Clinical analysis of Behçet disease: arthritic manifestations in Behçet disease may present as seronegative rheumatoid arthritis or palindromic rheumatism

Incidence and risk of developing rheumatic diseases in 19,724 patients with palindromic rheumatism in South Korea: A nationwide population-based study

OBJECTIVES

The spectrum of progression of palindromic rheumatism (PR) to chronic diseases is quite variable. Hence, this study aimed to investigate the incidence and risk of developing rheumatic diseases in PR using nationwide, population-based medical claims data from Korea.

METHODS

We assessed the incidence rate (IR) of PR in the population in the given year. After matching individuals with PR with those without PR (1:10) for age, gender, and the index year, we calculated the hazard ratios (HRs) with 95% confidence intervals (CIs) using the Cox proportional hazard model.

RESULTS

A total of 19,724 newly diagnosed incident PR cases were identified from 2010 to 2016. The mean age was 50.2±14.9 years. The incidence of PR was 7.02 (95% CI 6.92-7.12) per 100,000 person-years (6.22 and 7.80 in men and women, respectively). During observation, 8.79% patients with PR and 0.30% individuals without PR developed various outcome diseases. Patients with PR had an increased risk of seropositive rheumatoid arthritis (HR 46.51, 95% CI [41.05-52.69]), psoriatic arthritis (44.79 [15.16-132.35]), systemic lupus erythematosus (24.53 [16.15-37.24]), mixed connective tissue disease (22.01 [7.65-63.34]), Behçet's disease (21.04 [13.81-32.06]), Sjögren's syndrome (12.36 [8.54-17.88]), ankylosing spondylitis (9.00 [6.67-12.15]), dermatomyositis/polymyositis (6.14 [2.55-14.82]), and systemic sclerosis (3.75 [1.47-9.58]) compared with individuals without PR.

CONCLUSIONS

This nationwide, population-based cohort study demonstrated that about one-eleventh of patients with PR eventually develop systemic rheumatic diseases and that patients with PR have an increased risk of developing various rheumatic diseases including seropositive rheumatoid arthritis.

Imaging of Joints and Bones in Autoinflammation

Autoinflammatory disorders are commonly characterized by seemingly unprovoked systemic inflammation mainly driven by cells and cytokines of the innate immune system. In many disorders on this spectrum, joint and bone involvement may be observed and imaging of these manifestations can provide essential diagnostic information. This review aimed to provide a comprehensive overview of the imaging characteristics for major diseases and disease groups on the autoinflammatory spectrum, including familial Mediterranean fever (FMF), Behçet disease (BD), crystal deposition diseases (including gout), adult-onset Still's disease (AoSD), and syndromatic synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO)/chronic recurrent multifocal osteomyelitis (CRMO). Herein, we discuss common and distinguishing imaging characteristics, phenotypical overlaps with related diseases, and promising fields of future research.

A case with Behçet's disease involving erosive Metacarpophalangeal joint arthritis: the value of ultrasonography in the diagnosis of an Erosion

Background

Behçet’s disease (BD) is a chronic multisystemic vasculitis that may emerge with musculoskeletal system involvements, oral-genital recurrent aphthae, mucocutaneous lesions, and ocular symptoms. Arthritis in BD is usually non-erosive and not related to crippling disease. Erosive arthropathy is a very rare manifestation of BD.

Case presentation

Herein, we present a 60-year-old male patient suffering from BD for 33 years with erosive arthritis in his second metacarpophalangeal joint. After we assessed his finger by X-ray, we diagnosed erosive arthropathy quickly by musculoskeletal ultrasonography. In addition, a systematic literature search was performed via the PubMed and Scopus databases using the keywords, ‘Behçet’s disease [AND] erosive/destructive arthritis’.

Conclusions

Erosive arthritis due to BD can be evaluated by ultrasonography in an easy, fast and cost-effective manner. The literature search between 1985 and December 2019 revealed a total of 19 patients with peripheral erosive arthropathy related to BD and the characteristics of the results are summarized in the paper.

Long-term effectiveness and safety of secukinumab for treatment of refractory mucosal and articular Behçet's phenotype: a multicentre study

OBJECTIVE

To evaluate the effectiveness and safety of secukinumab in patients with a mucosal and articular Behçet's phenotype resistant to conventional and biologic treatment.

METHODS

A multicentre retrospective study was performed on 15 patients with a mucosal and articular phenotype of Behçet's syndrome fulfilling the International Criteria for Behçet's Disease and refractory to treatment with colchicine, disease-modifying antirheumatic drugs and at least one antitumour necrosis factor-α agent. Minimum follow-up was set at 6 months. Six patients with a polyarticular involvement were treated with secukinumab 300 mg/month, while all other cases received secukinumab 150 mg/month. Dose increase from 150 to 300 mg per month and shortening of administration frequency were allowed for poor disease control. Response evaluation was based on the number of oral ulcers in the previous 28 days and Disease Activity Score-28 for articular manifestations.

RESULTS

At 3 months of follow-up, nine (66.7%) patients achieved a response (complete or partial), and this proportion further increased to 86.7% at 6 months, 76.9% at 12 months, 90.0% at 18 months and 100.0% after 24 months. Notably, all patients who started with secukinumab 300 mg/month achieved complete response by month 6. Seven (46.7%) patients could achieve a response only after switching to a higher dosage.

CONCLUSIONS

Our study suggests that secukinumab at a dose of 150 and 300 mg per month is safe and effective for the long-term treatment of patients with Behçet's syndrome with a mucosal and articular phenotype refractory to previous treatments. Notably, secukinumab 300 mg/month resulted in superior complete mucosal and articular responses with no serious or dose-related adverse effects.

Exercise effectiveness of arteriovenous fistula maturation in chronic renal patients: A systematic review with meta-analysis

Aims:

The purpose of this research is to evaluate the effectiveness of upper limb exercises to improve arteriovenous fistula maturation in patients with chronic kidney disease.

Methods:

A bibliographic search was carried out from February to August 2015 in the following databases: PUBMED, CINAHL, Web of Science, SCOPUS, LILACS, SCIELO and CENTRAL.

Results:

Three studies were included, involving 134 participants (total). According to the total effect estimation, a mean difference of 0.36 (-0.95–1.67) was found for vein diameter, meanwhile a mean difference of 107.87 (-3.90–219.64) was found for blood flow.

Conclusion:

It was not possible to determine the effect size of the treatment due to a high bias risk of all included studies. Given this, the available evidence is still insufficient to support the prescription of upper limb exercises in order to improve arteriovenous fistula maturation. Therefore, randomised and controlled clinical trials monitored by methodological rigour should be developed in order to verify if the AVF maturation process can be evidenced through exercise.

The effect of two different hand exercises on grip strength, forearm circumference, and vascular maturation in patients who underwent arteriovenous fistula surgery

Objective

To compare the effect of two different hand exercises on hand strength and vascular maturation in patients who underwent arteriovenous fistula surgery.

Methods

We recruited 18 patients who had chronic kidney disease and had undergone arteriovenous fistula surgery for hemodialysis. After the surgery, 10 subjects performed hand-squeezing exercise with GD Grip, and other 8 subjects used Soft Ball. The subjects continued the exercises for 4 weeks. The hand grip strength, pinch strength (tip, palmar and lateral pinch), and forearm circumference of the subjects were assessed before and after the hand-squeezing exercise. The cephalic vein size, blood flow velocity and volume were also measured by ultrasonography in the operated limb.

Results

All of the 3 types of pinch strengths, grip strength, and forearm circumference were significantly increased in the group using GD Grip. Cephalic vein size and blood flow volume were also significantly increased. However, blood flow velocity showed no difference after the exercise. The group using Soft Ball showed a significant increase in the tip and lateral pinch strength and forearm circumference. The cephalic vein size and blood flow volume were also significantly increased. On comparing the effect of the two different hand exercises, hand-squeezing exercise with GD Grip had a significantly better effect on the tip and palmar pinch strength than hand-squeezing exercise with Soft Ball. The effect on cephalic vein size was not significantly different between the two groups.

Conclusion

The results showed that hand squeezing exercise with GD Grip was more effective in increasing the tip and palmar pinch strength compared to hand squeezing exercise with soft ball.

Behçet's disease with severe destructive arthritis

Abstract Behçet's disease is a systemic disease characterized by oral aphta, genital ulcers, and ocular lesions, and arthritic manifestations also appear to be common. However, this disease rarely produces loss of function or deformity in arthritic joints. We report the case of a 52-year-old woman with Behçet's disease who had a history of recurrent oral aphta, genital ulcerations, and intestinal lesions for almost 30 years. When she was about 30 years old, she began to notice significant morning stiffness and polyarthritis, and progressive destructive arthritic changes in the bilateral fingers, wrists, and left ankle. Behçet's disease with severe destructive arthritic changes is rare, and the underlying mechanism is still unknown.

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.

[Skeletal manifestations in Behçet's disease. A report of 79 cases]

PURPOSE

Our aim is to describe the skeletal manifestations of Behcet's disease (BD) among young adults in a military population.

METHODS

We conducted a retrospective study of 176 patients with BD who were followed between 1980 and 2005. All the patients fulfilled the international study group on Behcet's disease diagnostic criteria.

RESULTS

Rheumatic manifestations were noticed in 79 out of 176 patients (45%), ranking second after the skin and mucosal manifestations of the disease. Articular manifestations were the first disease manifestation in 16.5% of the patients. Inflammatory arthralgias were the most common manifestation and observed in 81%, interesting mainly the large lower limb joints. Disease course was acute in most of the patients. Arthritis was less common: oligoarthritis (7.5%), monoarthritis (6.5%) and polyarthritis (5%). Axial involvement was also noted: spine pain in 29%, isolated sacroiliitis in 7.5%, and definite ankylosing spondylitis in 5%.

CONCLUSION

Joint involvement is common in BD and could be the first manifestation of the disease. Most of the patients present with inflammatory arthralgias of the large lower limb joints. Disease course is usually favourable, spontaneously or with treatment. However, in our study population, skeletal manifestations were responsible for significant disability.

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.

Managing the symptoms of Behçet's disease

Behçet's disease (BD) is a chronic, relapsing, systemic inflammatory vasculitis of unknown aetiology with a myriad of immunological and pathological consequences. Patients with BD are clustered along the ancient silk road, extending from Far-East Asia to Turkey. The disease affects both genders of all ages from infants to the elderly. It is a long-term, cyclical disease and such patients may have symptom-free periods of weeks, months or years that are interrupted by exacerbations of varying intensities lasting a few days, weeks or months. Clinical features include oral aphthae, genital ulcers, ocular inflammation, skin lesions, as well as articular, vascular, neurological, pulmonary, gastrointestinal, renal and genitourinary manifestations. The main histopathological finding is a widespread vasculitis of the arteries and veins of any size or thrombophilia according to the site of involvement. BD may start with just one or two small symptoms but other symptoms may gradually appear over the years. Recurrent ocular inflammation, which occurs in approximately 50% of cases, is the major morbidity that may eventually lead to blindness. The treatment of BD is usually symptomatic and palliative. Therefore, the main objectives are to relieve symptoms associated with mucocutaneous lesions and arthritis, to modify the course of the disease, to control inflammatory eye disease, clinically suppress the inflammation and vasculitis, to prevent recurrences and thus, prevent irreversible damage. The choice of treatment is based on the severity of systemic involvement, clinical presentation and the site affected. The preferred treatment modalities are combined drug therapy and include topical therapies as well as systemic corticosteroids, NSAIDs, colchicine, dapsone and immunosuppressive and cytotoxic agents. Such therapies are tailored to the individual patient depending on clinical manifestations. Thalidomide, tacrolimus, IFN-alpha and anti-TNF monoclonal antibody have recently attracted attention as novel therapeutic approaches.

Arthropathy in Behçet disease: MR imaging findings in two cases

Arthropathy is part of the protean manifestations of Behçet disease. Imaging findings reported thus far have been based on those of conventional radiography. Magnetic resonance imaging in two cases of Behçet disease with arthropathy demonstrated synovial thickening and effusion, as well as myositis manifested by high signal intensity on T2-weighted images.

Vasculitides of the gastrointestinal tract

Systemic vasculitides, and especially their gastrointestinal manifestations, are a continuous challenge not only for gastroenterologists and rheumatologists but also for every practising physician. Owing to their chameleon-like appearance, overt clinical symptoms of vasculitides may be restricted to distinct parts of the human body including the intestine. In clinical practice, it is therefore essential to search for the systemic disease underlying the gastrointestinal symptoms such as abdominal pain, bleeding, ileus and necrosis in case vasculitis is suspected or likely as a cause for these sequelae. Classification of intestinal vasculitides is also difficult, since most of the criteria currently used have been established by rheumatologists and, in general, biopsies of the affected vessels cannot be obtained. However, there are increasing data that not only facilitate diagnosis but also allow adequate immunosuppressive and anti-inflammatory therapeutic approaches, which will be outlined in detail in this chapter.