Characteristics of vascular involvement in Behçet's disease

Management of abdominal trauma in a patient with Behçet's disease: A case report

INTRODUCTION

Managing blunt abdominal trauma in Behçet's disease poses challenges due to underlying vasculitis and potential vascular complications.

CASE PRESENTATION

This case report discusses a patient who suffered abdominal trauma following a vehicular accident. Initial management focused on stabilizing hemodynamics and assessing injuries using diagnostic imaging. Surgical intervention, including exploratory laparotomy, was necessary to address bleeding and evaluate abdominal injuries amidst collateral circulation and mesenteric hematoma.

DISCUSSION

Surgical intervention was essential in this case, with exploratory laparotomy required to control bleeding and assess abdominal injuries. The presence of collateral circulation can obscure the visualization of bleeding sources and complicate the surgical approach. Moreover, mesenteric hematoma, a potential complication in such cases, further complicates the surgical management by potentially masking other injuries and contributing to increased risk of intra-abdominal complications.

CONCLUSION

Postoperative care involves monitoring for complications related to trauma and Behçet's disease, emphasizing a multidisciplinary approach for optimal patient outcomes.

Cardiovascular Manifestations in Behçet's Disease

Cardiovascular involvement in Behçet's disease (BD) is considerably related to morbidity and mortality. However, the cardiovascular manifestation is sometimes difficult to distinguish from those of other causes. The suspicion of BD and proper treatment is pivotal in the management of BD. Histology demonstrates perivasculitis. Neutrophil seems to play an important role in the inflammation of BD. It is thought that inflammation causes venous thrombosis and arterial aneurysm. Characteristically, BD involves both arteries and veins of variable size in any region. Venous thrombosis needs immunosuppression, and inferior vena cava thrombosis and Budd-Chiari syndrome require intensive immunosuppressive therapy. Arterial involvement causes aneurysm which usually is treated by surgical or endovascular intervention with immunosuppression. Pulmonary artery aneurysm and cardiac involvement require multimodal managements.

Imaging characteristics and prognostic factors of Behcet's disease with arterial involvement: A long-term follow-up study

PURPOSE

To investigate the imaging characteristics and prognostic factors for the long-term survival of Behcet's disease (BD) with arterial involvement.

METHODS

In this retrospective study, BD patients with arterial involvement were identified from January 2003 to January 2020. Arterial lesions were detected by ultrasonography, traditional arteriography, and/or computed tomography angiography (CTA). Cox proportional hazards regression analyses were performed to identify the prognostic factors.

RESULTS

Totally, 84 BD patients with arterial involvement were identified (73.8 % males). The mean age at BD diagnosis was 39.1 ± 13.1 years. Arterial involvement was the initial manifestation in 33.3 % of the patients, and the median time from BD diagnosis to arterial involvement was 6 (IQR 1-15.5) years for the rest of patients. Systemic artery involvement and pulmonary artery involvement (PAI) were found in 64 and 27 patients, respectively. Approximately 94.0 % (79/84) of the patients had more than one artery involved concurrently or successively during the course of BD. Aneurysm/dilation was the most prevalent lesion in the aorta (76.0 %), while stenosis/occlusion was the main lesion of the coronary artery (90.9 %) and other aortic branches (74.5 %). Pulmonary hypertension was found in 70.4 % (19/27) of patients with PAI. The 5- and 10-year survival rates of BD patients with arterial involvement were 87.4 % and 84.1 %, respectively. Cardiac involvement (HR: 4.34) and pulmonary artery aneurysm/dilation (HR: 4.89) were independently associated with mortality.

CONCLUSIONS

Arterial lesions associated with BD usually involve multiple arteries and manifest differently in different types of arteries. Cardiac involvement and pulmonary artery aneurysm/dilation are independent prognostic factors of BD patients with arterial involvement.

Recommendations for the management of the vascular involvement in Behçet's disease by the Japanese National Research Committee for Behçet's disease-secondary publication

OBJECTIVES

This study aimed to develop clinical guidelines for the management of vascular Behçet's disease (BD) by the Behçet's Disease Research Committee of the Ministry of Health, Labour and Welfare of the Japanese Government.

METHODS

A task force proposed clinical questions (CQs) concerning vascular BD based on a literature search. After screening, draft recommendations were developed for each CQ and brushed up in three blinded Delphi rounds, leading to the final recommendations.

RESULTS

This study provides recommendations for 17 CQs concerning diagnosis and differential diagnoses, assessment of disease activity, and treatment. The guidelines recommend immunosuppressive treatments, for both arterial and venous involvement with active inflammation. Anticoagulation is also recommended for deep vein thrombosis except in high-risk patients. Surgical and endovascular therapies can be optional, particularly in patients with urgent arterial lesions undergoing immunosuppression. In addition, two sets of algorithms for diagnosis and treatment are shown for arterial and venous involvement.

CONCLUSIONS

These recommendations are expected to serve as useful tools in the daily clinical practice of BD. This content has already been published in Japanese in the Guideline for the Management of Behçet's Disease 2020 and is submitted with permission from both the primary and secondary publishers.

Proteomics Landscape Mapping of Organ-Resolved Behçet's Disease Using In-Depth Plasma Proteomics for Identifying Hyaluronic Binding Protein 2 Expression Associated With Vascular Involvement

OBJECTIVE

This study was undertaken to elucidate the pathogenesis and heterogeneity of Behçet's disease (BD) involving different organs using in-depth proteomics to identify the biomarkers for clinical assessment and treatment of patients with BD.

METHODS

We measured the expression levels of proteins in plasma samples from 98 patients with BD and from 31 healthy controls using our in-depth proteomics platform with a data-independent acquisition mass spectrometer and antibody microarray. We performed bioinformatics analyses of the biologic processes and signaling pathways that were changed in the BD group and constructed a proteomics landscape of organ-resolved BD pathogenesis. We then validated the biomarkers of disease severity and the vascular subset in an independent cohort of 108 BD patients and 29 healthy controls using an enzyme-linked immunosorbent assay.

RESULTS

The BD group had 220 differentially expressed proteins, which discriminated between BD patients (88.6%) and healthy controls (95.5%). The bioinformatics analyses revealed different biologic processes associated with BD pathogeneses, including complement activation, wound healing, angiogenesis, and leukocyte-mediated immunity. Furthermore, the constructed proteomics landscape of organ-resolved BD identified proteomics features of BD associated with different organs and protein targets that could be used for the development of therapeutic treatment. Hyaluronic binding protein 2, tenascin, and serpin A3 were validated as potential biomarkers for the clinical assessment of vascular BD and treatment targets.

CONCLUSION

Our results provide valuable insight into the pathogenesis of organ-resolved BD in terms of proteomics characteristics and potential biomarkers for clinical assessment and potential therapies for vascular BD.

[Vascular manifestations of Behcet's disease]

Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. It is one of the main causes of death in Behçet's disease. Venous involvement is significantly more common than arterial disease and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressant's are the recommended first-line treatments in vasculo-Behçet. Furthermore, randomized controlled trials are still needed to assess the role of adding anticoagulation to current standard therapy in venous thrombosis in Behçet's disease and to assess the role of anti-TNF alpha therapy in vasculo-Behçet.

Risk factors of cardiovascular involvement in patients with Behcet's disease

Objectives

Behcet's disease (BD) is a multi-systemic inflammatory vasculitis which may be life-threatening if combined with cardiovascular problems. The aim of the study was to identify potential risk factors associated with cardiovascular involvement in BD.

Methods

We reviewed the medical databases of a single center. All BD patients identified as fulfilling the 1990 International Study Group criteria or the International Criteria for Behcet's Disease criteria. Cardiovascular involvement, clinical manifestations, laboratory features, and treatments were recorded. The relationship between parameters and cardiovascular involvement was analyzed.

Results

111 BD patients were included: 21 (18.9%) had documented cardiovascular involvement (CV BD group) and 99 (81.1%) had no cardiovascular involvement (non-CV BD group). Compared with non-CV BD, the proportion of males and smokers were significantly increased in CV BD (p = 0.024 and p < 0.001, respectively). Levels of activated partial thromboplastin time (APTT), cardiac troponin I and C-reactive protein were significantly higher (p = 0.001, p = 0.031, and p = 0.034, respectively) in the CV BD group. Cardiovascular involvement was associated with smoking state, the presence of papulopustular lesions, and higher APTT in multivariate analyzed (p = 0.029, p = 0.021, and p = 0.006, respectively). The ROC curve showed that APTT predicts the risk of cardiovascular involvement (p < 0.01) at a cut-off value of 33.15 s with a sensitivity of 57.1% and specificity of 82.2%.

Conclusion

Cardiovascular involvement in BD patients was associated with gender, smoking state, the presence of papulopustular lesions, and higher APTT. All patients newly diagnosed with BD should be systematically screened for cardiovascular involvement.

Arterial and venous involvement in Behçet's syndrome: a narrative review

Behçet syndrome (BS) is a unique type of vasculitis that affects veins and arteries of all sizes, leading to recurrent vascular events, mostly venous thrombosis. The prevalence of venous thromboembolism in BS patients ranges between 15 and 40%. Thrombosis is usually an early manifestation leading to diagnosis of BS in up to 40% of patients. BS is per se a model of inflammation-induced thrombosis. The primary autoimmune response activates lymphocytes that in turn produce a cytokine cascade that activates neutrophils, which modify the secondary structure of fibrinogen making it less susceptible to plasmin-induced lysis. This leads to endothelial dysfunction, platelet activation and overexpression of tissue factor leading to inflammatory thrombi, usually attached to the wall. The pathogenesis of thrombosis is especially relevant to direct the specific treatment, that is based on immunosuppression rather than anticoagulation. Superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) are the most common form of thrombosis in BS, but thrombosis in atypical sites (cava vein, suprahepatic veins, intracardiac thrombus) and arterial involvement can also occur. We assessed the latest update of the European League Against Rheumatism recommendations for the management of BS. Vascular Behçet treatment is usually based of immunosuppressants, and the role of anticoagulation remains controversial. The use of interventional and surgical procedures should be carefully evaluated, due to the risk of triggering a vascular pathergy phenomenon.

Vascular complications of Behçet disease

Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological, and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. Venous involvement is significantly more common than arterial disease, and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressants are the recommended first-line treatments in vasculo-Behçet. Furthermore, controlled trials are still needed to assess the role of adding anticoagulation to the treatment regimen, with an accent on new oral anticoagulants. Treatment with anti-TNF alpha agents seems promising, but the management strategies are not clear yet.

Thrombotic manifestations of VEXAS syndrome

VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome is a recently described autoinflammatory syndrome characterized by diffuse inflammatory manifestations, predisposition to hematological malignancy, and an association with a high rate of thrombosis. VEXAS is attributed to somatic mutations in the UBA1 gene in hematopoietic stem and progenitor cells with myeloid restriction in mature forms. The rate of thrombosis in VEXAS patients is approximately 40% in all reported cases to date. Venous thromboembolism predominates thrombotic events in VEXAS. These are classified as unprovoked in etiology, although systemic and vascular inflammation are implicated. Here, we review the clinical and laboratory characteristics in VEXAS that provide insight into the possible mechanisms leading to thrombosis. We present knowledge gaps in the mechanisms and management of VEXAS-associated thromboinflammation and propose areas for future investigation in the field.

Analysis of vascular involvement in 460 patients with Behçet's syndrome: Clinical characteristics and associated factors

OBJECTIVES

To describe demographic and clinical characteristics of vascular involvement in patients with Behçet's syndrome (BS) and to evaluate associations with such involvement.

METHODS

We retrospectively evaluated records of 2118 BS patients. In total, 460 patients diagnosed with superficial thrombophlebitis (ST) and/or major vascular events (venous and/or arterial involvements) were included in current analysis. Isolated ST with no accompanying deep venous thrombosis might be accepted as part of skin involvement; therefore, we defined two different outcomes for vascular involvement ("any vascular event" and "major vascular events") and performed univariable and multivariable logistic regression to assess factors associated with these outcome variables.

RESULTS

Overall, 68 (14.8%) patients had isolated ST, and 392 (85.2%) had major vascular events. The mean age of vascular BS was 33.8 (SD: 10.5) years and median follow-up was 13.9 (Q1-Q3: 8.3-22.9) years. The primary sites of major vascular events were deep venous thrombosis (n=358, 77.8%), pulmonary arterial involvement (n=66, 14.3%), extrapulmonary arterial involvement (n=52, 11.3%), and intracardiac thrombosis (n=14, 3.0%), respectively. Male sex was significantly associated with a higher risk for both outcome variables. When it was added to analysis, ST itself was the strongest explanatory variable that was associated with major vascular events in all multivariable models (ORs=11.9, 12.0, 13.0, and 18.9). While HLA-B51 was significantly associated with any vascular event, there was no similar observation for major vascular events.

CONCLUSION

Male sex is a well-known risk factor for major vascular events in BS, but our study established that presence of ST was the strongest risk factor.

An association study between FokI, BsmI, miR-146a, and miR-155 and Behcet’s disease in the Egyptian population

Background

Behcet’s disease (BD) is a systemic inflammatory disease of the blood vessels and affects various body parts. This study aimed to determine the association of four single-nucleotide polymorphisms (SNPs) and BD in the Egyptian population using multiple statistical models and show the resulting associations along with previous studies of different populations. Four SNPs were examined for their association with BD: two SNPs from vitamin D receptor gene (FokI and BsmI) were selected and the other two were selected from miR-146a and miR-155. These four SNPs were selected for their association and role with BD in different populations and in the immune system. A marker check was conducted using the Hardy-Weinberg equilibrium and minor allele frequency. The associations were tested using four different statistical models: multiplicative, dominant, recessive, and codominant models. All statistical models used the odd’s ratio (OR) with confidence interval (CI) of 95% to evaluate the association of each SNP.

Results

BsmI showed association using the four models, while FokI did not show any association through any model. miR-155 showed association using the multiplicative and recessive models. miR-146a showed association using the multiplicative model only.

Conclusions

As a result, BsmI, miR-155, and miR-146a SNPs could have a role in the development of BD in the Egyptian population, while FokI could have a weak role, if any, in the development of BD in the Egyptian population.

Behçet’s Syndrome Complicated with Pulmonary Artery Thrombosis: Response to Tocilizumab Treatment

Die Beteiligung der Lungenarterie ist eine seltene, aber tödliche Komplikation des Morbus Behçets (MB). Hier berichten wir über einen männlichen MB-Patienten mit zwei vaskulären Komplikationen, nämlich dem Budd-Chiari-Syndrom und der Pulmonalarterienthrombose. Der Patient litt unter einer rezidivierenden Lungenarterienthrombose, die gegen mehrere immunsuppressive Medikamente, einschließlich hochdosierter Glukokortikoide und dem Anti-TNF-Mittel Infliximab, refraktär war. Infolge mehrerer Rezidive wurde er effektiv mit Tocilizumab behandelt, wodurch auch eine vollständige Rekanalisation der thrombosierten Arterien erreicht wurde.

Characterization of Venous Involvement in Vasculo-Behçet Disease

Background

Behçet disease is a chronic inflammatory disorder with a varying etiology. Herein, we report the involvement of peripheral veins in Behçet disease and discuss the treatment thereof.

Methods

Thirty-four patients with venous involvement in vasculo-Behçet disease were retrospectively analyzed over 15 years. We reviewed the clinical manifestations, treatment choices, and complications of these patients.

Results

Deep vein thrombosis (DVT) was observed in 24 patients (70.59%) and varicose veins in 19 (52.94%). Immunosuppressive treatment was administered to all patients due to the pathological feature of vein wall inflammation. In patients with DVT, anticoagulation therapy was also used, but post-thrombotic syndrome was observed in all patients along with chronic luminal changes. Eleven patients with isolated varicose veins underwent surgery; although symptoms and lesions recurred in half of these patients, no cases of secondary DVT occurred.

Conclusion

When DVT was diagnosed in patients with Behçet disease, there was no cure for the lesions. Ultrasonographic abnormalities were observed in all patients, and post-thrombotic syndrome remained to varying degrees. In cases of isolated varicose veins in patients with Behçet disease, DVT did not occur after surgical treatment. If the activity of Behçet disease is controlled, surgical correction of varicose veins is preferable.

Serious Right Coronary Artery Thrombosis Revealing Behçet's Disease in a Female Patient: A Case Report

Although atherosclerosis remains the major cause of acute coronary syndrome, there are many other etiologies that should be taken into account, especially in young patients with no atherosclerotic risk factors. Coronary involvement is extremely rare in patients with Behçet's disease, notably in young patients. In addition, acute inferior myocardial infarction revealing Behçet's disease has rarely been reported. Through this article, we report a case of Behçet's disease with arterial involvement diagnosed after myocardial infarction resulting from thrombosis of the right coronary artery in a 50-year-old woman with no specific medical history.

Recurrent myocardial infarction associated with vasculo-Behçet's disease: a case report

A 39-year-old Japanese man presented with chest oppression in February 2017. Electrocardiogram showed ST-elevation myocardial infarction (MI), and cardiac catheterisation revealed thrombotic occlusion of the right coronary artery (RCA), which was treated with thrombectomy, and he received warfarin. Three days after discharge, he complained of chest oppression again, and re-cardiac catheterisation showed thrombi occlusion of the circumflex artery (LCX) and 90% stenosis with thrombosis in the proximal site of the anterior descending artery (LAD) and RCA. Drug eluting stent was implanted in the LAD and RCA; aspirin and prasugrel hydrochloride were added to warfarin. Before discharge, coronary computed tomography angiography (CTA) found new thrombi in the RCA, LAD, and LCX, and he was referred to our hospital on suspicion of Behçet's disease (BD). Past medical history was notable for recurrent aphthous stomatitis, a pudendal ulcer, and Crohn's disease, for which he had been taking infliximab (5 mg/kg) every 8 weeks until December 2016. Notably, his C-reactive protein (CRP) level increased before and after each MI, suggesting that the thrombi were caused by inflammation. Consequently, we concluded that his abnormalities were manifestations of vasculo-BD. After 3 days of hospitalisation, treatment with prednisolone and colchicine was started. His CRP and D-dimer levels decreased, and coronary CTA after 8 days showed disappearance of the thrombi. We tapered the prednisolone dose, and cardiovascular events have not been observed for 7 months after the treatment initiation. In summary, we report a rare case of MI associated with vasculo-BD and review the relevant literature.

Cardiac involvement in the adult primary vasculitides

INTRODUCTION

Heart involvement in vasculitis is rare, but potentially severe. The ascertainment of cardiac disease in vasculitis is complex and requires an integrated multidisciplinary approach involving the Rheumatologist, Radiologist, Cardiologist, and Heart surgeon.

AREAS COVERED

the authors searched PubMed using the keywords 'heart'[Mesh] and vasculitis"[Mesh].

EXPERT OPINION

Virtually any vasculitis can affect the heart, but cardiac involvement is more common in some vasculitides such as Takayasu arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis. Immunosuppressive treatment and when indicated surgery can improve the prognosis.

Clinical characteristics and factors influencing the prognosis of Behçet’s disease complicated with vascular involvement

Summary: Background: Vascular Behçet's disease (VBD) might involve all sizes of arterial and venous vessels. Major vascular involvement caused the primary death in Behçet's syndrome (BS). We aimed to investigate the clinical characteristics and factors influencing the prognosis of VBD. Patients and methods: A retrospective analysis of the prospectively collected data of the Shanghai BS database from October 2012 to October 2018 was conducted. Patients who were diagnosed with BS and merged with venous thrombosis, arterial aneurysms, and arterial stenosis/occlusions were enrolled. Results: There were 47 patients with vascular involvement among 836 BS patients, 38 males and 9 females. The numbers of patients with venous thrombosis, arterial aneurysm, and arterial stenosis/occlusion were 25 (53.2 %), 21 (44.7 %), and 12 (25.5 %), respectively. Nearly half of the venous thromboses were located in limbs (n = 22, 46.8 %). Arterial aneurysm was the main form of arterial lesion. Most of the patients (93.6 %) were treated with corticosteroids and immunosuppressants. Late onset of BS or with arterial involvement had lower treatment response. Therapy with biological agents had significantly better results than that in the group without biological treatment (94.1 % vs. 80 %, P = 0.005). Conclusions: VBD showed a male preponderance and more than half of the patients presented with venous thrombosis. Late onset and arterial involvement were associated with poor prognosis. Therapy with biological agents is a viable alternative treatment to improve the prognosis.

Behçet's disease; A rare refractory patient with vena cava superior syndrome treated with infliximab: a case report and review of the literature

Objectives: Behçet's disease (BD) is a multi-systemic inflammatory disorder which can affect all types and sizes of vessels.The usage of TNF-α antagonists is increasing in different involvements of BD that is inadequately controlled by standard immunosuppressive regimens. Methods: Here we reported a rare BD case that is controlled by only infliximab (IFX) treatment. Results: A 24-years-old male patient was diagnosed as BD with recurrent oral and genital ulcerations,uveitis,femoral vein thrombosis and HLA-B5 positivity.He had had terminal ileitis,epididymitis,bilateral internal iliac artery aneurysm and superior sagittal sinus thrombosis after the diagnosis.He admitted to our outpatient clinic with dyspnea,orthopnea,chest pain and facial swelling.We detected facial edema,plethora,venous distention on neck and chest.We suspected vena cava superior syndrome(VCSS) and performed CT angiography that demonstrated high-grade vena cava superior stenosis and thrombus where SVC opens to the right atrium.Patient was anticoagulated with warfarin and a shunt was implanted between the left brachiocephalic vein and right atrium.Colchicine and interferon-alfa treatment were continued and 1mg/kg steroid was added.But the patients' symptoms relapsed one month later and his shunt was revised with balloon angioplasty.5mg/kg IFX was started.We  performed a CT-angiography annually for two years.VCSS and other symptoms of BD are resolved and have not relapsed yet. Conclusions: Vascular involvement of BD are generally treated with immunosuppressive agents such as steroids and immunomodulators.IFX was found effective and well tolerated in the treatment of intestinal,neurological and vascular involvement of BD especially in patients with poor response or intolerance to conventional therapy.This case report supports IFX as a new therapeutic option for patients with vascular BD.

Geographical variations in ocular and extra-ocular manifestations in Behçet's disease

OBJECTIVE

Behçet's disease (BD) is a rare vasculitis that results in multi-organ inflammatory disease. At-risk populations are most prevalent in the Middle East and East Asia. Clinical data on BD in Western countries, especially in the United States, are scarce. We have compared clinical patterning of BD vasculitis in two geographically defined patient cohorts in the Western United States and Iran.

METHODS

Comparative analysis of a retrospective cohort of 56 patients with BD evaluated at Stanford University Hospital between 2000 and 2016 and a cohort of 163 patients from the BD Registry at Tehran University of Medical Sciences. Clinical, demographic, laboratory, and treatment data were available. Comparisons were performed using descriptive statistics, Student's t-test, and χ²-test.

RESULTS

The Stanford patients with BD were significantly younger at disease onset, had a higher proportion of females, and had longer disease duration than Iranian patients with BD. Genital ulcers, skin, joint, neurological, vascular, cardiopulmonary manifestations were all significantly more common in the Stanford cohort and 38% of Stanford patients had four or more organ systems involved compared with approximately 10% of Iranian patients. In contrast, Stanford patients had fewer ocular lesions (Stanford 21.4% vs. Iran 53.4% p<0.05), with the biggest difference seen for retinal vasculitis.

CONCLUSION

Patients with BD from the Western US have a more severe disease course when compared to Iranian patients with BD, as demonstrated by earlier onset and a higher rate of multi-organ involvement. The high risk of Iranian patients with BD developing vasculitis of ocular structures suggests distinct pathomechanisms driving ocular versus extra-ocular BD.

The relationship of serum VEGF and sVEGFR-1 levels with vascular involvement in patients with Behçet's disease

Behçet's disease (BD) is a rare, chronic, inflammatory disorder characterized by multisystemic vasculitis including mucocutaneous, neurologic, and ophthalmic involvement. Our aim is to compare vascular endothelial growth factor (VEGF) and soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) levels in BD, among the patients having or not having organ involvement, disease activation and especially vascular involvement. Fifty-five patients with BD, 25 of which were accompanied by vascular involvement, and 31 control subjects were included in the study. Disease activity was assessed with the Turkish version of Behçet Disease Current Activity Form (BDCAF) and active vasculitis lesions at the time of study were recorded. Age at diagnosis was 32.2 ± 4.6, while the mean duration of BD was 96.3 (72.3) months. The median for BDCAF score was 2.0 (range 0, 3.0), and 29 (52%) of patients had active BD. The serum VEGF and sVEGFR-1 levels in patients with BD were significantly higher than that in controls [(298 (338.5) pg/mL; 93 (93.5) pg/mL in patients and 136.2 (73) pg/mL; 56.5 (48.5) pg/mL in controls, respectively, p < .001 for both values] while difference in VEGF/sVEGFR-1 ratio was obtained close to borderline of significance (p = .03). Our study is the first report indicating elevated serum VEGF, sVEGFR-1, and more importantly VEGF/sVEGFR-1 ratio could play an important role in the development of trombosis in BD. VEGF and/or sVEGFR-1 should not be evaluated independently in the same patient group and the ratio of these two parameters is a more important indicator, especially in the evaluation of BD especially with vascular involvement together with the duration of disease.

Can anticoagulation therapy in cerebral venous thrombosis associated with Behçet's disease be stopped without relapse?

There is as yet no consensus on the treatment of cerebral venous thrombosis (CVT) in Behçet's disease, and the place of anticoagulation is also still being debated. This report is of a series of seven patients with Behçet's disease (BD)-associated CVT, for which anticoagulation was stopped, and discusses the possibility of stopping anticoagulation during follow-up while receiving optimal treatment for BD. The diagnosis of BD was established during follow-up, which lasted a median of 120 [range: 60-1490] days after CVT diagnosis. The median duration of anticoagulation therapy was 29.5 months. On stopping anticoagulation, concomitant treatment then included colchicine, steroids and azathioprine, all introduced after BD was diagnosed. With a median follow-up of 25 months after anticoagulation interruption, only one relapse of CVT was observed. No relapse of CVT or other venous thrombosis was observed in the six patients treated by steroids associated with an immunosuppressant or colchicine. Our results emphasize that corticosteroids are essential for the treatment of BD-associated CVT, and that anticoagulant therapy may be safely stopped during follow-up in the presence of optimal BD treatment (steroids alone or with immunosuppressive drugs).

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.

The association between P selectin glycoprotein ligand 1 gene variable number of tandem repeats polymorphism and risk of thrombosis in Behçet's disease

OBJECTIVES

Behçet's disease (BD) has been recognized as an unclassified type of vasculitis with an accompanying tendency to thrombosis. No disease-specific pathology has been demonstrated so far to explain the prothrombotic state, and this predisposition is considered to be associated with endothelial activation/dysfunction. P-selectin glycoprotein ligand-1 (PSGL-1) variable number of tandem repeat (VNTR) polymorphism has an impact on the protein length, and heterozygosity affect of the PSGL-1 to P-selectin interaction, which has been found to be associated with an increased risk of thrombosis in patients with antiphospholipid syndrome. We aimed to analyze the association of PSGL-1 gene polymorphism, in a group of BD patients with and without thrombosis.

METHODS

The study group consisted of 136 BD patients (112 male, 24 female) with thrombosis, 120 BD patients without thrombosis (54 male, 66 female) during at least 5 years disease course, and 190 healthy controls (103 male, 87 female) All patients fulfilled the International Study Group criteria for classification of BD. Genotyping for the PSGL-1 gene exon 2 VNTR polymorphism was carried out with the amplification of genomic DNA and running of the polymerase chain reaction product on agarose gel electrophoresis.

RESULTS

The frequency of heterozygous genotypes (AB+AC+BC) was greater in BD patients with thrombosis compared to BD patients without thrombosis (33.1% vs. 20.8%, P = 0.028, odds ratio = 1.85). However, the increased frequency of heterozygous genotypes in BD patients with thrombosis did not reach a statistically significant level compared to healthy controls (33.1% vs. 32.6%).

CONCLUSIONS

PSGL-1 VNTR polymorphism may have limited contribution to the thrombotic tendency in patients with BD.

[Behçet's disease: Intracardiac thrombosis (a description of two cases and a review of literature)]

Behçet's disease (BD) is systemic vasculitis of unknown etiology, which is more common in the countries located along the Great Silk Road. The disease is diagnosed if a patient has 4 key diagnostic signs: aphthous stomatitis, genital sores, and eye and skin lesions. Vascular diseases referred to as minor criteria for BD are characterized by the formation of aneurysms and thrombosis, predominantly in the venous bed. In venous disorders, a blood clot can form in any vessel, including caval, cerebral, pulmonary, and other veins. The paper describes two clinical cases of BD with intracardiac thrombosis. In one case, a 24-year-old male patient with a documented diagnosis of BD, echocardiography revealed a left ventricular spontaneous echo contrast phenomenon that disappeared due to immunosuppressive therapy. The other case was a 34-year-old female patient, in whom the diagnosis was based on the international disease criteria: aphthous stomatitis, skin lesions (pseudopustulosis, erythema nodosum), and genital sores. Computed tomographic angiography showed a 3.7×2.2-cm mass (thrombus) in the right atrium. In addition, blood clots were present in the hepatic and inferior vena cava. No abnormalities in the coagulation system were found in both cases.

Clinical and Ultrasonographic Evaluation of Lower-extremity Vein Thrombosis in Behcet Syndrome: An Observational Study

Vascular involvement can be seen in up to 40% of patients with Behcet syndrome (BS), the lower-extremity vein thrombosis (LEVT) being the most common type. The aim of the current study was to compare venous Doppler findings and clinical features between BS patients with LEVT and control patients diagnosed as having LEVT due to other causes.All consecutive 78 patients (71 men, 7 women; mean age 38.6 ± 10.3 years) with LEVT due to BS and 50 control patients (29 men, 21 women; mean age 42.0 ± 12.5 years) who had LEVT due to other causes, or idiopathic, were studied with the help of a Doppler ultrasonography after a detailed clinical examination. Patterns of venous disease were identified by cluster analyses. Clinical features of chronic venous disease were assessed using 2 classification systems. Venous claudication was also assessed.Patients with BS were more likely to be men, had significantly earlier age of onset of thrombosis, and were treated mainly with immunosuppressives and less frequently with anticoagulants. Furthermore, they had significantly more bilateral involvement, less complete recanalization, and more frequent collateral formation. While control patients had a disorganized pattern of venous involvement, BS patients had a contiguous and symmetric pattern, involving all deep and superficial veins of the lower extremities, with less affinity for crural veins. Clinical assessment, as measured by the 2 classification systems, also indicated a more severe disease among the BS patients. In line, 51% of the BS patients suffered from severe post-thrombotic syndrome (PTS) and 32% from venous claudication, whereas these were present in 8% and 12%, respectively, among the controls. Among BS patients, a longer duration of thrombosis, bilateral femoral vein involvement, and using no anticoagulation along with immunosuppressive treatment when first diagnosed were found to be associated independently with severe PTS.Lower-extremity vein thrombosis associated with BS, when compared to LEVT due to other causes, had distinctive demographic and ultrasonographic characteristics, and had clinically a more severe disease course.

Pulmonary manifestations in a group of patients with Behcet's disease

AIM

In this study we investigated the frequency and characteristics of pulmonary manifestations in a group of patients with Behcet's disease (BD) who were admitted to Cairo University Hospital.

METHODS

Fifteen patients were included in our study, 14 men (93.3%) and one woman (6.66%).Their mean age was 30.06 ± 9.8 years and the mean age of onset of BD was 23.7 ± 5.54 years. All patients were subjected to full history taking, clinical examination, plain chest X-ray and helical computed tomography (CT) study of the chest.

RESULTS

Pulmonary involvements were detected in 11 patients with BD, 73.3% of cases: 10 men (90.9%) and one woman (9.09%).Their mean age was 28.8 ± 8.07, the mean age of onset of BD was 23.2 ± 5.59 years and the mean disease duration until lung manifestations appear was 3.7 ± 4.8 years. The main pulmonary and constitutional symptoms in these 11 patients were as follows: dyspnea 81.8%, cough 63.6%, weight loss 63.6%, chest tightness 54.5%, hemoptysis 45%, massive hemoptysis 27.2%, fever 36.3% and expectoration 36.3. Analysis of both vascular and parenchymal lung lesions in helical CT scan in the 11 patients with BD were as follows: pulmonary artery aneurysm (PAA) occurred in 5/11 patients (45.4%), pulmonary nodules occurred in 3/11 patients (27.2%), pleural effusion occurred in 3/11 patients (27.2%), pulmonary embolism and infarction occurred in 1/11 patients (9.09%) and pneumonitis occurred in 1/11 patients (9.09%).

CONCLUSION

The higher frequency of pulmonary manifestations in our patients (73.3%) and the higher frequency of PAA (33.3%) could be related to the fact that this study was conducted on a group of patients who were admitted to the hospital with more severe illnesses.

Endovascular Repair and Adjunctive Immunosuppressive Therapy of Aortic Involvement in Behçet's Disease

OBJECTIVES

Aortic aneurysm is a serious problem in Behçet's disease, but open surgical therapy carries the risk of recurrent pseudoaneurysm. Here the outcomes of endovascular repair and adjunctive immunosuppressive therapy for aortic disease in Behçet's disease are presented.

MATERIALS

This was a retrospective study. Between 2002 and 2012, nine patients with Behçet's disease (8 male, median age 41 years, range 33-60 years) were treated by endovascular stent grafting for abdominal or thoraco-abdominal aortic pseudoaneurysm.

METHODS

Computed tomography angiography revealed infrarenal pseudoaneurysm in six (66.6%) patients and suprarenal pseudoaneurysm in three (33.3%). Patients received immunosuppressive therapy with oral prednisolone (60 mg/day) and cyclophosphamide (200 mg/day) for 2 weeks or more before the procedure, and intravenous hydrocortisone (200 mg/day) combined with cyclophosphamide (200 mg/day) for 3 days after the procedure. Thereafter, oral immunosuppressive therapy was continued for 2 years.

RESULTS

A straight tube graft was implanted in seven patients and a bifurcated graft in two patients. Two stage procedures (debranching before endovascular therapy) were performed in three patients for thoraco-abdominal aortic pseudoaneurysms. Stent grafting was successful in all patients, without any peri-operative complications. However, two patients needed abdominal exploration later: one for seroma around the graft and the other for a fistula between the duodenum and the graft. No recurrence of aneurysm was observed during a mean follow up of 40 ± 16 months. One patient died in the 15th month from a non-vascular cause.

CONCLUSIONS

Endovascular stent graft implantation and adjunctive immunosuppressive therapy seems to be safe and effective in the treatment of aortic involvement in Behçet's disease, but this approach needs further evaluation.

Non-dipping blood pressure patterns and arterial stiffness parameters in patients with Behcet's disease

Behcet's disease is a multisystemic vasculitis involving veins and arteries of various sizes. Non-dipping status, augmentation index and pulse wave velocity are important determinants of cardiovascular mortality and morbidity. We investigated the non-dipping status and arterial stiffness in patients with Behcet's disease. In this cross-sectional study, we examined the vascular parameters of 96 patients with Behcet's disease (53% female) and 60 age- and sex-matched control subjects. The non-dipping status and arterial distensibility were assessed using a Mobil-O-Graph Arteriograph, an automatic oscillometric device. In total, 65.6% of 96 patients were systolic non-dippers, and 34.4% exhibited high augmentation indices. Ten percent of the control subjects were systolic non-dippers, and 11.7% exhibited high augmentation indices. Nocturnal decreases in systolic blood pressure correlated with central systolic blood pressure and diastolic blood pressure, as well as nocturnal decreases in diastolic blood pressure. Furthermore, non-dipper patients with Behcet's disease exhibited higher nocturnal cardiac outputs than did dipper patients with Behcet's disease. Augmentation index correlated negatively with C-reactive protein and correlated positively with both 24 h and nocturnal peripheral resistance, as well as 24 h pulse wave velocity. The patients with high augmentation indices exhibited lower creatinine clearance, as well as lower nocturnal cardiac outputs, higher 24 h peripheral resistance and higher 24 h pulse wave velocities. Non-dipping status and arterial stiffness may exacerbate the harmful cardiovascular effects of the other. In addition to conventional risk factors, non-dipping status and arterial stiffness should be examined during the follow-up evaluations of patients with Behcet's disease.

Thrombosis in vasculitic disorders-clinical manifestations, pathogenesis and management

Inflammation and coagulation are known to affect each other in many ways. Vasculitis represents a group of disorders where blood vessels (small, medium, large or variable) are infiltrated with inflammatory cells. Accumulating evidence in the literature suggests both clinical and physiological association between vasculitis and thrombosis. Vasculitis-associated thrombosis involves arteries and veins, and a tight connection has been reported between the activity of vasculitis and the appearance of thrombosis. Pathophysiology of these relations is complex and not completely understood. While thrombophilic factors are associated with vasculitis, it remains unclear whether a true association with clinical thrombosis is present. Furthermore, several factors leading to hemostasis, endothelial injury and induction of microparticles were described as possibly accounting for thrombosis. Management of thrombosis in vasculitis patients is challenging and should be further assessed in randomized controlled studies. The current review describes clinical manifestations, pathogenesis and management of thrombosis associated with different vasculitides.

An intracardial mass in a young Syrian refugee

A 35-year-old previously healthy man presented with orogenital ulcerations, high fever, weight loss and leg thrombosis. Antibiotics were ineffective. His symptoms persisted and 3 years later he suffered from exertional dyspnoea. Inflammatory markers were elevated and all cultures were negative. CT of the thorax showed bilateral pulmonary embolism and a mass attached to the septum of the right ventricle, as well as an occluded vena cava inferior. Histology of the cardiac mass revealed a thrombus. The pulmonary embolisation progressed despite treatment with full-dose dalteparin. After being diagnosed with Behçet's disease, a multisystemic large-vessel vasculitis, and treated with high-dose prednisolone and cyclophosphamide, his ulcerations and his symptoms of dyspnoea disappeared.

Left ventricular intracardiac thrombus in a patient with Behçet disease successfully treated with immunosuppressive agents without anticoagulation: a case report and review of the literature

Behçet disease (BD) is a chronic multisystem disorder with vasculitis underlying its systemic manifestations. Cardiac involvement and particularly left ventricular intracardiac thrombus are rarely diagnosed in the course of BD and are often associated with poor prognosis. The causes of intracardiac thrombi are unknown. It is plausible that specific proinflammatory pathways resulting in the endothelial cell injury and hypercoagulation contribute to the formation of thrombotic masses in the heart. Known thrombophilic factors such as methylenetetrahydrofolate reductase gene mutations, factor V Leiden mutation, proteins S and C, antithrombin III, activated protein C resistance, and antiphospholipid antibodies may contribute to the formation of intracardiac thrombi in BD. We report a case of a 24-year-old male patient with BD presented with left ventricular thrombus. Transthoracic echocardiography allowed to describe and monitor such a rare cardiac manifestation of the disease. A combination of high-dose corticosteroid and azathioprine successfully dissolved intracardiac thrombus within ten days without anticoagulation.

Aortic thrombosis in a patient with a late diagnosis of Behcet's disease

Behcet's disease is form of systemic vasculitis of unknown etiology. One surprising feature is that arterial involvement is less common in this disease than venous forms, accounting for 1 to 7% of patients. In 7 to 30% of cases the vascular symptoms precede the clinical diagnosis of Behcet. We describe the case of a patient with Thromboangiitis Obliterans who was treated with lumbar sympathectomy and an aortobiiliac bypass. Around 1 year later he was diagnosed with Behcet's disease after presenting with oral ulcers, genital ulcers and scaling lesions on the hands.

Thrombosis in vasculitis: from pathogenesis to treatment

In recent years, the relationship between inflammation and thrombosis has been deeply investigated and it is now clear that immune and coagulation systems are functionally interconnected.

Inflammation-induced thrombosis is by now considered a feature not only of autoimmune rheumatic diseases, but also of systemic vasculitides such as Behçet’s syndrome, ANCA-associated vasculitis or giant cells arteritis, especially during active disease.

These findings have important consequences in terms of management and treatment. Indeed, Behçet’syndrome requires immunosuppressive agents for vascular involvement rather than anticoagulation or antiplatelet therapy, and it is conceivable that also in ANCA-associated vasculitis or large vessel-vasculitis an aggressive anti-inflammatory treatment during active disease could reduce the risk of thrombotic events in early stages.

In this review we discuss thrombosis in vasculitides, especially in Behçet’s syndrome, ANCA-associated vasculitis and large-vessel vasculitis, and provide pathogenetic and clinical clues for the different specialists involved in the care of these patients.

Acute coronary syndrome in Behcet's disease caused by a coronary artery aneurysm and thrombosis

Behcet's disease (BD) is a multisystemic vasculitis that can involve vessels of all sizes and is characterized by recurrent oral and genital ulcers with variable manifestations affecting the skin, eyes, and central nervous and musculoskeletal systems. Vascular involvement in BD is reported to be up to 40% in different series. The abdominal and thoracic aorta and pulmonary and femoral arteries are the most commonly involved arteries. However coronary arteries are rarely affected. Herein, we present a 29-year-old man who was consulted with progressive severe chest pain of 3 days in duration to our clinic. The patient was diagnosed with BD with mucocutaneous symptoms and a positive pathergy test 1 year ago and was in clinical remission for the last 6 months. At the first evaluation in the emergency department, the patient's vital signs were stable, whereas he had elevated troponin T levels with a normal electrocardiogram and hypokinetic areas in the apex of the heart in the echocardiography. Conventional and computed tomography coronary angiography revealed aneurysms and intramural thrombosis in the left anterior descending and right coronary arteries. Although ischemic symptoms and signs improved with anticoagulant and antiaggregant therapies, coronary aneurysms were observed to increase in size. Immunosuppressive (IS) treatment was started with pulse intravenous corticosteroids and cyclophosphamide. Because of the high re-stenosis risk, stents were not applied to the affected vessels during the acute thrombosis period. During routine investigations, an in situ pulmonary thrombosis was also detected bilaterally in the peripheral pulmonary arteries. In conclusion, coronary artery aneurysm is a rare and poor prognostic manifestation of BD. The treatment protocol for these aneurysms is not well clarified. IS therapies are definitely indicated, but the role of anticoagulants and invasive vascular interventions is controversial.

Behçet's disease complicated with thrombosis: a report of 93 Chinese cases

To investigate the clinical features of Behçet's disease (BD) complicated with thrombosis. Medical records of patients with BD at Peking Union Medical College Hospital from 1993 to 2013 were reviewed to identify thrombosis. Of the 766 patients with BD, 93 patients (16 female and 77 male) developed thrombosis. The most common thrombosis was extremity vein thrombosis (86.0%), including deep vein thrombosis (n=78) and superficial thrombophlebitis (n=4). The other thrombosis types associated with BD in descending frequency of order were: vena cava thrombosis (30.1%), pulmonary thromboembolism (15.1%), cerebral venous thrombosis (CVT) (12.9%), intracardiac thrombosis (8.6%), Budd-Chiari syndrome (7.5%), and renal vein thrombosis (4.3%), etc. Venous thrombosis is more frequent than arterial thrombosis, and most of patients (94.6%) experienced multiple thrombosis. A male predominance of extremity vein thrombosis and positive pathergy test, and a female predominance of CVT and genital ulcers were noted. All of these patients exhibited active disease during the emergence of thrombotic events. After treating with glucocorticosteroids, immunosuppressants, and/or anticoagulants, the thrombosis resolved in 89 patients. Three patients died from aneurysm rupture, myocardial infarction and Budd-Chiari syndrome, respectively. One patient with septic shock discontinued therapy during follow-up. Thrombosis in BD patients is male predominance, mainly multiple and venous thrombosis is more common. Active disease patients are prone to thrombosis, which suggest the key role of immunosuppressive therapy for the complication.

Abdominal aortic aneurysm causing lumbar vertebral erosion in Behçet's disease presenting by low back pain

Behçet's disease (BD) is a chronic multi-system disorder commonly seen in Mediterranean, middle east and far eastern populations. In this report, we describe a case of a 55-year-old male with Behçet's disease who presented with a low back pain and sciatica. Imaging studies showed that he had a destruction of the third lumbar vertebra because of abdominal aortic aneurysm-related Behçet's disease. Aortic aneurysms with vertebral body erosion have been rarely reported, but this vascular complication is a life-threatening clinical picture. Therefore, among the causes of chronic lumbar pain in a BD patient, abdominal aortic aneurysm should be remembered.

Genital aphthosis in Behçet's disease: is it associated with less eye involvement?

Behçet's disease (BD) is a multisystem disease classified among the vasculitides with various clinical features. Genital aphthosis (GA) is one of the major manifestations of BD. The aim of this study was to evaluate the characteristics of BD patients with GA. A cross-sectional sample of BD patients registered in 37 years was selected. We determined clinical and laboratory features of BD patients with GA (GA cases) and compared them with the patients who never developed GA (non-GA cases). The comparisons were performed by the chi-square test and logistic regression analysis. Odds ratios (ORs) with 95 % confidence intervals were calculated to estimate the precision of ORs. Among 6,935 BD patients, 4,489 cases (64.7 %) were ascribed to GA cases. Male to female ratio (1.11:1.00 vs. 1.48:1.00 OR 0.753, P value <0.001) and mean age of disease onset (OR = 0.9, P value <0.001) were lower in GA subset. In GA cases, oral aphthosis (OA) was a more common onset manifestation (OR 2.250, P value <0.001), while uveitis (OR 0.140, P value <0.001) and retinal vasculitis (OR 0.077, P value <0.001) were less common at the disease onset. In the whole course of disease, eye involvement was less common in GA cases (OR 0.215, P value <0.001). On the contrary, OA (OR 19.698, P value <0.001), skin (OR 1.762, P value <0.001), joint (OR 1.257, P value = 0.001), gastrointestinal (OR 1.302, P value = 0.009), neurological (OR 1.624, P value <0.001) and vascular involvements (OR 1.362, P value <0.001), epididymitis (OR 1.596, P value <0.001), positive pathergy test (OR 1.209, P value <0.001) and positive familial history of OA (OR 1.325, P value <0.001) were more common in GA subset. This study showed that GA subset of BD is associated with less eye involvement but higher rates of other BD manifestations.