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Bettiol A, Alibaz-Oner F, Direskeneli H, Hatemi G, Saadoun D, Seyahi E, Prisco D, Emmi G. Vascular Behçet syndrome: from pathogenesis to treatment. Nat Rev Rheumatol 2023; 19:111-126. [PMID: 36544027 DOI: 10.1038/s41584-022-00880-7] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2022] [Indexed: 12/24/2022]
Abstract
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.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy.,Internal Interdisciplinary Medicine Unit, Behçet Center, Careggi University Hospital, Firenze, Italy
| | - Fatma Alibaz-Oner
- Vasculitis Clinic, Marmara University, School of Medicine, Department of Internal Medicine, Division of Rheumatology, Istanbul, Turkey
| | - Haner Direskeneli
- Vasculitis Clinic, Marmara University, School of Medicine, Department of Internal Medicine, Division of Rheumatology, Istanbul, Turkey
| | - Gulen Hatemi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University-Cerrahpasa, School of Medicine, Istanbul, Turkey.,Behçet's Disease Research Centre, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - David Saadoun
- Sorbonne Universités AP-HP, Groupe Hospitalier Pitié-Salpêtrière, Département de Médecine Interne et Immunologie Clinique, F-75013, Paris, France.,Centre National de Références Maladies Autoimmunes Systémiques Rares, Centre National de Références Maladies Autoinflammatoires et Amylose Inflammatoire; Inflammation-Immunopathology-Biotherapy Department (DMU 3iD); INSERM 959, Groupe Hospitalier Pitie-Salpetriere, AP-HP, Paris, France
| | - Emire Seyahi
- Division of Rheumatology, Department of Internal Medicine, Istanbul University-Cerrahpasa, School of Medicine, Istanbul, Turkey.,Behçet's Disease Research Centre, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy.,Internal Interdisciplinary Medicine Unit, Behçet Center, Careggi University Hospital, Firenze, Italy
| | - Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy. .,Internal Interdisciplinary Medicine Unit, Behçet Center, Careggi University Hospital, Firenze, Italy. .,Centre for Inflammatory Diseases, Monash University Department of Medicine, Monash Medical Centre, Clayton, Victoria, Australia.
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Zhang Y, Wang Z, Zhang C, Chen K, Fang M, Wang H. Surgical treatment for Behcet's disease with acute superior vena cava syndrome. J Card Surg 2022; 37:5559-5563. [PMID: 36349719 DOI: 10.1111/jocs.17119] [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: 07/27/2022] [Revised: 10/21/2022] [Accepted: 10/24/2022] [Indexed: 11/11/2022]
Abstract
BACKGROUND AND AIM OF THE STUDY Behcet's disease (BD) is a multisystem vasculitis with unknown etiology. The involvement of superior vena cava (SVC) is reported in less than 2% of patients with BD. METHODS We report a patient with acute edema of neck and face associated with dyspnea as the primary manifestation. So a diagnosis of superior Vena Cava syndrome (SVCS) was made and the thickening wall of SVC was resected. An Operation was performed under cardiopulmonary bypass to remove the mass and thrombus for avoiding for pulmonary embolism. RESULTS The diagnosis of Behcet's disease (BD) didn't not be made until the recurrent oral and genital ulceration occurred 2 weeks later. The patient taked aspirin and prednisolone orally as prescribed and no recurrence were observed during the 30 months follow-up. CONCLUSIONS BD should be suspected in patients presenting with SVCS, when there is thickening of SVC, whether thrombosis or not. Early diagnosis and treatment are essential for management of BD.
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Affiliation(s)
- Yong Zhang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Zengwei Wang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Chunzhen Zhang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Ke Chen
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China.,Graduate School of China Medical University, Shenyang, China
| | - Minhua Fang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
| | - Huishan Wang
- Department of Cardiovascular Surgery, General Hospital of Northern Theater Command, Shenyang, China
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Tazi Mezalek Z, Khibri H, Chadli S, El Fari S, Ammouri W, Harmouche H, Maamar M, Adnaoui M. Vascular complications of Behçet disease. Minerva Med 2022; 112:767-778. [PMID: 35168306 DOI: 10.23736/s0026-4806.21.07490-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Behçet disease is a multi-systemic complex vasculitis with unknown etiology characterized by different clinical involvements, including mucocutaneous, ocular, vascular, articular, neurological, and gastrointestinal manifestations. Growing evidence supports that different phenotypes, characterized by clusters of co-existing involvements, can be distinguished. Namely, the vascular phenotype identifies a specific group of patients who suffer from recurrent inflammatory thrombosis and arterial involvement. Vascular disease develops in up to 40% with a definite male preponderance and is usually an early manifestation. Venous involvement is significantly more common than arterial disease, and lower extremity deep vein thrombosis is its most frequent manifestation. Arterial disease involves mostly pulmonary arteries and aorta and manifests mainly in the form of aneurysms. Glucocorticoids and immunosuppressants are the recommended first-line treatments in vasculo-Behçet. Furthermore, controlled trials are still needed to assess the role of adding anticoagulation to the treatment regimen, with an accent on new oral anticoagulants. Treatment with anti-TNF alpha agents seems promising, but the management strategies are not clear yet.
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Affiliation(s)
- Zoubida Tazi Mezalek
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco - .,Department of Clinical Hematology, Ibn Sina University Hospital, Rabat, Morocco - .,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco -
| | - Hajar Khibri
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Sarra Chadli
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco
| | - Safae El Fari
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco
| | - Wafaa Ammouri
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Hicham Harmouche
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Mouna Maamar
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
| | - Mohamed Adnaoui
- Department of Internal Medicine, Ibn Sina University Hospital, Rabat, Morocco.,Faculty of Medicine and Pharmacy, Mohammed V. University, Rabat, Morocco
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Choudhary V, Chandra A, Ray AK, Chakraborty U, Karmakar PS, Saha SK. A Case of Systemic Lupus Erythematosus without Antiphospholipid Syndrome Causing Superior Vena Cava Syndrome. Oman Med J 2021; 36:e317. [PMID: 34804599 PMCID: PMC8596387 DOI: 10.5001/omj.2021.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/14/2020] [Indexed: 11/07/2022] Open
Abstract
Systemic lupus erythematosus (SLE) is an autoimmune disease with multisystem involvement. Superior vena cava (SVC) syndrome is mainly caused by malignant tumors such as lung carcinoma, lymphoma, and metastatic tumors. We report a 20-year-old woman who was admitted with features of SVC syndrome secondary to SVC thrombus. Further evaluation confirmed the diagnosis of SLE without associated antiphospholipid syndrome (APS). The patient was treated with heparin with oral anticoagulant, steroids, and hydroxychloroquine. Complete resolution of thrombus was documented within a few weeks. SVC thrombosis as an initial presenting feature of SLE without associated APS has not been reported so far in the literature.
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Affiliation(s)
- Vivek Choudhary
- Department of Medicine, RG Kar Medical College, Kolkata, India
| | - Atanu Chandra
- Department of Medicine, RG Kar Medical College, Kolkata, India
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Maalej F, Achour I, Zaidi A, Thabet W, Chaabouni MA, Hammami B, Ben Mahfoudh K, Mnejja M, Charfeddine I. Retropharyngeal edema secondary to superior vena cava syndrome revealing Behcet's disease. Clin Case Rep 2021; 9:1453-1456. [PMID: 33768866 PMCID: PMC7981641 DOI: 10.1002/ccr3.3800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/29/2020] [Accepted: 12/30/2020] [Indexed: 11/05/2022] Open
Abstract
Retropharyngeal edema, uncommon in superior vena cava syndrome, can exceptionally represent the first manifestation of Behcet's disease, which should be taken into account in the differential diagnosis of this condition.
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Affiliation(s)
- Firas Maalej
- ENT DepartmentUniversity of Sfax, Faculty of Medicine of SfaxSfaxTunisia
| | - Imen Achour
- ENT DepartmentUniversity of Sfax, Faculty of Medicine of SfaxSfaxTunisia
| | - Anis Zaidi
- ENT DepartmentUniversity of Sfax, Faculty of Medicine of SfaxSfaxTunisia
| | - Wadii Thabet
- ENT DepartmentUniversity of Sfax, Faculty of Medicine of SfaxSfaxTunisia
| | | | - Bouthaina Hammami
- ENT DepartmentUniversity of Sfax, Faculty of Medicine of SfaxSfaxTunisia
| | | | - Malek Mnejja
- ENT DepartmentUniversity of Sfax, Faculty of Medicine of SfaxSfaxTunisia
| | - Ilhem Charfeddine
- ENT DepartmentUniversity of Sfax, Faculty of Medicine of SfaxSfaxTunisia
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Bettiol A, Prisco D, Emmi G. Behçet: the syndrome. Rheumatology (Oxford) 2021; 59:iii101-iii107. [PMID: 32348523 DOI: 10.1093/rheumatology/kez626] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/15/2019] [Indexed: 01/20/2023] Open
Abstract
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.
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Affiliation(s)
- Alessandra Bettiol
- Department of Experimental and Clinical Medicine.,Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, Firenze, Italy
| | | | - Giacomo Emmi
- Department of Experimental and Clinical Medicine
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Internal Jugular Vein Thrombosis: A Serious Presentation of Behçet Disease. J Clin Rheumatol 2020; 26:e1. [PMID: 31860542 DOI: 10.1097/rhu.0000000000000784] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Ha-ou-nou F, Essaadouni L. Fréquence et facteurs prédictifs de thrombose veineuse au cours de la maladie de Behçet. Rev Med Interne 2020; 41:578-582. [DOI: 10.1016/j.revmed.2020.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 02/05/2020] [Accepted: 03/06/2020] [Indexed: 10/24/2022]
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Emmi G, Bettiol A, Silvestri E, Di Scala G, Becatti M, Fiorillo C, Prisco D. Vascular Behçet's syndrome: an update. Intern Emerg Med 2019; 14:645-652. [PMID: 30499073 DOI: 10.1007/s11739-018-1991-y] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 11/20/2018] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Giacomo Emmi
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy.
| | - Alessandra Bettiol
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
- Department of Neurosciences, Psychology, Drug Research and Child Health (NEUROFARBA), University of Firenze, Firenze, Italy
| | - Elena Silvestri
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Gerardo Di Scala
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
| | - Matteo Becatti
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Firenze, Firenze, Italy
| | - Claudia Fiorillo
- Department of Experimental and Clinical Biomedical Sciences "Mario Serio", University of Firenze, Firenze, Italy
| | - Domenico Prisco
- Department of Experimental and Clinical Medicine, University of Firenze, Firenze, Italy
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10
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Auditory involvement in Behcet’s disease: relationship with demographic, clinical, and therapeutic characteristics. Clin Rheumatol 2016; 36:445-449. [DOI: 10.1007/s10067-016-3367-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Revised: 07/20/2016] [Accepted: 07/24/2016] [Indexed: 12/17/2022]
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