Plasma von Willebrand factor, tissue plasminogen activator, plasminogen activator inhibitor, and antithrombin III levels in Behçet's disease

Venous and arterial thrombosis in patients with VEXAS syndrome

ABSTRACT

VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, caused by somatic mutations in UBA1, is an autoinflammatory disorder with diverse systemic manifestations. Thrombosis is a prominent clinical feature of VEXAS syndrome. The risk factors and frequency of thrombosis in VEXAS syndrome are not well described, due to the disease's recent discovery and the paucity of large databases. We evaluated 119 patients with VEXAS syndrome for venous and arterial thrombosis and correlated their presence with clinical outcomes and survival. Thrombosis occurred in 49% of patients, mostly venous thromboembolism (VTE; 41%). Almost two-thirds of VTEs were unprovoked, 41% were recurrent, and 20% occurred despite anticoagulation. The cumulative incidence of VTE was 17% at 1 year from symptom onset and 40% by 5 years. Cardiac and pulmonary inflammatory manifestations were associated with time to VTE. M41L was positively associated specifically with pulmonary embolism by univariate (odds ratio [OR]: 4.58, confidence interval [CI] 1.28-16.21, P = .02) and multivariate (OR: 16.94, CI 1.99-144.3, P = .01) logistic regression. The cumulative incidence of arterial thrombosis was 6% at 1 year and 11% at 5 years. The overall survival of the entire patient cohort at median follow-up time of 4.8 years was 88%, and there was no difference in survival between patients with or without thrombosis (P = .8). Patients with VEXAS syndrome are at high risk of VTE; thromboprophylaxis should administered be in high-risk settings unless strongly contraindicated.

Giant right ventricular thrombus as the revealing form of Behçet's disease

BACKGROUND

Behçet's disease BD is a rare multisystemic disease, with rare cardiac involvement. This case illustrates a rare cardiac involvement as a giant intracavitary thrombus which was the revealing form of Behçet disease.

CASE PRESENTATION

An 15-year-old male admitted to the emergency department for progressive dyspnoea, hemoptysis for which an echocardiogram displayed a large echogenic mass in the right ventricle and angio CT revealed associated bilateral pulmonary embolism. The patient was then proposed for surgery for removal and pathological study the later confirmed its fibrin thrombotic nature. Behçet disease was suspected based on past history of recurrent oral aphthosis and confirmed with a positive pathergy test. Further management by anticoagulants, immunosuppressants and corticosteroids seemed effective to avoid relapse.

CONCLUSIONS

Cardiac involvement during BD can be life-threatening as it is not always diagnosed in timely manner. However, intracardiac thrombus is uncommon with only few case reports. Echocardiography is the key tool for the diagnosis of intracardiac thrombus.

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.

Vascular complications of Behçet disease

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.

Serious Right Coronary Artery Thrombosis Revealing Behçet's Disease in a Female Patient: A Case Report

Although atherosclerosis remains the major cause of acute coronary syndrome, there are many other etiologies that should be taken into account, especially in young patients with no atherosclerotic risk factors. Coronary involvement is extremely rare in patients with Behçet's disease, notably in young patients. In addition, acute inferior myocardial infarction revealing Behçet's disease has rarely been reported. Through this article, we report a case of Behçet's disease with arterial involvement diagnosed after myocardial infarction resulting from thrombosis of the right coronary artery in a 50-year-old woman with no specific medical history.

Cardiac involvement in the adult primary vasculitides

INTRODUCTION

Heart involvement in vasculitis is rare, but potentially severe. The ascertainment of cardiac disease in vasculitis is complex and requires an integrated multidisciplinary approach involving the Rheumatologist, Radiologist, Cardiologist, and Heart surgeon.

AREAS COVERED

the authors searched PubMed using the keywords 'heart'[Mesh] and vasculitis"[Mesh].

EXPERT OPINION

Virtually any vasculitis can affect the heart, but cardiac involvement is more common in some vasculitides such as Takayasu arteritis, polyarteritis nodosa, and eosinophilic granulomatosis with polyangiitis. Immunosuppressive treatment and when indicated surgery can improve the prognosis.

Colchicine therapy for deep vein thrombosis in a patient with vascular-type Behçet disease: A case report

RATIONALE

Behçet Disease (BD) is a chronic inflammatory vasculitis with thrombogenicity and multisystem involvement. Deep vein thrombosis (DVT) in the lower extremities is the most frequent manifestation of vascular involvement in BD. The causes of thrombosis vary widely and include congenital predisposition and acquired factors, but of all the thrombosis, the cause is rarely BD. Furthermore, there are few reports of treatment for thrombosis in BD.

PATIENT CONCERNS

We herein describe the case of an Asian male patient aged 40 years, admitted to our hospital for left leg pain, edema, and swelling.

DIAGNOSES

We confirmed the DVT and pulmonary artery thrombosis (PAT) by contrast computed tomography angiogram. At the same time, the patient developed oral ulcerations and skin lesions consistent with BD.

INTERVENTIONS

The patient was initially treated with anticoagulants. However, because the improvement of DVT was inadequate, we added colchicine in anticipation of anti-inflammatory effects. After that, anticoagulation was discontinued, and only colchicine was continuously prescribed.

OUTCOMES

We observed an almost complete resolution of DVT and PAT with no recurrence of thrombosis for 6 months after discharge.

LESSONS

This case shows us that we should consider BD as a differential diagnosis of DVT and that colchicine therapy is effective for inflammation-induced thrombosis in BD.

Epidemiology, morbidity and mortality in Behçet’s disease: a cohort study using The Health Improvement Network (THIN)

Objectives

The epidemiology of Behçet’s disease (BD) has not been well characterized in the UK. Evidence on the risk of cardiovascular disease, thromboembolic disease and mortality in patients with BD compared with the general population is scarce.

Methods

We used a large UK primary care database to investigate the epidemiology of BD. A retrospective matched cohort study was used to assess the following outcomes: risk of cardiovascular, thromboembolic disease and mortality. Controls were selected at a 1:4 ratio (age and gender matched). Cox proportional hazard models were used to derive adjusted hazard ratios (aHR).

Results

The prevalence of BD was 14.61 (95% CI 13.35–15.88) per 100 000 population in 2017. A total of 1281 patients with BD were compared with 5124 age- and gender-matched controls. There was significantly increased risk of ischaemic heart disease [aHR 3.09 (1.28–7.44)], venous thrombosis [aHR 4.80 (2.42–9.54)] and mortality [aHR 1.40 (1.07–1.84)] in patients with BD compared with corresponding controls. Patients with BD were at higher risk of pulmonary embolism compared with corresponding controls at baseline [adjusted odds ratio 4.64 (2.66–8.09), P < 0.0001]. The majority of patients with pulmonary embolism and a diagnosis of BD had pulmonary embolism preceding the diagnosis of BD, not after (87.5%; n = 28/32).

Conclusion

BD has a higher prevalence than previously thought. Physicians should be aware of the increased risk of developing ischaemic heart disease, stroke/transient ischaemic attack and deep venous thrombosis in patients with BD at an earlier age compared with the general population. Risk of embolism in patients with BD might vary across the disease course.

The relationship of serum VEGF and sVEGFR-1 levels with vascular involvement in patients with Behçet's disease

Behçet's disease (BD) is a rare, chronic, inflammatory disorder characterized by multisystemic vasculitis including mucocutaneous, neurologic, and ophthalmic involvement. Our aim is to compare vascular endothelial growth factor (VEGF) and soluble vascular endothelial growth factor receptor-1 (sVEGFR-1) levels in BD, among the patients having or not having organ involvement, disease activation and especially vascular involvement. Fifty-five patients with BD, 25 of which were accompanied by vascular involvement, and 31 control subjects were included in the study. Disease activity was assessed with the Turkish version of Behçet Disease Current Activity Form (BDCAF) and active vasculitis lesions at the time of study were recorded. Age at diagnosis was 32.2 ± 4.6, while the mean duration of BD was 96.3 (72.3) months. The median for BDCAF score was 2.0 (range 0, 3.0), and 29 (52%) of patients had active BD. The serum VEGF and sVEGFR-1 levels in patients with BD were significantly higher than that in controls [(298 (338.5) pg/mL; 93 (93.5) pg/mL in patients and 136.2 (73) pg/mL; 56.5 (48.5) pg/mL in controls, respectively, p < .001 for both values] while difference in VEGF/sVEGFR-1 ratio was obtained close to borderline of significance (p = .03). Our study is the first report indicating elevated serum VEGF, sVEGFR-1, and more importantly VEGF/sVEGFR-1 ratio could play an important role in the development of trombosis in BD. VEGF and/or sVEGFR-1 should not be evaluated independently in the same patient group and the ratio of these two parameters is a more important indicator, especially in the evaluation of BD especially with vascular involvement together with the duration of disease.

Recurrent symptomatic ischemic stroke in a 46-year-old African male revealing Angio-Behçet with severe cardiovascular involvement

Behçet’sdisease (BD) is a chronic, multisystem vasculitis. It is categorized under variable vessel vasculitis in the new Chapel Hill nomenclature as it involves blood vessels of any type and size. It is characterized by relapsing aphthous ulcers commonly occurring in the oral mucosa and genitalia with ocular involvement. Other organ systems may be involved any time throughout the course of the disease. The exact cause is unknown. However, combination of genetic and environmental factors is likely to play a role.

Cardiac involvement may occur in the form of intracardiac thrombus, endocarditis, myocarditis, pericarditis, endomyocardial fibrosis, coronary arteritis, myocardial infarction, and valvular disease.

We present a case of Angio-Behçet in a 46-year-old African male with severe cardiovascular involvement including pulmonary artery hypertension (PAH), right ventricular failure and left ventricular diastolic dysfunction diagnosed after 2 episodes of symptomatic ischemic stroke resulting from complete occlusion of the right internal carotid artery (ICA) up to its intracranial portion.

Immunosuppressive and anticoagulant therapies have induced improvement in cardiac manifestations. Nevertheless, prompt recognition of the primarily vascular manifestation of BD without mucocutaneous manifestations was responsible for considerable delay that did not afford surgical therapy for the carotid occlusion.

Could be serum uric acid a risk factor for thrombosis and/or uveitis in Behcet's disease?

Introduction Serum uric acid level increases in many inflammatory conditions. Uric acid triggers the vascular inflammation and artery damage, which causes to an increased risk of endothelial dysfunction and atherosclerosis. It is not clear in the literature whether uric acid contributes to uveitis by similar mechanisms. We investigated whether uric acid level increases in Behcet's disease patients with thrombosis or anterior uveitis. Patients and methods We reviewed the medical records of 914 Behcet's disease. After screening for exclusion criteria, there were 50 Behcet's disease patients with thrombotic complication and as the control group 202 BD patients without any vascular complication were included to the study. In the Anterior uveitis group, there were 53 Behcet's disease patients. The Control group consisted of 39 Behçet's disease patients without eye findings. Results Mean uric acid value was 4.96 ± 1.06 mg/dl in Behcet's disease patients with thrombosis whereas 4.08 ± 0.94 mg/dl in controls, indicating a significant difference ( p < 0.001). There was no significant difference between the mean ages of the patients in both groups. The mean age of the BD group without eye findings was 39.31 ± 10.47 years and that of the Behcet's disease with Anterior Uveitis group was 37.72 ± 9.65 years ( p = 0.453). The mean serum UA in the BD group without eye findings was 4.21 ± 1.21 mg/dl, while in the BD with Anterior Uveitis group it was 4.57 ± 1.37 mg/dl ( p = 0.201). Conclusion The extent of increase in uric acid level was greater in Behcet's disease patients that have a thrombotic complication compared to those without thrombotic complication. Uric acid seems to play a role in the pathogenesis of thrombosis. It is concluded that the elevation of serum uric acid level in patients with anterior uveitis with Behcet's disease is not statistically significant.

Behcet's disease and pregnancy: what to expect?

The relationship between Behcet's disease (BD) and pregnancy is only reported in limited number of studies. We retrospectively collected data of 26 women with BD diagnosis and their 66 pregnancies. We analysed patients according to disease activity, age at BD diagnosis, age at first/last pregnancy, obstetric history, obstetric complications, neonatal birthweight, associated foetal abnormalities and pregnancy-related complications. Sixteen miscarriages (24.2%), two intrauterine deaths (3%) and 48 live births (72.8%) were identified. Preterm labour was observed in 12 (24%) of 50 deliveries. Colchicine was used in six pregnancies, however, there was no drug treatment for BD in the remaining 59. There was a higher rate of preterm labour and low birthweight in patients using colchicine. BD was in remission in 60 (90.9%) of 66 pregnancies, and disease flared up only in six cases. In conclusion, BD patients with altered symptoms during pregnancy carry an increased risk of obstetric complications. IMPACT STATEMENT What is already known on this subject: There are limited and conflicting data about the interaction between BD and gestation. What the results of this study add: Our findings indicated that patients who were in an active symptomatic phase of BD and were being treated with colchicine had an increased risk of preterm delivery and low birthweight. What the implications are of these findings for clinical practice and/or further research: Clinicians should consider increased obstetric complication risk among patients with active BD.

Colon perforation and Budd-Chiari syndrome in Behçet's disease

BACKGROUND

Behçet's disease is a chronic inflammatory disease involving multiple systems, with vasculitis being the most important pathological feature. Multiple colon perforations are thought to be secondary to vasculitis and they occur in patients with ulcers. These may be encountered within the entire colon but most commonly in the ileocecal region. Intestinal perforation and Budd-Chiari syndrome are infrequent in Behçet's disease, and are associated with high mortality and morbidity. Budd-Chiari syndrome results from occlusion of either hepatic veins or adjacent inferior vena cava, or both.

CASE REPORT

We report a patient with Behçet's disease having multiple perforations in the transverse colon, descending colon, and sigmoid colon. The patient also had Budd-Chiari syndrome due to inferior vena cava thrombosis extending into the right and middle hepatic vein. Our observations are presented with a review of the literature.

CONCLUSIONS

In Behçet's disease, treatment of colon perforation necessitates urgent surgery, whereas management of Budd-Chiari syndrome is directed towards the underlying cause. Behçet's disease, as a chronic multisystemic disease with various forms of vasculitis, is resistant to medical and surgical treatment. Prognosis is worse in Behçet's disease with colon perforation than that in Budd-Chiari syndrome alone.

Thrombosis in vasculitis: from pathogenesis to treatment

In recent years, the relationship between inflammation and thrombosis has been deeply investigated and it is now clear that immune and coagulation systems are functionally interconnected.

Inflammation-induced thrombosis is by now considered a feature not only of autoimmune rheumatic diseases, but also of systemic vasculitides such as Behçet’s syndrome, ANCA-associated vasculitis or giant cells arteritis, especially during active disease.

These findings have important consequences in terms of management and treatment. Indeed, Behçet’syndrome requires immunosuppressive agents for vascular involvement rather than anticoagulation or antiplatelet therapy, and it is conceivable that also in ANCA-associated vasculitis or large vessel-vasculitis an aggressive anti-inflammatory treatment during active disease could reduce the risk of thrombotic events in early stages.

In this review we discuss thrombosis in vasculitides, especially in Behçet’s syndrome, ANCA-associated vasculitis and large-vessel vasculitis, and provide pathogenetic and clinical clues for the different specialists involved in the care of these patients.

Identification of possible pathogenic pathways in Behçet's disease using genome-wide association study data from two different populations

Behçet's disease (BD) is a multi-system inflammatory disorder of unknown etiology. Two recent genome-wide association studies (GWASs) of BD confirmed a strong association with the MHC class I region and identified two non-HLA common genetic variations. In complex diseases, multiple factors may target different sets of genes in the same pathway and thus may cause the same disease phenotype. We therefore hypothesized that identification of disease-associated pathways is critical to elucidate mechanisms underlying BD, and those pathways may be conserved within and across populations. To identify the disease-associated pathways, we developed a novel methodology that combines nominally significant evidence of genetic association with current knowledge of biochemical pathways, protein-protein interaction networks, and functional information of selected SNPs. Using this methodology, we searched for the disease-related pathways in two BD GWASs in Turkish and Japanese case-control groups. We found that 6 of the top 10 identified pathways in both populations were overlapping, even though there were few significantly conserved SNPs/genes within and between populations. The probability of random occurrence of such an event was 2.24E-39. These shared pathways were focal adhesion, MAPK signaling, TGF-β signaling, ECM-receptor interaction, complement and coagulation cascades, and proteasome pathways. Even though each individual has a unique combination of factors involved in their disease development, the targeted pathways are expected to be mostly the same. Hence, the identification of shared pathways between the Turkish and the Japanese patients using GWAS data may help further elucidate the inflammatory mechanisms in BD pathogenesis.

Left main coronary artery thrombosis revealing angio-Behçet syndrome

Although acute myocardial infarction commonly results from coronary atherothrombosis, there are several other etiologies that should be taken initially into account, especially in young adults without significant atherosclerotic risk factors. Thrombophilia and coronary arteritis are, in this context, examples of etiologies that should be looked after. Through this article, we present a case of Behçet's disease with arterial involvement diagnosed after myocardial infarction resulting from thrombosis of the left main coronary artery in a 38-year-old young man without any particular past medical history.

Behçet's disease, echocardiographers, and cardiac surgeons: together is better

Behçet's disease is an inflammatory disorder of unknown etiology, characterized by recurrent oral aphthous ulcers, genital ulcers, uveitis, and skin lesions. Many abnormal echocardiographic findings have been previously reported in patients with Behçet's disease. Some of these; namely, aortic root dilation, aortic valve regurgitation, intracardiac thrombi, and pulmonary artery aneurysm may precede other manifestations of the disease and occasionally require surgical intervention for proper management. Compared to patients without Behçet's disease, management of these complications in patients with the disease is challenging and requires different treatment strategies. If diagnosis of Behçet's disease is missed prior to surgical intervention, higher incidence of surgical failure, recurrence, and even higher postoperative mortality may occur. In this review, the author discusses these major cardiac complications of Behçet's disease.

Insertion/deletion polymorphism of the ACE gene increased risk of Behcet disease: evidence from a meta-analysis

BACKGROUND AND OBJECTIVES

Endothelial dysfunction has a role in the development of the Behcet disease (BD). Local renin-angiotensin system (RAS) plays a crucial role in the endothelial control, and angiotensin-converting enzyme (ACE) is the monitoring component of the RAS. We investigated the relationship between the ACE Ins/Del (I/D) variants and the risk of BD.

DESIGN AND SETTINGS

A meta-analysis was conducted from all published studies on the associations be.tween the ACE I/D polymorphism and BD.

METHODS

We systemically searched all published studies from PubMed and EMBASE, and data were quantitatively synthesized. Pooled odds ratios (ORs) and 95% confidence intervals (95% CIs) were calculated for allele, homozygous, heterozygous, and combined genetic models.

RESULTS

Out of 5 eligible studies, 676 healthy controls and 534 BD cases were included in the present meta.analysis. D allele carrier was significantly associated with increased BD risk (D vs I: P=.002; OR=1.321, 95% CI=1.111-1.570). Homozygous mutant DD genotype also revealed 1.5-fold increased risk (DD vs II; P=.004; OR=1.573, 95% CI=1.156-2.141). In addition, the dominant genetic model demonstrated an increased risk of developing BD (DD vs II+ID: P=.001; OR=1.610, 95% CI=1.242-2.087).

CONCLUSION

The current study suggests that ACE gene polymorphism (Ins/Del) contributes an increased susceptibility to BD. However, larger studies with stratified case control population and biological characterization are needed to validate this finding.

Behçet's Disease and Intracardiac Thrombosis: A Report of Three Cases

We present three patients with Behçet's disease associated with intracardiac thrombus and pulmonary vascular involvement. One of these patients had also Budd-Chiari syndrome. All patients were treated with corticosteroid plus monthly intravenous cyclophosphamide as first line treatment and with no recurrences. Immunosuppressive therapy was successful in the treatment of intracardiac thrombus and also in the regression of pulmonary vascular thromboses in these patients. Intracardiac thrombus in Behçet's disease is rarely seen. Behçet's disease should be remembered in the differential diagnosis of the patients with intracardiac mass, especially in patients from the Mediterranean and Middle East populations.

Behçet's disease: new insight into the relationship between procoagulant state, endothelial activation/damage and disease activity

BACKGROUND

Behçet disease (BD) is associated with a prothrombotic state of unknown origin that may lead to life-threatening events. Calibrated Automated Thrombogram (CAT) and Rotational Thromboelastometry (ROTEM) are two global haemostasis assays that may reveal new insights into the physiopathological mechanisms of the disease and its procoagulant condition.

METHODS

23 BD patients who had no signs or symptoms of current thrombosis and 33 age- and sex-matched controls were included in the study. We performed ROTEM and CAT tests and assessed erythrocyte count, platelet count, platelet contribution to clot formation and plasma levels of tissue-type plasminogen activator, plasminogen activator inhibitor type 1 (PAI-1), fibrinogen, C-reactive protein (CRP), thrombin-antithrombin III complex (TAT), D-dimer and E-selectin (ES).

RESULTS

Both ROTEM and CAT tests showed a hypercoagulable state in the BD patients. Plasma levels of PAI-1, fibrinogen, TAT, CRP and ES were significantly increased in this group compared to controls. The disease activity (DA) was significantly correlated with levels of ES and the maximum clot firmness, and this last one, in turn, correlated with rising levels of ES, PAI-1, CRP and fibrinogen. CAT parameters did not correlate with DA or ES.

CONCLUSIONS

Both ROTEM and CAT tests reveal that patients with BD have a procoagulant state even in the absence of thrombosis. ROTEM test indicates that increased levels of fibrinogen and PAI-1 may be involved in the prothrombotic state of this pathology, while platelets do not significantly contribute. Moreover, CAT assay demonstrate that plasma from BD patients is able to generate more thrombin than controls in response to the same stimulus and that this effect is independent of the DA and the endothelial impairment suggesting the involvement of another factor in the hypercoagulable state observed in BD patients. This study also shows that endothelium activation/damage may be a contributing factor in both the procoagulant and clinical conditions of BD, as shown by the direct correlation between ES levels, ROTEM parameters and DA.

JAK2 (V617F) mutation is not associated with thrombosis in Behcet syndrome

The Janus kinase 2(V617F) (JAK2 (V617F)) mutation is an acquired genetic defect that is considered to enhance thrombosis in Philadelphia chromosome-negative myeloproliferative neoplasms (MPNs). Thrombosis is also a well-defined component of Behcet syndrome (BS). The aim of this study was to determine the frequency of JAK2 ( V617F ) mutation in BS-associated thrombosis. A total of 152 patients with BS (62 with thrombosis and 90 without thrombosis) were enrolled. An additional 186 patients with MPNs and 107 healthy blood donors were included to serve as diseased and healthy controls, respectively. None of the patients with BS and healthy controls carried the JAK2 (V617F) mutation, whereas 67% of patients with MPNs were positive for JAK2 ( V617F ). The frequency of thrombosis in patients with MPNs was not statistically different between carriers and non-carriers of JAK2 ( V617F ) mutation. Our data suggest that JAK2 (V617F) is not directly related to thrombosis in MPNs and in other thrombotic entities, such as BS.

Recurrent pseudotumor cerebri in childhood: a case of neuro-Behçet disease complicated with thrombotic risk factors

Pseudotumor cerebri with or without venous sinus thrombosis is a rare clinical presentation of Behçet disease in childhood. We present here a case of childhood pseudotumor cerebri without a previous diagnosis of Behçet disease. The detailed history and physical examination of the case led to the diagnosis of neuro-Behçet disease. The investigation of predisposition to thrombosis revealed heterozygous factor V Leiden mutation along with the high lipoprotein(a) level. The symptoms resolved dramatically by treatment with the combination of immunosuppression and anticoagulation with regard to the detected factor V Leiden mutation and high lipoprotein(a) level. After a symptom-free period of 9 months, the cerebral vein thrombosis recurred. We present this case to draw attention to this rare cause of pseudotumor cerebri in childhood and to emphasize the importance of additional thrombotic risk factors regarding the potential recurrence of thrombotic events in Behçet disease.

Hyperhomocysteinaemia in Behçet's Disease

Objectives. The aim of this study was to investigate if hyperhomocysteinaemia is a contributive risk factor for the pathogenesis and the activity of Behçet's disease (BD). Design and Methods. Fifty four patients fullfiling the criteria of the International Study Group for BD were enrolled. Fifty healthy volunteers matched for age and sex with the BD group were included as a negative control group. Patients, with any condition that might affect plasma homocysteine concentration, were excluded. Results. Mean serum homocysteine concentration was significantly higher in patients with BD than in the healthy controls (P < .001), in patients with active disease (P = .04), and in masculine gender (P = .05). There was no significant difference between homocysteine level and clinical involvement. Conclusions. We demonstrated that plasma total homocysteine level (tHcy) is increased in BD and correlated with disease activity. No association was found between homocysteine levels and clinical involvement.

[Multiple arterial thrombosis in Behçet's disease]

Behcet's disease (BD) is a multisystemic vasculitis. Its etiopathogeny remains unknown. Vascular involvement in BD is frequent and venous thrombosis is the most common manifestation (30% of cases). Arterial involvement is rare (2.7 to 7%). The latter is often severe and considered as a life threatening complication. Pathogenesis of thrombosis occurring in BD remains unclear. We report a 45-year-old man, from south of Tunisia, who presented a BD with a bifocal arterial involvement: right internal carotid thrombosis and bilateral proximal thrombosis of the two pulmonary arteries. Therapeutic strategies to address this multiple arterial involvement and the pathogenesis of thrombosis raise many questions.

Behçet's Disease as a Model of Venous Thrombosis

Behçet's disease (BD) is a chronic inflammatory disease of unknown aetiology characterized by recurrent oral, genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in BD. The frequency of vascular lesions in BD, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%. In this review, various factors of thrombogenesis in BD, particularly pro- and antithrombotic endothelial and non-endothelial factors, factors of coagulation, platelet activation and rheological changes are presented and discussed from positions of Virchow's triad of venous thrombosis. Despite advances in understanding of thrombogenesis in BD, still many issues of diagnosis and targeted preventive and therapeutic measures remain unresolved. Further studies are needed to clarify the pathobiology of BD-related thrombosis and to provide the clinicians with recommendations over the utility, safety and effectiveness of the antithrombotic therapy in BD.

Behçet’s Disease as a Model of Venous Thrombosis

Behçet’s disease (BD) is a chronic inflammatory disease of unknown aetiology characterized by recurrent oral, genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in BD. The frequency of vascular lesions in BD, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%.

In this review, various factors of thrombogenesis in BD, particularly pro- and antithrombotic endothelial and non-endothelial factors, factors of coagulation, platelet activation and rheological changes are presented and discussed from positions of Virchow’s triad of venous thrombosis.

Despite advances in understanding of thrombogenesis in BD, still many issues of diagnosis and targeted preventive and therapeutic measures remain unresolved. Further studies are needed to clarify the pathobiology of BD-related thrombosis and to provide the clinicians with recommendations over the utility, safety and effectiveness of the antithrombotic therapy in BD.

Dermatological features in Behçet disease-associated vena cava obstruction

BACKGROUND

Behçet disease (BD) is a multisystemic disorder that is classified as vasculitis and can affect all types and sizes of blood vessels. Although vascular diseases are not regarded as essential for a diagnosis of BD, vascular complications can be fatal.

OBJECTIVES

The purpose of this study was to examine the clinical characteristics of 14 patients with BD accompanied by an obstruction of the superior vena cava (VC), the inferior VC, or both, and then determine the dermatological features that indirectly suggest VC obstructions in patients with BD.

METHODS

Among the 3500 patients registered at the BD Specialty Clinic of Severance Hospital from 1997 to 2006, 14 patients were diagnosed with BD-associated VC obstructions. Their medical records were reviewed.

RESULTS

Nine of the 14 patients with BD were male, and the age range for disease onset was 11-46 years. Computed tomography revealed superior VC thrombosis in seven patients, inferior VC thrombosis in four patients, and the involvement of both in three patients. The most prominent features in superior VC obstruction were facial oedema (n = 7, 50%) and neck vein distension (n = 6, 43%). Other features included dilated veins in the chest wall, upper body oedema, proptosis, and upper extremity swelling. Patients with an inferior VC obstruction commonly had dilated veins on the abdominal walls. These patients also had abdominal distension and lower extremity swelling. Corticosteroids, colchicine, immunosuppressants, and anticoagulants with or without heparinization were the most common treatment regimens giving good response. Attempts to treat patients with a high dose of steroid pulse therapy were ineffective. Ballooning venoplasty was a useful therapeutic modality for VC thrombosis during the early stage, although this procedure could not be performed in patients with BD with severe thrombosis.

CONCLUSIONS

Several cutaneous features of VC obstruction should be recognized in patients with BD. Early detection might permit an early diagnosis and treatment of occlusion of the VC.

[Retinal venous occlusion in Behçet disease]

PURPOSE

The aim of our study is to report three cases of retinal venous occlusion in patients with Behçet disease and to discuss the physiopathology of this vascular accident.

METHODS

In this retrospective study, out of a series of 32 patients suffering from Behçet disease, we report three cases of retinal venous occlusion. General and ophthalmologic features are described. Treatment strategy is detailed for each case.

RESULTS

There were 2 cases of branch retinal venous occlusion and one case of central retinal venous occlusion. Relapses and retinal neovascularization were the most common complications.

CONCLUSION

The retinal venous occlusion in Behçet's disease is a non-common but severe complication. Early and appropriate treatment is required to improve the functional prognosis.

Intima-media thickness and arterial stiffness of carotid artery in Korean patients with Behçet's disease

Behçet's disease (BD) is a systemic vasculitis involving diverse sizes of arteries and veins. We performed this study to evaluate the vascular changes by assessment of the arterial stiffness and intima-media thickness (IMT) of carotid artery in Korean patients with BD. Forty-one patients with BD and age-, and sex-matched 53 healthy subjects were recruited in this study. Carotid arterial stiffness and IMT were assessed by using high-resolution B-mode ultrasonography. Arterial stiffness parameters such as carotid arterial distensibility coefficient, stiffness index, and incremental elastic modulus (E(inc)) were significantly increased in BD patients compared with those in healthy subjects, but not in IMT. Positive relationship was noted between age and IMT, whereas age of onset was significantly associated with arterial stiffness in BD. This finding suggests impaired endothelial function before visible structural changes of arterial wall in BD. Age and age of onset may be an independent risk factor for carotid IMT and arterial stiffness, respectively. Further studies in more large populations are required to confirm our results.

Homocysteine: An activity marker in Behçet's disease?

BACKGROUND

Behçet's disease (BD) is a chronic multisystem inflammatory disorder commonly complicated by vascular thrombosis.

OBJECTIVE

In this study, we investigated whether hyperhomocysteinaemia, being a well known risk factor for atherothrombogenesis, is also a contributive risk factor for the pathogenesis and the activation of Behçet's disease.

METHODS

Sixty-four patients fulfilling the criteria of the International Study Group for Behçet's disease (48 males, 16 females, 33+/-8 years) were enrolled. They were separated into two groups with respect to activation features of Behçet's disease. Additionally, we collected the blood samples from 13 patients with BD in both active stage and in inactive stage. Twenty-six healthy individuals were included as a negative control group. Serum total homocysteine (Hcy) levels were determined by chemiluminescence immunoassay.

RESULTS

Mean serum homocysteine concentrations in total BD patients were significantly higher than in the healthy controls (11.7+/-4.6 versus 8.7+/-2.8micromol/L, p<0.01). Mean serum homocysteine concentrations in the active patients were significantly higher than in the inactive patients and the healthy controls (13.3+/-3.6; 10.8+/-5.0; 8.7+/-2.8micromol/L, respectively) (p<0.05 and p<0.001, respectively). There was no significant difference between the patients with inactive disease and the healthy controls. When the active and the inactive stage of 13 patients with BD were compared, we found that mean serum total homocysteine levels were higher in the active stage than in the inactive stage (p<0.05).

CONCLUSION

Hyperhomocysteinaemia may be responsible for the endothelial damage in BD and assumed to be a risk factor and a marker for activation of BD.

Decreased protein S activity is related to the disease activity of Behcet's disease

We wanted to see whether the active inflammation in Behcet's disease (BD) can cause a thrombotic disorder by decreasing the protein S (PS) activity, and we evaluated the relationship between the decreased PS activity and the disease activity of BD. We included 122 patients with BD whose PS activity levels were measured. In 51 patients, the PS activity was measured again when there were changes in the number of items of "The Behcet's Disease Current Activity Form (BDCAF)". The thrombosis rate was 2.5% (3/122), and the PS activity was low in all three of the patients with thrombosis. The incidence of low PS activity in the total 122 BD patients was 27% (33/122). The incidence of the low PS activity in the active BD patients was 33.7% (31/92), and this was significantly more frequent than in the inactive BD patients, (6.7%, 2/30) (chi(2)-test, P value = 0.0038). The decrease of PS activity had good correlation with the increase of the number of BDCAF items (r = -0.351, P value = 0.012). The PS activity decrease is related to the BD activity. The low PS activity can be the risk factor for thrombotic disorder and also the activity marker for BD and other inflammatory diseases.

Myocardial infarction and deep venous thrombosis in a young patient with Behçet disease

Behçet disease (BD) is a chronic relapsing systemic vasculitic disorder affecting the arteries, veins, and vessels of any size. Vascular lesions in BD usually represent an occlusive nature suggesting a hypercoagulable/ prothrombotic state. Coronary arteries are rarely involved in BD. In this report, a 27-year-old male patient in whom myocardial infarction developed secondary to coronary arterial thrombosis together with deep venous thrombosis was presented. This is a review of the pathologic hemostasis and the prothrombotic state of BD.

Characteristics of vascular involvement in Behçet's disease

OBJECTIVE

Behçet's disease (BD) is a multisystemic inflammatory disorder classified among the vasculitides, which can affect all types and sizes of blood vessels. Vascular involvement may be seen in 25-50% of BD patients. In this study, we examined the characteristics of vascular involvement in patients with BD.

METHODS

One hundred and eighty patients with BD were included in the study. The diagnosis of vascular involvement was made on clinical signs, by Doppler ultrasonography and/or angiography using computed tomographic or magnetic resonance techniques where appropriate. Detailed clinical characteristics were recorded for each patient.

RESULTS

Seventy-one patients (39.4%) had vascular involvement. In patients with vascular lesions, the frequency of male sex was significantly higher than in patients without vascular lesions (89.8% vs. 63.3%, respectively; p < 0.001). Of 71 BD patients with vascular involvement, 68 had venous lesions (95.8%). Three patients had arterial lesions without venous thrombosis. Eleven patients had arterial involvement with venous thrombosis. The most frequent type of vascular involvement was deep venous thrombosis in the lower extremities (n = 56, 78.9%). There was a significant association between deep venous thrombosis and superficial thrombophlebitis (r = 0.325, p < 0.01). Twenty-four patients (33.8%) had vena cava thrombosis and two had vena hepatica thrombosis. In patients with vascular involvement, the frequency of erythema nodosum was significantly higher (p = 0.001) and the frequency of ocular involvement was significantly lower (p < 0.05) than in patients without vascular involvement.

CONCLUSION

Our study illustrates the frequency and significance of vascular involvement in BD.

Morphologic evidence of subclinical atherosclerosis obtained by carotid ultrasonography in patients with Behcet’s disease

Subclinical atherosclerosis can be demonstrated by measuring the intima-media thickness (IMT) of the carotid arteries by high-resolution B-mode ultrasonography (US). Endothelial injury appears a key event in the atherogenesis. Endothelial cell activation and/or injury are the characteristic features of Behçet's disease (BD). In this study, we investigated morphologic evidence of subclinical atherosclerosis in the BD patients by using high-resolution B-mode US. Thirty-four patients with BD without arterial involvement (male/female 21/13; mean age 34.6+/-8.5 years) were individually matched to control subjects on the basis of age (within 2 years) and sex. Subjects with diabetes mellitus, hypertension, evidence of myocardial infarction or cerebrovascular disease, and patients on long-term steroids (i.e., >6 months) were excluded from the study. Mean IMT values of the right carotid arteries were 0.81+/-0.17 mm for patients with BD, and 0.54+/-0.13 mm for healthy controls (P<0.001). Mean IMT values of the left carotid arteries were 0.82+/-0.16 mm for patients with BD, and 0.55+/-0.12 mm for healthy controls (P<0.001). The overall prevalence of carotid atherosclerotic plaques was higher among the patients than the controls [prevalence of plaques were 17.6% (6/34) in BD patients and 0% in healthy controls, P<0.05]. In conclusion, our data indicate morphologic evidence of subclinical atherosclerosis in patients with BD.

Constitutional trisomy 8 mosaicism with myelodysplastic syndrome complicated by intestinal Behcet disease and antithrombin III deficiency

Trisomy 8 is the most common acquired chromosomal abnormality associated with myeloid malignancy. As a constitutional trisomy 8 mosaicism (T8M), it exhibits an extremely variable phenotype. In addition, Behcet disease (BD) has been reported as an unusual complication of myelodysplastic syndrome (MDS). To our knowledge, 12 case reports of various hematologic malignancies in patients with T8M and 18 case reports of MDS with acquired trisomy 8 complicated by BD have been published to date. We report a case of constitutional T8M with MDS complicated by intestinal BD and antithrombin III deficiency.

Haemorheological alterations in Behçet's disease are not related to a tendency for venous thrombosis

INTRODUCTION

Behçet's disease is associated with an increased risk of thrombosis, although the prothrombotic mechanisms are unclear. Alterations in blood rheology, particularly increased erythrocyte aggregation, might play a role in the development of such thrombotic events.

MATERIALS AND METHODS

We measured plasma lipids, fibrinogen, haematocrit, erythrocite aggregation, erythrocyte deformability, blood viscosity, plasma viscosity and erythrocyte indexes in patients with a nonactive disease at sampling, and in a well-matched control group. The patient group comprised 42 patients with BD (21 male, 21 female aged 43+/-12 years) and the control group comprised 46 healthy volunteers (23 male, 23 female aged 45+/-13 years). Twelve of the 42 patients with BD had a previous documented history of deep vein thrombosis at least 6 months before entering the study, and the other 30 did not.

RESULTS

Compared with controls, patients showed statistically higher fibrinogen concentrations (P=0.001), plasma viscosity (P=0.002), blood viscosity (P=0.006) and erythrocyte aggregation, both at stasis (P=0.001) and at a low shear rate (P=0.002): the other rheological parameters were not statistically significant. No differences were observed in the rheological parameters when patients with and without previous thrombotic episodes were compared.

CONCLUSIONS

Although patients with BD show a moderate hyperviscosity syndrome, possibly related to chronic inflammation, this does not seem to play a role in the development of thrombotic events.

Long-term outcome after surgical treatment of arterial lesions in Behçet disease

OBJECTIVE

Surgical treatment of arterial lesions associated with Behçet disease (BD) is often complicated by graft occlusion and recurrence of aneurysms. The purpose of this study was to clarify the long-term outcome of surgical intervention for arterial involvement in BD.

METHODS

Ten patients with BD (9 men, 1 woman) who underwent surgical treatment for arterial aneurysms between 1980 and 2004 were included in the study. The age of patients at the first operation ranged from 36 to 69 years (mean, 50.4 +/- 9.0 years). The mean period between the onset of BD and that of arterial manifestations was 8.0 +/- 5.0 years. We retrospectively reviewed their postoperative courses, including survival, graft occlusion, formation of anastomotic false aneurysms, and the development of aneurysms at different sites. The Kaplan-Meier method was used to calculate the chronologic incidence of complications after surgery.

RESULTS

The mean follow-up period was 133 +/- 92 months, ranging from 5 to 285 months. One patient died of rupture of a dissecting aortic aneurysm after undergoing several surgical interventions for multiple aneurysms. There were five graft occlusions among 21 grafts. The cumulative primary graft patency rate in the infrainguinal region was 83.9% at 3 years. Five anastomotic false aneurysms formed among 49 anastomoses between grafts and host arteries. The overall cumulative incidence of formation of anastomotic pseudoaneurysm was 12.9% at 5 and 10 years. All of them formed within 18 months after surgery. Development of new aneurysms in different arteries was observed in two patients.

CONCLUSIONS

Early occurrence of anastomotic false aneurysm is characteristic of BD. Further investigation is necessary to establish effective postoperative treatment.

Endothelial functions in Behçet’s disease

Behçet's disease (BD) is a systemic vasculitis, capable of involving all types of vessels. Endothelial dysfunction (ED) has been previously documented in BD. The aim of the study was to see whether ED was more prominent in Behçet's patients with vascular involvement (VI) than in those without. The study population consisted of 65 patients with BD, 27 of whom had VI, and 30 healthy controls. High-resolution ultrasound was used to measure endothelium-dependent vasodilatation (EDVD) of brachial artery. Overall, regardless of VI, EDVD was significantly impaired in patients with BD compared with controls (11.4 +/- 6.3 vs 20.4 +/- 9.1%,P = 0.001); however, EDVD was similar in BD patients with and without VI (9.7 +/- 6.3% vs 12.6 +/- 6.1%, P = 0.07). Patients with BD had significantly-higher plasma homocysteine levels than controls (13 +/- 6 micromol/L vs 9 +/- 3 micromol/L, P = 0.001). Plasma homocysteine levels were significantly higher in the subgroup with VI than in those without (15 +/- 7 micromol/L vs 12 +/- 4 micromol/L, P = 0.03); however, we found no positive/significant correlation between plasma homocysteine levels and EDVD. ED is a constant feature of BD, regardless of VI. Etiology of ED in BD is probably multifactorial, including high homocysteine levels. As both ED and elevated homocysteine levels may represent an early atherosclerotic process, a more structured approach to risk factor assessment is needed in BD.

Successful treatment with stent angioplasty for Budd-Chiari syndrome in Behçet's disease

Budd-Chiari syndrome (BCS) is a very rare vascular complication of Behçet's disease (BD) which often leads to death as a result of portal hypertension and liver failure. We report a 45-year-old BD patient who presented with BCS. Diagnosis was confirmed with CT scan and contrast-enhanced MR angiography which showed ascites, short-segment stenosis of the inferior vena cava (IVC), and middle and left hepatic venous thrombosis. Percutaneous transluminal angioplasty (PTA) of the obstructed segment in the IVC was performed and resulted in dramatic reduction of portal venous pressure. Our experience indicates that PTA may be a safe and effective therapeutic modality for BCS in BD which is caused by short segmental obstruction of the IVC.

Vascular manifestations of Behçet's disease. Eighteen cases among 140 patients

OBJECTIVES

To describe the features, prognosis, and treatment of vascular involvement in Behçet's disease (BD).

PATIENTS

Among 140 patients with BD seen at the Hôtel-Dieu Hospital in Beirut between 1980 and 2000, 18 (13%) had vascular involvement and were included in this retrospective study. All these patients fulfilled International Study Group criteria for BD.

RESULTS

Men with BD were more likely to have vascular involvement (13/77, 17%) than women (5/63, 8%) (P = 0.12) and were younger at diagnosis of vascular disease (32 +/- 7 vs. 36 +/- 7.5 years; P < 0.01). Many patients had vascular disease at more than one site: 17 had thrombophlebitis, 10 had arterial thromboses, and one had an aneurysm. Thrombophlebitis was more common in men (82% vs. 18%; P < 0.03) and arterial occlusion in women (70% vs. 30%; P > 0.05). Caval thrombosis and arterial occlusions were the most serious complications. Combined treatment with glucocorticoids, anticoagulants, and immunosuppressants was effective in superior vena cava syndrome and extracranial arterial occlusion.

CONCLUSION

Vascular manifestations of BD are common in Lebanon, particularly venous lesions. Aneurysms are seen less often than arterial occlusions. Medical treatment may be sufficient in superior vena cava syndrome and arterial occlusion.

Hyperhomocysteinaemia is associated with uveitis but not with deep venous thrombosis in Behçet's disease

Plasma homocysteine was assessed in Behçet's disease (BD) patients in order to determine the prevalence of hyperhomocysteinaemia in BD and to test its association with clinical manifestations of the disease. The study included 59 patients with BD and 118 age- and sex-matched healthy subjects. Plasma homocysteine, vitamin B

Serum homocysteine level is higher in Behçet’s disease with vascular involvement

OBJECTIVE

Behçet's disease (BD) is a multisystemic inflammatory disorder of unknown etiology that is sometimes associated with thrombosis. However, the mechanism of hypercoagulability is not known. In this study, we investigated whether hyperhomocysteinemia, being a well-known risk factor for thrombosis, is also a contributing risk factor to venous and arterial thromboses of BD.

METHODS

Forty-five patients with BD and 40 healthy subjects were included in the study. Sixteen patients had vascular involvement. Serum homocysteine levels were determined by fluorescence polarization immunoassay.

RESULTS

In male patients, the frequency of vascular involvement was significantly higher than in females (46.7% vs 13.3%, P < 0.05). Serum homocysteine levels were significantly higher in patients with BD than healthy controls (P < 0.01), in patients with vascular involvement than those with mucocutaneous involvement (P < 0.01) and healthy controls (P = 0.001), and in male patients than in female patients (P < 0.001). There was no significant difference in homocysteine levels between the BD patients with mucocutaneous involvement and healthy subjects. In multiple regression analysis, serum homocysteine level was independently associated with thrombosis (odds ratio 1.29, P < 0.01), but male sex was not.

CONCLUSIONS

This preliminary study suggests that elevated serum homocysteine levels may play some role in the development of venous and arterial thromboses in BD.