Coexistence of Behçet's disease with ankylosing spondylitis and familial Mediterranean fever: a rare occurrence

A case of familial Mediterranean fever presenting with ankylosing spondylitis: A rare case-report

Key Clinical Message

The association of familial Mediterranean fever and ankylosing spondylitis is rare, but it is essential to consider this diagnosis in patients with a history of FMF who develop symptoms of back pain or other rheumatologic conditions.

Abstract

Familial Mediterranean fever (FMF) is an inherited inflammatory disorder characterized by recurrent fever episodes, abdominal pain, and arthralgia. Ankylosing spondylitis (AS) is a chronic inflammatory disease that affects the spine's joints. The association of FMF and AS is rare. We report the case of a 22-year-old male patient with a history of FMF and a positive family history of FMF in his father, who presented with inflammatory back pain. The patient was found to have sacroiliitis on MRI, which is a characteristic feature of AS. The patient was negative for HLA-B27, a genetic marker often associated with AS. This case report highlights the importance of considering AS in patients with a history of FMF who develop back pain symptoms or other rheumatologic conditions.

Concurrence of familial Mediterranean fever and Behçet's disease: a case report and review of the literature

BACKGROUND

Familial Mediterranean fever and Behçet's disease are distinct disorders that are prevalent in the Mediterranean and Middle Eastern populations. They are characterized by unprovoked inflammatory episodes caused by overexpression of proinflammatory cytokines. Although reported previously, the overlapping presentation of familial Mediterranean fever and Behçet's disease remains uncommon.

CASE PRESENTATION

A 46-year-old Lebanese-Canadian man who presented with recurrent oral and genital ulcers, polyarticular synovitis, ocular swelling, recurrent infections, and fevers was later found to have heterozygous mutations of pathogenic MEFV c.2080A > G (p. Met 694Val) and c.2082G > A (p.Met694IIe) genes indicating familial Mediterranean fever. He was treated with prednisone, colchicine, and azathioprine, with inadequate symptoms control. Treatment was complicated by recurrent infections.

CONCLUSIONS

Our case contributes to the growing literature demonstrating the presentation of predominantly Behçet's disease-like features in the setting of diagnosis of familial Mediterranean fever. These findings emphasize that clinicians should be aware that patients with familial Mediterranean fever may present with Behçet's disease-like clinical manifestations.

Behçet disease, familial Mediterranean fever and MEFV variations: More than just an association

Behçet disease (BD) and familial Mediterranean fever (FMF) are two inflammatory disorders that share many features including historical background, ethnical distribution and inflammatory characteristics. Several studies suggested that BD and FMF might occur in the same individual more commonly than expected. Additionally, the pathogenic MEFV gene variants, especially p.Met694Val, activating the inflammasome complex have been shown to increase the risk for BD in regions where both FMF and BD are prevalent. Whether these variants are associated with certain disease subtypes and whether they may help in the planning of treatment need to be explored. This review provides a recent overview of the plausible association between FMF and BD and the role of MEFV variants in the pathogenesis of BD.

Ankylosing spondylitis occurring in a patient with Behçet disease after chronic brucellosis infection: A case report and review of the literature

Behçet disease and ankylosing spondylitis are rarely seen together. This report presents a rare case of ankylosing spondylitis occurring in a patient with Behçet disease after chronic brucellosis infection. Infectious agents have long been considered one of the triggers for autoimmune and autoinflammatory diseases. Therefore, rheumatic processes should be kept in mind, especially in treatment-resistant cases.

The Prevalence of Familial Mediterranean Fever and Behçet's Disease: A Cross-Sectional Study

Objectives

This study aims to investigate the coexistence of familial Mediterranean fever (FMF) and Behçet's disease (BD).

Patients and methods

This cross-sectional study was conducted between May 2009 and August 2009. The study included 14,881 randomized children (7,741 males, 7,140 females; mean age 13.0 years; range, 12 to 14 years) from sixth to eighth grades, in 72 primary schools in the center of Turkey's Sivas province. Of these children, 985 were randomly selected and interviewed with their parents. During these interviews, the family trees up to second-degree relatives were drawn. The presence of a diagnosis of FMF or BD was questioned. Patient history, physical examination, eye examination, and pathergy test were performed when needed. The methods of this study were reported in accordance with the STrengthening the Reporting of OBservational studies in Epidemiology guidelines.

Results

Nine hundred and eighty-five students, 978 mothers, 953 fathers, and 1,876 relatives (4,792 in total) were included in the study. The ratio of consanguineous marriage ratio was 13.6%. Only 30 patients (0.6%) were diagnosed with FMF, while three (0.06%) were diagnosed with BD. In patients with FMF, consanguineous marriage was statistically significant (p=0.015). In terms of low back, heel, and joint pain and morning stiffness, there was a statistically significant difference between patients with and without FMF (p<0.05). Of the three BD patients, one had concomitant FMF.

Conclusion

The prevalence of FMF in Sivas province was higher than Turkey's prevalence; however, the prevalence of BD was lower. According to these findings, it is not easy to conclude that the two diseases share a common pathogenesis.

Risk of immune-mediated inflammatory diseases in newly diagnosed ankylosing spondylitis patients: a population-based matched cohort study

Objective

To investigate the risk of immune-mediated inflammatory diseases (IMIDs) in patients with ankylosing spondylitis (AS).

Methods

Using 2003–2012 claims data from the Taiwanese National Health Insurance Research Database, we identified 30,911 newly diagnosed AS patients requiring medical therapy from 2006 to 2012. In addition, we randomly selected 309,110 non-AS individuals matching (1:10) the AS patients with regard to age, sex and the year of the index date. After excluding subjects with the corresponding prior IMIDs, we calculated the incidence rates (IRs) of various IMIDs in the AS and non-AS cohorts and estimated the hazard ratios (HRs) with 95% confidence intervals after adjusting for age, sex, the Charlson comorbidity index, the frequency of ambulatory visits during the follow-up period and medications. We conducted sensitivity analyses by excluding those who developed IMIDs within 3 months after the index date.

Results

In the follow-up period, we found that newly diagnosed AS patients had significantly increased risks of acute anterior uveitis, psoriasis, Sjögren’s syndrome, thromboangiitis obliterans, Behcet’s disease and sarcoidosis. However, the risk of Sjögren’s syndrome did not increase in AS patients in the sensitivity analysis. In the same period, this study found no significant differences in the risks of Crohn’s disease, ulcerative colitis, systemic lupus erythematosus, systemic sclerosis, dermatomyositis, polymyositis, pemphigus and vitiligo between newly diagnosed AS patients and non-AS individuals. AS patients had a significantly reduced risk of rheumatoid arthritis.

Conclusion

Newly diagnosed Taiwanese AS patients had increased risks of acute anterior uveitis, psoriasis, thromboangiitis obliterans, Behcet’s disease and sarcoidosis, but a reduced risk of rheumatoid arthritis.

Electronic supplementary material

The online version of this article (10.1186/s13075-019-1980-1) contains supplementary material, which is available to authorized users.