An immune-related adverse event of Behcet's-like syndrome following pembrolizumab treatment

BACKGROUND

In recent years, the emergence of immunotherapy has renewed therapeutic modality. Different from traditional anti-tumor therapy, immune-related adverse events of skin, gastrointestinal tract, liver, lung, endocrine glands commonly occurred. At present, only one case of immune-related adverse event of Behcet's-like syndrome following pembrolizumab treatment was reported in USA, and no one is reported in China.

CASE PRESENTATION

Here, we report a rare case of Behcet's-like symptom following pembrolizumab treatment. A 43-year-old female was diagnosed as lymph node and bone metastasis of adenocarcinoma with unknown primary lesion, probably being of pulmonary origin. She was treated with pembrolizumab 200 mg every three weeks in combination with chemotherapy for 6 cycles, followed by pembrolizumab monotherapy maintenance. However, she developed Behcet's-like syndrome with oral ulcer, genital uler, phlebitis, and vision loss after 9 cycles of pembrolizumab treatment. She was treated with prednisone 5 mg orally three times a day. Two weeks later, dose of glucocorticoid gaven to the patient gradually decreased with improved symptoms. After a treatment-free withdrawal period, the patient requested to continue pembrolizumab treatment. Unfortunately, the above symptoms recurred on the second day following pembrolizumab treatment, and glucocorticoid was taken once again. The symptoms improved and the condition was under control.

CONCLUSIONS

In view of the exponential growth of immunocheckpoint inhibitors (ICIs) in a variety of tumors, we should be alert to related adverse events, especially the rare rheumatic manifestations.

Does anticoagulation in combination with immunosuppressive therapy prevent recurrent thrombosis in Behçet's disease?

Vascular involvement in Behçet's disease (BD) occurs in up to 50% of patients. The main mechanism of thrombosis is inflammation. Thus, immunosuppressants (IS) are the mainstay of therapy, and adding anticoagulation (AC) is controversial. In daily practice, we observed that patients who received AC in combination with IS experienced less recurrent thrombosis and decided to investigate our BD patients retrospectively. We hypothesized that adding AC to immunosuppressive therapy may lower the risk of recurrent thrombosis. Treatment at the time of first or recurrent thrombotic events was recorded. Events under the only IS and IS + AC treatments were compared. There were 40 patients (33 males). The most common types of first vascular events were deep vein thrombosis (77.5%) followed by pulmonary embolism (PE) (52.5%). One patient did not receive any treatment. Among the 39 patients, 32 received glucocorticoid and at least one of the azathioprine, or cyclophosphamide, anti-TNF, 5 received monotherapy with azathioprine, 1 received monotherapy with corticosteroid, and the remaining 1 received monotherapy with cyclophosphamide. In total, 22 patients (55%) experienced 27 recurrent venous thromboembolism (VTE) events. Two (7.4%) events while only on AC, 2 (7.4%) events while on AC + IS, and 15 (55.5%) events occurred while on only IS. Eight (19.6%) patients were not receiving any treatment during relapses. The recurrence rate was statistically significantly lower in the IS + AC treatment group compared to IS alone. In conclusion, IS are the mainstay of treatment for BD, and adding AC may help to lower the recurrence risk of thrombotic events.

Biological therapy for ocular Behçet's disease with off-label drug prescription in Turkey

OBJECTIVE

The use of biological agents in the treatment of ocular Behçet's disease has recently become more frequent. The use of two agents, infliximab (IFX) and adalimumab (ADA), for the treatment of Behçet's disease requires prior approval by the Turkish Medicines and Medical Devices Agency. We report on a review of such applications with a view to informing on how such agents are used off-label in Turkey.

METHODS

Prescriptions for off-label use of IFX or ADA sent from hospitals in Turkey to the Turkish Medicines and Medical Devices Agency in 2018 were evaluated. Demographic data, previous treatment regimens and reasons for referral were extracted from the files of the cases.

RESULTS

A total of 662 patients were considered for off-label use of IFX or ADA for the treatment of ocular Behçet's disease. The mean age of the patients was 35.7±10.8 years (range 12-76); 61.5% of patients were men and 38.5% were women. Of the applications, 345 (52.1%) were for IFX and 317 (47.9%) for ADA. Among the referring hospitals, the public university hospitals ranked first, accounting for 77.9% of IFX and 88.6% of ADA prescriptions. Most applications were made after the failure of conventional therapy, which included steroids and immunosuppressive agents.

CONCLUSION

IFX and ADA are rarely used as initial therapy. Stepwise treatment is still preferred in the treatment of ocular Behçet's disease in Turkey. Our report informs on the management of this difficult-to-treat condition.

FROSTED BRANCH ANGIITIS IN METHIMAZOLE-INDUCED ANTINEUTROPHIL CYTOPLASMIC ANTIBODY-POSITIVE VASCULITIS

PURPOSE

To describe an unusual case of frosted branch angiitis that developed in a patient with acute onset systemic vasculitis possibly triggered by the antithyroid medication methimazole.

METHODS

We conducted a thorough review of the medical records of a 16-year-old female patient who presented with frosted branch angiitis. During the initial hospital admission, the patient underwent an extensive systemic workup to determine the etiology of her disease and ophthalmologic testing including fundus photographs and fluorescein angiography.

RESULTS

Our patient presented with a unilateral acute onset loss of vision, whose fundus examination revealed the pathognomonic features of frosted branch angiitis. Extensive systemic workup revealed an antineutrophilic cytoplasmic antibody-positive vasculitis, possibly triggered by methimazole.

CONCLUSION

This case is the first reported frosted branch angiitis associated with a drug-induced antineutrophilic cytoplasmic antibody-positive vasculitis triggered by methimazole.

Tropomyosin-induced arthritis in rats

OBJECTIVE

Immunization of rats with alpha-tropomyosin (TPM) led to arthritis, uveitis and dermatitis, typical features of Behçet's disease (BD). The present study characterizes the arthritic features of this animal model, not previously described.

METHODS

Lewis rats were immunized with bovine alpha-TPM and another group of rats was treated with neutralizing anti- tumor necrosis factor-alpha (TNF-alpha) antibodies.

RESULTS

Clinically more than 90% of the immunized rats developed severe acute arthritis 12 days after vaccination. Rats that were followed-up for 6 months had persistent inflammation of the leg joints. Histologic studies demonstrated predominant mononuclear infiltrations in the acute phase of arthritis; the chronic arthritic process resulted in cartilage and bone damage and abundant fibrosis which led to joint deformations. Male and female rats had a similar clinical course. Analysis of the splenocyte cytokine profile kinetics revealed a persistently high level of interferon-gamma (INF-gamma) and an increase in TNF-alpha secretion during the acute phase. Increasing levels of interleukin (IL)-10 heralded the decline in clinical arthritis. No IL-4 was detected. No arthritis was detected in the rats treated with anti-TNF-alpha antibodies.

CONCLUSION

The data indicates that alpha-TPM serves as an autoantigen to induce acute and chronic destructive arthritis in rats. This model is a TNF-alpha dependent autoimmune disease, with a Th1 cytokine profile.

[Essential thrombocythemia associated with incomplete type intestinal Behçet disease during hydroxyurea treatment]

A 77-year-old man was diagnosed as having essential thrombocythemia in 1992. Treatment with hydroxyurea was started in 1997, which stabilized the platelet count. The patient then suffered from pharyngalgia and rhinitis with a high fever, immediately after which he developed tarry stools and anemia and was admitted to our hospital. The physical examination revealed splenomegaly, oral aphthous ulcers, genital ulcers and skin lesions on the lower limbs. His hematological and biochemical tests revealed anemia and increased level of C-reactive protein. He also had an HLA-B51 phenotype. The findings of gastro-intestinal and colon fiberoscopy showed a duodenal ulcer and multiple ulcers on ascending colon. He was thus diagnosed as having intestinal tract-type Behçet disease. After withdrawal of the hydroxyurea administration, the intestinal ulcers, oral aphthous ulcers and genital ulcers improved.

Decreased cerebral blood flow in neuro-Behçet's syndrome patients with neuropsychiatric manifestations and normal magnetic resonance imaging--a preliminary report

Involvement of the brain is one of the most important complications of Behçet's disease, but its diagnosis is difficult because of the lack of effective imaging tools. Therefore, technetium-99m ethyl cysteinate dimer (Tc-99m ECD) single-photon emission computed tomography (SPECT) of the brain was used to detect abnormal regional cerebral blood flow in patients with neuro-Behçet's syndrome (NBS). Tc-99m ECD brain SPECT was performed to detect hypoperfusion areas of the brain in 10 NBS patients with definite neuropsychiatric symptoms or signs and normal brain magnetic resonance imaging (MRI) findings. Tc-99m ECD brain SPECT demonstrated hypoperfusion areas of the brain in all of the 10 NBS patients. The parietal lobes were the most common areas with hypoperfusion lesions. Tc-99m ECD brain SPECT is a more sensitive and useful tool than brain MRI for detecting hypoperfusion areas of the brain in NBS patients.

Behcet's disease in a patient with chronic myelogenous leukemia under hydroxyurea treatment: a case report and review of the literature

Behcet's disease (BD) is a chronic, relapsing vasculitis of unknown etiology. Its association with chronic myelogenous leukemia (CML) is extremely rare, and typical manifestations of BD were observed in a very few patients with CML, mainly under interferon-alpha (IFN-alpha) treatment. Skin pathergy test, being positive in about 50% of patients with BD, is also positive in some IFN-alpha-treated patients with CML without any evidence of BD symptoms. We describe a 62-year-old woman with CML who developed characteristic features of BD, including a positive skin hyperactivity test, during treatment with hydroxyurea. Hydroxyurea has been implicated in the appearance of skin vasculitic ulceration, but this is the first case, according to our knowledge, where the development of BD was observed during hydroxyurea maintenance in the chronic phase of CML.

Steroid sensitivity and postoperative course of seven patients with Behçet's disease

Systemic administration of steroids to patients with Behçet's disease in Japan is often followed by a worsening in ocular symptoms. The sensitivity of 7 patients with Behçet's disease to steroids which were administered during and after intraocular surgery was therefore measured, and their postoperative course was reviewed. Three of the 7 showed a low steroid sensitivity, and the frequency of postoperative inflammatory episodes and the intraocular pressure were both higher for this group than for the 4 who showed high steroid sensitivity.

Behçet's disease in patients with chronic myelogenous leukemia: possible role of interferon-alpha treatment in the occurrence of Behçet's symptoms

Two patients with chronic myelogenous leukemia (CML) who developed characteristic features of Behçet's disease (BD) during alpha-interferon (IFN-alpha) treatment and another patient who had a diagnosis of BD preceding CML are presented. In the first two patients, features of BD appeared 6 months after the initiation of IFN-alpha treatment: they included recurrent oral aphthae, genital ulceration, arthritis, folliculitis, and a positive skin pathergy test. The third patient, however, had a diagnosis of Behçet's disease 4 years before diagnosis of Philadelphia-positive CML. We prospectively examined the skin pathergy reaction in a group of patients with CML, multiple myeloma, and hairy cell leukemia both before and after IFN-alpha treatment and found two additional patients with CML who developed a positive skin pathergy test following IFN-alpha treatment.

[Manifestation of neuro-Behçet disease in cyclosporin A therapy]

Behçet's disease is a chronic inflammatory disorder characterized by the triad of oral and genital ulcers and ocular lesions. One of the most life-threatening manifestations results from involvement of the central nervous system, presenting as necrotising meningo-encephalitis, most typically affecting the brain stem, internal capsula and basal brain ganglia. We report on a young Caucasian mate with Behçet's disease (HLA B 51+) and recurrent uveitis, who presented with acute neurologic involvement under CyA therapy 5 years after first diagnosis. At the time of admission MRI showed two high intensity lesions in the brain stem on T1 weighted images enhanced with Gd-DTPA, reflecting active inflammation. Shortly after admission the CyA treatment was stopped and a therapy with high dose steroids and chlorambucil, starting with a dose of 2 mg daily was initiated. This led to improvement of neurologic symptoms, also documented by brain stem evoked potentials and investigations of cerebrospinal fluid, as well as of ophtalmologic symptoms within few days of treatment. Steroids were reduced to a maintenance dose of 12 mg Prednyliden daily. The brain MRI taken 8 weeks after onset of chlorambucil treatment showed the same lesions in the brain stem, with low intensity in the T1 weighted images an no longer enhanced Gd-DTPA uptake. Chlorambucil dose was reduced to 2 mg every second day after 8 months. There was no exacerbation in the follow-up of 12 months. We conclude that a 6-week Chlorambucil therapy consisting of 2 mg/p.o./d led to remission of neurologic involvement firstly evolving under CyA-medication which suggests superiority of chlorambucil as a treatment modality in neurologic as well as ophtalmologic features of the disease.

[Neuro-Behçet disease with bilateral cheiro-oral syndrome following simultaneous multiple brain hemorrhage]

A 34-year-old man with neuro-Behçet disease showed bilateral cheiro-oral syndrome following simultaneous multiple brain hemorrhage. The patient suddenly developed fever, headache, right-sided heminumbness, and gait disturbance after ciclosporin therapy was instituted. Bilateral uveitis, oral aphthous ulcers and follicular skin eruptions were observed. Neurologically, apathetic state, horizontal gaze palsy, spastic paraparesis with right Babinski sign, gait difficulty, and painful dysesthesia of perioral regions, right upper and lower extremities and left hand were revealed as main symptoms. Erythrocyte sedimentation rate was elevated and C-reactive protein was positive. Cerebrospinal fluid examination showed lymphocytic pleocytosis. A brain CT scan demonstrated focal high density areas with slight contrast enhancement in the median region of the tegmentum of pons, and in the subcortex of right superior parietal lobe. T1, T2 and proton density images of MRI taken 50 days after the onset disclosed small irregular low signal intensities in the lesions that correspond to the CT findings. Corticosteroid was administered immediately after admission, which resulted in a rapid improvement of clinical symptoms and a complete disappearance of laboratory abnormalities and CT changes. As dysesthesia was attenuated, bilateral typical symptoms of cheiro-oral syndrome were found. These results suggest that the intracerebral hemorrhage was caused by angitis related to Behçet disease. MRI findings implicate that the involvement of bilateral paramedian areas including medial parts of both the medial leminiscus and the ventral secondary ascending tract of the trigeminal nerve is responsible for bilateral cheiro-oral syndrome.(ABSTRACT TRUNCATED AT 250 WORDS)