Fatal hemoptysis from Behcet's disease in a child

The Challenge of Treating Pulmonary Vasculitis in Behçet Disease: Two Pediatric Cases

Behçet disease (BD) is a multisystemic autoinflammatory disorder characterized by recurrent mucocutaneous, ocular, musculoskeletal, gastrointestinal, central nervous system, and vascular manifestations. Pulmonary arterial involvement (PAI) of BD is probably the most severe form of vasculitis, at least in children. PAI has a high mortality, morbidity, and recurrence rate. There are limited data regarding treatment and outcomes of pediatric patients with BD with PAI. Herein, we report 2 pediatric patients with BD presented with hemoptysis and support our data with a systematic review. These patients were given immunosuppressive therapy, which covered pulse methylprednisolone followed by oral prednisolone, intravenous cyclophosphamide every 3 weeks for a total of 6 cycles, and interferon-α2a concomitantly. These are the first reported cases in the literature successfully treated with this treatment modality in a complication with 50% mortality. These patients have been followed up for a period of at least 4 years without any vascular recurrence. Pediatricians should be aware that patients with BD may not present with full diagnostic criteria. They should consider BD in a child with PAI to avoid diagnostic delay and start life-saving accurate immunosuppressive treatment.

Pulmonary artery aneurysms in Behçet disease

Pulmonary artery aneurysms (PAAs) are the most common type of pulmonary involvement in Behçet's disease. However, the relationships between clinical features and prognosis have not been sufficiently evaluated. This article describes the results of a comprehensive review, revealing that PAAs have a predilection for hemoptysis manifestations, increased dimensions, right lower lobar location, multiplicity and concurrent intramural thrombus formation. Surgical intervention was needed in one third of patients. Patients with massive hemoptysis and PAA rupture warranted emergency operations. Conservatively treated patients were prone to PAA progression; interventional embolization was associated with higher risks of recurrence and reintervention for PAAs; and surgically treated patients exhibited the highest mortality rates. In conclusion, PAAs in Behçet's disease are characterized by a predilection for hemoptysis manifestations, right lower lobar location, multiplicity, and concurrent intramural thrombus formation. Both the condition itself and the surgical operations it warrants are linked with high mortality due to PAA hemorrhage.

Massive hemoptysis in an 11-year-old girl with isolated pulmonary arteritis

A 10-year-old girl developed recurrent bouts of massive hemoptysis over a 9-month period. No obvious bleeding source was detected. Her pulmonary angiogram showed a pulmonary aneurysm of the second branch of the left main pulmonary artery as well as widespread irregularities of the pulmonary arteries including areas of stenosis and pruning. Elective embolization of the aneurysm did not control hemoptysis and emergency left upper lobectomy had to be performed. Histology showed large artery wall injury with acute leucocytoclastic inflammation, fibrinoid necrosis, granulomatous inflammation, and ectasia of vessel wall. This combination of abnormalities has not been described to date and represents the first case of isolated pulmonary arteritis in children prior to puberty.

[Hemoptysis revealing a pulmonary arterial aneurysm on Behçet disease in children: role of computed tomography]

Behçet's disease is a systemic condition whose discovery during hemoptysis on a pulmonary artery aneurysm is rare, especially in children. Through the case of a 11-year-old boy, the authors emphasize the importance of imaging in diagnosis of this disease, whose progression can be fatal if hemoptysis is violent.

Pulmonary vasculitis in behcet disease: a cumulative analysis

STUDY OBJECTIVES

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

DESIGN

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

SETTING

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

PATIENTS

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

RESULTS

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

CONCLUSIONS

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

Update on childhood vasculitides

PURPOSE OF REVIEW

The purpose of this review is to provide an update on the new developments in pediatric vasculitis.

RECENT FINDINGS

Because most childhood vasculitides are rare, few large systematic studies have been done. Studies of Henoch-Schönlein purpura have focused on pathogenesis and outcome. Genetic associations and molecular changes occurring during Henoch-Schönlein purpura, including cytokines, and endothelial and nitric oxide metabolism are discussed. Risk factors for renal involvement and poor renal outcome are described. Uncontrolled series of treatment protocols for severe Henoch-Schönlein purpura nephritis are mentioned. Several studies have focused on the pathogenesis of other primary vasculitides, especially polyarteritis nodosa. Series describing the clinical manifestations of childhood vasculitis and case reports of uncommon manifestations of vasculitis in children are presented. The efficacy of new therapies, including the use of thalidomide and biologic modifiers, has been shown in individual childhood cases; however, there are no controlled studies of these agents.

SUMMARY

Besides studies of Henoch-Schönlein purpura, advances in pediatric vasculitis are few as a result of the rarity of most vasculitides in childhood. Multicenter collaboration is necessary to substantially increase the scientific base of investigating and treating childhood vasculitis.