POS1255 SAFETY OF THE PFIZER/BIONTECH AND SINOVAC/CORONAVAC VACCINES AMONG PATIENTS WITH BEHCET’S SYNDROME AND FAMILIAL MEDITERRANEAN FEVER

Background

Since first emerged in December 2019, the COVID-19 pandemic has resulted in a death toll surpassing 5.5 million worldwide and had severe consequences on the global economy, environment, public health and social life [1, 2]. Multiple potential vaccines against COVID-19 have been developed swiftly and as shown in several phase 3 clinical trials, they demonstrated considerable efficacy without an unusual safety signal in healthy individuals.

Objectives

In this study, we aimed to evaluate vaccine reactivity and disease flare following vaccination with either Sinovac/CoronaVac or Pfizer/BioNTech among BS and FMF patients compared with patients with various diagnosis of RD and healthy controls.

Methods

Only those patients and healthy controls who rece,ved at least one single shot of either CoronoVac or BioNTech against COVID-19 were included in the study. We tried to contact all of these patients and controls consecutively by telephone and attempted to make interviews with the eligible ones.

Results

We studied the efficacy, side effects and disease flares after COVID-19 vaccination in 256 patients with Behcet’s syndrome (BS), 247 with familial Mediterranean fever (FMF), 601 with rheumatic diseases (RD) and 612 healthy controls (HC). Study participants were vaccinated either with CoronaVac (BS:109, FMF: 90, RD: 343, and HC: 334) or BioNTech (BS: 147, FMF:157, RD: 258 and HC: 278). BioNTech ensured a significantly better efficacy than CoronaVac against COVID-19 in all patient groups (BS: 1.4% vs 10.1%; FMF: 3.2% vs 12.2%, RD:2.7% vs 6.4%). Those with at least one adverse event (AE) were significantly more frequent among those vaccinated with BioNTech than those with CoronaVac (BS: 86.4% vs 45%; FMF: 83.4% vs 53.3%; RD: 83.3% vs 45.5% and HC: 86.3% vs 52.1%). The majority of AEs were mild to moderate and transient and this was true for either vaccine. There were also AEs that required medical attention in all study groups following CoronaVac (BS:5.5%, FMF:3.3%, RD:2.9% and HC:3.3%) or BioNTech (BS:5.4%, FMF:1.9%, RD:4.7% and HC:4.7%). The main causes for medical assistance were disease flare, and cardiovascular events. Disease flares after vaccination were significantly more frequent among BS (41/256; 16.0%) and FMF (43/247; 17.4%) patients compared to patients with RD (36/601; 6.0%). This was true for both CoronaVac (BS: 11.0%, FMF: 24.4% and RD: 5.2%, p<0.001) and BioNTech (BS: 19.7%, FMF: 13.4% and RD: 7.0%, p=0.001)(Table 1).

Table 1.

Flares among patients with Behçet’s syndrome, familial Mediterranean fever, rheumatic diseases after vaccination with CoronaVac and BioNTech

CoronaVacBehçet’s syndrome,n=109Familial Mediterranean Fever,n=90Rheumatic diseases, n=343Flares, n (%)Flares, n (%)Flares, n (%)12 (11.0)22 (24.4)18 (5.2)BioNTechBehçet’s syndrome, n=147Familial Mediterranean Fever, n=157Rheumatic diseases, n=258Flares, n (%)Flares, n (%)Flares, n (%)29 (19.7)21 (13.4)18 (7.0)

RA, Rheumatoid Arthritis; BS, Behçet’s syndrome; FMF, Familial Mediterranean Fever

Conclusion

Our study demonstrates that BS and FMF patients vaccinated with either CoronaVac or BioNTech demonstrated almost similar AE profile and frequency compared to RD patients and HC. AEs that required physician consultation or hospitalization occurred in all study groups after either CoronaVac or BioNTech. Caution should be required when monitoring these patients after vaccination. Increased frequency of flares in BS and FMF compared to that seen in RD might reflect defects in innate immunity and deserves further investigation.

References

[1]https://covid19.who.int Accessed date 22.01.2022

[2]Nicola M, Alsafi Z, Sohrabi C, Kerwan A, Al-Jabir A, Iosifidis C, Agha M, Agha R. The so-cio- economic implications of the coronavirus pandemic (COVID-19): A review. Int J Surg. 2020 Jun; 78:185-193. doi: 10.1016/j.ijsu.2020.04.018. PMID: 32305533; PMCID: PMC7162753.

Disclosure of Interests

Ayse Ozdede: None declared, Sabriye Güner: None declared, Guzin Ozcifci: None declared, Berna Yurttas: None declared, Zeynep Toker Dincer: None declared, Zeynep Atli: None declared, Ugur Uygunoglu: None declared, Eser Durmaz: None declared, Didar Ucar: None declared, Serdal Ugurlu Speakers bureau: Novartis,Pfizer,Celltrion and Lilly, Sebahattin Saip: None declared, Ömer Fehmi Tabak Speakers bureau: Abbvie, Gilead, MSD and GSK, Consultant of: Abbvie, Gilead, MSD and GSK, Vedat Hamuryudan: None declared, Emire Seyahi Speakers bureau: Pfizer, Abbvie, Novartis and Gilead,

FRI0202 WHAT IS NOT NERVOUS SYSTEM INVOLVEMENT IN BEHÇET SYNDROME: A SURVEY OF PATIENTS WITH BEHÇET SYNDROME REFERRED TO NEUROLOGY

Background:

Nervous system involvement of Behçet syndrome (neuroBS) is a serious, but infrequent manifestation of Behçet syndrome (BS). Although many BS patients present with signs and symptoms related to the nervous system, several of these are diagnosed with conditions other than neuroBS. The differential diagnosis may be difficult in such patients.

Objectives:

To identify conditions mimicking neuroBS among patients with BS and to determine clinical, laboratory and imaging findings that may help the differential diagnosis.

Methods:

We retrospectively screened the charts of 500 BS patients who were registered to our clinic between February 2012 and April 2015, to identify those who were referred to neurology at any time during their follow-up. We follow our BS patients in a multidisciplinary clinic and all patients with a sign or symptom related to the nervous system are seen by one of the neurologist members of the clinic. The final diagnoses, as well as presenting signs and symptoms, laboratory and imaging results and results of any other diagnostic modalities were retrieved from patient charts. Patients who did not have a follow-up visit during the last 3 months were invited to the clinic for their final condition. Those who were not able to come, or one of their family members if they were not able to talk, were interviewed on the phone.

Results:

Among the 500 BS patients who were screened, 116 (23%) were referred to neurology (53 men, 63 women, mean age 32.8 (±9.8), 98 (84%) fulfilled ISG criteria). Among these, 29 (5.8%) were diagnosed with neuroBS, 30 (6%) had other conditions related to the nervous system, 46 (9.2%) were not diagnosed with a nervous system disorder and their symptoms disappeared and 11 (2.2%) were inconclusive and lost to follow-up. Of the 29 patients with neuroBS, 20 had parenchymal involvement, 7 had cerebral venous sinus thrombosis, 1 had concurrent parenchymal involvement and cerebral venous sinus thrombosis and 1 had atypical neuroBS. Of the 30 BS patients who were diagnosed with another nervous system condition, 14 (2.8%) had primary headache syndromes including tension type headache (n=5) and migraine (n=9), 6 (1.2%) had psychiatric disorders including psychotic disorder (n=1), depression (n=4) and somatization disorder (n=1), the remaining patients had other diagnoses which were entrapment neuropathy (n=2), epilepsy, glial tumor, multiple sclerosis, Meniere’s disease, optic neuritis, neuroretinitis, steroid myopathy and polyneuropathy in one patient each. Presentation features such as cerebellar symptoms, motor symptoms, visual problems, altered consciousness, seizure, fever and facial palsy were more common among patients with neuroBS, whereas sensory symptoms and isolated headache were more common among BS patients with other nervous system conditions (Table).

Table.

Clinical characteristics of patients with neuroBS versus other diagnoses

Clinical findings at presentationBS patients with nervous system involvement (neuroBS) (n=29)BS patients with other nervous system conditions (n=30)Only headache2 (7%)17 (56%)Cerebellar symptoms*8 (27%)4 (13%)Motor symptoms*4 (14%)2 (7%)Sensory symptoms*3 (10%)5 (17%)Visual problems*(diplopia, blurred vision)9 (31%)1 (3%)Cognitive symptoms*2 (7%)2 (7%)Other* (Alteration of consciousness, seizure, fever, facial palsy)9 (31%)1 (3%)

* Accompanying more than 1 symptom/sign

Conclusion:

Nervous system conditions other than neuroBS are common in patients with BS who present with nervous system findings. Caution is required to avoid misdiagnosis of these patients as neuroBS.

Disclosure of Interests:

Elif Dincses: None declared, E. Buse Caliskan: None declared, Z. Ece Kaya: None declared, Ugur Uygunoglu: None declared, Melih Tutuncu: None declared, Sabahattin Saip: None declared, Aksel Siva: None declared, Melike Melikoglu: None declared, Vedat Hamuryudan Speakers bureau: Pfizer, AbbVie, Amgen, MSD, Novartis, UCB, Gulen Hatemi Grant/research support from: BMS, Celgene Corporation, Silk Road Therapeutics – grant/research support, Consultant of: Bayer, Eli Lilly – consultant, Speakers bureau: AbbVie, Mustafa Nevzat, Novartis, UCB – speaker

Susac Syndrome: Clinical characteristics, diagnostic findings and treatment in 19 cases

Susac's Syndrome (SS), which was first described in 1979, is a rare and presumably autoimmune disorder characterized by encephalopathy, hearing loss, and visual disturbance resulting from branch retinal artery occlusion (BRAO). This study reports 19 SS patients' clinical characteristics, MRI features, CSF analysis, treatment strategies and outcomes. At initial presentation, only three of 19 patients demonstrated the complete clinical triad. Clinic presentation varied from isolated hemiparesis to the full triad (encephalopathy, hearing loss and visual disturbances). Corpus callosum (CC) involvement was noted in the MRI of 18 patients (97%) and BRAO was detected in 17 (95%) patients. All patients were treated with intravenous methylprednisolone after the initial assessment. This case series is presented to emphasize the differences in clinical presentation of SS and the importance of MRI and FFA in diagnosis.

Reduced inhibition in brainstem circuits in classical trigeminal neuralgia

OBJECTIVE

We hypothesized that prepulse modulation (PPM) would be altered in trigeminal neuralgia (TN) if suprasegmental inhibitory network involvement was present and tested our hypothesis in a group of patients with classical TN.

METHODS

The study enrolled nine consecutive patients with classical TN and 14 healthy subjects. Diagnosis and classification followed the International Classification of Headache Disorders-third edition (beta version). The blink reflex (BR) and BR-PPM were recorded. Ipsilateral recordings were made after stimulating each trigeminal nerve in the patient group whereas right-sided recordings were performed after stimulating the right trigeminal nerve in the healthy subjects. A conditioning electrical stimulus was applied to the ipsilateral median nerve at interstimulus intervals (ISIs) of 50 and 100 ms before the test stimulus to the supraorbital nerve.

RESULTS

The unconditioned BR recordings were similar in all groups. In the healthy subjects, the prepulse stimulus resulted in a reduced R2 magnitude (p = 0.000, Friedman's test) and longer R2 latency (p = 0.008, Friedman's test) at ISIs of 50 and 100 ms in comparison with unconditioned recordings. The R2 latency differed significantly between the unconditioned recordings and the ISI of 100 ms. In the patients with TN, no significant change was observed on either the symptomatic or asymptomatic sides.

CONCLUSIONS

There is a bilateral prepulse inhibition deficit in TN, even on the asymptomatic side. Our findings provide electrophysiological evidence for suprasegmental changes and loss of filtering activity at the brainstem in level TN.

Effects of multiple sclerosis on respiratory functions

Objectives: To measure respiratory functions of ambulatory patients with multiple sclerosis and compare the results with expected values from healthy general population data. Further, to study the correlation of respiratory function impairment with the multiple sclerosis-induced disability level.

Subjects: Thirty-eight patients with definite diagnosis of multiple sclerosis from the multiple sclerosis outpatient clinic.

Methods: The Expanded Disability Status Scale (EDSS) scores (mean 4.34±1.39) were evaluated to measure disability level. Respiratory functions tested in the laboratory included spirometric (FVC, FEV1, FEV1/FVC), maximal inspiratory (MIP) and expiratory (MEP) mouth pressure measurements. Patients were clinically assessed using a pulmonary dysfunction index (PDI) and dyspnoea index; various breathing features were also recorded.

Results: With respect to expected values from healthy general population, important decreases were found in mouth pressures with MIP (77%±23%, p ≃ 0) and MEP (60%±13%, p ≃ 0) while spirometric measures were significantly but less affected (FVC 94%±12%, p < 0.01, FEV191%±16%, p < 0.001). FEV1/FVC ratios were normal. Notable increases in PDI (5.58±0.68, p ≃ 0) and dyspnoea index (0.32±0.47, p ≃ 0) were observed. Significant relationships (p < 0.01) between respiratory function impairment and the multiple sclerosis disability level could be detected for FVC, MEP and PDI.

Conclusions: Multiple sclerosis clearly impairs respiratory functions; maximal mouth pressures are more severely reduced. This impairment increases with multiple sclerosis-induced disability level but is found to be independent from duration of disease.

Investigation of Neuromuscular Transmission in Some Rare Types of Migraine

The aim of this study was to delineate any dysfunction of neuromuscular transmission (NMT) by single-fibre electromyography (SFEMG) in some rare types of migraine. Recent studies have shown subclinical dysfunction of NMT in migraine with aura and cluster headache by using SFEMG, whereas another recent study has shown NMT to be normal in familial hemiplegic migraine (FHM) with CACNA1A mutations. Thirty patients with rare primary headache syndromes [18 with sporadic hemiplegic migraine (SHM), six with FHM and six with basilar-type migraine (BM)] and 15 healthy control subjects without any headache complaints underwent nerve conduction studies, EMG and SFEMG during voluntary contraction of the extensor digitorum communis muscle. Ten to 20 different potential pairs were recorded and individual jitter values calculated. The results obtained from patient groups were compared with those from the normal subjects. Of 600 individual jitter values of the patients, 27 (4.5%) were abnormally high, whereas only 3/205 (1.5%) jitter values from normal subjects were abnormal. Abnormal NMT was found in 4/30 (13.3%) patients (three SHM and one BM), but in none of the control subjects. Only in SHM patients was the number of individual abnormal jitter values slightly but significantly different from normal controls. The present study demonstrates that subclinical NMT abnormality is slightly present in only SHM and BM patients, but not in FHM patients.

Conversion from clinically isolated syndrome to multiple sclerosis: A large multicentre study

Background and objective:

We explored which clinical and biochemical variables predict conversion from clinically isolated syndrome (CIS) to clinically definite multiple sclerosis (CDMS) in a large international cohort.

Methods:

Thirty-three centres provided serum samples from 1047 CIS cases with at least two years’ follow-up. Age, sex, clinical presentation, T2-hyperintense lesions, cerebrospinal fluid (CSF) oligoclonal bands (OCBs), CSF IgG index, CSF cell count, serum 25-hydroxyvitamin D3 (25-OH-D), cotinine and IgG titres against Epstein-Barr nuclear antigen 1 (EBNA-1) and cytomegalovirus were tested for association with risk of CDMS.

Results:

At median follow-up of 4.31 years, 623 CIS cases converted to CDMS. Predictors of conversion in multivariable analyses were OCB (HR = 2.18, 95% CI = 1.71–2.77, p < 0.001), number of T2 lesions (two to nine lesions vs 0/1 lesions: HR = 1.97, 95% CI = 1.52–2.55, p < 0.001; >9 lesions vs 0/1 lesions: HR = 2.74, 95% CI = 2.04–3.68, p < 0.001) and age at CIS (HR per year inversely increase = 0.98, 95% CI = 0.98–0.99, p < 0.001). Lower 25-OH-D levels were associated with CDMS in univariable analysis, but this was attenuated in the multivariable model. OCB positivity was associated with higher EBNA-1 IgG titres.

Conclusions:

We validated MRI lesion load, OCB and age at CIS as the strongest independent predictors of conversion to CDMS in this multicentre setting. A role for vitamin D is suggested but requires further investigation.

Characterization of neuromyelitis optica and neuromyelitis optica spectrum disorder patients with a late onset

BACKGROUND

Few data are available for patients with a late onset (≥ 50 years) of neuromyelitis optica (LONMO) or neuromyelitis optica spectrum disease (LONMOSD), defined by an optic neuritis/longitudinally extensive transverse myelitis with aquaporin-4 antibodies (AQP4-Ab).

OBJECTIVE

To characterize LONMO and LONMOSD, and to analyze their predictive factors of disability and death.

METHODS

We identified 430 patients from four cohorts of NMO/NMOSD in France, Germany, Turkey and UK. We extracted the late onset patients and analyzed them for predictive factors of disability and death, using the Cox proportional model.

RESULTS

We followed up on 63 patients with LONMO and 45 with LONMOSD during a mean of 4.6 years. This LONMO/LONMOSD cohort was mainly of Caucasian origin (93%), women (80%), seropositive for AQP4-Ab (85%) and from 50 to 82.5 years of age at onset. No progressive course was noted. At last follow-up, the median Expanded Disability Status Scale (EDSS) scores were 5.5 and 6 in the LONMO and LONMOSD groups, respectively. Outcome was mainly characterized by motor disability and relatively good visual function. At last follow-up, 14 patients had died, including seven (50%) due to acute myelitis and six (43%) because of opportunistic infections. The EDSS 4 score was independently predicted by an older age at onset, as a continuous variable after 50 years of age. Death was predicted by two independent factors: an older age at onset and a high annualized relapse rate.

CONCLUSION

LONMO/LONMOSD is particularly severe, with a high rate of motor impairment and death.

Clinical and radiological characteristics of tumefactive demyelinating lesions: follow-up study

BACKGROUND

Demyelinating lesions over 20 mm in size, referred to as tumefactive demyelinating lesions, can be misdiagnosed as being either a tumor or an abscess. Although some radiological characteristics can help make a differential diagnosis easier, a cerebral biopsy may still be necessary.

OBJECTIVE

Our objective was to assess the clinical characteristics of tumefactive lesions, with or without a diagnosis of multiple sclerosis (MS), and present follow-up data for 54 patients with tumefactive lesions.

METHODS

Demographic, clinical, radiological and laboratory data were gathered and treatment responses were evaluated in a total of 54 patients from five medical centers.

RESULT

Twenty-nine patients were diagnosed with tumefactive lesions at the onset, whereas 25 patients were diagnosed with tumefactive lesions after a diagnosis of MS. Median follow-up was 38.12 months. At final examination, 19 of the patients with a tumefactive lesion diagnosis at the onset eventually developed relapsing-remitting MS, while 10 remained with the condition as a clinically isolated syndrome. The tumefactive lesions studied were mostly focal, with closed-ring enhancement. We found that oligoclonal band positivity was less frequent in the patients with tumefactive onset.

CONCLUSION

Although our demographic data were similar to formerly collected Turkish MS data, we found that the distribution of the patients' clinical course differed if there was an absence of primary progressive MS and that there was a lower frequency of secondary progressive MS cases in our group of patients. We believe that less frequent oligoclonal band positivity and the difference we witnessed in the clinical course of disease in our study groups suggest that there is a need for further studies to compare all the biological and immunological differences between MS and tumefactive lesion cases, in order to reveal whether there are different pathogenetic mechanisms involved.

Evaluation of parenchymal neuro-behçet disease by using susceptibility-weighted imaging

BACKGROUND AND PURPOSE

Neurologic involvement in Behçet disease, also known as NBD, is one of the most devastating manifestations of the disease. The precise pathologic mechanism of parenchymal NBD lesions has not been established. We evaluated lesion characteristics and probable venous hemorrhage in parenchymal NBD by using SWI, and we compared the imaging results with conventional MR imaging sequences.

MATERIALS AND METHODS

We performed cranial MR imaging by using a 1.5T scanner in 23 patients with a definitive diagnosis of parenchymal NBD. We compared the proportion of lesion detection and the performance of hemorrhagic detection with the T2 FSE, T2*GE, and SWI magnitude, and SWI mIP by using the χ(2) test.

RESULTS

The proportion of lesion detection with both SWI magnitude and SWI MinMIP was significantly larger than that with T2*GE. The proportions of lesion detection among all other pairs of methods were not significantly different according to the corresponding P value (χ(2) = 17.4929, df = 3, P = .0006). Proportions of hypointense hemorrhagic lesions with T2 FSE and T2*GE were not significantly different, and likewise for the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP. In contrast, the proportions of hypointense hemorrhagic lesions with SWI magnitude and SWI mIP were significantly larger than that with T2 FSE and T2*GE (χ(2) = 108.5396, df = 3, P < .0001).

CONCLUSIONS

Most of the lesions in parenchymal NBD were found to be hemorrhagic with SWI, supporting the proposed venous theory in pathology. In addition, compared with T2 FSE and T2*GE sequences, SWI was more successful in the determination of widespread involvement of the disease, particularly in nonchronic cases.

Multiple sclerosis risk in radiologically uncovered asymptomatic possible inflammatory-demyelinating disease

BACKGROUND

Natural history of patients with incidentally discovered lesions that fulfill magnetic resonance imaging (MRI) criteria for multiple sclerosis (MS) in the absence of objective clinical symptoms suggestive of central nervous system (CNS) inflammatory-demyelinating disease is not well defined.

OBJECTIVE

We evaluated the risk of developing symptomatic MS in patients with radiologically uncovered asymptomatic possible inflammatory-demyelinating disease (RAPIDD).

METHODS

We identified and longitudinally followed a cohort of 22 patients from two tertiary care MS centers: Istanbul University, Cerrahpasa School of Medicine, Istanbul, Turkey, and Mayo Clinic, Rochester, Minnesota, after an initial MRI study fulfilling the Barkhof-Tintore MRI criteria completed for other reasons unrelated to MS.

RESULTS

Eight of 22 patients developed an objective clinical symptom consistent with a CNS inflammatory-demyelinating syndrome and fulfilled dissemination in space and time criteria for definite MS. Median age at the time of diagnosis of MS was 44.8 years (range 28.3-71.4 years). Time taken for the development of definite MS was studied by survival analysis. Cumulative event rates were; 12 months: 9%, 24 months: 15%, 36 months: 30.4%, and 60 months: 44.6%. Six of 22 patients were followed beyond 60 months. Two of these six patients developed MS later (at 66 and 112 months, respectively). Three patients remained asymptomatic despite follow-up of 10 years.

CONCLUSIONS

PATIENTS

with RAPIDD develop MS at a similar rate to treated patients (and less frequently than placebo groups) with clinically isolated syndromes from prior randomized controlled studies. Some patients with RAPIDD continue to have radiological evolution of subclinical disease without MS symptoms despite long follow-up periods.

A comparative ID migraine screener study in ophthalmology, ENT and neurology out-patient clinics

Migraine is more likely to be misdiagnosed in patients with comorbid diseases. Not only primary care physicians, but also specialists might misdiagnose it due to the lack of diagnostic criteria awareness. The ID migraine test is a reliable screening instrument that may facilitate and accelerate migraine recognition. This study aimed to compare the prevalence and characteristics of migraine in a large sample of patients admitted to clinics of ophthalmology (OC), ear, nose and throat diseases (ENTC) and neurology (NC), as well as to validate the use of the ID migraine test in OC and ENTC settings. This was a multicentre (11 cites) study of out-patients admitting either to NC, ENTC or OC of the study sites during five consecutive working days within 1 week. From each of the clinics, 100 patients were planned to be recruited. All recruited patients were interviewed and those having a headache complaint received an ID migraine test and were examined for headache diagnosis by a neurologist, blinded to the ID migraine test result. A total of 2625 subjects were recruited. Only 1.3% of OC patients and 5.4% of ENTC patients have been admitted with a primary complaint of headache, whereas the percentage of NC patients suffering from headache was 37.6%. Whereas 138 patients (19.3%) in OC, 154 (17.3%) in ENTC and 347 (34%) in NC were found to be ID migraine test positive, 149 patients (20.8%) in OC, 142 (16%) in ENTC and 338 (33.1%) in NC were diagnosed with migraine. The sensitivity, specificity, and positive and negative predictive ratios of the ID migraine test were found to be similar in all clinics. An important fraction of the patients admitted to NC, as well as to OC and ENTC, for headache and/or other complaints were found out to have migraine by means of a simple screening test. This study validated the ID migraine test as a sensitive and specific tool in OC and ENTC, encouraging its use as a screening instrument.

Validity of the ID-Migraine screener in the workplace

OBJECTIVE

The impact of migraine on physical, social, and emotional performance is considerable, yet it remains an underdiagnosed disorder. ID-Migraine is a validated migraine-screening tool developed to facilitate diagnosis. This study evaluated the validity and use of the Turkish version of the ID-Migraine screener (ID-Ms) in the workplace, and measured the impact of headache on disability, productivity, and quality of life among the workforce.

METHODS

A total of 465 employees from four companies were interviewed for screening with the ID-Ms. Subjects were included in the study if they reported two or more headaches in the past 3 months and gave a positive answer to one of the two ID-Ms prescreening questions. Eligible subjects completed the ID-Ms, the Migraine Disability Assessment Questionnaire, and the Medical Outcomes Study 36-Item Short Form Health Survey. Subjects were then evaluated for confirmation of their diagnosis according to the International Classification of Headache Disorders, 2nd edition (ICHD-2) criteria.

RESULTS

A total of 227 subjects (mean age 31.9 +/- 5.9 years; 65.6% women) completed the study. Migraine was diagnosed in 106 of the 227 subjects (46.7%) according to the ID-Ms and in 117 of the 227 subjects (51.5%) according to ICHD-2 criteria. The sensitivity of the ID-Ms was 70.9%, specificity was 79.1% and Cohen kappa value was 0.50. Workdays lost over the previous 3 months due to headache amounted to 8.7 +/- 9.5 days for migraine-positive and 4.9 +/- 6.6 days for migraine-negative subjects.

CONCLUSION

The Turkish version of the ID-Migraine screener is a valid tool for identifying subjects with migraine in the workplace.

Fatigue and sleep disturbance in multiple sclerosis

Considering the association of sleep disturbance and fatigue in multiple sclerosis (MS), we investigated the presence of sleep disturbances that may be related to fatigue by using objective and subjective measures. We included 27 MS patients with fatigue, 10 MS patients without fatigue and 13 controls. The Pittsburgh sleep quality index score showed significant differences between patient groups and controls. Beck depression inventory scores were significantly higher in fatigued than non-fatigued patients. Comparison of patient groups and controls revealed significant differences for time in bed, sleep efficiency index, sleep continuity index, wake time after sleep onset, total arousal index and periodic limb movement arousal index. Our study confirms that MS causes sleep fragmentation in terms of both macro and microstructure. Fatigue in MS could be partially explained by disruption of sleep microstructure, poor subjective sleep quality and depression.

The R110C mutation in Notch3 causes variable clinical features in two Turkish families with CADASIL syndrome

Mutations in Notch3 gene are responsible for the cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL). It is a late onset neurological disorder recognized by recurrent strokes and dementia. We describe here the clinical and molecular findings of three unrelated Turkish families with CADASIL syndrome. Two of the families were identified to have the same mutation, p.R110C (c.C328T), located in exon 3 of the Notch3 gene. Interestingly, the phenotypic expression of the disease in these two families was markedly different in severity and age of onset implicating additional genetic and/or non-genetic modulating factors involved in the pathogenesis. In addition, we identified the novel p.C201R (c.T601C) mutation in exon 4 of the Notch3 gene in a proband of the third family with two consecutive stroke-like episodes and typical MRI findings. Mutations described here cause an odd number of cysteines in the N-terminal of the EGF domain of Notch3 protein, which seems to have an important functional effect in the pathophysiology of CADASIL. The phenotypic variability in families carrying the same molecular defect as presented here makes the prediction of prognosis inconceivable. Although DNA analysis is effective and valuable in diagnosing approximately 90% of the CADASIL patients, lack of genotype-phenotype correlation and prognostic parameters makes the presymptomatic genetic counseling very difficult.

Cerebral venous thrombosis is associated with major vessel disease in Behçet's syndrome

OBJECTIVE

To examine the association between the type of central nervous system (CNS) involvement (parenchymal disease and cerebral venous thrombosis (CVT)) and extra-cranial large vessel events, mainly venous thrombosis, in Behcet's syndrome (BS).

METHODS

Conventional venous angiograms, Doppler ultrasonography, computed tomography, and MR angiography were used to study 88 patients with BS, with (n = 88) and without (n = 80) CNS disease for the presence of major vessel disease.

RESULTS

Major vessel involvement among the male patients with and without CNS disease (21/73 (29%) v 18/80 (23%), respectively) showed no significant differences (p = 0.374). When patients with CNS disease were stratified according to the type of CNS involvement, 7/11 (64%) patients with CVT had major vessel disease compared with 15/77 (19%) patients with parenchymal disease (p = 0.004). The mean (SD) age of onset of CVT (23.1 (8.8) years) among the male patients was significantly earlier than among the men with parenchymal disease (32.0 (7.5); p = 0.002).

CONCLUSIONS

CVT in BS was strongly associated with peripheral major vessel disease and occurred earlier in the disease course than the parenchymal type of CNS disease. As superficial thrombophlebitis also occurs more frequently in patients with major vessel disease in BS, this may suggest a common pathogenic mechanism.

MRI findings in pediatric neuro-Behçet's disease

Behçet's disease (BD), a systemic vasculitis of unknown cause, affects many organs and systems. Neurological involvement is seen in 5-15% of the patients, and the two major forms of neurological disease seen in BD are central nervous system (CNS) parenchymal involvement and cerebral venous sinus thrombosis. We report a 14-year-old boy with BD who had neuro-parenchymal involvement. The diagnosis of the systemic disease was not made until the onset of the neurological manifestations, which led to an MRI study that revealed findings suggestive of CNS involvement of BD. We therefore emphasize the importance of the localization and appearance of other characteristics of the lesions on MRI in the differential diagnosis of parenchymal neuro-Behçet syndrome.

Two cases of neuro-Behcet's disease mimicking cerebral tumor

Two cases of neuro-Behcet's disease with isolated, solitary fronto-temporal and mesencephalic lesions respectively are reported. The cases were misdiagnosed as cerebral tumor. The postoperative outcome of the first patient was not satisfactory as he developed hemispheric edema. The second patient, with mesencephalic lesion, was treated only with corticosteroids, and the patient improved significantly. The lesion in this case resolved completely at six-month follow-up. We conclude that distinguishing the isolated solitary cerebral lesion of the Behcet's disease from a tumor may prevent surgical intervention.

Hepatitis B vaccine related-myelitis?

We present four incidental cases that developed partial myelitis following the administration of hepatitis B vaccine in 1998. The first two cases, a 33-year-old man and a 42-year-old woman developed progressive sensory symptoms without motor involvement within 4 weeks following the vaccination. Their magnetic resonance imaging (MRI) disclosed similar lesions consistent with myelitis at their cervical spinal cord. A comparable inflammatory lesion was seen at the T9-T10 levels of the spinal cord in the third case, who was a 40-year-old woman presenting with numbness in her legs and urinary retention following the vaccination. The fourth case who was a 42-year-old woman, presented with sensory symptoms in her left extremities, which developed 3 months after the vaccination. Her MRI showed a hyperintense lesion at C6. She also had two tiny lesions in her cranial MRI. In all cases, there was no history of preceding infections and no clinical evidence suggestive of any other disorders that may cause myelopathy. All patients recovered completely within 3 months with the exception of the third patient who developed new neurological symptoms after 12 months. Similar clinical and imaging presentation of myelitis following hepatitis B vaccination within a 1 year period with no other demonstrable clinical and laboratory evidence for any other disorder raise the probability of a causal link between these two events.

Behçet's disease: diagnostic and prognostic aspects of neurological involvement

This study was conducted to describe clinical and prognostic aspects of neurological involvement in Behçet's disease (BD). Patients referred for neurological evaluation fulfilled the criteria of the International Study Group for Behçet's Disease. We analyzed disability and survival by the Kaplan-Meier method, using Kurtzke's Extended Disability Status Scale (modified for BD) and the prognostic effect of demographic and clinical factors by Cox regression analysis. We studied 164 patients; of the 107 diagnostic neuroimaging studies: 72.1% showed parenchymal involvement, 11.7% venous sinus thrombosis (VST) and the others were normal. CSF studies were performed in 47 patients; all with inflammatory CSF findings (n = 18) had parenchymal involvement. An isolated increase in pressure was compatible with either VST or normal imaging. The final diagnoses were VST (12.2%), neuro-Behçet syndrome (NBS) (75.6%), isolated optic neuritis (0.6%), psycho-Behçet syndrome (0.6%), and indefinite (11%). VST and NBS were never diagnosed together. Ten years from onset of BD 45.1% (all NBS) reached a disability level of EDSS 6 or higher, and 95.7 +/- 2.1% of the patients were still alive. Having accompanying cerebellar symptoms at onset or a progressive course is unfavorable. Onset with headache or a diagnosis of VST is favorable. Two major neurological diagnoses in BD are NBS and VST. These are distinct in clinical, radiological, and prognostic aspects, hence suggesting a difference in pathogenesis.

CNS involvement in neuro-Behçet syndrome: an MR study

BACKGROUND AND PURPOSE

Behçet disease (BD) is a multisystem vasculitis of unknown origin in which neurologic involvement has been reported in the range of 5% to 10% in large series. Reports on clinical and radiologic aspects of neuro-Behçet syndrome (NBS) are in general limited in number. Our purpose was to determine the MR patterns in patients with NBS who had neural parenchymal involvement and to correlate our findings with possible vascular pathophysiology.

METHODS

The MR images of 65 patients with NBS and neural parenchymal involvement were reviewed. In a subgroup of patients who had serial MR studies, we evaluated the anatomic-radiologic location and distribution of the lesions and whether they corresponded to any vascular territory, and studied their extension, enhancement patterns, and temporal course.

RESULTS

The most common imaging finding in NBS patients who had neural parenchymal involvement was a mesodiencephalic junction lesion with edema extending along certain long tracts in the brain stem and diencephalon in 46% of the patients. The next most common location of involvement was the pontobulbar region, seen in 40% of the cases. Three primary cervical spinal cord lesions and one case of isolated optic nerve involvement were observed.

CONCLUSION

The parenchymal distribution of lesions in NBS appears to support the hypothesis of small-vessel vasculitis; mainly, venular involvement. The anatomic distribution of intraaxial veins of the CNS explains the predominant involvement of the brain stem structures observed in our patients. This pattern of lesion distribution might help to differentiate NBS from other vasculitides as well as from the inflammatory-demyelinating diseases of the CNS, such as multiple sclerosis.

Corticosteroid therapy augments gastroduodenal permeability to sucrose

OBJECTIVE

The aim of the present study was to investigate whether corticosteroid therapy alters gastroduodenal mucosal permeability and whether permeability alteration is associated with macroscopic mucosal damage.

METHODS

Eight patients taking oral corticosteroid therapy (total prednisone-equivalent dose, 1.5+/-0.1 g; duration, approximately 30 days), nine patients with multiple sclerosis taking high-dose intravenous methyl-prednisolone therapy (total dose, 11.7+/-0.5 g; duration, approximately 9 days), and 20 age- and gender-matched controls were studied. Gastroduodenal permeability was determined using sucrose as a site-specific permeability probe. Five-hour urine was collected after ingesting 100 g of sucrose and its urinary excretion rate was measured using high-pressure liquid chromatography. Gastroduodenal endoscopy was performed before steroid therapy to exclude subjects with evidence of macroscopic mucosal lesions. The sucrose test and endoscopy were repeated after completion of corticosteroid therapy.

RESULTS

The urinary sucrose excretion rates were similar in the control group and in patient groups before corticosteroid therapy. The median excretion rate of sucrose increased four (one to 28)- and eight (two to 35)-fold, respectively, as compared with pretreatment values in patients taking oral steroid and high-dose intravenous methyl-prednisolone therapy (p < 0.01). Considering all patients together, subjects who received a mean prednisone-equivalent dose of 8.4+/-1.5 g exhibited mucosal lesions, whereas patients who received 3.3+/-1.8 g did not (p = 0.06). The post-therapy increments in sucrose excretion rates were associated with neither the presence of macroscopic lesions nor with the total steroid dose received.

CONCLUSIONS

Corticosteroid therapy augments gastroduodenal permeability and high doses are associated with macroscopic mucosal lesions. Steroid-induced permeability increase does not appear to be associated with the presence of macroscopic mucosal lesions.

Thalidomide in the treatment of the mucocutaneous lesions of the Behçet syndrome. A randomized, double-blind, placebo-controlled trial

BACKGROUND

Recurrent oral and genital ulcers are the most frequent problem in the management of the Behçet syndrome. Uncontrolled experience suggests that thalidomide may help prevent recurrences of these ulcers.

OBJECTIVE

To determine the efficacy of two thalidomide dosages in the treatment of mucocutaneous lesions of the Behçet syndrome.

DESIGN

Randomized, double-blind, placebo-controlled trial.

SETTING

Specialist outpatient clinic for the Behçet syndrome in Turkey.

PATIENTS

96 male patients with the Behçet syndrome who primarily had mucocutaneous lesions without major organ involvement.

INTERVENTION

Thalidomide, 100 mg/d or 300 mg/d, or placebo for 24 weeks.

MEASUREMENTS

Sustained absence of any oral and genital ulceration during treatment (complete response) and changes in the number of mucocutaneous lesions. An additional evaluation was done 4 weeks after treatment ended.

RESULTS

A complete response occurred in 2 of the 32 patients (6% [95% CI, 0.8% to 20.8%]) receiving thalidomide, 100 mg/d; in 5 of the 31 patients (16% [CI, 5.5% to 33.7%]) receiving thalidomide, 300 mg/d; and in none of the 32 patients (0% [CI, 0% to 10.9%]) receiving placebo (P = 0.031). The suppressive effect of thalidomide with either dosage was evident at 4 weeks for oral ulcers (P < 0.001) and at 8 weeks for genital ulcers (P < 0.001) and follicular lesions (P = 0.008). This effect persisted during treatment but diminished rapidly after treatment was discontinued. Both thalidomide dosages led to significant increases in the number of erythema nodosum lesions during the first 8 weeks of treatment (P = 0.03). Polyneuropathy developed in 4 patients (1 in the 100-mg/d group and 3 in the 300-mg/d group); in 3 of these patients, the condition was diagnosed after the trial had ended.

CONCLUSIONS

Thalidomide is effective for treating the oral and genital ulcers and follicular lesions of the Behçet syndrome. A dosage of 100 mg/d is as effective as a dosage of 300 mg/day.