[Ocular manifestations of Behçet's disease]

[Ocular manifestations of Behçet's disease]

INTRODUCTION

Behçet's disease is a systemic inflammatory disease. Ocular involvement is an important diagnostic criterion, and this disease may be associated with severe visual loss.

PURPOSE

The goal of this study was to specify the epidemiological, clinical and therapeutic features of ocular involvement in patients with Behçet's disease and to identify risk factors for poor visual outcomes.

METHODS

A retrospective study was performed in 93 patients diagnosed with ocular Behçet's disease over a period of 9 years. Epidemiological, clinical, and therapeutic data was obtained from medical records and analyzed retrospectively. Poor visual outcome was defined as visual acuity limited to light perception without projection or no light perception.

RESULTS

The male:female ratio was 1.9. The mean age was 34.5 years. Ocular involvement was the presenting sign in 4%, bilateral in 61% and active in 68.8%. Uveitis was the most common presentation (57%), dominated by panuveitis, followed by retinal vasculitis (51.6%) and papilledema (10.7%). Maculopathy (26.8%) and cataract (18.2%) were the most common complications. Twenty patients (21.5%) had no light perception or light perception without projection. Treatment was based on corticosteroids in combination with immunosuppressive therapy (Azathioprine) in 55.9% of cases. Our study indicates a significant association of male gender and panuveitis with a poor visual outcome.

CONCLUSION

Ocular involvement in Behçet's disease is frequent and serious, which may lead to blindness. Male gender and panuveitis were predictors of poor visual prognosis.

[Use of biotherapy in the management of Behçet's disease in a department of internal medicine]

BACKGROUND

Behçet's disease (BD) is a recurrent multisystemic disease responsible for occlusive vasculitis with arterial, venous and capillary involvement. The aim of this study was to determine the frequency and the features associated with the use of biotherapy in the management of patients followed in our department for BD.

METHODS

This is a retrospective study of patients medical records followed for BD in a department of internal medicine from January 2005 to August 2018.

RESULTS

A total of 41 patients were included with a mean age at diagnosis of 42.5±12.1 years (range 16 to 63) and a sex ratio men/women of 1.05. Oral and/or genital aphtosis was present in 70.7% of the patients. Other lesions were: ocular (78.0%), articular (46.3%), cutaneous (41.5%), central neurological (34.1%), vascular (26.8%), digestive (7.3%), pericardial (2.4%) and epididymal (2.4%). A biotherapy, interferon α and monoclonal antibodies, was used in 15 patients (36.6%), after failure of conventional treatments. The monoclonal antibodies were anti-TNFα (infliximab, adalimumab, certolizumab and golimumab) except in one patient for whom ustekinumab was used. Biotherapy was used in 46.9% of the patients with ocular involvement and never used in those patients without ocular involvement (P=0.01).

CONCLUSION

Biotherapy is effective and represents a solution to the failures of conventional treatments in severe forms of Behçet's disease with ocular involvement.

Asymptomatic Progression of Ocular Behçet's Disease

BACKGROUND AND OBJECTIVE

To emphasize the importance of auxiliary exams to detect progression of ocular Behçet's disease (BD) in asymptomatic patients.

PATIENTS AND METHODS

This was a retrospective review of the clinical records of a consecutive series of patients with BD and asymptomatic visual deterioration, imaged on fundus photograph (FP), visual field (VF), fluorescein angiography (FA), and optical coherence tomography (OCT).

RESULTS

Patients presented with no clinical findings or with mild inflammation on ophthalmic examination. However, during follow-up, VF examination indicated a progressive enlargement of previously visualized scotomas. On FA, the authors detected leakage and ischemia. On OCT, there was macular anatomical disruption, and the FP showed areas of atrophic retina.

CONCLUSION

In patients with ocular BD, the visual acuity deterioration may be asymptomatic and progressive. This should justify the importance of early and sequential ancillary exams in the management of BD patients to detect subclinical ocular involvement. [Ophthalmic Surg Lasers Imaging Retina. 2017;48:18-25.].

[Management of uveomeningitis in internal medicine: Proposal for a diagnostic work-up]

Uveomeningitis relates to an inflammatory state extending from iris and ciliary bodies to the choroid behind the eye. Because of a close contact between eye and brain, and barrier disruption, the inflammation can spread into the central nervous system (CNS). We review the clinical manifestations of uveitis, which are known to provide helpful clues to the diagnosis and describe the infectious, inflammatory, and neoplastic conditions classically associated with the uveomeningitis. Inflammatory or auto-immune diseases are probably the most common clinically recognized causes of uveomeningitis associated with a significant pleiocytosis. These entities often cause inflammation of various tissues in the body, including ocular structures and the meninges (i.e., sarcoidosis, Behçet's disease, and Vogt-Koyanagi-Harada syndrome). The association of an infectious uveitis with an acute or a chronic meningo-encephalitis is unusual but occasionally the eye examination may suggest an infectious etiology or even a specific organism responsible for an uveomeningitis. One should consider the diagnosis of primary ocular-CNS lymphoma in patients of 40 years of age or older with bilateral uveitis, especially with prominent vitritis, showing poor response to corticosteroid therapy. Finally, an algorithm for the diagnostic approach of uveomeningitis is proposed.

[Vascular endothelial injury induced by anti-endothelial cell antibody in allogeneic hematopoietic stem cell transplantation]

OBJECTIVE

To clarify the role of endothelial cells (ECs) injury induced by anti-endothelial cell antibody (AECA) in allogeneic hematopoietic stem cell transplantation (allo-HSCT).

METHODS

Serum immunoglobulin (IgG) from allo-HSCT recipients were purified and incubated with human umbilical vein vascular endothelium (HUVEC) in vitro, then the functional changes and cell apoptosis were tested.

RESULTS

After incubation with AECA positive IgG, soluble adhesion molecules significantly elevated in culture supernatant. When concentration of IgG was 160, 320, and 640 μg/ml, concentrations of soluble intercellular adhesion molecule-1 in supernatant were statistically higher in AECA positive groups [(117.10 ± 12.82) vs (78.17 ± 4.90) pg/ml, (151.30 ± 15.35) vs (89.46 ± 6.02) pg/ml, (239.00 ± 32.53) vs (127.80 ± 13.86) pg/ml, P<0.01)]. When concentration of IgG was 40, 80, 160, 320, and 640 μg/ml, concentrations of soluble vascular cell adhesion molecule-1 in supernatant were also statistically higher in AECA positive groups [(38.51 ± 3.76) vs (24.78 ± 2.59) pg/ml, (61.34 ± 6.99) vs (38.20 ± 3.17) pg/ml, (135.60 ± 24.46) vs (63.73 ± 5.08) pg/ml, (221.30 ± 29.40) vs (112.80 ± 8.91) pg/ml, (420.90 ± 31.70) vs (224.40 ± 20.79) pg/ml, P<0.01]. Clotting activity factors also elevated in culture supernatant after incubation with AECA positive IgG. When concentration of IgG was 80, 160, 320, and 640 μg/ml, concentrations of von Willebrand factor were statistically higher in AECA positive groups [(19.51 ± 0.72) vs (17.17 ± 0.60) ng/ml, P=0.0193; (22.97 ± 1.18) vs (18.27 ± 0.61) ng/ml, (26.40 ± 1.54) vs (19.53 ± 0.70) ng/ml, (34.35 ± 1.60) vs (23.81 ± 0.92) ng/ml, P<0.01]. When concentration of IgG was 320 and 640 μg/ml, concentrations of thrombomodulin were statistically higher in AECA positive groups [(57.50 ± 4.50) vs (40.31 ± 4.39) pg/ml, P=0.0132; (59.18 ± 4.11) vs (38.84 ± 5.16) pg/ml, P<0.01]. However, inflammatory factors (IL-1β, IL-6, IL-8 and ANG2) were not statistically different in AECA positive and negative groups (P>0.05). Moreover, IgG from AECA positive samples did not change the proliferation or cell apoptosis.

CONCLUSION

AECA from allo-HSCT recipients dysregulates ECs' function in vitro, but do not induce apoptosis, which is valuable in the pathophysiology of graft-versus-host disease (GVHD) and other complications after allo-HSCT.

A systematic approach to emergencies in uveitis

Uveitis is a common cause of preventable blindness although it is consider a sight-threatening condition particularly in cases with posterior segment inflammation. To deal with emergency conditions in uveitis, we must aware of the essential signs and symptoms that reflect a true uveitic emergency. Failure to recognize these essential signs and symptoms of a true uveitic emergency may result in a devastating visual outcome. This review provides general ophthalmologists and residents, clinical guidelines for the main uveitic entities that require immediate recognition and urgent intervention in the emergency room to prevent severe permanent visual loss.

Interleukin-28A promotes IFN-γ production by peripheral blood mononuclear cells from patients with Behçet's disease

Behçet's disease (BD) is an autoimmune disease of unknown etiology. Interleukin-28A (IL-28A) promotes immune responses and may participate in the pathogenesis of autoimmune diseases. To examine the role of IL-28A in the pathogenesis of BD, we measured the expression of IFN-γ and IL-17 by IL-28A-stimulated peripheral blood mononuclear cells (PBMCs) from 19 patients with BD and 16 healthy individuals. We found that IFN-γ and IL-17 were undetectable in the sera from BD patients and control subjects. The mRNA expression and protein production of IFN-γ by IL-28A-stimulated PBMCs from BD patients were significantly increased compared to healthy individuals. No significant difference was observed in the mRNA expression and protein production of IL-17 by IL-28A-stimulated PBMCs between BD patients and normal individuals.

Evaluation of the Macular, Peripapillary Nerve Fiber Layer and Choroid Thickness Changes in Behçet's Disease with Spectral-Domain OCT

Purpose. To assess the macular, choroid, and peripapillary nerve fiber layer thickness (RNFL) in Behçet's disease (BD) patients with and without ocular involvement by means of optical coherence tomography (OCT) and compare these findings with healthy controls. Design. Eighty patients with BD and 40 healthy controls who were followed up at the Uveitis and Retina Clinic of the Kayseri Research and Education Hospital in Turkey were enrolled in this prospective study. Subjects and Controls. The patients with BD were divided into two groups according to the presence of ocular involvement. Group 1 consisted of 40 eyes of 40 patients with ocular involvement and group 2 consisted of 40 eyes of 40 patients without ocular involvement. Methods. All of the patients and controls underwent macular, choroid, and peripapillary nerve fiber layer thickness analysis with Spectralis domain OCT (Spectralis OCT Heidelberg Engineering, Dossenheim, Germany). Main Outcome Measures. The differences in macular, choroid, and peripapillary nerve fiber layer thicknesses between groups were analyzed statistically. Results. Macular thickness was thinner in patients with BD than in the control group; this result was statistically significant (P = 0.05). There was no statistically significant difference in thickness between RNFL analysis of the patients with BD and control subjects. However, the BD patients with ocular involvement had statistically significant thinning in RNFL compared with BD patients without ocular involvement. Although the choroid was thicker in patients with BD than in the control group, it did not reach a statistically significant level (P = 0.382). Conclusions. BD with ocular involvement may be associated with decreased macular and RNFL thickness measured with spectral-domain OCT.

Ocular manifestations of Behçet's disease in Jordanian patients

PURPOSE

To study the prevalence, manifestations and severity of ocular involvement of Behçet's disease in Jordanian patients.

METHODS

The study population consisted of 43 patients diagnosed to have Behçet's disease through Rheumatologist's examinations conducted at Jordan University Hospital between January 2002 and July 2009. The sample involved patients who displayed ocular manifestations. This included 18 patients; 12 males and 6 females with a mean age of 35 years (SD = 17.26). Ophthalmological examinations and retrospective analysis of medical files were carried on.

RESULTS

Ocular manifestations were seen in 41.9% of patients. The most common manifestation for Behçet's disease was vitritis with a prevalence of 55.6%, followed by anterior uveitis and retinal vasculitis (50% for each). On the other hand, the most frequent complications involved were cataract, cystoid macular edema (CMO), posterior synechiae and glaucoma with a prevalence of (44.4%), (33.3%), (11.1%) and (5.6%), respectively.

CONCLUSION

The prevalence and severity of ocular lesions in Behçet's disease is relatively low in Jordanian patients. This result indicates that early diagnoses and intervention might delay or even prevent vision loss for those patients.

[Behçet's disease in women]

PURPOSE

Behçet's disease (BD) is a multisystemic inflammatory disease characterized, on the one hand, by the frequency of benign mucocutaneous and articular manifestations, and on the other hand by the severity of ocular, neurological, vascular and digestive manifestations which may threaten functional or vital prognosis. The male BD predominance is obvious in many retrospective studies and a few studies only have focused on BD in women.

METHODS

In this study, we report the epidemiological, clinical, outcome and therapeutic data of a series of 71 female BD compared to a series of 111 male BD. This retrospective study was conducted in the internal medicine department of Monastir university hospital over a 19-year period (1990 to 2008), including all patients followed-up and treated for BD.

RESULTS

The comparison of clinical manifestations of BD between men and women showed the predominance of erythema nodosum (P=0.016), necrotic pseudofolliculitis (P=0.001), and joint involvement (P=0.009) in women, while genital ulcers (P=0.039), ocular involvement (P=0.003) and vascular (P=0.002) involvement were more common in men.

CONCLUSION

Our results confirmed the results of previous studies regarding the benign nature of BD in women compared to men.

Behçet's disease

DEFINITION OF THE DISEASE: Behçet disease (BD) is a chronic, relapsing, multisystemic disorder characterized by mucocutaneous, ocular, vascular and central nervous system manifestations.

EPIDEMIOLOGY

BD seems to cluster along the ancient Silk Road, which extends from eastern Asia to the Mediterranean basin. European cases are often described, not exclusively in the migrant population.

CLINICAL DESCRIPTION

The clinical spectrum includes oral and genital ulcerations, uveitis, vascular, neurological, articular, renal and gastrointestinal manifestations.

ETIOLOGY

The etiopathogenesis of the disease remains unknown, although genetic predisposition, environmental factors and immunological abnormalities have been implicated.

DIAGNOSTIC METHODS

Diagnosis is only based on clinical criteria. DIFFERRENTIAL DIAGNOSIS: It depends on the clinical presentation of BD, but sarcoidosis, multiple sclerosis, Crohn's disease, Takayasu's arteritis, polychondritis or antiphospholipid syndrome need to be considered.

MANAGEMENT

Treatment is symptomatic using steroids and immunomodulatory therapy. It is efficient depending on the rapidity of initiation, the compliance, and the duration of therapy.

PROGNOSIS

The prognosis is severe due to the ocular, neurological and arterial involvement.

Clinical and Pathological Manifestations with Differential Diagnosis in Behçet's Disease

Behçet's disease is a multisystemic inflammatory disease of unknown etiology which usually occurs as a trait of symptoms: aphthous stomatitis, genital ulcerations, and ocular disease. At the beginning of the disease the diagnosis is uncertain because of various clinical manifestations and a long period up to the full clinical picture manifestation. Since neither the laboratory data nor the histopathological signs are truly pathognomonic in Behçet's disease, the differential diagnosis depends on a careful evaluation of the medical history and meticulous physical examination to detect concomitant systemic manifestations. Sometimes, some laboratory test may help establish the diagnosis. Subspecialty referral to ophthalmology, rheumatology, neurology, and gastroenterology should be considered when indicated.