Behçet disease in children

Diagnostic/classification criteria in pediatric Behçet's disease

Behçet's disease (BD) is a variable vessel vasculitis characterized by recurrent oral and genital aphthosis accompanied by skin, ocular, gastrointestinal, neurologic, and articular involvement. BD is not common in childhood and the disease characteristics considerably differ between adults and children. 18 diagnostic/classification criteria have been published for BD to date. The pediatric BD (PEDBD) criteria, published in 2015, focused on pediatric BD, while the others mainly based on adult studies and are not validated for children. The aim of this review is to summarize the data about diagnostic/classification criteria for BD and to discuss the use and performance of the current criteria in pediatric BD. The covered topics are the characteristics of the diagnostic/classification criteria sets for BD, the factors restricting the universal use/acceptance of these criteria, and pediatric studies testing the performance of BD criteria sets. Having valid and universally accepted criteria with high performance is very important in pediatric BD as they help us determine patients for our studies and guide us through our clinical practice. There are less than 10 pediatric studies testing the performances of BD diagnostic/classification criteria. Their results suggest that revised ICBD (The International Criteria for BD) has the highest sensitivity, while ISG (The International Study Group) criteria remain as the most specific criteria set. Larger multinational pediatric BD cohorts with adequate control groups are required to compare the performance of the different criteria sets in children and to improve the performance of the existing PEDBD criteria.

Paediatric Behçet's disease: a UK tertiary centre experience

There are currently limited data regarding paediatric Behçet's disease (BD), particularly in the UK. We describe the clinical spectrum, treatment and outcome of BD, and explore the relative sensitivities of the criteria for the diagnosis of BD in a UK paediatric cohort. Single retrospective case note review of children with a clinical diagnosis of BD presenting between 1987 and 2012. Demographics, clinical features, treatment and outcomes were recorded. The sensitivities of the International Study Group (ISG) and International Criteria for BD (ICBD) criteria were explored. BD disease activity was calculated using the Behçet's Disease Activity Index (BDAI). Forty-six patients (22 male) were identified. Median age of onset was 4.87 (0.04-15.71) years; median time to diagnosis was 3.74 (0.25-13.48) years. Clinical features were recurrent oral ulceration (97.8 %), recurrent genital ulceration (73.9 %), gastrointestinal (58.7 %), musculoskeletal (47.83 %), cutaneous (23.9 %) involvement and uveitis (2 %). Recurrent genital ulceration was more common in female patients (P = 0.044). Thirty-seven patients (80.4 %) fulfilled the ICBD criteria; only 12 patients (26.1 %) fulfilled the ISG criteria. BDAI score at diagnosis was 7/20 (0-10/20) and significantly decreased to 5/20 (0-9/20) (P < 0.0001) at latest follow-up. The commonest systemic treatment was colchicine (76.1 %); anti-TNFα treatment was reserved for severe cases (15.5 %). Paediatric BD in the UK may present very early in life, sometimes with a family history, and with a low incidence of ocular involvement. Diagnostic delay is common. The majority of our patients required systemic therapy; anti-TNFα was reserved for severe cases and has largely superseded the use of thalidomide.

Behçet's Uveitis

Behçet's disease is a multisystem inflammatory disorder that is most common in countries along the ancient “Silk Road”. The eye is the most commonly involved vital organ in Behçet's patients and the typical form of involvement is a relapsing remitting panuveitis and retinal vasculitis. Uveitis is the initial manifestation of the disease in 10-15% of the patients. Anterior uveitis is always nongranulomatous. Diffuse vitritis, retinal infiltrates, sheathing of predominantly retinal veins, and occlusive vasculitis are the typical signs of posterior segment inflammation. Spontaneous resolution of acute inflammatory signs is a diagnostic feature. Fundus fluorescein angiography is the gold standard in monitoring inflammatory activity. Laser flare photometry is a useful noninvasive tool since flare readings correlate with fluorescein angiographic leakage. The most common complications are cataract, maculopathy, and optic atrophy. Male patients have a more severe disease course and worse visual prognosis. Immunomodulatory therapy is indicated in all patients with posterior segment involvement. Corticosteroids combined with azathioprine and/or cyclosporine is used initially. Biologic agents, including interferon alfa and infliximab, are used in resistant cases. Visual prognosis has improved in recent years with an earlier and more aggressive use of immunomodulatory therapy and the use of biologic agents in resistant cases.