Value of certain echocardiographic findings in the initial suspicion of Behçet's disease

A huge serpentine embolic intracardiac thrombus: A rare manifestation of Behcet's disease

Behcet's disease is a systemic vasculitis that can manifest as an intracardiac thrombus, which is rare but a serious complication. We report a case of a young male with a history of diabetes mellitus and erythema nodosum, who was admitted for pulmonary embolism associated with a huge serpentine right ventricle thrombus leading to the diagnosis of Behcet's disease. The patient was managed medically with a favorable evolution. The development of intracardiac thrombus is a life-threatening manifestation of the disease, and its discovery, especially in young subjects must suggest the diagnosis of Behcet's disease even if there is no predisposing ethnic or geographical factor.

The pattern of cardiovascular manifestations in Egyptian Behçet’s patients and its relation to disease activity

Background

Behçet’s disease (BD) is also referred to as vascular BD when it frequently involves the heart and vessels. This study aimed to describe the cardiovascular manifestations in patients with BD and its correlation to disease activity. We conducted a cross-sectional study on 40 patients diagnosed with BD according to the International Criteria for Behçet’s Disease 2014. All the patients were subjected to detailed history taking, full clinical examination, lab investigations, resting electrocardiogram, trans-thoracic echocardiography, and carotid artery duplex for measuring intimal thickness, peripheral arterial and venous duplex, computed tomography pulmonary angiography, and full ophthalmological examination. Regarding the activity of the disease, it was assessed according to the score of Behçet’s Disease Current Activity Form (BDCAF).

Results

The most common cardiac manifestation was valvular lesion (67.5%) where the most frequently affected valve was the tricuspid valve (27.5%). Although 25% of patients had left ventricular diastolic dysfunction, only 5% had intracardiac masses. Approximately 52.5% of patients had vascular lesion (deep venous thrombosis 45%, arterial involvement 7.5% [as pulmonary artery thrombosis 5% and aneurysm 2.5%]). Increase in intima media thickness (IMT) was observed in 7.5% of patients, while 60% had abnormal lipid profiles. Hypercholesterolemia was the most common lipid abnormality (50%). BDCAF score range was 4–12, which was significantly correlated to multiple cardiovascular parameters as a mitral, tricuspid valve, and vascular venous involvement (p < 0.05), while not significantly correlated to lipid profile (p > 0.05).

Conclusion

Cardiovascular complications are frequent among patients with BD, even those who are asymptomatic; therefore, these complications must be screened for early detection and proper management.

Uveitis as a potential predictor of acute myocardial infarction in patients with Behcet's disease: a population-based cohort study

OBJECTIVES

To investigate whether uveitis is a predictor of acute myocardial infarction (AMI) among patients with Behcet's disease (BD).

DESIGN

Retrospective cohort study.

SETTING

Patients with BD were retrieved from the whole population of the Taiwan National Health Insurance Research Database from 1 January 2001 to 31 December 2013.

PARTICIPANTS

Among the 6508 patients with BD, 2517 (38.7%) were in the uveitis group and 3991 were in the non-uveitis group.

PRIMARY AND SECONDARY OUTCOME MEASURES

Kaplan-Meier curves were generated to compare the cumulative hazard of AMI in the uveitis and non-uveitis groups. Multivariate Cox regression analysis was used to estimate the adjusted HRs and 95% CI of AMI, and was adjusted for age, gender, systemic comorbidities (eg, hypertension, diabetes, hyperlipidaemia, smoking) and clinical manifestation of BD (eg, oral ulcers, genital ulcers, skin lesions, arthritis and gastrointestinal involvement).

RESULTS

The mean age of the BD cohort was 38.1±15.1 years. Compared with non-uveitis patients, uveitis patients were significantly younger and male predominant. There was no significant difference between the two groups for most proportions of systemic comorbidities and clinical manifestations. The Kaplan-Meier method with the log-rank test showed that the uveitis group had a significantly higher cumulative hazard for patients with AMI compared with the non-uveitis group (p<0.0001). In the multivariable Cox regression after adjustment for confounding factors, patients with uveitis had a significantly higher risk of AMI (adjusted HR 1.87; 95% CI 1.52 to 2.29). Other significant risk factors for AMI were age, hypertension, smoking, and skin lesions.

CONCLUSIONS

Statistical analyses from the nationwide database demonstrated that uveitis is a potential predictor of AMI in patients with BD.

Cardiac findings in patients with Behçet's disease: Facts and controversies

Behçet’s disease (BD) is a systemic vasculitis of unknown etiology. It is characterized by recurrent oral and genital ulcers, uveitis, and a number of systemic manifestations. Although the disease is recognized worldwide, its prevalence is highly variable. A detailed review and analysis of the worldwide published reports on BD showed that not only the prevalence of the disease but also its cardiac complications differ according to the geographic distribution of the studied population. With the exception of France, Greece, Spain, and Italy, very few reports and studies regarding BD have been published from the western countries. Cardiovascular complications are an important cause of poor outcome in patients with BD. Over the past few years, many case reports and studies have been published, providing more facts about these complications. For example, peculiar echocardiographic findings in patients with aortic valve regurgitation and intracardiac thrombi secondary to BD were recently described. The role of these findings in the initial diagnosis of the disease, however, remains to be evaluated. On the other hand, some reports present contradictory results, especially concerning the left ventricular diastolic function, pathogenesis of coronary artery disease, and proper management of the cardiac complications in BD. Importantly, management of these complications is based mainly on the discretion of the treating physician due to the absence of large controlled studies and clear guidelines. This approach sometimes creates inconsistent data and allows controversies to persist. The review presented here will discuss some of the facts and controversies related to cardiac complications in BD.

CT and MR Imaging of Cardiothoracic Vasculitis

The term vasculitis includes a variable group of entities in which the common characteristic is inflammation of the walls of blood vessels occurring at some time during the course of the disease. The vasculitides can be divided into primary and secondary vasculitides, depending on the etiology and according to the size of the vessel affected. Both primary vasculitis and secondary vasculitis are associated with cardiac morbidity that is often subclinical. Cardiac involvement is associated with prognostic implications and higher rates of related mortality. Vasculitis of cardiac structures and the assessment of disease extent are important for appropriate management and selection of treatment. Although echocardiography, radionuclide imaging, and catheter-directed coronary angiography remain the cornerstones of cardiac imaging, cardiac computed tomography and magnetic resonance imaging can offer a 360° assessment of cardiac anatomy, function, and complications secondary to vasculitis. Postoperative complications, which are more frequent in patients with active disease, can also be depicted with those imaging modalities. A multidisciplinary approach is important to yield an appropriate estimate of the disease activity and extent and, therefore, to enable better treatment selection and monitoring. Online supplemental material is available for this article. ^©RSNA, 2018.

Assessment of Left Ventricular Diastolic Function in Egyptian Patients With Behçet's Disease

Objectives

This study aims to evaluate left ventricular diastolic function in Egyptian patients with Behçet's disease using variable echocardiographic parameters by combining both transmitral and tissue Doppler velocities to overcome the occasional false interpretation of preload dependent transmitral parameters and to detect the correlation between various left ventricular diastolic parameters and different disease manifestations.

Patients and methods

Forty patients (35 males, 5 females; mean age 31±8 years; range 19 to 52 years) with Behçet's disease and 32 age- and sex- matched healthy controls (26 males, 6 females; mean age 28±6 years; range 19 to 60 years) were enrolled. Left ventricular diastolic function was assessed using an algorithm that combined transmitral and tissue Doppler derived parameters.

Results

Mean disease duration of the patients was 7.4±6 years. Left and right ventricular systolic function was normal in both groups. The transmitral E/A was<1 in six patients (15%). There was no difference between patients and controls regarding the other left ventricular diastolic parameters. Compared to patients with an E/A ratio >1, patients with E/A<1 were significantly older and had a longer disease duration (p=0.001 and p<0.001, respectively). All the other echocardiographic parameters in both groups were comparable.

Conclusion

Egyptian patients with Behçet's disease have normal left ventricular diastolic function regardless of disease duration and activity.

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.