Clinical patterns of disease: From early systemic lupus erythematosus to late-onset disease

Systemic lupus erythematosus (SLE) is a complex disease with an insidious clinical presentation. In up to half of the cases, SLE onset is characterized by clinical and serological manifestations that, although specific, are insufficient to fulfill the classification criteria. This condition, called incomplete SLE, could be as challenging as the definite and classifiable SLE and requires to be treated according to the severity of clinical manifestations. In addition, an early SLE diagnosis and therapeutic intervention can positively influence the disease outcome, including remission rate and damage accrual. After diagnosis, the disease course is relapsing-remitting for most patients. Time in remission and cumulative glucocorticoid exposure are the most important factors for prognosis. Therefore, timely identification of SLE clinical patterns may help tailor the therapeutic intervention to the disease course. Late-onset SLE is rare but more often associated with delayed diagnosis and a higher incidence of comorbidities, including Sjogren's syndrome. This review focuses on the SLE disease course, providing actionable strategies for early diagnosis, an overview of the possible clinical patterns of SLE, and the clinical variation associated with the different age-at-onset SLE groups.

Cardiac Magnetic Resonance Imaging and Clinical Follow-up in Antimalarial-induced Cardiomyopathy in Patients With Systemic Lupus Erythematosus

Antimalarial-induced cardiomyopathy is under-recognized in clinical practice and there is limited data on the evolution of cardiac imaging abnormalities after cessation of anti-malarial therapy. In this case series of 9 patients with antimalarial-induced cardiomyopathy, follow-up cardiac magnetic resonance imaging demonstrated interval increase in late gadolinium enhancement extent in 89% of patients and interval decrease in left ventricular ejection fraction in all, despite cessation of anti-malarial therapy. Progression of cardiac abnormalities despite cessation of therapy underscores the important role of imaging in the early recognition of antimalarial-related treatment changes.

Cardiac Magnetic Resonance Imaging T1 and T2 Mapping in Systemic Lupus Erythematosus in Relation to Antimalarial Treatment

PURPOSE

Patients with systemic lupus erythematosus (SLE) are at risk of cardiac disease including antimalarial-induced cardiomyopathy (AMIC). The purpose of this study is to evaluate cardiac magnetic resonance imaging parametric mapping findings in SLE patients with AMIC and investigate the relationship of T1/T2 mapping to antimalarial (AM) treatment duration.

MATERIALS AND METHODS

All patients with SLE who had undergone cardiac magnetic resonance imaging with T1/T2 mapping for evaluation of suspected cardiac disease between 2018 and 2021 were evaluated and compared with healthy controls. To facilitate comparison between scanners, T1/T2 values were converted to a z -score using scanner-specific local reference values. Patients were classified into 3 groups: AMIC, myocarditis, and other (no AMIC or myocarditis).

RESULTS

Forty-five SLE patients (47±17 y, 80% female; 8 [18%] with AMIC and 7 [16%] with myocarditis) and 30 healthy controls (39±15 y, 60% female) were included. Patients with AMIC had higher T1 and T2 compared with controls ( z -score 1.1±1.3 vs. 0±0.6, P =0.01 and 1.7±1.1 vs. 0±1.0, P <0.01, respectively) and lower values compared with those with myocarditis (3.7±1.6, P <0.01 and 4.0±2.0, P <0.01, respectively). T1 correlated negatively with AM treatment duration in patients without AMIC or myocarditis ( r =-0.36, P =0.048) and positively in patients with AMIC ( r =0.92, P =0.001). AM treatment duration did not correlate significantly with T1 in patients with myocarditis or with T2 in any group.

CONCLUSIONS

The relationship between T1 and AM treatment duration differed between groups. Native T1 decreases with longer treatment in patients without AMIC or myocarditis, possibility due to glycosphingolipid accumulation. In patients with AMIC, increasing T1 with longer treatment could reflect fibrosis.

POS0740 IMPACT OF TIME TO REMISSION, FLARES AND EXPOSURE TO IMMUNOSUPPRESSIVES ON THE DEVELOPMENT OF ADVANCED CHRONIC KIDNEY DISEASE (STAGE IV OR WORSE) IN LUPUS NEPHRITIS

Background

Lupus nephritis (LN) affects up to 40% of patients with SLE and leads to end stage kidney disease (ESKD) in 17-33% after 10 years. The prevalence of chronic kidney disease stage IV (estimated glomerular filtration rate, eGFR=15-29ml/min/1.73m2) is not known; however, approximately two thirds of such patients will progress to ESKD after 6 years on average.1

Objectives

To determine the impact of time to remission and flares on the development of advanced CKD (stage IV or worse) in LN.

Methods

Patients with LN based on biopsy or abnormal proteinuria (>0.5g/day) with or without hematuria/pyuria/casts for two consecutive visits in the absence of other plausible explanation were retrieved from the Toronto Lupus Clinic database. Individuals with advanced CKD at baseline were excluded. All patients were followed for at least 5 years. The primary outcome was the development of advanced CKD (eGFR≦29ml/min/1.73m2). Remission was defined as proteinuria<0.5g/24h, no active urinary sediment and serum creatinine of ≤120% of baseline. Flare was defined as any abnormal proteinuria (>0.5g/day) after remission. Death was treated as competing risk in survival analysis. Statistical analysis with SAS 9.4; p<0.05 was considered significant.

Results

Out of 418 eligible patients, 209 (50%) achieved remission within the first year from LN diagnosis, 102 (24.4%) within the 2nd and 3rd years, 70 (16.7%) after 3 years and 37 (8.9%) never achieved remission. Sixty-six patients (15.8%) developed advanced CKD after 9.5 years on average (37 with ESKD). At baseline, these patients had a higher SLICC/Damage Index (0.6±1.2 vs. 0.3±0.7, p=0.003), lower eGFR (73±38 vs. 94±33ml/min/1.73m2, p<0.001), higher prevalence of hypertension (85% vs. 73%, p=0.046), proliferative nephritis (combined class III and IV, 66% vs. 47.8%, p=0.017) and more often treated with ACE inhibitors or angiotensin receptor blockers (35% vs. 22%, p=0.02). The other variables did not differ significantly. Remission rates, flares and exposure to immunosuppressives after remission are shown in Table 1.

Table 1.

A. Time to remission, exposure to immunosuppressives and flares in all patients

VARIABLEAdvanced CKD (n=66)No advanced CKD (n=352)pYears from LN to complete remission3.0 ± 3.41.6 ± 2.1<0.001Years on Immunosuppressives from complete remission to outcome/last date (median)2 (0-7)4 (0-8)0.008Number of flares in first five years after LN 012 (18.2%)156 (44.3%)<0.001 114 (21.2%)79 (22.4%) 2 or more40 (60.6%)117 (33.2%)B. Multivariate analysis for the outcome of advanced CKD (stage IV or worse)HR95%CIpSerum creatinine at baseline1.021.01-1.02<0.0001Complete remission between 1-3 years (compared to remission within 1 year)2.481.14-5.370.022Complete remission after 3 years or no remission (compared to remission within 1 year)2.991.41-6.340.004Years on Immunosuppressives from complete remission to outcome/last date0.890.83-0.95<0.0001One flare (compared to no flares)2.681.05-6.860.04Two or more flares (compared to no flares)3.551.51-8.340.004

Patients who achieved remission within one year from diagnosis demonstrated better outcomes compared to all other groups (p<0.0001), Figure 1. Patients with complete remission between one and three years had similar outcomes for the first 10 years from diagnosis and deteriorated during the second decade of follow-up.

Figure 1.

Conclusion

Complete remission within the 1st year from LN diagnosis strongly protects against advanced CKD. Flares significantly affect prognosis. One flare was associated with 2.7-fold increased risk for advanced CKD (3.6-fold for 2 or more flares). Longer time on immunosuppressives after remission is associated with decreased risk for advanced CKD. Our findings emphasize the importance of early remission as well as flare prevention with prolonged immunosuppressive use to maximize renal survival in LN.

References

[1]Tselios K, Gladman DD, Su J, Urowitz MB. Advanced Chronic Kidney Disease in Lupus Nephritis: Is Dialysis Inevitable? J Rheumatol 2020; 47: 1366-73

Acknowledgements

The University of Toronto Lupus Clinic is supported by a grants from Lupus Ontario and Lupus Canada and donations from the Marissa and Lou Rocca, Diana and Mark Bozzo and the Stacey and Mark Krembil Families.

Disclosure of Interests

Konstantinos Tselios: None declared, Dafna D Gladman Consultant of: AstraZeneca, Jiandong Su: None declared, Murray B Urowitz Consultant of: GlaxoSmithKline, AstraZeneca, Merck, Bayer, UCB, Grant/research support from: GlaxoSmithKline

OP0140 IMPACT OF TIME TO REMISSION, FLARES AND TIME ON IMMUNOSUPPRESSIVES ON THE ESTIMATED GLOMERULAR FILTRATION RATE IN LUPUS NEPHRITIS

Background

Time to complete remission, subsequent flares and time on immunosuppressives after complete remission are major determinants of the progression to advanced chronic kidney disease in lupus nephritis (LN). However, the impact of these factors on the rate of glomerular filtration rate (GFR) deterioration is not known.

Objectives

To determine the impact of time to remission, flares and time on immunosuppressives after remission on the estimated GFR in LN.

Methods

Patients with LN based on biopsy or abnormal proteinuria (>0.5g/day) with or without hematuria or pyuria or casts for two consecutive visits were retrieved from the Toronto Lupus Clinic long-term longitudinal database. Individuals with advanced chronic kidney disease at baseline (eGFR≦29ml/min/1.73m2) were excluded. All patients were followed for at least 5 years. The primary outcome was any decrease of the estimated GFR on an annual basis (slope). Remission was defined as proteinuria<0.5g/24h, inactive urinary sediment and serum creatinine ≤120% of the baseline value. Flare was defined as any abnormal proteinuria (>0.5g/day) or increase in serum creatinine (SCR) from normal to abnormal or >120% of the baseline value after remission. Slopes of eGFR changes (standard error) were calculated using Ordinary Least Square method in each complete remission/flare group. Linear Mixed model was performed to account for factors associated with deterioration of eGFR.

Results

Out of 418 eligible patients, 209 (50%) achieved remission within the first year from LN diagnosis, 102 (24.4%) within the 2nd and 3rd years, 70 (16.7%) after 3 years and 37 (8.9%) never achieved remission. Regarding flares, 82 patients (19.6%) never flared, 75 (18%) had one flare and 261 (62.4%) had two or more flares. The trajectory and annual slope of eGFR according to time to remission and number of flares is shown in the Figure 1.

Figure 1.

Regression analysis (linear mixed model) for the outcome of eGFR was performed to adjust for other variables that impact eGFR (Table 1).

PredictorsEstimateStandard Errorp valueEach one later decade of LN onset4.450.93<0.0001Years on immunosuppressives since remission0.710.19<0.0001Age at LN onset-0.760.11<0.0001Hypertension at LN-7.732.750.005CR < 1 year after LN0 (Ref.)CR between 1-3 years comparing to < 1 year after LN-1.602.900.581No CR or CR later than 3 years comparing to < 1 year after LN-12.312.90<0.0001No Flare0 (Ref.)One flare any time after LN vs. no flare-3.483.790.358Two or more flares any time after LN vs. no flare-14.793.01<0.0001

Conclusion

Complete remission after 3 years or no remission is associated with a significant decrease in eGFR, while remission during the 2nd and 3rd year from LN diagnosis is not associated with significant decrease of renal function over time. Patients with one flare did not have significant impact on their renal function. Patients with 2 or more flares had a significant decrease of eGFR over 20 years, even after adjustment for other covariates. Time on immunosuppressives after complete remission is protective against eGFR decline. Our findings emphasize the importance of rapid remission and flare prevention by prolonged maintenance treatment with immunosuppressives to optimize renal outcomes.

Acknowledgements

The University of Toronto Lupus Clinics is supported by grants from Lupus Ontario and Lupus Canada and donations from the Marissa and Lou Rocca, the Diana and Mark Bozzo and the Stacey and Mark Krembil Families.

Disclosure of Interests

Konstantinos Tselios: None declared, Dafna D Gladman Consultant of: AstraZeneca, Jiandong Su: None declared, Murray B Urowitz Consultant of: GlaxoSmithKline, AstraZeneca, Merck, Bayer, UCB, Grant/research support from: GlaxoSmithKline

Disease course patterns in systemic lupus erythematosus

BACKGROUND

Disease activity in systemic lupus erythematosus follows three different courses: long quiescent, relapsing remitting and persistently active. However, the patterns of disease course since diagnosis are not known. This study aimed to assess the prevalence and characteristics of such patterns over 10 years.

PATIENTS AND METHODS

The inception cohort of the Toronto Lupus Clinic (≥10 year follow up, between visit interval ≤18 months) was investigated. Prolonged remission was defined as a clinical Systemic Lupus Erythematosus Disease Activity Index 2000 = 0 achieved within 5 years of enrolment and maintained for ≥10 years. The relapsing-remitting pattern was defined based on ≥2 remission periods (clinical Systemic Lupus Erythematosus Disease Activity Index 2000 = 0 for two consecutive visits). Patients with no remission were categorized as persistently active. Groups were compared for baseline characteristics, cumulative damage, flare rate, mortality and certain co-morbidities.

RESULTS

Of 267 patients, 27 (10.1%) achieved prolonged remission, 180 (67.4%) relapsing-remitting and 25 (9.4%) persistently active. In total, 35 (13.1%) had only one remission period (hybrid). At enrollment, there were no differences regarding clinical and immunological variables. At 10 years, persistently active patients had accumulated significantly more damage than the prolonged remission and relapsing-remitting patients. Being of Black race and higher adjusted mean Systemic Lupus Erythematosus Disease Activity Index 2000 over the first 2 years were associated with a more severe disease course. Relapsing-remitting and persistently active patients had an increased flare rate and accrued more osteoporosis, osteonecrosis and cardiovascular events.

CONCLUSIONS

Approximately 70% of systemic lupus erythematosus patients followed a relapsing-remitting course, whereas 10% displayed prolonged remission and another 10% a persistently active course. Early response to treatment was associated with a less severe course and better prognosis.

Severe brady-arrhythmias in systemic lupus erythematosus: prevalence, etiology and associated factors

Background

Severe brady-arrhythmias, requiring a permanent pacemaker (PPM), have been sparsely reported in systemic lupus erythematosus (SLE). The aim of this study was to describe the characteristics of such arrhythmias in a defined lupus cohort.

Patients and methods

The database of the Toronto Lupus Clinic ( n = 1366) was searched for patients who received a PPM. Demographic, clinical, immunological and therapeutic variables along with electrocardiographic (ECG) and echocardiographic findings (based on the last available test prior to PPM) were analyzed. Patients with a PPM (cases) were compared with age-, sex- and disease duration-matched patients without a PPM (controls). Analysis was performed with SAS 9.0; p < 0.05 was considered significant.

Results

Eighteen patients were identified, 13 (0.95%) with complete atrioventricular block and 5 (0.37%) with sick sinus syndrome. Disease duration at PPM implantation was 22 ± 12 years. Compared to controls, cases had more frequently coronary artery disease, hypertension, dyslipidemia and longer antimalarial (AM) treatment duration. The prevalence of first-degree atrioventricular block, right bundle branch block, left anterior fascicular block and septal hypertrophy was also higher. AM treatment was significantly associated with brady-arrhythmias (OR = 1.128, 95% CI = 1.003–1.267, p = 0.044). Nine patients had prior heart disease and one received a PPM two years after renal transplantation. Eight patients did not have any potential risk factors; prolonged AM therapy (mean 22 years) might have been the cause.

Conclusions

Apart from known causes, prolonged AM treatment may be associated with severe brady-arrhythmias in SLE. Certain ECG and echocardiographic characteristics may represent indicators of an ongoing damage in the conduction system.

Lupus myocarditis: a single center experience and a comparative analysis of observational cohort studies

Background Lupus myocarditis (LM) is reported in 3-9% of patients with systemic lupus erythematosus (SLE) but limited evidence exists regarding optimal treatment and prognosis. This study aims to describe LM in a defined lupus cohort as compared with the existing literature. Patients and methods Patients with LM were identified from the University of Toronto Lupus Clinic database. Diagnosis was based on clinical manifestations and electrocardiographic, imaging, and biochemical criteria. Demographic, clinical, diagnostic and therapeutic variables and outcomes were collected in a standardized data retrieval form. A literature review was performed to identify cohort studies reporting on LM treatment and outcome. A comparative analysis was conducted between our patients and the combined cohort of the existing studies. Results Thirty patients were diagnosed with LM (prevalence 1.6%) and compared with a cumulative cohort of 117 patients from five distinct studies. No significant differences were found regarding the age at diagnosis (32.6 ± 13.4 years) and SLE duration (2.5 years median). Concomitant lupus activity from other organ systems was observed in 97% of the patients. Chest pain was more frequently reported in our cohort whereas dyspnea was more prominent in the other studies. Diagnostic criteria were similar across studies. Therapeutic approach was comparable and consisted of glucocorticosteroids (96.6%) and immunosuppressives (70%). Mortality was approximately 20% whereas another 20% of the patients achieved partial and 60% complete recovery. Conclusions LM usually occurs early in the disease course and in the context of generalized lupus activity. Despite aggressive therapy, approximately 40% of the patients died or had residual heart damage.

Shrinking lung syndrome in systemic lupus erythematosus: a single-centre experience

Introduction Shrinking lung syndrome (SLS) is a rare manifestation of systemic lupus erythematosus (SLE), characterized by decreased lung volumes and extra-pulmonary restriction. The aim of this study was to describe the characteristics of SLS in our lupus cohort with emphasis on prevalence, presentation, treatment and outcomes. Patients and methods Patients attending the Toronto Lupus Clinic since 1980 ( n = 1439) and who had pulmonary function tests (PFTs) performed during follow-up were enrolled ( n = 278). PFT records were reviewed to characterize the pattern of pulmonary disease. SLS definition was based on a restrictive ventilatory defect with normal or slightly reduced corrected diffusing lung capacity for carbon monoxide (DLCO) in the presence of suggestive clinical (dyspnea, chest pain) and radiological (elevated diaphragm) manifestations. Data on clinical symptoms, functional abnormalities, imaging, treatment and outcomes were extracted in a dedicated data retrieval form. Results Twenty-two patients (20 females) were identified with SLS for a prevalence of 1.53%. Their mean age was 29.5 ± 13.3 years at SLE and 35.7 ± 14.6 years at SLS diagnosis. Main clinical manifestations included dyspnea (21/22, 95.5%) and pleuritic chest pain (20/22, 90.9%). PFTs were available in 20 patients; 16 (80%) had decreased maximal inspiratory (MIP) and/or expiratory pressure (MEP). Elevated hemidiaphragm was demonstrated in 12 patients (60%). Treatment with prednisone and/or immunosuppressives led to clinical improvement in 19/20 cases (95%), while spirometrical improvement was observed in 14/16 patients and was mostly partial. Conclusions SLS prevalence in SLE was 1.53%. Treatment with glucocorticosteroids and immunosuppressives was generally effective. However, a chronic restrictive ventilatory defect usually persisted.

Antimalarials as a risk factor for elevated muscle enzymes in systemic lupus erythematosus

Objective

To investigate the relationship between antimalarials (AM) and elevated muscle enzymes in systemic lupus erythematosus (SLE).

Patients—Methods

325 lupus patients with abnormal creatine phosphokinase (CPK) for at least two consecutive clinic visits were enrolled; 54 patients on statins/fibrates ( n = 43) and/or active myositis ( n = 14) were excluded. The control group consisted of 1453 lupus patients with no CPK elevation during follow-up. Descriptive statistics and Cox regression analyses were performed, p < 0.05 was considered significant.

Results

Cases and controls did not differ regarding age at SLE diagnosis, gender ratio, or disease duration. AM use was more frequent in cases, which had more prolonged AM use. Total frequency of elevated CPK in AM users was 216/1322 (16.3%). Chloroquine was associated with a 3.3-fold, and hydroxychloroquine with a 3.1-fold, increased risk for CPK elevation. Black race was associated with higher CPK (HR = 2.941), whereas female gender was protective (HR = 0.697). 203 patients were followed for 7.3 ± 5.6 years; 49.8% had persistent and 14.8% intermittent CPK elevation, while in 35.4% CPK was normalized. Clinical proximal muscle weakness developed in 5/203 patients.

Conclusions

Chronic AM use is a potential risk factor for muscle enzyme elevation in SLE patients. CPK abnormalities persist in almost two thirds of the patients, but this remains mainly a biochemical finding, evolving to clinical myopathy in about 2.5%.

ADAMTS-13 metalloprotease abnormalities in systemic lupus erythematosus: is there a correlation with disease status?

To clarify the role of ADAMTS-13 in the pathogenesis of thrombotic microangiopathy in systemic lupus erythematosus (SLE) we evaluated ADAMTS-13 profile (metalloprotease antigen levels, anti-ADAMTS-13 autoantibody levels, activity) in distinct patient groups according to disease activity, extent of cumulative tissue damage and history of antiphospholipid syndrome or end-organ damage. Forty-one lupus patients were analysed. ADAMTS-13 metalloprotease antigen levels and anti-ADAMTS-13 autoantibodies were evaluated by ELISA. ADAMTS-13 activity was measured by Fluorescence resonance energy transfer (FRET) technique. ADAMTS-13 metalloprotease antigen levels were significantly decreased in patients with Systemic Lupus International Collaborative Clinics/American College of Rheumatology (SLICC/ACR) >1 (p<0.05). ADAMTS-13 metalloprotease antigen levels also exhibited a significant inverse correlation with anti-dsDNA levels (r= -0.60, p<0.05). Anti-ADAMTS-13 autoantibodies were marginally higher in patients with positive anti-dsDNA (p=0.08). Additionally, patients with positive anti-ADAMTS-13 autoantibodies exhibited the lowest activity levels (p<0.05). To our knowledge ADAMTS-13 profile in SLE has not been studied in regard to composite structured indices. The results of this study suggest that in patients with active SLE or considerable cumulative tissue damage, ADAMTS-13 levels may be decreased and anti-ADAMTS-13 autoantibodies may partially mediate this reduction. Further evaluation of ADAMTS-13 profile may explain its role in the pathogenesis of thrombotic microangiopathy in lupus patients and reveal a potential prognostic marker of microthrombotic manifestations in SLE.

Genetic polymorphism study of regulatory B cell molecules and cellular immunity function in an adult patient with Common Variable Immunodeficiency

A 43 year old female patient presented for recurrent bacterial lower respiratory infections. A research for immunodeficiency status revealed total hypogammaglobulinemia, reduced IgG1, IgG2, IgG3 subclass levels, and low number of B lymphocytes (CD19+). Common Variable Immunodeficiency (CVID) 11.2 category was diagnosed according to recent criteria of primary immunodeficiencies (PID). Further immunological study consisting of genetic polymorphism of genes relating to differentiation, activation and function of B cells (ICOS, BAFF receptor BCMA and TACI) was performed, which did not reveal any related mutations. T cell parameters and Th1/Th2 cytokine network did not show any disturbances. It is postulated that probable endstage B cell differentiation defects should be investigated. The patient receives IVIGs replacement thereafter and the rate and severity of infections have significantly improved.

Adamantiades-Behcet disease (ABD) in northern Greece patients: experience from a single center

OBJECTIVE-METHODS: Adamantiades-Behcet disease (ABD) is a multi-systemic vasculitis of unknown origin, with a characteristic geographic distribution, that affects vessels of all kinds and sizes and is characterized by recurrent mucosal, skin and ocular lesions. In the present study, a series of 36 patients from Northern Greece is analyzed retrospectively in regard to the epidemiological, clinical and immunological parameters.

RESULTS

All patients had recurrent oral ulcerations (36/36, 100%), while 23/36 (63.9%) experienced genital ulcerations and 22/36 (61.1%) developed ocular disease. Skin manifestations were observed in 23/36 patients (63.9%) and pathergy test was found positive in 14/36 patients (38.9%). Other manifestations included central nervous system involvement, recurrent genitourinary inflammations, arthralgias and superficial thrombophlebitis. Laboratory findings were not specific, partly reflecting the severity of inflammation. Ocular disease was more often observed in HLA-B51 (+) patients (20/31, 64.5%) than in HLA-B51 (-) patients. Standard of care (SOC) treatment consisted of cyclosporine A, azathioprine, methylprednisolone and aspirin, whereas refractory disease was treated with intravenous pulses of methylprednisolone and cyclophosphamide. Occasionally, anti-TNF agents (infliximab) were applied to treat refractory ocular disease.

CONCLUSION

The findings of the present study come in agreement with those reported for other Mediterranean series. HLA-B51 seems to predispose to more severe disease, while early therapeutic intervention is beneficial for these patients.

Concurrent relapsing central nervous system and ocular involvement in a case of life-threatening Adamantiades-Behçet Disease (ABD)

Adamantiades-Behçet disease (ABD) is characterised by oral and genital ulcerations, skin lesions and ocular manifestations and, rarely, by central nervous system (CNS) involvement. Neuro-Behçet disease (NBD) is categorised to parenchymal or non-parenchymal, while combined CNS disease is rarely reported in the literature. A case of NBD, with severe relapsing ocular and neurological disease of combined pattern is presented. Neurological complications included brainstem manifestations, as well as neurovascular involvement, while ocular involvement consisted of bilateral uveitis and branch retinal vein occlusion. Manifestations responded to corticosteroid plus cyclophosphamide pulse therapy. Maintenance therapy included cyclosporine A, azathioprine and corticosteroids. Case individualities are discussed, focusing on scepticism concerning treatment of NBD relapses in the long term.