Treatment of Behçet's disease--an update

Prevalence and risk factors for gallstone and renal stone formation in patients with intestinal Behçet's disease

BACKGROUND/AIMS

The association between inflammatory bowel disease (IBD) and gallstone and renal stone formation has been established. However, few studies have investigated this association in patients with intestinal Behçet's disease (BD). We aimed to examine the prevalence of gallstones and renal stones in patients with intestinal BD and identify potential risk factors.

METHODS

We analyzed gallstone and renal stone occurrences in 553 patients diagnosed with intestinal BD who had undergone cross-sectional imaging examinations between March 2005 and April 2021 at the IBD Center, Severance Hospital, Seoul, South Korea. Logistic regression models were used to identify risk factors for gallstone and renal stone formation.

RESULTS

Of 553 patients over a mean 12.1-year duration, 141 (25.4%) patients had gallstones and 35 (6.3%) had renal stones. In multivariate logistic regression analysis, disease duration > 19 years (OR 2.91, 95% CI 1.56-5.44, 0.002). No significant correlation 0.001), prior intestinal BD-related surgery (OR 2.29, 95% CI 1.42-3.68, p < 0.001), and disease activity index for intestinal BD scores ≥ 75 (OR 2.23, 95% CI 1.12-4.45, p = 0.022) were associated with increased gallstone occurrence. A positive correlation was observed between renal stones, disease duration > 19 years (OR 5.61, 95% CI 1.98-15.90, p = 0.001) and frequent hospitalization (> 3 times) (OR 3.29, 95% CI 1.52-7.13, p = 0.002). No significant correlation was observed between gallstone and renal stone occurrence.

CONCLUSION

These findings contribute to greater understanding concerning gallstone and renal stone prevalence and associated risk factors in patients with intestinal BD.

Effects of nanocurcumin supplementation on T-helper 17 cells inflammatory response in patients with Behcet's disease: a randomized controlled trial

OBJECTIVE

Present research was performed to assess the effects of nanocurcumin supplementation on T-helper 17 (Th17) cells inflammatory response in patients with Behcet's disease (BD).

METHODS

In this randomized double-blind, placebo-controlled trial, 36 BD subjects were randomly placed into two groups to take 80 mg/day nanocurcumin or placebo for eight weeks. Disease activity, frequency of Th17 cells and expression of related parameters including retinoic acid-related orphan receptor γ (RORγt) transcription factor messenger RNA (mRNA), related microRNAs (miRNAs) such as miRNA-155, miRNA-181, and miRNA-326 as well as proinflammatory cytokines including interleukin (IL)-17 and IL-23 were evaluated.

RESULTS

Thirty-two patients (17 in the nanocurcumin and 15 in the placebo groups) completed the trial. Number of Th17 cells decreased significantly in the nanocurcumin group compared to baseline (p = .012) and placebo (p = .047). Moreover, RORγt, IL-17, IL-23, miRNA-155, miRNA-181, and miRNA-326 mRNA expression decreased significantly in the nanocurcumin group compared with baseline (p = .004, p = .009, p < .001, p < .001, p < .001, p < .001, respectively) and placebo (p = .002, p = .021, p = .006, p = .035, p < .001, p = .017, respectively). Significant reductions in IL-17 and IL-23 were seen in nanocurcumin group compared with baseline (p = .017 and p = .015) and placebo (p = .047 and p = .048, respectively). Significant reduction in disease activity was observed in nanocurcumin group compared with placebo group (p = .035).

CONCLUSION

Nanocurcumin supplementation had favorable effects in improving inflammatory factors and disease activity in BD patients. Additional studies are warranted to suggest nanocurcumin as a safe complementary therapy in BD.HighlightsNanocurcumin supplementation decreased Th17 cells frequency significantly compared with baseline and placebo group.Nanocurcumin supplementation decreased mRNA expression of RORγt, IL-17, IL-23, miRNA-155, miRNA-181, and miRNA-326 significantly compared to baseline and placebo group.Nanocurcumin supplementation decreased cell supernatant IL-17 and IL-23 significantly compared to baseline and placebo group.Nanocurcumin supplementation decreased disease activity significantly compared to placebo group.

Nanocurcumin supplementation ameliorates Behcet's disease by modulating regulatory T cells: A randomized, double-blind, placebo-controlled trial

Current research was designed to assess the effects of nanocurcumin supplementation on regulatory T (Treg) cells frequency and function in Behçet's disease (BD). In this randomized double-masked, placebo-controlled trial, 36 BD subjects were randomly put into two groups to take one 80 mg nanocurcumin capsule or placebo daily for 8 weeks. Before and after trial, disease activity, Treg cells frequency and expression of related immunologic parameters including forkhead box protein P3 (Foxp3) transcription factor messenger RNA (mRNA) and microRNAs (miRNAs) such as miRNA-25 and miRNA-106b as well as cytokines including transforming growth factor (TGF)-β and interleukin (IL)-10 were studied. Thirty-two patients (17 in the nanocurcumin and 15 in the placebo groups) completed the trial. Treg cells frequency increased significantly in the nanocurcumin group compared with baseline (P < 0.001) and placebo group (P < 0.001). Moreover, FoxP3, TGF-β, IL-10, miRNA-25, and miRNA-106b mRNA expression levels increased considerably in the nanocurcumin group compared to baseline (P < 0.001) and placebo group (P < 0.001, P < 0.001, P = 0.025, P = 0.011, and P < 0.001, respectively). Significant increases in serum TGF-β and IL-10 were seen in nanocurcumin group compared with baseline (P < 0.001) and placebo group (P = 0.001 and P < 0.001, respectively). Significant decrease in disease activity was found in nanocurcumin group compared with placebo group (P = 0.044). Our study provided a promising view for desirable effects of nanocurcumin supplementation in improving immunological parameters and disease activity in BD.

Vasculitis damage index in Behçet's disease

BACKGROUND

Vasculitis damage index (VDI) is a validated damage index for systemic vasculitis, and as Behçet's disease is considered one of systemic vascular disease we aimed to study the relationship of the vasculitis damage index to clinical manifestations and comorbidity in patients with Behçet's disease (BD) to determine if VDI could be used to assess damage in patients with BD.

METHODS

A total of 109 patients with BD were recruited from the Rheumatology Department (outpatient and inpatient clinic), Cairo University Hospitals. All patients were subjected to full history taking, clinical examination, and routine laboratory investigations. Disease activity was assessed by the BD current activity form, and the VDI was calculated in all patients. The relationship of the VDI to the disease clinical manifestations was studied. Mann-Whitney and Kruskal Wallis tests were used to estimate differences in quantitative variables. Spearman correlation test was used to test for correlation between quantitative variables.

RESULTS

In the current study, the VDI ranged from 1 to 10, with a mean of 3.5 ± 1.8. It was significantly associated with total thrombosis (P = 0.022); total neurological manifestations (P = 0.000), especially stroke and cranial nerve affection; uveitis (P = 0.005); avascular necrosis (AVN) (P = 0.015); osteoporosis (P = 0.01); impaired vision (P < 0.0001); cataract (P < 0.0001); and diabetes (P = 0.012). Generally, immunosuppressive treatment was significantly associated with VDI (P = 0.039), especially cyclophosphamide (P < 0.0001), biological agent (P = 0.008), chlorambucil (P = 0.003), and anticoagulant (P = 0.02). VDI was also significantly correlated with age (P = 0.033), disease duration (P = 0.029), and duration of eye involvement (P = 0.003).

CONCLUSION

VDI is significantly associated with most disease parameters of BD, except for parameters such as mucocutaneous manifestations and uncomplicated venous thrombosis; however, further studies may be needed to establish BD-specific damage index.

Effectiveness and Safety of Anti-Tumor Necrosis Factor-Alpha Agents Treatment in Behcets' Disease-Associated Uveitis: A Systematic Review and Meta-Analysis

Purpose

We conducted a systematic review and meta-analysis to determine the effectiveness and safety of anti-tumor necrosis factor-alpha (TNF-α) agents in the treatment of Behcets’ disease (BD)-associated uveitis.

Method

Three electronic databases, Embase, MEDLINE, and the Cochrane Library, were searched for eligible papers focusing on the anti-TNF-α agents treatment in BD-associated uveitis with at least 6 months follow-up time. A systematic review and meta-analysis was conducted on selected papers with appropriate clinical and methodological homogeneity. The effectiveness outcomes included inflammation remission, visual acuity (VA) improvement, central macular thickness (CMT) decrease, corticosteroid (CS)-sparing effects, and the safety outcomes included minor and severe drug-related adverse events (AEs).

Result

From Jan 2010 to Dec 2019, there were 504 records produced in total, in which 18 clinical trials were selected for meta-analysis (15 trials were retrospective studies, and 3 were prospective studies). The number of patients in each study ranged from 11 to 163 and the mean follow-up time from 0.9 to 6.44 years. During the follow-up, the pooled inflammation remission rate was 68% with a 95% confidence interval (CI) of 0.59–0.79, VA improvement rate was 60% (95% CI 0.47–0.77), CMT decrease was 112.70 μm (95% CI 72.8–153.0 μm). The proportions of patients who had CS-suspended and CS-tapered reached 38% (95% CI 0.23–0.65) and 34% (95% CI 0.16–0.70), respectively. The severe AEs were reported but not common, which included severe infusion reactions, pneumonia, bacteremia, tuberculosis, melanoma, and lymphoma.

Conclusion

Anti-TNF-α agents treatment has high effectiveness including efficient inflammation remission, satisfactory VA improvement, obvious CMT reduction, and significant CS-sparing effects. Although some drug-related AEs were reported, the incidence of severe AEs was acceptable. Anti-TNF-α agents treatment is a promising option for controlling BD-associated uveitis.

Epidemiology of Behcet's Disease in Taiwan: A Population-Based Study

PURPOSE

To study the incidence and epidemiology of Behcet's disease in Taiwan.

METHODS

This retrospective cohort study was conducted using the nationwide reimbursement database in Taiwan. One million registered beneficiaries of the Taiwan National Health Insurance system in 2000 were randomly selected. All medical claims of these persons were collected. The definition of having Behcet's disease was based on diagnostic codes. Persons who had incomplete registry data or diagnoses prior to 2001 were excluded. Annual incidence between 2001 and 2011 was calculated and risk factors for incidence were explored using the Cox proportional regression model. Characteristics of patients with Behcet's disease with and without uveitis were compared.

RESULTS

A total of 236 newly diagnosed patients with Behcet's disease were found between 2001 and 2011. The average incidence was 2.40 cases per 100,000 person-years (ranging from 1.29 to 3.53). Female patients and those aged between 40 and 65 years were at the highest risk of Behcet's disease. Only 18.2% of the patients had also suffered from uveitis. The subspecialties of doctors making initial diagnoses and the number of prescribed immunomodulatory agents differed significantly between the patients with and without uveitis (p < 0.001 and <0.05, respectively).

CONCLUSION

Incidence of Behcet's disease was not high in Taiwan and relatively few of the patients developed uveitis. Patients of working age or who were female were more likely to have Behcet's disease. However, age of onset and clinical severity differed between patients with and without uveitis.

Herbal medicine for Behcet's disease: A protocol for a systematic review and meta-analysis

BACKGROUND

Herbal medicine treatment is often recommended in order to raise immunity levels and reduce the possibility of recurrence of symptoms, and treating the fundamental causes of the disease. This systematic review will assess the efficacy of herbal medicine in treating Behcet's disease.

METHODS AND ANALYSIS

We will search the following 11 electronic databases from their inception: PubMed, EMBASE, and CENTRAL; 3 Chinese databases (CNKI, Wanfang, and VIP); and 5 Korean databases (OASIS, DBpia, RISS, KISS, and KoreaMed). The data will be extracted independently by 2 authors using predefined criteria. Disagreements will be resolved by discussion between the authors. The risk of bias will be assessed using the Cochrane tool for assessing risk of bias.

ETHICS AND DISSEMINATION

Ethical approval will not be required, given that this protocol is for a systematic review. The review will be published in a journal. Updates of the review will be conducted periodically to inform and guide healthcare practice and policy.

TRIAL REGISTRATION NUMBER

PROSPERO 2018 CRD42018085493.

A 25-Year-Old Male with Orogenital Ulcers, Rash, and Difficulty Swallowing

A 25-year-old otherwise healthy male presented with new-onset odynophagia, rash, and orogenital ulcers. Despite treatment with antibiotics for presumed bacterial pharyngitis, the patient remained symptomatic, with abnormal vital signs and laboratory values. Upon dermatology consultation and histopathologic correlation, he was diagnosed with Behçet disease. Behçet disease is a rare rheumatologic condition that presents with recurrent oral ulcers and varying degrees of ophthalmic, neurologic, cardiac, and vascular disease. Given its protean nature, the treatment of Behçet disease is tailored to the patient's presentation and severity of organ involvement. Following treatment with colchicine and prednisone, the patient's symptoms improved rapidly.

Severe panuveitis in neuro-Behçet's disease in Malaysia: a case series

Behçet’s disease (BD) is a multisystemic disease that is very rare in Malaysia. About 5% of patients develop central nervous system involvement, termed neuro-Behçet’s. Neuro-Behçet’s is one of the most serious causes of long-term morbidity and mortality. We report two cases of neuro-Behçet’s associated with uveitis (ocular BD) highlighting the clinical presentation, diagnostic measurement, and therapeutic management of these cases.

Analysis of Th Cell-related Cytokine Production in Behçet Disease Patients with Uveitis Before and After Infliximab Treatment

PURPOSE

To examine antigen-stimulated cytokine production by Behçet disease patients (BD) before and after infliximab infusion.

METHODS

PBMCs were obtained before and after infliximab infusion in BD patients with or without recurrent uveitis during at least 1 year of infliximab therapy, and from healthy subjects. PBMCs were cultured with IRBP, and Th-related cytokines in cultures were measured.

RESULTS

Levels of IL-4, IL-6, IL-10 IL-17A, IL-17F, IL-31, IFN-γ, and TNFα were higher in BD before infliximab infusion than in healthy subjects, and these levels were the highest in BD with recurrent uveitis. After infliximab infusion, these cytokine levels were reduced to a greater extent in BD without recurrent uveitis than in BD with recurrence.

CONCLUSIONS

Th-related cytokines produced by IRBP-stimulated PBMCs were elevated in BD, and infliximab infusion suppressed these cytokines to a greater extent in BD without recurrent uveitis than in those with recurrence.

Behçet syndrome: from pathogenesis to novel therapies

Behçet syndrome is a chronic disease hallmarked by inflammation of the blood vessels that is related to an autoimmune reaction caused by inherited susceptibility due to specific genes and environmental factors, probably components of infectious microorganisms, which turn on or get going the disease in genetically susceptible subjects. The more common clinical expression of the disease is represented by a triple-symptom complex of recurrent oral aphthous ulcers, genital ulcers, and uveitis, sometimes associated with inflammatory arthritis, phlebitis, iritis, as well as inflammation of the digestive tract, brain, and spinal cord. The treatment strategies used to manage the manifestations of Behçet syndrome have gradually progressed, and a number of new therapeutic resources have been implemented in recent years, allowing better control of pathogenic mechanisms, reducing symptoms and suffering, and ameliorating patient's outcome.

Behcet's disease presenting with recurrent ocular, oral, and scrotal inflammatory lesions in a young Tanzanian man: a case report

KEY CLINICAL MESSAGE

Behcet's disease (BD) is a rare condition which is diagnosed clinically. Only few cases have been reported in sub-Saharan Africa. We report a Tanzanian male who presented with typical features of BD and was successfully treated. There should be an increase in awareness on BD to improve the management.

Etanercept therapy in Behçet's disease. The tight control strategy in refractory disease

STUDY OBJECTIVE

The goal of the present study was to investigate patient outcome when using the TNF receptor fusion protein etanercept in addition to conventional immunosuppressive drugs in ameliorating disease intensity and reducing relapses in refractory Behçet's disease (BD).

PATIENTS AND METHODS

A single center, prospective study was conducted over 1 year. A total of 15 patients with the established diagnosis of BS were enrolled (mean age: 36.5 ± 6.75 years, mean disease duration: 3.86 ± 1.30 years). Clinical features were classified as refractory if the patients failed to achieve the desired response within 6 months of immunosuppressive and oral glucocorticoid therapy or flare of lesions developed while on the maximum tolerable doses of these drugs. The study included 2 patients who were on previous infliximab therapy for refractory disease. Inflammatory biomarkers (ESR and CRP) were investigated.

RESULTS

Baseline clinical features in the study prior to inclusion showed recurrent oro-genital ulcers were observed in 100 % of patients, the pathergy test was positive in 17.6 %, ocular involvement was observed in 86.7 %, and acne lesions were recorded in 73.3 %. The following values were also recorded: mean ESR 22 ± 16.97 mm/h, mean CRP level 6.87 ± 4.44 mg/l, mean visual analog score 5.46 ± 1.55, and mean patient global score 5.13 ± 1.30. At the beginning of the study, all patients were on oral prednisolone (mean dose: 20.16 ± 11.81 mg/day), azathioprine (mean dose: 126.66 ± 25.81 mg/day), and oral colchicine (mean dose: 1.08 ± 0.10 mg/day), then etanercept was added at a regular weekly dose of 50 mg subcutaneously for 1 year. By 8 weeks, 100 % of the patients achieve the primary endpoint, which included clinical resolution of refractory mucocutaneous, joint, and active ocular lesions with normalization of the acute phase symptoms.

CONCLUSION

Patients with refractory BD who received a 12-month treatment with etanercept in addition to conventional immunosuppressive therapy achieved a good therapeutic response with successful reduction of oral prednisolone to a mean dose of 6.66 ± 2.24 mg/day. No serious infections or drug-related adverse events reported.

Rapidly evolving large extracranial vertebral artery pseudoaneurysm in Behçet's disease: Case report and review of the literature

Behçet's disease is a multisystem chronic autoimmune disease of unknown etiology with a wide spectrum of symptoms and organ system involvement. Arterial manifestations, particularly of the extracranial vertebral arteries, are rare. We report an unusual case of an African American patient with Behçet's disease, who presented with bilateral spontaneous vertebral artery pseudoaneurysms. The patient underwent successful endovascular parent vessel occlusion with detachable coils and on follow-up had complete clinical and angiographic signs of recovery.

Combination of pulse cyclophosphamide and azathioprine in ocular manifestations of Behcet's disease: longitudinal study of up to 10 years

AIM

Ocular lesions of Behcet's disease (BD) need aggressive treatment to prevent severe loss of vision or blindness. Cytotoxic drugs are the main therapeutic agents and the first line treatment. Retinal vasculitis is the most aggressive lesion of ocular manifestations and predicts a worse systemic outcome. We present here the outcome with a combination of pulse cyclophosphamide, azathioprine and prednisolone, on long-term usage, up to 10 years, on 295 patients (18 493 eye-months of follow-up).

METHODS

Cyclophosphamide was used as a 1-g monthly pulse for 6 months and then every 2-3 months as necessary. Azathioprine was used at 2-3 mg/kg daily. Prednisolone was initiated at 0.5 mg/kg daily. Upon the suppression of the inflammatory reaction, prednisolone was tapered gradually. Patients fulfilled the International Criteria Behcet's Disease (ICBD) and had active posterior uveitis (PU) and/or retinal vasculitis (RV). Visual acuity (VA), PU, RV and TADAI (Total Adjusted Disease Activity Index) were calculated.

RESULTS

Overall results: mean VA improved from 3.5 to 4.3 (P < 0.0001), 44% of eyes improved (95% CI = 40-50). Mean PU improved from 2.1 to 0.8 (P < 0.0001), 73% of eyes improved (95% CI = 69-78). Mean RV improved from 3.0 to 1.4 P < 0.0001), 70% of eyes improved (95% CI = 65-74). Mean TADAI improved from 29 to 18 (P < 0.0001), 72% of patients improved (95% CI = 66-77). The details of the longitudinal studies are given in the main article.

CONCLUSION

All parameters significantly improved. VA improvement was the least, mainly due to cataracts. This combination is the best treatment choice for retinal vasculitis before opting for biologic agents.

Behcet's disease: systemic and ocular manifestations

AIM

The aim of this study was to evaluate if patients with Behcet's disease who have ocular involvement have a more severe form of this disease as compared to patients with Behcet's disease alone.

METHODS

A total of 99 patients were included in the study. 76 patients were used as part of the examined group, and 23 patients formed a control group.

RESULTS

The following are the results of examined and control groups, respectively: recurrent oral aphthous ulcers 89.5%, 95.7%; genital ulcers 61.8%, 97.0%; articular involvement 72.4%, 65.2%; vasculitis 81.6%, 60.9%; positive pathergy test 25.0%, 47.8%. Higher frequency of genital ulcerations was noted in control group (P = 0.001). More than two major criteria were met in 100% of the cases. HLA B51 was present in 78.9% of the cases in the examined group and 43.5% of the cases in control group; thus there is significant difference between them (P = 0.001). Visual acuity >0.5 occurred in 76% (examined group). Most frequent ocular manifestations in the examined group were retinal periphlebitis 81.6%, periphlebitis and periarteritis 65%, and serofibrinous uveitis 63.2%. Macular edema as a complication was present in 63.2%. The majority of patients (55.3%) were treated with combined therapy consisting of cyclosporine A and systemic corticosteroids. In 38.2% of patients, laser photocoagulation was used on retinal periphery.

Correlation between Ocular Manifestations and Their Complications as Opposed to Visual Acuity and Treatment in Behcet's Disease

The aim of this study was to analyze ocular manifestations, their complications, and treatment in a sample of 40 patients with confirmed Behcet's disease. Results. Serofibrinous iridocyclitis was the most common form of uveitis (60%). Retinal periphlebitis manifested in 92.5% of cases, and periphlebitis in conjunction with periarteritis was diagnosed in 72.5% of cases. Macular edema was the most frequent complication on the posterior segment (60%) and it correlated with periphlebitis (P = 0.45) and periphlebitis associated with periarteritis (P = 0.51). Cyclosporine A and corticosteroids were used in the majority of cases (67%). Following six months of therapy, a significant improvement of visual acuity occurred in patients with initial visual acuity >0.5 on both eyes. Level of visual acuity before and after treatment had a strong significant correlation coefficient with various ocular complications. Previously proven significant increase of visual acuity in patients with macular edema depicts effectiveness of treatment in these types of ocular manifestations of Behcet's disease. Conclusions. Significant improvement of visual acuity occurred in patients with initial visual acuity >0.5 on both eyes. The highest increase in visual acuity was achieved by laser photocoagulation in combination with triamcinolone acetonide P = 0.038 < 0.050.

Methotrexate in ocular manifestations of Behcet's disease: a longitudinal study up to 15 years

BACKGROUND

Ocular manifestations of Behcet's disease (BD) need aggressive treatment to prevent severe loss of vision or blindness. Cytotoxic drugs are the main therapeutic agents and the first line treatment. Methotrexate is the least toxic, used mainly for posterior uveitis. We present here the outcome of eye lesions with methotrexate and prednisolone, in a longitudinal study of up to 15 years, on 682 patients (5447 eye-years of follow-up).

PATIENTS AND METHODS

Methotrexate was started at 7.5-15 mg/week. Prednisolone was added at 0.5 mg/kg/daily, then adjusted as needed.

INCLUSION CRITERIA

(i) fulfilling the International Criteria for Behcet's Disease; and (ii) having active posterior uveitis (PU). Visual acuity (VA) was calculated on a scale of 10. Activity indexes were calculated for PU and retinal vasculitis (RV) for each eye. Total Inflammatory Activity Index (TIAI) demonstrating the inflammatory index of both eyes of the patient, and Total Adjusted Disease Activity Index (TADAI) showing both TIAI + VA were also calculated.

RESULTS

Overall results: the mean VA improvement was 0.4 (P < 001), PU 1.2 (P < 0.001) and RV 0.6 (P < 0.001). VA improved in 46.5%, PU in 75.4%, and RV in 53.7% of eyes. TIAI improved in 74% of patients and TADAI in 69.4%. VA was aggravated in 37.2%, PU in 11.1%, and RV in 30.3% of eyes. TIAI was aggravated in 17.4% and TADAI in 21.6% of the patients. The remaining kept their baseline values.

CONCLUSION

All parameters improved, PU better than RV. Improvement of VA was the least, mainly due to secondary cataracts.

Long-term efficacy and safety of infliximab in the treatment of Behçet's disease

PURPOSE

To assess the long-term efficacy and safety of infliximab therapy for the treatment of Behçet's disease patients with ocular involvement who failed to respond or did not tolerate conventional treatment.

METHODS

Retrospective study of 12 patients treated with infliximab at a starting dose of 5 mg/kg.

RESULTS

Infliximab was infused during a mean of 31.43 months. The mean follow-up period was 35.77 months (range: 6-94). All patients achieved remission, 7 of whom did not need any adjuvant immunosuppressive therapy and 9 of whom were able to discontinue systemic corticosteroids. Visual acuity remained stable or improved in 20/21 eyes. Ten patients did not report any side effect of the medication or those were mild and tolerable. We observed two major adverse events requiring withdrawal of infliximab.

CONCLUSIONS

Infliximab therapy is an effective biologic agent for the treatment of ocular inflammation in Behçet's disease unresponsive to the standard immunosuppressive therapy.

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.

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.

[Behcet syndrome: thirty comments with lung and vascular injury of peripheral vessels]

INTRODUCTION

Behcet's disease is a systematic vasculitis of unknown cause, characterized essentially by eye, cutaneous, articular, neurological and vascular manifestations.

METHODS

We retrospectively analysed the Behcet's disease cases that were followed up in our ward from January 2000 to January 2009. The inclusion criteria were those of International Study Group on Behçet's disease (aphthosis mouth was required). Data were retrieved and analysed with two softwares (Access(®) and Epi Info(®)).

RESULTS

We observed 30 cases with vascular lesions on a series of 92 patients with Behcet's disease. Most patients were male, with an average age around 40. The venous manifestations, concerning essentially the lower limbs (deep and superficial thrombosis) were found at 27 patients (90 %), and the average of age during the appearance of the venous lesions was 40 years. Arterial lesions appear more late in 13 patients (43 %) (average of age 43 years). We noted, on the other hand, 11 cases of aneurysms and five cases of arterial thrombosis. The use of corticosteroids was necessary in all cases in association with the others drugs (anticoagulants, colchicine, immunosuppressors). Among the patients having had aneurysms, six were treated surgically. The outcome was favorable for most patients. Two patients had pulmonary embolism and two post-surgery complications. One patient died in the consequences of an intragastric break of an aneurysm of the abdominal aorta.

CONCLUSION

The vascular involvement in Behcet's disease is manifested primarily by thrombophlebitis. Achieving blood pressure, less common, is problematic therapeutic because of the recurrent and life threatening.

Evaluation of current therapeutic strategies in Behçet's disease

Behçet's disease (BD) is a chronic relapsing vasculitis with multifunctional pathogenesis. The mucocutaneous and ocular lesions are the commonest manifestations, but BD also affects the musculoskeletal, intestinal, cardiac, and central nervous system. BD therapy is based on the suppression of the inflammatory process, using immunomodulating and immunosuppressive agents. In selected cases, invasive procedures may be required.

[Multiple arterial thrombosis in Behçet's disease]

Behcet's disease (BD) is a multisystemic vasculitis. Its etiopathogeny remains unknown. Vascular involvement in BD is frequent and venous thrombosis is the most common manifestation (30% of cases). Arterial involvement is rare (2.7 to 7%). The latter is often severe and considered as a life threatening complication. Pathogenesis of thrombosis occurring in BD remains unclear. We report a 45-year-old man, from south of Tunisia, who presented a BD with a bifocal arterial involvement: right internal carotid thrombosis and bilateral proximal thrombosis of the two pulmonary arteries. Therapeutic strategies to address this multiple arterial involvement and the pathogenesis of thrombosis raise many questions.

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.

Safety and efficacy of infliximab therapy in active behcet's uveitis: an open-label trial

In this open-label trial, ten male patients with active Behcet's uveitis were enrolled. Initially, two infliximab infusions (5 mg/kg) were given at weeks 0 and 2. The patients continued to receive conventional therapy on recurrence of severe uveitis (RSU) attack. The patients with further attack were regularly given infliximab infusions every 8 weeks. In cases of further RSU attacks, the infusion interval was reduced to 6 weeks. The total follow-up period was 3 years. The patients were monitored for RSU, visual acuity and adverse effects. Reduction in the doses of prednisolone was also monitored. After receiving two infliximab infusions at weeks 0 and 2, three patients remained attack-free and seven patients had another RSU attack between 8th and 47th week. These patients were regularly given infliximab at 8-week intervals. Five out of seven patients remained attack-free. In two patients who had further attack, infusion frequency was increased to 6 weeks. There was a remarkable improvement in visual acuity with no significant adverse reaction except mild respiratory tract infection (two patients), headache (one patient) and mild infusion reaction (one patient). Infliximab is a safe and effective drug for the management of Behcet's uveitis. Selection of optimal dose and frequency of infusion required standardization for individual patient.

Interrelated modulation of endothelial function in Behcet's disease by clinical activity and corticosteroid treatment

Corticosteroids are commonly used in empirical treatment of Behçet's disease (BD), a systemic inflammatory condition associated with reversible endothelial dysfunction. In the present study we aimed to dissect the effects of clinical disease activity and chronic or short-term corticosteroid treatment on endothelial function in patients with BD. In a case-control, cross-sectional study, we assessed endothelial function by endothelium dependent flow mediated dilatation (FMD) at the brachial artery of 87 patients, who either were or were not receiving chronic corticosteroid treatment, and exhibiting variable clinical disease activity. Healthy individuals matched for age and sex served as controls. Endothelial function was also assessed in a prospective study of 11 patients before and after 7 days of treatment with prednisolone given at disease relapse (20 mg/day). In the cross-sectional component of the study, FMD was lower in patients than in control individuals (mean ± standard error: 4.1 ± 0.4% versus 5.7 ± 0.2%, P = 0.003), whereas there was a significant interaction between the effects of corticosteroids and disease activity on endothelial function (P = 0.014, two-factor analysis of variance). Among patients with inactive BD, those who were not treated with corticosteroids (n = 33) had FMD comparable to that in healthy control individuals, whereas those treated with corticosteroids (n = 15) had impaired endothelial function (P = 0.023 versus the respective control subgroup). In contrast, among patients with active BD, those who were not treated with corticosteroids (n = 20) had lower FMD than control individuals (P = 0.007), but in those who were receiving corticosteroids (n = 19) the FMD values were comparable to those in control individuals. Moreover, FMD was significantly improved after 7 days of prednisolone administration (3.7 ± 0.9% versus 7.6 ± 1.4%, P = 0.027). Taken together, these results imply that although corticosteroid treatment may impair endothelial function per se during the remission phase of the inflammatory process, it restores endothelial dysfunction during active BD by counteracting the harmful effects of relapsing inflammation.

An atypical case of Whipple's disease: case report and review of the literature

We report the case of a 57-year-old man, presenting with bilateral panuveitis, bilateral sacroiliitis, intermittent pyrexia and a pulmonary nodule. The patient had been under immunosuppressive treatment for 2 years for Behçet's disease. However, he did not fulfill the diagnostic criteria of Behçet's disease. Blood analysis showed a very high C reactive protein (CRP at 34 mg/dl). In view of severe intra-ocular inflammation, the anterior chamber was punctured. Polymerase chain reaction (PCR) on the aqueous humour and on the blood revealed the presence of Tropheryma whippelii DNA, an agent responsible for Whipple's disease. The patient was treated with ceftriaxone followed by trimethoprim-sulfamethoxazol for 1 year with good clinical and biological evolution. This case illustrates the difficulty to diagnose an atypical Whipple's disease. In cases of uveitis with atypical signs and/or not responding to the treatment, the internist must consider to perform an analysis of the ocular fluids.

Pentoxifylline inhibits Vgamma9/Vdelta2 T lymphocyte activation of patients with active Behçets disease in vitro

The aim of this study is to evaluate the in vitro effect of pentoxifylline (PTX) on T Vgamma9/Vdelta2 lymphocyte function in Behçets disease (BD). We investigated the effect of PTX on Vgamma9/Vdelta2 T cell expansion and expression of TNFRII receptor and perforin content before and after PTX addition by means of FACS analysis lymphocyte cultures from patients with active and inactive BD and healthy subjects. The addition of PTX at a concentration of 1 mg/ml determined a significant inhibition of cell expansion, a down regulation of TNF receptor expression and inhibited the PMA-induced degranulation of perforin. Taken together these data indicate that PTX is capable of interfering with Vgamma9/Vdelta2 T cell function in BD, and although cell culture models cannot reliably predict all of the potential effects of the drug in vivo, our results encourage the possibility that this drug may find use in a range of immunological disorder characterized by dysregulated cell-mediated immunity.

Major arterial involvement and review of Behcet's disease

Behcet's disease was first defined by Hulusi Behcetin 1937 as a multisystemic disorder with characteristic pathologic findings including recurrent orogenitalulcers, vascular disorders, and ocular and cutaneous lesions. The disease is mostly encountered at the third and fourth decades of life and especially prevalent in Mediterranean and Far East Asia.Behcet's disease may have both venous and arterial manifestations. The arterial form is rare but it is bore with its manner and to consider recurrent surgical treatments. In this retrospective study, we reviewed the literature related to Behcet's disease and discussed in respect to vascular involvement and the prognosis of surgical treatment.Thirty-one consecutive patients with vasculo-Behcet's disease visiting the departments of cardiovascular surgery, dermatology, and internal medicine in Medical Faculty of Istanbul have been reviewed retrospectively. All available clinical,pathologic, and postoperative data were reviewed and analyzed. Venous system pathologies were present in 15 patients. The pathologies in the remaining patients were related to the arterial tree. Ten patients with aneurysms and/or pseudoaneurysms and six patients with occlusive lesions have undergone surgical treatment. Pseudoaneurysms occurred in six patients at least twice or more. Vascular manifestations are the main predictors of mortality and morbidity in Behcet's disease. Arterial complications may lead to difficult surgical problems.Any invasive methods to arterial system may cause pseudoaneurysms. Repairs by using autogenous veins or synthetic grafts may lead to anastomotic false aneurysms. Surgical treatment should not to be applied in the acute phase of the disease and systemic therapy including colchicine, aspirin,and corticosteroids should be considered for all patients.

Tumor necrosis factor antagonists: preliminary evidence for an emerging approach in the treatment of ocular inflammation

The anti-tumor necrosis factor (TNF) monoclonal antibody infliximab and the soluble TNF receptor etanercept inhibit the pleiotropic actions of TNF and are widely used for the treatment of rheumatoid arthritis (RA), juvenile idiopathic arthritis (JIA), spondyloarthropathies (SpA), Crohn's disease, and psoriasis with an acceptable safety profile. A pathogenetic role of TNF in ocular inflammatory conditions has recently emerged from small trials reporting preliminary results on the efficacy of these agents in patients with noninfectious uveitis, regardless of the origin of the disease. The authors review the published experience, derived mostly from investigator-sponsored trials and uncontrolled case series, on the use of TNF antagonists in approximately 280 patients with various ocular conditions who were inadequately controlled on currently available therapy. These reports suggest that TNF antagonists, mainly infliximab, which may have better efficacy than etanercept, are useful in the treatment of ocular inflammation associated with Adamantiades-Behçet's disease, RA, JIA, SpA, Crohn's, sarcoidosis, and Graves' disease ophthalmopathy. Infliximab was also beneficial in small numbers of patients with idiopathic uveitis or scleritis, birdshot retinochoroiditis, uveitic and diabetic cystoid macular edema, and age-related macular degeneration. The currently available data are nonrandomized and thus preliminary, providing the foundation and justification for randomized trials to assess efficacy and safety. Until such results are available, knowledge regarding the use of anti-TNF regimens in ophthalmology is incomplete. However, the preliminary evidence points to a growing optimism for targeting TNF in patients with ocular inflammation.

Bone mineral density and bone turnover markers of patients with Behçet's disease

BACKGROUND

Behçet's disease (BD) is a systemic inflammatory disease of unknown aetiology. The pathogenesis of rheumatological findings and the status of bone metabolism in this disease are unknown. Inflammatory diseases may predispose to a decrease in bone mineral density (BMD) and there are many studies concerning osteoporosis in chronic inflammatory diseases.

OBJECTIVE

The aim of this study was to investigate BMD and bone turnover markers in patients with BD.

METHODS

Thirty BD patients (17 male and 13 female patients, mean age 36.9+/-12.6 years) and a total of 30 age- and sex-matched healthy controls (17 male and 13 female controls, mean age 34.9+/-8.95 years) recruited from the general population were enrolled in the study. Bone mineral density was measured at the lumbar spine (L1-4) and the left hip (total hip) using dual energy X-ray absorptiometry. Serum samples were collected between 8 and 10 am after overnight fasting. Serum calcium (Ca), phosphate (P), parathormone (PTH), total alkaline phosphatase (ALP), osteocalcin (OC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured. Free deoxypyridinoline cross-links (DPD) in second-void urine and total daily urinary calcium excretion were analysed.

RESULTS

No statistically significant difference in lumbar spine or femoral BMD and bone turnover markers were found between BD patients and control groups (P>0.05).

CONCLUSION

Although it is difficult to draw definite conclusions because of the limited number of patients involved, our study indicates that bone mineral density and bone turnover markers in Behçet's disease were no different than in healthy subjects.

Behçet disease: recommendation for clinical management of mucocutaneous lesions

Mucocutaneous lesions are the most common manifestation of Behçet disease. These lesions can often become refractory to multiple treatments and present challenges to physicians. In this article, different treatments for mucocutaneous lesions in Behçet disease are reviewed and discussed. Topical or intralesional corticosteroids, oral pentoxifylline, sucralfate, dapsone, colchicine, and systemic low-dose corticosteroids, used either alone or in combination, are safe and having varying evidence for effect in mild to moderate mucocutaneous disease. Azathioprine or methotrexate can be used if the lesions are refractory to the previously mentioned therapies. Tumor necrosis factor (TNF) inhibitors such as infliximab or etanercept should be considered as the next step in the treatment if azathioprine or methotrexate fails. Tacrolimus, cyclosporine, and interferon-alpha-2a should be used generally only if TNF inhibitors have failed as a result of their toxicities.

Neutrophilic dermatoses

Neutrophils may infiltrate all layers of the skin and consequently may cause different disorders, each with its own characteristic clinical and laboratory findings. We discuss how these disorders present and how they are diagnosed and treated. In addition, important associations with internal diseases are discussed to assist clinicians in evaluating for a concurrent illness. Because treatment of these disorders may often require systemic therapy, the potential short-term and long-term effects of commonly used medications are discussed. Finally, treatment of recalcitrant diseases, mostly by use of therapies published in the form of small case series or reports, is also included to guide clinicians in dealing with the more challenging cases.

Serum and erythrocyte adenosine deaminase activities in patients with Behçet's disease

OBJECTIVES

Adenosine deaminase (ADA) is a non-specific marker of the activation of the T cell, which has an important role in the etiology of Behçet's disease (BD). The purpose of this study was to investigate the determination of ADA activity as an index of T-lymphocyte function in BD, which is known to have an T-cell-mediated immune response.

MATERIALS AND METHODS

Adenosine deaminase activities in both serum and erythrocytes were measured in 23 untreated patients with BD and in 20 healthy controls. The patients with BD were divided into two groups: active (n = 10) and inactive (n = 13).

RESULTS

When compared with the control group, serum ADA activity was high (P < 0.01) and erythrocyte ADA activity was significantly low (P < 0.01) in BD. Serum ADA activity of active BD was higher than that of inactive BD (P < 0.01), but erythrocyte ADA activity was found to be lower in active BD than inactive BD (P < 0.01).

COMMENT

These findings may provide an additional benefit for the diagnosis of BD and sub-typing of active and inactive BD.

Behçet’s disease associated with superior vena cava syndrome without thrombosis

Behçet's disease is a multisystemic vasculitis of unknown etiology, which is characterized by recurrent urogenital ulceration, cutaneous eruptions, ocular manifestations, arthritis and vasculitis, and its diagnosis is based on clinical criteria. Superior vena cava (SVC) thrombosis is a rare but well-recognized manifestation of Behçet's disease, whereas SVC syndrome due to vasculopathy, without evidence of thrombosis, has not yet been described in the literature. The authors report the case of a patient with Behçet's disease, who presented SVC syndrome with reduction in the lumen of the SVC due to thickening of the vessel wall, without evidence of thrombosis upon computed tomography and magnetic angioresonance. The patient received early anticoagulant therapy, corticosteroid and monthly cyclophosphamide pulse therapy. Clinical control without recurrence was observed after 6 months of follow-up. Behçet's disease should be suspected in young patients presenting with SVC syndrome, in the absence of thrombosis or of a hypercoagulable state.