Th17-Inducing Conditions Lead to in vitro Activation of Both Th17 and Th1 Responses in Behcet's Disease

OBJECTIVES

Interleukin-17 (IL-17) has been associated with the pathogenesis of various autoimmune/inflammatory diseases. The aim of this study was to investigate the expression of Th17-related immunity in an innate immunity-dominated vasculitis, namely Behcet's disease (BD).

METHODS

Peripheral blood mononuclear cells from 37 patients (age: 38.5 ± 9.8 years) with BD, and 25 healthy controls (HC) (age: 39.1 ± 9.3 years), were cultured in Th17-inducing conditions (IL-6, Phytohemagglutinin (PHA), IL-1β, and IL-23) for 6 days. Cultured cells were stained with CD4, CD8, CD3, TCR gamma/delta, CD19, interferon-γ (IFN-γ), and IL-17 antibodies to determine the intracellular cytokine secretion by flow cytometry.

RESULTS

IL-17 expression by CD8+ and γδ+ T cells was higher in BD compared to HC (p = 0.004, p = 0.003, respectively). No differences were observed between the groups in the IL-17 production by B cells. Under Th17-inducing conditions, production of IFN-γ by CD4+, CD8+, and γδ+ T cells was also higher in BD compared to HC (p < 0.05 in all).

CONCLUSION

Our results suggest that under Th17-stimulating conditions, T cells express both IL-17 and IFN-γ in BD. More prominent IL-17 and IFN-γ production by all lymphocyte subsets in BD might be associated with the increased innate responses, early tissue neutrophil infiltrations and late adaptive immunity in BD.

Paraoxonase and Arylesterase Levels in Behcet's Disease and Their Relations with the Disease Activity

The aim of this study was to determine the paraoxonase (PON) and arylesterase (ARE) enzyme activity levels in Behcet's disease (BD) and to investigate whether they are associated with the disease activity. Twenty-six patients (study group) with active BD and 28 healthy controls (control group) were included in this study. While the patients who had at least one of the symptoms related to genital ulcer, skin lesions, active uveitis, arthritis, thrombophlebitis, or central nervous system involvement in addition to oral ulcers were considered as the active group, the patients who did not show clinical symptoms in the last one month due to the medical treatment were considered as the inactive group in the clinical evaluation of patients with BD. The PON and ARE levels were found to be significantly lower in the study group than the control group (p < 0.05). The PON levels of the active and inactive groups were 96.23 ± 57.84 and 112.2 ± 65.14, respectively. The ARE levels of the active and inactive groups were 30.49 ± 5.81 and 30.85 ± 6.40, respectively. No significant correlations were found between clinical findings and the activity levels of PON and ARE in the active patient group (p > 0.05). The activities of the antioxidant PON and ARE enzymes are reduced in BD. Therefore, it may be useful to add antioxidant therapy to the conventional treatment of the disease.

Pulmonary Sarcoidosis in Behçet's Disease Treated with Adalimumab

TNF-α antagonists are used to treat various rheumatic diseases including sarcoidosis. However, there have been increasing reports of sarcoidosis in relation to treatment using these drugs. The pathogenesis of this reaction remains unknown.

This is a report of a clinical case of sarcoidosis in Behçet’s disease (DB) with mucocutaneous and intestinal involvement in treatment using adalimumab, with improvement after anti-TNF suspension and corticosteroid therapy.

Effects of in vivo and in vitro administration of neuro-Behcet's disease IgG

Antibodies directed against membrane antigens of neuronal axonal processes (neuropil) have been recently identified in neuro-Behcet's disease (NBD) patients. To delineate the potential pathogenic action of these antibodies, pooled sera from seven NBD patients with neuropil antibodies and seven healthy controls were divided into purified IgG and IgG-depleted serum (IgG-DS) fractions and each fraction was administered into lateral ventricles of rats. NBD IgG-injected rats showed reduced locomotor activity in the open field test as compared to NBD IgG-DS, healthy control IgG, healthy control IgG-DS and PBS injected rats (n = 10 for each group). There were no significant differences among treatment groups by means of anxiety-like behaviors (assessed by elevated plus maze test) and learning/memory functions (assessed by passive avoidance test). Administration of NBD IgG on cultured SH-SY5Y neuroblastoma cells induced significantly increased cell death and apoptosis (as measured by nucleosome levels in the supernatants) as compared to other treatment groups. Our results suggest that IgGs isolated from sera of neuropil antibody-positive NBD patients have a neurotoxic action, which is presumably mediated by apoptotic mechanisms. Motor deficits frequently observed in NBD patients might at least partially be caused by the pathogenic action of anti-neuronal IgG.

Serum ghrelin levels in patients with Behcet's disease

Introduction

Behcet’s disease (BD) is a chronic, relapsing, systemic vasculitis of unknown etiology.

Aim

To measure serum ghrelin levels in BD patients and healthy controls and to investigate its association with metabolic syndrome (MetS).

Material and methods

Thirty BD patients and 30 healthy individuals were enrolled in the study. Ghrelin levels were measured in blood samples using ELISA.

Results

The mean serum ghrelin level in BD patients (28.57 ±14.04) was significantly lower compared to healthy controls (40.72 ±23.21) (p = 0.01). The mean serum ghrelin level in BD patients who had MetS (24.18 ±12.73) was lower compared to BD patients who did not have MetS (30.77 ±14.45), but this difference was not significant (p > 0.05).

Conclusions

Ghrelin levels were lower in BD patients compared to healthy controls. There was no association between reduced ghrelin levels and MetS; however, there was a negative correlation between ghrelin levels and disease activity.

Neuro-Behcet disease presenting as a solitary cerebellar hemorrhagic lesion: a case report and review of the literature

Background

Behcet’s disease is a heterogeneous, multisystem, inflammatory disorder of unknown etiology. The classic triad of oral and genital ulcerations in conjunction with uveitis was originally described by the Turkish dermatologist Hulusi Behcet in 1937, but associated symptoms of the cardiovascular, central nervous, pulmonary, and gastrointestinal systems were later identified. In fact, Behcet’s disease with neurological involvement (neuro-Behcet’s disease) is not uncommon. Patients with neuro-Behcet’s disease typically exhibit a diverse array of symptoms, most commonly in the brainstem and diencephalic regions. Herein, we report an unusual case of neuro-Behcet’s disease in a patient who presented with a solitary cerebellar hemorrhage.

Case presentation

A 39-year-old Asian woman was admitted to our hospital with complaints of a sudden speech difficulty that had manifested the same morning, and dizziness and mild vomiting experienced over the previous 3 days. Magnetic resonance images revealed target-like hemorrhagic lesions in the right hemisphere of the cerebellum. Risk factors that may result in cerebellar hemorrhage, such as high blood pressure or bleeding diathesis, were ruled out, and subsequent brain angiograms were normal.

Conclusions

These findings suggest that the patient’s cerebellar hemorrhage could have been due to intracranial vasculitis in a rare, if not unique, complication of neuro-Behcet’s disease.

An elevated pro-inflammatory cytokines profile in Behcet's disease: A multiplex analysis

The serum levels of sixteen cytokines related to innate immunity, Th1, Th2 and Th17 cells in the sera of 44 patients with Behcet's Disease (BD) and 44 healthy controls have been investigated using the cytokine array technique. Among the cytokines related to innate immunity, the levels of IL-1α, IL-1 β, IL-6, IL-12, IL-15 and TNF-α were statistically higher in BD patients than healthy controls. In the case of Th1- and Th17-related cytokines, IL-2, IFN-γ, IL-17 and IL-23 were significantly higher in patients. From Th2-related cytokines, only IL-13 showed statistically higher levels in patients than controls. Among different evaluated cytokines, the differences in IL-1 α, IL-1 β, IL-6 and Ʃinnate-related cytokines were more prominent between cases and controls. In addition, the results showed that Ʃinnate- and ƩTh17-related cytokines are better indicators of cytokines imbalances in BD than each one of the innate- and Th17-related cytokines. Moreover, disease activity score and clinical activity index can also be affected by the levels of pro-inflammatory (IL-6) and anti-inflammatory (IL-4) cytokines. In conclusion, the results revealed that imbalances in the expression of innate immunity- as well as Th1- and Th17-related cytokines may play not only a pivotal role in BD pathogenesis but also can be important in disease severity.

Association study of rs924080 and rs11209032 polymorphisms of IL23R-IL12RB2 in a Northern Chinese Han population with Behcet's disease

OBJECTIVES

Two genome-wide association studies (GWAS) have identified the IL-23 receptor- IL-12 receptor β2 (IL23R-IL12RB2) as the susceptibility genetic region in Turkish and Japanese population with Behçet's disease (BD). We investigated the association of this region with BD in a Northern Chinese Han population.

METHODS

A total of 407 patients with BD and 421 healthy controls were genotyped for single nucleotide polymorphisms (SNPs) rs924080 and rs11209032 using the Sequenom MassArray system.

RESULTS

Statistically significant associations with BD were detected at two SNPs namely, rs924080 and rs11209032, both, by allele analysis (OR=1.58, 95% CI=1.25-2.00, P_c=2.52×10^-4, and OR=1.45, 95% CI=1.19-1.76, P_c=3.46×10^-4, respectively), and genotype analysis (P_c=1.22×10^-3andP_c=1.77×10^-3, respectively). Significant differences were observed in the genotype frequency distribution for these SNPs under the additive, dominant and recessive models (all P_c<0.05). The haplotypes (AT and GC) formed by the two SNPs were associated with BD (all permutation P<0.05). A meta-analysis also appeared to support the association of the two SNPs with BD.

CONCLUSION

SNPs (rs924080 and rs11209032) of the IL23R-IL12RB2 region were found to be associated with BD in a Northern Chinese Han population.

The role of MEFV mutations in the concurrent disorders observed in patients with familial Mediterranean fever

OBJECTIVE

This study aimed to investigate the frequency in which familial Mediterranean fever (FMF) coexists with other diseases and determine whether Mediterranean fever (MEFV) gene mutations are involved in such coexistence.

MATERIAL AND METHODS

In total, 142 consecutive patients with FMF investigated for MEFV mutation were enrolled in this study [Female: 87; Male: 55, mean age 32±12 years (11-62)]. All the patients were questioned for the presence of concurrent disorders, and the medical records of these patients were revised retrospectively. A previous diagnosis of inflammatory disorder other than FMF was considered true if it met the relevant criteria. MEFV mutations were divided into 2 groups, namely M694V and its subgroup (homozygous or heterozygous) (Group I) and others (Group II). Compound heterozygosity for M694V mutation was included in Group II to form a homogeneous group for Group I. Group I and Group II were compared according to phenotypical features. The presence of MEFV mutation was investigated in exons 2, 3, 5, and 10 by the multiplex-PCR reverse hybridization method.

RESULTS

Concomitant disorders were found in 17 of 73 patients with FMF (23%) in Group I and 5 of 56 patients (8.9%) in Group II (p=0.04). Concomitant disorders in Group I were as follows: 7 cases of amyloidosis, 2 cases of Behcet's disease (BD), 4 cases of ankylosing spondylitis (AS), 1 case of antiphospholipid syndrome, 1 case of Henoch-Schonlein purpura (HSP), 1 case of combination of psoriatic arthritis, HSP, and membranoproliferative glomerulonephritis, and 1 case of AS and amyloidosis. In Group II, the following disorders were found: 1 case of amyloidosis, 1 case of BD, 1 case of AS, 1 case of ulcerative colitis, and 1 case of vitiligo.

CONCLUSION

The presence of M694V mutation may predispose patients with FMF to developing other inflammatory disorders.

Genetic Association of HLA-A*26, -A*31, and -B*51 with Behcet's Disease in Saudi Patients

BACKGROUND

HLA-B*51 has been universally associated with Behcet’s disease (BD) susceptibility, while different alleles of HLA-A have also been identified as independent BD susceptibility loci in various ethnic populations. The objective of this study was to investigate associations of HLA-A and -B alleles with BD in Saudi patients.

MATERIALS AND METHODS

Genotyping for HLA-A and HLA-B was performed using HLA genotyping kit (Lab type^(R) SSO) in 120 Saudi subjects, including 60 BD patients and 60 matched healthy controls.

RESULTS

Our results revealed that frequencies of HLA-A*26, -A*31, and -B*51 were significantly higher in BD patients than in controls, suggesting that HLA-A*26, -A*31, and -B*51 are associated with BD. The frequency of HLA-B*15 was significantly lower in BD patients than in controls. Stratification of genotyping results into active and nonactive forms of BD revealed that the frequency of HLA-A*31 was significantly higher in the nonactive form than in the active form of BD, while there was no significant difference in the distribution of other alleles between the two forms of BD.

CONCLUSION

This study suggests that HLA-A*26, -A*31, and -B*51 are associated with susceptibility risk to BD, while HLA-B*15 may be protective in Saudi patients. However, larger scale studies are needed to confirm these findings.

Headache in Behcet's disease: types and characteristics

BACKGROUND

Behcet's disease involves several systems in the body. Neurological involvement is identified by different symptoms. Headache is one of the common complaints of patients with Behcet's disease. It might be a part of neurological involvement or may arise independently in the course of disease. Studies with small sample size have resulted in various findings in this field. Since the prevalence of Behcet's disease is relatively high in Iran, this study was carried out to compare the features of headache between an acceptable number of patients with this rare disease and a control group.

METHODS

The current case-control study was performed to compare the features of headache between 312 patients with definite Behcet's disease who referred to a Behcet's clinic and healthy individuals. Patients with Behcet's disease were randomly selected. Controls were matched for age and sex. They were personally examined and interviewed meticulously using a questionnaire that met the standards of the International Headache Society classification for different types of headache.

RESULTS

The incidence of headache in the case and control groups was 28.3 % (n = 120) and 18.6 % (n = 59), respectively (p < 0.05; OR 2.73). Tension-type headache was observed in 12.2 % (n = 38) of cases which was significantly higher than control group (n = 6.3 %) (p = 0.011; OR 2.05). The most frequent type of headache in the case group was tension-type headache (12.2 %). In the control group, however, migraine without aura was the most common type (9.1 %). A correlation between ophthalmological involvement and headache was observed in 11 patients in the case group. In addition, a significantly higher systolic blood pressure was found in the case group compared to the controls (125.1 vs. 121.7 mmHg; p = 0.007). There was no major correlation between prednisolone consumption in patients with Behcet's disease and the type and frequency of headache.

CONCLUSIONS

Headache, especially tension-type headache, is more common in patients with Behcet's disease. This might be the result of specific types of uveitis-related and non-structural headaches seen in Behcet's disease.

Differentiation of severe bilateral panuveitis following phacoemulsification: a case report

BACKGROUND

Cataract surgery typically offers instant visual rehabilitation with rare postoperative complications. However, if complications occur, these complications may be confusing and threatening. We present a case of severe bilateral panuveitis following phacoemulsification and intraocular lens implantation and discuss the importance of a correct diagnosis and management.

CASE PRESENTATION

A 75-year-old Asian male with bilateral phacoemulsification and intraocular lens implantation developed severe inflammation with sharp vision loss in both eyes after the surgeries. Physical examination indicated bilateral panuveitis. With a presumptive diagnosis of suppurative endophthalmitis and a history of effective treatment with intravenous antibiotics plus ofloxacin and steroid drops, intravenous ceftazidime and vancomycin were administered. However, the effects were minimal. With a supplemental history of recurrent oral, perineal, and gastrointestinal ulcers, a diagnosis of Behcet's disease was made, and systemic immune inhibitors were prescribed instead of invasive treatments, which might exacerbate the condition. After 5 days of medication, the inflammation was markedly relieved, and no recurrence was observed 2 weeks later.

CONCLUSION

Correct differentiation of confusing conditions is crucial to implement appropriate management. Postoperative complications of cataract surgery should be differentiated carefully, and perioperative management in patients with autoimmune uveitis should be provided with caution.

Facing Terminal Ileitis: Going Beyond Crohn's Disease

Terminal ileitis (TI) is an inflammatory condition of the terminal portion of the ileum that may occur acutely with right lower quadrant pain followed or not by diarrhea, or exhibit chronic obstructive symptoms and bleeding and normally it is associated to Crohn's disease (CD) although it may be associated to other different conditions. This review intended to contribute to a better understanding of TI in order to help in the diagnosis, medical approach and patient care. This work was performed on a survey of articles collected in different databases and a retrospective search was carried out to identify relevant studies in the field. Pathological conditions such as ulcerative colitis, the intake of non-steroidal anti-inflammatory drugs, infectious diseases, eosinophilic enteritis, malignant diseases, spondyloarthropathies, vasculitides, ischemia, sarcoidosis, amyloidosis and others may be related to ileitis but it is commonly referred to CD. To a correct therapeutic approach, it is necessary to understand the causes of this inflammation process. The performance of a clinical, laboratory, endoscopic, and histopathological evaluation of the individuals is crucial to the correct diagnosis and treatment once the inflammation of the ileum may occur due to different pathological conditions besides CD, leading to difficulties in the diagnosis. Thus, an individual approach is necessary once the correct diagnosis is crucial for the immediate therapeutic approach and recovering of the patient.

Intracardiac thrombus in patients with Behcet's disease: clinical correlates, imaging features, and outcome: a retrospective, single-center experience

Intracardiac thrombus (ICT) is a rare but serious complication of Behcet's disease (BD). The study was to report the clinical characteristics, imaging features, treatment, and outcomes of BD patients with ICT in a single tertiary center. A series of 626 BD patients admitted to Peking Union Medical College hospital between April 2003 and April 2013 were reviewed. A total of 12 (1.9 %) BD patients with ICT were included. ICT was presenting manifestation of BD in 5 of the 12 patients (41.7 %) and occurred mostly in men (9/12, 75 %) younger than 40 years. Patients with ICT had more arterial (66.7 vs. 7.3 %, p < 0.001) and venous involvement (75.0 vs. 8.1 %, p < 0.001) compared to those without ICT. Right heart was the most frequent site of ICT (11/12, 91.7 %). Thrombus were hyperechogenic and immobile with a broad-based attachment on echocardiography in most cases (11/12, 91.7 %). Cardiac magnetic resonance (CMR) was performed in four patients. All thrombi showed isointense on T1-weighted image, while all but one were hypointense on T2-weighted image without delayed enhancement. Remission of ICT was associated with therapy of anticoagulant, corticosteroid, and immunosuppressant in most cases (10/12, 83.3 %). There was no death, and relapses of ICT occurred in only one patient after tapering of immunosuppressant during follow-up. A diagnosis of BD should be considered when a young male patient presents with a mass in the right-sided heart accompanied by vascular lesions. Medical therapy especially adequate immunosuppressants might be the first choice for BD patients with ICT.

Tocilizumab in severe and refractory Behcet's disease: Four cases and literature review

INTRODUCTION

In Behcet's disease (BD), interleukin (IL)-6 drive the immune-mediated inflammatory process. The IL-6 receptor can be targeted using tocilizumab. As an off-label treatment, we tested its efficacy in patients with BD.

METHODS

Overall, 4 patients with refractory BD were treated with tocilizumab, 8mg/kg/4 weeks. Patients were clinically and biologically assessed before administering each dose and the literature was reviewed.

RESULTS

Tocilizumab was found to be safe and well tolerated. BD activity decreased significantly in all patients, and prednisone dose was reduced in all cases (up to 50% of the baseline dose). Treatment appeared effective in alleviating skin/mucosal effects, neurological involvement, and uveitis, but less effective for arthralgia and abdominal pain. A very short time lag between the onset of treatment with tocilizumab and the clinical response was observed. The literature review revealed 11 previous cases reporting improvement to BD with this treatment, and 3 previous cases without efficacy.

CONCLUSIONS

We reported the most important study treating refractory BD with tocilizumab; this treatment could be safe and efficient, but will require further evaluation by randomized clinical trials.

Durability of aneurysm treatments in patients with active Behcet's disease

OBJECTIVE

Aneurysms in Behcet's disease are rare, serious, and recurrent. To achieve durable treatment, patients should receive immunosuppressive therapy before intervention to induce remission. We present early and long-term results of emergency cases of active Behcet's disease, which did not permit waiting for suppressive treatment.

PATIENTS AND METHODS

The study was undertaken on all cases admitted to the vascular unit, King Fahd Hospital of University for aneurysm treatment in patients with active Behcet's disease over about 10 years. All patients had exclusion of the aneurysm either by open surgery or endovascular intervention. Morbidities and mortality were recorded within the hospital admission and on the follow-up.

RESULTS

During the study period, three cases were included. All interventions were successful and lifesaving. However, two cases, treated with surgical interposition grafts, were blocked in the intermediate term follow-up (2-12 months) and one case, treated with endovascular treatment, complicated with pseudoaneurysm at femoral puncture site after six months.

CONCLUSION

Although early results were good, intermediate ones were not satisfactory because of progressive graft thrombosis and formation of new aneurysms. Awareness of these rare cases help for early identification and proper immunosuppressive before emergency vascular intervention is warranted.

Temperament and Character Traits in Patients with Behçet's Disease with/without Eye Involvement

PURPOSE

Ophthalmic involvement may lead to permanent vision loss in 25% of cases in patients with BD and it is a main concern in the literature. Although several studies have been investigated, the etiology and the cause of the disease and attacks are not yet known. This study aimed to investigate the correlation between visual impairment and personal characteristics and social circumstances in patients with BD.

MATERIALS AND METHODS

A total of 153 patients with BD and age-and gender-matched 26 healthy control subjects completed the self-report Temperament and Character Inventory (TCI), Beck Depression Inventory (BDI), and State and Trait Anxiety Inventory (STAI-S and STAI-T). We classified the study participants into three groups with respect to severity of eye involvement and one control group. Each group was compared with the other two study groups and control group.

RESULTS

According to TCI, we revealed that there was a trend in BD patients with eye involvement + poor prognosis having less disorderliness traits than BD patients with eye involvement + good prognosis (p = 0.016). The BD patients with eye involvement + poor prognosis had significantly lower attachment scores than BD patients with eye involvement + good prognosis (p = 0.005) and healthy controls (p = 0.005). The BD with eye involvement + poor prognosis had lower empathy scores than healthy controls (p = 0.002). In the way of average TCI parameters, only SD was statistically significant. In terms of subdimensions of TCI parameters, RD_3, SD_3, SD₅, and C₂ were shown to be statistically significant among some of the groups.

CONCLUSION

BD patients with eye involvement were demonstrated to be more extravagant and socially disinterested. It may reflect that severe visual loss caused BD patients to be more systematic, depressive, self-contained, and exhausted. Considering psychological aspects of BD and its visual manifestations may contribute to helping these patients more effectively.

Retinal vascular fractals in Behçet's Disease: A screening method?

Objective

The branching pattern of retinal vessels may be affected in Behçet’s Disease (BD). Fractal analysis can be used as a new method to quantify the changes of the vascular branching pattern. In this study, we examined, for the first time, the relationship between retinal fractal dimension (D_f) and retinal vascular changes seen in patients with BD.

Methods

We conducted a retrospective study of 10 new cases of BD with clinically ocular involvement. Color fundus images taken from both eyes of the participants have been analyzed, and D_f of the whole retinal vasculature was quantified using a novel computer-based program. The resultant D_f was compared with that of healthy individuals.

Results

The mean D_f, calculated from 20 fundus images of cases with BD, was 1.59 ± 0.064. It was lower than that of healthy participants (1.65 ± 0.060) significantly (P = 0.013).

Conclusion

Retinal fractal analysis of cases with BD has been performed for the first time, and the results showed that early retinal vascular changes seen in new cases of BD are associated with lower retinal D_f. Retinal fractal analysis in BD can be practically utilized as a potential tool for screening of retinal involvement, evaluating the prognosis and the response to treatment.

Possible association of proinflammatory cytokines including IL1β and TNFα with enhanced Th17 cell differentiation in patients with Behcet's disease

We have reported that helper T type 17 (Th17) cells increased in patients with Behcet's disease (BD). It remains obscure how Th17 cells increase in the patients. We here analyzed whether T cells preferentially differentiate into Th17 cells in response to various inflammatory cytokines in patients with BD. Exogenous interleukin (IL)23 sustained the higher Th17 cell frequencies of CD4+CD45RO+ T cells after a 2-day culture in vitro in patients with BD, whereas the T cell subpopulation of normal individuals did not respond to IL23 to sustain/increase Th17 cell frequencies. IL23 receptor positive cell frequencies in freshly isolated BD CD4+CD45RO+ T cells correlated with Th17 cell frequencies assessed by intracellular cytokine staining. After a 2-day culture with IL23, BD CD4+ T cells retained the correlation between IL23 receptor expression level and extent of IL17 secretion (as indicated by Th17 cell frequencies), whereas such correlation was not noted in normal individuals. IL23 signals with its receptor were thus suggested to induce IL17 secretion (Th17 cell frequencies) in a short-time culture in patients with BD. We cultured CD4+CD45RO- T cells for 11 days with various inflammatory cytokines to study which cytokine associated with the enhanced Th17 frequencies in the patients. IL17 production by CD4+CD45RO- T cells of BD patients increased significantly by the supplementation of IL1β and tumor necrosis factor (TNF)α, in addition to IL23, compared with that of normal individuals. These results suggest that proinflammatory cytokines, such as IL1β, TNFα, and IL23, may associate with the expansion of Th17 cells in patients with BD. This study was registered with the University Hospital Medical Information Network-Clinical Trials Registry (UMIN000003806).

Antistreptolysin O Levels in Patients with Behcet's Disease

OBJECTIVE

Behcet's disease is a multisystem inflammatory disorder, and its etiology has not been defined clearly yet. In this study, we aimed to investigate the antistreptolysin O (ASO) levels of patients with Behcet's disease.

MATERIALS AND METHODS

Thirty patients with Behcet's disease and 30 healthy controls were enrolled in this study. We measured erythrocyte sedimentation rate (ESR), serum C-reactive protein (CRP), and ASO levels in both groups.

RESULTS

There was no statistically significant difference between the two groups with respect to demographic data (p>0.05). The ASO levels of the patients and the controls were 288.4±145.7 and 170.6±142.4 ng/ml, respectively. In the patients with Behcet's disease, ASO (p<0.01) and ESR (p<0.05) values were significantly higher than in the healthy controls. There was no other significant difference in serum CRP levels between the patients and the controls. We could not find any correlation among ASO, CRP, and ESR values.

CONCLUSION

Our results suggest that serum ASO levels may increase in patients with Behcet's disease. Further studies are needed in order to define the relationship between ASO levels and inflammation status in Behcet's disease.

The Effect of Colchicine on Mean Platelet Volume in Behcet's Disease

BACKGROUND

Patients with Behcet's Disease are recognized to be at an increased risk for venous and/or arterial thrombosis. Colchicine reduces the initiation and amplification of inflammation and is believed to suppress secretion of cytokines and chemokines and in vitro platelet aggregation.

OBJECTIVES

To evaluate the effect of colchicine on levels of mean platelets volume, platelets, erythrocyte sedimentation rate, and C-reactive protein in patients with Behcet's Disease.

METHODS

Patients with Behcet's Disease were evaluated for mean platelets volume before colchicine therapy (Group 1) and after 6-month from beginning of colchicine treatment (Group 2).

RESULTS

Fifty-two subjects were evaluated. The mean age was 38.3 years and the female/male ratio was 28/24=1.16. Laboratory tests were evaluated in Group 1 and Group 2. The median level of mean platelets volume was 9.2±0.8 fl in Group 1 and 8.9±0.9 fl in Group 2. Levels of mean platelets volume was found as significant between Group 1 and 2 (p=0.001).

CONCLUSIONS

Given the proposed relationship between MPV and platelet activity, MPV may serve as a surrogate essay for Behcet's response to colchicine. Colchicine might suppress platelet function and be used in vascular involvement together with immunosuppressant agents in Behcet's Disease. Further studies in large population are needed to evaluate the role of colchicine in platelet function and the effect of colchicine on thrombosis in BD.

Acute coronary syndrome in Behcet's disease caused by a coronary artery aneurysm and thrombosis

Behcet's disease (BD) is a multisystemic vasculitis that can involve vessels of all sizes and is characterized by recurrent oral and genital ulcers with variable manifestations affecting the skin, eyes, and central nervous and musculoskeletal systems. Vascular involvement in BD is reported to be up to 40% in different series. The abdominal and thoracic aorta and pulmonary and femoral arteries are the most commonly involved arteries. However coronary arteries are rarely affected. Herein, we present a 29-year-old man who was consulted with progressive severe chest pain of 3 days in duration to our clinic. The patient was diagnosed with BD with mucocutaneous symptoms and a positive pathergy test 1 year ago and was in clinical remission for the last 6 months. At the first evaluation in the emergency department, the patient's vital signs were stable, whereas he had elevated troponin T levels with a normal electrocardiogram and hypokinetic areas in the apex of the heart in the echocardiography. Conventional and computed tomography coronary angiography revealed aneurysms and intramural thrombosis in the left anterior descending and right coronary arteries. Although ischemic symptoms and signs improved with anticoagulant and antiaggregant therapies, coronary aneurysms were observed to increase in size. Immunosuppressive (IS) treatment was started with pulse intravenous corticosteroids and cyclophosphamide. Because of the high re-stenosis risk, stents were not applied to the affected vessels during the acute thrombosis period. During routine investigations, an in situ pulmonary thrombosis was also detected bilaterally in the peripheral pulmonary arteries. In conclusion, coronary artery aneurysm is a rare and poor prognostic manifestation of BD. The treatment protocol for these aneurysms is not well clarified. IS therapies are definitely indicated, but the role of anticoagulants and invasive vascular interventions is controversial.

Efficacy of rebamipide and levamisole in the treatment of patients with recurrent aphthous ulcer - a comparative study

Context (Background): Recurrent aphthous stomatitis is an inflammatory condition of unknown aetiology characterized by painful recurrent, single or multiple ulcerations of the oral mucosa.

AIMS

To compare the efficacy of rebamipide, a gastro-protective agent and levamisole, an immunomodulating agent in the treatment of recurrent aphthous stomatitis.

MATERIALS AND METHODS

Hundred patients diagnosed with recurrent aphthous stomatitis were enrolled in the study. Fifty patients were assigned randomly to each of the two treatment groups. After the clinical diagnosis and ulcer measurement, a subjective evaluation of symptoms was done for each subject. Both the drugs were given orally at specified intervals. Ulcer measurements and subjective evaluations were made at day one.

STATISTICAL ANALYSIS

Analysis was done using various test like Mann Whitney and t-test.

RESULTS AND CONCLUSION

The overall results showed mean number of episodes whose values were not statistically significant (p=0.43), neither were the mean number of ulcers (p=0.75), or values for mean size of ulcers (p=0.91). However, the overall results suggested that efficacy of rebamipide is almost same as that of the efficacy of previously proved drug levamisole. The current study with a three months follow up, including patients with high scores of pain, aphthae count, ulcer size and frequency of occurrence showed better results in both the study groups. However, rebamipide is suggested to be well tolerated and may therefore be useful in the treatment and prevention of frequently recurrent aphthous ulcers not restricted to Behcet's disease.

Behcet's disease in Budd-Chiari syndrome

Background

Behcet’s disease (BD) is a well-known cause of Budd-Chiari syndrome (BCS). Data are lacking on the presentation and outcome of BCS related to BD.

Methods

We investigated the relationship between BD and BCS in 14 patients with both diseases and compared the results to 92 BCS patients without BD.

Results

Male gender (p = 0.003), North African origin (P = 0.007) and inferior vena cava obstruction (P < 0.0001) were more frequent in patients with BD and BCS than in those with BCS alone and the plasma C-reactive protein level was higher (p = 0.003). Two of the patients with the combined diseases underwent recanalization of the vena cava and the hepatic veins, none received transjugular intrahepatic portosystemic shunts (TIPS), one received a surgical shunt and one underwent liver transplantation. TIPS were less frequent in patients with BD and BCS than in those with BCS alone (P = 0.019). Eighty six per cent of patients with BCS and BD received corticosteroids and immunosuppressive therapy. The 5-year transplantation-free survival rate was 63% in patients with BCS alone and 91% in those without BD (P = 0.11). In our series and in the literature, a high number of patients [12 (61.5%) and 11 (64.7%) respectively] treated with anticoagulation and corticosteroids and/or immunosuppressants did not require invasive treatment.

Conclusion

This study shows a higher frequency of IVC obstruction in patients with BCS and BD. Medical treatment with anticoagulation and immunosuppressive agents may improve the symptoms of BCS. Therefore early management with immunosuppressive and anticoagulation therapy appears to be the treatment of choice in patients with BCS and BD.

Demographical and Clinical Characteristics of Behcet's Disease in Southeastern Turkey

BACKGROUND

We aimed to determine the demographic and clinical features of patients with Behcet's disease (BD) in Southeastern Turkey.

METHODS

In this study, files of 132 patients with BD (76 females and 56 males) who were diagnosed with BD according to the International Study Group criteria at the Department of Dermatology of Dicle University Faculty of Medicine from 2005 to 2009 were evaluated retrospectively. Demographical and clinical characteristics of the cases were recorded.

RESULTS

Mean age of the cases was 32.40 ± 9.4 years (range 15 - 59 years) and male/female ratio was 0.73. The mean age at diagnosis was 28.71 ± 9.1 years. Six cases were diagnosed as juvenile BD (4.45%). Oral aphthous lesions (100%) and genital ulcers (94%) were found to be the most common findings of the disease, followed by pathergy positivity (75%), papulopustular lesions (74.2%), erythema nodosum (43.2%), thrombophlebitis (6.8%) and extragenital ulcers (6.1%). Systemic involvement was noted as joint involvement in 79.5%, ocular involvement in 28.8%, vascular involvement in 9.8%, pulmonary involvement in 2.3%, neurologic involvement in 2.3% and genitourinary system involvement in 0.8%. There was no significant difference between mucocutaneous findings and systemic involvement ratios of male and female cases.

CONCLUSION

Demographic and clinical features of BD may vary according to geographical region, gender and ethnicity. We hope that this study will contribute to the epidemiologic data of BD which may exhibit different clinical and demographic features in different parts of the world.

Identification of prohibitin as an antigen in Behcet's disease

OBJECTIVE

This study is intended to screen potential antigen for Behcet's disease (BD) by using human microvascular endothelial cells (HUVEC).

METHODS

Following cell-based indirect immunofluorescence assay with sera from BD patients, proteins extracted from HUVEC were separated and detected by Western blotting. Then the target protein was identified by LC-MALDI-TOF/TOF, the recombinant target protein was expressed, purified and then used as coating antigen to test the prevalence of autoantibodies in patient's sera.

RESULTS

The Western blotting result showed that some patients' sera could react with a protein band with about 30 kDa of molecular weight, which was further identified as prohibitin by mass spectrometry. The prevalence of serum antibodies against recombinant human prohibitin was detected in 16 of 58 BD patients (28%) but none in healthy controls.

Assessment of genotoxicity associated with Behcet's disease using sister-chromatid exchange assay: vitamin E versus mitomycin C

Behcet's disease (BD) is a multisystemic chronic inflammatory disorder that presents throughout the world with high frequency in Turkey and Middle East. BD has been shown to be associated with genotoxicity as patients with the disease have demonstrated high rates of sister chromatid exchange (SCE) and oxidative DNA damage. In this study, we examined the effect of vitamin E, which is known for its strong antioxidant activity, on the rate of SCE in cultured lymphocytes obtained from BD patients. In addition, the susceptibility of patient lymphocytes to the mutagenic agent mitomycin C (MMC) was also investigated. The results showed significant elevation in the rate of SCE in lymphocytes obtained from patients compared to those from healthy subjects (P < 0.01). Treatment with vitamin E normalized the elevated rate of SCE to a comparable level observed in the control group (P < 0.01). Finally, treatment of cultures with MMC significantly increased the rate of SCE in the lymphocytes of both patients and controls (P < 0.001). The magnitude of change in the rate of SCE induced by MMC was equivalent in both groups. This result suggests similar sensitivity of BD lymphocytes and control ones to MMC. In conclusion, genotoxicity associated with BD can be overcome by treatment with vitamin E. Lymphocytes of BD have normal sensitivity to the mutagenic agent MMC.

Multiple Right and Left Pulmonary Arteries and Subdivisions of Inferior Mesenteric Artery Aneurysms in Behcet's Disease Case: A Rare Clinical Presentation

Behcet's disease is a multi-systemic inflammatory disorder with cutaneous acneiform eruptions, orogenital aphthae, uveitis, arthritis and systemic vascular inflammation. One of the rare vascular manifestations is thoraco-abdominal aortic and pulmonary aneurysm that is associated with high risk of morbidity and mortality. We report a 36-year-old man with chronic cough, hemoptysis, significant weight loss, and orogenital ulcers from one year before referral. Initial assessments revealed multiple parahillar nodules in chest X-ray, chronic inflammatory anemia, erythrocyte sedimentation rate more than 100, and positive Human Leukocyte Antigen B5 and B51. Evaluation for infection and malignancies was unremarkable. Open exploratory lung study showed multiple pulsatile nodules in both lungs. AMIGO computed tomogram confirmed multiple right and left pulmonary artery aneurysms and impending to rupture aneurysm at subdivision of inferior mesenteric artery. After beginning of three methylprednisolone and cyclophosphamide pulse doses, the clinical aspect of the patient dramatically improved. Although pulmonary aneurysm is a rare manifestation of Behcet's disease and it is more infrequent in the distal branches, it can be seen in patients presenting with inflammatory disease and respiratory manifestations and with Behcet's disease diagnosis. Corticosteroid pulse-therapy could be considered as the first line of medical treatment in these patients.

Aneurysm of the tibio-peroneal trunk: case report

Behcet's disease is an inflammatory disorder of unknown cause. It's a systemic disorder that may affect any system in the body. Vascular system involvement occurs in 25%-30%. The case presented here elicits both venous and arterial complications of Behcet's disease in the same patient. The patient presented to our emergency with signs and symptoms of ruptured tibioperoneal aneurysm that was treated both medically and surgically.

Genetic and non-genetic factors affecting the visual outcome of ocular Behcet's disease

OBJECTIVE

To examine the prognostic factors for visual outcome in Korean BD patients with uveitis.

METHODS

Seventy-seven Korean BD patients with uveitis were enrolled. HLA-B and HLA-A genotypes were determined by PCR-based method. Visual acuity was measured by Snellen chart. Vision loss was graded into visual impairment (VI) defined as VA<20/40 for more than 6 months, loss of useful vision (LUV) as VA < 20/200, and near total blindness (NTB) as VA of light perception or worse.

RESULTS

VI was associated with a longer duration of uveitis, posterior uveitis, and cataract, LUV with male gender, a longer duration of uveitis, posterior uveitis, and cataract, and NTB with a longer duration of uveitis, cataract, and glaucoma. HLA-B*51 and HLA-A*26:01 did not show any association with VI, LUV, or NTB. However, HLA-B*51 carriers had earlier onset of uveitis and HLA-A*26:01 was strongly associated with posterior uveitis. In patients with posterior uveitis, VI was associated with a longer duration of uveitis and cataract, LUV with a longer duration, and NTB with HLA-B*51.

CONCLUSION

Longer duration of uveitis, posterior uveitis, male gender, cataract, and glaucoma were found to be associated with poor visual outcome in BD-related uveitis. HLA-B*51 was associated with NTB in patients with posterior uveitis. HLA-A*26:01 showed no association with VI, LUV, or NTB, however, was strongly associated with posterior uveitis.

Methylenetetrahydrofolate reductase C677T and A1298C polymorphisms and variations of homocysteine concentrations in patients with Behcet's disease

BACKGROUND

Behcet's disease (BD) is a chronic, relapsing, multi-systemic inflammatory disorder of unknown causes. This disease is mainly characterized by mucocutaneous, ocular, vascular, and central nervous system manifestations. The aim of this study is to investigate the associations between C677T and A1298C polymorphisms in the methylenetetrahydrofolate reductase (MTHFR) gene and the plasma homocysteine (Hcy), folate, and B12 levels in a relatively large cohort of Tunisian patients with BD.

METHODS

The study included 142 patients with BD and 172 healthy controls. The C677T and A1298C polymorphisms were genotyped using PCR-RFLP. Serum Hcy level was determined using a fluorescence polarization immunoassay. Serum folate and vitamin B12 levels were measured by electrochemiluminescence immunoassay.

RESULTS

Genotype and allele frequencies of the two studied MTHFR polymorphisms did not show any significant differences among BD patients compared to controls. Patient carriers of the 677TT variant and the 677T allele displayed significantly higher Hcy concentration. Moreover, no significant association was found between neither A1298C polymorphism nor the C allele and Hcy, folate, and B12 levels. In multivariate analyses, we reported that 677T allele, male gender, and creatinine level were independent risk factors for hyperhomocysteinemia (HHC).

CONCLUSIONS

In the present study, we report the absence of any significant differences between genotype and allele frequencies for both studied polymorphisms among BD patients compared to healthy controls. Besides, we showed that the T allele of MTHFR C677T polymorphism influenced the Hcy level which is an independent risk factor for HHC in Tunisian BD patients.

Successful Treatment of Vasculo-Behcet's Disease Presenting as Recurrent Pseudoaneurysms: the Importance of Medical Treatment

INTRODUCTION

Vasculo-Behcet's disease is a subtype of Behcet's disease, characterized by cases in which vascular complications are present and often dominate the clinical features. In this disease, there are four different vascular complications: arterial occlusion, arterial aneurysm or pseudoaneurysm, venous thrombosis, and variceal formation. It is rare that arterial lesions are multiple, but without venous involvement. So far, the optimal treatment of the disease has not been established.

CASE REPORT

The authors report a rare case of vasculo-Behcet's disease with multiple and recurrent pseudoaneurysms in large arteries, but without affecting the venous system. The patient underwent three rounds of surgery, but developed a new pseudoaneurysm after each operation in short term. However, the patient was successfully treated with a combination of prednisone and immunosuppressive agents.

CONCLUSION

For Vasculo-Behcet's disease, surgical and endovascular interventions alone increased the incidence of pseudoaneurysm. Early diagnosis and early initiation of prednisone in combination with immunosuppressive therapy are critical for inhibiting the progression of vascular lesions and provide a good prognosis.

The role of an uncommon type of oral streptococcus sanguis in the etiology of behcet's disease

The relationships of Behcet's disease (BD) with oral diseases and the prevalence of an uncommon type of oralStreptococcus sanguis (Str. sanguis) in the oral cavity were investigated in a case-control study. BD patients were compared to patient controls (collagen disease) and healthy controls.An interview questionnaire survey of BD and oral diseases showed that during the pre-onset, onset, and post-onset periods, the incidences of tonsillitis and dental caries, or the history of dental treatment, were greater in BD cases. Typological analysis showed a higher prevalence of an uncommon type ofStr. sanguis, differing from the common type, among BD cases compared to control groups. These results, showing a higher incidence of tonsillitis and dental caries during the presymptomatic period, a greater frequency of dental treatments during the symptomatic period, and the presence of an uncommon type ofStr. sanguis, indicate thatStr. sanguis of an uncommon type is related to increased risk of BD, and the possibility of a causal role is suggested.

Subtotal colectomy for intestinal Behcet's disease: a histopathological surprise

A 40-year-old male who was diagnosed to be having ileocaecal tuberculosis by colonoscopy elsewhere was put on antitubercular treatment. Despite therapy over three months patient had recurrent bouts of lower abdominal pain and was admitted repeatedly with features of subacute intestinal obstruction. CT- abdomen revealed concentric large bowel thickening at multiple sites with features of stenosing lesions. Patient underwent an exploratory laparotomy and subtotal colectomy was done for the diseased large bowel. Post operative histopathological examination revealed it to be Behcet's disease. We report a rare case of intestinal Behcet's disease requiring subtotal colectomy.

Intravitreal triamcinolone for intraocular inflammation and associated macular edema

Triamcinolone acetonide (TA) is a corticosteroid that has many uses in the treatment of ocular diseases because of its potent anti-inflammatory and anti-permeability actions. Intraocular inflammation broadly referred to as uveitis can result from several causes, including the immune system and after ophthalmic surgery. One of the most common reasons for vision loss with uveitis is macular edema. TA has been used for many years as an intravitreal injection for the treatment of ocular diseases. Several case control studies have been reported showing the efficacy of TA in the treatment of intraocular inflammation and associated macular edema caused by Behcet's disease, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia and white dot syndromes. It has also been shown efficacious in cases of pars planitis and idiopathic posterior uveitis. Some authors have reported its use in postoperative cystoid macular edema. Many of the studies on the use of TA in controlling intraocular inflammation and concomitant macular edema showed its effect to be transient in many patients requiring reinjection. Complications can arise from intravitreal injection of TA including elevated intraocular pressure and cataract. Rarely, it can be associated with infectious and non-infectious endophthalmitis. TA may be useful as an adjuvant in the treatment of uveitis and its associated macular edema, especially in patients resistant or intolerant to standard treatment.

The Influence of Age on Behcet's Disease Activity

OBJECTIVE

Behcet's disease (BD) is a multi-systemic vasculitis characterized by a relapsing and remitting, rather than a persisting, disease course. It is thought that BD activity decreases as the age of the afflicted individual increases. Furthermore, disease severity is reported to be greater in individuals that first present with the disease at a young age. This study investigates the association between disease activity scores and both the current ages of BD patients and patient age at disease onset.

MATERIALS AND METHODS

Fifty patients with BD participated in this study. The gender, age, and age at disease onset of each patient was recorded. A BD Current Activity Form (BDCAF) was used to assign a clinical disease activity score for all enrolled patients. The participants were divided into subgroups according to 1) their current ages and 2) their ages at the onset of BD disease. In addition to BDCAF scores, erythrocyte sedimentation rates (ESR) and C-reactive protein (CRP) levels were compared across groups. Statistical analyses were performed using one-way ANOVA.

RESULTS

The mean patient age and the mean patient age at the time of disease onset were 34.68±9.71 and 26.10±7.07 years, respectively. Patients that were younger than 30 years of age exhibited significantly higher rates of oral ulceration and arthralgia, and had higher total BDCAF scores than patients that were older than 40 years of age (p=0.038, p=0.020, and p=0.026, respectively). Patients who developed BD before their twentieth year showed significantly higher total disease activity scores than patients in the oldest age at disease onset group (p < 0.05). No significant difference was observed in ESR and CRP levels between groups.

CONCLUSION

Our results demonstrate that younger BD patients and patients that first present with disease symptoms at a younger age have higher disease activity scores. Our results reinforce the importance of considering the age at disease onset when clinically treating individuals with BD.