Managing the symptoms of Behçet's disease

Long-term efficacy, safety, and cumulative retention rate of antitumor necrosis factor-alpha treatment for patients with Behcet's uveitis: A systematic review and meta-analysis

AIM

This study aims to evaluate the long-term efficacy, safety, and cumulative retention rate of antitumor necrosis factor-alpha (anti-TNF-α) therapy for patients with Behcet's uveitis (BU) using meta-analysis.

METHODS

We searched the Web of Science and PubMed databases for eligible studies up to December 1, 2022. The quality of each identified study was assessed using the Joanna Briggs Institute's case series literature quality assessment tool. Statistical analysis was conducted using Stata 16.0 software with a random-effects model.

RESULTS

Twelve studies comprising 1156 patients with BU were included in our analysis. We found that 85.0% of patients achieved ocular inflammation remission after receiving anti-TNF-α treatment, with a 95% confidence interval (CI) ranging from 78.7% to 90.5%. Additionally, 77.4% (95% CI: 57.5%-92.5%) experienced an improvement in visual acuity (VA). Moreover, the pooled dose reduction of glucocorticoids (GCs) was 11.08 mg (95% CI: -13.34 mg to -8.83 mg). Throughout the follow-up period, the cumulative retention rate of the medication was 67.3% (95% CI: 53.7%-79.6%). Serious adverse events occurred in 5.8% (95% CI: 3.1%-8.9%) of cases, with the three most common types being severe infusion or injection reactions (2.7%; 95% CI: 0.8%-5.4%), tuberculosis (1.3%; 95% CI: 0.0%-3.9%), and bacterial pneumonia (1.3%; 95% CI: 0.1%-3.4%). Subgroup analysis revealed that ocular inflammation remission rates were 89.3% (95% CI: 81.2%-95.5%) for adalimumab treatment and 83.7% (95% CI: 75.3%-90.8%) for infliximab treatment. The drug retention rate after adalimumab therapy was 70.3% (95% CI: 62.0%-78.0%) compared to 66.4% (95% CI: 48.6%-82.2%) for infliximab treatment. Furthermore, the incidence of severe infusion or injection reactions was 2.2% (95% CI: 0.1%-5.8%) following adalimumab treatment and 3.5% (95% CI: 0.7%-7.7%) following infliximab treatment.

CONCLUSIONS

Anti-TNF-α therapy represents an effective treatment for BU patients with favorable safety profile and high drug retention rate and a potential advantage of adalimumab over infliximab in terms of ocular inflammation remission, drug retention, and the incidence of severe infusion or injection reactions.

Efficacy and Safety of Adalimumab in Patients with Behçet Uveitis: A Systematic Review and Meta-Analysis

PURPOSE

To examine the long-term efficacy and safety of adalimumab (ADA) in patients with Behçet uveitis (BU).

METHODS

A systematic review and meta-analysis of observational studies was performed. Pooled results are presented as mean difference or standardized mean difference (std diff) and 95% confidence intervals (CI). Visual acuity (VA), intraocular inflammation grade, central macular thickness, corticosteroid (CS) sparing effect and adverse events were evaluated.

RESULTS

Ten studies were included finally for quantitative and qualitative synthesis. ADA therapy resulted in 0.124 (95%CI: 0.084, 0.165) logMAR improvement in VA. In addition, ADA therapy resulted in decreased grade of intraocular inflammation [std diff, -1.187 (95%CI: -1.508, -0.866)] and macular thickness [std diff, -0.564 (95%CI: -0.843, -0.286)] and caused a decrease in CS dosage [std diff, -1.809 (95%CI: -2.420, -1.198)]. The pooled rate of overall adverse events for ADA in 301 patients was 8.5% (95%CI: 0.039, 0.177).

CONCLUSION

ADA is an efficient therapy that improves VA and controls intraocular inflammation, macular edema and retinal vasculitis. As the disease exposure time increased, improvement in VA was less. The safety and CS-sparing effect of ADA were demonstrated with few adverse effects. The results provided evidence that ADA can be used safely and efficiently as the first-line drug in patients with BU.

Adalimumab rapidly controls both anterior and posterior inflammation in patients with ocular Behçet syndrome and non-infectious uveitis refractory to conventional therapy: a prospective, 6-month follow-up investigation

PURPOSE

To evaluate the efficacy and safety of adalimumab (ADA, Humira®) for treatment of non-infectious uveitis (NIU) refractory to conventional medications.

METHODS

Anti-tumor necrosis factor-α naive patients with NIU unresponsive to conventional immunosuppressive treatment were treated with ADA. Most cases with NIU were related to ocular Behçet syndrome. Adult cases used 80 mg ADA subcutaneously on day 0, 40 mg in the first week, and then 40 mg every 2-week, while this was 20 mg in children. Evaluations were performed pre-treatment and at weeks 2, 8, and 24. The study endpoints were best-corrected visual acuity (BCVA, LogMAR) improvement, anterior chamber (AC) cell grade, vitreous cell and haze grades, decrease in macular thickness and edema, prednisolone dose, immunosuppressive dose, and adverse reactions.

RESULTS

Thirty-eight eyes (19 right, 19 left) of 24 patients (14 female, 10 male) with (ocular Behçet syndrome) OBS (n = 27 eyes/18 patients) and NIU (n = 11 eyes/6 patients) were included. Mean age was 29.0 ± 14.1 years (range, 5-49) and follow-up time was 24 weeks. After ADA, BCVA increased (p < 0.001), and improvements in AC cell grade (p < 0.001), vitreous cell grade (p < 0.001), and vitreal haze grade (p < 0.001) were achieved at the final visit. Mean macular thickness decreased from 243.5 to 235.5 µm (p < 0.001). Such a rapid control of both anterior and posterior uveitis was observed in all eyes as early as the second week without relapses during follow-up. No ocular or systemic complications emerged during treatment.

CONCLUSIONS

ADA is effective and well-tolerated in pediatric and adolescent patients with NIU including OBS refractory to traditional medications and demonstrated corticosteroid- and immunosuppressive-sparing effects with no major side effects.

Prompt and Sustained Suppression of Intraocular Inflammation with Adalimumab in Pediatric Patients with Non-Infectious Uveitis Resistant to Traditional Managements: A 6-Month Follow-Up Research

PURPOSE

To assess the efficacy of adalimumab (ADA) on visual acuity (VA), ocular inflammation, vitreous haze and central macular thickness (CMT) in pediatric refractory non-infectious uveitis.

METHODS

Thirty-one eyes of 16 pediatric patients with uveitis of various etiologies were treated with ADA. VA, intraocular active inflammatory cells, vitreous haze, and CMT were evaluated at the baseline and 2nd, 4th, 12th, and 24th weeks following ADA treatment.

RESULTS

Twenty-three of 31 eyes had active and the remaining 8 eyes had inactive uveitis (with frequent relapse) before ADA therapy. VA (LogMAR) increased at 12th week following ADA treatment (p< .001). Intraocular inflammation degrees significantly improved within 4 weeks (p< .001). Vitreous haze decreased at fourth week and stabilized at 12th week (p= .038). CMT started to decrease within weeks and stabilized at 12th week (p= .006).

CONCLUSIONS

ADA was found to be safe and effective to suppress intraocular inflammation in pediatric non-infectious uveitis, which prevented sight-threatening complications.

Choroidal vascularity index and submacular choroidal thickness in patients with Behçet disease assessed with enhanced-depth OCT

PURPOSE

To investigate changes in the choroid using the choroidal vascularity index (CVI) and choroidal thickness (ChT) in patients with ocular (OBD) and non-ocular Behçet disease (non-ocular BD).

METHODS

Sixty-eight OBD patients, 40 non-ocular BD patients, and 40 healthy control subjects were included. ChT was measured using optical coherence tomography (OCT) in enhanced-depth imaging (EDI) mode (EDI-OCT; sub-foveal ChT at 1000 μm, nasal ChT at 1000 μm temporal ChT). The CVI value (%) was calculated by dividing the luminal area by the sub-foveal total choroidal area.

RESULTS

The mean sub-foveal ChT (297 ± 68 µm), nasal ChT (261 ± 66 µm), and temporal ChT (272 ± 68 µm) in eyes with OBD and the mean sub-foveal ChT (286 ± 31 µm), nasal ChT (266 ± 29 µm), and temporal ChT (269 ± 32 µm) in eyes with non-ocular BD were significantly decreased compared with those regions in healthy control subjects (333 ± 69, 301 ± 75, and 312 ± 70 µm, respectively). Additional subgroup analysis was performed for active OBD, inactive OBD, non-ocular BD, and the control group, and in pairwise comparisons, the CVI value was significantly decreased in both active (64.3 ± 3.1) and inactive OBD groups (64.2 ± 4.5) compared with healthy control subjects (67.2 ± 3.6; p = 0.026 and p < 0.001, respectively). There was no significant difference between non-ocular BD (65.9 ± 3.4) and control subjects (67.2 ± 3.6) for CVI measurements (p > 0.05).

CONCLUSIONS

Decreased CVI values in OBD suggest that uveitis affects the choroidal vasculature and that perfusion is affected by uveitis, whereas systemic inflammation in non-ocular BD does not affect them. In addition, the choroid in uveitis is affected by the chronicity of the disease rather than disease activity. ChT measurements and CVI values may be a novel and robust prognosticating biomarker to evaluate choroidal vasculature and to monitor disease progression in OBD patients because EDI-OCT is a non-invasive imaging modality. However, CVI does not seem to be a biomarker for monitoring of disease activity or treatment efficacy.

A nonspecific ulcer on upper lip presented as the first and sole sign of syphilis

Syphilis, a sexually transmitted disease, can be categorized as acquired syphilis and congenital syphilis, manifesting diverse lesions involving multiple sites. Oral manifestations at the primary stage of acquired syphilis are usually characterized by its short period and non-specific varied presentations. And oral ulcers as initial and the only presentation of syphilis oral lesions are infrequent and occur in less than 2% of patients. Because of its transient nature and variable manifestations which could mimic other oral ulcerative lesions, oral syphilis presenting as sole ulceration at early stage can be easily neglected and rather difficult to diagnose. Herein, we report a 35-year-old female patient manifested a sole atypical ulceration on her upper lip for approximately 1 month. We highlighted the importance of early and accurate diagnosis, focused on the characteristics of oral chancre, and gave an insight to the differential diagnoses, which would be enlightening and useful in clinical practice.

Ultrasonographic assessment of femoral cartilage thickness in patients with and without uveitis in Behçet's disease

The objective for this study is to evaluate the femoral cartilage thickness in patients with/without uveitis in Behçet's disease (BD). Patients with BD aged 18-70 years were included. The demographic and clinical characteristics of the patients were recorded. The thickness of femoral articular cartilage was measured with musculoskeletal ultrasound. Cartilage thickness was measured bilaterally from the central points of medial condyle (MFC), lateral condyle (LFC), and intercondylar area (ICA). 20 patients with uveitis [uveitis (+)] and 20 patients without uveitis [uveitis (-)] were included. Both right and left MFC and LFC had statistically significant thinner cartilage in uveitis (+) group (p < 0.05). For the ICA, uveitis (+) patients had thinner femoral cartilage than uveitis (-) patients; however, in the left side, statistically significance could not be detected. Femoral cartilage was thinner in uveitis (+) patients than in uveitis (-) patients in BD. This relationship between uveitis and femoral cartilage thickness may be helpful in the prevention and early treatment of cartilage degeneration.

Genetics and immunodysfunction underlying Behçet's disease and immunomodulant treatment approaches

Behçet's disease (BD) is a chronic autoimmune condition primarily prevalent in populations along the Mediterranean Sea. The exact etiology of BD has not been fully explained yet, but the disease occurrence is associated with a genetic factor, human leukocyte antigen (HLA)-B51 antigen. Among the various immunodysfunctions that are found in BD, patients are increased neutrophil motility and superoxide production, as well as elevated production of tumor necrosis factor (TNF)-α and decreased production of interleukin (IL)-10. Elevated levels of inflammatory cytokines like IL-1 and IL-17 in BD have been found associated with aberrant expression of microRNA. Gene polymorphisms in BD patients have been observed in molecules involved in responses to pathogens that can ultimately modulate the host antimicrobial response. Moreover, several single nucleotide polymorphisms (SNPs) have been reported in genes encoding chemokines and adhesion molecules; many of these changes manifest as increases in vascular inflammation and vascular damage. Lastly, genetic and epigenetic changes have been suggested as involved in the pathogenesis of BD. Modifications in DNA methylation have been found in BD patient monocytes and lymphocytes, leading to adverse function of these cells. This review presents a comprehensive compilation of the literature with regard to the immunodysfunction underlying BD, as well as of the genetics, newly described clinical specifications and novel treatment strategies using immunomodulants based on the current understanding of BD.

The seroprevalence and salivary shedding of herpesviruses in Behçet's syndrome and recurrent aphthous stomatitis

Background

Behçet's syndrome (BS) is one of the multisystemic diseases that presents with oral ulceration and several other systemic manifestations including genital ulceration, folliculitis, erythema nodosum-like lesions, uveitis, and arthropathy. Ocular manifestation, central nervous system involvement, and gastrointestinal manifestation account for most of the complications of this disease, whereas orogenital ulceration and dermatological involvement affects the quality of life. The cause of the disease is not fully elucidated; however, herpesviruses have long been thought to play a pivotal role in the disease pathogenesis.

Objective

To investigate the seroprevalence and salivary shedding of herpesviruses in BS.

Method

The levels of specific immunoglobulin G in six different herpesviruses in serum samples collected from 54 BS, 28 healthy controls (HC), and 7 recurrent aphthous stomatitis (RAS) patients were investigated. Salivary viral load was also quantified for these viruses in matched saliva samples using quantitative real-time polymerase chain reaction.

Results

The BS had lower cytomegalovirus (CMV) IgG level in comparison to HC (p=0.0226) and RAS (p=0.0450). There was statistically significant higher salivary shedding of Epstein-Barr virus (EBV) in BS in comparison to HC (p=0.0052), but not RAS (p=0.3318).

Conclusions

A high EBV shedding was observed in both BS and RAS and a lower level of CMV IgG was observed in BS only. The reason for the observed lower level of CMV IgG in BS is not clear. However, one explanation might be a defect in the cross-talk between innate and adaptive immune responses which was suggested by a previously described defect in the toll-like receptor 1 and 2 heterodimer formation and function, this being the initial receptor sensing of CMV.

Behcet's disease: systemic and ocular manifestations

AIM

The aim of this study was to evaluate if patients with Behcet's disease who have ocular involvement have a more severe form of this disease as compared to patients with Behcet's disease alone.

METHODS

A total of 99 patients were included in the study. 76 patients were used as part of the examined group, and 23 patients formed a control group.

RESULTS

The following are the results of examined and control groups, respectively: recurrent oral aphthous ulcers 89.5%, 95.7%; genital ulcers 61.8%, 97.0%; articular involvement 72.4%, 65.2%; vasculitis 81.6%, 60.9%; positive pathergy test 25.0%, 47.8%. Higher frequency of genital ulcerations was noted in control group (P = 0.001). More than two major criteria were met in 100% of the cases. HLA B51 was present in 78.9% of the cases in the examined group and 43.5% of the cases in control group; thus there is significant difference between them (P = 0.001). Visual acuity >0.5 occurred in 76% (examined group). Most frequent ocular manifestations in the examined group were retinal periphlebitis 81.6%, periphlebitis and periarteritis 65%, and serofibrinous uveitis 63.2%. Macular edema as a complication was present in 63.2%. The majority of patients (55.3%) were treated with combined therapy consisting of cyclosporine A and systemic corticosteroids. In 38.2% of patients, laser photocoagulation was used on retinal periphery.

[Otorhinolaryngological manifestations in patients with Behçet disease]

INTRODUCTION AND OBJECTIVES

Behçet disease (BD) is a systemic immune-mediated vasculitis of unknown origin characterised by recurrent orogenital ulceration, ocular inflammation and skin lesions. The aim of our study was to identify ear, nose and throat (ENT) manifestations associated with BD.

PATIENTS AND METHODS

Retrospective review of the medical records of all patients diagnosed with BD who attended a tertiary public hospital in Cantabria (Spain) over a period of 22 years. Clinical manifestations, in particular those concerning ENT, were retrieved from medical records. A medical literature review of ENT manifestations was conducted.

RESULTS

Thirty-three patients (age range: 17-64 years) were included in the study. Most of them presented oral ulcers (97%). Eight patients (24%) presented oropharyngeal ulcers and 5 patients (15%) experienced audiovestibular symptoms (high frequency sensorineural hearing loss, vertigo and bilateral vestibular hypofunction). One patient had symptoms compatible with vestibular neuronitis as the presentation manifestation of Neuro-Behçet. In 4 patients (12%) the presence of odynophagia secondary to the presence of oropharyngeal lesions, initially interpreted as acute or recurrent tonsillitis, was the first manifestation of the disease, alone or associated with cutaneous or ocular lesions.

CONCLUSIONS

In addition to the characteristic oral ulcers present in most patients with BD, ulcers in the oropharynx, occasionally interpreted as acute pharyngitis, are also common in these patients. Audiovestibular manifestations frequently appear during the course of the disease and may be the first symptom of central nervous system involvement.

Correlation between Ocular Manifestations and Their Complications as Opposed to Visual Acuity and Treatment in Behcet's Disease

The aim of this study was to analyze ocular manifestations, their complications, and treatment in a sample of 40 patients with confirmed Behcet's disease. Results. Serofibrinous iridocyclitis was the most common form of uveitis (60%). Retinal periphlebitis manifested in 92.5% of cases, and periphlebitis in conjunction with periarteritis was diagnosed in 72.5% of cases. Macular edema was the most frequent complication on the posterior segment (60%) and it correlated with periphlebitis (P = 0.45) and periphlebitis associated with periarteritis (P = 0.51). Cyclosporine A and corticosteroids were used in the majority of cases (67%). Following six months of therapy, a significant improvement of visual acuity occurred in patients with initial visual acuity >0.5 on both eyes. Level of visual acuity before and after treatment had a strong significant correlation coefficient with various ocular complications. Previously proven significant increase of visual acuity in patients with macular edema depicts effectiveness of treatment in these types of ocular manifestations of Behcet's disease. Conclusions. Significant improvement of visual acuity occurred in patients with initial visual acuity >0.5 on both eyes. The highest increase in visual acuity was achieved by laser photocoagulation in combination with triamcinolone acetonide P = 0.038 < 0.050.

Clinical application of development of nonantibiotic macrolides that correct inflammation-driven immune dysfunction in inflammatory skin diseases

BACKGROUND

Inflammation-driven immune dysfunction supports the development of several chronic human disorders including skin diseases. Nonantibiotic macrolides have anti-inflammatory and/or immunomodulatory activity that suggests the exploitation of these in the treatment of skin diseases characterized by inflammatory disorders.

MATERIALS AND METHODS

We performed an extensive review of the nonantibiotic macrolide literature published between 2005 and 2012, including cross-references of any retrieved articles. We also included some data from our own experience.

RESULTS

Calcineurin antagonists such as tacrolimus and ascomycins (e.g., pimecrolimus) act by inhibiting the activation of the nuclear factor for activated T cells (NFAT). There are new applications for these macrolides that have been available for several years and have been applied to skin and hair disorders such as atopic dermatitis, oral lichen planus, vitiligo, chronic autoimmune urticaria, rosacea, alopecia areata, pyoderma gangrenosum, Behcet's disease, neutrophilic dermatosis, and lupus erythematosus. We also reviewed new macrolides, like rapamycin, everolimus, and temsirolimus. In addition to the literature review, we report a novel class of nonantibiotic 14-member macrocycle with anti-inflammatory and immunomodulatory effects.

CONCLUSIONS

This paper summarizes the most important clinical studies and case reports dealing with the potential benefits of nonantibiotic macrolides which have opened new avenues in the development of anti-inflammatory strategies in the treatment of cutaneous disorders.

Ocular Behçet disease: current therapeutic approaches

PURPOSE OF REVIEW

To alert physician to timely recognition and current treatment of recurrent hypopyon iridocyclitis or panuveitis in ocular Behçet disease (OBD).

RECENT FINDINGS

Interferon-α, rituximab, intravitreal triamcinolone, and biological response modifiers by tumor necrosis factor inhibitors such as infliximab and adalimumab are being used increasingly for the treatment of severe sight-threatening ocular inflammation including retinal vasculitis and cystoid macular edema (CME).

SUMMARY

Biological agents offer tremendous potential in the treatment of OBD. Given that OBD predominantly afflicts the younger adults in their most productive years, dermatologist, rheumatologist, internist, or general practitioners supervising patients with oculo-articulo-oromucocutaneous syndromes should be aware of systemic Behçet disease. Early recognition of ocular involvement is important and such patients should strongly be instructed to visit immediately an ophthalmologist, as uveitis management differs from extraocular involvements with high ocular morbidity from sight-threatening complications due to relapsing inflammatory attacks in the posterior segment of the eye. A single infliximab infusion should be considered for the control of acute panuveitis, whereas repeated long-term infliximab infusions were proved to be more effective in reducing the number of episodes in refractory uveoretinitis with faster regression and complete remission of CME.

Ocular Behçet disease: current therapeutic approaches

PURPOSE OF REVIEW

To alert physician to timely recognition and current treatment of recurrent hypopyon iridocyclitis or panuveitis in ocular Behçet disease (OBD).

RECENT FINDINGS

Interferon-α, rituximab, intravitreal triamcinolone, and biological response modifiers by tumor necrosis factor inhibitors such as infliximab and adalimumab are being used increasingly for the treatment of severe sight-threatening ocular inflammation including retinal vasculitis and cystoid macular edema (CME).

SUMMARY

Biological agents offer tremendous potential in the treatment of OBD. Given that OBD predominantly afflicts the younger adults in their most productive years, dermatologist, rheumatologist, internist, or general practitioners supervising patients with oculo-articulo-oromucocutaneous syndromes should be aware of systemic Behçet disease. Early recognition of ocular involvement is important and such patients should strongly be instructed to visit immediately an ophthalmologist, as uveitis management differs from extraocular involvements with high ocular morbidity from sight-threatening complications due to relapsing inflammatory attacks in the posterior segment of the eye. A single infliximab infusion should be considered for the control of acute panuveitis, whereas repeated long-term infliximab infusions were proved to be more effective in reducing the number of episodes in refractory uveoretinitis with faster regression and complete remission of CME.

Anticardiolipin antibodies in patients with Behcet's disease

The aims of this study are to determine anticardiolipin antibodies in patients with Sy Behcet and to determine correlation between the levels of anticardiolipin antibodies in serum in patients with clinic systemic and ocular manifestations. The study was conducted on 11 patients with Behcet disease (group I), and on 11 healthy subjects (group II). Anticardiolipin antibodies -aCL were determined by the standard ELISA method, where 1GPL= 1 microgram/ml IgG aCL and 1 MPL= 1 microgram/ ml IgM, and were considered negative < 10 GPL or MPL, low positive (10-40 GPL and MPL), or high positive (>40 GPL and MPL). In the group of 11 patients with the diagnosis Sy Behcet, 6 of them were (54.5%) with values of anticardiolipin antibodies over 10 positive. In the control group of the healthy examinees aCl were positive in 2 cases (18.2%). There are no statistically significant differences in the presence of systemic clinic characteristics between aCl positive and negative patients. All the patients with SY Behcet in whom anticardiolipn antibodies were found have extremely severe visual damage which is not present in the group of those patients where the values of aCl were low. The difference is statistically significant. The level of anticardiolipin antibodies is increased in the patients with Behcet. There are no statistically significant differences in the presence of systemic clinical characteristics between aCL positive and negative patients. Visual acuity in patients with SY Behcet is statistically significantly much lower in patients who had increased values of aCL.

Diagnostic and prognostic biomarker discovery strategies for autoimmune disorders

Current clinical, laboratory or radiological parameters cannot accurately diagnose or predict disease outcomes in a range of autoimmune disorders. Biomarkers which can diagnose at an earlier time point, predict outcome or help guide therapeutic strategies in autoimmune diseases could improve clinical management of this broad group of debilitating disorders. Additionally, there is a growing need for a deeper understanding of multi-factorial autoimmune disorders. Proteomic platforms offering a multiplex approach are more likely to reflect the complexity of autoimmune disease processes. Findings from proteomic based studies of three distinct autoimmune diseases are presented and strategies compared. It is the authors' view that such approaches are likely to be fruitful in the movement of autoimmune disease treatment away from reactive decisions and towards a preventative stand point.

Current trends in the management of ocular symptoms in Adamantiades-Behçet's disease

Adamantiades-Behçet’s disease (ABD) is a multisystemic vasculitic disease. It is most prevalent in the Eastern Mediterranean countries and the Eastern region of Asia. Its effect on the eye can range from mild to debilitating, resulting in total blindness. A necrotizing and obliterative vasculitis affects both arteries and veins of organs. Recurrent attacks of uveitis, oral aphthous ulcers, skin lesions, and genital ulcers are common. Topical and systemic corticosteroids have been the mainstay in the treatment of ocular inflammation for many years; however, due to the several known side effects of corticosteroids and thanks to scientific advances, more novel approaches to ABD treatment have been emerging. Antimetabolites such as methotrexate and azathioprine have been utilized with the latter showing positive results. Chlorambucil has been utilized effectively for ocular manifestations of ABD. Interferon alpha has shown encouraging results in the management of refractory ocular inflammation associated with ABD, either alone or in combination with other immunosuppressive agents. Surgical interventions to deal with complications from ABD can be safely done if adequate control of inflammation is achieved peri-operatively. Early detection and aggressive treatment, when needed, have proven to be essential in the management of this relentlessly explosive disease.

Lenalidomide: Behçet Syndrome

Off-Label Drug Uses

This Hospital Pharmacy feature is extracted from Off-Label DrugFacts, a quarterly publication available from Wolters Kluwer Health. Off-Label DrugFacts is a practitioner-oriented resource for information about specific FDA-unapproved drug uses. This new guide to the literature will enable the health care professional/clinician to quickly identify published studies on off-label uses and to determine if a specific use is rational in a patient care scenario. The most relevant data are provided in tabular form, so the reader can easily identify the scope of information available. A summary of these data—including background, study design, patient population, dosage information, therapy duration, results, safety, and therapeutic considerations—precedes each table of published studies. References direct the reader to the full literature for more comprehensive information prior to patient care decisions. Direct questions or comments regarding “Off-Label Drug Uses” to hospitalpharmacy@wolterskluwer.com .

Tumor necrosis factor-alpha: a promising therapeutic target for asthma?

Asthma is a disease that encompasses a variety of features including airway smooth muscle abnormalities, airway inflammation, and structural changes in the airway. Historically, it has been classified depending on the severity of the disease, the frequency of symptoms, and the level of treatment required to control them. Severe or refractory asthma accounts for approximately 10% of the patient population with asthma and for about 30% of the healthcare costs of this disease. It is often associated with conditions that might lead to activation of innate immunity in the lung, and it has been suggested that some of the features of severe asthma might be due to upregulation of the tumor necrosis factor-alpha (TNFalpha) pathway. In support of this, studies have shown that severe asthma is associated with an increased presence of TNFalpha within the airway and an increase in TNFalpha expression on peripheral blood mononuclear cells. Moreover, TNFalpha has the ability to induce several of the pro-inflammatory changes associated with severe asthma. Interest in the role of TNFalpha in severe asthma has increased following reports that antagonism with etanercept or infliximab is associated with improvement in asthma control in patients with severe asthma. In this article, we discuss the biology, function, and clinical effects of TNFalpha with particular reference to severe asthma.

Antitumor necrosis factor-alpha therapy for early postoperative recurrence of gastrointestinal Behçet's disease: report of a case

Behçet's disease is a chronic, relapsing, systemic inflammatory disease characterized by recurrent oral and genital ulcers, skin lesions, and ocular lesions. Gastrointestinal tract is occasionally involved in Behçet's disease, and the typical gastrointestinal lesions are punched-out, discrete mucosal ulcerations. Corticosteroids, 5-aminosalicylic acid derivatives, thalidomide, and immunomodulators have been used to treat Behçet's disease. Some patients with gastrointestinal Behçet's disease undergo surgical management because of the refractoriness to these medical measures or complications, such as perforation and bleeding. Even after successful surgery, postoperative complications, such as poor healing of the anastomosis site and postoperative ulcer recurrence, are so common that repeated operations are frequently required. However, there have been few reports addressing the most effective way to reduce and treat postoperative complications and recurrences. We describe a patient with Behçet's disease involving the distal ileum, who was treated with infliximab as rescue therapy of an unhealed anastomosis site and early recurrent ulcers after a distal ileocecectomy because of persistent bleeding. Abdominal pain from recurrent ulcers improved by the fifth day after the infliximab infusion and almost disappeared by the second week. An ileocolonoscopy performed 15 days after the infliximab infusion showed near complete healing of the recurrent ulcers. This report suggests that infliximab may be an effective novel therapy for the management of early postoperative complications and recurrences in gastrointestinal Behçet's disease.

Clinical features of Behcet's disease in children

BACKGROUND

Behçet's disease (BD) is a systemic inflammatory vasculitis of young adults with unknown etiology.

OBJECTIVE

The aim of this study was to determine the clinical features and outcome of BD in childhood.

PATIENTS AND METHODS

Seventeen patients with BD within a pediatric age group were studied since 1997.

RESULTS

Boys : girls ratio was 12:5. Familial cases were very frequent (45%). Oral aphthous ulcers were present in all patients (100%), genital aphthous ulcers were present in 16 (94%), ocular lesions in 4 (24%), erythema nodosum in 3 (18%), papulopustules in 8 (47%), joint symptoms in 13 (76%), mild gastrointestinal symptoms in 2 (12%), neurological involvement in 2 (12%), positive pathergy reactions in 13 (76%), and thrombophlebitis in 1 (6%). We used colchicine, systemic corticosteroids, cyclosporine, nonsteroidal anti-inflammatory drugs, sulfasalazine, and topical agents for the treatment of children with BD.

CONCLUSION

The findings of BD in children are similar as in adults, but the frequency of familial cases is significantly higher.

Serum levels of soluble P-selectin are increased and associated with disease activity in patients with Behçet's syndrome

Behçet's syndrome (BS) is a relapsing, chronic, inflammatory disease characterized by endothelial dysfunction, atherothromboembogenesis, and leukocytoclastic vasculitis with complex immunologic molecular interactions. Generalized derangements of the lymphocyte and neutrophil populations, activated monocytes, and increased PMNLs motility with upregulated cell surface molecules such as ICAM-1, VCAM-1, and E-selectin, which are found on the endothelial cells, leukocytes, and platelets, have all been demonstrated during the course of BS. Our aim is to investigate the association of serum concentrations of soluble P-selectin in patients with BS, and to evaluate whether disease activity has an effect on their blood levels. This multicenter study included 31 patients with BS (15 men and 16 women) and 20 age- and sex-matched healthy control volunteers (11 men and nine women). Neutrophil count, erythrocyte sedimentation rate, and acute-phase reactants as well as soluble P-selectin levels were determined. The mean age and sex distributions were similar (P > .05) between BS patients (35 years) and control volunteers (36 years). Serum levels of soluble P-selectin in patients with BS (399 +/- 72 ng/mL) were significantly (P < .001) higher when compared with control subjects (164 +/- 40 ng/mL). In addition, active BS patients (453 +/- 37 ng/mL) had significantly (P < .001) elevated levels of soluble P-selectin than those in inactive period (341 +/- 52 ng/mL). This study clearly demonstrated that serum soluble P-selectin levels are increased in BS patients when compared with control subjects, suggesting a modulator role for soluble P-selectin during the course of platelet activation and therefore, atherothrombogenesis formation in BS, especially in active disease.

Ojo y piel

Las relaciones entre la patología del ojo y de su revestimiento cutáneo son muy numerosas. Debido a las analogías embriológicas e histológicas, sus principales consecuencias oftalmológicas afectan a la superficie ocular en el sentido más amplio: tegumentos de los párpados, conjuntivas y córnea. La exploración clínica dermatológica sospechará estas alteraciones, que confirmará el oftalmólogo. No obstante, algunos trastornos pueden afectar a todos los demás tejidos oculares. Ya se trate de una localización ocular de algunas enfermedades dermatológicas, como las dermatosis infecciosas, o de auténticos síndromes oculocutáneos, la exploración clínica especializada, y a veces repetida, suele orientar el tratamiento. Las consecuencias sobre la función visual de algunas de estas alteraciones pueden ser graves. La epidermólisis tóxica de Lyell constituye el ejemplo extremo que puede provocar una ceguera corneal bilateral de tratamiento temible. La dermatitis atópica es otro ejemplo de enfermedad más frecuente, pero cuyas complicaciones oculares también pueden amenazar la visión si el tratamiento oftalmodermatológico no es correcto. El ojo y la piel se asocian de nuevo en numerosas enfermedades generales, congénitas, hereditarias o no, o bien adquiridas, cuyos síntomas específicos relacionados con ambas especialidades ayudan a establecer el diagnóstico positivo. Los ejemplos más frecuentes son el lupus, la enfermedad de Behçet, la sarcoidosis y las facomatosis. La superficie ocular conjuntivocorneal comparte con la piel una cierta similitud en cuanto al desarrollo de tumores, pigmentados o no. Por último, merecen describirse las consecuencias oculares de algunos tratamientos dermatológicos. También se hará mención a las situaciones inversas, que son más excepcionales.

5,10-Methylenetetrahydrofolate reductase C677T gene polymorphism in Behcet's patients with or without ocular involvement

BACKGROUND

Increased serum levels of homocysteine (Hcy) have been reported in patients with Behçet's disease (BD) with an established risk factor for vascular involvement. Recently, the authors demonstrated that elevated Hcy levels are associated with ocular involvement in such patients. On the other hand, elevated levels of Hcy can result from genetic errors. Indeed, a mutation in the 5,10-methylenetetrahydrofolate reductase (MTHFR C677T) gene influences Hcy metabolism and, therefore, MTHFR C677T polymorphism provokes hyperhomocysteinaemia.

AIM

To investigate the possible genetic factor for the elevation of plasma Hcy level in patients with BD by examining gene interaction with the MTHFR C677T polymorphism, a crucial factor of the Hcy metabolism. In addition, the authors aimed to evaluate if there is an association between the C677T polymorphism and the presence of ocular involvement in such patients.

METHOD

A total of 59 patients with BD (25 men, 34 women) with a mean age of 34.9 years and 42 age and sex matched healthy control subjects (19 men, 23 women; mean age 32.2) were included in this investigation. MTHFR gene polymorphism was investigated by the polymerase chain reaction (PCR) and restriction fragment length polymorphism (RFLP) of a genomic DNA fragment at nucleotide 677 in all subjects in both groups. The genetic equilibrium is assumed for the gene frequencies of the MTHFR polymorphism in both samples.

RESULTS

The genotype of the MTHFR gene differed between the Behçet's patients and control subjects (TT: 11.9 v 2.4%; CT: 55.9 v 61.9%; CC: 32.2 v 35.7 %). TT homozygous genotype was more frequently in BD patients than the controls, though the difference was not significant (p = 0.063). In BD patients with ocular involvement, however, the frequencies of MTHFR TT homogenetic type (27.8%) were significantly and statistically higher than those in BD patients without ocular involvement (4.9%, p = 0.022, odds ratio = 7.5), or the controls (2.4%, p = 0.003, odds ratio = 20.0). TT homozygous genotype was associated with an increased risk for ocular involvement.

CONCLUSION

Elevated serum levels of Hcy seem to be a result of C677T polymorphism of the MTHFR gene, with increased TT individuals over CC and CT genotype BD patients. Although no association was shown between the MTHFR reductase C677T polymorphism and the increased risk of oral aphtahe or genital ulcers, a mutation in this gene was associated with an increased risk of ocular involvement, suggesting genetic instability with a potential initiation of Hcy lowering therapy in this patient group.

Blood-tinged Stools and Blood-shot Eyes

A 37-year-old woman developed red painful eyes, diarrhea, and painful oral and genital ulcerations. Optic disk swelling was noted bilaterally. Colonoscopy was significant for granulomatous lesions consistent with Crohn disease. Epidemiologic factors, diagnostic criteria, and differentiating characteristics for Behcet disease and Crohn disease are discussed.

Synovial nitric oxide concentrations are increased and correlated with serum levels in patients with active Behçet's disease: a pilot study

Behçet's disease (BD) is a relapsing immunoinflammatory vasculitis of unknown etiology characterized by endothelial dysfunction. Articular symptoms and signs are present in about 75% of cases and characterized by seronegative arthritis and nonspecific synovitis. We demonstrated that both serum and erythrocyte nitric oxide (NO(.)) levels, the most abundant free radical in the body, were elevated in BD and associated with disease activity. This study further investigated NO(.) levels in the synovial fluid and serum from patients with active and inactive BD. A total of 23 BD patients with articular involvement (14 men and 9 women) satisfying International Study Group criteria and 15 age- and sex-matched healthy control subjects (9 men and 6 women) undergoing elective arthroscopy were included in this case-control investigation. The synovial fluid and serum were obtained from BD patients and controls. Clinical and laboratory findings including neutrophil count and erythrocyte sedimentation rate (ESR) were used to classify BD patients as active (n = 11) or inactive (n = 12). Synovial as well as serum NO(.) levels were compared between the groups and correlation analysis was performed. Acute phase reactant levels were significantly higher (for each, p < 0.01) in BD patients than control subjects in the active period. The mean synovial NO(.) level in active Behçet's patients (mean +/- SD 76.61 +/- 11.95 micromol/l) was significantly higher than in inactive patients (46.16 +/- 8.89 micromol/l, p < 0.001) and healthy control subjects (39.60 +/-8.03 micromol/l, p < 0.001). The difference between inactive patients and controls was not significant (p > 0.05). Active BD patients had significantly higher serum NO(.) levels (38.84 +/- 9.15 micromol/l) than inactive patients (30.91 +/- 5.88 micromol/l, p = 0.018) and control subjects (28.86 +/- 5.91 micromol/l, p = 0.002). In addition, synovial NO(.) levels were positively correlated with serum levels (r(2) = 0.621, p < 0.001). Increased synovial NO(.) levels in active BD patients probably reflect a nonspecific inflammatory process of the synovium and, therefore, arthralgia and arthritis as a common finding of BD.

Adenosine deaminase enzyme levels, their relation with disease activity, and the effect of colchicine on adenosine deaminase levels in patients with Behçet's disease

Behçet's disease (BD) is a systemic vasculitis. Although its clinical characteristics are well defined, the etiology and immune pathogenesis are not clear yet. Neutrophilic vasculitis, which is a consequence of immunological events, is suggested as the underlying pathophysiological mechanism. Adenosine deaminase (ADA) is a non-specific marker of T-lymphocyte activation. A total of 75 patients with BD (45 women and 30 men) and 25 age-matched and gender-matched healthy control volunteers (13 women and 12 men) were included in this study. BD patients were divided into three groups according to their clinical findings: inactive BD patients (group 1, n=25); active BD patients under colchicine treatment (group 2, n=25); and active BD patients without colchicine treatment (group 3, n=25). Plasma ADA (p-ADA) levels of all BD patients and the control group were measured and compared. The relationship between p-ADA levels and disease activity, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) levels was evaluated and correlated. Patients with BD had significantly higher p-ADA levels (20.6+/-6.3 U/l) than control subjects (12.8+/-1.8 U/l; P<0.001). The p-ADA levels of patients with active BD were significantly (for each, P<0.05) higher than those of inactive BD patients or controls. On the other hand, the difference was not significant (P>0.05) between active patients with or without colchicine use. In addition, there were significantly positive correlations between p-ADA, ESR and CRP levels in patients with BD (for each, P<0.05). However, disease duration or haemoglobin levels were not relevant. ADA level may be a valuable and supportive indicator of disease activity and is not affected by colchicine therapy in BD.