Behçet's disease with a large intracardiac thrombus: a case report

[Left ventricular thrombosis: an exceptional manifestation of Behçet's disease (a case report)]

Intracardiac thrombus is an exceptional complication revealing Behçet's disease. We here report the case of a 48-year-old patient admitted with stroke. Clinical examination showed recurrent oral aphthous ulcers. Cardiovascular examination was normal, magnetic resonance imaging (MRI) objectified left posterior parietal stroke. Transthoracic echocardiogram showed totally thrombosed apical aneurysm measuring 42mm/36mm. Total-body computed tomography (CT) scan was performed to detect other abnormalities. It was normal apart from cardiac involvement. The diagnosis of Behçet's disease was made based on oral aphthous ulcers, polyarteritis nodosa and thrombosed left ventricular aneurysm. Outcome was favorable under medical treatment combining anticoagulants, corticosteroids and immunosuppression.

Intracardiac thrombus in Behçet's disease: a rare case in Morocco

Behçet’s syndrome is a systemic inflammatory disease generally presented with the triad of uveitis, oral and genital ulcers. However, it may present with gastrointestinal, central nervous system, skin and vascular disease manifestations. Intracardiac thrombus is a rare but serious complication of Behçet’s disease. A 16-year-old man with Behçet’s syndrome was hospitalized into our department with a history of cough, fever, chest pain, hemoptysis, and weight loss. Transthoracic echocardiography and chest scan revealed a right ventricular thrombus. After one month of treatment with cyclophosphamide, and corticosteroid the intracardiac thrombus has been resolved.

Prolonged fever and intra-cardiac thrombosis revealing Behçet's disease

BACKGROUND

Prolonged fever (PF) is a challenging problem for physicians since it can be the first manifestation of a large variety of pathologies. Exceptionally, intra-cardiac thrombus (ICT) could explain PF and reveal Behçet's disease (BD). We are reporting a 45-year-old man with BD who has these unusual manifestations.

CASE REPORT

A 45-year-old man presented with PF and inflammatory biological syndrome during a few months. Echocardiography showed an inhomogeneous and mobile mass in the left auricle. During his hospitalization, the patient had multiple oral aphtosis. The angioscanner showed a sacciform aneurysm of the coeliac trunk. The diagnosis of BD was retained and he was treated with high doses of steroids and cyclophosphamide with a favorable follow-up.

CONCLUSION

The search for BD should be systematic in view of any suggestive manifestation of severe cardiovascular complications like ICT especially in a young adult man from a high endemicity region.

Right ventricular thrombosis as a manifestation of Behçet's syndrome

BACKGROUND

Behçet's disease (BD) is a rare condition with a classic triad of oral and genital ulceration and eye disease. Cardiovascular complication is a rare finding in BD.

CASE REPORT

In this report, we present a seventeen years old patient with a history of fever for 20 days, who developed a clot in right ventricle (RV). Cardiac magnetic resonance imaging (MRI) and echocardiography demonstrated a thrombosis in RV and a thoracic multi detector computed tomographic image showed pulmonary thromboembolism (PTE) in patient. The patient was administered with methylprednisolone, cyclophosphamide and anticoagulant. A regular follow-up was carried out. Two months later, the RV clot had disappeared on transthoracic echocardiography (TTE).

CONCLUSION

In BD, early cardiac MRI and echocardiography should be performed for the detection of cardiac involvement, and medical treatment is the first choice of treatment.

Inhibition of SA Node at Supine Position in Right Atrial Thrombus Complicating Behçet's Disease - From Cardiac Surgical Point of View

Patient: Female, 27

Final Diagnosis: Right atrial thrombus compressing the sinoatrial node

Symptoms: Dyspnea • cough and hemoptysis with supine bradycardia reaching 36/min and dizziness

Medication: —

Clinical Procedure: Cardiac surgical intervention removing the mechanical cause if conservative management failed can be done safely

Specialty: Surgery

Pulmonary Nodules as an Initial Manifestation of Behçet's Disease

Behçet's disease (BD) is a systemic vasculopathy, characterized by recurrent oral aphthae, genital ulcers, uveitis, and skin lesions. Although vascular involvement, including venous and arteries of any size, is a usual manifestation, cases with pulmonary thrombosis as the initial symptom are not common in the absence of pulmonary artery aneurysm (PAA). This report describes a 36-year-old man with recurrent fever, nonmassive hemoptysis, and persistent cough with lung nodules in CT scan who had undergone open lung biopsy. On the basis of morphological findings, BD was suggested and more precise evaluation confirmed the diagnosis.

Acute inferior myocardial infarction in a young male patient associated with Behcet's disease and sildenafil

Behcet's disease (BD) is a multisystemic inflammatory disorder of unknown origin, presenting with mucocutaneous, ocular, articular, vascular, gastrointestinal and central nervous system manifestations. Coronary involvement is very rare in patients with BD. Sildenafil, an oral drug used to treat erectile dysfunction, was shown to cause significant cardiovascular problems including acute myocardial infarction (MI) and sudden cardiac death. Acute MI associated with BD and sildenafil has not been reported previously. We present a case of a 23-year-old male patient with an acute inferior MI associated with BD diagnosed after admission of sildenafil, who was successfully treated with thrombus aspiration and tirofiban administration.

[Cardiovascular involvement in Behçet's disease]

Vascular involvement is a common complication of Behçet's disease (BD) and affects up to 40% of BD patients. These complications worsen the prognosis of BD. The concept of vasculo-Behçet has been adopted for cases in which vascular complications dominate the clinical features. Vascular manifestations affect particularly young men, during the first years following onset of the disease. Venous complications are the most frequent vascular complications, affecting 14 to 40% of BD patients. Superficial and deep lower limb thrombosis is the most frequent venous complications but one third of venous thrombosis concern large vessels (such as cerebral venous thrombosis, pulmonary embolism, and inferior or superior vena cava, etc.). Budd-Chiari syndrome is the worst prognostic factor increasing mortality by 9 times. Arterial complications (2 to 17% of BD patients) include aneurysms and occlusions/stenosis. Main locations of arterial lesions are aortic (abdominal and thoracic), femoral, pulmonary and iliac arteries. Aneurysms are the most severe arterial complications, particularly pulmonary aneurysms associated with a high risk of massive bleeding. Cardiac complications (up to 6% of BD patients) include pericarditis, endocardial lesions (aortic regurgitation and less often mitral insufficiency), myocardial lesions (myocardial infarction, myocarditis and endomyocardial fibrosis) and intracardiac thrombosis (right ventricle and atrium). Coronary lesions complicated to myocardial infarction are the most severe cardiac complications. Treatment is based on corticosteroids and immunosuppressive drugs. The use of anticoagulation in venous thrombosis is still controversial.

Behcet's Disease: New Concepts in Cardiovascular Involvements and Future Direction for Treatment

Behcet's disease (BD) is the only systemic vasculitis involving both arteries and vein in any sizes. It frequently encounters in rheumatology clinics. It has some major morbidities and even fatal outcomes in some cases. The aim of this paper is to analyze the main concepts on pathophysiology and treatment options in BD, focusing on cardiovascular aspects, thrombosis, and potential future treatment.

Spectrum of cardiac lesions in Behçet disease: a series of 52 patients and review of the literature

Cardiac abnormalities in patients with Behçet disease (BD) include pericarditis, myocarditis, endocarditis with valvular regurgitation, intracardiac thrombosis, endomyocardial fibrosis, coronary arteritis with or without myocardial infarction, and aneurysms of the coronary arteries or sinus of Valsalva. Data regarding the clinical spectrum, prevalence, and outcome of cardiac lesions in BD are lacking. In this study, we report the main characteristics, treatment, and long-term outcomes of 52 patients with cardiac lesions from a cohort of 807 (6%) BD patients. Forty-five (86.5%) patients were male, with a mean (±SD) age at BD diagnosis of 29.3 ± 10.3 years.Cardiac involvement was the first feature of BD in 17 (32.7%) patients. Cardiac lesions included pericarditis (n = 20; 38.5%), endocarditis (mostly aortic insufficiency) (n = 14; 26.9%), intracardiac thrombosis (n = 10; 19.2%), myocardial infarction (n = 9; 17.3%), endomyocardial fibrosis (n = 4; 7.7%) and myocardial aneurysm (n = 1; 1.9%). Patients with cardiac involvement were more frequently male (86.5% vs. 64.9%; p < 0.01) and had more arterial (42.3% vs. 11.1%; p < 0.01) and venous lesions (59.6% vs. 35.8%; p < 0.01) compared to those without cardiac manifestations. Factors associated with complete remission of cardiac involvement were treatment regimens with oral anticoagulants, immunosuppressants, and colchicine. The 5-year survival rate was 83.6% and 95.8% (p = 0.03) in BD patients with and without cardiac involvement, respectively. After a median (Q1-Q3) follow-up of 3.0 (1.75-4.2) years, 8 patients had died, in 3 cases directly related to cardiac involvement.In conclusion, cardiac lesions affected 6% of our large cohort of BD patients. The prognosis of cardiac involvement in BD is poor and improves with oral anticoagulation, immunosuppressive therapy, and colchicine.

Successful treatment of intracardiac and pulmonary thrombi in Behçet's disease with oral anticoagulant and immunosuppressive therapy

Behçet's disease is a multisystem chronic inflammatory disease generally presenting as recurrent oral-genital ulcers and uveitis. Vascular involvement is a common presentation. However, cardiac involvement is rare in this disorder. In this case report, we present a large right ventricular thrombus detected both in computed tomography and echocardiography in a 32 year-old male patient with complaints of fever, haemoptysis and weight loss. Intracardiac thrombus showed both clinical and radiological regression with oral anticoagulant and immunosuppressive therapy.

Cardiac thrombosis as a manifestation of Behçet syndrome

Herein, we report 3 cases of Behçet syndrome that were accompanied by intracardiac thrombus. The 1st patient was a 30-year-old man who presented with dyspnea; a right atrial thrombus was identified upon transthoracic echocardiography. The 2nd patient was a 52-year-old man who was admitted for dyspnea; transthoracic echocardiography revealed an echogenic mass in the right ventricle. The 3rd patient was a 23-year-old man who was hospitalized for hemoptysis; the diagnosis of pulmonary embolism was made, and right ventricular thrombosis was found.Because these patients had no hemodynamic compromise, medical management consisting of immunosuppressive and anticoagulative therapy was adopted. This treatment resulted in complete dissolution of the thrombi.

MALDI-TOF/TOF-MS reveals elevated serum haptoglobin and amyloid A in Behcet's disease

Behcet's disease (BD) is a multisystemic autoimmune disease with unclear etiology and pathogenesis. To screen aberrant serum proteins in BD, serum samples were obtained from eight male BD patients with active uveitis and eight male healthy volunteers with informed consent. The serum samples from active BD patients and normal controls were pooled. Highly abundant serum proteins (albumin and IgG) were depleted from these two samples using an affinity capture based kit. The obtained samples were subjected to two-dimensional gel electrophoresis (2-DE). Protein spots were visualized with the "blue silver" staining. Differently expressed proteins were subsequently identified by matrix-assisted laser desorption /ionization tandem time-of-flight mass spectrometry (MALDI-TOF/TOF-MS). Western blot and enzyme-linked immunosorbent assay (ELISA) were performed using the serum samples from 18 patients with active BD, 6 patients with inactive BD, 22 patients with Vogt-Koyanagi-Harada (VKH) syndrome, and 20 healthy volunteers to validate the results of 2-DE and MS. Proteomic profiles of the pooled samples were compared, and approximately 800 protein spots were observed in each of the gels. Expression levels of four of the protein spots in active BD were significantly higher than those in the normal controls. Mass spectrometric protein identification revealed that the four protein spots corresponded to two proteins: haptoglobin (Hp) and serum amyloid A (SAA). Western blot and ELISA showed that Hp was only overexpressed in active BD but not in inactive BD, VKH syndrome, or healthy controls. An obvious band of SAA was detected in 72.2% of the serum samples from BD patients, whereas a vague band of this protein was found in 10.0% of the tested normal samples and 9.1% of VKH samples. Our results revealed a significantly increased expression of Hp and SAA in serum of active BD patients. These two proteins may be involved in the development of BD.

Evaluation of myocardial perfusion and function by gated SPECT in patients with Behçet's disease

BACKGROUND

Behçet's disease (BD) is a systemic multi-system vasculitis that can have a wide range of effects on the cardiovascular system.

OBJECTIVE

To determine the existence of myocardial perfusion defects caused by coronary microvascular dysfunction in BD and to evaluate coronary arterial distribution and left ventricular systolic function by gated single-photon emission computed tomography (SPECT).

METHODS

The study population consisted of 23 (15 men and 8 women) patients with BD and 20 healthy controls (12 men and 8 women). Technetium-99m methoxyisobutylisonitrile (Tc-99m MIBI) gated SPECT studies were performed at stress and rest in a 2-day protocol. Stress and rest left ventricular ejection fraction (LVEF) were calculated. Using non-gated SPECT images myocardial perfusion scores [summed stress score (SSS), summed rest score (SRS), summed difference score (SDS), and fix defect score (FDS)] and perfusion defect extent as percentage (stress, rest ischemic, and fix %LV) were determined. Using gated SPECT images, wall motion score indices (stress wall motion score indices and rest wall motion score indices) were calculated. Coronary angiography (CAG) was applied to patients with abnormal myocardial perfusion scintigraphy (MPS).

RESULTS

The mean ages of the BD and control groups were 39.3 +/- 10.6 years and 36.2 +/- 8.3 years, respectively. No statistically significant differences were observed between the two groups regarding clinical features and cardiologic findings. Abnormal MPS was found in 13 (56.5%) of the BD patients; 3 patients had non-transmural infarcts and 10 patients reversible perfusion defects. Reversible perfusion defects were also found in two controls (10.0%). When the two groups were compared regarding the gated SPECT findings, differences were determined in the following parameters; SSS, SRS, SDS, FDS, stress and rest LVEF, stress and rest %LV, and stress and rest WMSI. In the BD group, when gated SPECT results were compared between those with and without abnormal MPS, differences were determined in SSS, SRS, SDS, FDS, stress and rest %LV, and stress and rest WMSI. Epicardial coronary arteries were normal in CAG.

CONCLUSIONS

Myocardial perfusion and function are disturbed owing to influenced coronary microvascularity in BD, and CAG is frequently observed to be normal. Gated SPECT is a non-invasive reliable method that simultaneously evaluates the existence, extent and severity of myocardial ischemia or infarction and the wall movements in cardio-Behçet.

Intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism in a patient with Behçet's disease: a case report and literature review

A 26-year-old woman with intermittent fever was admitted to our hospital, and gradually developed facial edema. Examinations including computed tomography, transesophageal echocardiography, digital subtraction angiography, and pulmonary perfusion scintigraphy revealed intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism. Clinical findings and laboratory data led us to make a diagnosis of Behçet's disease. Combination of intracardiac thrombus, superior vena cava syndrome, and pulmonary embolism are rare complications in Behçet's disease. Behçet's disease should be considered in the differential diagnosis of intracardiac mass of the right heart, and early diagnosis and treatment are essential for the management of Behçet's disease especially with large-vessel manifestations. In addition to a case report, we review the literature and report the characteristics of intracardiac thrombus in Behçet's disease.

Successful Treatment of Right Ventricular Thrombus with Heparin and Sodium Warfarin Therapy: A Case Report

A 75-year-old woman came to our emergency clinic complaining of abdominal pain. Acute cholecystitis was diagnosed, and parenteral antibiotic therapy was initiated. Because of palpitation, she had a consultation with the cardiology clinic. Echocardiography showed a 2.7 x 2.2 cm mobile thrombus attached to the apex of the right ventricle. Since no thromboembolic complications were present, we decided to begin administering heparin and oral anticoagulant. After the administration of unfractionated heparin for 48 hours, the patient was shifted to low-molecular weight heparin because it is easier to use and requires no follow-up. The patient received low-molecular weight heparin in addition to sodium warfarin for 5 days. Administration of heparin was then stopped and treatment was continued with sodium warfarin. In the series of weekly echocardiography evaluations, a gradual reduction was noted in the apical mass, which was initially considered to be a thrombus, and 3 weeks later evaluation revealed that the thrombus in the right ventricle had disappeared completely. No thromboembolic complications were observed during the follow-up period.

Right ventricular thrombus with Behçet's syndrome: successful treatment with warfarin and immunosuppressive agents

Behçet's syndrome is a chronic multisystem disease that presents with recurrent oral and genital ulceration and recurrent uveitis. Cardiac involvement is an extremely rare manifestation of this disorder. A 33-year-old man with Behçet's syndrome was admitted to our department with a history of cough, fever, chest pain, hemoptysis, and weight loss. Transthoracic and transesophageal echocardiography revealed a right ventricular thrombus. After 1 month of treatment with warfarin, cyclophosphamide, and corticosteroid, the intracardiac thrombus resolved.

Intracardiac thrombus in Behçet's disease: two case reports

Intracardiac thrombus in Behçet's disease is an extremely rare manifestation. We report two such cases. A 20-year-old man presented with dyspnoea, cough and haemoptysis. Right heart thrombus associated with pulmonary artery aneurysm and thromboembolism was identified by helical CT and transoesophageal echocardiography. The second case was a 29-year-old male admitted for fever and chest pain. A diagnosis of right atrial thrombosis associated with pulmonary embolism and hyperhomocysteinemia was made. Due to the absence of haemodynamic compromise, medical management consisting of immunosupressive and anticoagulation therapy was adopted which resulted in complete dissolution of the thrombus with dramatic clinical improvement in both cases of clinical status.

Conclusion: intracardiac thrombus is a rare complication of Behçet's disease. As shown in our patients, medical treatment should be considered as the first line.

Pseudotumeur cardiaque révélant une maladie de Behçet

INTRODUCTION

Cardiac thrombosis is a rare complication of Behçet's disease (BD), which may present as a cardiac tumor. Its discovery precedes, in half of the cases, the diagnosis of BD. The high mortality may be associated to postsurgical complications and/or an associated involvement of pulmonary arteries.

CASE REPORT

We present the case of a 31 years old Caucasian French woman, with a history of venous thromboembolic disease, who had surgery after the discovery of a right ventricle tumor. That was an organised thrombus with endomyocardial fibrosis and a diagnosis of Behçet's disease was made after the surgery. The outcome was favourable under medical treatment associating corticosteroids, colchicine and antivitamin K (AVK), without relapse four years later.

CONCLUSION

The discovery of an intracardiac mass in a young patient must evoke the diagnosis of cardiac thrombus and Behçet's disease, even in the absence of predisposing ethnic or geographic factor.

[Intracardiac thrombus in Behçet's disease. A report of three cases]

Intracardiac thrombus formation is exceptional in Behçet's disease (less than 50 cases had been reported). Among 180 patients with Behçet's disease (according to the criteria of the international study group for Behçet's disease), three were diagnosed as having intracardiac thrombus. All were male, the mean age at the time of the diagnosis of the intracardiac thrombus was 27 years and the mean disease duration was 4.8 years. The presenting symptom was hemoptysis in two patients and heart failure in the third. Surgery was the first attempted treatment in two patients but thrombus recurred and resolved after medical treatment. The third patient was given corticosteroids and anticoagulants as the first line treatment. The thrombus did not resolve and the patient declined surgery. Intracardiac thrombus formation should be considered when a young Behçet's disease patient presents with an intracardiac mass. Medical treatment including corticosteroids, immunosuppressive drugs and anticoagulants should be considered as the first line treatment and surgery should be considered when there is no resolution of the thrombus or when it becomes massive and extensive. In certain cases, thrombolytic treatment becomes an interesting alternative to surgery.