Hughes-Stovin syndrome

Beyond the ordinary: TNF-alpha inhibitor as a rescue therapy in relapsing Hughes-Stovin syndrome with intracardiac thrombosis-a case report and literature review

Background

Hughes-Stovin syndrome (HSS) is a rare vasculitis characterized by the association of thrombophlebitis with pulmonary artery aneurysms (PAAs). Because it is rarely reported, there are currently no established diagnostic criteria or standardized treatment guidelines for HSS. While conventional immunosuppressants are generally effective as first-line treatment, relapsing and refractory cases urge the need to investigate alternative therapies, such as TNF-alpha inhibitors. However, with only five cases published in the literature, knowledge of their efficacy in HSS is very limited.

Case summary

A 28-year-old man, with no past medical history, presented with haemoptysis, chest pain, and dyspnoea on exertion. Physical examination found bilateral leg swelling, with no associated lesions. CT angiography showed multiple bilateral PAA, proximal pulmonary artery thrombosis (PAT), and deep venous thrombosis (DVT) in the superior mesenteric vein and spleno-mesaraic confluence. Echocardiography was performed, identifying right intracardiac thrombosis (ICT). Initial management included high-dose corticosteroids and monthly cyclophosphamide cycles, followed by maintenance treatment with oral azathioprine. Eighteen months later, the patient presented with haemoptysis revealing a relapse of ICT and two new PAA. Infliximab was initiated, allowing complete and sustained remission after one year of follow-up.

Discussion

We report the challenging case of an HSS patient presenting with multiple PAA, proximal PAT, right ICT, and extended abdominal DVT. The positive response of our patient to infliximab, following a relapse under conventional immunosuppressants, supports the efficacy of TNF-alpha inhibitors as second-line treatment in relapsing/refractory HSS.

Lung Involvement in Pulmonary Vasculitis: A Radiological Review

Pulmonary vasculitis identifies a heterogeneous group of diseases characterized by inflammation, damage and necrosis of the wall of pulmonary vessels. The most common approach to classify vasculitis is according to etiology, therefore dividing them into primary and secondary, with a further sub-classification of primary vasculitis based on the size of the affected vessels (large, medium, and small). Pulmonary involvement is frequently observed in patients with systemic vasculitis and radiological presentation is not pathognomonic, but may vary between diseases. The main findings using high-resolution computed tomography (HRCT) include small vessel wall thickening, nodular lesions, cavitary lesions, reticular opacities, ground-glass opacities (GGO), consolidations, interlobular septal thickening, tracheobronchial stenosis, and aneurysmal dilatation of pulmonary arteries, with or without pleural effusion. Radiological diagnosis alone is difficult since signs and symptoms of lung vessel involvement are often non-specific and might overlap with other conditions such as infections, connective tissue diseases and neoplasms. Therefore, the aim of this review is to describe the most common radiological features of lung involvement in pulmonary vasculitis so that, alongside detailed clinical history and laboratory tests, a prompt diagnosis can be performed.

Behçet's syndrome

Behçet's syndrome is a rare, chronic multisystemic inflammatory disorder also known as the Silk Route disease due to its geographical distribution. Behçet's syndrome is a multifactorial disease and infectious, genetic, epigenetic, and immunological factors contribute to its pathogenesis. Its heterogeneous spectrum of clinical features include mucocutaneous, articular, ocular, vascular, neurological, and gastrointestinal manifestations that can present with a relapsing and remitting course. Differential diagnosis is often hampered by the non-specific clinical presentation and the absence of laboratory biomarkers or pathognomonic histological features. The therapeutic approach is tailored on the basis of patient-specific manifestations and relies on glucocorticoids, colchicine, and traditional and biological immunosuppressants. Despite progress in the knowledge and management of the disease, unmet needs in diagnostics, monitoring, prediction, and treatment personalisation challenge clinical practice, making Behçet's syndrome a complex disorder associated with an increased risk of morbidity.

Hughes-Stovin syndrome-An important differential diagnosis in patients with suspected chronic thromboembolic pulmonary hypertension : A case report

Hughes-Stovin syndrome (HSS) is a rare vasculitis of unknown etiology. The disease is characterized by pronounced inflammation and damage to the vessel walls, with subsequent widespread vascular thrombosis and the formation of pulmonary artery aneurysms that can lead to fatal hemoptysis. This disorder can be mistaken for other conditions, such as chronic thromboembolic pulmonary disease (CTEPD) without or with pulmonary hypertension at rest (CTEPH).We report the case of a 20-year-old female with HSS, which was misdiagnosed as CTEPH and subsequently treated with anticoagulants, which led to severe hemoptysis and eventually death of the patient. This case highlights the challenges of diagnosing HSS at early stages of the disease.HSS should be considered in young patients with signs of large vessel vasculitis in combination with thrombotic occlusions of pulmonary arteries, with or without aneurysms of the pulmonary arteries, and particularly, if there are no risk factors for thromboembolic disease.

Recommendations for the management of the vascular involvement in Behçet's disease by the Japanese National Research Committee for Behçet's disease-secondary publication

OBJECTIVES

This study aimed to develop clinical guidelines for the management of vascular Behçet's disease (BD) by the Behçet's Disease Research Committee of the Ministry of Health, Labour and Welfare of the Japanese Government.

METHODS

A task force proposed clinical questions (CQs) concerning vascular BD based on a literature search. After screening, draft recommendations were developed for each CQ and brushed up in three blinded Delphi rounds, leading to the final recommendations.

RESULTS

This study provides recommendations for 17 CQs concerning diagnosis and differential diagnoses, assessment of disease activity, and treatment. The guidelines recommend immunosuppressive treatments, for both arterial and venous involvement with active inflammation. Anticoagulation is also recommended for deep vein thrombosis except in high-risk patients. Surgical and endovascular therapies can be optional, particularly in patients with urgent arterial lesions undergoing immunosuppression. In addition, two sets of algorithms for diagnosis and treatment are shown for arterial and venous involvement.

CONCLUSIONS

These recommendations are expected to serve as useful tools in the daily clinical practice of BD. This content has already been published in Japanese in the Guideline for the Management of Behçet's Disease 2020 and is submitted with permission from both the primary and secondary publishers.

Diagnostic Approach to Recurrent Intracardiac Masses That Present With Systemic Symptoms

Cardiac masses are difficult to diagnose in the pediatric population, especially in the setting of systemic symptoms. Although multiple imaging modalities are available to characterize cardiac masses, it is important to consider a different diagnostic approach in the setting of recurrent cardiac masses and nonspecific systemic symptoms. We present a case involving a previously healthy adolescent with multiple hospitalizations because of persistent fevers, cachexia, and recurrent cardiac masses. Echocardiography and cardiac computed tomography imaging suggested endocarditis, but the patient failed to respond to multiple intravenous antibiotic treatments. He developed recurrent cardiac masses in the right atrium and right ventricle that were debulked and biopsied. The biopsy did not yield a conclusive diagnosis. The patient returned to the hospital with hemoptysis and large pulmonary pseudoaneurysms that had to be occluded during cardiac catheterization. Given his constellation of symptoms and improvement with steroids during surgical procedures, he was ultimately diagnosed with a variant of Behcet's disease known as Hughes-Stovin syndrome. His symptoms resolved completely with steroids and immunosuppression therapy. Our report reveals the limitations of the standard diagnostic approach toward cardiac masses and the importance of considering response to treatment as a clue to the etiology of an unusual cardiac mass.

Is pulmonary arterial hypertension associated with schistosomiasis distinct from pulmonary arterial hypertension associated with portal hypertension?

Pulmonary arterial hypertension associated with schistosomiasis (SchPAH) and pulmonary arterial hypertension associated with portal hypertension (PoPAH) are lung diseases that develop in the presence of liver diseases. However, mechanistic pathways by which the underlying liver conditions and other drivers contribute to the development and progression of pulmonary arterial hypertension (PAH) are unclear for both etiologies. In turn, these unknowns limit certainty of strategies to prevent, diagnose, and reverse the resultant PAH. Here we consider specific mechanisms that contribute to SchPAH and PoPAH, identifying those that may be shared and those that appear to be unique to each etiology, in the hope that this exploration will both highlight known causal drivers and identify knowledge gaps appropriate for future research. Overall, the key pathophysiologic differences that we identify between SchPAH and PoPAH suggest that they are not variants of a single condition.

A Rare but Fatal Behçet Variant: The Hughes-Stovin Syndrome-Successful Case Report and New Evidence from Literature Review

Hughes-Stovin syndrome (HSS) is a rare potentially fatal vasculitis supposedly belonging to the spectrum of Behçet disease without ocular involvement. HSS tends to play by a temporal pattern, starting with thrombosis and followed by formation of pulmonary aneurysms. Since its mortality can reach 25% of cases, early recognition and appropriate therapy represent the major clinical challenges. We describe a rare case of HSS successfully treated via multidisciplinary management by an endovascular approach and immunosuppressive therapy.

Hughes-Stovin Syndrome: A Rare Cause of Thrombosis and Pulmonary Artery Aneurysm

Hughes-Stovin Syndrome (HSS) is a rare clinical condition characterized by thrombophlebitis as well as multiple pulmonary and bronchial aneurysms. It commonly presents with coughing, dyspnea, fever, chest pain, and hemoptysis, and its management usually consists of surgical and medical approaches. In this report, we discuss a case of a patient with HSS. A 30-year-old male patient was admitted to the pulmonary medicine ward for hemoptysis. After evaluation with chest CT, bilateral pulmonary embolism and pulmonary aneurysms were observed. Due to a history of aphthous lesions, Behçet's disease (BD) was considered the initial diagnosis; however, the patient did not fit the criteria and was later diagnosed with HSS. Intravenous methylprednisolone was initiated, along with a maintenance treatment with cyclophosphamide. Treatment response was observed in the fourth month; however, due to the persistence of hemoptysis, additional cycles of cyclophosphamide were later required, under which the patient's condition has been stable. HSS currently lacks clear diagnostic criteria, and further studies are needed to investigate genetic backgrounds, familial transmissions, and treatment alternatives.

Frail Silk: Is the Hughes-Stovin Syndrome a Behçet Syndrome Subtype with Aneurysm-Involved Gene Variants?

Hughes-Stovin syndrome is a rare disease characterized by thrombophlebitis and multiple pulmonary and/or bronchial aneurysms. The etiology and pathogenesis of HSS are incompletely known. The current consensus is that vasculitis underlies the pathogenic process, and pulmonary thrombosis follows arterial wall inflammation. As such, Hughes-Stovin syndrome may belong to the vascular cluster with lung involvement of Behçet syndrome, although oral aphtae, arthritis, and uveitis are rarely found. Behçet syndrome is a multifactorial polygenic disease with genetic, epigenetic, environmental, and mostly immunological contributors. The different Behçet syndrome phenotypes are presumably based upon different genetic determinants involving more than one pathogenic pathway. Hughes-Stovin syndrome may have common pathways with fibromuscular dysplasias and other diseases evolving with vascular aneurysms. We describe a Hughes-Stovin syndrome case fulfilling the Behçet syndrome criteria. A MYLK variant of unknown significance was detected, along with other heterozygous mutations in genes that may impact angiogenesis pathways. We discuss the possible involvement of these genetic findings, as well as other potential common determinants of Behçet/Hughes-Stovin syndrome and aneurysms in vascular Behçet syndrome. Recent advances in diagnostic techniques, including genetic testing, could help diagnose a specific Behçet syndrome subtype and other associated conditions to personalize the disease management.

Vascular Behçet syndrome: from pathogenesis to treatment

Behçet syndrome is a rare, chronic inflammatory disease of unknown aetiopathogenesis, most commonly presenting with mucocutaneous and ocular manifestations. Vascular involvement, most frequently superficial vein and deep vein thrombosis, can occur in up to 50% of patients with Behçet syndrome. Venous thrombosis at atypical sites (inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right atrium and/or ventricle) and arterial involvement (mostly in situ thrombosis and aneurysms of the pulmonary arteries, as well as aneurysms of the abdominal aorta, and peripheral and visceral arteries) are also unique features of Behçet syndrome. Behçet syndrome is considered a natural model of inflammation-induced thrombosis in humans, with an impaired immune-inflammatory response rather than traditional cardiovascular risk factors contributing to thrombogenesis. Specifically, neutrophil hyperactivation and neutrophil-mediated mechanisms of damage directly promote endothelial dysfunction, platelet activation and thrombogenesis in Behçet syndrome. This unusual pathogenesis directly determines the treatment approach, which relies mostly on immunosuppressants rather than anticoagulants for treatment of thrombosis and for secondary prevention. This Review discusses the main histopathological, pathogenetic and clinical aspects of vascular Behçet syndrome, addressing their implications for therapeutic management. Future perspectives in terms of pathogenetic studies, disease monitoring and treatment strategies are also discussed.

Successful Medical-Surgical Management of Intracardiac Thrombosis and Pulmonary Pseudoaneurysms in an Adolescent With Hughes-Stovin Syndrome

We present an adolescent male with a single intracardiac mass and pulmonary emboli, complicated by peripheral venous thrombosis and subsequent development of pulmonary pseudoaneurysms, leading to diagnosis of Hughes-Stovin syndrome. Remission was achieved with cyclophosphamide, corticosteroids, and pseudoaneurysm resection and maintained with infliximab and methotrexate.

Behçet's Disease: A Radiological Review of Vascular and Parenchymal Pulmonary Involvement

Behcet's disease (BD) is a chronic systemic inflammatory disorder characterized by underlying chronic vasculitis of both large- and small-caliber vessels. Thoracic involvement in BD can occur with various types of manifestations, which can be detected with contrast-enhanced MSCT scanning. In addition, MR can be useful in diagnosis. Characteristic features are aneurysms of the pulmonary arteries that can cause severe hemoptysis and SVC thrombosis that manifests as SVC syndrome. Other manifestations are aortic and bronchial artery aneurysms, alveolar hemorrhage, pulmonary infarction, and rarely pleural effusion. Achieving the right diagnosis of these manifestations is important for setting the correct therapy and improving the patient's outcome.

Hughes-Stovin Syndrome and the Acute Management of Recurrent Pulmonary Aneurysms

Hughes-Stovin syndrome (HSS) is a rare autoimmune disease that is considered to be a variant of Behçet’s disease. It typically presents with multiple venous thrombi, thrombophlebitis, as well as pulmonary and bronchial aneurysms. The disease is typically associated with high morbidity and mortality in those diagnosed. This case discusses a 28-year-old male with HSS complicated by venous cardiac emboli and a mechanical valve on chronic anticoagulation. Despite medical and surgical management, the patient experienced continued progression of his pulmonary aneurysms and excessive bleeding, eventually requiring lung transplantation.

Arterial Stiffness and Adult Onset Vasculitis: A Systematic Review

Chronic inflammation represents the cornerstone of the raised cardiovascular (CV) risk in patients with inflammatory rheumatic diseases (IRD), including vasculitis. Standardized mortality ratios in these patients are higher as compared to the general population, and the excess of premature mortality is due to early atherosclerotic events. Thus, IRD patients need appropriate CV risk assessment and management according to this CV disease (CVD) burden. Adequate control of CV risk is still lacking in usual care, but early diagnosis of silent and subclinical CVD is crucial to improve the long-term prognosis of these patients. Increased arterial stiffness may provide a pathophysiological link between inflammation and increased cardiovascular risk. Several noninvasive methods are now available to estimate artery stiffness in the clinical setting, including pulse wave velocity assessment. The independent predictive value of arterial stiffness for cardiovascular events has been demonstrated in general as well as in selected populations, and reference values adjusted for age and blood pressure have been suggested. Thus, arterial stiffness is an interesting biomarker for cardiovascular risk stratification. This systematic review summarizes the additional value that PWV measurement can provide in the setting of vasculitis, with a focus in the different clinical stages and CV risk prevention. This systematic review is registered with registration number: Prospero CRD42021259603.

Pulmonary artery aneurysm: Harbinger of an ominous disease

An 11-year-old girl presented with chronic cough and recurrent hemoptysis. On examination, she had features of right heart failure and cyanosis, with severe pulmonary hypertension on echocardiogram. Computed tomography pulmonary angiography showed aneurysmal dilatations of the pulmonary artery with elevated erythrocyte sedimentation rate and C-reactive protein and positive human leukocyte antigen B51. A diagnosis of Hughes-Stovin syndrome (vascular variant of Behcet's syndrome) was confirmed, and she was started on immunosuppression, on which there was improvement.

Recurrent Haemoptysis Revealing Hughes-Stovin Syndrome

Hughes-Stovin syndrome is a very rare condition with no defined diagnostic criteria. We present the case of a 26-year-old man who had haemoptysis revealing Hughes-Stovin syndrome. We will consider the aetiology, therapeutic and evolutionary aspects of this disease.

LEARNING POINTS

Hughes-Stovin syndrome is a very rare disorder of unknown aetiology which can be fatal.It is considered a variant of Behcet's disease.Early diagnosis and treatment improve prognosis.

The combined prevalence of classified rare rheumatic diseases is almost double that of ankylosing spondylitis

BACKGROUND

Rare diseases (RDs) affect less than 5/10,000 people in Europe and fewer than 200,000 individuals in the United States. In rheumatology, RDs are heterogeneous and lack systemic classification. Clinical courses involve a variety of diverse symptoms, and patients may be misdiagnosed and not receive appropriate treatment. The objective of this study was to identify and classify some of the most important RDs in rheumatology. We also attempted to determine their combined prevalence to more precisely define this area of rheumatology and increase awareness of RDs in healthcare systems. We conducted a comprehensive literature search and analyzed each disease for the specified criteria, such as clinical symptoms, treatment regimens, prognoses, and point prevalences. If no epidemiological data were available, we estimated the prevalence as 1/1,000,000. The total point prevalence for all RDs in rheumatology was estimated as the sum of the individually determined prevalences.

RESULTS

A total of 76 syndromes and diseases were identified, including vasculitis/vasculopathy (n = 15), arthritis/arthropathy (n = 11), autoinflammatory syndromes (n = 11), myositis (n = 9), bone disorders (n = 11), connective tissue diseases (n = 8), overgrowth syndromes (n = 3), and others (n = 8). Out of the 76 diseases, 61 (80%) are classified as chronic, with a remitting-relapsing course in 27 cases (35%) upon adequate treatment. Another 34 (45%) diseases were predominantly progressive and difficult to control. Corticosteroids are a therapeutic option in 49 (64%) syndromes. Mortality is variable and could not be determined precisely. Epidemiological studies and prevalence data were available for 33 syndromes and diseases. For an additional eight diseases, only incidence data were accessible. The summed prevalence of all RDs was 28.8/10,000.

CONCLUSIONS

RDs in rheumatology are frequently chronic, progressive, and present variable symptoms. Treatment options are often restricted to corticosteroids, presumably because of the scarcity of randomized controlled trials. The estimated combined prevalence is significant and almost double that of ankylosing spondylitis (18/10,000). Thus, healthcare systems should assign RDs similar importance as any other common disease in rheumatology.

Hugh-Stovin syndrome: the 'incomplete Behcet's disease'. A case study of a young adult with recurrent pulmonary embolism and pulmonary arterial aneurysms

Hugh-Stovin Syndrome (HSS) is characterized by recurrent thrombophlebitis and multiple pulmonary and/or bronchial artery aneurysms indistinguishable from the cardiovascular features seen in Behcet's disease (BD). Our case describes a 30-year-old male with recurrent pulmonary embolism and bilateral pulmonary aneurysms. Autoimmune, hypercoagulable, and infectious work up were negative. Elevated inflammatory markers and absence of the typical clinical findings seen in BD led to the diagnosis of Hugh-Stovin syndrome (HSS). Immunosuppression using steroids and azathioprine led to clinical response. Anticoagulation was continued based on risk/benefit ratio.

Getting to the <em>heart</em> of the matter: diagnostic tools and therapeutic approach to cardiac involvement in Behçet syndrome A Tunisian case series

The aim was to investigate the frequency and spectrum of cardiac involvement (CI) in patients with Behçet syndrome (BS) in the Tunisian context, and to assess the clinical and imaging features, treatment, and outcomes. We retrospectively retrieved the medical records of patients with CI among 220 BS patients admitted to the hospital internal medicine department between February 2006 and April 2019, who fulfilled the International Study Group diagnostic criteria for BS. Ten patients (8 men, 2 women) were eligible for the study. Mean age was 37.3 years. Three patients had 2 isolated episodes of cardiac BS. The different types of CI were coronary artery disease (5/10), intracardiac thrombus (4/10), pericarditis (1/10), myocarditis (1/10), and myocardial fibrosis (1/10). Five patients had associated vascular involvement (50%). Medical treatment was based on corticosteroids and colchicine in all patients (100%), anticoagulants in 8 (80%), and cyclophosphamide followed by azathioprine in 9 (90%). The clinical course was favorable in 9 patients; 1 patient died. CI remains an important feature of BS because of its association with increased risk of mortality and morbidity. Therefore, early screening and detection with imaging methods are paramount. Also, better cooperation between rheumatologists and cardiologists could improve outcomes.

Behçet: the syndrome

Behçet's syndrome (BS) is a systemic vasculitis characterized by a relapsing and remitting course. It can involve the skin, mucosa, joints, vessels (arteries and/or veins), eyes, and nervous and gastrointestinal systems, and so is referred to as a syndrome rather than as a unique and nosologically distinct condition. These involvements may present alone or co-exist in the same patient. Although all the possible combinations of the above-mentioned manifestations may occur, clusters of commonly co-existing involvements (also referred to as 'disease phenotypes') have been suggested, namely 'mucocutaneous and articular', 'peripheral vascular and extra-parenchymal neurological' and 'parenchymal neurological and ocular' phenotypes have been described. Patient-specific demographic and genetic features have been described as positively or negatively associated with specific disease phenotypes. This review will focus on the different clinical features of Behçet's syndrome, summarizing current evidence on the distinct disease manifestations as well as the major phenotypes.

Interleukin 1α: a comprehensive review on the role of IL-1α in the pathogenesis and treatment of autoimmune and inflammatory diseases

The interleukin (IL)-1 family member IL-1α is a ubiquitous and pivotal pro-inflammatory cytokine. The IL-1α precursor is constitutively present in nearly all cell types in health, but is released upon necrotic cell death as a bioactive mediator. IL-1α is also expressed by infiltrating myeloid cells within injured tissues. The cytokine binds the IL-1 receptor 1 (IL-1R1), as does IL-1β, and induces the same pro-inflammatory effects. Being a bioactive precursor released upon tissue damage and necrotic cell death, IL-1α is central to the pathogenesis of numerous conditions characterized by organ or tissue inflammation. These include conditions affecting the lung and respiratory tract, dermatoses and inflammatory skin disorders, systemic sclerosis, myocarditis, pericarditis, myocardial infarction, coronary artery disease, inflammatory thrombosis, as well as complex multifactorial conditions such as COVID-19, vasculitis and Kawasaki disease, Behcet's syndrome, Sjogren Syndrome, and cancer. This review illustrates the clinical relevance of IL-1α to the pathogenesis of inflammatory diseases, as well as the rationale for the targeted inhibition of this cytokine for treatment of these conditions. Three biologics are available to reduce the activities of IL-1α; the monoclonal antibody bermekimab, the IL-1 soluble receptor rilonacept, and the IL-1 receptor antagonist anakinra. These advances in mechanistic understanding and therapeutic management make it incumbent on physicians to be aware of IL-1α and of the opportunity for therapeutic inhibition of this cytokine in a broad spectrum of diseases.

Insidious Hughes Stovin Syndrome: Journey From Pulmonary Embolism to Pulmonary Arterial Aneurysm

Hughes-Stovin syndrome (HSS) is a rare disease characterized by deep vein thrombosis and pulmonary and/or bronchial artery aneurysms. A 28-year-old female patient was followed-up for 5 months with pulmonary embolism. When she presented with hemoptysis at her 5th month, pulmonary artery aneurysm was detected on thoracic CT angiography. The abdominal magnetic resonance (MR) angiography revealed thrombus in the inferior vena cava. Because she didin't carry the criteria for Behcet's disease, she was diagnosed as Hughes-Stovin Syndrome (HSS) and steroid treatment was started. The patient who had a response to the treatment, stay in remission for a long time. The prognosis was poor in patients with HSS, and aneurysmal rupture was the main cause of death. In order to emphasize the fact that, when the pulmonary arterial aneurysm is seen, in view of the possibility of Behçet or its variant HSS,rapid onset of treatment can be life-saving. A rare female case is presented in the light of the literature.

Thoracic Complications in Behçet's Disease: Imaging Findings

Behçet's disease (BD) causes vascular inflammation and necrosis in a wide range of organs and tissues. In the thorax, it may cause vascular complications, affecting the aorta, brachiocephalic arteries, bronchial arteries, pulmonary arteries, pulmonary veins, capillaries, and mediastinal and thoracic inlet veins. In BD, chest radiograph is commonly used for the initial assessment of pulmonary symptoms and complications and for follow-up and establishment of the response to treatment. With the advancement of helical or multislice computed tomography (CT) technologies, such noninvasive imaging techniques have been employed for the diagnosis of vascular lesions, vascular complications, and pulmonary parenchymal manifestations of BD. CT scan (especially, CT angiography) has been used to determine the presence and severity of pulmonary complications without resorting to more invasive procedures, in conjunction with gadolinium-enhanced three-dimensional (3D) gradient-echo magnetic resonance (MR) imaging with the subtraction of arterial phase images. These radiologic methods have characteristics that are complementary to each other in diagnosis of the thoracic complications in BD. 3D ultrashort echo time (UTE) MR imaging (MRI) could potentially yield superior image quality for pulmonary vessels and lung parenchyma when compared with breath-hold 3D MR angiography.

Hughes Stovin Syndrome: A Case of Recurrent Pulmonary Artery Aneurysms

Approximately 40 cases of Hughes-Stovin syndrome have been recorded in the literature. The disease process exhibits an indefinite nature. It shares histopathologic and clinical features with Behçet disease, although there is no established association. The natural course of the disease is fatal in most cases. We report a case of a 31-year-old man with Hughes-Stovin syndrome who initially presented with occasional hemoptysis and a history of deep vein thrombosis. There was evidence of right-sided lower lobe pulmonary artery aneurysm that was managed with a lobectomy, after which he developed aneurysmal recurrence in the contralateral lung. Histopathologic analysis identified myxoid degeneration in the hilar region.

The filling defect of pulmonary artery, an imaging finding what we should know

The most common cause of pulmonary artery filling defects on computed tomography pulmonary angiography or magnetic resonance imaging is pulmonary thromboembolism, but not infrequently, the presentation of this finding lacks specificity. Given that the morbidity and mortality associated with pulmonary thromboembolism is high, proper diagnosis of the condition is essential. Unusual or more rarely encountered etiologies must be considered when clinical manifestations and imaging findings are inconsistent. With this review, our purpose is to describe possible causes of pulmonary arterial filling defects. We aim to provide clinicians with a comprehensive list of differential diagnoses to facilitate a measured approach to the assessment of pulmonary arterial filling defects on computed tomography pulmonary angiography or magnetic resonance imaging.

Localized Bronchial Hyperemia in Cases of Iatrogenic Hemoptysis: Clinical Presentations and Pathophysiological Mechanisms

Hemoptysis is a frequently encountered symptom in many clinical settings, and etiologic diagnosis can sometimes prove challenging. Bronchoscopy may not promptly reveal the source or the cause of bleeding and few reports have focused so far on the abnormalities of bronchial mucosa vasculature that may unveil the underlying pathophysiology. In this special feature article, we present a series of cases presenting with hemoptysis after angiographic interventions in the thoracic vessels. Localized hyperemia and vascular dilatations in the bronchial mucosa observed during bronchoscopy as unique findings became clues enabling the correct diagnosis and management. We suggest the relevant pathophysiological mechanisms and discuss the available published experience on similar clinical entities.

Pulmonary arteries: imaging of pulmonary embolism and beyond

The pulmonary arteries are not just affected by thrombus. Various acquired and congenital conditions can also affect the pulmonary arteries. In this review we discuss cross sectional imaging modalities utilized for the imaging of the pulmonary arteries. Acquired pulmonary artery entities, including pulmonary artery sarcoma (PAS), vasculitis, aneurysm, and arteriovenous malformations, and congenital anomalies in adults, including proximal interruption of the pulmonary artery, pulmonary sling, pulmonary artery stenosis, and idiopathic dilatation of the pulmonary trunk, are also discussed. An awareness of these entities and their imaging findings is important for radiologists interpreting chest imaging.

Vascular Behçet's syndrome: an update

Behçet's syndrome (BS) is a complex vasculitis, characterised by peculiar histological, pathogenetic and clinical features. Superficial venous thrombosis (SVT) and deep vein thrombosis (DVT) are the most frequent vascular involvements, affecting altogether 15-40% of BS patients. Atypical thrombosis is also an important clinical feature of BS, involving the vascular districts of the inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right ventricle. On the other hand, arterial involvement, although affecting only 3-5% of patients, represents a unique feature of BS, with aneurysms potentially affecting peripheral, visceral and pulmonary arteries. Vascular events in BS are promoted by inflammation, with neutrophils playing a key role in the pathogenesis of thrombotic events; in turn, coagulative components such as fibrinogen, thrombin, factor Xa and factor VIIa amplify the inflammatory cascade. Understanding the contribution of inflammatory and coagulation components in the pathogenesis of BS vascular events is crucial to define the most effective therapeutic strategy. Control of vascular thrombosis is achieved with immunosuppressants drugs rather than anticoagulants. In particular, use of azathioprine and cyclosporine in association with low-dose corticosteroids should be considered in DVT and SVT cases, while treatment with cyclophosphamide together with anti-TNF-α agents can be effectively used in arterial involvement. More recently, the anti-TNF-α drugs have also been reported as a valid alternative for the treatment also of venous events, especially DVT. An exception to the use of anticoagulant in BS could be represented by cerebral veins thrombosis. In this review, we will depict the main characteristics of the vascular involvement in BS, briefly describing histological and pathogenetic features, while focusing on the clinical and therapeutical approaches of the vascular manifestations of BS.

An Enigmatic Case of an Uncommon Syndrome: The Hughes-Stovin Syndrome

Hughes-Stovin syndrome is a disorder characterized by deep vein thrombosis and pulmonary artery aneurysms with potentially life-threatening complications. The case of a 22-year-old Moroccan male patient, presenting with signs of sepsis of unclear etiology, is presented here. Computed tomography (CT) scan revealed thrombosis of the inferior vena cava up to the hepatic veins, thrombosis of both common iliac veins and a thrombus in the right atrium. Primarily suspecting septic thrombosis, surgical thrombectomy was performed. The patient recovered uneventfully and was discharged with oral anticoagulants. Three weeks later, he was admitted again with acute shortness of breath. A new CT scan showed bilateral pulmonary embolism and multiple pulmonary artery aneurysms. Hughes-Stovin syndrome was diagnosed, and high-dose heparin and an immunosuppressant (prednisolon) were administered. Two weeks later, the patient presented again with massive epistaxis and hemoptysis. A CT scan showed diffuse parenchymal bleeding. After prophylactic intubation and conservative treatment, he recovered rapidly and was again discharged uneventfully. Under immunosuppressants, a rapid reduction in the diameter of the pulmonary aneurysms was observed and the patient remained symptom-free during follow-up.

Pulmonary manifestations of large, medium, and variable vessel vasculitis

The hallmark of vasculitis is autoimmune inflammation of blood vessels and surrounding tissues, resulting in an array of constitutional symptoms and organ damage. The lung is commonly targeted in the more familiar ANCA-associated small vessel vasculitidies, but large and medium vessel vasculitides, including Takayasu arteritis, giant cell arteritis, polyarteritis nodosa, Behcet's disease, and necrotizing sarcoid granulomatosis, may also feature prominent pulmonary involvement. Pulmonary manifestations of these conditions include pulmonary arterial aneurysms, pulmonary hypertension, diffuse alveolar hemorrhage, pulmonary nodules, and parenchymal infiltrates. An understanding of the diverse manifestations of vasculitis and a high index of clinical suspicion are essential to avoid delays in disease recognition that may result in permanent or life threatening morbidity. In this review, we outline the general clinical manifestations, pulmonary manifestations, diagnostic workup, imaging findings, and treatment of medium, large, and variable vessel vasculitides.

Transcatheter embolotherapy of pulmonary artery aneurysms as emergency treatment of hemoptysis in Behcet patients: experience of a referral center and a review of the literature

Hemoptysis is a life-threatening complication of Behcet's disease that is likely related to pulmonary artery aneurysm (PAA). Vascular interventional radiology may offer effective emergency therapeutic option, but has not been thoroughly investigated in this setting. A case series of a French referral center for hemoptysis combined with a literature review of case reports was conducted. Between 1995 and 2016, 12 patients were referred to our center for hemoptysis revealing or complicating the course of Behcet's disease. Pulmonary artery aneurysm (PAA) was the mechanism of hemoptysis in ten patients, nine of whom were treated by a transcatheter embolotherapy. Combining an additional 8 case reports from the literature, 17 patients treated by transcatheter embolotherapy for PAA were analyzed. The duration of the course of Behcet's disease was 22 months [IQR 3-45] at the time of PAA diagnosis. Transcatheter embolotherapy of PAA was successful for immediately controlling hemoptysis in all patients, without major complication except for one. Hemoptysis recurred in seven patients (41%) within 5 months [IQR 1-12]. The use of coils for transcatheter embolotherapy was associated with hemoptysis recurrence. A bronchosystemic hypervascularization related to the previously occluded PAA was the main mechanism of bleeding recurrence, leading to bronchosystemic artery embolization in four patients and surgery in two patients. Behcet's disease-related hemoptysis is mainly due to PAA. Transcatheter embolotherapy should be considered as the first-line emergency treatment for PAA-related hemoptysis, in association with the immunosuppressive regimen. Hemoptysis may recur in half of the cases, involving preferentially a bronchosystemic arterial mechanism.

Hughes-Stovin syndrome revealing the presence of Behçet's Disease

Background:

Hughes-Stovin Syndrome (HSS) is a rare clinical disorder characterized by deep venous thrombosis and multiple pulmonary and/or bronchial aneurysms. Aneurysms in systemic circulation can also be seen.

Case presentation:

We report the first case of HSS with aortic aneurysm in a 55-year-old man who initially presented with deep venous thrombosis. The diagnosis of HSS revealing Behçet’s disease was made given the history of recurrent oral and genital ulcers. Treatment consisted of 3 daily pulses of methylprednisolone (1g) followed by oral prednisone (1mg/kg daily) and 6 monthly pulses of cyclophosphamide. Oral anticoagulation treatment was held 3 months and then was stopped with good outcome.

Conclusion:

Systemic aneurysms in Hughes Stovin is a worth knowing complication which may reveal Behçet’s disease.

Persistent fever with chills and an endocardial mass in a child: an unusual presentation of Hughes-Stovin syndrome

A 12-year-old boy with a right atrium endocardial mass was initially diagnosed as having Lemierre's syndrome on the basis of previous mastoiditis and jugular vein and cerebral venous thrombosis. Lack of response to antibiotics, persistent high fever with chills, acute-phase reactants, and peripheral arterial pseudoaneurysms made us reconsider the diagnosis. Only after the late appearance of radiological pulmonary lesions and recognition of pulmonary artery aneurysms, Hughes-Stovin syndrome was diagnosed. Hughes-Stovin syndrome is an exceedingly rare vasculitis, especially in childhood, consisting of multiple pulmonary artery aneurysms and deep venous thromboses. The lack of formal diagnostic criteria and the rarity of the disease make the diagnosis very challenging, especially when respiratory complaints are not present at onset, as in the presented case. The treatment aims to reduce inflammation, although there is debate about anticoagulation therapy because of the risk of pulmonary haemorrhage.

Life threatening hemoptysis from Hughes Stovin syndrome: Is it that rare?

Introduction

Hughes-Stovin syndrome is a life-threatening disorder of unknown etiology. This condition is characterized by vasculitis, deep venous thrombosis and aneurysms that mainly involve the pulmonary arteries resulting in hemoptysis. It has been described in literature less than 40 times. However, we believe it is not very uncommon as it might be diagnosed as pulmonary embolism solely. In such cases, anticoagulation therapy augments the risk of life-threatening hemoptysis.

Materials and methods

We report the case of a 35 years old, Egyptian female patient with Hughes-Stovin syndrome, who initially presented with lower limb deep vein thrombosis and coughing of blood. Anticoagulation regimen for pulmonary embolism was given. This resulted in massive hemoptysis that was successfully controlled by medical therapy.

Conclusion

Adults who present with venous thrombosis and hemoptoic cough, with no predisposing factors of thrombosis, normal platelet count and coagulation, the possibility of Hughes-Stovin syndrome has to be considered.

Case report: A rare cause of haemoptysis in a male with unprovoked deep venous thrombosis

A 29 year-old previously healthy Egyptian male complained of a 4-day vague abdominal pain for which he underwent an abdominal ultrasound. An inferior vena cava (IVC) thrombus was suspected by the sonographer who recommended undergoing an abdominal computed tomography (CT) with intravenous contrast. The IVC thrombus was confirmed by CT, but the study did not delineate any cause for the thrombus or any additional abdominal pathology. The basal chest scans revealed multiple peripheral cavitary nodules in both lower lung lobes. The patient was referred to our institution for evaluation of the pulmonary lesions. At the time, the patient only complained of an occasional cough and a small amount of mucopurulent sputum, but no chest pain. He was moderate smoker and substance abuser (tramadol and cannabis). The patient strongly denied i.v. drug abuse as well as taking any medications.

A case report depicting a rare cause for the unusual entity of pulmonary artery aneurysmhttp://ow.ly/YvA1y

A rare case of multiple bronchial artery aneurysms associated with a double aortic arch

Bronchial artery aneurysm is uncommon, and the occurrence of multiple aneurysms arising from a bronchial artery is even rarer. To date, there has been only one published case report describing double bronchial artery aneurysms. We herein describe a case of three aneurysms arising from a left bronchial artery, accompanied by multiple bilateral hypertrophied bronchial and intercostobronchial arteries, as well as a double aortic arch. Bronchial artery aneurysm is potentially life-threatening, and immediate treatment is recommended to minimise the potential risk of rupture. The aneurysms in our case were successfully treated via transcatheter arterial embolisation using coils.