Behçet's disease and complex aphthosis

Case Report: Intravascular Ultrasound-guided Intervention for Anastomosis Stenosis of the Left Main Coronary Artery Post-Cabrol Technique

Introduction

Some cases of percutaneous coronary intervention (PCI) for the anastomotic site between the Cabrol-type conduit and the left main coronary artery (LMCA) have been reported. Nevertheless, the combination of PCI with a detailed description of lesion appearance using virtual histology-intravascular ultrasound (VH-IVUS) has never been reported. In this study, we present a case of acute myocardial infarction that was successfully treated with intravascular ultrasound (IVUS)-guided PCI for focal stenosis at the anastomotic site, and the plaque composition was studied in detail.

Case Presentation

A 35-year-old Korean male with Behçet's disease was diagnosed with acute myocardial infarction. He had previously undergone three cardiothoracic surgeries including two aortic replacements, followed by modified Bentall operation with a Cabrol-type aortocoronary anastomosis. Coronary angiogram (CAG) showed focal critical stenosis at the anastomosis site between the conduit and the LMCA, and VH-IVUS showed fibrotic plaque with mainly fibrous tissue but without a confluent necrotic core. PCI was performed using a drug-eluting stent (4.5 × 12 mm, Synergy^TM, Boston Scientific, Marlborough, MA, USA). Since a repeat CAG and IVUS post-surgery showed an under-expanded stent strut, post-dilation ballooning was additionally performed. Subsequently, the repeat IVUS revealed wellapposed and optimized deployment of the drug-eluting stent with full lesion coverage. Final CAG showed optimal angiographic results. After successful PCI, the patient's anginal symptoms improved dramatically, and he was successfully discharged from our hospital.

Conclusion

This study presents an IVUS-guided PCI case for an anastomotic site between the conduit and the LMCA. It is the first to investigate the characteristics of this lesion through VH-IVUS, which demonstrated the presence of fibrous plaques at the anastomotic site. IVUS radiofrequency data allow for a detailed assessment of plaque composition and provide new insights into the histopathological nature of stenotic lesions at the anastomotic site, especially in patients with chronic inflammatory diseases like Behçet's disease.

Behçet Disease: An Update for Dermatologists

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

Experimental Therapeutic Solutions for Behcet's Disease

Behcet's disease (BD) is a chronic systemic vasculitis with inflammation attacks that involve multiple organs. In addition to numerous mucocutaneous symptoms, notably recurrent oral and genital ulcers, ocular, articular, vascular, gastrointestinal, cardiac, and neurological system involvement can be observed. Mucocutaneous lesions are the primary symptom of the disease in most patients, and they usually occur before major organ involvement and other symptoms of the disease. Recognizing the disease's mucocutaneous lesions is very important to diagnose at an early stage, control with appropriate treatment and close follow-up, and prevent major organ involvement. Genome-wide association studies (GWAS) in recent years have confirmed that HLA-B*51 is the most significant genetic predisposing factor. The majority of gene polymorphisms have been detected in molecules that respond to microorganisms and genes encoding cytokines and adhesion molecules. The infectious agent S. sanguinis -commonly found in the oral mucosa of patients with BD- or the differences in the salivary or intestinal microbiome composition can trigger innate immune-mediated inflammation sustained by acquired or adaptive immune responses. In antigen-presenting cells (APCs), epistatic interactions between HLA-B*51 and endoplasmic reticulum aminopeptidase 1 (ERAP1) variants lead to the disruption of T-cell homeostasis, especially the activation of Type1 T-helper and Th17 pathway and suppression of regulatory T-cells. Recent developments to clarify the disease's etiopathogenesis provided us with a better understanding of the mechanism of action of the relatively old drugs while opening a way for many new treatment methods. Apremilast has become an important option in the treatment of mucocutaneous symptoms with its high efficacy and safety. The disease increases the mortality rate, especially in young male patients. New treatments, especially anti-TNF-α agents, have provided significant progress and decreased the mortality rates with their rapid effect and high efficacy in patients with severe organ involvement and resistance to traditional immunosuppressive and immunomodulatory therapies. The use of IL-1, IL-6, IL-17, IL-12/IL-23 antagonists in different organ involvement has gradually increased, and the quality of life has significantly improved in many patients.

New mouthwash: an efficacious intervention for oral ulceration associated with Behçet's disease

Topical interventions to treat oral ulcers in Behçet's disease (BD) are crucial to control disease activity and improve patients' quality of life. Our aim was to evaluate the effectiveness of a new BD mouthwash (BD MW) for oral ulceration. A retrospective cross-sectional study was carried out on 261 BD patients (141 women, mean (SD) age 39.9 (11.8) years, and 120 men, mean (SD) age 41.141(3.7) years). All were assessed using the oral ulcer severity score (OUSS), oral health quality of life (OHQoL), and the Behçet's disease current activity form (BDCAF). Patients were divided into three groups: one group used the BD MW, one group used a betamethasone mouthwash, and the other used no therapeutic mouthwash. Patients were assessed at three and six months. The OUSS in those using the BD MW was nine times lower than it was in those using betamethasone mouthwash (p=0.001), and 12 times lower than it was in the no mouthwash group (p=0.001). Compared with the baseline data, use of the BD MW during the first three months significantly reduced the OUSS, the BDCAF score, and intraoral scarring, and also improved OHQoL (p=0.001, 0.019, 0.012, and 0.001, respectively). Ongoing use of the BD MW after six months significantly improved the OUSS, OHQoL, and intraoral scars, and kept oral and systemic disease activity under control. A total of 20/31 patients reported high levels of satisfaction with its use, and a patients' satisfaction score showed a preference for it. This study confirms the efficacy of the BD MW in patients with recurrent oral ulceration (ROU). It is more efficacious than betamethasone mouthwash used alone.

Evaluation of hearing loss and tinnitus in Behcet's disease

OBJECTIVE

The aim of this study is to evaluate sensorineuralhearing loss (SHNL) and tinnitus in patients with Behcet's disease (BD), while also determining the association between the clinical symptoms of BD and the disease duration with the development of hearing loss.

MATERIALS AND METHODS

The study included 44 patients with BD and 42 healthy volunteers as the control group. The level of tinnitus-induced annoyance and the effects of tinnitus on daily life were evaluated with Visual Analog Scale (VAS) and the Tinnitus Reaction Questionnaire (TRQ). The hearing levels of all participants were measured with high-frequency audiometry and transient auto-acoustic emission tests.

RESULTS

The patients with BD were significantly more affected by SNHL and tinnitus than the controls (p < 0.05). The correlation between disease duration and age among those with SNHL was statistically significant (p < 0.05). No association was found between the clinical findings and SNHL and tinnitus (p > 0.05) in the BD patients.

CONCLUSION

In the present study, high-frequency SNHL was found to be common in among the patients with BD. SNHL in BD is positively correlated with the patients' age of the and the disease duration.

Investigation of the arterial intima-media thickness in Behcet’s disease patients without vascular complaints

Objectives

Behcet’s disease is a multisystemic, inflammatory disease. Various factors have been implicated in the disease, including genetics, infections, immunoglobulins, immune complexes, antibodies, and oxidative stress. However, the underlying etiopathogenesis remains unclear. Behcet’s disease can occur with or without vascular involvement. This prospective study investigated the relationship between the intima-media thickness of the major arteries, in addition to other factors affecting the disease process, in Behcet’s disease without vascular involvement.

Methods

Twenty-four patients (average age: 38.50 ± 10.931) without vascular involvement or any vascular complaints who were diagnosed with Behcet’s disease were included in the study. Sixteen healthy subjects (average age: 39.75 ± 7.793) were included as a control group. Demographic information and medical histories were recorded, and routine blood tests were performed in both groups. The intima-media thickness of the subclavian, axillary, femoral, and carotid arteries of all the participants were recorded using Doppler ultrasonography. The data were then subjected to intergroup statistical and correlation analyses.

Results

There were no significant differences between the arterial intima-media thickness values of the Behcet’s disease patients and those of the control group ( p > 0.05). However, there was a significant difference between the neutrophil–lymphocyte ratio ( p = 0.004), low-density lipoprotein ( p = 0.007), and triglyceride ( p = 0042) levels of the two groups. Significant correlations were found between intima-media thickness and neutrophil–lymphocyte ratio levels ( p = 0.012) and the disease duration ( p = 0.030). There was also a significant correlation between the intima-media thickness of the femoral artery and disease duration ( p = 0.014).

Conclusions

The results showed that the duration of illness had a significant effect on arterial intima-media thickness in Behcet’s disease. Blood neutrophil–lymphocyte ratio levels were also associated with increased intima-media thickness.

[Ocular Behçet]

Our study aimed to determine the clinical, therapeutic and prognostic features of ocular involvement in patients with Behçet's disease treated in our Department of ophthalmology. We conducted a retrospective data collection from medical records of 20 patients treated at the military hospital in Laayoune. All patients underwent complete ophthalmological examination and fluorescein angiography if necessary. OCT exam was performed in two patients. Ten patients had anterior uveitis, complicated in one case by ocular hypertonia; two patients had intermediate uveitis; eight patients had posterior segment involvement complicated in one case by intravitreal hemorrhage. Behcet's Disease (BD) is an systemic idiopathic inflammatory disease currently classified within primary non-necrotizing vasculitis. Ocular involvement is common and severe in Behçet's disease, with the potential to compromise the visual prognosis. Behcet's disease is common in Morocco. It can compromise patient's visual prognosis making the collaboration between ophthalmologists and internists particularly important.

Recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common acute oral ulcerative condition in North America. RAS is divided into a mild, common form, simple aphthosis, and a severe, less common form, complex aphthosis. Aphthosis is a reactive condition. The lesions of RAS can represent the mucosal manifestation of a variety of conditions. These include conditions with oral and genital aphthae such as ulcus vulvae acutum, reactive nonsexually related acute genital ulcers, and Behçet disease. The mouth is the beginning of the gastrointestinal (GI) tract, and the lesions of RAS can be a manifestation of GI diseases such as gluten-sensitive enteropathy, ulcerative colitis, and Crohn disease. Complex aphthosis may also have correctable causes. The clinician should seek these in a careful evaluation. Successful management of both simple and complex aphthosis depends on accurate diagnosis, proper classification, recognition of provocative factors, and the identification of associated diseases. The outlook for patients with both simple and complex aphthosis is positive.

Genital ulcer severity score and genital health quality of life in Behçet's disease

Background

Behçet’s Disease (BD) is a chronic auto-inflammatory, multisystem relapsing/remitting disorder of unknown aetiology. Oro-genital ulceration is a key feature of the disease and has a major impact on the patients’ quality of life. Other clinical manifestations include ocular inflammation, rheumatologic and skin involvement, while CNS and vascular complications can lead to considerable morbidity. The availability of a valid monitoring tool for BD activity is crucial in evaluating the impact of the disease on daily life activity. The aims of this study were to validate a novel tool for monitoring genital ulceration severity in BD and to assess the impact of genital ulcers on the Genital Health Quality of Life (GHQoL).

Methods

Genital Ulcer Severity Score (GUSS) was developed using six genital ulcer characteristics: number, size, duration, ulcer-free period, pain and site. A total of 207 BD patients were examined, (137 females: mean age ± SD: 39.83 ± 13.42 and 70 males: mean age ± SD: 39.98 ± 11.95) from the multidisciplinary Behçet’s Centre of Excellence at Barts Health NHS Trust. GUSS was used in conjunction with Behçet’s Disease Current Activity Form (BDCAF).

Results

The over-all score of GUSS showed a strong correlation with all genital ulcer characteristics, and the strongest correlation was with the pain domain (r = 0.936; P < 0.0001). Ulcer average size and ulcer pain were the major predicting factors in GUSS (β = 0.284; β = 0.275) respectively, and P-values were significant. Multivariate regression analysis indicated that the ulcer pain, size and site are the main ulcer characteristics having an influence on the GHQoL (R²: 0.600; P < 0.0001).

Conclusions

This study established the practicality of GUSS as a severity monitoring tool for BD genital ulcers and validated its use in 207 patients. Genital ulcers of BD have a considerable impact on the patients GHQoL.

Electronic supplementary material

The online version of this article (doi:10.1186/s13023-015-0341-7) contains supplementary material, which is available to authorized users.

Antistreptolysin O Levels in Patients with Behcet's Disease

OBJECTIVE

Behcet's disease is a multisystem inflammatory disorder, and its etiology has not been defined clearly yet. In this study, we aimed to investigate the antistreptolysin O (ASO) levels of patients with Behcet's disease.

MATERIALS AND METHODS

Thirty patients with Behcet's disease and 30 healthy controls were enrolled in this study. We measured erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), and ASO levels in both groups.

RESULTS

There was no statistically significant difference between the two groups with respect to demographic data (p>0.05). The ASO levels of the patients and the controls were 288.4±145.7 and 170.6±142.4 ng/ml, respectively. In the patients with Behcet's disease, ASO (p<0.01) and ESR (p<0.05) values were significantly higher than in the healthy controls. There was no other significant difference in serum CRP levels between the patients and the controls. We could not find any correlation among ASO, CRP, and ESR values.

CONCLUSION

Our results suggest that serum ASO levels may increase in patients with Behcet's disease. Further studies are needed in order to define the relationship between ASO levels and inflammation status in Behcet's disease.

Histopathologic Study of Pathergy Test in Behçet's Disease

Background:

The pathergy test (PT) is important in the diagnosis of Behçet's disease (BD). However, misinterpretation of the test might cause false-positive or false-negative results. Therefore, immunopathologic and histopathologic tests are recommended with PT.

Aims and Objectives:

The aim of this study is to determine histopathologic findings of positive pathergy reaction at BD.

Materials and Methods:

This study was performed on 23 patients with BD. All patients were in active period of the disease. After 48 h from the injection, biopsy was performed on positive pathergy lesions.

Results:

Of the specimen from positive PT lesions of patients with BD, nine revealed mixed type inflammatory cell infiltration (39.1%), two revealed lobular panniculitis without vasculitis (8.7%), two revealed neutrophil rich infiltration (8.7%), and five revealed lymphocyte rich infiltration (21.7%) at the subcutaneous tissue. Mixed type inflammatory cell infiltration (43.4%), endothelial swelling and thickening (17.3%), erythrocyte extravasation (26.0%), perivascular cell infiltration (13.0%), lymphocytic vascular reaction (8.6%), lymphocytic vasculitis (13.0%), and leukocytoclastic vasculitis (21.7%) were detected in dermis by histopathologic examinations. There was no statistically significant difference between histopathologic findings and sex, family history, and systemic involvement except uveitis.

Conclusion:

This is an exceptional study since it is the first study that determines subcutaneous tissue findings of positive pathergy reaction in Behçet patients. In our study, uveitis was found to be statistically significant in the patients who had vasculitis in dermis. It can be a clue for prediction of disease severity and course. Further, studies that include wide number of patients will better illuminate the correlation between subcutaneous tissue findings and disease severity and clinical course.

Demographical and Clinical Characteristics of Behcet's Disease in Southeastern Turkey

BACKGROUND

We aimed to determine the demographic and clinical features of patients with Behcet's disease (BD) in Southeastern Turkey.

METHODS

In this study, files of 132 patients with BD (76 females and 56 males) who were diagnosed with BD according to the International Study Group criteria at the Department of Dermatology of Dicle University Faculty of Medicine from 2005 to 2009 were evaluated retrospectively. Demographical and clinical characteristics of the cases were recorded.

RESULTS

Mean age of the cases was 32.40 ± 9.4 years (range 15 - 59 years) and male/female ratio was 0.73. The mean age at diagnosis was 28.71 ± 9.1 years. Six cases were diagnosed as juvenile BD (4.45%). Oral aphthous lesions (100%) and genital ulcers (94%) were found to be the most common findings of the disease, followed by pathergy positivity (75%), papulopustular lesions (74.2%), erythema nodosum (43.2%), thrombophlebitis (6.8%) and extragenital ulcers (6.1%). Systemic involvement was noted as joint involvement in 79.5%, ocular involvement in 28.8%, vascular involvement in 9.8%, pulmonary involvement in 2.3%, neurologic involvement in 2.3% and genitourinary system involvement in 0.8%. There was no significant difference between mucocutaneous findings and systemic involvement ratios of male and female cases.

CONCLUSION

Demographic and clinical features of BD may vary according to geographical region, gender and ethnicity. We hope that this study will contribute to the epidemiologic data of BD which may exhibit different clinical and demographic features in different parts of the world.

Is There Any Association between Hepatitis G Virus (HGV), Other Hepatitis Viruses (HBV, HCV) and Behçet's Disease?

Infectious agents, especially viruses, have been implicated in the pathogenesis of Behçet's disease (BD). The aim of this study was to determine whether BD is associated with hepatitis viruses. In this study, the serological markers of hepatitis (HBsAg, anti-HBs, anti-HBc and anti-HCV) and viral nucleic acid (HGV-RNA) were studied in the sera of 35 patients, all of whom fulfilled the diagnostic criteria of the International Study Group for BD, and the results were compared with those of 36 healthy controls. The prevalences of HBsAg, anti-HBs, anti-HBc in BD patients were 2.9%, 45.7%, and 31.4%, respectively, which were not significantly different from those in healthy controls. None of the subjects in either group were found to be positive for anti-HCV. HGV-RNA was detected in two patients with BD and in none of the healthy controls. In conclusion, BD does not seem to be associated with hepatitis viral infections including hepatitis B, C, or G.

The Significance of Serum Nitric Oxide Levels in Behçet's Disease and Recurrent Aphthous Stomatitis

Behçet's disease (BD) is an inflammatory multisystem disorder characterized by recurrent oral and genital aphthous ulcers, arthritis, uveitis, and thrombophlebitis; it can involve several organs. However, recurrent aphthous stomatitis (RAS) can be seen without a confirmed diagnosis of BD. Moreover, there is no way of predicting whether a patient with RAS will develop BD. Nitric oxide (NO) is a free radical synthesized from L-arginine by one of the family of nitric oxide synthase (NOS) enzymes. Increased production of NO during several inflammatory and infectious processes has been recently postulated. Our aim was to investigate the serum NO levels in patients with active and inactive BD and RAS. Forty-six patients with BD, 30 patients with RAS and 30 healthy controls were enrolled in the study. The patients with BD were separated into two groups: clinically active (n = 24) and inactive (n = 22). A blood sample was collected from all subjects in order to determine their serum NO levels. In patients with active BD, higher serum levels of NO metabolite were found in comparison with patients with inactive BD, in patients with RAS, or healthy controls (p < 0.05). We also found higher serum NO metabolite levels in patients with RAS than in healthy controls (p < 0.05). In patients with inactive BD, statistically significant higher levels of serum NO levels were found in comparison with the control group (p < 0.05). However, we found no statistically significant difference between the patients with inactive BD and RAS, which indicated that inactive BD cannot be distinguished from RAS by serum NO levels. We conclude that serum NO levels may be an important marker for estimating the severity of BD. However, further studies are needed to confirm our findings.

Mean Platelet Volume in Recurrent Aphthous Stomatitis and Behçet Disease

Behcet disease (BD) and recurrent aphthous stomatitis (RAS) are systemic inflammatory diseases, but the exact pathogenesis of both the diseases is unknown. Mean platelet volume (MPV) is an indicator of platelet activation. The aim of this study was to investigate the MPV levels in patients with BD, RAS, and healthy participants. A total of 61 patients with BD, 60 patients with RAS, and 60 healthy controls were included in this study. The MPV levels and erythrocyte sedimentation rate in patients with BD and RAS groups were significantly higher than the control groups ( P < .001). In the BD group as well as in the RAS group, the disease activity does not affect the levels of MPV. The MPV levels may be used as a cheap and feasible diagnostic marker in patients with BD and RAS. Nevertheless, the MPV does not have a predictive value in differentiating the diagnosis of BD and RAS.

Oral Aphthosis: Management Gaps and Recent Advances

Introduction: Though oral aphthosis is common, it has a significant impact on the quality of life in the patients. It is the most common oral ulcerative condition encountered in clinical practice. This study describes the characteristics and patterns of oral aphthosis seen at a tertiary dermatological centre in Singapore, with emphasis in evaluating the management gaps and in identifying underlying systemic diseases and nutritional deficiencies. Materials and Methods: This is a retrospective review of medical records over a 10-year period between June 2000 and June 2010. Two hundred and thirteen patients were identified using the search terms ‘oral ulcers’, ‘aphthous ulcers’, ‘oral aphthosis’, and ‘Behcet’s disease’. Patients with Behcet’s disease without oral ulcers and other diagnoses such as pemphigus vulgaris, lichen planus and herpes simplex were excluded. The remaining patients were evaluated with regard to demographic characteristics, characteristics of oral ulcers, associated connective tissue disorders and nutritional deficiencies, diagnostic tests results, treatment response as well as follow-up duration. Results: One hundred and seventy-five patients were included in this study. One hundred and one patients had recurrent oral aphthosis, with 77 having simple aphthosis and 24 having complex aphthosis. Fourteen patients (8%) fulfilled the International Study Criteria (ISG) for Behcet’s disease, of which, 85.71% had complex aphthosis. The therapeutic ladder for such patients ranged from topical steroids and colchicine through to oral corticosteroids and/or dapsone therapy. Conclusion: Recurrent oral aphthosis is a niche condition in which dermatologists are well-poised to manage. This study demonstrates that a more definitive management and therapeutic algorithm for oral aphthosis are needed for better management patients in the future. In particular, complex aphthosis needs to be monitored for progression onto Behcet’s disease. Key words: Behcet’s disease, Oral ulcers, Recurrent aphthosis

Rapidly Progressive Cardiac Manifestation of Behçet's Disease Involving Conduction System and Aortic Valve

Cardiac conduction system impairment is a rare clinical manifestation of Behçet's disease. We report a patient who showed 1st degree atrioventricular block at first presentation, and showed aggravated finding of 3rd degree atrioventricular block on five months later. His cardiac manifestation finally developed to acute severe aortic regurgitation on six months later from his first cardiac manifestation. We observed this rapid progression during 6 months and successfully improved symptom and disease severity of the patient with treatment targeting Behçet's disease.

Ocular Behçet disease: current therapeutic approaches

PURPOSE OF REVIEW

To alert physician to timely recognition and current treatment of recurrent hypopyon iridocyclitis or panuveitis in ocular Behçet disease (OBD).

RECENT FINDINGS

Interferon-α, rituximab, intravitreal triamcinolone, and biological response modifiers by tumor necrosis factor inhibitors such as infliximab and adalimumab are being used increasingly for the treatment of severe sight-threatening ocular inflammation including retinal vasculitis and cystoid macular edema (CME).

SUMMARY

Biological agents offer tremendous potential in the treatment of OBD. Given that OBD predominantly afflicts the younger adults in their most productive years, dermatologist, rheumatologist, internist, or general practitioners supervising patients with oculo-articulo-oromucocutaneous syndromes should be aware of systemic Behçet disease. Early recognition of ocular involvement is important and such patients should strongly be instructed to visit immediately an ophthalmologist, as uveitis management differs from extraocular involvements with high ocular morbidity from sight-threatening complications due to relapsing inflammatory attacks in the posterior segment of the eye. A single infliximab infusion should be considered for the control of acute panuveitis, whereas repeated long-term infliximab infusions were proved to be more effective in reducing the number of episodes in refractory uveoretinitis with faster regression and complete remission of CME.

Evaluation of patients with Behçet's disease by cervical cytology and colposcopic examination

PURPOSE

We evaluated the genital involvement in women with Behçet's disease (BD) by cervical cytology and colposcopy, and compared these findings with healthy controls.

METHODS

A total of 152 women were referred to the Gynecology Clinic of Meram School of Medicine between March 2008 and December 2009. The study group was composed of 78 women with BD, and the control group included 74 healthy women admitted for routine gynecologic examination. These patients were subjected to cervical cytology and colposcopic examination. Cervical biopsy was performed in cases with abnormal cytology. These findings and some gynecologic complaints were compared.

RESULTS

The demographic features were similar between each group. Genital involvement (scar + ulcer) was detected in 58 (74.3%) patients. The most common sites of ulcers (55.1%) and scars (7.6%) were the labia majora. Abnormal cytology in study and control groups was detected in nine (11.5%) and three (4%) of the patients, respectively, and a slight statistical significance was obtained (p = 0.048). Acetowhite and iodine-negative epithelium were higher in the study group than in controls (p = 0.015 and p = 0.042). Dyspareunia was higher in BD patients (p = 0.001).

CONCLUSION

Patients with BD are more prone to having an abnormal cervical cytology and acetowhite and iodine-negative epithelium on colposcopic examination. However, these findings are mostly benign conditions. The complaint of dyspareunia should be considered during treatment of female patients with BD.

Behçet disease: visual prognosis and factors influencing the development of visual loss

PURPOSE

To assess the visual prognosis of patients with ocular Behçet disease and to determine factors predictive of visual loss and severe visual loss.

DESIGN

Retrospective case series.

METHODS

One hundred seventy-five eyes of 107 patients diagnosed with ocular Behçet disease were included. The main outcome measures were visual loss (best-corrected visual acuity, worse than 20/40) and severe visual loss (best-corrected visual acuity, 20/200 or worse).

RESULTS

The mean duration of follow-up was 6.5 years. Presenting visual acuity was worse than 20/40 in 50% of eyes and 20/200 or worse in 21% of eyes; approximately one third of this was reversible with treatment. The most common cause of irreversible severe visual loss was ischemic maculopathy. At 10 years, there was a 39% risk of visual loss and a 24% risk of severe visual loss, the latter figure being reduced to 13% if patients with irreversible visual loss at presentation were excluded. After controlling for potentially confounding variables, male sex, unilateral disease, and left eye involvement all were statistically significant risk factors for severe visual loss at 5 and 10 years. Patients who were treated with biologic agents were less likely to have severe visual loss in either eye at both 5 and 10 years.

CONCLUSIONS

Many patients with ocular Behçet disease still have irreversible visual loss at presentation. However, the visual prognosis is otherwise improved, with a 10-year risk of severe visual loss of 13% in this cohort. The use of biologic agents is associated with a lower risk of severe visual loss at 5 and 10 years.

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.

Pathophysiology of the Behçet's Disease

Behçet's disease (BD) is a multisystemic disease of unknown etiology characterized by chronic relapsing oral-genital ulcers and uveitis. Multiple systemic associations including articular, gastrointestinal, cardiopulmonary, neurologic, and vascular involvement are also observed in BD. Although the etiopathogenesis of the disease remains unknown, increased neutrophil functions such as chemotaxis, phagocytosis, and excessive production of reactive oxygen species (ROS), including superoxide anion, which may be responsible for oxidative tissue damage seen in BD, and also immunological alterations, T lymphocyte abnormalities in both subpopulation and function have been considered to be correlated with the etiopathogenesis of BD. There is some clinical evidence suggesting that emotional stress and hormonal alterations can influence the course and disease activity of BD.

Urban legends: recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçet's disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Urban legends: recurrent aphthous stomatitis

Recurrent aphthous stomatitis (RAS) is the most common idiopathic intraoral ulcerative disease in the USA. Aphthae typically occur in apparently healthy individuals, although an association with certain systemic diseases has been reported. Despite the unclear etiopathogenesis, new drug trials are continuously conducted in an attempt to reduce pain and dysfunction. We investigated four controversial topics: (1) Is complex aphthosis a mild form of Behçet's disease (BD)? (2) Is periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome a distinct medical entity? (3) Is RAS associated with other systemic diseases [e.g., celiac disease (CD) and B12 deficiency]? (4) Are there any new RAS treatments? Results from extensive literature searches, including a systematic review of RAS trials, suggested the following: (1) Complex aphthosis is not a mild form of BD in North America or Western Europe; (2) Diagnostic criteria for PFAPA have low specificity and the characteristics of the oral ulcers warrant further studies; (3) Oral ulcers may be associated with CD; however, these ulcers may not be RAS; RAS is rarely associated with B12 deficiency; nevertheless, B12 treatment may be beneficial, via mechanisms that warrant further study; (4) Thirty-three controlled trials published in the past 6 years reported some effectiveness, although potential for bias was high.

Drug usage evaluation of dapsone

Dapsone has been the principal drug in a multidrug regimen recommended by the World Health Organization for the treatment of leprosy. It is also widely used by dermatologists in varied skin conditions like dermatitis herpetiformis, bullous pemphigoid, Behcet's disease, lupus erythematous and a host of other skin diseases. Hence an attempt has been made to review the utilization and qualitative evaluation of dapsone over a period of 6 months in a tertiary care teaching hospital. The study consisted of 80 patients (54 leprosy and 26 non-leprosy patients), prescribed with dapsone 100 mg oral once daily. The prescribing patterns of dapsone in leprosy and other dermatological conditions (non-leprosy) were analyzed and the safety, efficacy and appropriateness of the doses prescribed were reviewed. The adverse drug reactions observed in the study population were type I Lepra reactions, gastrointestinal side effects (abdominal pain and anorexia), peripheral neuropathy, other nervous side effects (insomnia, headache and vertigo) and other adverse reactions (fever and tinnitus). Patient information leaflets were distributed to patients to educate on the appropriate use of dapsone.

Varicocele and epididymitis in Behcet disease

OBJECTIVE

Behçet disease is a systemic disease with protean manifestations. Vasculitis is a hallmark of the disease and may involve arteries, veins, and capillaries. Varicocele is dilatation of the pampiniform plexus veins. We aimed to investigate the incidence of varicocele in patients with Behçet disease.

METHODS

The study included 47 male patients with Behçet disease and 31 healthy control participants. All underwent a clinical evaluation including a medical history and systemic and scrotal examinations. Subsequently, 2 investigators blinded to the clinical data performed sonographic examinations and measured pampiniform plexus vein diameters.

RESULTS

The mean age of the patients ± SD was 23.4 ± 3.2 years; disease durations ranged from 3 to 120 months (46 ± 31 months). Scrotal pain or a palpable mass was detected by clinical examination in 24 patients with Behçet disease (51.1%) and 5 healthy participants (16.1%; P = .002). By color Doppler examination, left varicocele was diagnosed in 26 patients with Behçet disease (55.3%) and 9 healthy participants (29%; P = .02). All patients with right varicocele also had left varicocele; that condition was detected in 10.6% (5 patients) of the Behçet disease group and 6.4% (2 patients) of the control group (P > .05). Eight patients with Behçet disease (17%) had epididymitis, whereas none of the healthy participants did (P = .019, Fisher exact test). Genital ulcers and erythema nodosum lesions were more common among patients with varicocele (P = .034 and .058, respectively). There were no differences in smoking, epididymitis, arthritis, uveitis, or other clinical parameters for distinguishing varicocele in patients with Behçet disease.

CONCLUSIONS

The incidence of varicocele was increased in Behçet disease. Whether varicocele confers fertility problems in patients with Behçet disease and the underlying mechanism for a possible association are yet to be determined.

Lipschutz ulcers: evaluation and management of acute genital ulcers in women

Acute genital ulcers are painful and distressing to women and perplexing to the providers who care for them. The differential diagnosis includes sexually and nonsexually transmitted infections, autoimmune conditions, drug reactions, and local manifestations of systemic illness. However, in many cases, no causative agent is identified, and lesions are classified as idiopathic aphthosis. In the setting of fever and acute onset of genital ulcers in girls and women, the term Lipschutz ulcers has been used to describe ulcers associated with an immunologic reaction to a distant source of infection or inflammation. The aims of this article are to review the differential diagnosis and pathogenesis of acute genital ulcers, to offer an evaluation and classification scheme, and to discuss treatment options for the dermatologist who cares for women and girls with vulvar ulcers.

Diagnosis and management of vulvar ulcers

The diagnosis and management of the following non-infectious vulvar ulcers are reviewed: vulvar aphthae in adult and pediatric patients, aphthae associated with Behçet's disease, vulvar ulcers resulting from Crohn's disease, and vulvar ulcers associated with human immunodeficiency virus infection. There are many resources providing excellent reviews of infectious ulcers; therefore this topic will not be covered here.

Laryngeal manifestations in atypical recurrent aphthous stomatitis

Recurrent aphthoid stomatitis is characteristically observed in children and adolescents in the form of painful relapsing ulcers in the oral mucosa unaccompanied by evidences of systemic disease. The ulcers appear every one or two weeks for at least one entire year. Some patients suspected for recurrent aphthoid stomatitis develop lesions in atypical sites - mainly in the larynx - concurrently to the ones found in the oral mucosa.

Aim

this study aims to describe a series of recurrent aphthoid stomatitis patients with atypical laryngeal injuries. Study design: this is a case series study.

Materials and method

patients diagnosed with recurrent aphthoid stomatitis with oral mucosa ulcers and laryngeal symptoms without altered lab test results and no evidence of systemic disease underwent fibroscopic examination, oral and laryngeal biopsies, followed by specimen evaluation by direct immunofluorescence.

Results

all six patients in this series had acute and chronic inflammatory processes according to pathology studies and negative direct immunofluorescence test results.

Conclusion

laryngeal involvement in recurrent aphthoid stomatitis is rare. Therefore, during diagnostic examination thorough clinical history and meticulous physical examination accompanied by fibroscopic examination are necessary. When atypical lesions are found, biopsies for histological evaluation and direct immunofluorescence tests are required.

The clinical feature of Behçet's disease in Northeastern China

PURPOSE

Behçet's disease (BD) is a chronic, relapsing, multi-system vasculitis of unknown aetiology with complicated and diversified clinical features predominantly involving oral and genital ulcers, and ocular and cutaneous lesions. The clinical features of this disease have been described to be different according to geographical areas and gender. We investigated the specific clinical features of BD patients in Northeastern China.

MATERIALS AND METHODS

116 patients involved in this study fulfilled the classification criteria of the International Study Group for BD. The clinical manifestations and results of laboratory tests of BD were recorded in each patient.

RESULTS

The onset was typically between 20-39 years with a slight female predominance. Oral ulcers were the most common manifestation, followed by skin lesions, positive pathergy reaction/genital ulcers, and ocular lesions. Vascular lesion and epididymitis were rare in patients with BD. The frequency of erythema nodosum-like lesion and articular involvement were significantly higher in females, while gastrointestinal involvement was significantly higher in males. The results of laboratory tests showed that the human leukocyte antigen (HLA)-B*51 alleles were positive in 30.9% of patients and the immunological abnormities were present in some patients.

CONCLUSION

The clinical features of BD showed geographical and gender difference. Genetic and immune factors might participate in aetiopathogenesis of BD.

Current trends in the management of ocular symptoms in Adamantiades-Behçet's disease

Adamantiades-Behçet’s disease (ABD) is a multisystemic vasculitic disease. It is most prevalent in the Eastern Mediterranean countries and the Eastern region of Asia. Its effect on the eye can range from mild to debilitating, resulting in total blindness. A necrotizing and obliterative vasculitis affects both arteries and veins of organs. Recurrent attacks of uveitis, oral aphthous ulcers, skin lesions, and genital ulcers are common. Topical and systemic corticosteroids have been the mainstay in the treatment of ocular inflammation for many years; however, due to the several known side effects of corticosteroids and thanks to scientific advances, more novel approaches to ABD treatment have been emerging. Antimetabolites such as methotrexate and azathioprine have been utilized with the latter showing positive results. Chlorambucil has been utilized effectively for ocular manifestations of ABD. Interferon alpha has shown encouraging results in the management of refractory ocular inflammation associated with ABD, either alone or in combination with other immunosuppressive agents. Surgical interventions to deal with complications from ABD can be safely done if adequate control of inflammation is achieved peri-operatively. Early detection and aggressive treatment, when needed, have proven to be essential in the management of this relentlessly explosive disease.

Evaluation of pathergy test positivity in familial Mediterranean fever patients and comparison of clinical manifestations of FMF with Behçet's disease

Familial Mediterranean fever (FMF) shares a number of features with Behçet's disease (BD), such as their common ethnic origin, etiopathogenetic mechanisms, symptoms, and treatment. Pathergy reaction is accepted as a major criterion in BD. We aimed to determine the frequency of pathergy positivity in FMF patients and compared clinical features between FMF and BD. Pathergy test was performed in patients with FMF, BD, and healthy controls. Diagnostic criteria for FMF and BD were screened in both groups. None of the FMF patients or healthy controls yielded positive pathergy test. Pathergy test was positive in 13 out of 31 (41.9%) of the patients with BD. None of the FMF patients fulfilled the International Study Group criteria for BD. None of the BD patients fulfilled the Livneh diagnostic criteria for FMF. BD and FMF are associated with neutrophilic dermatoses and neutrophil hyper-reactivity. Although pathergy test and erysipelas-like erythema share some histological findings, pathergy test was negative among FMF patients.

Vitamin levels in Behçet's disease

OBJECTIVE

To determine the role of oxidative stress and the antioxidant defense mechanism in the etiopathogenesis of active and inactive Behçets disease. In line with this objective, the present study aimed to examine the levels of nitric oxide (NO) and malondialdehyde (MDA), which are the end products of oxidant stress, and vitamins, which are non-enzymatic antioxidants, for the diagnosis and particularly the follow-up of Behçet's disease.

MATERIALS AND METHODS

The study group consisted of a total of 60 individuals: 40 of whom were Behçet's disease patients and 20 were healthy individuals. Of the 40 Behçet's patients, 29 had the active and 11 had the inactive (stable) form of the disease.

RESULTS

Although plasma MDA and NO (its stable form nitrite) levels in the total patient group were statistically significantly higher than those in the control group (p<0.06), there was no statistically significant difference as such between inactive Behçet's patients and the control group (p>0.05). Vitamin E, C, B1, B2 and flavin mononucleotide (FMN) values were significantly lower in the patient group in comparison with the control group (p<0.05). There was no statistically significant difference in other vitamin values.

DISCUSSION

It is contemplated that measurement of such oxidative stress factors as MDA and NO and an accompanying evaluation of the antioxidant defense system can be significant in the diagnosis and treatment follow-up of Behçet's disease.

Homocysteine levels in patients with Behçet's disease and patients with recurrent aphthous stomatitis

The mechanism for vascular involvement of Behçet disease (BD) includes arterial and venous thrombosis. Although the exact etiology of systemic vasculitis and thrombosis is still unknown, many hypotheses have been suggested. One of these hypotheses is that hyperhomocysteinemia causes vascular disease and thrombosis. The aim of this study was to compare the levels of homocysteine, vitamin B(12), and folic acid of BD patients with those of recurrent aphthous stomatitis (RAS) patients and healthy controls. Forty-five BD patients, 47 RAS patients, and 69 healty control subjects were included in this study. Vitamin B(12), folic acid, and homocysteine levels of the patients and controls were measured, and statistical differences among the groups were determined. BD patients had mostly cutaneous symptoms. Arthritis and ocular and vascular involvement were seen in 24.4%, 22%, and 11% of BD patients, respectively. No significant difference was detected among the groups in the levels of vitamin B(12), folic acid, and homocysteine. There was no significant difference in any parameters according to sex and age of the patients and activity of BD and if the patients with BD were treated or not. Homocysteine level inversely correlated with vitamin B(12) and folic acid levels in the BD group. We could not find any differences in homocysteine, vitamin B(12), and folic acid levels between BD and RAS patients and controls. This may be due to the fact that our patients mostly had cutaneous symptoms rather than vascular involvement.

Vitiligo koebnerized by behçet disease genital ulceration

A 50-year-old man was diagnosed with Behçet disease (BD) on the basis of an 8-year history of episodes of recurrent oral aphthous ulcers, papulopustular lesions on physical examination, and a positive pathergy test. Two years prior to diagnosis of BD, vitiligo had also been diagnosed on the basis of hypopigmented lesions on the scrotum following genital ulceration. To our knowledge, this is the first case of incidental coexistence of BD and vitiligo, and, furthermore, the first case of koebnerization of genital ulceration of BD.

Classifying patients with Behçet's disease for disease severity, using a discriminating analysis method

BACKGROUND

Interleukin (IL)-8 has been shown to correlate with the activity of Behçet's disease (BD). The aim of this study was to develop tools as reliable as IL-8 levels in defining BD severity.

METHODS

In total, 32 patients with BD and 16 healthy controls were included in the study. Medical history, physical examination, routine laboratory investigations and measurement of serum IL-8 levels were performed. The patients were classified as groups I and II based on the serum IL-8 levels. The patients were then reassigned to groups based on the predictions through discriminating analysis.

RESULTS

In addition to the differences between patient and control groups, the differences between groups I and II, group I and controls, and group II and controls were statistically significant. The discriminating analysis results showed that the patients had been assigned to groups I and II with 100% accuracy.

CONCLUSION

Discriminating analysis using clinical and routine laboratory findings indicated that 100% of the patients were accurately assigned to the same groups as their IL-8 levels indicated. This suggests that the classification made according to discriminating analysis using these routine variables is a reliable method in determination of the disease severity.