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Shah JM, Fong W, De Silva DA. NeuroBehcet's-related intracranial hypertension without cerebral venous thrombosis: case report and review of literature. BMC Neurol 2024; 24:203. [PMID: 38877431 PMCID: PMC11177394 DOI: 10.1186/s12883-024-03708-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024] Open
Abstract
BACKGROUND We present a rare case of NeuroBehcet's-related intracranial hypertension without cerebral venous thrombosis (NBrIHwCVT), occurring as the first presentation of NeuroBehcet's. In addition, we describe the novel use of subcutaneous tocilizumab for this indication. This is followed by a review of the literature on this topic. CASE The patient was a 28-year-old lady of Southern Chinese origin with a known history of Behcet's disease with oral ulcers and ocular findings for which she was on mycophenolate mofetil and adalimumab. She presented with a headache and bilateral disc swelling associated with an intracranial pressure (ICP) of > 40cmH20. There were no structural lesions or cerebral venous thrombosis (CVT) on imaging. Initial lumbar puncture had raised leucocytes and protein. We discuss diagnostic challenges given persistently elevated ICP despite subsequent non-inflammatory cerebrospinal fluid (CSF) profiles and non-response to acetazolamide. She eventually showed a response to immunosuppressant therapy in the form of pulsed methylprednisolone, cyclophosphamide and subsequently subcutaneous tocilizumab, supporting the diagnosis of NBrIHwCVT. Complete normalization of ICP remains challenging. Her disease course was severe, unusual for her ethnicity. LITERATURE REVIEW We identified 34 patients (including ours) from 14 publications. We found that the majority of NBrIHwCVT patients were young (average age of 34 years), with a slight female preponderance. Of the 17 cases in the literature with available data on CSF profile, none had raised leucocytes whilst one patient had elevated protein. Patients were generally treated with steroids and occasionally azathioprine, in line with the suspected autoimmune pathophysiology. Of 22 patients with data on outcome, six (27%) were noted to have recurrence of symptoms generally occurring a few months later. CONCLUSION As demonstrated by this case, NBrIHwCVT can present with BD with raised ICP even if there is no prior history of NB, central Asian ethnicity, cerebral venous thrombosis or features of inflammation on the CSF. We demonstrated how novel use of Tocilizumab may have a role in the management of NBrIHwCVT. Based on our literature review, patients were more likely to be young, female, display a non-inflammatory CSF picture, be treated with steroids and harbour a possibility of recurrence.
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Affiliation(s)
- Jinesh Mukesh Shah
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital Campus, Singapore, Singapore.
| | - Warren Fong
- Department of Rheumatology and Immunology, Singapore General Hospital, Singapore, Singapore
| | - Deidre Anne De Silva
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital Campus, Singapore, Singapore
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2
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Hirahara L, Kirino Y, Soejima Y, Iizuka Y, Yoshimi R, Fujieda Y, Atsumi T, Tono T, Kobayashi D, Meguro A, Takeuchi M, Sakamaki K, Takeno M, Mizuki N, Nakajima H. Association of high disease activity and serum IL-6 levels with the incidence of inflammatory major organ events in Behçet disease: a prospective registry study. Front Immunol 2024; 15:1354969. [PMID: 38686380 PMCID: PMC11057327 DOI: 10.3389/fimmu.2024.1354969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 02/22/2024] [Indexed: 05/02/2024] Open
Abstract
Background Little is known about the relationship between the disease activity of Behçet disease (BD) and the incidence of inflammatory major organ events. Objectives In this prospective registry study, we investigated the association between the Behçet Disease Current Activity Form (BDCAF) and incidence of inflammatory major organ events, defined as the inflammation of the ocular, central nervous, intestinal, and vascular systems in BD. Methods We enrolled participants from Japanese multicenter prospective cohorts. The BDCAF was evaluated annually. BD-related symptoms, including inflammatory major organ events, were monitored. The association between BDCAF and inflammatory major organ events was analyzed by time-to-event analysis. An unsupervised clustering of the participants' BDCAF, therapeutic agents, and multiple serum cytokines was also performed to examine their association with inflammatory major organ events. Results A total of 260 patients were included. The patients had a median BDCAF score of 2 [Interquartile range, 1-3] at the enrolment and remained disease active at 1- and 2-year follow-ups, indicating residual disease activity in BD. Patients with a BDCAF score of 0 had a longer inflammatory major organ event-free survival at 52 weeks than those with a score of 1 or higher (p=2.2 x 10-4). Clustering analysis revealed that patients who did not achieve remission despite treatment with tumor necrosis factor inhibitors had high serum inflammatory cytokine levels and incidences of inflammatory major organ events. Among the elevated cytokines, IL-6 was associated with inflammatory major organ events. Conclusion This study suggests that treatment strategies targeting overall disease activity and monitoring residual serum IL-6 may help prevent inflammatory major organ events in BD.
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Affiliation(s)
- Lisa Hirahara
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yohei Kirino
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yutaro Soejima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuki Iizuka
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Ryusuke Yoshimi
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Yuichiro Fujieda
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Tatsuya Atsumi
- Department of Rheumatology, Endocrinology and Nephrology, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Toshihiro Tono
- Department of General Medicine, Kitasato University School of Medicine, Sagamihara, Japan
| | - Daisuke Kobayashi
- Division of Clinical Nephrology and Rheumatology, Kidney Research Center, Niigata University Graduate School of Medical and Dental Sciences, Niigata, Japan
| | - Akira Meguro
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masaki Takeuchi
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kentaro Sakamaki
- Faculty of Health Data Science, Juntendo University, Urayasu, Japan
| | - Mitsuhiro Takeno
- Department of Allergy and Rheumatology, Nippon Medical School Musashi Kosugi Hospital, Kawasaki, Japan
| | - Nobuhisa Mizuki
- Department of Ophthalmology and Visual Science, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Hideaki Nakajima
- Department of Stem Cell and Immune Regulation, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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3
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Moriano Morales C, Graña Gil J, Brito García N, Martín Varillas JL, Calvo Del Río V, Moya Alvarado P, Narváez García FJ, Espinosa G, Díaz Del Campo Fontecha P, Guerra Rodríguez M, Mateo Arranz J, López Gómez M, Francisco Hernández FM, Trujillo MM, Dos Santos Sobrín R, Martín Sánchez JI, Maese Manzano J, Suárez Cuba J. SER recommendations on treatment of refractory Behçet's syndrome. REUMATOLOGIA CLINICA 2024; 20:204-217. [PMID: 38614885 DOI: 10.1016/j.reumae.2023.12.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Accepted: 12/04/2023] [Indexed: 04/15/2024]
Abstract
OBJECTIVE To develop multidisciplinary recommendations based on available evidence and expert consensus for the therapeutic management of patients with refractory Behçet's syndrome (BS) (difficult to treat, severe resistant, severe relapse) to conventional treatment. METHODS A group of experts identified clinical research questions relevant to the objective of the document. These questions were reformulated in PICO format (patient, intervention, comparison and outcome). Systematic reviews of the evidence were conducted, the quality of the evidence was evaluated following the methodology of the international working group Grading of Recommendations Assessment, Development, and Evaluation (GRADE). After that, the multidisciplinary panel formulated the specific recommendations. RESULTS 4 PICO questions were selected regarding the efficacy and safety of systemic pharmacological treatments in patients with BS with clinical manifestations refractory to conventional therapy related to mucocutaneous and/or articular, vascular, neurological parenchymal and gastrointestinal phenotypes. A total of 7 recommendations were made, structured by question, based on the identified evidence and expert consensus. CONCLUSIONS The treatment of most severe clinical manifestations of BS lacks solid scientific evidence and, besides, there are no specific recommendation documents for patients with refractory disease. With the aim of providing a response to this need, here we present the first official Recommendations of the Spanish Society of Rheumatology for the management of these patients. They are devised as a tool for assistance in clinical decision making, therapeutic homogenisation and to reduce variability in the care of these patients.
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Affiliation(s)
| | - Jenaro Graña Gil
- Servicio de Reumatología, Complejo Hospitalario Universitario de A Coruña (CHUAC), A Coruña, Spain
| | - Noé Brito García
- Unidad de Investigación, Sociedad Española de Reumatología, Madrid, Spain.
| | - José Luis Martín Varillas
- Servicio de Reumatología, Hospital de Laredo, Laredo, Cantabria, Spain; Grupo de Inmunopatología, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Cantabria, Spain
| | - Vanesa Calvo Del Río
- Grupo de Inmunopatología, Servicio de Reumatología, Hospital Universitario Marqués de Valdecilla-IDIVAL, Santander, Cantabria, Spain
| | | | | | - Gerard Espinosa
- Servicio de Enfermedades Autoinmunes, Hospital Clínic, Barcelona, Spain
| | | | | | - José Mateo Arranz
- Unidad de Hemostasia y Trombosis, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - M Mar Trujillo
- Fundación Canaria Instituto de Investigación Sanitaria de Canarias, Santa Cruz de Tenerife, Spain
| | - Raquel Dos Santos Sobrín
- Servicio de Reumatología, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - Juan Ignacio Martín Sánchez
- Instituto Aragonés de Ciencias de la Salud, Centro de Investigación Biomédica de Aragón (CIBA), Zaragoza, Spain
| | | | - Julio Suárez Cuba
- Servicio de Reumatología, Hospital Universitario Príncipe de Asturias, Alcalá de Henares, Madrid, Spain
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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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5
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Khieu C, Chanthan D. Novel approach to Behçet's disease in the era of biologic agents. Curr Opin Ophthalmol 2023; 34:535-542. [PMID: 37610430 DOI: 10.1097/icu.0000000000000992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/24/2023]
Abstract
PURPOSE This review aims to provide better understanding of modern modalities to investigate ocular symptoms of Behçet's disease in order to achieve appropriate management protocols and reduce irreversible visual loss. RELEVANT FINDINGS Current methods of diagnosing intraocular involvement in Behçet's disease gives clue to early diagnosis. In addition to standard ocular examination and fluorescein angiography, new noninvasive methods include ocular coherence tomography (OCT) and OCT angiography provide early detection of macular and retinal involvement that can be treated early to improve the prognosis. SUMMARY Over the last decade, new multimodal imagings are becoming more accessible; therefore, rapid diagnosis can be made. In addition to newer approved biologic agents, ocular Behçet's disease is seen to be in better controlled with fewer complications.
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Affiliation(s)
- Chansathya Khieu
- Department of Ophthalmology, Khmer-Soviet Friendship Hospital, Phnom Penh, Cambodia
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6
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Li B, Li H, Huang Q, Zheng Y. Shaping the Future of Behçet's Uveitis Management: A Comprehensive Review of Efficacy, Challenges, and Prospects of Biologic Therapies. Ophthalmol Ther 2023; 12:2295-2321. [PMID: 37477857 PMCID: PMC10442050 DOI: 10.1007/s40123-023-00767-0] [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: 05/03/2023] [Accepted: 06/29/2023] [Indexed: 07/22/2023] Open
Abstract
Behçet's uveitis (BU), a vision-threatening manifestation of Behçet's disease, poses substantial management challenges due to its chronic, relapsing nature and potential for vision loss. This review explores the role of biologic therapies in the treatment of BU, providing a comprehensive overview of their effectiveness, drawbacks, and future possibilities. Traditionally, management has relied heavily on corticosteroids and conventional immunosuppressants. However, their long-term use is frequently associated with systemic side effects and insufficient control of ocular inflammation. Biologic therapies, particularly TNF-alpha inhibitors like infliximab and adalimumab, have emerged as effective alternatives, offering better disease control and a more favorable safety profile. We critically evaluated these agents, noting their clinical efficacy in reducing inflammatory flares and preserving visual acuity. Despite their benefits, several issues remain. Accessibility, cost, and lack of long-term safety data limit their widespread use. Additionally, individual variability in treatment response necessitates personalized therapeutic strategies. Recent research has shown promise in addressing these challenges, with the emergence of novel biologic agents and personalized medicine approaches. In summary, biologic therapies represent a paradigm shift in BU management, contributing to better patient outcomes. Yet, there are significant challenges to be overcome. As we move forward, continued research, development of novel biologic agents, and a precision medicine approach will shape the future landscape of BU treatment.
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Affiliation(s)
- Biao Li
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Haoran Li
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Qun Huang
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China
| | - Yanlin Zheng
- Department of Ophthalmology, Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, Sichuan Province, China.
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7
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Grebenciucova E, VanHaerents S. Interleukin 6: at the interface of human health and disease. Front Immunol 2023; 14:1255533. [PMID: 37841263 PMCID: PMC10569068 DOI: 10.3389/fimmu.2023.1255533] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 09/11/2023] [Indexed: 10/17/2023] Open
Abstract
Interleukin 6 (IL-6) is a pleiotropic cytokine executing a diverse number of functions, ranging from its effects on acute phase reactant pathways, B and T lymphocytes, blood brain barrier permeability, synovial inflammation, hematopoiesis, and embryonic development. This cytokine empowers the transition between innate and adaptive immune responses and helps recruit macrophages and lymphocytes to the sites of injury or infection. Given that IL-6 is involved both in the immune homeostasis and pathogenesis of several autoimmune diseases, research into therapeutic modulation of IL-6 axis resulted in the approval of a number of effective treatments for several autoimmune disorders like neuromyelitis optica spectrum disorder (NMOSD), rheumatoid arthritis, juvenile idiopathic arthritis, polyarticular juvenile idiopathic arthritis, giant cell arteritis (GCA), and cytokine release syndrome, associated with SARS-CoV2 pneumonia. This review discusses downstream inflammatory pathways of IL-6 expression and therapeutic applications of IL-6 blockade, currently investigated for the treatment of several other autoimmune conditions such as autoimmune encephalitis, autoimmune epilepsy, as well as myelin oligodendrocyte glycoprotein associated demyelination (MOGAD). This review further highlights the need for clinical trials to evaluate IL-6 blockade in disorders such neuropsychiatric lupus erythematosus (SLE), sarcoidosis and Behcet's.
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Affiliation(s)
- Elena Grebenciucova
- Feinberg School of Medicine, Department of Neurology, Northwestern University, Chicago, IL, United States
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8
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He K, Yan X, Wu D. Intestinal Behcet's Disease: A Review of the Immune Mechanism and Present and Potential Biological Agents. Int J Mol Sci 2023; 24:ijms24098176. [PMID: 37175882 PMCID: PMC10179024 DOI: 10.3390/ijms24098176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2023] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/15/2023] Open
Abstract
Behcet's disease (BD) is a chronic and recurrent systemic vasculitis involving almost all organs and tissues. Intestinal BD is defined as BD with predominant gastrointestinal involvement, presenting severe complications such as massive gastrointestinal hemorrhage, perforation, and obstruction in some cases. To some extent, intestinal BD is classified as a member of inflammatory bowel disease (IBD), as it has a lot in common with classical IBD including Crohn's disease (CD) and ulcerative colitis (UC). Certainly, the underlying pathogenesis is not the same and dysregulation of immune function is believed to be one of the main pathogeneses in intestinal BD, although the etiology has not been clear up to now. Biological agents are an emerging category of pharmaceuticals for various diseases, including inflammatory diseases and cancers, in recent decades. Based on the deep understanding of the immune mechanism of intestinal BD, biological agents targeting potential pathogenic cells, cytokines and pathways are optimized options. Recently, the adoption of biological agents such as anti-tumor necrosis factor agents has allowed for the effective treatment of patients with refractory intestinal BD who show poor response to conventional medications and are faced with the risk of surgical treatment. In this review, we have tried to summarize the immune mechanism and present potential biological agents of intestinal BD.
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Affiliation(s)
- Kun He
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xiaxiao Yan
- Eight-year Medical Doctor Program, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Dong Wu
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
- Clinical Epidemiology Unit, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
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9
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Corbitt K, Nowatzky J. Inflammatory eye disease for rheumatologists. Curr Opin Rheumatol 2023; 35:201-212. [PMID: 36943695 PMCID: PMC10461883 DOI: 10.1097/bor.0000000000000933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSE OF REVIEW This review provides a framework for understanding inflammatory eye disease diagnosis, differential diagnosis, and management for rheumatologists. Uveitis, scleritis, episcleritis, peripheral ulcerative keratitis, and orbital inflammation are all discussed. The goal is to facilitate the development of approaches to inflammatory eye diseases that will help rheumatologists co-manage these patients with eye care providers specializing in ocular inflammation. RECENT FINDINGS In recent years, studies have aimed to advance biologic treatments and define standard-of-care therapy. Inflammatory eye diseases are highly heterogeneous and often rare, which poses significant challenges to their research and the interpretation of existing data. To date, glucocorticoids, mycophenolate, methotrexate, and TNF inhibitors remain the mainstay of treatment options for many of these diseases. SUMMARY Patients with inflammatory eye diseases require multidisciplinary care for best outcomes, frequently including rheumatologists. Understanding the differentials, diagnostics, and treatment are essential to preserving vision in these patients. The diverse nature of the disease processes within this field requires focusing on specific disease phenotypes and endotypes in research and clinical practice.
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Affiliation(s)
- Kelly Corbitt
- New York University Grossman School of Medicine, Department of Medicine, Division of Rheumatology
| | - Johannes Nowatzky
- New York University Grossman School of Medicine, Department of Medicine, Division of Rheumatology
- New York University Grossman School of Medicine, Department of Medicine, Division of Rheumatology, NYU Langone Behçet’s Disease Program, NYU Ocular Rheumatology Program
- New York University Grossman School of Medicine, Department of Pathology
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10
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Giani T, Luppino AF, Ferrara G. Treatment Options in Pediatric Behçet's Disease. Paediatr Drugs 2023; 25:165-191. [PMID: 36626047 PMCID: PMC9838500 DOI: 10.1007/s40272-022-00548-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2022] [Indexed: 01/11/2023]
Abstract
Behçet's disease is a rare and poorly understood vasculitis affecting blood vessels of all types and sizes. Uveitis and oral and genital ulcers represent the typical clinical triad. Populations along the ancient trading route connecting the Mediterranean basin with the Middle and Far East are most affected. Up to a quarter of the cases has a pediatric onset, typically around puberty. The aim of the treatment is early intervention to control inflammation, with symptom relief and prevention of relapses, damage, and complications. The heterogeneous clinical presentation often requires a multidisciplinary and tailored approach. Ocular, neurological, gastrointestinal, and vascular involvement is associated with a worse prognosis and needs more aggressive treatments. In young patients with expected prolonged disease, treatment should also focus on preventive measures and lifestyle advice. In recent years, the pharmacological armamentarium has grown progressively, although only a limited number of drugs are currently authorized for pediatric use. Most evidence for these drugs still derives from adult studies and experience; these are prescribed as off-label medications and are only available as adult formulations. Corticosteroids frequently represent the mainstay for the management of the initial acute phases, but their potential serious adverse effects limit their use to short periods. Different conventional disease-modifying anti-rheumatic drugs have long been used. Many other biologic drugs targeting different cytokines such as interleukin-1, interleukin-6, and interleukin-17 and treatments with small molecules including the phosphodiesterase 4 and Janus kinase inhibitors are emerging as novel promising therapeutic agents. In recent years, a growing interest has developed around anti-tumor necrosis factor agents that have often proven to be effective in severe cases, especially in those with a gastrointestinal and ocular involvement.
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11
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Tugal-Tutkun I. Uveitis in Behçet disease - an update. Curr Opin Rheumatol 2023; 35:17-24. [PMID: 36255985 DOI: 10.1097/bor.0000000000000911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Uveitis is a major manifestation of Behçet disease (BD) and potentially has a high morbidity. This article reviews recently published data on BD uveitis. RECENT FINDINGS A set of classification criteria and a diagnostic algorithm have been developed for BD uveitis. Recent reports have confirmed male predominance and posterior segment inflammation in the majority of BD uveitis patients. A high uveitis attack severity score, fluorescein angiographic leakage at the posterior pole, and disruption of outer retinal layers on optical coherence tomography (OCT) predict poor visual outcome. OCT-angiography studies have suggested subclinical changes of retinal capillaries in patients with or without ocular involvement. In a randomized controlled trial, interferon-α was superior to cyclosporine. Favorable outcomes were reported with earlier initiation, optimization, and withdrawal of infliximab after remission. Adalimumab as first-line was superior to conventional therapy. SUMMARY Classification criteria will be used to select a homogeneous group of patients for research and the diagnostic algorithm may help ophthalmologists predict the probability of BD uveitis based on ocular findings. Fluorescein angiography and OCT are the routine imaging modalities. Clinical relevance of OCT-angiography is unclear. Interferon-α, infliximab, and adalimumab have proven superior efficacy compared to conventional therapy.
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Affiliation(s)
- Ilknur Tugal-Tutkun
- Department of Ophthalmology, Istanbul Faculty of Medicine, Istanbul University
- Bayrampasa Eye Hospital, Eye Protection Foundation, Istanbul, Turkey
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12
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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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13
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Efthimiou P, Petryna O, Nakasato P, Kontzias A. New insights on multigenic autoinflammatory diseases. Ther Adv Musculoskelet Dis 2022; 14:1759720X221117880. [PMID: 36081748 PMCID: PMC9445512 DOI: 10.1177/1759720x221117880] [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: 12/22/2021] [Accepted: 07/14/2022] [Indexed: 11/16/2022] Open
Abstract
Autoinflammatory diseases are disorders of the innate immune system, which can be either monogenic due to a specific genetic mutation or complex multigenic due to the involvement of multiple genes. The aim of this review is to explore and summarize the recent advances in pathogenesis, diagnosis, and management of genetically complex autoinflammatory diseases, such as Schnitzler's syndrome; adult-onset Still's disease; synovitis, acne, pustulosis, hyperostosis, osteitis syndrome/chronic recurrent multifocal osteomyelitis/chronic non-bacterial osteomyelitis; Adamantiades-Behçet's disease; Yao syndrome; and periodic fever with aphthous stomatitis, pharyngitis, and adenitis syndrome. The PubMed database was screened for relevant articles using free text words and specific search strings. The search was limited to English-language articles, reporting the results of studies in humans, published through March 2021. Evidence from literature suggest that these rare multigenic autoinflammatory diseases can present with different clinical features and the diagnosis of these diseases can be challenging due to a combination of nonspecific manifestations that can be seen in a variety of other conditions. Diagnostic delays and disease complications may occur due to low disease awareness and the lack of pathognomonic markers. The pathogeneses of these diseases are complex and in some cases precise pathogenesis is not clearly understood. Conventional treatments are commonly used for the management of these conditions, but biologics have shown promising results. Biologics targeting proinflammatory cytokines including IL-1, IL-6, TNF-α, IL-17A and IL-18 have been shown to ameliorate signs and symptoms of different multigenic autoinflammatory diseases.
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Affiliation(s)
- Petros Efthimiou
- New York Rheumatology Care, Ross University School of Medicine, New York, USA
| | - Olga Petryna
- NYU Grossman School of Medicine, New York, NY, USA
| | | | - Apostolos Kontzias
- Department of Rheumatology, Stony Brook University School of Medicine, Stony Brook, NY, USA
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14
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Cui B, Jia HZ, Gao LX, Dong XF. Risk of anxiety and depression in patients with uveitis: a Meta-analysis. Int J Ophthalmol 2022; 15:1381-1390. [PMID: 36017044 DOI: 10.18240/ijo.2022.08.23] [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: 05/21/2021] [Accepted: 10/11/2021] [Indexed: 11/23/2022] Open
Abstract
AIM To quantitatively evaluate the risk of anxiety and depression in patients with uveitis via performing a Meta-analysis. METHODS Three electronic database (PubMed, Embase, and Cochrane Library databases) were searched for studies recording data about uveitis and anxiety as well as depression simultaneously up to January 2021. The incidence rate and standard mean difference (SMD) with a 95% confidence interval (95%CI) were calculated to analyse the association using random-effects models based on heterogeneity tests. RESULTS In total, 12 observational studies containing 874 patients with uveitis were included. The results showed that there was a significant association between uveitis and anxiety (SMD=0.97, 95%CI: 0.39 to 1.54, P=0.0009) and depression (SMD=0.79, 95%CI: 0.51 to 1.07, P<0.00001). The overall morbidities of anxiety and depression in patients with uveitis were 39% and 17%, respectively. With subgroup analysis, the heterogeneity actually came from different kinds of uveitis. Specifically, the incidence rates of both anxiety and depression were relatively low in patients with anterior uveitis (33% and 15%), moderate in patients with infectious uveitis (46% and 22%), and high in patients with unspecified uveitis (59% and 35%). CONCLUSION It is preliminarily indicated that patients with uveitis may have a high risk of anxiety and depression. Ophthalmologists and psychologists should pay more attention to the psychological state when dealing with patients with uveitis. Further high-quality studies with detailed direct data are needed to draw more precise conclusions.
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Affiliation(s)
- Bei Cui
- Senior Department of Ophthalmology, the Third Medical Centre of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Hong-Zhen Jia
- Senior Department of Ophthalmology, the Third Medical Centre of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Li-Xiong Gao
- Senior Department of Ophthalmology, the Third Medical Centre of Chinese People's Liberation Army General Hospital, Beijing 100039, China
| | - Xiao-Fei Dong
- Department of Ophthalmology, No.967 Hospital of the Joint Logistics Support Force of the Chinese PLA, Dalian 116000, Liaoning Province, China
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15
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Narazaki M, Kishimoto T. Current status and prospects of IL-6–targeting therapy. Expert Rev Clin Pharmacol 2022; 15:575-592. [DOI: 10.1080/17512433.2022.2097905] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Affiliation(s)
- Masashi Narazaki
- Department of Advanced Clinical and Translational Immunology, Osaka University Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Respiratory Medicine, Clinical Immunology, Osaka University Graduate School of Medicine, Osaka University, Osaka, Japan
- Department of Immunopathology, World Premier International Immunology Frontier Research Center, Osaka University, Osaka, Japan
| | - Tadamitsu Kishimoto
- Laboratory of Immune Regulation, World Premier International Immunology Frontier Research Center, Osaka University, Osaka, Japan
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16
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Higashida-Konishi M, Akiyama M, Shimada T, Hama S, Takei H, Izumi K, Oshima H, Okano Y. Acute encephalitis in primary Sjögren's syndrome: A case report and literature review. Mod Rheumatol Case Rep 2022; 6:209-216. [PMID: 34850084 DOI: 10.1093/mrcr/rxab042] [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: 08/10/2021] [Revised: 09/01/2021] [Accepted: 10/11/2021] [Indexed: 06/13/2023]
Abstract
Acute encephalitis is an extremely rare condition in primary Sjogren's syndrome (pSS), and its characteristics and prognosis remain unclear. Here, we report the case of pSS presented with acute encephalitis. She was admitted to our hospital for acute disturbance of consciousness. Acute encephalitis was diagnosed based on the results of the cerebrospinal fluid test (the increase of leucocyte counts, proteins, and interleukin-6 levels), magnetic resonance imaging, and single-photon emission computed tomography with 99mTc. The infectious aetiologies and underlying malignancies were excluded. Serum anti-Sjogren's syndrome-related antigen A autoantibody was positive with extremely high titre. The biopsy specimen of her labial salivary gland revealed a focal lymphocytic sialadenitis with a score of grade 4 in the Greenspan grade. She also developed diffuse alveolar haemorrhage during the clinical course. She was diagnosed with pSS complicated with acute encephalitis followed by diffuse alveolar haemorrhage and successfully treated with pulse steroids, high dose of prednisolone and intravenous cyclophosphamide. Our present case and literature review suggest that acute encephalitis associated with pSS can be treatable with the immunosuppressive therapy, and thus early recognition and treatment initiation are important for this life-threatening condition. Thus, pSS should be included in the differential diagnosis of unexplained encephalitis. Notably, our case characteristically showed diffuse alveolar haemorrhage, adding new insights into the pathogenesis of acute encephalitis associated with pSS that capillaritis might be the underlying cause of this condition.
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Affiliation(s)
- Misako Higashida-Konishi
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Mitsuhiro Akiyama
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Tatsuya Shimada
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Satoshi Hama
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Hiroshi Takei
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Keisuke Izumi
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
- Division of Rheumatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hisaji Oshima
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
| | - Yutaka Okano
- Department of Connective Tissue Diseases, National Hospital Organization Tokyo Medical Center, Tokyo, Japan
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17
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Herrero-Morant A, Martín-Varillas JL, Castañeda S, Maíz O, Sánchez J, Ortego N, Raya E, Prior-Español Á, Moriano C, Melero-González RB, Graña-Gil G, Urruticoechea-Arana A, Ramos-Calvo Á, Loredo-Martínez M, Salgado-Pérez E, Sivera F, Torre I, Narváez J, Andreu JL, Martínez-González O, Gómez-de la Torre R, Fernández-Aguado S, Romero-Yuste S, González-Mazón Í, Álvarez-Reguera C, Hernández JL, González-Gay MÁ, Blanco R. Biologic therapy in refractory Neurobehçet's disease: a multicenter study of 41 patients and literature review. Rheumatology (Oxford) 2022; 61:4427-4436. [PMID: 35166821 DOI: 10.1093/rheumatology/keac097] [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: 11/22/2021] [Revised: 01/17/2022] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES To assess efficacy and safety of biologic therapy (BT) in Neurobehçet's disease (NBD) refractory to glucocorticoids and at least one conventional immunosuppressive drug. METHODS Open-label, national, multicenter study. NBD diagnosis was based on the International Consensus Recommendation criteria. Outcome variables were efficacy and safety. Main efficacy outcome was clinical remission. Other outcome variables analyzed were glucocorticoid-sparing effect and improvement in laboratory parameters. RESULTS We studied 41 patients (21 women; age 40.6±10.8 years). Neurological damage was parenchymal (n = 33, 80.5%) and non-parenchymal (n = 17, 41.5%). First BTs used were infliximab (n = 19), adalimumab (n = 14), golimumab (n = 3), tocilizumab (n = 3) and etanercept (n = 2). After 6 months of BT, neurological remission was complete (n = 23, 56.1%), partial (n = 15, 37.6%), no response (n = 3, 7.3%). In addition, mean dose of oral prednisone decreased from 60 [30-60] mg/day at the initial visit to 5 [3.8-10] mg/day after 6 months, p < 0.001). It was also the case for mean erythrocyte sedimentation rate (31.5±25.6 to 15.3±11.9 mm/1st hour, p = 0.005) and median [IQR] C-reactive protein (1.4 [0.2-12.8] to 0.3 [0.1-3] mg/dL, p = 0.002). After a mean follow-up of 57.5 months, partial or complete neurological remission persisted in 37 patients (90.2%). BT was switched in 22 cases (53.6%) due to inefficacy (n = 16) or adverse events (AEs) (n = 6) and discontinued due to complete prolonged remission (n = 3) or severe AE (n = 1). Serious AEs were observed in 2 patients under infliximab treatment. CONCLUSIONS BT appears to be effective and relatively safe in refractory NBD.
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Affiliation(s)
- Alba Herrero-Morant
- Rheumatology, Hospital Universitario Marqués de Valdecilla,IDIVAL,University of Cantabria, Santander, Spain
| | | | - Santos Castañeda
- Rheumatology, Hospital Universitario La Princesa, IIS-Princesa, Madrid, Spain
| | - Olga Maíz
- Rheumatology and Ophthalmology, Hospital Universitario de Donostia, San Sebastián, Spain
| | | | - Norberto Ortego
- Rheumatology and Internal Medicine, Hospital San Cecilio, Granada, Spain
| | - Enrique Raya
- Rheumatology and Internal Medicine, Hospital San Cecilio, Granada, Spain
| | | | | | | | - Genaro Graña-Gil
- Rheumatology, Hospital Universitario de A Coruña, A Coruña, Spain
| | | | | | | | - Eva Salgado-Pérez
- Rheumatology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - Francisca Sivera
- Rheumatology, Hospital General Universitario de Elda, Elda, Spain
| | | | | | - José Luis Andreu
- Rheumatology, Hospital Universitario Puerta de Hierro-Majadahonda, Madrid, Spain
| | | | | | | | - Susana Romero-Yuste
- Rheumatology, Complejo Hospitalario Universitario de Pontevedra, Pontevedra, Spain
| | - Íñigo González-Mazón
- Rheumatology, Hospital Universitario Marqués de Valdecilla,IDIVAL,University of Cantabria, Santander, Spain
| | - Carmen Álvarez-Reguera
- Rheumatology, Hospital Universitario Marqués de Valdecilla,IDIVAL,University of Cantabria, Santander, Spain
| | - José Luis Hernández
- Internal Medicine, Hospital Universitario Marqués de Valdecilla,IDIVAL, Santander, Spain
| | - Miguel Ángel González-Gay
- Rheumatology, Hospital Universitario Marqués de Valdecilla,IDIVAL,University of Cantabria, Santander, Spain
| | - Ricardo Blanco
- Rheumatology, Hospital Universitario Marqués de Valdecilla,IDIVAL,University of Cantabria, Santander, Spain
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18
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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: 21] [Impact Index Per Article: 10.5] [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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19
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Zhong H, Liu T, Liu Y, Zhang X, Zhou Y, Su Y. Efficacy and safety of tocilizumab in Behçet's syndrome with refractory arterial lesions: A single-centre observational cohort study in China. Rheumatology (Oxford) 2021; 61:2923-2930. [PMID: 34791076 PMCID: PMC9258597 DOI: 10.1093/rheumatology/keab840] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/02/2021] [Indexed: 11/16/2022] Open
Abstract
Objective The aim of this observational cohort study was to assess the effectiveness and safety of the IL-6-receptor inhibitor tocilizumab (TCZ) in Behçet’s syndrome (BS) with refractory arterial involvement. Methods Ten patients admitted to the Rheumatology and Immunology Department of Peking University People’s Hospital between January 2014 and December 2019 were enrolled. The enrolled patients met the BS international criteria and exhibited severe arterial impairments. Refractory arterio-BS was diagnosed based on objective vascular symptoms unexplainable by other known illnesses, and resistance to traditional immunosuppressants and glucocorticoids after 12 weeks. Patients received 8 mg/kg TCZ infusions every 4 weeks for ≥24 weeks, with simultaneous continuation of immunosuppressants and glucocorticoids. Clinical and imaging data were assessed before and after TCZ treatment. Results The enrolled patients were men aged 44.3 (10.5) years; the median disease duration was 186.5 (45.7) months, and the average age of arterial impairment onset was 38.7 (12.9) years. The following trends were observed: improvement and maintenance of symptoms after the 26.8 (7.2)-month follow-up, n = 9; complete remission, n = 6; partial response, n = 3; immunosuppressant dose reduction, n = 4; radiologic improvement of arterial lesions, n = 4; and TCZ discontinuation owing to enlarged abdominal aortic aneurysm relapse, n = 1. The average daily glucocorticoid dose reduced from 54.5 (20.6) to 8.3 (3.6) mg/d (P < 0.001), while the median ESR and CRP values reduced from 50 (2–82) mm/h and 32.9 (2.1–62.3) mg/dl to 4 (1–10) mm/h and 2.9 (0.2–12.1) mg/dl, respectively (P < 0.001). No TCZ-associated side effects were noted. Conclusion TCZ proved to be safe and effective for refractory arterial lesions in BS, with a steroid- and immunosuppressant-sparing benefit.
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Affiliation(s)
- Hua Zhong
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing, China
| | - Tian Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing, China
| | - Yanying Liu
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing, China
| | - Xiaoying Zhang
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing, China
| | - Yunshan Zhou
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing, China
| | - Yin Su
- Department of Rheumatology and Immunology, Peking University People's Hospital, Beijing, China.,Beijing Key Laboratory for Rheumatism Mechanism and Immune Diagnosis, Beijing, China
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20
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Arbrile M, Radin M, Rossi D, Menegatti E, Baldovino S, Sciascia S, Roccatello D. Vedolizumab for the Management of Refractory Behçet's Disease: From a Case Report to New Pieces of Mosaic in a Complex Disease. Front Immunol 2021; 12:769785. [PMID: 34759935 PMCID: PMC8573273 DOI: 10.3389/fimmu.2021.769785] [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] [Received: 09/02/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Objectives When treating Behçet’s disease (BD), anti-tumor necrosis factor (TNF)-α agents have become a second-line therapy when conventional immunosuppressive drugs have failed. However, in the case of failure of treatment with anti-TNFα drugs, further options are limited. Based on previous reports of the efficacy of vedolizumab (VDZ) in inflammatory bowel diseases, we decided to administer VDZ to treat a patient with intestinal BD. Methods We present the case of a 49-year-old female patient with BD. Her clinical manifestations included erythema nodosum, oro-genital ulcers, positive Pathergy test, positive HLA-B51, and biopsy-proven intestinal BD. The patient was unsuccessfully treated with conventional immunosuppressive and several biological agents. Results Treatment with VDZ was started intravenously at a dose of 300 mg at 0, 2, and 6 weeks and then every 4 weeks. After the second dose of VDZ, the patient reported a marked improvement of intestinal BD and a concomitant amelioration of arthralgia, erythema nodosum lesions and aphthosis. Clinical remission was achieved at 6 months after starting VDZ. Conclusion VDZ might represent a valid option to treat patients with BD who are non-responsive to standard treatments or anti-TNFα agents, particularly, those cases with intestinal involvement.
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Affiliation(s)
- Marta Arbrile
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, Complex Structure with University Management (SCDU) Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Massimo Radin
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, Complex Structure with University Management (SCDU) Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Daniela Rossi
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, Complex Structure with University Management (SCDU) Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Elisa Menegatti
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, Complex Structure with University Management (SCDU) Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Simone Baldovino
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, Complex Structure with University Management (SCDU) Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Savino Sciascia
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, Complex Structure with University Management (SCDU) Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
| | - Dario Roccatello
- Center of Research of Immunopathology and Rare Diseases-Coordinating Center of Piemonte and Valle d'Aosta Network for Rare Diseases, Department of Clinical and Biological Sciences, Complex Structure with University Management (SCDU) Nephrology and Dialysis, S. Giovanni Bosco Hospital and University of Turin, Turin, Italy
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21
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Han MM, Yuan XR, Shi X, Zhu XY, Su Y, Xiong DK, Zhang XM, Zhou H, Wang JN. The Pathological Mechanism and Potential Application of IL-38 in Autoimmune Diseases. Front Pharmacol 2021; 12:732790. [PMID: 34539413 PMCID: PMC8443783 DOI: 10.3389/fphar.2021.732790] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 08/17/2021] [Indexed: 12/19/2022] Open
Abstract
Interleukin-38 (IL-38), a new cytokine of interleukin-1 family (IL-1F), is expressed in the human heart, kidney, skin, etc. Recently, new evidence indicated that IL-38 is involved in the process of different autoimmune diseases. Autoimmune diseases are a cluster of diseases accompanied with tissue damage caused by autoimmune reactions, including rheumatoid arthritis (RA), psoriasis, etc. This review summarized the links between IL-38 and autoimmune diseases, as well as the latest knowledge about the function and regulatory mechanism of IL-38 in autoimmune diseases. Especially, this review focused on the differentiation of immune cells and explore future prospects, such as the application of IL-38 in new technologies. Understanding the function of IL-38 is helpful to shed light on the progress of autoimmune diseases.
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Affiliation(s)
- Miao-Miao Han
- School of Health Management, Anhui Medical University, Hefei, China
| | - Xin-Rong Yuan
- Department of Neurology, Xiangya Hospital, Central South University, Changsha, China
| | - Xiang Shi
- School of Health Management, Anhui Medical University, Hefei, China
| | - Xing-Yu Zhu
- School of Pharmacy, Bengbu Medical College, Bengbu, China.,National Drug Clinical Trial Institution, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Yue Su
- National Drug Clinical Trial Institution, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China.,Public Basic College, Bengbu Medical College, Bengbu, China
| | - De-Kai Xiong
- School of Health Management, Anhui Medical University, Hefei, China
| | - Xing-Min Zhang
- School of Health Management, Anhui Medical University, Hefei, China
| | - Huan Zhou
- School of Pharmacy, Bengbu Medical College, Bengbu, China.,National Drug Clinical Trial Institution, The First Affiliated Hospital of Bengbu Medical College, Bengbu, China
| | - Ji-Nian Wang
- Department of Education, The First Affiliated Hospital of Anhui Medical University, Hefei, China.,Department of Epidemiology and Biostatistics, School of Public Health, Anhui Medical University, Hefei, China
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22
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An update on the pathogenic role of IL-6 in rheumatic diseases. Cytokine 2021; 146:155645. [PMID: 34303949 DOI: 10.1016/j.cyto.2021.155645] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Revised: 07/01/2021] [Accepted: 07/06/2021] [Indexed: 12/17/2022]
Abstract
Interleukin (IL)-6 is a pleiotropic cytokine that is involved in the pathogenesis of various rheumatic diseases. Direct inhibition of the IL-6 pathway by an anti-IL-6 receptor or inhibiting the ligand itself has proved to be efficacious in the treatment of these diseases. Juvenile idiopathic arthritis, adult-onset Still's disease, large vessel vasculitis including giant cell arteritis and Takayasu disease, systemic sclerosis, and polymyalgia rheumatica respond well to IL-6 inhibition as expected. However, no clinically meaningful effect has been observed with regard to IL-6 blockade in ankylosing spondylitis, psoriatic arthritis, and systemic lupus erythematosus. This review discusses the current state of IL-6 targeting approaches in various rheumatic diseases other than rheumatoid arthritis.
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23
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Ozguler Y, Ozdede A, Hatemi G. Recent Insights into the Management of Behçet Syndrome. J Inflamm Res 2021; 14:3429-3441. [PMID: 34321904 PMCID: PMC8313432 DOI: 10.2147/jir.s285400] [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] [Received: 04/16/2021] [Accepted: 06/12/2021] [Indexed: 01/01/2023] Open
Abstract
Behçet syndrome (BS) is a multisystem vasculitis with variable vessel involvement that shows significant heterogeneity among patients in terms of clinical manifestations and disease course. Treatment choice and response are both influenced by this heterogeneity. BS treatments’ main goals are to quickly suppress inflammatory exacerbations and prevent relapses in order to protect organ functions and provide good quality of life. Besides the long-term experience with steroids and traditional immunosuppressives, biologic drugs, especially TNF inhibitors, have gained increasing importance in the treatment of BS over the years. In this review, we aimed to give an overview of the studies with conventional and biological drugs with proven efficacy in the treatment of BS, as well as promising drugs and current management strategies according to clinical phenotypes.
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Affiliation(s)
- Yesim Ozguler
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Internal Medicine, Division of Rheumatology and Behçet Disease Research Center, Istanbul, Turkey
| | - Ayse Ozdede
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Internal Medicine, Division of Rheumatology and Behçet Disease Research Center, Istanbul, Turkey
| | - Gulen Hatemi
- Istanbul University-Cerrahpasa, Cerrahpasa Medical Faculty, Department of Internal Medicine, Division of Rheumatology and Behçet Disease Research Center, Istanbul, Turkey
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24
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Gueudry J, Leclercq M, Saadoun D, Bodaghi B. Old and New Challenges in Uveitis Associated with Behçet's Disease. J Clin Med 2021; 10:jcm10112318. [PMID: 34073249 PMCID: PMC8198480 DOI: 10.3390/jcm10112318] [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] [Received: 04/13/2021] [Revised: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 12/13/2022] Open
Abstract
Behçet’s disease (BD) is a systemic vasculitis disease of unknown origin occurring in young people, which can be venous, arterial or both, classically occlusive. Ocular involvement is particularly frequent and severe; vascular occlusion secondary to retinal vasculitis may lead to rapid and severe loss of vision. Biologics have transformed the management of intraocular inflammation. However, the diagnosis of BD is still a major challenge. In the absence of a reliable biological marker, diagnosis is based on clinical diagnostic criteria and may be delayed after the appearance of the onset sign. However, therapeutic management of BD needs to be introduced early in order to control inflammation, to preserve visual function and to limit irreversible structural damage. The aim of this review is to provide current data on how innovations in clinical evaluation, investigations and treatments were able to improve the prognosis of uveitis associated with BD.
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Affiliation(s)
- Julie Gueudry
- Department of Ophthalmology, Hôpital Charles Nicolle, F-76000 Rouen, France
- Correspondence: ; Tel.: +33-2-32-88-80-57
| | - Mathilde Leclercq
- Department of Internal Medicine, Hôpital Charles Nicolle, F-76000 Rouen, France;
| | - David Saadoun
- Department of Internal Medicine and Clinical Immunology, AP-HP, Centre National de Références Maladies Autoimmunes et Systémiques Rares et Maladies Autoinflammatoires Rares, Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France;
- Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR S 959, Immunology-Immunopathology-Immunotherapy (I3), F-75005 Paris, France
- Biotherapy (CIC-BTi), Hôpital Pitié-Salpêtrière, AP-HP, F-75651 Paris, France
| | - Bahram Bodaghi
- Department of Ophthalmology, IHU FOReSIGHT, Sorbonne-AP-HP, Groupe Hospitalier Pitié-Salpêtrière, F-75013 Paris, France;
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25
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Choong DJ, Tan E. Does tocilizumab have a role in dermatology? A review of clinical applications, its adverse side effects and practical considerations. Dermatol Ther 2021; 34:e14990. [PMID: 34004074 DOI: 10.1111/dth.14990] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/15/2021] [Accepted: 05/12/2021] [Indexed: 12/29/2022]
Abstract
Tocilizumab is a humanized monoclonal antibody to the interleukin-6 (IL-6) receptor which was first approved for use in refractory rheumatoid arthritis almost a decade ago. Since then, its use has expanded to a number of rheumatological and inflammatory conditions. In dermatology, off-label use of tocilizumab has been reported to be efficacious in morphoea, systemic sclerosis, psoriasis, atopic dermatitis, vitiligo, graft-versus-host disease, pyoderma gangrenosum, Behcet's disease, Schnitzler's syndrome, sarcoidosis, and cutaneous adverse reactions. That being said, the evidence demonstrating tocilizumab's efficacy in dermatology is predominantly low-level case-based evidence, and one must consider the potential for publication bias. In this review we will discuss the reported clinical applications of tocilizumab in dermatology, mechanisms of action, and the range of associated adverse effects (both cutaneous and non-cutaneous) that can occur. Additionally, we will discuss the role of tocilizumab in the management of COVID-19.
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Affiliation(s)
- Dean Jeremy Choong
- Dermatology Department, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Ernest Tan
- Dermatology Department, Nedlands, Sir Charles Gairdner Hospital, Western Australia, Australia
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Abstract
Purpose of Review To assess current management of Behcet’s disease (BD). Controversies on therapeutic approaches to different manifestations, whether conventional immunosuppressives (IS) or biologic agents, should be chosen, and options for refractory disease are discussed. Recent Findings Glucocorticoids are still the main agents for remission-induction and azathioprine the first-line conventional IS in maintenance phase to prevent relapses of major organ involvement. Apremilast is shown to be a safe and effective option approved by the FDA for oral ulcers. Large case series confirmed the efficacy and safety of TNFα inhibitors and Interferon-α. Promising results are observed with IL-1 inhibitors, ustekinumab, secukinumab, and tocilizumab for refractory BD. Summary Although both conventional IS and biologic agents are effectively used to suppress inflammation in BD, there is still an unmet need for clear therapeutic strategies in the management for different manifestations. Further controlled studies with new biologic agents, anticoagulants and the benefit of concomitant IS usage with biologics are needed to optimize the management of BD.
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Eroglu DS, Colaklar A, Ceran A, Sezer S, Torgutalp M, Kinikli G. Behçet’s Syndrome Complicated with Pulmonary Artery Thrombosis: Response to Tocilizumab Treatment. AKTUEL RHEUMATOL 2021. [DOI: 10.1055/a-1400-2586] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/30/2022]
Abstract
ZusammenfassungDie Beteiligung der Lungenarterie ist eine seltene, aber tödliche Komplikation des Morbus Behçets (MB). Hier berichten wir über einen männlichen MB-Patienten mit zwei vaskulären Komplikationen, nämlich dem Budd-Chiari-Syndrom und der Pulmonalarterienthrombose. Der Patient litt unter einer rezidivierenden Lungenarterienthrombose, die gegen mehrere immunsuppressive Medikamente, einschließlich hochdosierter Glukokortikoide und dem Anti-TNF-Mittel Infliximab, refraktär war. Infolge mehrerer Rezidive wurde er effektiv mit Tocilizumab behandelt, wodurch auch eine vollständige Rekanalisation der thrombosierten Arterien erreicht wurde.
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Affiliation(s)
- Didem Sahin Eroglu
- Department of Internal Medicine, Division of Rheumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Anil Colaklar
- Department of Radiology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Alparslan Ceran
- Department of Internal Medicine, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Serdar Sezer
- Department of Internal Medicine, Division of Rheumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Murat Torgutalp
- Department of Internal Medicine, Division of Rheumatology, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gulay Kinikli
- Department of Internal Medicine, Division of Rheumatology, Ankara University Faculty of Medicine, Ankara, Turkey
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Uygunoglu U, Siva A. An uncommon disease included commonly in the differential diagnosis of neurological diseases: Neuro-Behçet's syndrome. J Neurol Sci 2021; 426:117436. [PMID: 33984547 DOI: 10.1016/j.jns.2021.117436] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Accepted: 04/06/2021] [Indexed: 10/21/2022]
Abstract
Behçet's Syndrome (BS) may present with different neurological problems, related either directly (primary) or indirectly (secondary) to BS. Primary neurological involvement is named as neuro-Behcet's syndrome (NBS), and its two major subtypes that are classified mainly on the clinical and MRI findings are (1) Parenchymal-NBS (p-NBS) and (2) Extra parenchymal neuro-vascular involvement mostly seen as cerebral dural venous sinus thrombosis (CVST). The less commonly seen forms of NBS are cognitive and behavioral syndromes and peripheral nervous system involvement. Parenchymal-NBS is the most common clinical neurological presentation of BS. It is a rare disease with distinct MRI features and is often included in the differential diagnosis of neuro-vascular and neuro-inflammatory disorders. The most commonly affected neuro-anatomical site in p-NBS is the meso-diencephalic junction (MDJ), followed by the ponto-bulbar and thalamic regions, the basal ganglia, and the spinal cord. These varied locations may explain to a certain extent why BS is considered in the differential of so many neurological disorders. The other relatively common form of NBS that results in CVST may also be confused with other conditions resulting in CVST, especially when the systemic clinical features suggestive of BS are missed.
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Affiliation(s)
- Ugur Uygunoglu
- Istanbul University Cerrahpaşa School of Medicine, Department of Neurology, Istanbul, Turkey
| | - Aksel Siva
- Istanbul University Cerrahpaşa School of Medicine, Department of Neurology, Istanbul, Turkey.
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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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Tocilizumab for the treatment of TAFRO syndrome: a systematic literature review. Ann Hematol 2020; 99:2463-2475. [DOI: 10.1007/s00277-020-04275-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 09/17/2020] [Indexed: 02/07/2023]
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31
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Akiyama M, Kaneko Y, Takeuchi T. Tocilizumab for the treatment of polyarteritis nodosa: a systematic literature review. Ann Rheum Dis 2020; 81:e204. [PMID: 32907804 DOI: 10.1136/annrheumdis-2020-218710] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 08/02/2020] [Indexed: 01/07/2023]
Affiliation(s)
- Mitsuhiro Akiyama
- Division of Rheumatology, Department of Internal Medicine, Keio University - Shinanomachi Campus, Shinjuku-ku, Tokyo, Japan
| | - Yuko Kaneko
- Division of Rheumatology, Department of Internal Medicine, Keio University - Shinanomachi Campus, Shinjuku-ku, Tokyo, Japan
| | - Tsutomu Takeuchi
- Division of Rheumatology, Department of Internal Medicine, Keio University - Shinanomachi Campus, Shinjuku-ku, Tokyo, Japan
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