising, but the management strategies are not clear yet.
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Affiliation(s)
- Zoubida Tazi Mezalek
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco - .,Department of Clinical Hematology, Ibn Sina University Hospital, Rabat, Morocco - .,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco -
| | - Hajar Khibri
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Sarra Chadli
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco
| | - Safae El Fari
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco
| | - Wafaa Ammouri
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Hicham Harmouche
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Mouna Maamar
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Mohamed Adnaoui
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
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21
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van der Houwen TB, van Hagen PM, van Laar JAM. Immunopathogenesis of Behçet's disease and treatment modalities. Semin Arthritis Rheum 2022; 52:151956. [PMID: 35038644 DOI: 10.1016/j.semarthrit.2022.151956] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/29/2021] [Accepted: 01/05/2022] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Behçet's disease (BD) is an auto-inflammatory disease, primarily characterized by recurrent painful mucocutaneous ulcerations. METHODS A literature search was performed to write a narrative review into the pathogenesis and current treatment options of BD. RESULTS The pathogenesis of BD remains to be elucidated, but is considered a genetically primed disease in which an external trigger causes immune activation resulting in inflammatory symptoms. GWAS data show an association between multiple genetic polymorphisms (HLA-B51, ERAP1, IL10 and IL23R-IL12RB2) and increased susceptibility to BD. Bacteria as streptococci, an unbalanced microbiome or molecular mimicry trigger the inflammation in BD. Increased production or responsiveness of pro-inflammatory components of the innate immune response (TLR, neutrophils, NK-cells or γδ T-cells) to these triggers may be a crucial step in the pathogenesis of BD. Additionally to an increased autoinflammatory response there is evidence of a dysregulated adaptive immune system, with a disturbed Th1/Th2 balance, expansion of Th17 cells and possibly a decrease in regulatory T cells, resulting in a surplus in pro-inflammatory cytokines. The inflammation causes a typical clinical phenotype including orogenital ulcerations, uveitis and skin lesions. Treatment is aimed at the aberrations found in the innate (neutrophils and γδ-T cells) and adaptive immune system (TNF-α, INF-γ, IL-1), directed at organ involvement and individualized based on patient characteristics. CONCLUSION We presented an extensive review into the pathogenesis and treatment options of BD.
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Affiliation(s)
- T B van der Houwen
- Section of Clinical Immunology, Department of Internal Medicine and Immunology, Erasmus University Medical Center Rotterdam, Room RG 535, PO Box 2040, Rotterdam, 3000CA, the Netherlands
| | - P M van Hagen
- Section of Clinical Immunology, Department of Internal Medicine and Immunology, Erasmus University Medical Center Rotterdam, Room RG 535, PO Box 2040, Rotterdam, 3000CA, the Netherlands
| | - J A M van Laar
- Section of Clinical Immunology, Department of Internal Medicine and Immunology, Erasmus University Medical Center Rotterdam, Room RG 535, PO Box 2040, Rotterdam, 3000CA, the Netherlands.
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22
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Choi SJ, Koo HJ, Kang JW, Ahn SM, Oh JS, Kim YG, Lee CK, Yoo B, Hong S. Angiographic patterns and temporal changes of arterial lesions in Behcet's disease. Vascular 2021; 30:1160-1167. [PMID: 34565249 DOI: 10.1177/17085381211046465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Behcet's disease (BD) can entail vascular involvement in various forms including aneurysm. We evaluated the angiographic patterns and changes in arterial lesions over time in BD patients with arterial involvement. METHODS We reviewed the medical records of BD patients diagnosed with arterial lesions between 1995 and 2018. Angiographic patterns were categorized as stenosis, occlusion, dilatation, or aneurysm. Patients were divided according to symptom duration (<5, 5-10, >10 years). Cox proportional-hazards model was used to evaluate the risk factors for vascular progression. RESULTS 47 BD patients had arterial involvement in the following patterns: aneurysm (n = 31), stenosis (n = 17), dilatation (n = 13), and occlusion (n = 8). Aneurysm (70.8%) was the most common pattern in 24 patients with short (<5 years) symptom duration. Stenosis was more common (50.0%) in 12 patients with longer symptom durations (>10 years). In 23 patients with follow-up imaging (median, 5.7 years), eight (34.8%) developed 11 new lesions: stenosis (n = 5), dilatation (n = 1), and aneurysm (n = 5). One stenotic lesion progressed to occlusion, and two dilated lesions progressed to aneurysms. Lower extremity involvement and methotrexate use were associated with arterial progression, with hazard ratios of 5.716 (p = 0.029) and 0.101 (p = 0.049), respectively. CONCLUSION In BD patients with arterial involvement, aneurysm was the most common pattern in earlier stages of BD, while stenosis was more common in later stages of BD. Methotrexate use was associated with lower risk of arterial lesion progression.
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Affiliation(s)
- Su Jin Choi
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea.,Department of Rheumatology, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, South Korea
| | - Hyun Jung Koo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joon-Won Kang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Soo Min Ahn
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Seon Oh
- Department of Information Medicine, 65526Asan Medical Center, Seoul, South Korea
| | - Yong-Gil Kim
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Chang-Keun Lee
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Bin Yoo
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Seokchan Hong
- Department of Rheumatology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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Alpsoy E, Bozca BC, Bilgic A. Behçet Disease: An Update for Dermatologists. Am J Clin Dermatol 2021; 22:477-502. [PMID: 34061323 DOI: 10.1007/s40257-021-00609-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/04/2021] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Erkan Alpsoy
- Department of Dermatology and Venereology, Akdeniz University School of Medicine, 07059, Antalya, Turkey.
| | - Burcin Cansu Bozca
- Department of Dermatology and Venereology, Akdeniz University School of Medicine, 07059, Antalya, Turkey
| | - Asli Bilgic
- Department of Dermatology and Venereology, Akdeniz University School of Medicine, 07059, Antalya, Turkey
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24
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Ukemenam C, Muppaneni SP, De D, Lacasse A. Hugh-Stovin syndrome: the 'incomplete Behcet's disease'. A case study of a young adult with recurrent pulmonary embolism and pulmonary arterial aneurysms. J Community Hosp Intern Med Perspect 2021; 11:566-567. [PMID: 34211671 PMCID: PMC8221138 DOI: 10.1080/20009666.2020.1816273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
Hugh-Stovin Syndrome (HSS) is characterized by recurrent thrombophlebitis and multiple pulmonary and/or bronchial artery aneurysms indistinguishable from the cardiovascular features seen in Behcet's disease (BD). Our case describes a 30-year-old male with recurrent pulmonary embolism and bilateral pulmonary aneurysms. Autoimmune, hypercoagulable, and infectious work up were negative. Elevated inflammatory markers and absence of the typical clinical findings seen in BD led to the diagnosis of Hugh-Stovin syndrome (HSS). Immunosuppression using steroids and azathioprine led to clinical response. Anticoagulation was continued based on risk/benefit ratio.
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Affiliation(s)
- Chinedu Ukemenam
- Department of Internal Medicine, SSM Saint Mary's Hospital, Saint Louis, Missouri, USA
| | | | - Debapriya De
- Department of Internal Medicine, SSM Saint Mary's Hospital, Saint Louis, Missouri, USA
| | - Alexandre Lacasse
- Department of Internal Medicine, SSM Saint Mary's Hospital, Saint Louis, Missouri, USA
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25
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Alpsoy E, Leccese P, Emmi G, Ohno S. Treatment of Behçet's Disease: An Algorithmic Multidisciplinary Approach. Front Med (Lausanne) 2021; 8:624795. [PMID: 33996847 PMCID: PMC8115406 DOI: 10.3389/fmed.2021.624795] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Accepted: 03/01/2021] [Indexed: 12/22/2022] Open
Abstract
Behçet's disease (BD) is a chronic, relapsing inflammatory, multisystem disease of unknown etiology. The disease has a wide clinical spectrum of mucocutaneous lesions and ocular, vascular, articular, neurologic, gastrointestinal and cardiac involvement. Although the number of effective drugs used in the disease's treatment has increased in recent years, BD is still associated with severe morbidity because of mainly mucocutaneous, articular and ocular symptoms and an increased mortality because of large vessel, neurological, gastrointestinal and cardiac involvement. Many factors are associated with a more serious course, such as male gender and a younger age of onset. While the severity of the disease is more pronounced in the first years of the disease, it decreases in most patients after the age of forties. The primary goal of treatment should be the prevention of irreversible organ damage. Therefore, early diagnosis and appropriate treatment and close follow-up are mandatory to reduce the morbidity and mortality of the disease. Treatment varies depending on the organ involved and the severity of the involvement. For all these reasons, the treatment should be personalized and arranged with a multidisciplinary approach according to the organs involved. Treatment is mainly based on suppression of the inflammatory attacks of the disease using local and systemic immunomodulatory and immunosuppressive drugs. In this review, based on the mainly controlled studies and personal experience in clinical practice and basic research in this field, we propose a stepwise, symptom-based, algorithmic approach for the management of BD with a holistic perspective.
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Affiliation(s)
- Erkan Alpsoy
- Department of Dermatology and Venereology, School of Medicine, Akdeniz University, Antalya, Turkey
| | - Pietro Leccese
- Rheumatology Department of Lucania, Rheumatology Institute of Lucania, San Carlo Hospital of Potenza and Madonna delle Grazie Hospital of Matera, Potenza and Matera, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Shigeaki Ohno
- Ophthalmology Center, Aishin Memorial Hospital, Sapporo, Japan.,Department of Ophthalmology, Faculty of Medicine, Graduate School of Medicine, Hokkaido University, Sapporo, Japan
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Clinical characteristics of pulmonary artery involvement in patients with Behçet's syndrome: single-centre experience of 61 patients. Clin Rheumatol 2021; 40:4127-4134. [PMID: 33907905 DOI: 10.1007/s10067-021-05748-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2021] [Revised: 04/18/2021] [Accepted: 04/21/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE To report the clinical characteristics of pulmonary artery involvement (PAI) in patients with Behçet's syndrome (BS) and to define the predictors of relapses. METHODS We performed retrospective analysis of BS patients with PAI who fulfilled international study group criteria. Among 460 patients with vascular Behçet's syndrome (VBS), 66 were diagnosed with PAI. For final analyses, 61 patients with PAI were included who had at least 2 follow-up visits (72.1% male, mean age at BS diagnosis 29.34 ± 10.1 years). The patient data were recorded. Relapse was defined as the reoccurrence of vascular event in any vascular structure. Factors associated with relapse were assessed by logistic regression analysis. RESULTS There were no differences considering demographic and clinical features of the patients with and without PAI in the VBS group, except that intracardiac thrombosis was more common in the patients with PAI (19.7% vs 0.3%). Among 61 patients, 50 (82.0%) had isolated pulmonary artery thrombosis (PAT), whereas 11 (18.0%) had pulmonary artery aneurysm with or without PAT. Twenty-four (39.3%) patients experienced vascular relapse during median follow-up of 65.9 (Q1-Q3: 20.1-109.0) months. To define the factors associated with relapses, patients with isolated PAT were analysed. On multivariable logistic regression analysis, older age at BS diagnosis and anticoagulation usage seemed to be protective (OR: 0.92, 95% CI 0.86-1.02, OR: 0.34, 95% CI 0.09-1.33, respectively). CONCLUSION Our results indicate a higher frequency of intracardiac thrombosis in BS patients with PAI and possible efficacy of anticoagulation usage in preventing relapses. Key Points • This study shows that intracardiac and intracranial thromboses are seen more frequently in patients with PAI and the prevalence of pulmonary artery thrombosis has been increasing in the case of PAI. Furthermore, our report indicates that anticoagulation might be effective in preventing further vascular relapses.
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Ahmadzai O, Ozakin E, Canakci ME, Acar N, Korkmaz C. Therapeutic Dilemmas Regarding Anticoagulation, Pulmonary Embolism, and Diffuse Alveolar Hemorrhage Due to Behçet's Disease. Cureus 2021; 13:e14429. [PMID: 33996295 PMCID: PMC8114959 DOI: 10.7759/cureus.14429] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The use of anticoagulants is still a matter of debate in deep venous thrombosis (DVT) and other thrombotic events in Behcet's disease (BD). Anticoagulant therapy is an integral part of treatment in cases of a pulmonary embolism (PE) that develops in other disorders. The issue of how to act when a pulmonary artery thrombosis is reported in the Behçet's patient may pose a major dilemma among emergency physicians. A 61-year-old male came to our ED with a complaint of chest pain and hemoptysis. The patient had tachypnea, dyspnea, tachycardia, a decrease of breath sounds in the basal regions of both lungs, and a few crackling rales were heard in the left lung field. Chest CT angiography showed pulmonary thromboembolism in the right middle and lower lobe segment arteries with pulmonary infarction as well as ground glass densities compatible with alveolar hemorrhage. High-dose steroid and cyclophosphamide were administered immediately without anticoagulant therapy based on pulmonary vasculitis and de novo clot formation in the pulmonary circulation. Clinical improvement was observed after four days of admission. The patient remained under observation with oral prednisolone and cyclophosphamide monthly. PE is almost non-existent in patients with BD, and signs of pulmonary artery thrombosis are associated with pulmonary vasculitis. Delaying immunosuppressive therapy may result in unwanted results in these kinds of patients. This case underlines the importance of recognizing this manifestation early to prevent potentially fatal consequences.
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Affiliation(s)
| | - Engin Ozakin
- Emergency Medicine, Eskişehir Osmangazi University, Eskişehir, TUR
| | | | - Nurdan Acar
- Emergency Medicine, Eskişehir Osmangazi University, Eskişehir, TUR
| | - Cengiz Korkmaz
- Division of Rheumatology, Eskişehir Osmangazi University, Eskişehir, TUR
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Kötter I, Lötscher F. Behçet's Syndrome Apart From the Triple Symptom Complex: Vascular, Neurologic, Gastrointestinal, and Musculoskeletal Manifestations. A Mini Review. Front Med (Lausanne) 2021; 8:639758. [PMID: 33898481 PMCID: PMC8063110 DOI: 10.3389/fmed.2021.639758] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/12/2021] [Indexed: 12/13/2022] Open
Abstract
Behçet‘s Syndrome (BS) is a variable vessel vasculitis according to the Chapel Hill Consensus Nomenclature (1) and may thus affect any organ, including major and minor arterial and venous vessels to a varying degree and with varying frequency. Although the main features of BS are recurrent oral and genital aphthous ulcers, cutaneous lesions, ocular inflammation and arthritis—major vessel and life—or organ threatening involvement of internal organs and the central and peripheral nervous system occur. In general, BS in Europe appears to form six phenotypes of clinical manifestations (2), which are (1) mucocutaneous only, (2) predominant arthritis/articular involvement, (3) vascular phenotype, (4) ocular manifestations, which are most likely associated with CNS manifestations and HLA-B51, (5) dominant parenchymal CNS manifestations (being associated with the ocular ones), and (6) gastrointestinal involvement. Mucocutaneous manifestations are present in almost all patients/all phenotypes. In the following review, we summarize the current knowledge concerning vascular, neurologic, gastrointestinal and musculoskeletal manifestations of the disease.
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Affiliation(s)
- Ina Kötter
- Division of Rheumatology and Inflammatory Rheumatic Diseases, University Hospital Hamburg Eppendorf and Clinic for Rheumatology and Immunology Bad Bramstedt, Bad Bramstedt, Germany
| | - Fabian Lötscher
- Department of Rheumatology and Immunology, Inselspital Bern, University of Bern, Bern, Switzerland
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Rodríguez-Carrio J, Nucera V, Masala IF, Atzeni F. Behçet disease: From pathogenesis to novel therapeutic options. Pharmacol Res 2021; 167:105593. [PMID: 33826948 DOI: 10.1016/j.phrs.2021.105593] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/17/2021] [Accepted: 03/31/2021] [Indexed: 10/21/2022]
Abstract
Behçet disease (BD) is a complex, multi-systemic inflammatory condition mainly hallmarked by oral and genital ulcers which can also affect the vessels, gastrointestinal tract, central nervous system and even the axial skeleton. Without a clear classification among autoimmune or autoinflammatory conditions, BD has been recently classified as a MHC-I-opathy. BD aetiology is still obscure, but it is thought that certain microorganisms can elicit an aberrant adaptive immune response in the presence of a permissive genetic background. Altered T-cell homeostasis, mostly Th1/Th17 expansion and Treg impairment, could lead to an overactivation of the innate immunity, which underlies tissue damage and thus, signs and symptoms. Immunosuppression and/or immunomodulation are central to the BD management. A complex armamentarium ranging from classical synthetic disease-modifying antirrheumatic drugs to new-era biologic agents or small molecules is available in BD, with different therapeutic outcomes depending on disease manifestations. However, the precise disease mechanisms that underlie BD symptoms are not fully deciphered, which may limit their therapeutic potential and add a significant layer of complexity to the treatment decision-making process. The aim of the present review is to provide an exhaustive overview of the latest breakthroughs in BD pathogenesis and therapeutic options.
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Affiliation(s)
- Javier Rodríguez-Carrio
- Department of Functional Biology, Immunology Area, Faculty of Medicine, University of Oviedo, Oviedo, Spain; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, Spain
| | - Valeria Nucera
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy
| | - Ignazio Francesco Masala
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy; Trauma and Orthopedic Unit, Santissima Trinità Hospital, Cagliari, Italy
| | - Fabiola Atzeni
- Rheumatology Unit, Department of Experimental and Internal Medicine, University of Messina, Messina, Italy.
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30
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Xie X, Li X, Yu F. Multiple bilateral pulmonary arterial aneurysms with massive thrombosis in inferior vena cava and hepatic vein. J Card Surg 2021; 36:1541-1542. [PMID: 33625728 DOI: 10.1111/jocs.15426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 01/12/2021] [Accepted: 01/29/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Xiaojun Xie
- Department of Cardiovascular Surgery, The Affiliated Hospital Of Southwest Medical University, Luzhou, China.,Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital Of Southwest Medical University, Luzhou, China
| | - Xin Li
- Department of Cardiovascular Surgery, The Affiliated Hospital Of Southwest Medical University, Luzhou, China.,Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital Of Southwest Medical University, Luzhou, China
| | - Fengxu Yu
- Department of Cardiovascular Surgery, The Affiliated Hospital Of Southwest Medical University, Luzhou, China.,Cardiovascular and Metabolic Diseases Key Laboratory of Luzhou, The Affiliated Hospital Of Southwest Medical University, Luzhou, China
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31
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Bozca BC, Alpsoy E. Experimental Therapeutic Solutions for Behcet's Disease. J Exp Pharmacol 2021; 13:127-145. [PMID: 33603502 PMCID: PMC7886245 DOI: 10.2147/jep.s265645] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 01/19/2021] [Indexed: 12/17/2022] Open
Abstract
Behcet’s disease (BD) is a chronic systemic vasculitis with inflammation attacks that involve multiple organs. In addition to numerous mucocutaneous symptoms, notably recurrent oral and genital ulcers, ocular, articular, vascular, gastrointestinal, cardiac, and neurological system involvement can be observed. Mucocutaneous lesions are the primary symptom of the disease in most patients, and they usually occur before major organ involvement and other symptoms of the disease. Recognizing the disease’s mucocutaneous lesions is very important to diagnose at an early stage, control with appropriate treatment and close follow-up, and prevent major organ involvement. Genome-wide association studies (GWAS) in recent years have confirmed that HLA-B*51 is the most significant genetic predisposing factor. The majority of gene polymorphisms have been detected in molecules that respond to microorganisms and genes encoding cytokines and adhesion molecules. The infectious agent S. sanguinis -commonly found in the oral mucosa of patients with BD- or the differences in the salivary or intestinal microbiome composition can trigger innate immune-mediated inflammation sustained by acquired or adaptive immune responses. In antigen-presenting cells (APCs), epistatic interactions between HLA-B*51 and endoplasmic reticulum aminopeptidase 1 (ERAP1) variants lead to the disruption of T-cell homeostasis, especially the activation of Type1 T-helper and Th17 pathway and suppression of regulatory T-cells. Recent developments to clarify the disease’s etiopathogenesis provided us with a better understanding of the mechanism of action of the relatively old drugs while opening a way for many new treatment methods. Apremilast has become an important option in the treatment of mucocutaneous symptoms with its high efficacy and safety. The disease increases the mortality rate, especially in young male patients. New treatments, especially anti-TNF-α agents, have provided significant progress and decreased the mortality rates with their rapid effect and high efficacy in patients with severe organ involvement and resistance to traditional immunosuppressive and immunomodulatory therapies. The use of IL-1, IL-6, IL-17, IL-12/IL-23 antagonists in different organ involvement has gradually increased, and the quality of life has significantly improved in many patients.
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Affiliation(s)
- Burçin Cansu Bozca
- Akdeniz University School of Medicine, Department of Dermatology and Venereology, Antalya, Turkey
| | - Erkan Alpsoy
- Akdeniz University School of Medicine, Department of Dermatology and Venereology, Antalya, Turkey
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Gurcan M, Esatoglu SN, Hamuryudan V, Saygin D, Ugurlu S, Seyahi E, Melikoglu M, Fresko I, Yurdakul S, Yazici H, Hatemi G. Long term follow-up of Behçet's syndrome patients treated with cyclophosphamide. Rheumatology (Oxford) 2021; 59:2264-2271. [PMID: 31840168 DOI: 10.1093/rheumatology/kez598] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 10/31/2019] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES CYC remains an important treatment option for Behçet's syndrome (BS) patients with life-threatening manifestations. However, adverse events may occur with CYC and this has led to increased use of biologic agents in other vasculitides. We investigated short and long term adverse events associated with CYC use in BS patients. METHODS We conducted a retrospective chart review of all BS patients treated with CYC between 1972 and 2006. Patients were called in and a standard form was used for collecting demographic characteristics, indication for CYC, its cumulative dose and short term adverse events, defined as those causing discontinuation of CYC, hospitalization and/or death, long term adverse events, including infertility and malignancy, and outcome. RESULTS Of 5790 BS patients, 198 (3.4%) had used at least one dose of CYC. Main indications were vascular or neurological involvement. After a median follow-up of 17 years, 52 (26%) patients had died, 113 (57%) could be contacted, and 33 (17%) were lost to follow-up. Vascular involvement was the leading cause of death (n = 27). Seventeen (9%) patients experienced short term adverse events with haemorrhagic cystitis being the most common. After a median follow-up of 25 years (interquartile range: 15-26 years), 17 malignancies occurred in 15 (8%) patients. Infertility was experienced by 26 (30%) patients. CONCLUSION Long term adverse events such as malignancy and infertility were major problems in our BS patients treated with CYC. These results underline the need for safer treatment modalities that are at least as effective as CYC.
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Affiliation(s)
- Mert Gurcan
- Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sinem Nihal Esatoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Vedat Hamuryudan
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Didem Saygin
- Department of Internal Medicine, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Serdal Ugurlu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Emire Seyahi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Melike Melikoglu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Izzet Fresko
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sebahattin Yurdakul
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Hasan Yazici
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Tijani Y, Zahdi O, Hormat-Allah M, El Bhali H, El Khloufi S, Sefiani Y, El Mesnaoui A, Lekehal B. Superficial femoral artery false aneurysm revealing Behçet's disease. JOURNAL DE MÉDECINE VASCULAIRE 2020; 45:351-353. [PMID: 33248539 DOI: 10.1016/j.jdmv.2020.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 09/19/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Y Tijani
- Mohammed VI University of Health Sciences (UM6SS), Casablanca, Morocco
| | - O Zahdi
- Mohammed V University of Rabat, Rabat, Morocco; Vascular surgery department, Ibn Sina Hospital, 10104 Souissi, Rabat, Morocco.
| | - M Hormat-Allah
- Mohammed V University of Rabat, Rabat, Morocco; Vascular surgery department, Ibn Sina Hospital, 10104 Souissi, Rabat, Morocco
| | - H El Bhali
- Mohammed V University of Rabat, Rabat, Morocco; Vascular surgery department, Ibn Sina Hospital, 10104 Souissi, Rabat, Morocco
| | - S El Khloufi
- Mohammed V University of Rabat, Rabat, Morocco; Vascular surgery department, Ibn Sina Hospital, 10104 Souissi, Rabat, Morocco
| | - Y Sefiani
- Mohammed V University of Rabat, Rabat, Morocco; Vascular surgery department, Ibn Sina Hospital, 10104 Souissi, Rabat, Morocco
| | - A El Mesnaoui
- Mohammed V University of Rabat, Rabat, Morocco; Vascular surgery department, Ibn Sina Hospital, 10104 Souissi, Rabat, Morocco
| | - B Lekehal
- Mohammed V University of Rabat, Rabat, Morocco; Vascular surgery department, Ibn Sina Hospital, 10104 Souissi, Rabat, Morocco
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Pazzola G, Pipitone N, Salvarani C. Cardiac involvement in the adult primary vasculitides. Expert Rev Clin Immunol 2020; 16:985-991. [PMID: 32954889 DOI: 10.1080/1744666x.2021.1823219] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Heart involvement in vasculitis is rare, but potentially severe. The ascertainment of cardiac disease in vasculitis is complex and requires an integrated multidisciplinary approach involving the Rheumatologist, Radiologist, Cardiologist, and Heart surgeon. AREAS COVERED the authors searched PubMed using the keywords 'heart'[Mesh] and vasculitis"[Mesh]. EXPERT OPINION Virtually any vasculitis can affect the heart, but cardiac involvement is more common in some vasculitides such as Takayasu arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis. Immunosuppressive treatment and when indicated surgery can improve the prognosis.
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Affiliation(s)
- Giulia Pazzola
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia , Reggio Emilia, Italy
| | - Nicolò Pipitone
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia , Reggio Emilia, Italy
| | - Carlo Salvarani
- Rheumatology Unit, Department of Internal Medicine, Azienda USL-IRCCS di Reggio Emilia e Università di Modena e Reggio Emilia , Reggio Emilia, Italy
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Alkhurassi HF, Ocheltree MR, Alsomali A, Alqunfoidi RA, Saadallah A. Pleural Effusion Presenting in a Young Man With Behcet's Disease. Cureus 2020; 12:e10273. [PMID: 32923298 PMCID: PMC7478535 DOI: 10.7759/cureus.10273] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
Behcet's disease (BD) is a rare multisystem chronic vasculitis of variable clinical presentation and unknown origin. Pulmonary involvement in BD is uncommon, with pleural effusion being an even rarer and difficult to diagnose manifestation. Herein, we report a challenging case of a young man who presented with recurrent pleural effusion and hepatic vein thrombosis and a recent history of papilledema with idiopathic intracranial hypertension. The patient was hospitalized for diagnostic and therapeutic thoracocentesis. Biochemistry and cytological analysis showed an exudative aspect of the collected pleural fluid with lymphocyte-dominated cytology. A multidisciplinary discussion was held, and thorough investigation was carried out to rule out malignant and infectious etiologies, among other differentials. During the second hospitalization, the patient complained of genital ulcers, which were verified to be recurrent along with oral ulcers. The diagnosis of BD was established based on the International Classification Criteria for BD, and the symptoms improved significantly upon using colchicine and immune-suppressive drugs.
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Affiliation(s)
| | | | - Ahlam Alsomali
- Internal Medicine/Geriatric, International Medical Center, Jeddah, SAU
| | - Reem A Alqunfoidi
- Internal Medicine/Hematology, International Medical Center, Jeddah, SAU
| | - Asmaa Saadallah
- Internal Medicine, International Medical Center, Jeddah, SAU
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36
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Thoracic Complications in Behçet's Disease: Imaging Findings. Can Respir J 2020; 2020:4649081. [PMID: 32566055 PMCID: PMC7275231 DOI: 10.1155/2020/4649081] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Accepted: 04/27/2020] [Indexed: 11/17/2022] Open
Abstract
Behçet's disease (BD) causes vascular inflammation and necrosis in a wide range of organs and tissues. In the thorax, it may cause vascular complications, affecting the aorta, brachiocephalic arteries, bronchial arteries, pulmonary arteries, pulmonary veins, capillaries, and mediastinal and thoracic inlet veins. In BD, chest radiograph is commonly used for the initial assessment of pulmonary symptoms and complications and for follow-up and establishment of the response to treatment. With the advancement of helical or multislice computed tomography (CT) technologies, such noninvasive imaging techniques have been employed for the diagnosis of vascular lesions, vascular complications, and pulmonary parenchymal manifestations of BD. CT scan (especially, CT angiography) has been used to determine the presence and severity of pulmonary complications without resorting to more invasive procedures, in conjunction with gadolinium-enhanced three-dimensional (3D) gradient-echo magnetic resonance (MR) imaging with the subtraction of arterial phase images. These radiologic methods have characteristics that are complementary to each other in diagnosis of the thoracic complications in BD. 3D ultrashort echo time (UTE) MR imaging (MRI) could potentially yield superior image quality for pulmonary vessels and lung parenchyma when compared with breath-hold 3D MR angiography.
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Toledo-Samaniego N, Galeano-Valle F, Pinilla-Llorente B, Del-Toro-Cervera J, Marra A, Proietti M, Demelo-Rodríguez P. Clinical features and management of venous thromboembolism in patients with Behçet's syndrome: a single-center case-control study. Intern Emerg Med 2020; 15:635-644. [PMID: 31802406 DOI: 10.1007/s11739-019-02237-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2019] [Accepted: 11/15/2019] [Indexed: 12/15/2022]
Abstract
Almost one third of patients with Behçet's syndrome (BS) display vascular involvement. However, data regarding the prevalence and management of venous thromboembolism (VTE) in BS are scanty. We assessed the differential characteristics between patients with and without VTE and the factors associated with VTE incidence. A case-control study in a cohort of patients with BS was performed. 57 patients were included (56.1% women) with a mean follow-up of 10.56 (± 10.7) years. Mean age at diagnosis of BS and diagnosis of the first VTE episode was 34.7 (± 12.1) and 31.2 (± 8.9) years, respectively. Erythema nodosum (OR 4.6, CI 95% 1.2-18.1) and fever (OR 8.2, CI 95% 1.6-42.1) were associated with a higher risk of VTE. 26 episodes of VTE were registered in 12/57 (21%) patients. 83.3% of patients were not diagnosed with BS when the first episode of VTE occurred and, among them, the episode of VTE led to the diagnosis of BS in 40% of cases. Half of patients had at least one VTE recurrence. The absence of immunosuppressive treatment was associated with a higher risk of developing a first episode of VTE (OR 20 CI 95% 19.2-166.6). All patients were treated with anticoagulation and 75% were treated with immunosuppressants after the first VTE event. The diagnosis of VTE usually precedes that of BS, with a high frequency of VTE recurrence. Erythema nodosum and fever were associated with a higher risk of VTE, while the immunosuppressants showed a protective role for the development of VTE.
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Affiliation(s)
- Neera Toledo-Samaniego
- Venous Thromboembolism Unit, Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Francisco Galeano-Valle
- Venous Thromboembolism Unit, Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain.
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain.
- Instituto de Investigación Sanitaria Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain.
| | - Blanca Pinilla-Llorente
- Venous Thromboembolism Unit, Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Jorge Del-Toro-Cervera
- Venous Thromboembolism Unit, Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
| | - Alberto Marra
- Department of Cardiovascular Imaging, IRCCS (Istituto Di Ricovero E Cura a Carattere Scientifico)-SDN Research Institute, Via Giovanni Amendola 209, 70126, Bari, Italy
| | - Marco Proietti
- Department of Neuroscience, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Via Mario Negri, 2, 20156, Milan, MI, Italy
- Department of Internal Medicine and Medical Specialties, Sapienza University of Rome, Piazzale Aldo Moro, 5, 00185, Rome, RM, Italy
| | - Pablo Demelo-Rodríguez
- Venous Thromboembolism Unit, Department of Internal Medicine, Hospital General Universitario Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
- School of Medicine, Universidad Complutense de Madrid, Madrid, Spain
- Instituto de Investigación Sanitaria Gregorio Marañón, Calle Doctor Esquerdo 46, 28007, Madrid, Spain
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Nishiyama T, Kondo Y, Okamoto S, Terasaki M, Toko H, Yagishita M, Takahashi H, Yokosawa M, Tsuboi H, Matsumoto I, Sumida T. Aortic Arch Aneurysm in Behçet Disease Successfully Treated with Infliximab. Intern Med 2020; 59:1087-1091. [PMID: 31915317 PMCID: PMC7205534 DOI: 10.2169/internalmedicine.3946-19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Aortic arch aneurysm (AAA) is a rare involvement in Behçet disease (BD). It is often life-threatening, yet few reports related to the treatment of AAA have been published. We herein report a 27-year-old woman with AAA caused by vascular BD. She was initially treated with prednisolone 1 mg/kg/d. However, the inflammation had not subsided after three weeks, so infliximab (IFX) was added for relief. After IFX administration, the C-reactive protein level normalized, and computed tomography at three months after therapeutic intervention revealed that the aneurysm had disappeared. This case suggests that early induction of IFX might be effective for aortic aneurysm in BD.
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Affiliation(s)
- Taihei Nishiyama
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Yuya Kondo
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Shota Okamoto
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Mayu Terasaki
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Hirofumi Toko
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Mizuki Yagishita
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Hiroyuki Takahashi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Masahiro Yokosawa
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Hiroto Tsuboi
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Isao Matsumoto
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
| | - Takayuki Sumida
- Department of Internal Medicine, Faculty of Medicine, University of Tsukuba, Japan
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39
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Association between serum homocysteine and arterial stiffness in patients with Behçet’s disease. EGYPTIAN RHEUMATOLOGIST 2020. [DOI: 10.1016/j.ejr.2019.06.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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40
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An Overview of Conventional and Recent Treatment Options for Behcet’s Disease. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2020. [DOI: 10.1007/s40674-020-00143-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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41
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The Clinical Features, Risk Factors, and Outcome of Aneurysmal Lesions in Behcet's Disease. J Immunol Res 2019; 2019:9198506. [PMID: 31930152 PMCID: PMC6942855 DOI: 10.1155/2019/9198506] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Revised: 11/24/2019] [Accepted: 11/29/2019] [Indexed: 02/05/2023] Open
Abstract
Objective To investigate the clinical features and potential risk factors of aneurysmal lesions in Behcet's disease (BD). Methods We retrospectively reviewed the clinical data of BD patients with aneurysmal lesions in our institute from 1997 to 2017 and compared them with 207 BD patients without aneurysmal lesions. The treatment and outcome of these patients were also analyzed. Results Sixty-nine patients were included with 117 aneurysmal lesions. The average period between BD onset and diagnosis of aneurysmal lesion was 5.4 ± 5.5 years. Thirty-three patients (47.8%) had multiple aneurysmal lesions. Ten patients developed 20 pulmonary artery aneurysms alone. For the other 97 aortic and/or peripheral artery aneurysms in 59 patients, the most commonly affected vessels were abdominal aorta (27/97, 27.8%), coronary artery (10/97, 10.3%), and superficial femoral artery (8/97, 8.2%). Multivariate analysis revealed pathergy reaction (OR = 3.78 (1.70-8.41)), arterial stenosis or occlusion (OR = 44.12 (11.56-168.35)), and arterial thrombosis (OR = 9.27 (2.33-36.93)) as independent predictors of aneurysmal lesions in BD. With a mean follow-up of 5.5 ± 4.0 years, 40 patients (58.0%) achieved clinical improvements, 15 patients (21.7%) relapsed, and 10 patients (14.5%) died. The respective estimated cumulative 1- and 5-year relapse-free rates were 91.3% and 76.3%, and the respective estimated 1- and 5-year survival rates were 95.0% and 87.2%. Conclusion Aneurysmal lesions are severe complications in BD. Pathergy reaction, arterial stenosis or occlusion, and arterial thrombosis are the risk factors of aneurysmal lesions in BD. Achieving BD remission and performing surgical or interventional procedures are both important in the treatment of these patients.
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Abstract
Dermatologic changes occur in a variety of rheumatic diseases. Skin can be the initial site of involvement, thus providing important clues for an accurate diagnosis based on cutaneous findings. Dermatologic findings can also be an indicator of systemic involvement and prognostic outcome; however, many connective tissue disorders have a wide variety of cutaneous manifestations, with significant overlap between different diseases. These skin signs often precede systemic clinical manifestations. Careful attention to characteristic dermatologic findings in Behçet's disease, systemic lupus erythematosus, rheumatoid arthritis, and various vasculitis can provide prompt therapeutic approaches in the case of life-threatening complications of systemically involved rheumatologic diseases.
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Affiliation(s)
- Burhan Engin
- Department of Dermatology and Venereology, Cerrahpaşa Medical Faculty, Istanbul University-Cerrahpaşa, Istanbul, Turkey.
| | - Ayşegül Sevim
- Department of Dermatology and Venereology, Haydarpasa Numune Research and Teaching Hospital, Istanbul, Istanbul, Turkey
| | - Seher Küçükoğlu Cesur
- Department of Dermatology and Venereology, Altınbaş University, Bahçelievler Medical Park Hospital, Istanbul, Istanbul, Turkey
| | - Yalçın Tüzün
- Department of Dermatology and Venereology, Bahçelievler Medical Park Hospital, Istanbul, Istanbul, Turkey
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Elrobaa I, Elserhy M, Ahmad M, Subidar M, Alhadi H. Al Wakra emergency presentation of Behcet's disease. AME Case Rep 2019; 3:34. [PMID: 31616862 DOI: 10.21037/acr.2019.08.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 08/06/2019] [Indexed: 11/06/2022]
Abstract
This is atypical presentation of Behcet's disease and it's important for emergency physician and doctors who are working in acute medicine. We reported a case of a young patient presenting back pain concerning the right leg, a result of extensive bilateral deep vein thrombosis (DVT) in both legs that extended to inferior vena cava (IVC) and renal veins. After a bundle of investigations and medical examinations, the case was diagnosed as Behcet's disease with an atypical presentation. Al Wakra emergency presentation of Behcet's disease: low back pain with lower limb pain that result of DVT which is one of vascular complication of Behcet's disease.
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Affiliation(s)
- Islam Elrobaa
- Al Wakra Emergency Department, Al Wakra Hospital, Hamad Medical Corporation, Al Wakrah, Qatar
| | - Mohamed Elserhy
- Al Wakra Emergency Department, Al Wakra Hospital, Hamad Medical Corporation, Al Wakrah, Qatar
| | - Muayad Ahmad
- Al Wakra Emergency Department, Al Wakra Hospital, Hamad Medical Corporation, Al Wakrah, Qatar
| | - Mohamed Subidar
- Al Wakra Emergency Department, Al Wakra Hospital, Hamad Medical Corporation, Al Wakrah, Qatar
| | - Hassan Alhadi
- Al Wakra Emergency Department, Al Wakra Hospital, Hamad Medical Corporation, Al Wakrah, Qatar
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Abdo M, Alkemary A, El Mallah R. What is the impact of traditional risk factors for vascular affection on Behcet’s disease vascular involvement: a retrospective cohort study. EGYPTIAN RHEUMATOLOGY AND REHABILITATION 2019. [DOI: 10.4103/err.err_27_19] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Emmi G, Bettiol A, Silvestri E, Di Scala G, Becatti M, Fiorillo C, Prisco D. Vascular Behçet's syndrome: an update. Intern Emerg Med 2019; 14:645-652. [PMID: 30499073 DOI: 10.1007/s11739-018-1991-y] [Citation(s) in RCA: 85] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/20/2018] [Indexed: 12/20/2022]
Abstract
Behçet's syndrome (BS) is a complex vasculitis, characterised by peculiar histological, pathogenetic and clinical features. Superficial venous thrombosis (SVT) and deep vein thrombosis (DVT) are the most frequent vascular involvements, affecting altogether 15-40% of BS patients. Atypical thrombosis is also an important clinical feature of BS, involving the vascular districts of the inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right ventricle. On the other hand, arterial involvement, although affecting only 3-5% of patients, represents a unique feature of BS, with aneurysms potentially affecting peripheral, visceral and pulmonary arteries. Vascular events in BS are promoted by inflammation, with neutrophils playing a key role in the pathogenesis of thrombotic events; in turn, coagulative components such as fibrinogen, thrombin, factor Xa and factor VIIa amplify the inflammatory cascade. Understanding the contribution of inflammatory and coagulation components in the pathogenesis of BS vascular events is crucial to define the most effective therapeutic strategy. Control of vascular thrombosis is achieved with immunosuppressants drugs rather than anticoagulants. In particular, use of azathioprine and cyclosporine in association with low-dose corticosteroids should be considered in DVT and SVT cases, while treatment with cyclophosphamide together with anti-TNF-α agents can be effectively used in arterial involvement. More recently, the anti-TNF-α drugs have also been reported as a valid alternative for the treatment also of venous events, especially DVT. An exception to the use of anticoagulant in BS could be represented by cerebral veins thrombosis. In this review, we will depict the main characteristics of the vascular involvement in BS, briefly describing histological and pathogenetic features, while focusing on the clinical and therapeutical approaches of the vascular manifestations of BS.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy.
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, Firenze, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Gerardo Di Scala
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Matteo Becatti
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Firenze, Firenze, Italy
| | - Claudia Fiorillo
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Firenze, Firenze, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
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46
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Demir S, Sag E, Kaya Akca U, Hazirolan T, Bilginer Y, Ozen S. The Challenge of Treating Pulmonary Vasculitis in Behçet Disease: Two Pediatric Cases. Pediatrics 2019; 144:peds.2019-0162. [PMID: 31320468 DOI: 10.1542/peds.2019-0162] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/10/2019] [Indexed: 11/24/2022] Open
Abstract
Behçet disease (BD) is a multisystemic autoinflammatory disorder characterized by recurrent mucocutaneous, ocular, musculoskeletal, gastrointestinal, central nervous system, and vascular manifestations. Pulmonary arterial involvement (PAI) of BD is probably the most severe form of vasculitis, at least in children. PAI has a high mortality, morbidity, and recurrence rate. There are limited data regarding treatment and outcomes of pediatric patients with BD with PAI. Herein, we report 2 pediatric patients with BD presented with hemoptysis and support our data with a systematic review. These patients were given immunosuppressive therapy, which covered pulse methylprednisolone followed by oral prednisolone, intravenous cyclophosphamide every 3 weeks for a total of 6 cycles, and interferon-α2a concomitantly. These are the first reported cases in the literature successfully treated with this treatment modality in a complication with 50% mortality. These patients have been followed up for a period of at least 4 years without any vascular recurrence. Pediatricians should be aware that patients with BD may not present with full diagnostic criteria. They should consider BD in a child with PAI to avoid diagnostic delay and start life-saving accurate immunosuppressive treatment.
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Affiliation(s)
- Selcan Demir
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey; and
| | - Erdal Sag
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey; and
| | - Ummusen Kaya Akca
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey; and
| | - Tuncay Hazirolan
- Department of Radiology, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey; and
| | - Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Faculty of Medicine, Hacettepe University, Ankara, Turkey; and
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47
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Sahutoglu T, Artim Esen B, Aksoy M, Kurtoglu M, Poyanli A, Gul A. Clinical course of abdominal aortic aneurysms in Behçet disease: a retrospective analysis. Rheumatol Int 2019; 39:1061-1067. [PMID: 30888471 DOI: 10.1007/s00296-019-04283-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 03/13/2019] [Indexed: 12/29/2022]
Abstract
Arterial aneurysms are rare manifestations of Behçet Disease (BD) with high morbidity and mortality. This study aimed to investigate the clinical course of BD patients with abdominal aortic aneurysms (AAA). We retrospectively searched charts of BD patients, followed up between 1988 and 2011, to identify those with AAA with at least 6-month clinical and radiological follow-up data. Chart review revealed 12 patients (11 males) with AAA amongst 1224 patients; follow-up data from 11 patients were available. The most common symptoms were lower back and abdominal pain. The only pre-treatment complication was a spontaneous rupture. All but one patient received corticosteroid and cyclophosphamide pulses for the induction, and corticosteroid and azathioprine for the maintenance treatment; one patient received only the maintenance treatment. Two patients had surgical graft interposition, without postoperative complications. Seven patients had endovascular stenting; five of them (71.4%) showed radiological regression after 32.5 (13.4-53.8) months, while four (57%) had clinical improvement after 11.8 (0.2-29.4) months. However, one non-responsive patient developed stent infection and exsanguinated during percutaneous drainage, and one patient developed femoral artery pseudo-aneurysm at the catheter insertion site. Another patient developed a new aneurysm under the maintenance treatment. Medical treatment alone yielded radiological regression in one of two patients. Current immunosuppressive, surgical or endovascular approaches can provide clinical and radiological improvements lately in BD patients with AAA. Furthermore, complication rates seem to be high with interventional approaches. These findings suggest an unmet need for safer alternative treatments.
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Affiliation(s)
- Tuncay Sahutoglu
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Fatih, 34093, Istanbul, Turkey
- Department of Nephrology, Sanliurfa Mehmet Akif Inan Training and Research Hospital, Health Sciences University, Urfa, Turkey
| | - Bahar Artim Esen
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Fatih, 34093, Istanbul, Turkey
| | - Murat Aksoy
- Division of Vascular Surgery, Department of Surgery, Istanbul University, Istanbul, Turkey
| | - Mehmet Kurtoglu
- Division of Vascular Surgery, Department of Surgery, Istanbul University, Istanbul, Turkey
| | - Arzu Poyanli
- Department of Radiology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Ahmet Gul
- Division of Rheumatology, Department of Internal Medicine, Istanbul Faculty of Medicine, Istanbul University, Fatih, 34093, Istanbul, Turkey.
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48
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Abstract
Behçet syndrome is considered to be a multisystemic vasculitis involving the skin, mucosa, eyes, joints, nervous system, cardiovascular system, and gastrointestinal system. The exact pathogenesis of the disease is unknown, but autoimmune factors are thought to play the main role. Vasculitis in Behçet syndrome can involve any kind and size of vessels, and this explains why the disease has the ability of multisystemic involvement. The commonest clinical presentation of Behçet syndrome is recurrent and painful mucocutaneous ulcerations known as aphthosis. The other clinical manifestations vary among patients and populations. The disease tends to be more severe in men. Ocular, vascular, and central nervous system involvements are the major causes of morbidity and mortality. Behçet syndrome is a mimicker of many diseases with its several faces and considered as one of the great imitators in dermatology.
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Affiliation(s)
- Necmettin Akdeniz
- Department of Dermatology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ömer Faruk Elmas
- Department of Dermatology, Faculty of Medicine, Ahi Evran University, Kırşehir, Turkey.
| | - Ayşe Serap Karadağ
- Department of Dermatology, Faculty of Medicine, Istanbul Medeniyet University, Istanbul, Turkey
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49
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Adams TN, Zhang D, Batra K, Fitzgerald JE. Pulmonary manifestations of large, medium, and variable vessel vasculitis. Respir Med 2018; 145:182-191. [PMID: 30509707 DOI: 10.1016/j.rmed.2018.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 09/14/2018] [Accepted: 11/06/2018] [Indexed: 02/01/2023]
Abstract
The hallmark of vasculitis is autoimmune inflammation of blood vessels and surrounding tissues, resulting in an array of constitutional symptoms and organ damage. The lung is commonly targeted in the more familiar ANCA-associated small vessel vasculitidies, but large and medium vessel vasculitides, including Takayasu arteritis, giant cell arteritis, polyarteritis nodosa, Behcet's disease, and necrotizing sarcoid granulomatosis, may also feature prominent pulmonary involvement. Pulmonary manifestations of these conditions include pulmonary arterial aneurysms, pulmonary hypertension, diffuse alveolar hemorrhage, pulmonary nodules, and parenchymal infiltrates. An understanding of the diverse manifestations of vasculitis and a high index of clinical suspicion are essential to avoid delays in disease recognition that may result in permanent or life threatening morbidity. In this review, we outline the general clinical manifestations, pulmonary manifestations, diagnostic workup, imaging findings, and treatment of medium, large, and variable vessel vasculitides.
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Affiliation(s)
- Traci N Adams
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States.
| | - Da Zhang
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States
| | - Kiran Batra
- University of Texas Southwestern Medical Center, Department of Radiology, United States
| | - John E Fitzgerald
- University of Texas Southwestern Medical Center, Department of Pulmonary and Critical Care Medicine, United States
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50
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Wei B. Behcet's Syndrome: Fear Not the Unknown. Semin Thorac Cardiovasc Surg 2018; 30:379-380. [PMID: 30236452 DOI: 10.1053/j.semtcvs.2018.09.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 09/10/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Benjamin Wei
- Department of Surgery, University of Alabama Birmingham School of Medicine, Birmingham, Alabama..
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