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Puyade M, Patel A, Lim YJ, Blank N, Badoglio M, Gualandi F, Ma DD, Maximova N, Greco R, Alexander T, Snowden JA. Autologous Hematopoietic Stem Cell Transplantation for Behçet's Disease: A Retrospective Survey of Patients Treated in Europe, on Behalf of the Autoimmune Diseases Working Party of the European Society for Blood and Marrow Transplantation. Front Immunol 2021; 12:638709. [PMID: 34025648 PMCID: PMC8136432 DOI: 10.3389/fimmu.2021.638709] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/26/2021] [Indexed: 12/29/2022] Open
Abstract
Background Behçet’s Disease (BD) is an autoimmune disease mostly presenting with recurrent oral and genital aphthosis, and uveitis. Patients are rarely refractory to immunosuppressive treatments. Autologous hematopoietic stem cell transplantation (aHSCT) is a standard of care in other autoimmune diseases. Some patients with BD have been treated with aHSCT based on compassionate use. Objectives Evaluate the outcome of aHSCT in adult patients with BD treated in member centers of the European Society for Blood and Marrow Transplantation (EBMT). Methods Adults who received aHSCT primarily for BD were identified retrospectively in the EBMT registry and/or in published literature. Data were extracted from either medical records of the patient or from publications. Results Eight out of 9 cases reported to the registry and extracted data of 2 further patients from literature were analyzed. Four were female, median age at onset of BD was 24y (range 9-50). Median age at aHSCT was 32y (27-51). Patients had received median 4 (2-11) previous lines of therapy (89% corticosteroids, 50% methotrexate, anti-TNFα therapy or cyclophosphamide). All patients had active disease before mobilization. Conditioning regimen was heterogeneous. Median follow-up was 48 months (range 6-240). No treatment-related mortality was reported. This procedure induced complete remission (CR) in 80%, partial remission in 10% and lack of response in 10% of the patients. Relapse rate was 30% (2 relapses in patients in CR and 1 relapse in the patient in PR) with panuveitis (n=1), aphthosis (n=2) and arthralgia (n=1). Six patients were in CR. No late complications were reported. Conclusion aHSCT has an acceptable safety profile and represents a feasible and relatively effective procedure in severe and conventional treatment-resistant cases of BD and has the potential to stabilize BD in patients with life-threatening involvements.
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Affiliation(s)
- Mathieu Puyade
- CHU de Poitiers, Service de Médecine Interne et Maladies Infectieuses, Poitiers, France.,CHU de Poitiers, CIC-1402 Poitiers, France
| | - Amit Patel
- Haematology and Transplant Unit, The Christie NHS Foundation Trust, Manchester, United Kingdom
| | - Yeong Jer Lim
- Haemato-Oncology Department, Clatterbridge Cancer Centre, University of Liverpool, Liverpool, United Kingdom
| | - Norbert Blank
- Department of Hematology, Oncology and Rheumatology, Internal Medicine V, University Hospital of Heidelberg, Heidelberg, Germany
| | | | - Francesca Gualandi
- U.O. Ematologia Centro Trapianti Midollo - Ospedale Policlinico San Martino, Genova, Italy
| | - David D Ma
- Department of Haematology and BM Transplantation, St Vincent's Hospital Sydney and St Vincent's Clinical School, Faculty of Medicine, University of New South Wales (UNSW) Sydney, Sydney, NSW, Australia
| | - Natalia Maximova
- Institute for Maternal and Child Health - IRCCS Burlo Garofolo, Trieste, Italy
| | - Raffaella Greco
- Haematology and Bone Marrow Transplant Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Tobias Alexander
- Department of Rheumatology and Clinical Immunology, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Deutsches Rheuma-Forschungszentrum (DRFZ), an Institute of the Leibniz Association, Berlin, Germany
| | - John A Snowden
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, United Kingdom
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Zeher M, Papp G, Nakken B, Szodoray P. Hematopoietic stem cell transplantation in autoimmune disorders: From immune-regulatory processes to clinical implications. Autoimmun Rev 2017; 16:817-825. [PMID: 28572052 DOI: 10.1016/j.autrev.2017.05.020] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Accepted: 04/28/2017] [Indexed: 12/29/2022]
Abstract
Autoimmune diseases are characterized by the development of autoreactive T- and B-cells targeting self-antigens, which eventually can result in chronic and persistent organ damage. The autologous hematopoietic stem cell transplantation (AHSCT) opened new avenues in the treatment of patients with severe, treatment-resistant autoimmune diseases. This paper reviews the immune-regulatory mechanisms behind AHSCT, and also summarizes the experiences of clinical practice related to the therapy in organ-specific and systemic autoimmune diseases. It seems that the intricate interplay of various immune competent cells with regulatory capacity control in a synergistic manner the repopulated immune system after AHSCT, which potentially leads to a significant clinical improvement in certain autoimmune diseases. However, the widespread use of AHSCT was intrinsically limited, due to the serious side-effects of conditioning treatment and relatively high treatment-related mortality; moreover, the development of new effective and safe therapeutic approaches and the dawn of biological agents further limited its indications in the last decade. Nevertheless, with an appropriate patient selection and increased experience of transplant centres, the risks can be minimized, and AHSCT remained still a reasonable choice in multiple sclerosis and systemic sclerosis when the conventional therapy failed and further progression of disease is inevitable.
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Affiliation(s)
- Margit Zeher
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.
| | - Gábor Papp
- Division of Clinical Immunology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Britt Nakken
- Centre for Immune Regulation, Department of Immunology, University of Oslo, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Peter Szodoray
- Centre for Immune Regulation, Department of Immunology, University of Oslo, Oslo University Hospital, Rikshospitalet, Oslo, Norway
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3
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Nair JR, Moots RJ. Behçet's disease: Review of management. INDIAN JOURNAL OF RHEUMATOLOGY 2015. [DOI: 10.1016/j.injr.2015.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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4
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Stem cell autograft and allograft in autoimmune diseases. Clin Exp Med 2014; 16:13-20. [PMID: 25501897 DOI: 10.1007/s10238-014-0330-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 12/06/2014] [Indexed: 10/24/2022]
Abstract
Autoimmune diseases are characterized by an insufficiency of immune tolerance and, although treated with a number of useful drugs, may need more unconventional therapeutic strategies for their more severe presentations. Among such unconventional therapeutic approaches, stem cell autograft and allograft have been used, with the aim of stimulating disease remission by modifying the pathogenic mechanisms that induce anomalous responses against self-antigens. Autologous transplantation is performed with the purpose of retuning autoimmune cells, whereas allogeneic transplantation is performed with the purpose of replacing anomalous immune effectors and mediators. In this article, we comprehensively review up-to-date information on the autoimmune diseases for which the transplantation of stem cells is indicated.
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5
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Abstract
Pulmonary artery aneurysms (PAAs) are the most common type of pulmonary involvement in Behçet's disease. However, the relationships between clinical features and prognosis have not been sufficiently evaluated. This article describes the results of a comprehensive review, revealing that PAAs have a predilection for hemoptysis manifestations, increased dimensions, right lower lobar location, multiplicity and concurrent intramural thrombus formation. Surgical intervention was needed in one third of patients. Patients with massive hemoptysis and PAA rupture warranted emergency operations. Conservatively treated patients were prone to PAA progression; interventional embolization was associated with higher risks of recurrence and reintervention for PAAs; and surgically treated patients exhibited the highest mortality rates. In conclusion, PAAs in Behçet's disease are characterized by a predilection for hemoptysis manifestations, right lower lobar location, multiplicity, and concurrent intramural thrombus formation. Both the condition itself and the surgical operations it warrants are linked with high mortality due to PAA hemorrhage.
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Affiliation(s)
- Shi-Min Yuan
- Fujian Medical University, People's Republic of China
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6
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Soysal T, Salihoğlu A, Esatoğlu SN, Gültürk E, Eşkazan AE, Hatemi G, Hatemi I, Öngören Aydın Ş, Erzin YZ, Başlar Z, Tüzüner N, Ferhanoğlu B, Çelik AF. Bone marrow transplantation for Behçet's disease: a case report and systematic review of the literature. Rheumatology (Oxford) 2014; 53:1136-41. [PMID: 24505123 DOI: 10.1093/rheumatology/ket479] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES Behçet's disease (BD) can be life threatening and may be refractory to corticosteroids and immunosuppressives. There has been some experience with haematopoietic stem cell transplantation (HSCT) in BD either for severe, refractory disease or for a haematological condition. The objectives of this study were to describe a BD patient undergoing HSCT and to evaluate the outcomes of BD patients who underwent HSCT. METHODS We report a BD patient with refractory gastrointestinal (GI) involvement who had HSCT for concomitant myelodysplastic syndrome (MDS). We also performed a systematic literature search regarding HSCT for either refractory disease or concomitant haematological conditions in BD patients. RESULTS A 30-year-old woman with refractory GI BD involvement with trisomy 8 MDS underwent a successful myeloablative allogeneic HSCT resulting in complete resolution of both BD and MDS. Additionally we identified 14 manuscripts providing data on 19 patients with BD who had HSCT. Among these 20 patients, including ours, refractory disease was the indication of transplantation in 9, while 11 patients were transplanted because of accompanying haematological conditions. Transplant indications for the nine patients (four male, five female) with refractory BD were neurological involvement in five, pulmonary artery aneurysm in two, GI disease in one and not reported in one patient. Three patients with neurological disease, both patients with pulmonary artery aneurysm and the patient with intestinal involvement achieved complete remission of their disease. Six patients transplanted for haematological conditions, including the presented case, also had GI involvement of BD. All of these patients achieved complete remission of GI findings after HSCT. CONCLUSION When considering HSCT, the potential adverse events and complications, which can be fatal, need to be kept in mind.
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Affiliation(s)
- Teoman Soysal
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ayşe Salihoğlu
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey.
| | - Sinem Nihal Esatoğlu
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Emine Gültürk
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ahmet Emre Eşkazan
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Gülen Hatemi
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Ibrahim Hatemi
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Şeniz Öngören Aydın
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Yusuf Ziya Erzin
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Zafer Başlar
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Nükhet Tüzüner
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Burhan Ferhanoğlu
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
| | - Aykut Ferhat Çelik
- Division of Hematology, Division of Rheumatology, Division of Gastroenterology, Department of Internal Medicine and Division of Hematopathology, Department of Pathology, Cerrahpasa Medical Faculty, Istanbul University, Istanbul, Turkey
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7
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Comarmond C, Wechsler B, Cacoub P, Saadoun D. Traitement de la maladie de Behçet. Rev Med Interne 2014; 35:126-38. [DOI: 10.1016/j.revmed.2013.12.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2013] [Accepted: 12/02/2013] [Indexed: 12/14/2022]
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8
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Comarmond C, Wechsler B, Cacoub P, Saadoun D. Approaches to immunosuppression in Behçet's disease. Immunotherapy 2013; 5:743-54. [PMID: 23829625 DOI: 10.2217/imt.13.66] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Behçet's disease (BD) is a systemic large-vessel vasculitis characterized by a wide clinical spectrum including recurrent oral and genital ulcerations, uveitis, and vascular, neurological, articular, renal and gastrointestinal manifestations. Therapeutic management of BD depends on the clinical presentation and organ involved. Although colchicine, nonsteroidal anti-inflammatory agents and topical treatments with corticosteroids are often sufficient for mucocutaneous and joint involvement, a more aggressive approach with immunosuppressive agents is warranted for severe manifestations such as posterior uveitis, retinal vasculitis and vascular, neurological and gastrointestinal involvement. However, some patients still have refractory disease, relapse, sight-threatening eye disease or irreversible organ damage. Recent improvements in the understanding of the pathogenic mechanisms have led to the identification of potential targets and future therapies for BD. In contrast to current nonspecific immunosuppressive agents, the emergence of immunomodulatory drugs provides the possibility of interfering with specific pathogenic pathways. Novel targeted immunosuppressive therapies might be used in the future for BD.
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Affiliation(s)
- Cloé Comarmond
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière, Service de Médecine Interne 2, Université Pierre et Marie Curie-Paris VI, 83 Boulevard de l'Hôpital, 75013 Paris, France
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9
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Snowden JA, Saccardi R, Allez M, Ardizzone S, Arnold R, Cervera R, Denton C, Hawkey C, Labopin M, Mancardi G, Martin R, Moore JJ, Passweg J, Peters C, Rabusin M, Rovira M, van Laar JM, Farge D. Haematopoietic SCT in severe autoimmune diseases: updated guidelines of the European Group for Blood and Marrow Transplantation. Bone Marrow Transplant 2012; 47:770-90. [PMID: 22002489 PMCID: PMC3371413 DOI: 10.1038/bmt.2011.185] [Citation(s) in RCA: 212] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2011] [Revised: 07/04/2011] [Accepted: 07/04/2011] [Indexed: 12/13/2022]
Abstract
In 1997, the first consensus guidelines for haematopoietic SCT (HSCT) in autoimmune diseases (ADs) were published, while an international coordinated clinical programme was launched. These guidelines provided broad principles for the field over the following decade and were accompanied by comprehensive data collection in the European Group for Blood and Marrow Transplantation (EBMT) AD Registry. Subsequently, retrospective analyses and prospective phase I/II studies generated evidence to support the feasibility, safety and efficacy of HSCT in several types of severe, treatment-resistant ADs, which became the basis for larger-scale phase II and III studies. In parallel, there has also been an era of immense progress in biological therapy in ADs. The aim of this document is to provide revised and updated guidelines for both the current application and future development of HSCT in ADs in relation to the benefits, risks and health economic considerations of other modern treatments. Patient safety considerations are central to guidance on patient selection and HSCT procedural aspects within appropriately experienced and Joint Accreditation Committee of International Society for Cellular Therapy and EBMT accredited centres. A need for prospective interventional and non-interventional studies, where feasible, along with systematic data reporting, in accordance with EBMT policies and procedures, is emphasized.
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Affiliation(s)
- J A Snowden
- Department of Haematology, Sheffield Teaching Hospitals NHS Trust, Sheffield, UK
- Department of Oncology, University of Sheffield, Sheffield, UK
| | - R Saccardi
- Department of Haematology, Careggi University Hospital, Firenze, Italy
| | - M Allez
- Service de Gastroentérologie, INSERM U 662, Hôpital St Louis, Paris, France
| | - S Ardizzone
- Department of Gastroenterology, Sacco University Hospital, Milan, Italy
| | - R Arnold
- Charite Hospital Berlin, Berlin, Germany
| | - R Cervera
- Department of Autoimmune Diseases, Hospital Clinic, Barcelona, Spain
| | - C Denton
- Centre for Rheumatology, Royal Free and University College Medical School, Hampstead, London, UK
| | - C Hawkey
- Nottingham Digestive Diseases Centre, University of Nottingham, Nottingham, UK
| | - M Labopin
- Hôpital Saint Antoine, Service d'Hématologie et Thérapie Cellulaire, AP-HP, UPMC Univ Paris 06, Paris, France
| | - G Mancardi
- Department of Neuroscience, Ophthalmology and Genetics, University of Genova, Genova, Italy
| | - R Martin
- Institute for Neuroimmunology and Clinical MS Research, Hamburg, Germany
| | - J J Moore
- St Vincent's Hospital, Sydney, NSW, Australia
| | - J Passweg
- Universitaetsspital Basel, Basel, Switzerland
| | - C Peters
- BMT Unit, St Anna Children's Hospital, Vienna, Austria
| | - M Rabusin
- BMT Unit, Department of Pediatrics, Institute of Maternal and Child Health Burlo Garofolo, Trieste, Italy
| | - M Rovira
- SCT Unit, Hematology Department, Hospital Clinic, Barcelona, Spain
| | | | - D Farge
- Department of Internal Medicine, INSERM U 796, Hôpital St Louis, Paris, France
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Schreiber BE, Noor N, Juli CF, Haskard DO. Resolution of Behçet's Syndrome Associated Pulmonary Arterial Aneurysms with Infliximab. Semin Arthritis Rheum 2011; 41:482-7. [DOI: 10.1016/j.semarthrit.2011.02.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Revised: 02/25/2011] [Accepted: 02/28/2011] [Indexed: 11/27/2022]
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New Evidence-Based Treatment Approach in Behçet's Disease. PATHOLOGY RESEARCH INTERNATIONAL 2011; 2012:871019. [PMID: 22007346 PMCID: PMC3189606 DOI: 10.1155/2012/871019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2011] [Accepted: 08/01/2011] [Indexed: 12/30/2022]
Abstract
Behçet's
disease (BD) is a chronic, relapsing, and
debilitating systemic vasculitis of unknown
aetiology with the clinical features of
mucocutaneous lesions, ocular, vascular,
articular, neurologic, gastrointestinal,
urogenital, and pulmonary involvement. The
disease is much more frequent along the ancient
“Silk Route” extending from Eastern
Asia to the Mediterranean basin, compared with
Western countries. The disease usually starts
around the third or fourth decade of life. Male
sex and a younger age of onset are associated
with more severe disease. Although the
treatment has become much more effective in
recent years, BD is still associated with severe
morbidity and considerable mortality. The main
aim of the treatment should be the prevention of
irreversible organ damage. Therefore, close
monitoring, early, and appropriate treatment is
mandatory to reduce morbidity and mortality. The
treatment is mainly based on the suppression of
inflammatory attacks of the disease using
immunomodulatory and immunosuppressive agents.
In this paper, current state of knowledge
regarding the therapeutic approaches is
outlined. To provide a rational framework for
selecting the appropriate therapy along the
various treatment choices, a stepwise,
symptom-based, evidence-based algorithmic
approach was developed.
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12
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Zeher M, Papp G, Szodoray P. Autologous haemopoietic stem cell transplantation for autoimmune diseases. Expert Opin Biol Ther 2011; 11:1193-201. [PMID: 21609185 DOI: 10.1517/14712598.2011.580272] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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13
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Henderson CF, Brodsky RA, Jones RJ, Levine SM. High-dose cyclophosphamide without stem cell rescue for the treatment of refractory Behcet's disease. Semin Arthritis Rheum 2011; 41:301-4. [PMID: 21295330 DOI: 10.1016/j.semarthrit.2010.12.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2010] [Revised: 12/08/2010] [Accepted: 12/09/2010] [Indexed: 12/29/2022]
Abstract
OBJECTIVE Behcet's disease (BD) is a systemic inflammatory disorder characterized by recurrent mucocutaneous ulcerations, ocular inflammation, and numerous severe systemic inflammatory manifestations. While most patients respond to standard immunosuppressive therapies, a subset will develop refractory disease. In this report, the use of a novel therapy for the treatment of BD is described. METHODS Two patients with severe refractory BD who were treated with nonmyeloablative high-dose cyclophosphamide therapy without stem cell rescue. RESULTS After treatment, both patients were completely weaned off immunosuppressive therapy and entered disease-free remissions of 18 and 24 months, respectively. CONCLUSIONS These data suggest high-dose cyclophosphamide therapy without stem cell rescue as an alternative for the treatment of refractory BD.
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Affiliation(s)
- Charles F Henderson
- Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, MD 21224, USA
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Fiehn C, Ho AD, Lorenz HM. Hematopoietic stem cell transplantation (HSCT) for primary systemic vasculitis and related diseases. Autoimmunity 2010; 41:648-53. [PMID: 18958761 DOI: 10.1080/08916930802197495] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Primary systemic vasculitis (PSV) as well as the related disorders behcet disease (BD) and relapsing polychondritis (RP) are a heterogenous group of autoimmune diseases with the potency for a severe and life threatening course. Patients with PSV seem to be ideal candidates for HSCT: First, when first line treatment has failed the patients are in high risk of severe organ damage or death due to active disease or treatment toxicity. Moreover, the chance to achieve complete remission with standard doses of cyclophosphamide-still standard treatment of severe manifestations of PSV- predicts that dose escalation to high dose chemotherapy will increase the effectiveness. The experience with HSCT in patients with severe PSV as published in case reports and from EULAR and EBMT-databases gives preliminary evidence that HSCT might be an effective treatment option in refractory cases of PSV and related diseases. Validated scores of disease activity and damage such as the Birmingham vasculitis activity score (BVAS) and the vasculitis activity damage index (VDI) could help to identify patients which might profit from HSCT.
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15
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Snowden JA, Martin-Rendon E, Watt SM. Clinical stem cell therapies for severe autoimmune diseases. Transfus Med 2009; 19:223-34. [DOI: 10.1111/j.1365-3148.2009.00927.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Kötter I, Schmalzing M, Henes J, Vogel W, Kanz L. [Current value of stem-cell transplantation in autoimmune diseases]. Z Rheumatol 2009; 67:716-22. [PMID: 19011875 DOI: 10.1007/s00393-008-0386-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Transplantations of autologous or allogeneic stem cells from bone marrow or peripheral blood are preformed for the treatment of resistant autoimmune diseases. Data have been systematically collected since 1996. We describe the historical development of this procedure for autoimmune diseases, the possible mechanisms of action, the options for stem cell collection, purging and conditioning (high-dose chemotherapy, combination with monoclonal anti-T- or B-cell antibodies, total body irradiation), as well as the reported outcomes in the literature.
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Affiliation(s)
- I Kötter
- Abteilung Innere Medizin II, Medizinische Universitätsklinik Tübingen, Otfried-Müller-Str. 10, 72076, Tübingen, Deutschland.
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Keogan MT. Clinical Immunology Review Series: an approach to the patient with recurrent orogenital ulceration, including Behçet's syndrome. Clin Exp Immunol 2009; 156:1-11. [PMID: 19210521 PMCID: PMC2673735 DOI: 10.1111/j.1365-2249.2008.03857.x] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2008] [Indexed: 01/30/2023] Open
Abstract
Patients presenting with recurrent orogenital ulcers may have complex aphthosis, Behçet's disease, secondary complex aphthosis (e.g. Reiter's syndrome, Crohn's disease, cyclical neutropenia) or non-aphthous disease (including bullous disorders, erythema multiforme, erosive lichen planus). Behçet's syndrome is a multi-system vasculitis of unknown aetiology for which there is no diagnostic test. Diagnosis is based on agreed clinical criteria that require recurrent oral ulcers and two of the following: recurrent genital ulcers, ocular inflammation, defined skin lesions and pathergy. The condition can present with a variety of symptoms, hence a high index of suspicion is necessary. The most common presentation is with recurrent mouth ulcers, often with genital ulcers; however, it may take some years before diagnostic criteria are met. All patients with idiopathic orogenital ulcers should be kept under review, with periodic focused assessment to detect evolution into Behçet's disease. There is often a delay of several years between patients fulfilling diagnostic criteria and a diagnosis being made, which may contribute to the morbidity of this condition. Despite considerable research effort, the aetiology and pathogenesis of this condition remains enigmatic.
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Affiliation(s)
- M T Keogan
- Department of Immunology, Beaumont Hospital, Dublin, Ireland.
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18
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Lim SH, Hulsey M, Esler WV. Resolution of Behcet's disease after non-myeloablative allogeneic stem cell transplant for acute myeloid leukaemia. Rheumatology (Oxford) 2008; 48:88-9. [DOI: 10.1093/rheumatology/ken413] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kapoor S, Wilson AG, Sharrack B, Lobo A, Akil M, Sun L, Dalley CD, Snowden JA. Haemopoietic stem cell transplantation--an evolving treatment for severe autoimmune and inflammatory diseases in rheumatology, neurology and gastroenterology. ACTA ACUST UNITED AC 2007; 12:179-91. [PMID: 17558693 DOI: 10.1080/10245330701255106] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The concept of haemopoietic stem cell transplantation (HSCT) to treat severe autoimmune diseases has been around for several decades. Advances in the safety of HSCT have made it a clinical reality since 1995. Databases have registered around a thousand patients treated specifically for a wide range of diseases, predominantly multiple sclerosis (MS), systemic sclerosis (SSc), rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Phase I/II prospective and retrospective studies have supported the potential of autologous HSCT as a treatment option in severely affected patients, with profound and prolonged clinical responses in some diseases, although procedures are generally not curative. Allogeneic HSCT appears to offer curative potential, but the potential of high toxicity has limited its use in this context. The exact role of HSCT remains to be defined, particularly in the context of other advances in the treatment of autoimmune disease. Along with other groups, the European Group for Blood and Marrow Transplantation (EBMT) are overseeing several phase III trials in autologous transplantation. Given the risks of the HSCT, eligibility is restricted to patients who have severe, treatment resistant disease, in whom the prognosis is otherwise poor. This review aims to summarise the current published data in this evolving treatment for relatively rare patients with resistant or rapidly progressive disease where treatment options are otherwise limited. This cross-fertilization of knowledge between many specialties may provide increasing therapeutic opportunities in otherwise untreatable diseases. Moreover, destroying and rebuilding immune systems may provide insights into autoimmune diseases.
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Affiliation(s)
- Sabrina Kapoor
- Department of Haematology, Sheffield Teaching Hospitals NHS Foundation Trust, Royal Hallamshire Hospital, Sheffield, UK
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Uzun O, Erkan L, Akpolat I, Findik S, Atici AG, Akpolat T. Pulmonary involvement in Behçet's disease. ACTA ACUST UNITED AC 2007; 75:310-21. [PMID: 17446699 DOI: 10.1159/000101954] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2006] [Accepted: 01/24/2007] [Indexed: 01/27/2023]
Abstract
BACKGROUND Behçet's disease (BD) is a multisystem vasculitis and pulmonary involvement in BD is reported to indicate poor prognosis and high mortality. OBJECTIVES The aims of this study were to report on patients with pulmonary involvement and to discuss pulmonary artery thrombus and small-sized vasculitis associated with BD, with respect to previously published cases. METHODS Fifteen patients with BD and pulmonary involvement were included in this study. Massive hemoptysis was observed in all patients having pulmonary artery aneurysm (PAA). RESULTS Eleven patients had macroscopic pulmonary vascular disease (2 PAA, 3 PAA and thrombi and 6 only thrombi) and 3 patients had microscopic pulmonary vascular disease. The remaining patient had pulmonary cryptococcosis. CONCLUSIONS Data regarding treatment and outcomes of patients having BD-related pulmonary emboli/infarct and small-sized vasculitis are limited. Pulmonary vasculitis affects different levels of the pulmonary artery in BD and should be classified as macroscopic and microscopic vascular disease. 'Pulmonary artery thrombosis' should be used instead of 'pulmonary emboli'. Spiral CT angiography is the best radiological tool for evaluation of pulmonary problems in BD. Treatment of vasculitis should be based on the type of vascular disease and may vary among different types of vascular disease. Anticoagulation can be used in patients with microscopic vascular disease and nonaneurysmal macroscopic vascular disease. More studies are needed to clarify this issue.
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Affiliation(s)
- Oğuz Uzun
- Department of Pulmonary Medicine, Faculty of Medicine, Ondokuz Mayis University, Samsun, Turkey.
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Nonami A, Takenaka K, Sumida C, Aizawa K, Kamezaki K, Miyamoto T, Harada N, Nagafuji K, Teshima T, Harada M. Successful treatment of myelodysplastic syndrome (MDS)-related intestinal Behçet's disease by up-front cord blood transplantation. Intern Med 2007; 46:1753-6. [PMID: 17938534 DOI: 10.2169/internalmedicine.46.0291] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Behçet's disease is a chronic, relapsing, inflammatory disease of unknown origin. The association of myelodysplastic syndrome and Behçet's disease is rare, and recent reports have indicated that immunosuppressive agents alone are not sufficient to control Behçet's disease associated with MDS and many patients die of infection or hemorrhage. We report a case of MDS with intestinal Behçet's disease. We performed cord blood transplantation with a myeloablative regimen as the primary treatment. The patient achieved complete remission for both diseases, which continued for more than 16 months. Our experience suggests that CBT may provide a potent therapeutic option for the treatment of MDS-related Behçet's disease.
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Affiliation(s)
- Atsushi Nonami
- First Department of Internal Medicine, Graduate School of Medicine, Kyushu University, Fukuoka.
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Daikeler T, Kötter I, Bocelli Tyndall C, Apperley J, Attarbaschi A, Guardiola P, Gratwohl A, Jantunen E, Marmont A, Porretto F, Musso M, Maurer B, Rinaldi N, Saccardi R, Tyndall A. Haematopoietic stem cell transplantation for vasculitis including Behcet's disease and polychondritis: a retrospective analysis of patients recorded in the European Bone Marrow Transplantation and European League Against Rheumatism databases and a review of the literature. Ann Rheum Dis 2006; 66:202-7. [PMID: 16950809 PMCID: PMC1798517 DOI: 10.1136/ard.2006.056630] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE To evaluate the feasibility of haematopoietic stem cell transplantation (HSCT) in vasculitis. METHODS This is a retrospective analysis of patients who had received HSCT for vasculitic diseases and have been reported to the European League Against Rheumatism autoimmune disease or European Bone Marrow Transplantation ProMISe databases. Information about the disease and outcome was obtained by a questionnaire sent to the referring centres. Response of the disease to HSCT was defined as partial or complete responses according to the ability to reduce immunosuppression after HSCT. In addition, the Medline database was searched for reports on HSCT in patients with vasculitis. RESULTS Detailed information was obtained for 15 patients, whose median age at HSCT was 37 years. The diagnoses were cryoglobulinaemia in four patients, Behçet's disease in three patients, Wegener's granulomatosis in three patients, and undifferentiated vasculitis, Churg-Strauss angiitis, polychondritis, Takayasu arteritis and polyarteritis nodosa in one patient each. 14 patients received autologous HSCT and 1 an allogeneic HSCT as the first transplant. In three patients, further transplantation was given because of relapse. The overall response, including all consecutive transplantations (HSCT/patient, n = 1-3, median 1.3) to HSCT, was 93%, with 46% complete responses and 46% partial responses; median (range) duration of response at the time of reporting was 45 (16-84) months. Three patients died, one from advanced disease, one from cancer and one from graft-versus-host disease. The Medline search showed five other patients who were effectively treated with HSCT for vasculitic diseases. CONCLUSION This retrospective study suggests that autologous HSCT is feasible for vasculitis. Its value remains to be tested in prospective controlled studies.
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Affiliation(s)
- Thomas Daikeler
- Department of Rheumatology, University of Basle, Petersgraben 4, CH-4031 Basle, Switzerland.
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Marmont AM, Gualandi F, Piaggio G, Podestà M, Teresa van Lint M, Bacigalupo A, Nobili F. Allogeneic bone marrow transplantation (BMT) for refractory Behçet's disease with severe CNS involvement. Bone Marrow Transplant 2006; 37:1061-3. [PMID: 16633360 DOI: 10.1038/sj.bmt.1705372] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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