Histohogical and direct immunofluorescence study of cutaneous hyperreactivity in Behçet's disease

Histopathological comparison of pathergy positive and negative areas of newly diagnosed Behçet patients

BACKGROUND

Behcet's disease is an inflammatory vasculitis, and pathergy reaction is a compulsory element of the diagnostic criteria. In the literature, there is no study comparing the histopathology of negative pathergy tests and positive pathergy tests in newly diagnosed Behcet's patients. The primary goal was to investigate the frequency of vasculitis, which is an important finding of Behcet's disease, in pathergy histopathology.

METHODS

The histopathology of patients with positive and negative pathergy tests revealed vasculitis or vasculopathy. In histopathology, neutrophils, lymphocytes, eosinophils, and mast cells in the perivascular area were counted and recorded as a percentage.

RESULTS

Of the 88 Behcet's patients who participated in the study, 45 were female and 43 were male. The rate of vasculitis in the histopathology of those who were positive for the pathergy test was not statistically different than those of those with negative pathergy tests (P = .14). In our study, although the relationship between the male gender and uveitis was significant at the border, and the relationship between pathergy positivity and uveitis was not found to be significant, a significant relationship was found between vasculitis in histopathology and uveitis (P = .023).

CONCLUSIONS

Based on the results of our study, we think that a pathergy test of histopathology will contribute to the clinical diagnostic evaluation in cases with suspicious clinical pathergy tests and especially in cases with negative pathergy tests.

Pathergy Phenomenon

Skin pathergy reaction (SPR) is a hyperreactivity response to needle induced trauma which is characterized by a papule or pustule formation, 24-48 h after sterile-needle prick. It is affected by a wide array of factors, including the physical properties of the needles being used, number of pricks and disease related factors such as male gender, active disease. There is a great variation in reactivity among different populations with very low positivity rate in regions of low prevalence like Northern Europe, and higher prevalance mainly in communities living along the historical Silk Road, like Turkey, China and Middle Eastern countries. SPR is not constant during the disease course, has lost its sensitivity over decades and can be positive in various disorders including Sweet's syndrome, pyoderma gangrenosum, Crohn's diesease, A20 haploinsufficiency, deficiency of IL-1-receptor antagonist and few others. Nevertheless, it is a criteria included into many currently used diagnostic or classification criteria for Behçet's disease. Although, not being fully uncovered yet, available data points to the activation of both innate and adaptive immune system with an inflammatory response mediated by polymorphonuclears and T-cells. In addition to its utility in diagnosis of Behçet's Disease, SPR may serve as a model for investigating the inflammatory pathways involved in the etiopathogenesis of this complex disease.

[Ulcerations of the extremities: An unusual manifestation of Behçet's disease]

BACKGROUND

Although cutaneous and mucosal involvement is a major manifestation in Behçet's disease, ulcerated lesions of the extremities are exceptional and poorly known.

CASE REPORT

A 57-year-old male patient was diagnosed 7 years ago with Behçet's disease. This diagnosis was made in the presence of recurrent bipolar aphtous ulcers, pseudofolliculitis lesions and retinal vasculitis. After having been lost to follow up for two years, during which his treatment was discontinued, he presented centimetric necrotic ulcerations of the fingers of the hand and of the right big toe. The biopsy revealed leucocytoclastic and necrotizing vasculitis. The patient improved with antibiotic, oral corticosteroids, colchicine and local care.

CONCLUSION

Linking extremity ulcers with Behçet's disease, though sometimes difficult, is essential for proper management.

Dietary and Nondietary Triggers of Oral Ulcer Recurrences in Behçet's Disease

OBJECTIVE

The nature and impact of food and other external triggers in recurrences of Behçet's disease (BD)-related oral ulcers (OUs) remain unknown. This survey investigated dietary and nondietary triggers of BD-related OU recurrences.

METHODS

Patients with BD who were followed in 7 French hospital departments completed a self-administered patient questionnaire. General and specific dietary triggering factors were sought in open questions. The questionnaire also included closed questions, notably to evaluate the effect of 6 general triggering situations and 24 selected foods. The results were expressed as number (percentage) of positive responses.

RESULTS

Among the 101 questionnaires distributed, 81 were usable. Among the 81 patients, 96% fulfilled the International Criteria for Behçet's Disease classification criteria, and 53% qualified their OU recurrences during the previous 12 months as very discomforting or discomforting. For the 6 general situations suggested, 50 patients (62%) declared ≥1 as a "sure" trigger of OU recurrences. In both open and closed questions, the most frequent triggers were fatigue/stress (37-47% of patients) and food (32-35%). Among the 24 suggested foods, nuts (48%), pineapple (42%), peanuts (32%), Emmental cheese (30%), almonds (23%), lemons (22%), and other cheeses (21%) were the most frequently reported. The corresponding open question gave consistent findings but with lower frequencies.

CONCLUSION

Most patients can identify triggers of recurring BD-related OUs, with fatigue/stress and food representing the most frequent triggers. The management of OU must consider such external factors. The histamine-rich or -liberating properties of the commonly cited OU-triggering foods suggest a hyperreactivity mechanism.

Histopathologic Study of Pathergy Test in Behçet's Disease

Background:

The pathergy test (PT) is important in the diagnosis of Behçet's disease (BD). However, misinterpretation of the test might cause false-positive or false-negative results. Therefore, immunopathologic and histopathologic tests are recommended with PT.

Aims and Objectives:

The aim of this study is to determine histopathologic findings of positive pathergy reaction at BD.

Materials and Methods:

This study was performed on 23 patients with BD. All patients were in active period of the disease. After 48 h from the injection, biopsy was performed on positive pathergy lesions.

Results:

Of the specimen from positive PT lesions of patients with BD, nine revealed mixed type inflammatory cell infiltration (39.1%), two revealed lobular panniculitis without vasculitis (8.7%), two revealed neutrophil rich infiltration (8.7%), and five revealed lymphocyte rich infiltration (21.7%) at the subcutaneous tissue. Mixed type inflammatory cell infiltration (43.4%), endothelial swelling and thickening (17.3%), erythrocyte extravasation (26.0%), perivascular cell infiltration (13.0%), lymphocytic vascular reaction (8.6%), lymphocytic vasculitis (13.0%), and leukocytoclastic vasculitis (21.7%) were detected in dermis by histopathologic examinations. There was no statistically significant difference between histopathologic findings and sex, family history, and systemic involvement except uveitis.

Conclusion:

This is an exceptional study since it is the first study that determines subcutaneous tissue findings of positive pathergy reaction in Behçet patients. In our study, uveitis was found to be statistically significant in the patients who had vasculitis in dermis. It can be a clue for prediction of disease severity and course. Further, studies that include wide number of patients will better illuminate the correlation between subcutaneous tissue findings and disease severity and clinical course.

A New Diagnostic Way for Behcet's Disease: Skin Prick with Self-Saliva

Behcet's disease (BD) is a mysterious multisystemic disorder characterized by recurrent involvement of mucocutaneous (including recurrent aphthous stomatitis; RAS), ocular, intestinal, vascular, and/or nervous system organs. Previously, the positivity of "pathergy test", which is one of the diagnostic examinations, was reported to be related to the possession of HLA-B51 gene in BD patients, even though the positivity is low and different from the countries. Here, instead of the ordinal pathergy test, we would like to propose the prick with self-saliva as a new diagnostic way for patients with RAS of BD based on the genetic intrinsic factors including HLA-B51 and extrinsic triggering factors. BD patients are considered to acquire the hypersensitivity against oral streptococci through the innate immune mechanism in the oral cavity. Bes-1 gene and 65 kD of heat shock protein (HSP-65) derived from oral S. sanguinis are supposed to play important roles as extrinsic factors in BD pathogenesis. Although the prick positivity was not related to the possession of HLA-B51 gene, the method is suggested to be a significant way for BD diagnosis. The results also suggest that BD symptoms are due to the vascular immune responses by monocytes expressed oral streptococcal agents of the patients.

Necrotizing Sweet syndrome: a new variant of neutrophilic dermatosis mimicking necrotizing fasciitis

BACKGROUND

We report a series of patients initially given the diagnosis of necrotizing fasciitis whose course progressed despite surgical debridement, antibiotic therapy, or both, but who responded rapidly to systemic corticosteroids.

OBJECTIVE

We sought to evaluate the clinical data, histopathologic and microbiology information, and treatment course of this unusual entity.

METHODS

This was a descriptive study/case series.

RESULTS

Three immunocompromised patients who presented with signs and symptoms of necrotizing fasciitis were included. They appeared septic, failed multiple courses of antibiotics, demonstrated pathergy, and two of them underwent extensive surgical debridement. None of the cases yielded a microbial source. Dermatologic consultation and histopathology confirmed deep Sweet syndrome in all cases, with marked necrosis of the soft tissue--including myonecrosis--in the two patients with debridement. All patients responded rapidly to high-dose systemic corticosteroids.

LIMITATIONS

To our knowledge, this is the first report of this unusual presentation; there are a limited number of cases.

CONCLUSION

We propose that these cases represent a new variant of neutrophilic dermatosis: "necrotizing Sweet syndrome," an acute necrotizing neutrophilic dermatosis. This subtype is also characterized by the rapid onset of progressive erythematous, warm, edematous cutaneous lesions with deep-tissue neutrophilic infiltration and soft-tissue necrosis, in the absence of infectious cause. Awareness of this entity and early dermatologic consultation is critical as debridement results in expansion of the process, resulting in additional and aggressive resection--a vicious cycle with significant possible morbidity.

Clinical and Pathological Manifestations with Differential Diagnosis in Behçet's Disease

Behçet's disease is a multisystemic inflammatory disease of unknown etiology which usually occurs as a trait of symptoms: aphthous stomatitis, genital ulcerations, and ocular disease. At the beginning of the disease the diagnosis is uncertain because of various clinical manifestations and a long period up to the full clinical picture manifestation. Since neither the laboratory data nor the histopathological signs are truly pathognomonic in Behçet's disease, the differential diagnosis depends on a careful evaluation of the medical history and meticulous physical examination to detect concomitant systemic manifestations. Sometimes, some laboratory test may help establish the diagnosis. Subspecialty referral to ophthalmology, rheumatology, neurology, and gastroenterology should be considered when indicated.

Histopathological Evaluation of Behçet's Disease and Identification of New Skin Lesions

Behçet's disease (BD) is a multisystemic, relapsing inflammatory disorder with an obscure etiology and pathogenesis. Diagnosis depends on the clinician's ability to identify a group of nonspecific mucocutaneous lesions, which also manifest in a number of other diseases. In recent years, there has been an increase in the studies focusing on the histopathological aspects of Behçet's disease diagnostic mucocutaneous lesions. Their results emphasize the value of histopathology and direct immunofluorescence (DIF) in the differential diagnosis of Behçet's disease.

Skin prick test with self-saliva in patients with oral aphthoses: a diagnostic pathergy for Behcet's disease and recurrent aphthosis

There may be some difficulties to differentiate Behcet's disease (BD), recurrent aphthosis (RA), and herpetic aphthous ulceration, from other mimicking oral disorders. Despite of unexpected sensitivity and responsiveness, the skin pathergy test regarding a non specific hypersensitivity has long been thought as one of auxiliary diagnostic benefits for BD. To determine the potential usefulness and disease specificity of the prick reaction with saliva, a skin prick test with neat and filter-sterilized saliva was performed on the forearm skin of 26 individuals; 10 patients with BD (8 incomplete type without uveitis, 1 complete type, and 1 neurological type), 5 with RA, 3 with herpetic oral aphthosis, 2 with erythema nodosum alone, and 6 healthy controls. We assessed the skin reaction at 48 hours after pricking, and the pricked skin lesions were biopsied and analyzed immunohistologically. Nine of 10 BD patients (90 %) exhibited an indurative erythema at the skin site pricked with self-saliva, whereas 3 of 5 RA patients (60%) were relatively weak reaction. Pricking with filter-sterilized saliva failed to recapitulate any of positive skin reactions, albeit a faint erythematous dot appeared in a few BD patients, implicating the involvement of causative microorganism(s) in oral bacterial flora. Culture of saliva from 3 randomly chosen BD patients revealed numerous streptococcal colonies on Mitis-Salivarius agar. Histology of the pricked skin sites showed perivascular inflammatory infiltrates, composed of CD4+ T cells and CD68+ monocyte/macrophage lineage, a feature consistent with a delayed type hypersensitive reaction. Our results suggested that skin prick test using self-saliva (a new diagnostic pathergy) can be a simple and valuable in vivo diagnostic approach for differentiating BD and RA from other mimicking mucocutaneous diseases. The positive skin prick may be triggered by resident intra-oral microflora, particularly streptococci, and may in part address the underlying immunopathology in BD.

The skin pathergy test: innately useful?

Pathergy is the term used to describe hyper-reactivity of the skin that occurs in response to minimal trauma. A positive skin pathergy test (SPT), characterised by erythematous induration at the site of the needle stick with a small pustule containing sterile pus at its centre, is among the criteria required for a diagnosis of Behçet's disease (BD) and in certain population has been shown to be highly specific for this condition. Problems with standardising the induction manoeuvre for the SPT as well as the method of assessment of the response have limited the usefulness of the SPT in the clinical setting. Extensive investigation into histopathological and immunological aspects of pathergy has led to a number of hypotheses relating to the aetiology of the skin pathergy reaction and the disease itself, but the cause is considered to be unknown. Pathergy lesions, the development of new skin lesions or the aggravation of existing ones following trivial trauma, are also reported in pyoderma gangrenosum and has been noted in other neutrophilic dermatoses such as Sweet's syndrome. The response of such patient groups to the systematic application of the SPT has not been described. We propose that a new way of considering the pathergy reaction is to see it as an aberration of the skin's innate reactivity from a homeostatic reactive mode closely coupled to tissue healing to an abnormal destructive/inflammatory mode. Our understanding of BD and other similar conditions would profit by more detailed mechanistic knowledge of skin homeostasis to minimal trauma in both health and disease through a more structured and systematic use of the SPT.

Direct immunofluorescence in Behçet's disease: a controlled study with 108 cases

PURPOSE

Behçet's disease (BD) is a disease of unknown etiology, which has multisystemic involvement. This multisystemic involvement might be the clue for an autoimmune pathogenesis. In order to evaluate an autoimmune pathogenesis, we examined immunoreactans depositions in the skin of BD patients.

MATERIALS AND METHODS

The skin samples of 108 BD patients (28 perilesional skin, 44 positive pathergy test site, 22 negative pathergy test site, 14 normal skin) were examined for the depositions of immunoglobulin (Ig)M, IgG, IgA, complement 3 (C(3)), and fibrinogen (F) using direct immunofluorescence (DIF). The data were statistically compared to the DIF of 36 systemic lupus erythematosus (SLE) patients and 20 healthy controls using chi(2) Fisher exact test.

RESULTS

Highly significant immunoreactans depositions were obtained in BD (deposition rates: IgM 70.3%, IgG 0%, IgA 20.3%, C(3) 62.9%, F 83.3%). The comparison with SLE revealed no differences in IgM, IgA, and C(3). However, IgG deposition was higher in SLE while F deposition was higher in BD. In both BD and SLE, the Ig depositions were highly significant when the data were compared with the healthy controls.

CONCLUSION

The significant deposition of immunoreactans in BD, especially in the negative pathergy and the normal skin sites, were observed. This study is the first controlled study revealing positive Ig depositions in BD, and it is expected to help us to reconsider the autoimmune pathogenesis in BD.

The significance of immunohistochemistry in the skin pathergy reaction of patients with Behcet's syndrome

BACKGROUND

Behçet's syndrome is a chronic systemic immuno-inflammatory disorder affecting multiple organs with generalized vasculitis of arteries and veins. Although the aetiology is still unknown, endothelial dysfunction is one of the most prominent features in Behçet's syndrome. The skin pathergy reaction (SPR) is a non-specific hyperreactive lesion formation that is one of the major features and diagnostic criteria of the disease. It develops after 24-48 h at the site of the needle-prick, especially in the exacerbation period, and it is very similar to the erythematous papules or pustules that appear spontaneously in patients with Behçet's syndrome. Therefore, an investigation into the formation of the SPR lesion may contribute to the pathophysiology of skin lesions of this unique disorder.

OBJECTIVE

To evaluate the immunological features of SPR formation by assessing the immunohistochemical staining of cell adhesion molecules and endothelial growth factor markers such as E-selectin, P-selectin and endoglin (CD 105).

METHODS

Patients with Behçet's syndrome showing positive (n = 15) or negative (n = 10) SPR and 15 age- and sex-matched hospital-based healthy control subjects from a similar ethnic background were included in this study. Patients were divided into active and inactive stage by clinical findings and acute-phase reactant parameters including erythrocyte sedimentation rate (ESR) and neutrophil count. Punch biopsy specimens were obtained both from the lesion site on the forearms at 48 h and from normal skin approximately 5 cm adjacent to the SPR site. A biopsy was also obtained from the test application site in Behçet's syndrome patients with negative SPR and healthy volunteers. Biopsy specimens were then evaluated by immunohistochemical staining.

RESULTS

Immunohistochemical examination demonstrated a mixed inflammatory cell infiltrate around the vessels and skin appendages that extended somewhat into the deep dermis. A positive segmental staining of E-selectin and P-selectin was noted in the endothelial cells of biopsies obtained from the patients with positive SPR. A positive segmental staining of CD 105 in the endothelial cells was also observed in the same group of patients. However, the immunostaining of the same markers was found to be negative in the biopsies obtained from normal skin of SPR-positive patients, SPR-negative patients and healthy control subjects. Both acute-phase reactant levels were significantly higher in the active stage than in inactive patients or healthy controls.

CONCLUSION

Interaction of cellular adhesion molecules together with endothelial proliferation may play an important role in the formation of SPR lesions in patients with Behçet's syndrome. The involvement of the vascular endothelium in a large number of diseases including Behçet's syndrome supports the importance of vascular-specific adhesion molecules for their aetiopathogenesis.

Evaluation of clinical findings according to sex in 2313 Turkish patients with Behçet's disease

BACKGROUND

Behçet's disease is a multisystem disease featuring mucocutaneous, ocular, articular, vascular, intestinal, urogenital, and neurologic involvement and occurs with a high prevalence in the Mediterranean including Turkey. Higher incidence of severe clinical course and systemic involvement is observed in male patients.

OBJECTIVE

To determine the influence of sex on the clinical course of Behçet' s disease.

METHODS

We retrospectively evaluated the clinical findings of 2313 Behçet patients followed up at the multidisciplinary Behçet's Disease Center at Ankara University.

RESULTS

The male/female patient ratio was 1.03. Oral aphthae was seen in all patients. In male Behçet patients, the prevalence of mucocutaneous lesions and systemic manifestations was as follows: 85.6% genital aphthae, 45.5% erythema nodosum, 59.5% papulopustular lesions, 17.5% thrombophlebitis, 38.1% ocular involvement, 11.3% articular involvement, 11.7% vascular involvement, 3.3% neurologic involvement, 1.4% gastrointestinal involvement, and 1.8% pulmonary involvement. In female Behçet patients, the prevalence of manifestations were as follows: 91% genital aphthae, 49.8% erythema nodosum, 48.3% papulopustular lesions, 3.5% thrombophlebitis, 19.8% ocular involvement, 11.8% articular involvement, 2.1% vascular involvement, 1.3% neurologic involvement, 1.4% gastrointestinal involvement, and 0.03% pulmonary involvement.

CONCLUSIONS

Only genital aphthae and erythema nodosum were more frequent in females. On the other hand papulopustular eruptions, thrombophlebitis, ocular, neurologic, pulmonary and vascular involvement were more frequent in males. While female patients had the best prognosis, male patients had a worse overall prognosis than females.

Reoperation results of arterial involvement in Behçet's disease

OBJECTIVES

to retrospectively evaluate the role of vascular interventions in Behçet's disease with arterial involvement. So far, little information is available on the surgical approach for arterial involvement in Behçet's disease.

MATERIAL AND METHODS

between February 1989 and August 1997, among 178 patients with Behçet's disease referred to our clinic, vascular involvement was established in total of 67 patients (38%) which consisted of 59 venous (33%) and 12 (7%) arterial involvements requiring urgent surgical intervention. Primary arterial lesions were occlusive in one patient, aneurysm formation in nine or both in four.

RESULTS

twelve primary operations and 12 reoperations were performed. The reasons for reoperations were anastomotic aneurysms, graft occlusion, occlusion of native vessel, graft infection, bleeding from anastomosis and aortoenteric fistula. First reoperation was performed after a mean period of 6.4 months (1-15 months). Postoperative follow-up was 12-60 months (mean 36 months) and three patients died during follow-up.

CONCLUSIONS

the surgical results were not satisfactory because of progressive graft thrombosis and formation of new aneurysms at the anastomosis. Aggressive medical treatment should be combined when major vessel involvement occurs. All types of arterial punctures for angiography or blood gases should be minimised because of the risk of new aneurysm formation. Surgical intervention is indicated only in patients with a growing aneurysm, acute rupture or severe ischaemia.

Comparison of histopathologic and clinical evaluations of pathergy test in Behçet's disease

BACKGROUND

The pathergy test, an important test in the diagnosis of Behçet's disease, is currently applied with disposable/sharp needles and evaluated only clinically (no histopathologic evaluation). In this study, the usefulness of the pathergy test conducted intradermally and intravenously with disposable/sharp needles in the diagnosis and determination of the activation of the disease is studied in comparison with the test conducted with nondisposable/blunt needles. In addition, histopathologic evaluation of the pathergy test is compared with the clinical evaluation.

METHODS

The study group consists of 43 Behçet's disease patients together with 15 patients with dermatosis as the control group. The pathergy test was applied to the Behçet's disease patients and the control group intradermally and intravenously with disposable/sharp and nondisposable/blunt needles.

RESULTS

The results of the pathergy test on the patients and the control group were evaluated clinically and histopathologically.

CONCLUSIONS

Clinical evaluation of the pathergy test conducted intradermally with nondisposable/blunt needles is sufficient for both the diagnosis and determination of the activation of Behçet's disease. Histopathologic evaluation of the test is not found to be more sensitive than the clinical evaluation.

The histopathology of pathergy: a chronologic study of skin hyperreactivity in Behçet's disease

BACKGROUND

Many patients with Behçet's disease (BD) demonstrate hyperreactivity (pathergy), and the induced skin lesions may serve as a model for the disease.

OBJECTIVE

This study examined the sequence of histopathologic changes after needle prick trauma.

METHODS

Eight patients fulfilling the International Study Group Criteria for Behçet's Disease, two patients with recurrent aphthous stomatitis, and two healthy controls each underwent intradermal injections with subsequent biopsies at 0, 4, 24, and 48 h. Hematoxylin and eosin sections were evaluated in a blinded fashion according to 11 histopathologic criteria.

RESULTS

At time zero, normal skin was seen. By 4 h, neutrophils were present usually admixed with lymphocytes (8 out of 10). The inflammatory cell density peaked by 24 h in 8 out of 10 patients and at 48 h in 2 out of 10 patients. Sparse leukocytoclasis was identifiable from 4 to 48 h, but was not associated with fibrin. True vasculitis (as evidenced by fibrin within vessel walls and/or intraluminal thrombi) was not seen. Intraepidermal pustules (IEPs) and polymorphonuclear (PMN) aggregates within the needle tract were seen as early as 4 h. The control patients and three out of eight of the BD patients failed to develop clinical lesions. Among this group histopathologic IEPs were lacking in all but two BD patients.

CONCLUSIONS

These data suggest that early pathergy is mediated by PMNs and lymphocytes without vasculitis. Hyperchemotaxis may explain the rapid accumulation of PMNs along the injection site.

Cutaneous vasculitis in Behçet's disease: a clinical and histopathologic study of 20 patients

BACKGROUND

Despite the frequency of small vessel vasculitis in skin lesions of Behçet's disease (BD), BD is classified as a neutrophilic dermatosis.

OBJECTIVE

Our goal was to determine whether the various cutaneous manifestations of BD are secondary to cutaneous vasculitis.

METHODS

Twenty-three specimens with histologically proven necrotizing vasculitis from 20 of 42 patients with BD were investigated.

RESULTS

The cutaneous vasculitic manifestations were characterized as erythema nodosum-like eruptions, palpable purpura, hemorrhagic blisters, infiltrated erythema, Sweet's syndrome-like eruptions, papulopustular lesions, and extragenital ulcerations. Combinations of various skin lesions were commonly seen in the same patient. Venous vessels in the entire dermis to the subcutis were affected with sparing of arterial vessels from middermis to subcutis. Histologic features included leukocytoclastic vasculitis in seven and lymphocytic vasculitis in 13 patients with extensive to focal localized fibrinoid necrosis of vessel walls.

CONCLUSION

Cutaneous vasculitis in BD is predominantly venulitis or phlebitis. Approximately half (48%; 20 of 42) of BD patients with cutaneous lesions had either lymphocytic (31%; 13 of 42) or leukocytoclastic vasculitis (17%; 7 of 42). We suggest that BD be considered as a vasculitis-associated disease separate from the neutrophilic dermatoses.

Immunopathologic study of the conjunctiva in patients with behçet disease

PURPOSE

Even though conjunctiva is not primarily involved in patients with uveitis due to Behçet disease, it may reflect the immunopathologic process when inflammation is induced by biopsy of conjunctiva, a phenomenon similar to the induced inflammation at skin pathergy sites.

METHODS

Conjunctival biopsy specimens obtained 48 hours after a 2-mm biopsy of the epibulbar conjunctiva in 26 Turkish patients with inactive ocular Behçet disease and 9 Turkish patients with inactive idiopathic uveitis were studied by immunoperoxidase using a panel of monoclonal antibodies: anti-CD1, -CD3, -CD4, -CD5, -CD14, -CD22, -CD25, and -CD67, HLA-DR, E-selectin, intercellular adhesion molecule-1 (ICAM-1), and vascular cell adhesion molecule-1 (VCAM-1).

RESULTS

Immunopathology of the conjunctival specimens obtained at the time of first biopsy was not significantly different between the Behçet disease and the idiopathic uveitis groups. The second-biopsy specimens of the patients with Behçet disease showed significantly greater numbers of T cells (CD3+, CD4+) and granulocytes (CD67+) as well as HLA-DR+ and ICAM-1+ cells in the substantia propria. Vascular endothelium of the conjunctiva in a patient with Behçet disease had significantly more pronounced expression of the adhesion molecules, E-selectin, and ICAM-1. None of the conjunctival specimens in either group showed VCAM-1 positivity.

CONCLUSIONS

These results show that a more intense antigen-independent inflammation develops with recruitment of both neutrophils and T lymphocytes of helper/ inducer phenotype in the conjunctiva of patients with Behçet disease in response to surgical trauma. Increased expression of E-selectin and ICAM-1 in the conjunctiva of patients with Behçet disease may suggest a critical role for these adhesion molecules in the initial events of inflammation.

Immunohistology of skin pathergy reaction in Behçet's disease

The immunophenotypic characteristics of the skin pathergy reaction (SPR) at 48 h in Behçet's disease (BD) were investigated in 12 patients with BD and in five controls. The findings in 11 positive and one negative SPR lesions of patients with BD were evaluated in comparison with those of normal adjacent skin and with the negative pathergy biopsies from the controls. Positive SPR biopsies showed variable epidermal thickening and cell vacuolization, as well as subcorneal pustule formation. In the SPR dermis, a variable dense focal mononuclear cell (MNC) infiltrate was seen around vessels and skin appendages, extending into the deep dermis. The MNC infiltrate was predominantly composed of T lymphocytes and monocytes/macrophages. The majority of the T lymphocytes were CD4+, and almost all expressed CD45RO. Approximately half of the infiltrating cells strongly expressed HLA-DR. Neutrophils constituted less than 5% of the infiltrating cells, but were present as clusters of elastase-positive cells at the needle-prick sites. Vessels within the lesion showed marked congestion and endothelial swelling. The endothelial cells expressed ICAM-1 strongly, and E-selectin moderately. VCAM-1 was not expressed on endothelial cells. The basal and mid-epidermal layers of keratinocytes expressed HLA-DR and ICAM-1 strongly, particularly so in areas close to the dermal MNC infiltrates. In negative pathergy biopsies, there were increased numbers of neutrophils and a few small clusters of macrophages and T lymphocytes only at the needle-prick site, and the endothelial cells of vessels close to these areas expressed E-selectin weakly.(ABSTRACT TRUNCATED AT 250 WORDS)

Behçet's disease

The reliability and ease of use of any activity form has to be balanced against the content validity of the questions being asked. Clinical experience over several years suggests that presence of a high disease activity score is consistent both with the clinician's and patient's overall impression of disease activity. If the onset of the more serious manifestations can be predicted by more readily measured symptoms such as oral and genital ulceration, skin lesions, arthritis and superficial thrombophlebitis, then these organ system subscores could be expanded to provide a more accurate representation of activity. Other organ systems such as auditory system may also provide a measure of disease activity. For the purpose of clinical trials it is likely that if treatment is targeted at a specific organ system then a more comprehensive measure of activity within that organ system would have to be used (e.g. the role of thalidomide in oral ulceration) (Revuz et al, 1990). This would require the use of a form which measured many facets of oral ulceration (duration of ulcers, number of ulcers, size of ulcers, number of crops of ulcers, site of ulcers, etc). However it is recommended that such a form should be used in conjunction with a validated general disease activity form to alert the clinician conducting any trials of the advantageous or deleterious effects of the trial drug on other organ systems.

Behçet's disease and surgical intervention

Behçet's Disease (BD) is a systemic disorder with an unknown etiopathogenesis. The need for clinical criteria in the establishment of diagnosis is of great importance. We present the case of a 27-year-old man with BD, who had a surgical operation during the active period of his disease and experienced subsequent complications. Cutaneous hyper-reactivity response to minor cutaneous trauma--the pathergy phenomenon--is found in most patients with BD. Theoretically, major traumas may lead to major reactions in the skin or any of the organs. In practice, we observed that while there was a severe inflammatory reaction--histopathologically a superficial perivascular dermatitis--which developed at the incision site, the systemic symptoms of the disease increased in spite of intensive treatment of the condition.

Histopathologic study of cutaneous lesions in Behçet's syndrome

Light microscopic studies of 55 patients with complete and incomplete types of Behçet's syndrome were reviewed. We reported here 39 skin biopsies from 30 patients with cutaneous lesions of oral, and genital ulcers, folliculitis, erythema multiforme, and thrombophlebitis. Leukocytoclastic vasculitis was seen in 5 of 12 (42%) cases of oral ulcers and 2 of 7 (29%) of genital ones. Lymphocytic vasculitis was demonstrated in 3 of 12 (25%) cases of oral ulcers and 4 of 7 (57%) of genital ulcers. However, the vasculitis was observed only locally in the areas with moderate or severe inflammation. From the biopsy specimens of our cases with fully developed mucocutaneous lesions of Behçet's syndrome, it appears that the forms of vasculitis that are often emphasized in the literature are a phenomenon secondary to the intense inflammation seen in such cutaneous lesions.

Skin hyperreactivity response (pathergy) in Behçet's disease

Behçet's disease is very difficult to diagnose because its clinical signs overlap with those of other systemic diseases. Thus there is a clear need for nonclinical diagnostic criteria for Behçet's disease. The nonspecific cutaneous hyperreactivity response, pathergy, may serve as an important diagnostic indicator. A test for pathergy may also clarify the role of an immune complex mechanism in the pathogenesis of Behçet's disease. In our study of 11 patients with Behçet's disease, deposition of immunoglobulins or complement was not found 4 hours after histamine or saline injection. In contrast, 24 hours after histamine or saline injection, 10 of 11 patients responded positively both clinically and histologically during the active stage of their disease. Vasculitis was noted in only two patients. Thus in most patients no evidence of an immune complex mechanism was observed. We conclude that any nonspecific intracutaneous injection is a good clinical tool for the diagnosis of Behçet's disease.

Abnormal B cell function in patients with Behçet's disease

We evaluated B lymphocyte function in 23 patients with Behçet's disease at various stages. The patients with active disease, but not those with inactive disease, were found to have elevated numbers of cells spontaneously secreting immunoglobulin and a decreased B cell response to the T cell-independent B cell mitogen, Staphylococcus aureus Cowan 1. Moreover, B cells from almost all patients with Behçet's disease were unresponsive to the T cell-dependent polyclonal activator, pokeweed mitogen. These results indicate that B cell abnormalities, including some which are associated with disease activity, could be involved in the pathogenesis of Behçet's disease.

Budd-Chiari syndrome and renal failure in Behcet disease. Report of a case and review of the literature

A case of Behcet syndrome associated with three rare complications is presented. The patient initially presented with asymmetric polyarticular arthritis, subcutaneous nodules, conjunctivitis, and episcleritis. Necrotizing vasculitis and renal failure subsequently evolved. Despite immunosuppressive therapy, Budd-Chiari syndrome with high grade hepatic obstruction developed. A Denver shunt procedure failed to alter the terminal course. At postmortem examination, skin lesions, carditis, hepatic vein thrombosis, gastric ulcerations, and focal proliferative glomerulonephritis were found. The immunoglobulins and complement present in skin and renal tissue suggest an immune complex pathogenesis.

Abnormal polymorphonuclear leukocyte motility in dermatologic diseases

A variety of skin diseases have been reported to have associated abnormalities in PMN chemotactic motility; however, the relationship of abnormal leukocyte motility to the pathogenesis of these diseases is poorly understood. A common feature in skin diseases associated with depressed chemotaxis has been the frequency of recurrent pyogenic infections. Since the chemotaxins and methodologies for evaluating leukocyte chemotaxis differ among laboratories, little is known about the specificity of these chemotactic defects. Further information regarding PMN motility defects may be obtained from detailed studies of migration to various doses of chemotaxins. The commercial availability of potent, structurally defined chemotaxins, such a N-formylated peptides, provides laboratories the opportunity to evaluate migration to "common" chemotaxins. In addition, the development of the multiple microwell chemotaxis chamber has made possible the opportunity to collect substantial leukocyte motility data from relatively small blood samples. Further investigations of leukocyte motility in various dermatologic diseases are clearly needed. A more systematic approach, i.e. (1) use of several different chemotaxins at various doses in chemotaxis assays and (2) use of standard, structurally defined chemotaxins, would facilitate comparative analyses of clinical studies among laboratories. It is likely that this approach would provide more specific information about the relevance of leukocyte motility defects in these diseases.

Immunoglobulins G, M, A, D and E in Behcet's syndrome

Serum IgG, IgM, IgA, IgD and IgE concentrations were examined in 26 patients with Behcet's syndrome, 70 patients with recurrent aphthous stomatitis and 56 healthy controls. IgA concentrations, but not IgG, IgM, IgD or IgE, were significantly raised in Behcet's syndrome compared with controls. Serum IgD and IgE concentrations but not IgA, IgG, or IgM were significantly greater in recurrent aphthous stomatitis than in controls.

Role of mucosal injury in initiating recurrent aphthous stomatitis

The buccal mucosa of 30 patients with recurrent aphthous stomatitis and 15 healthy controls was injured by suture and penetration with a tenaculum and a hypodermic needle and each of the six puncture wounds produced monitored for up to seven days for the development of ulcers. Altogether 26 lesions were induced in 13 patients, whereas none occurred in the controls (p less than 0.001). Sutures caused most of the lesions (15), and those so induced had a mean maximum diameter of 2.3 mm and lasted for an average of four days. Ulcers induced mechanically were clinically indistinguishable from those usually seen in the patients, except that they were generally smaller and healed more quickly. These findings confirm that mechanically induced injury of the oral mucosa may cause ulceration in people susceptible to aphthous stomatitis. Such a procedure may therefore be helpful in identifying subsets of patients.

Enhancement of granulocyte chemotaxis in Behcet's disease

The humoral and cellular immune status, the cutaneous pathergy, PMNL in vitro function tests as well as clinical and general laboratory examination were performed and evaluated on ten patients suffering from Behcet's disease (BD) and ten other patients with benign recurrent aphthosis (RA). The same set of in vitro tests (except PMNL exposure to solutions of copper sulfate or DDT) was carried out on a control group consisting of more than 100 healthy male and female individuals of various ages. Apart from general signs of inflammatory activity (leukocytosis, elevation of ESR, increased IgG serum levels), cutaneous pathergy to mild local highly injuries and marked enhancement of PMNL chemotaxis proved to be highly significant symptoms in acute phases of BD in contrast to benign RA. Both symptoms, in particular the hyperchemotaxis of PMNL, can be regarded as valuable diagnostic means in the early detection of beginning or atypical BD.

The quantification and significance of mast cells in lesions of Behçet's disease

Mast cells in the upper dermis and mucosal subepithelial layer were counted in thirty consecutive light microscopy oil-immersion fields of the following: thirty-four skin and oral specimens from lesions in patients with active Behçet's disease, eight specimens of apparently uninvolved skin of the same patients, and 102 lesions of a variety of other skin diseases. The results revealed a significant increase in the number of mast cells in Behçet's lesions. Furthermore, the histamine content of five reactive lesions showed a two-fold increase compared with that in apparently uninvolved skin of patients with active Behçet's disease. It is suggested that mechanisms similar to cutaneous basophil hypersensitivity may be involved in the production of Behçet's lesions.

Abnormal polymorphonuclear leucocyte chemotaxis in Behçet's syndrome

Experiments both in vitro and in vivo have been performed to study the chemotactic response of polymorphonuclear leucocytes (PMNs) in Behçet's syndrome. The experimental results were apparently contradictory. Using modified Boyden chambers we found that the PMNs from patients with Behçet's syndrome responded to a greater extent in vitro than normal cells, but with skin chambers placed over abrasions the in vivo response was less than normal. The significance of these findings is discussed and related to the histological appearances that may be seen in this condition.

Cardiac involvement and superior vena caval obstruction in Behçet's disease

A patient with Behçet's disease developed the rare complications of pericarditis and, two months later, superior vena caval obstruction. The latter complication was investigated by angiography to exclude other causes. As a result of this investigation the caval obstruction was managed conservatively, the symptoms and signs improving spontaneously.