Changes in the Gut Microbiome Contribute to the Development of Behcet's Disease via Adjuvant Effects

Behcet’s disease (BD) is associated with considerable gut microbiome changes. However, it still remains unknown how the composition of the gut microbiome exactly affects the development of this disease. In this study, transplantation of stool samples from patients with active ocular BD to mice via oral gavage was performed. This resulted in decreases of three short chain fatty acids (SCFAs) including butyric acid, propionic acid and valeric acid in the feces of the BD-recipient group. Intestinal barrier integrity of mice receiving BD feces was damaged as shown by a decreased expression of tight junction proteins and was associated with the release of Lipopolysaccharides (LPS) in the circulation. The mice also showed a higher frequency of splenic neutrophils as well as an enrichment of genes associated with innate immune responses in the neutrophils and CD4 + T cells as identified by single cell RNA sequencing. Analysis of neutrophils and T cells functions in these mice showed an enhanced mesenteric lymph node and splenic Th1 and Th17 cell differentiation in association with activation of neutrophils. Transplantation of BD feces to mice and subsequent induction of experimental uveitis (EAU) or encephalomyelitis (EAE) led to an exacerbation of disease in both models, suggesting a microbial adjuvant effect. These findings suggest that the gut microbiome may regulate an autoimmune response via adjuvant effects including increased gut permeability and enhancement of innate immunity.

Heart Rate Variability as an Indicator of Autonomic Nervous System Disturbance in Behcet's Disease

Background

Behçet’s disease (BD) is a multisystemic vasculiti where cardiac involvement is not common. Previous studies have shown that the incidence of ventricular arrhythmia and sudden cardiac death (SCD) is higher in patients with BD than in the healthy population. Among various possible explanations, autonomic nervous system (ANS) dysfunction has been suggested. Few studies have evaluated ANS function in patients with BD, and the results obtained are controversial.

Objective

We aimed to assess cardiac autonomic function by heart rate variability (HRV) in patients with BD; to evaluate circadian changes in HRV; and to study the relationship between HRV parameters and disease parameters.

Methods

Thirty-six patients with Behçet’s disease (median age 42 years, 28 men) and 36 age- and sex-matched healthy volunteers were included. HRV analyses were performed in the time and frequency domains for the entire 24-hour period and for the daytime and nighttime periods. BD activity was studied with Behcet’s disease current activity form (BDCAF).

Results

Patients with BD had significantly lower values of SDNN compared to controls. PNN50, RMSSD, and HF components mean values were significantly reduced in patients than in controls implying parasympathetic impairment. LF was comparable between the two groups, whereas LF/HF ratio was significantly higher in BD group. The circadian rhythm of HRV was preserved in patient group. There was no significant correlation of CRP or disease duration with HRV indices in Behçet’s subjects. BDCAF score was found to be negatively correlated with LF/HF.

Conclusion

Patients with BD, despite no cardiovascular involvement, have reduced parasympathetic activity compared with controls. However, circadian rhythms of autonomic function were preserved. As known, there is strong evidence for the role of the ANS in the pathogenesis of ventricular arrhythmias. Thus, being a practical tool, HRV can be an interesting approach for the rhythmic follow-up of BD patients.

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Lack of Association between Monocyte Chemoattractant Protein-1 (MCP-1) Gene Promoter Polymorphism and Behcet's Disease with and without Ocular Involvement in Iranian Population: A Case-Control Study

PURPOSE

This case-control study aimed to evaluate the possible association of MCP-1 - 2518A/G genetic polymorphism with Behcet's disease (BD) in the Iranian patients.

MATERIALS AND METHODS

This study was performed in 135 Behcet's patients (51 ocular and 84 non-ocular) and 79 healthy individuals. Peripheral blood samples were genotyped for MCP-1 - 2518A/G using the PCR-RFLP technique.

RESULTS

The statistical analysis of MCP-1 - 2518A/G showed no significant differences in genotype/allele frequencies between Behcet's patients and controls. There was no significant association in genotype/allele frequencies between either ocular or non-ocular BD patients and controls. Also, different genotype/allele frequencies between ocular and non-ocular BD were not statistically significant.

CONCLUSIONS

In this study, with a threshold P-value of 0.05 and an estimated power of 0.81 to detect a significant association (odds ratio ≥1.2), we did not observe any association of this variant with Behcet's disease.

Incidence and Risk Factors for Blindness in Uveitis: A Nationwide Cohort Study from 2002 to 2013

Purpose: To investigate the incidence and risk factors of blindness in uveitis.Methods: From a national sample cohort (n = 1,025,340), we selected 9,036 new-onset uveitis patients. Incidences of unilateral and bilateral blindness (visual acuities ≤20/400) were estimated and socioeconomic and clinical risk factors for unilateral blindness in uveitis patients were identified.Result: Incidence of unilateral and bilateral blindness was 2.93 and 0.42 per 1,000 person-years, respectively. The risk factors for unilateral blindness were age >40 (hazard ratio [HR], 2.77, 95% CI [confidence interval], 1.11-6.92) and low household income (HR, 1.50; 95% CI, 1.02-1.98) in uveitis overall, and Behçet's disease (HR, 4.49; 95% CI, 1.59-12.71) in non-anterior uveitis, respectively.Conclusions: Low household income and Behçet's disease influence the risk of blindness in uveitis patients. These findings will help in assessing blindness-related socioeconomic burdens and planning health-care strategies for uveitis patients.

Myocardial involvement in Behçet's disease may be higher in patients with Neuro-Behçet's disease: a speckle tracking echocardiographic study

BACKGROUND

Behcet's disease (BD) may present with life threating complications including neurological and cardiovascular involvement. Neuro-Behcet's disease (NBD) is one of the most important causes of morbidity and mortality in patients with BD. The aim of the present study is to investigate whether patients with NBD are different than BD patients with other manifestations in terms of subclinical myocardial dysfunction.

METHODS

Forty patients with NBD (23 female, mean age: 42.4 ± 9.4 years), 40 patients with BD (9 female, mean age: 39.7 ± 9.0 years) and 40 controls (20 male, mean age: 41.8 ± 6.5 years) were consecutively included in the study. All subjects underwent a transthoracic echocardiography for evaluation of left ventricular (LV) and atrial (LA) functions with two-dimensional (2D) speckle tracking echocardiography (STE).

RESULTS

Baseline characteristics, clinical data, LV dimensions, systolic and diastolic functions were all in normal range among the groups. LV global longitudinal strain (LV-GLS) was significantly lower in patients with NBD and BD patients without neurologic involvement compared to controls. LA conduit strain was significantly lower in patients with NBD compared to controls. Patients with both parenchymal NBD and vascular NBD manifestations had significantly lower LV-GLS and LA conduit strain compared to controls. Linear regression analysis demonstrated that among cardiovascular risk factors only presence of NBD was the independent predictor of LV-GLS.

CONCLUSIONS

BD is associated with impaired LV and LA functions. LV-GLS and LA conduit strains of the patients with NBD were lower. NBD was an independent predictor of LV-GLS, suggesting a link between neurological manifestations and cardiac dysfunction in BD patients.

Clinicodemographic pattern and treatment outcome of Behcet's disease cases presenting in a tertiary eye center of Nepal

PURPOSE

To know the clinical and demographic pattern, and the outcome of treatment of Behcet's disease (BD) cases in Nepal METHODS: Retrospective series of all the cases of BD who had come over the period of 12 years (Jan 2007-Dec 2015) Tilganga Institute of Ophthalmology.

RESULT

Twenty-one cases were included, 17 (81%) male and four (19%) female. Mean age was 28.88 ± 9.18 years. Mean follow-up period was 3.6 ± 2.6 years. All had nongranulomatous panuveitis. Hypopyon was seen in 13 (61.9%) cases. Small retinal infiltrates in 13 (61.9%) cases and retinal vasculitis in ten (47.6%) cases were seen. Cataract (in 13, 61.9%) and optic atrophy (in 11, 52.4%) cases were present. Oral ulcer was present in 20 (95.2%), genital ulcer in 15 (72%), and skin lesions in 13 (62%) cases.

CONCLUSION

BD affected mainly the most active age group and was predominant in male. Optic atrophy was the leading cause of irreversible vision loss. Despite being a less common condition, BD should be considered in the differential diagnosis of panuveitis cases in the Nepalese population.

Evaluation of diode laser versus topical corticosteroid in management of Behcet's disease-associated oral ulcers: a randomized clinical trial

OBJECTIVES

The current trial was conducted to assess the effect of diode laser therapy compared to topical corticosteroid in management of oral ulcers of BD.

MATERIALS AND METHODS

Fifty patients were divided randomly into two parallel groups. The first group received 980 nm diode laser; the second group received topical corticosteroid (0.1% triamcinolone acetonide). The outcome measures included oral ulcer activity index (composite index), pain (VAS), number of oral ulcers, healing time, and oral health-related quality of life (OHIP-14). The collected data were analyzed for any statistical significance.

RESULTS

A statistically significant difference was detected between laser and corticosteroid groups favoring laser on comparing composite index and VAS scores on the first and third days and on comparing number of ulcers on the third and fifth days. A statistically significant difference was detected between laser and corticosteroid groups on comparing scores of the questions assessing discomfort with eating food, irritability with other people, taste worsening, unsatisfactory diet, and painful aching on the first and/or third days. No adverse effects were reported by participants of both groups.

CONCLUSIONS

Diode laser is efficient safe treatment modality for management of BD-associated oral ulcers. Diode laser was more efficient than triamcinolone acetonide in controlling pain and reducing oral ulcer activity.

CLINICAL RELEVANCE

Laser therapy is efficient safe modality that could spare BD patient from adding a new medication to their long list, being just one visit compared to other regular daily regimen medications.

TRIAL REGISTRATION

ClinicalTrials.gov registration number: NCT03771768.

Hugh-Stovin syndrome: the 'incomplete Behcet's disease'. A case study of a young adult with recurrent pulmonary embolism and pulmonary arterial aneurysms

Hugh-Stovin Syndrome (HSS) is characterized by recurrent thrombophlebitis and multiple pulmonary and/or bronchial artery aneurysms indistinguishable from the cardiovascular features seen in Behcet's disease (BD). Our case describes a 30-year-old male with recurrent pulmonary embolism and bilateral pulmonary aneurysms. Autoimmune, hypercoagulable, and infectious work up were negative. Elevated inflammatory markers and absence of the typical clinical findings seen in BD led to the diagnosis of Hugh-Stovin syndrome (HSS). Immunosuppression using steroids and azathioprine led to clinical response. Anticoagulation was continued based on risk/benefit ratio.

Development and preliminary validation of the Behçet's syndrome Overall Damage Index (BODI)

Objective

To develop and validate the evidence-based and consensus-based Behçet’s Syndrome Overall Damage Index (BODI).

Methods

Starting from 120 literature-retrieved preliminary items, the BODI underwent multiple Delphi rounds with an international multidisciplinary panel consisting of rheumatologists, internists, ophthalmologists, neurologists, and patient delegates until consensus was reached on the final content. The BODI was validated in a cross-sectional multicentre cohort of 228 patients with Behçet’s syndrome (BS) through the study of (a) correlation between BODI and Vasculitis Damage Index (VDI) and (b) correlation between BODI and disease activity measures (ie, Behçet’s Disease Current Activity Form (BDCAF), Physician Global Assessment (PGA), Patient Global Assessment (PtGA)), c) content and face validity and (d) feasibility.

Results

The final BODI consists of 4 overarching principles and 46 unweighted-items grouped into 9 organ domains. It showed good to excellent reliability, with a mean Cohen’s k of 0.84 (95% CI 0.78 to 0.90) and a mean intra-class correlation coefficient of 0.88 (95% CI 0.80 to 0.95). Overall, 128 (56.1%) patients had a BODI score ≥1, with a median score of 1.0 (range 0–14). The BODI significantly correlated with the VDI (r=0.693, p<0.001), demonstrating to effectively measure damage (construct validity), but had greater sensitivity in identifying major organ damage and did not correlate with disease activity measures (ie, BDCAF: p=0.807, PGA: p=0.820, PtGA: p=0.794) discriminating damage from the major confounding factor. The instrument was deemed credible (face validity), complete (content validity) and feasible by an independent group of clinicians.

Conclusions

Pending further validation, the BODI may be used to assess organ damage in patients with BS in the context of observational and controlled trials.

Specific sweat metabolite profile in ocular Behcet's disease

BACKGROUND

Behcet's disease (BD) is an autoimmune disorder with the serious possibility of blindness, calling for further research on its pathogenesis. Our aim was to study the metabolite composition of sweat in BD and to identify possible biomarkers.

METHODS

Metabolomics analysis was performed on sweat samples from 20 BD patients and 18 normal controls by liquid chromatography tandem mass spectrometry.

RESULTS

A significantly different metabolic profile of sweat was observed when BD patients were compared with healthy controls. The result of the orthogonal partial least squared-discrimination analysis (OPLS-DA) showed that these two comparison groups could be separated with a relatively satisfactory fitting degree (R2Y = 0.995 and Q2 = 0.817 in positive ion mode; R2Y = 0.991 and Q2 = 0.721 in negative ion mode). Based on OPLS-DA, a panel of metabolites was selected as candidate biomarkers, including l-citrulline, l-pyroglutamic acid, urocanic acid, 2-oxoadipic acid, cholesterol 3-sulfate, and pentadecanoic acid.

CONCLUSION

This is the first report on the metabolite profile of sweat in BD. Our results demonstrated a significantly different metabolite composition of sweat in BD compared to that of healthy controls.

A Darwinian View of Behçet's Disease

Behçet's disease (BD) is a multisystem inflammatory disorder of unknown etiology, characterized by oral and genital ulceration, with other complications including eye, skin, joint, and central nervous system (CNS) lesions. Diagnosis is based on clinical findings, which may differ between patients. There is a strong genetic basis for BD; however, only a few genes have been associated with the disease across the geographical spread of BD. In this article, we discuss the history and combination of genes involved in this complex disease in relation to the geographical range and present our view that the disease has developed from a Darwinian perspective, with different gene polymorphisms that affect the same biological pathway. Moreover, these mutations individually are protective mechanisms against the disease relevant to each region, which affected both archaic and modern humans.

Clinical Characteristics of Adult Patients with Systemic Vasculitis: Data of 1348 Patients from a Single Center

OBJECTIVE

To investigate the clinical characteristics of patients with systemic vasculitis in China by analyzing the data from a nationwide registry database, the Chinese Registry for Systemic Vasculitis (CRSV).

METHODS

The demographic data, clinical presentations, image and laboratory test results, disease activity assessment, treatment, and outcome of patients enrolled with the confirmed diagnosis of systemic vasculitis, including Takayasu's arteritis (TAK), ANCA-associated vasculitis (AAV), Behcet's syndrome (BD), Polyangitis nodosa (PAN), and unclassified systemic vasculitis (USV), were collected since July 2013 in the CRSV. The data during July 2013 and February 28 of 2020 were retrieved and analyzed.

RESULTS

Up to February 2020, 3852 patients in total were registered in the CRSV. In Peking Union Medical College Hospital (PUMCH), 1348 patients were registered, including 730 patients with TAK, 343 with Behcet's disease (BD), 191 with AAV, 53 with USV, and 31 with PAN. More male patients were found in PAN (64.5%), BD (59.8%), and AAV (52.4%), while TAK was more prevalent in female patients (85.9%). The average age at disease diagnosis was 29.6 in TAK, 33.2 in BD, 28.6 in PAN, 39.4 in USV, and 48.1 in AAV. A significant difference was found between age at diagnosis of TAK and AAV. Gender comparisons revealed that the age at diagnosis of male patients with AAV was older than female patients. Hypertension (57.3%) and stroke (17.5%) were found to be more common in male patients with TAK, vascular involvement (27.3%) was found to be more common in male patients with BD, while neurological involvement (29.0%) was found to be more common in male patients with AAV than in females.

CONCLUSION

This registry is the first in China and provides rich information about the clinical characteristics of Chinese patients with systemic vasculitis. There are significant differences in clinical presentations between different categories of systemic vasculitis.

Adalimumab in Treatment of Uveitis in Pediatric Behcet's Disease-a Case Report

Introduction

Behcet's Disease (BD) is an inflammatory disease characterized by multisystemic involvement and featured by a chronic, relapsing disease course. Recurrent ocular inflammation and macular involvement may lead to severe loss of visual acuity. Prolonged use of local and systemic corticosteroids lead to numerous side effects and complications. Very often other immunosuppressive therapies are needed. Biologic agents are promising for the treatment of Behcet's disease-associated uveitis.

Aim

To report successful treatment of paediatric uveitis due to incomplete Behçet's disease with administration of adalimumab, after failing to react to all other modalities of treatment.

Case report

We present the case of a 15-year-old girl who was treated for reccurent uveitis in both eyes with developed complications on anterior and posterior ocular segment. She was earlier treated with topical and systemic steroids for uveitis, laser photocoagulation and methotrexate, however, relapses occurred inspite all treatment modalities. Patient was diagnosed with incomplete Behcet's disease, and adalimumab therapy was initiated. Inflammation was well-controlled by adalimumab administration without need for local or systemic corticosteroids.

Conclusion

Adalimumab is effective for treating children with Behcet's disease-associated uveitis. Control of ocular inflammation in our case was achieved without need for continuing local or systemic corticosteroids, thus preventing further complications and possible significant vision loss.

Advances in the Treatment of Behcet's Disease

Purpose of Review

To assess current management of Behcet’s disease (BD). Controversies on therapeutic approaches to different manifestations, whether conventional immunosuppressives (IS) or biologic agents, should be chosen, and options for refractory disease are discussed.

Recent Findings

Glucocorticoids are still the main agents for remission-induction and azathioprine the first-line conventional IS in maintenance phase to prevent relapses of major organ involvement. Apremilast is shown to be a safe and effective option approved by the FDA for oral ulcers. Large case series confirmed the efficacy and safety of TNFα inhibitors and Interferon-α. Promising results are observed with IL-1 inhibitors, ustekinumab, secukinumab, and tocilizumab for refractory BD.

Summary

Although both conventional IS and biologic agents are effectively used to suppress inflammation in BD, there is still an unmet need for clear therapeutic strategies in the management for different manifestations. Further controlled studies with new biologic agents, anticoagulants and the benefit of concomitant IS usage with biologics are needed to optimize the management of BD.

One-year results of stent graft repair for carotid artery pseudo-aneurysm in patients with Behcet's disease

OBJECTIVES

Behcet's disease is a multisystem disorder of unknown etiology with vascular complications. This study reviewed the mid-term outcome of Behcet's disease patients with carotid artery pseudo-aneurysms treated by endovascular stent-graft repair at our unit.

METHODS

During a period of 11 years, six cases were included. Postoperative ultrasound duplex results were recorded along with computed tomography angiography report done a year after intervention.

RESULTS

The mean age (±SD) was 38 (±5.2) years. The mean (±SD) pseudo-aneurysm size was 33 (±12.2) mm. Technical success was 83%; failed cannulation of the internal carotid artery was encountered in one case. On day 2 post-operative, a duplex ultrasound revealed complete exclusion and thrombosis of the false aneurysm in all cases. A year later, a computed tomography angiography revealed a primary patency rate of 80%, and only one case had a recurrent pseudo-aneurysm at the distal margin of the stent graft. All cases, however, had complete thrombosis in the pseudo-aneurysms lumen with a mean (±SD) regression in size of 18 (±6) mm. The mean (±SD) percentage of in-stent stenosis was 34.5% (±11.73%).

CONCLUSIONS

Stent graft repair for carotid artery pseudo-aneurysm in Behcet's disease patients might be the preferable first line of treatment since it had a high technical success and mid-term primary patency rates, with additional fact that it obviously avoids the hazardous complications of surgery.

The Clinical Spectrum and Outcome of Uveomeningitis: A Comprehensive Analysis of 110 Cases

Purpose: Uveitis can be associated with meningitis (uveomeningitis) and the inflammation shared with the central nervous system. We aimed to describe the characteristics and outcome of uveomeningitis.Methods: We retrospectively analyzed 110 consecutive adult patients with uveomeningitis.Results: The main causes of uveomeningitis were Vogt-Koyanagi-Harada (31%), syphilis (16%), sarcoidosis (12%), Behçet's disease (7%), and multiple sclerosis (5%). Sixteen percent of uveomeningitis remained of undetermined origin. Compared to etiology-matched uveitis without meningitis, patients with uveomeningitis were younger, had more frequent neurological manifestations, and had more frequent abnormal cerebral magnetic resonance imaging findings. In contrast, no ocular feature upon examination was significantly associated with the presence of meningitis. Patients with uveomeningitis were more frequently treated with immunosuppressants but uveitis relapse and systemic complications did not differ between groups.Conclusion: Uveomeningitis is associated with a limited spectrum of diseases. Meningitis does not seem to impact ocular and extraocular outcomes. Therefore, lumbar puncture should be performed on an individual basis during the diagnostic workup of uveitis.

Decreased microRNA-155 in Behcet's disease leads to defective control of autophagy thereby stimulating excessive proinflammatory cytokine production

BACKGROUND

Earlier, we reported that the microRNA (miR)-155 expression in dendritic cells (DCs) from Behcet's disease (BD) patients was decreased and affected cytokine production of DCs. In this study, we investigated the mechanisms whereby miR-155 regulates cytokine production by DCs.

METHODS

The formation of autophagosomes in DCs was detected by transmission electron microscopy. Western blotting was used to detect the protein levels of LC3, Beclin-1, P62, p-mTOR, and p-Akt in DCs. TNF-α, IL-6, and IL-1β expression were investigated by ELISA. MiR-155 mimics were transfected to DCs to evaluate its effects on autophagy and cytokine production. RNA interference was used to downregulate the expression of TAB2.

RESULTS

The formation of autophagosomes was found in DCs of active BD patients. The expressions of LC3-II, Beclin-1, and P62 were significantly increased in DCs of active BD patients compared to that of inactive BD patients and healthy controls. The expressions of IL-6, IL-1β, and TNF-α were significantly increased in DCs of active BD patients compared to that of healthy controls. The autophagy promoter (3-MA) and inhibitor (rapamycin) significantly decreased or increased the expression of TNF-α, IL-6, and IL-1β by DCs. The expression of LC3-II and Beclin-1 was significantly increased, but the expression of P62 proteins was decreased in DCs transfected with miR-155 mimics or after TAB2 was downregulated. The expression of TNF-α, IL-6, and IL-1β was decreased in DCs after miR-155 was upregulated or TAB2 was downregulated. The ratios of p-Akt/Akt and p-mTOR/mTOR were decreased in DCs after miR-155 was upregulated.

CONCLUSIONS

These results suggest that miR-155 affects the production of TNF-α, IL-6, and IL-1β by DCs through activation of the Akt/mTOR signaling pathway and by affecting the process of autophagy.

Pathogenesis of Non-Infectious Uveitis Elucidated by Recent Genetic Findings

Uveitis is a generic term for inflammation of the uvea, which includes the iris, ciliary body, and choroid. Prevalence of underlying non-infectious uveitis varies by race and region and is a major cause of legal blindness in developed countries. Although the etiology remains unclear, the involvement of both genetic and environmental factors is considered important for the onset of many forms of non-infectious uveitis. Major histocompatibility complex (MHC) genes, which play a major role in human immune response, have been reported to be strongly associated as genetic risk factors in several forms of non-infectious uveitis. Behçet’s disease, acute anterior uveitis (AAU), and chorioretinopathy are strongly correlated with MHC class I-specific alleles. Moreover, sarcoidosis and Vogt-Koyanagi-Harada (VKH) disease are associated with MHC class II-specific alleles. These correlations can help immunogenetically classify the immune pathway involved in each form of non-infectious uveitis. Genetic studies, including recent genome-wide association studies, have identified several susceptibility genes apart from those in the MHC region. These genetic findings help define the common or specific pathogenesis of ocular inflammatory diseases by comparing the susceptibility genes of each form of non-infectious uveitis. Interestingly, genome-wide association of the interleukin (IL)23R region has been identified in many of the major forms of non-infectious uveitis, such as Behçet’s disease, ocular sarcoidosis, VKH disease, and AAU. The interleukin-23 (IL-23) receptor, encoded by IL23R, is expressed on the cell surface of Th17 cells. IL-23 is involved in the homeostasis of Th17 cells and the production of IL-17, which is an inflammatory cytokine, indicating that a Th17 immune response is a common key in the pathogenesis of non-infectious uveitis. Based on the findings from the immunogenetics of non-infectious uveitis, a personalized treatment approach based on the patient’s genetic make-up is expected.

Ultra-Widefield Fluorescein Angiography to Monitor Therapeutic Response to Adalimumab in Behcet's Uveitis

Purpose: To investigate the role of ultra-widefield fluorescein angiography (UWFA) for monitoring therapeutic response to adalimumab in patients with Behcet's uveitis.Methods: Patients with Behcet's uveitis treated with adalimumab for ≥30 weeks were included. Intraocular inflammation, best-corrected visual acuity, systemic medications, and UWFA scores were evaluated.Results: Thirty-eight eyes of 20 patients were included. Significant decreases in grading of anterior chamber cells and vitreous haze were observed at 6, 14, and 30 weeks after adalimumab administration (p < .001 for all). UWFA scores on vascular and capillary leakage were decreased at week 6 and further improved at weeks 14 and 30. Moreover, UWFA score further decreased at 14 and 30 weeks, even after manifest inflammation became quiescent at 6 weeks. (p = .004 and 0.001, respectively).Conclusion: UWFA scores significantly improved in Behcet's uveitis patients treated with adalimumab, and further improvement of UWFA scores was found in patients with a clinically quiescent inflammatory state.

Integrative Medicine (Herbal Medicine Combined with Drug Therapy) for Behcet's Disease: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

This review aimed to investigate the efficacy of integrative medicine (herbal medicine combined with drug therapy) in the treatment of Behcet’s disease (BD). Eleven databases were searched from their inception to 7 December 2020, for randomized control trials (RCTs) that reported the effects of integrative medicine in treating BD. The risk of bias was assessed using seven domain criteria from the Cochrane Collaboration tool. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess the quality of evidence. The direction of the effect is also shown in the form of an albatross plot. Sixteen trials met the inclusion criteria and were analyzed. The overall risk of bias was determined to be uncertain. The meta-analysis showed a superior response rate with herbal medicine plus drug therapy (relative risk (RR) 1.19, 95% confidence interval (CI) 1.13 to 1.25, n = 1034, p < 0.00001, I² = 0%, low certainty of evidence (CoE)) compared to drug therapy. Integrative medicine also lowered the recurrence rate after 2 months of follow-up (RR 0.27, 95% CI 0.09 to 0.76, n = 120, p = 0.01, I² = 0%, low CoE). The erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, and skin lesions were also significantly improved using integrative medicine, but equivalent effects were seen for oral ulcers, genital ulcers, and eye inflammation. Minor adverse events were reported in both groups. Our findings suggest that herbal medicine combined with drug therapy is more effective for the treatment of BD than drug therapy alone. Although the type of drug therapy used varied across the studies, integrative medicine was shown to improve the total response rate, skin lesions, the ESR, and the CRP level. However, the overall risk of bias of the studies was concerning, and the CoE was low. Information on adverse events (AEs) was also insufficient. In addition, the number of studies included for data synthesis for most outcomes was small. Future studies with rigorous RCTs may help establish the efficacy of integrative medicine in the treatment of BD.

Genetic Association of Interleukin 33/ST2 Polymorphisms With Behcet's Uveitis

Interleukin (IL)33, a member of the IL1 superfamily, functions as a nuclear factor and mediates biological effects by interacting with the ST2 receptor. Recent studies have described IL33 as an emerging pro-inflammatory cytokine in the immune system, and IL33/ST2 gene polymorphisms have been implicated in the pathogenesis of various immune diseases. However, the underlying mechanisms of IL33/ST2 in Behcet's disease (BD) remain to be defined. Here, we investigated the association between IL33/ST2 gene polymorphisms and BD in 585 BD uveitis (BDU) patients and 834 healthy controls using Agena MassARRAY iPLEX platform. We found that rs3821204 was associated with the development of BDU. Moreover, the frequency of rs2210463 G allele was lower in patients with genital involvement. Association analysis revealed a much greater genetic difference between complete-type and incomplete-type BD groups, including three SNPs (rs7044343, rs1048274, and rs2210463). Our findings suggest that IL33/ST2 gene polymorphisms are involved in the pathogenesis of BDU. Different genetic backgrounds may exist in complete-type and incomplete-type BD patients.

Prosthetic valve detachment complicated with intervalvular fibrous body destruction in Behcet's disease: a case report

Background

Prosthetic valve detachment is not rare after aortic valve replacement in Behcet’s disease. However, destruction of the intervalvular fibrous body (IFB) due to Behcet’s disease was rarely reported.

Case presentation

We report a case of 30 year-old woman, with valve detachment and IFB separation. The patient received aortic valve replacement three months ago. Her medical history included recurrent oral ulcers and cutaneous lesions. Finally, reoperation was performed and peri-operative steroid therapy was carried out.

Conclusions

The case presented a rare complication of valve detachment in Behcet’s disease.

Fibromuscular dysplasia of mesenteric arteries: a rare cause of multiple bowel resections-a case report and literature review

Background

Fibromuscular dysplasia (FMD) is a type of unexplained nonatherosclerotic vascular disease that usually involves the renal and internal carotid arteries and rarely involves the mesenteric artery. Mesenteric artery FMD is difficult to distinguish from Crohn’s disease (CD) and Behcet’s disease (BD) solely based on symptoms. Patients with mesenteric artery FMD can present with an acute abdomen, but case reports of patients who have a long medical history and undergo multiple bowel resections are extremely rare.

Case presentation

The patient was a 45-year-old woman with an 11-year history of intermittent lower abdominal pain and fever. At the age of 34 years, she underwent right hemicolectomy and appendectomy due to an acute abdomen. She suffered from oral ulcers between 34 and 36 years old. A clinical diagnosis of presumed CD was made by the age of 41, and she was treated with mesalazine; however, the effect was poor. At the age of 42, she came to our centre, and based on her atypical symptoms and examination results, we thought she had CD. Hence, she was treated with glucocorticoids for 3 years. However, when she was 45, due to steroid dependence, thalidomide tablets were added. Unfortunately, she suffered from another episode of intestinal obstruction. Therefore, she underwent enterectomy. The postoperative histopathological diagnosis was mesenteric artery FMD. She no longer underwent pharmacotherapy after the surgery. Although she did not have any of her previous symptoms and postoperative colonoscopy showed no signs of recurrence, splenomegaly and abnormal routine blood results were still present.

Conclusions

Patients with mesenteric artery FMD can present with an acute abdomen. In addition, the symptoms and endoscopic manifestations of mesenteric artery FMD may appear similar to CD and BD. Hence, it is difficult to make a clear clinical diagnosis and proceed with treatment. Mesenteric artery FMD often requires surgical pathology to confirm its diagnosis. For patients who suffer from this disorder, surgery may be the best choice to improve the patient’s quality of life.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-021-01702-y.

Metabolomic Analysis of Aqueous Humor Identifies Aberrant Amino Acid and Fatty Acid Metabolism in Vogt-Koyanagi-Harada and Behcet's Disease

To investigate aqueous metabolic profiles in Vogt-Koyanagi-Harada (VKH) and Behcet's disease (BD), we applied ultra-high-performance liquid chromatography equipped with quadrupole time-of flight mass spectrometry in aqueous humor samples collected from these patients and controls. Metabolite levels in these three groups were analyzed by univariate logistic regression. The differential metabolites were subjected to subsequent pathway analysis by MetaboAnalyst. The results showed that both partial-least squares discrimination analysis and hierarchical clustering analysis showed specific aqueous metabolite profiles when comparing VKH, BD, and controls. There were 28 differential metabolites in VKH compared to controls and 29 differential metabolites in BD compared to controls. Amino acids and fatty acids were the two most abundant categories of differential metabolites. Furthermore, pathway enrichment analysis identified several perturbed pathways, including pantothenate and CoA biosynthesis when comparing VKH with the control group, and D-arginine and D-ornithine metabolism and phenylalanine metabolism when comparing BD with the control group. Aminoacyl-tRNA biosynthesis was altered in both VKH and BD when compared to controls. Our findings suggest that amino acids metabolism as well as two fatty acids, palmitic acid and oleic acid, may be involved in the pathogenesis of BD and VKH.

Relationship of diffusion tensor imaging parameters with neurocognitive dysfunction in patients with Behcet's disease

Behcet's disease (BD) is a chronic, multisystemic, relapsing-remitting, progressive inflammatory disorder with unknown etiology. The aim of the study is to investigate the white matter integrity and subclinical brain parenchymal involvement in Behcet's subjects by utilizing diffusion tensor imaging (DTI) and to correlate apparent diffusion coefficient (ADC), fractional anisotropy (FA), mean diffusivity (MD), and radial diffusivity (RD) values measured from the diverse distinct anatomic locations with the disease duration time and neurocognitive function test results. Thirty-five adults with Behcet's disease and 21 age-matched healthy controls were enrolled in this study. Neurocognitive functions of the patients were evaluated with the Brief Repetable Battery-Neuropsychological tests (BRB-N). In both groups, DTI metrics were calculated from 19 different locations in the brain. The association between the DTI parameters and disease duration time and neurocognitive function test results were investigated. In Behcet's disease, at the cingulum and the splenium of the corpus callosum (SCC), FA values were significantly lower compared with the controls (p = 0.0015, p = 0.003, respectively). The ADC values of the corona radiata and RD values of superior longitudinal fasciculus and SCC were significantly higher than the controls (p = 0.023, p = 0.028, p = 0.006, respectively). Significant negative correlations were found between the FA values of cingulum, genu of corpus callosum (GCC), posterior limb of internal capsule (PLIC) and disease duration time (r = - 0.368; p = 0.029 and r = - 0.337; p = 0.048 and r = - 0.527; p = 0.001 respectively). All BD subjects performed significantly lower test scores on the spatial recall test (SPART) (p = 0.001). In addition, negative correlation was found between the MD values of the parietooccipital white matter and the selective reminding test (SRT) results (r = - 0.353; p = 0.037). Our DTI study presented microstructural alterations in the neurocognitive-related areas and BRB-N test results even in patients without neurological symptoms which may imply insidious neurological involvement.

Management of Behcet's syndrome

Behcet's syndrome (BS) is a variable vessel vasculitis with heterogeneous clinical features. Skin, mucosa and joint involvement can cause impairment of quality of life but do not cause permanent damage whereas untreated eye, vascular, nervous system and gastrointestinal system involvement can cause serious damage and even death. Management of BS as a multidisciplinary team enables a faster and more accurate diagnosis and well-integrated treatment strategies. Corticosteroids are the mainstay of therapy. Colchicine, AZA, ciclosporin-A, cyclophosphamide, IFN alpha, and tumour necrosis factor alpha inhibitors are other agents used as induction and/or maintenance therapy. Although biologic agents have been increasingly used, there are still unmet needs. Head-to-head comparison studies of some therapeutic options (e.g. TNF inhibitors vs IFN alpha in uveitis) are required. Novel therapeutic agents in the pipeline could change the standard of care for BS in the future.

A20 Inhibits Intraocular Inflammation in Mice by Regulating the Function of CD4+T Cells and RPE Cells

A20 is a negative regulator of inflammation and immunity and plays a role in several autoimmune and inflammatory diseases. Here, we demonstrate that A20 overexpression significantly ameliorates severity of EAU by inhibiting the infiltration of Th1 and Th17 cells, and by protecting integrity of the blood retinal barrier. In vitro studies showed that A20 silencing could promote CD4+T cells toward a Th1 and Th17 phenotype. A decreased expression of A20 in CD4+T cells was noticed in active BD patients but not in VKH patients. Furthermore, silencing of A20 in hRPE cells induced the production of IL-6, IL-8, and MCP-1 and downregulated ZO-1 and occludin expression which is mediated by inhibition of MAPK and NF-κB pathways. This study reveals a mechanism by which A20 prevents autoimmune uveitis.

Elusive diagnosis of Behcet's disease in setting of painless vision loss

Behcet’s disease is a chronic, idiopathic vasculitis with multisystem involvement commonly characterized by the classic triad of oral lesions, genital ulcerations, and uveitis. We discuss the case of a 22-year-old woman with a long-standing history of oral ulcers and vulvovaginal burning who presented with acute painless uveitis. With this presentation, there was an initial concern for infectious retinitis for which she was started on systemic antiviral therapy. Subsequent infectious disease workup was ultimately negative. Given her medical history and current presentation, she was diagnosed and treated for an acute inflammatory episode of ocular Behcet’s disease. The patient’s vision returned to baseline prior to discharge after treatment with systemic glucocorticoids. The diagnosis of Behcet’s disease in the setting of painless vision loss can oftentimes be elusive. However, it is important for clinicians to keep this condition as a differential diagnosis in patients presenting with acute onset uveitis as the progression of Behcet’s disease can lead to severe vision loss and blindness without prompt and adequate treatment.

Possible Role of Regulatory B Cells in Different Behçet's Disease Phenotypes and Therapies: First Report from Egypt

BACKGROUND AND AIM

The data about the role of regulatory B cells (Breg) in Behcet Disease (BD) are scarce. We aimed to evaluate the frequency of total B lymphocytes and Breg cells in different BD phenotypes and therapies attempting to unravel their function.

METHODS

This cross-sectional study included 35 BD patients and 39 healthy controls (HCs). The demographic data of the study subjects were collected including age and gender. Current medications including disease-modifying anti-rheumatic drugs (DMARDs) were recorded. All patients underwent testing for baseline laboratory investigations including full blood count, liver and kidney function tests, erythrocyte sedimentation rate (ESR) by Westergren blot and C-reactive protein (CRP). Measurement of the total B lymphocytes and their subtypes B regulatory lymphocytes by flow cytometric assay. Assessment of BD activity was done using the revised Behçet's Disease Current Activity Form (BDCAF) 2006 and Behçet's Syndrome Activity Score (BSAS) ^1111111111. All participants were assessed for the presence of erectile dysfunction using the International Index of Erectile Function (IIEF-5 score), and for depression using the Beck Depression Inventory.

RESULTS

A dramatic drop in the number of B cells, total and regulatory, was observed in the patients compared to the HCs. Regulatory cells (Bregs) tend to be upregulated with genital ulcers or vascular disease. Bregs but not B lymphocytes were associated with BSAS and ESR. Neither the total B lymphocytes nor the Bregs correlated with CRP or the sexual function or depression scores. Of all the used medications, low-dose aspirin was seen with markedly high Bregs proportions.

CONCLUSION

This study supports the role of B cells in BD pathogenesis and strongly suggests a possible role for Bregs in the resolution of different BD manifestations.

Role of Neutrophils in Systemic Vasculitides

Neutrophils and neutrophil extracellular traps (NETs) contribute to the pathogenesis of many autoimmune diseases, including vasculitis. Though neutrophils, and NETs, can break self-tolerance by being a source of autoantigens for autoantibodies in anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, playing a key role in driving the autoimmune response, the role of neutrophils and NETs in large vessel vasculitis, including giant cell arteritis (GCA), is not well understood. In this review, we summarize the current insight into molecular mechanisms contributing to neutrophil-mediated pathology in small and medium vessel vasculitis, as well as provide potential translational perspectives on how neutrophils, and NETs, may partake in large vessel vasculitis, a rare disease entity of unclear pathogenesis.

[Autoimmunity and autoinflammation in pathogenesis of immunoinflammatory diseases]

Rheumatic diseases relate to the group of the immunoinflammatory diseases (IID), in pathogenesis of which have a value both autoimmune and autoinflammatory processes.

AIM

To present the heterogeneous pathogenesis of inflammation in IID.

MATERIALS AND METHODS

It is inspected 260 patients (pts) with IID: 242 pts with systemic autoimmune diseases (SAD): 65 systemic lupus erythematosis, 50 systemic sclerosis, 127 systemic vasculitides (SV) and 18 patients with autoinflammatory diseases (AID): 8 Behcets disease, 2 periodic disease, 5 familial cold fever, 2 idiopathic lobular panniculitis and 1 relapsing polychondritis. Is carried out a study of complement, antigen of von Willebrand factor (FW:AG), antinuclear antibodies, antibodies to DNA, anti-endothelial antibodies, antibodies to topoizomeraze I (anti-Scl-70), antineutrophilic cytoplasmic antibodies (ANCA), anticardiolipin antibodies (aCL IgG and aCL IgM), cryoglobulins, VS, CRP.

RESULTS

SAD were characterized by the synthesis of wide antibodies spectrum. As the basic serological marker at the screening it follows to consider antinuclear antibodies (75%). Practically in all groups it took place hypcomlemetemia with reduction of C3 and C4 complement. With systemic lupus erythematosis are revealed antibodies to DNA (71%), with ANCA-associated SV-ANCA (94%), aKL (14%); with SSD aScl-70 (17%). At Wegener granulomatosis ANCA are determined in 94% patients in the active stage. It is noted correlation ANCA with the index of the clinical activity of vasculitis. In the remaining SV groups ANCA were separated in the single cases. Cryoglobulins are noted in all patients with cryoglobulinemic vasculitis. aCL IgG and aCL IgM were the markers of antiphospholipid syndrome. Аnti-endothelial antibodies had significant oscillation spectrum. High indices FW:AG are noted with all above nosologic forms indicated, especially with Wegener granulomatosis and vasculitis hemorrhagic. Among the laboratory tests of inflammatory activity should be considered the determination of VS, CRP and FV:AG, which is also considered the marker of vascular wall defeat. Is given clinical characteristic and changes in the laboratory indices at AID: Conclusion.Isolation from the group IID of patients with AID serves as indication for a genetic study of this contingent with the approval of use for their treatment of biological therapy. Isolation from the group SAD patients with AID serves as indication for a genetic study of this contingent with the approval of use for their treatment of biological therapy.

Endovascular Treatment of Giant Celiac Artery Aneurysm in Behcet's Disease

We report a case of a 17-year-old male with Behcet's disease (BD) with giant celiac artery aneurysm and impending rupture. Over the past 8 weeks, patient began having intermittent back and abdominal pain that worsened and became persistent over the past few days. This was accompanied by anorexia and non-bilious vomiting. Computed tomography angiogram (CTA) demonstrated a wide neck large celiac artery aneurysm (60 mm diameter). Endovascular repair of the aneurysm was performed using stent graft of the aorta and transcatheter coil embolization of the aneurysm sac. Technical success was confirmed by interruption of flow in the aneurysm, and preservation of distal native circulation at the conclusion of the procedure. One-week post-embolization, a CTA demonstrated complete thrombosis of the aneurysm. On follow-up CTA at 3, 6, and 12 months after embolization, the aneurysm has completely thrombosed and decreased in size to 24 mm. Patient remains asymptomatic till date.

Association of lifestyle elements with self-rated wellness and health status in patients with Behcet's disease

Background

Assessment of the association of various lifestyle factors and wellness and health status in patients with Behcet’s disease was the main goal of this study.

Methods

Demographic information, body mass index, smoking habit, mood status, sleep quality, physical activity levels, nutritional data, symptoms, signs, laboratory findings and patient reported outcome (self-rated wellness and health) in 52 patients with Behcet’s disease were collected in this cross-sectional study. A multivariable linear regression model was used to assess the association of self-rated wellness and health status and lifestyle factors, adjusted for age, sex, BMI, major symptoms and signs, as well as laboratory findings.

Results

Female to male ratio was 21/31, and the mean age of participants was 44 years. Mean self-rated wellness and health score was 14.6 out of 20. Oral and genital aphthous, ocular involvement, pathergy, and skin involvement were observed in 100, 52, 92, 36.5, and 9.5% of patients, respectively. The mean values of sleep, mood and nutrition quality scores were 17.7 (out of 70), 13.8 (out of 35), and 9 (out of 21), respectively. Univariable regression analysis showed a significant association between sleep quality, mood status, and disease duration, with patients’ status in terms of self-rated wellness and health. In multivariable linear regression, sleep quality was the only significant predictive variable associated with self-rated wellness and health.

Conclusion

Sleep quality was the most important factor associated with low self-rated wellness and health status in patients with Behcet’s disease.

Variation of red blood cell parameters in Behcet's disease: association with disease severity and vascular involvement

INTRODUCTION/OBJECTIVES

Behcet's disease (BD) is a systemic and chronic inflammatory vasculitis with unknown etiology. Diagnosis is determined by evaluating several clinical criteria, but the lack of specific laboratory diagnostic markers makes the diagnosis of BD more difficult. Therefore, the aim of this study was to determine the changes in hematological parameters in BD patients to investigate their relationship with BD clinical features.

METHOD

A total of 48 BD patients and 96 healthy controls were included in this study. The severity of each BD patient was associated to a severity score according to the entire spectrum of disease manifestations. Several laboratory tests were assessed, and the difference in their results between BD patients and healthy controls was evaluated. Correlation analysis was performed to reveal the interaction of these parameters.

RESULTS

C-reactive protein (CRP), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), neutrophil count, platelet count, and plateletcrit significantly increased in BD patients compared with healthy controls (P < 0.05). CRP was higher in patients with skin lesions, MCH and MCHC were lower in patients with vascular involvement, and the neutrophil count was higher in patients with skin lesions and genital ulcers. In addition, higher CRP and lower MCH and MCHC were associated with a severe condition. Besides, MCH and MCHC were negatively correlated with the platelet count, plateletcrit, and neutrophil count.

CONCLUSIONS

This study revealed that MCH and MCHC are valuable parameters for BD. Their levels help assess the disease severity and indicate the vascular involvement in BD. Key Points • This is the first study reporting MCH and MCHC as important biomarkers in BD. • BD patients with vascular involvement and thrombosis potential have lower levels of MCH and MCHC. • MCH and MCHC are negatively correlated with platelet count, plateletcrit, and neutrophil count. • Lower MCH and MCHC are associated with a severe condition.

Genetic Polymorphisms in Transforming Growth Factor-β, Interferon-γ and Interleukin-6 Genes and Susceptibility to Behcet's Disease in Saudi Population

Background

Behcet’s disease (BD) is a complex, inflammatory, immune-mediated multi-systemic disease of unknown etiology. Cytokines play major roles in the pathophysiology of BD, and its production may be affected by polymorphism in cytokine genes. Hence, the present study was planned to investigate any possible association between the polymorphism in TGF-β, IFN-γ, and IL-6 genes and BD in the Saudi population.

Materials and Methods

The present study includes 79 BD cases and 117 age-matched controls. Polymerase chain reaction with restriction fragment length polymorphism (PCR-RFLP) and amplification refractory mutation systems (ARMS) PCR methods were used for polymorphic analysis.

Results

The heterozygous (CT) and (CT+TT) combined genotypes of TGF-β (509-C/T), heterozygous (AT), variant (TT), and (AT+TT) combined genotypes of IFN-γ (874-A/T) were significantly (P<0.05) associated with BD in the Saudi population. No significant differences were observed for IL-6 (174-G/C) genotypes and alleles between BD cases and controls. Gender does not reflect any significant genotypic and allelic association with males and females.

Conclusion

CT genotype of TGF-β, and AT and TT genotypes of IFN-γ could be associative genetic risk factors for BD in Saudis. Regulatory region polymorphism in cytokines gene can increase inflammation and deregulated immune response, which could be risk factor for BD.

Endovascular treatment with in-vitro fenestration and sac filling technique for ruptured thoracoabdominal aortic aneurysm with Behcet's disease

Purpose

We provided an endovascular strategy of treating ruptured aortic aneurysm with Behcet’s Disease.

Case report

A 25-year-old man was diagnosed ruptured thoracoabdominal aortic aneurysm with Behcet’s Disease according to his eye damage history, high level of ESR and C-reactive protein and the imaging result. We used in-vitro fenestration of the stent-graft combined with in-stent technique to occlude the ruptured aortic aneurysm and preserve the blood supply from the aorta for visceral arteries in emergency. Sac filling technique was used to treat the endoleak to quickly prevent bleeding. The patient kept post-operative immunotherapy for 1 year.

Conclusion

The patient had a good prognosis in the reduction of the cavity of aortic aneurysm to the normal size without any complications in a year follow-up.

A case of asthma with Behcet's disease: successful treatment with omalizumab and its effects on recurrent aphthous lesions

CONTEXT

Monoclonal antibody therapies have revolutionized the treatment of autoinflammatory-immune/genetic disease including spondylarthritis, asthma and rheumatoid arthritis. Behcet's disease (BD) is a multi-systemic vasculitis, which is generally recurrent aphthous lesions (RAL) as well as ocular and skin lesions. Today, the immunohistopathogenesis of BD is mostly unknown.

METHOD

Omalizumab (Anti-IgE humanized monoclonal antibody) therapy is given for severe persistent allergic asthma, and unintentionally it had effect on RAL. Our patient has received omalizumab treatment for 3 years. The steroid treatment was completely discontinued a month later and the systemic-steroid dependent diabetes mellitus was healed. The IL-1 β, IL-6, IL-8, IL-33, IL-25, IL-10, IL-23, and IL-17A levels were measured using an Enzyme-Linked Immunosorbent Assay (ELISA) kit.

RESULTS

After a long-term omalizumab treatment administered, the levels of WBC, d-dimer, IL-33, IL-6, IL-25 and IL-1 β decreased. The patient's hsCRP decreased from 3 to 0.1 and Eosinophil Cationic Protein (ECP) levels decreased from 78 to 21. A significant improvement was noticed in the RAL, the asthma symptoms (cough, shortness of breath), the number of emergency admissions, and the average length of stay of the patient within the days following the initiation of the omalizumab treatment.

CONCLUSIONS

Here, for the first time, we introduce omalizumab treatment of a patient diagnosed with BD and the examination of the treatment for the clinical manifestations and the cytokines/coagulant protein levels. A significant improvement is observed in the patient's RAL following the initiation of omalizumab. There is strong evidence that the serum proinflammatory cytokines/coagulant factors could also play an important role in the relationship between RAL and IgE-dependent vascular autoinflammation.

Behcet's disease with peripheral nervous system involvement successfully treated with golimumab: a case report and review of the literature

Nervous system involvement is a rare and serious complication of Behcet's disease (BD), and the peripheral type is rarer. This article aimed to describe a case of BD with the peripheral nervous system (PNS) involvement and present a comprehensive literature review. One case of BD with PNS involvement was reported and related literature was retrospectively reviewed via PubMed/MEDLINE and Scopus database. The patient was resistant to traditional treatments, such as glucocorticoids and immunosuppressants, but had rapid quiescence after using golimumab. Our literature review suggests that the involved peripheral nerves in BD were diverse, the most common were the tibial nerves and peroneal nerves, vasculitis might be the main cause, and prednisone was still the cornerstone of treatment. TNF-α inhibitors have been increasingly used for refractory BD in recent years. This well-illustrated case demonstrates the potential benefit of golimumab to the patient with PNS involvement. Given the diversity and complexity of PNS involvement, we recommend golimumab as a new trial treatment in clinical practice.

Superior vena cava thrombosis and dilated cardiomyopathy as initial presentations of Behcet's disease

Background

Bechet’s disease (BD) is a relatively rare disease that causes recurrent oral and genital ulcers in addition to a variety of systemic manifestations. Concomitant superior-vena-cava (SVC) thrombosis and cardiac involvement with dilated cardiomyopathy (DCM) as initial presentations for BD is considered rare.

Case presentation

A 32-year-old-man presenting with intractable headaches and dyspnea. He was later diagnosed with SVC thrombosis and DCM. A diagnosis of BD was made after detailed history-taking.

Conclusions

Cardiovascular manifisations can be the initial presentation of BD. We aim to highlight the importance of early clinical recognition of BD as a cause of DCM and SVC thrombosis.

Behcet's Disease: Pakistani Experience

OBJECTIVE

To analyze the clinical manifestation of patients with Behcet's disease, and performance of different classification criteria of Behcet's disease in our population.

METHODS

It was a retrospective analysis of all Behcet's disease patients attending Department of Rheumatology at Fatima Memorial Hospital, Lahore, Pakistan from April 2019 to July 2019. We performed a comprehensive clinical evaluation of patients with Behcet's disease, with focus on patients' age, gender and different clinical manifestations.

RESULTS

A consecutive cohort of 20 patients was studied. All patients met the International Criteria of Behcet's Disease criteria, and 18 out of 20 patients also met International Study Group criteria. Mean age of the cohort was 33.5±10.4 years and 45% was female (male to female ratio of 1:1.2). Around 90% of cohort had recurrent oral and genital ulcers. Ocular involvement was present in 80% patients, while Joint manifestations were present in 75% of patients. Cutaneous, neurological (both central and peripheral nervous system involvement), and GIT symptoms were present in 50%, 30%, and 15% of patients, consecutively. Joint pain and eye symptoms were major initial symptoms in males, while eye symptoms and neurological symptoms were more common in female patients at disease onset. Reaching border line significance, Cutaneous(p-value=0.479), ocular(p-value=0.61), and GIT involvement(p-value=0.59) were more prevalent in males while neurological involvement (p-value=0.336) in females.

CONCLUSION

Behcet's disease occurs commonly in middle age population with equal male to female ratio, with mucocutaneus aphthosis, ocular disease and joint pains being common manifestation. Gastrointestinal symptoms are more common in males while neurological symptoms in females.

Profiling tear proteomes of patients with unilateral relapsed Behcet's disease-associated uveitis using data-independent acquisition proteomics

Purpose

To explore whether unilateral relapse of Bechet’s disease-associated uveitis (BDU) causes differences in the tear proteome between the diseased and the contralateral quiescent eye and potential tear biomarkers for uveitis recurrence and disease monitoring.

Method

To minimize interindividual variations, bilateral tear samples were collected from the same patient (n = 15) with unilateral relapse of BDU. A data-independent acquisition (DIA) strategy was used to identify proteins that differed between active and quiescent eyes.

Results

A total of 1,797 confident proteins were identified in the tear samples, of which 381 (21.2%) were also highly expressed in various tissues and organs. Fifty-one (2.8%) proteins differed in terms of expression between tears in active and quiescent eyes, 9 (17.6%) of which were functionally related to immunity or inflammation. Alpha-1-acid glycoprotein 1 (fold change = 3.2, p = 0.007) was increased and Annexin A1 (fold change = −1.7, p < 0.001) was decreased in the tears of the active BDU eye compared to the contralateral quiescent eye.

Conclusions

A substantial amount of confident proteins were detected in the tears of BDU patients, including proteins that were deferentially expressed in the uveitis-relapsed eyes and the contralateral quiescent eyes. Some of these identified tear proteins play important roles in immune and inflammatory processes. Tear proteome might be a good source of biomarkers for uveitis.

The methylation status of TNF-α and SOCS3 promoters and the regulation of these gene expressions in patients with Behçet's disease

Introduction: The aim of this study was to evaluate the methylation status of TNF-α and SOCS3 promoters in patients with BD and compare them with a healthy group.Method: This was a case-control study, in which 47 subjects with BD and 61 individuals as the control participated. Blood samples were collected from all the participants. Then, PBMCs were isolated using the Ficoll method and methylation of considered sites was investigated using the qMS-PCR technique after DNA extraction by the rapid genomic DNA extraction method and its analysis with Nano-drop.Results: The methylation and expression of TNF-α showed that the methylation level significantly declined in the patient in comparison with the healthy (p < 0.05). Moreover, the results on the mean expression showed that it significantly increased in the patient group, as compared with the healthy group (p < 0.05). In addition, the expression of the SOCS3 gene was not significantly different between the patients and healthy subjects while the level of SOCS3 methylation was significantly higher in the patient group than that in the healthy group (p < 0.05).Discussion: The present study revealed that the gene expression of TNF-alpha increased in BD patients, suggesting that TNF-alpha likely has a role in the pathogenesis of BD.

The Rs12569232 SNP Association with Vogt-Koyanagi-Harada Disease and Behcet's Disease is Probably Mediated by Regulation of Linc00467 Expression

Purpose: To investigate whether the rs12569232 SNP association with Vogt-Koyanagi-Harada disease and Behcet's disease is mediated by regulation of Linc00467 expression.Methods: The expression of linc00467 was detected by real-time PCR. Adenovirus carrying the linc00467 was transduced into CD4⁺T cells and the effect on cell viability was measured by the CCK-8 test. Human proteome microarray and starBase 2.0 were used to identify the binding proteins of linc00467 and RNA Immunoprecipitation (RIP) was used to confirm the identity of bound proteins.Results: The rs12569232 was associated with the expression of linc00467. The expression of linc00467 was up-regulated in PBMCs and CD4⁺T cells from VKH disease and BD patients. Over-expression of linc00467 increased cell viability of CD4⁺T cells. HUR was the common binding protein identified by the two methods and confirmed by RIP.Conclusions: The rs12569232 association with VKH disease and BD may be mediated via regulating the expression of linc00467.

A Case Report of Sweet's Syndrome with Panuveitis and Rhegmatogenous Retinal Detachment

Purpose: To report a case of a patient who suffered from Sweet's syndrome with panuveitis in both eyes.Materials & Methods: Retrospective interventional case report.Results: A 54-year-old Chinese male patient complained of fever, painful skin lesions and blurry vision in both eyes lasting for 4 days. His visual acuity was hand motion in both eyes. Slit-lamp examination showed the hypopyon and severe vitreous opacification in both eyes. A skin pathology from head skin lesion demonstrated diffuse neutrophilic infiltration in the dermis with karyorrhexis. Based on the inspection above, the patient was diagnosed with Sweet's syndrome and given systemic corticosteroids therapy. However, he developed secondary rhegmatogenous retinal detachment in the right eye during his treatment.Conclusion: The association of bilateral uveitis with Sweet's syndrome has been described in this report.

Tumor necrosis factor (TNF)-308, -1031, and angiotensin-converting enzyme (ACE) DD/II polymorphisms' role in Behcet's disease with and without uveitis: a meta-analysis

PURPOSE

There are conflicting results of studies investigating the association between the tumor necrosis factor (TNF) and angiotensin-converting enzyme (ACE) gene polymorphisms and Behcet's disease (BD). The aim of this meta-analysis is to assess the association between these gene polymorphisms and ocular involvement in BD.

METHODS

We identified relevant studies and reviewed the full-text manuscripts of the studies in order to select those for inclusion. Heterogeneity of studies was evaluated using Cochran Q-test and I-square index. To modify the heterogeneity in the variables we used random effects model. Meta-analysis was performed using STATA.

RESULTS

We analyzed TNF-1031, -308 and ACE DD/II genotype difference between BD patients with and without uveitis. Among these polymorphic genetic loci TNF-308 AA genotype has a statistically significant protective effect against BD uveitis (OR = 0.45 vs 1.23, p = .017). Such a statistically significant effect was not seen for other studied genotypes.

CONCLUSION

This meta-analysis revealed a significant protective effect of TNF-308 AA genotype against ocular involvement in Behcet's disease.

Update on the Treatment of Behcet's Disease of the Small Bowel with Biologic Agents

PURPOSE OF REVIEW

The treatment of intestinal Behcet's disease (BD) is challenging, and one-third of patients require surgery due to failure of conventional therapies. Anti-tumor necrosis factor-α (TNF-α) and other new biologics have been actively investigated for managing intestinal BD. In this article, we review the updated experiences and up-to-date clinical data on anti-TNF-α and other biologics for the management of intestinal BD.

RECENT FINDINGS

Recent prospective studies have proved the efficacy and safety of infliximab and adalimumab for treating intestinal BD. Recent studies with other biologics such as anti-interleukin (IL)-1 (anakinra and canakinumab) and anti-IL-6 (tocilizumab) have shown promising results in patients with systemic, including intestinal, BD. Both infliximab and adalimumab can be useful in managing patients with intestinal BD, especially severe or refractory cases, with a similar efficacy and safety profile. More evidence for anakinra, canakinumab, tocilizumab, anti-IL-17 (secukinumab), and anti-IL-12/23 (ustekinumab) in intestinal BD is required.

Clinical features of Behcet's disease in Mongolia: a multicenter study

OBJECTIVE

The aim of the present study is to investigate the clinical features of patients with Behcet's disease (BD) in Mongolia.

METHODS

Patients were identified and examined from six medical institutions in Mongolia from January 2015 to January 2019. BD was diagnosed according to the diagnostic criteria for BD established by the International Study Group.

RESULTS

There were sixty-five patients (22 males and 43 females) recoded, the ratio of 1:1.95, with a marked female predominance. The age of disease onset was 22.2 ± 10.0 (mean ± SD), ranging from 11 to 66 years old. Oral aphthous ulcers, ocular lesions, skin lesions, genital ulcers, pathergy test positivity, articular lesions, superficial vasculitis, deep vein thrombosis, and epididymitis (male only) were observed in 100.0%, 63.1%, 81.5%, 89.2%, 7.7%, 86.2%, 32.3%, 4.6%, and 13.6% of the patients, respectively. The incidence of poor visual prognosis, ≤ 20/200, was significantly higher in males than in females (31.8 vs. 9.3%, incidence rate ratio 4.55 (95% CI 1.16-17.82), p < 0.05). The pathergy test was positive only in 7.7% of cases and only in female subjects. Nasal mucous ulcers were frequently seen in 55.4% of patients that may also be attributed to the environmental conditions of Mongolia. Headache was observed 76.9% of patients in this study.

CONCLUSIONS

Clinical manifestations of BD in Mongolia are presented for the first time. The visual prognosis was significantly worse in males. Nasal mucous membrane ulcers and recurrent headaches were frequent among Mongolian patients with BD. Key Points • First results of the examination of the clinical features of Behcet's disease patients in Mongolia. • Nasal ulcerations and recurrent headaches are frequent symptoms in Mongolia Behcet's disease patients, potentially attributed to climate. • Male Behcet's disease patients in Mongolia have a significantly worse prognosis for eye-related complications and vision.

Phosphorylation Modulates Survivin Function in Behcet's Disease

Purpose: Survivin is critical for proliferation, maturation, homeostasis and differentiation of effector and memory lymphocytes. In this study the baculoviral inhibitors of apoptosis proteins (IAPs) repeat containing 5 (BIRC5) mRNA, survivin, and phosphorylated survivin expression were evaluated in peripheral blood mononuclear cells (PBMCs), and plasma of patients with Behcet’s disease (BD).

Methods: In this study, 26 Iranian Azari patients diagnosed with BD and 30 healthy controls were recruited. Total RNA was extracted from PBMCs. The expression level of survivin was measured by quantitative real-time polymerase chain reaction (PCR). Survivin plasma levels were measured using survivin Enzyme-linked immunosorbent assays. Also, western blotting analysis was performed to measure phosphorylated-survivin and survivin levels in PBMCs and plasma of patients with BD.

Results: In a pilot study, we showed that BIRC5 gene expression increased in BD patients compared with healthy controls (P<0.05). Western blotting analysis indicated that there was an increase in phosphorylated survivin expression in PBMCs of BD patients. Our data from western blot analysis showed survivin level in plasma samples of BD patients was similar to healthy controls. No significant differences were observed between plasma survivin levels in the BD patients compared with control group (P>0.05). The expression of phosphorylated survivin at Thr34 in PBMCs of BD patients with active disease was increased. Plasma phosphorylated survivin levels in having BD patients were also downregulated compared to healthy individuals.

Conclusion: Analysis of PBMCs indicated increasing expression level of phosphorylated survivin in PBMCs of BD patients. There was also a downregulation in phosphorylated survivin levels in plasma of BD patients.

Behcet's disease involved the root of aorta in the treatment with modified Bentall procedure: a case report

Background

Behcet’s disease (BD) is a multisystemic vasculitis of unknown etiology, the incidence of cardiovascular system involvement is rare, about1–5% (Sakane et al., N Engl J Med 341:1284–91, 1999). BD combined with aortic pseudoaneurysm and aortic valve regurgitation is usually need surgical treatment, but there is controversy about which surgical method to choose.

Case presentation

We report a case of BD combined with severe aortic valve regurgitation and two giant pseudoaneurysms of the aortic sinus. The patient underwent modified Bentall procedure (MBP) and use oral immunosuppressive as well as corticosteroid strictly, after 8 months follow-up, the patient recovered well.

Conclusion

For patient with aortic valve regurgitation and ascend aortic pseudoaneurysm caused by BD, we recommend modified Bentall procedure when rheumatism in a stable period. Corticosteroids and immunosuppressive drugs should be used before and after surgery.

The Immediate Pain-Relieving Effects of Non-Thermal CO2 Laser Therapy on Genital Ulcers of Behcet's Disease: A Case Report

Behçet's disease (BD) is a chronic, relapsing, systemic vasculitis of unknown etiology. Oral and genital aphthous ulcers are considered as the hallmarks of BD. The genital ulcers of BD may be extremely painful and often refractory to multiple treatments. In addition, they exert a negative impact on the patient's quality of life. Some investigations have demonstrated the significant and immediate pain-relieving effects of NTCLT (non-thermal CO₂ laser therapy) on some oral lesions with no visible adverse effects. In this paper, we report a case of BD whose painful genital ulcers were irradiated with NTCLT and the patient's pain caused by the ulcers relieved immediately and significantly with no visible complications.