Immunopathogenesis of Behçet's disease

Myelin basic protein and index for neuro-Behçet's disease

Neuro-Behçet's disease (NBD) contributes to poor prognosis in BD patients which lacks reliable laboratory biomarkers in assessing intrathecal injury. This study aimed to determine the diagnostic value of myelin basic protein (MBP), an indicator of central nervous system (CNS) myelin damage, in NBD patients and disease controls. Paired samples of cerebrospinal fluid (CSF) and serum MBP were measured using ELISA, while IgG and Alb were routinely examined before the MBP index was developed. CSF and serum MBP in NBD were significantly higher than in NIND, which could distinguish NBD from NIND with a specificity exceeding 90%, moreover, they could also be excellent discriminators for acute NBD and chronic progressive ones . We found positive linkage between MBP index and IgG index. Serial MBP monitoring confirmed serum MBP's sensitive response to disease recurrence and drug effects, whereas MBP index suggests relapse prior to clinical symptoms. MBP has high diagnostic yield for NBD with demyelination and identifies CNS pathogenic processes before imaging or clinical diagnosis.

Protective effect of Echinacea purpurea (Immulant) against cisplatin-induced immunotoxicity in rats

PURPOSE

Cisplatin, one of the most effective anticancer drugs, is known to cause undesirable adverse effects, including immunotoxicity. Echinacea purpurea is an important medicinal plant with immunostimulatory and anti-inflammatory activities. We have investigated the protective effect of an herbal formulation (Immulant) containing E. purpurea extract against cisplatin-induced immunotoxicity in rats.

METHODS

Forty mature albino rats were randomized into four groups (10 rats/group). Control (group 1) animals were subjected to intraperitoneal (i.p.) injection of saline solution (0.2 ml) once every 3 days. Group 2 animals received cisplatin (3.5 mg/kg, i.p.) once every 3 days for successive 2 weeks. Group 3 rats received oral Immulant (150 mg/kg) once daily for 2 weeks. Group 4 animals received oral Immulant treatment as in group 3 in addition to cisplatin as in group 2. Serum level of total protein and albumin, total and differential leukocytic count, phagocytic activity of monocytes, humoral activity and splenic histopathology and immunohistochemistry were used as diagnostic markers of immunotoxicity.

RESULTS

Cisplatin induced marked inhibition of cellular immunity as exhibited by significant decrease of leukocytic count, lymphocyte percentage and phagocytic activity with marked increase in neutrophil percentage. Humoral immunity represented by marked inhibition in total protein and γ-globulin concentration and significant inhibition in antibody titer against Mycoplasma gallisepticum were recorded. Histopathological and immunohistochemical observation of the spleen of cisplatin-treated rats revealed obvious pathological findings of marked depletion and degeneration of lymphoid tissue. Co-oral administration of Immulant resulted in substantial improvement of various immunotoxicological indices compared to cisplatin control.

CONCLUSION

The herbal medicine Immulant is an immunostimulant which could be used to treat the immunotoxic effects of cisplatin. Graphical abstract Cisplatin (CP) is a highly effective antineoplastic DNA alkylating agent. CP induces free radical production causing an oxidative damage.Cisplatin induced marked inhibition in cellular and humoral immunityEchinacea purpurea (Immulant) is a powerful anticytotoxic agent against cisplatin toxicity.

Phenotypic abnormalities of peripheral blood mononuclear cells in patients with Behçet's disease and association with HLA-B51 expression

The aim of this study was to investigate the subclasses and the immunophenotypic profile of peripheral mononuclear cells in patients with Behçet's disease (BD) and to assess associations between the expression of HLA-B51 antigen and that of other cell markers. Thirty healthy volunteer blood donors and forty patients with BD were enrolled into this study. Phenotyping was performed using two color flow cytometry. HLA-B51 typing was performed using the complement dependent microlymphocytotoxicity assay. Unlike controls, patients with BD presented a modified immunophenotypic profile of lymphocytes. Compared to those in the remission phase, patients with active BD showed an increased mean of MFI ratio of CD56 on CD16+CD56+ cells (32.47 ± 14.26 versus 23.87 ± 10.3; p = 0.032), increased absolute numbers of CD4(-)CD8(bright) and CD4(+)CD8(+) cells (657.1 ± 463.6 cells/µL versus 319.24 ± 116.4 cells/µL; p = 0.017 and 40.77 ± 36.41 cells/µL versus 10.77 ± 9.78 cells/µL; p < 0.0001, respectively) and an elevated mean of MFI ratio of CD19 on B cells (252.3 ± 56.7 versus 205.67 ± 32.3; p = 0.021). However, expression of HLA-B51 was not associated with any specific immunophenotypic profile. In conclusion, abnormal immunophenotypic profile of peripheral lymphocytes was found in patients with BD, especially in active phase, reflecting an immune dysregulation. Moreover, HLA-B51 expression was not found to be related to the expression of other cell markers.

Noninfectious immune-mediated uveitis and ocular inflammation

Noninfectious uveitis encompasses a diverse group of ocular inflammatory disorders that share an underlying immune etiology and may be associated with systemic disease or confined primarily to the eye. Uveitis is commonly classified by anatomical location of inflammation into anterior, intermediate, posterior, and panuveitis. The treatment of noninfectious uveitis consists of corticosteroids, immunosuppressive agents, and surgically placed steroid implants. We review the epidemiology, immunopathology, and clinical features of several noninfectious immune-mediated uveitides, including HLA-B27 acute anterior uveitis, juvenile idiopathic arthritis, intermediate uveitis, sarcoidosis, Behcet's disease, Vogt-Koyanagi-Harada syndrome, sympathetic ophthalmia, and white dot syndromes. We also discuss the stepwise approach to medical treatment of immune-mediated uveitis as well as the characteristics, safety, and efficacy of immunosuppressive agents used to treat ocular inflammatory disease.

Fractalkine (CX3CL1) levels in patients with Behçet's disease and neuro-Behçet's disease

OBJECTIVE

The aim of the present study was to assess the role of CX3CL1 in patients with active and inactive Behçet's Disease (BD), Neuro-Behçet's Disease (NBD) and control subjects.

METHODS

Fifty-six patients admitted to the BD and NBD Outpatient Clinics, and 30 healthy controls were enrolled in the study. Serum CX3CL1 levels were measured by an enzyme linked immunosorbent assay (ELISA).

RESULTS

No significant difference was found between the serum CX3CL1 levels of control subjects, and patients with active and inactive BD or NBD, regardless of treatment.

CONCLUSION

To our knowledge, this is the first study analyzing CX3CL1 levels in patients with BD and NBD. Our results demonstrated that serum CX3CL1 levels were not changed in active and inactive BD and NBD. However, further large-scale studies are needed to confirm our results.

Ocular Behçet disease: current therapeutic approaches

PURPOSE OF REVIEW

To alert physician to timely recognition and current treatment of recurrent hypopyon iridocyclitis or panuveitis in ocular Behçet disease (OBD).

RECENT FINDINGS

Interferon-α, rituximab, intravitreal triamcinolone, and biological response modifiers by tumor necrosis factor inhibitors such as infliximab and adalimumab are being used increasingly for the treatment of severe sight-threatening ocular inflammation including retinal vasculitis and cystoid macular edema (CME).

SUMMARY

Biological agents offer tremendous potential in the treatment of OBD. Given that OBD predominantly afflicts the younger adults in their most productive years, dermatologist, rheumatologist, internist, or general practitioners supervising patients with oculo-articulo-oromucocutaneous syndromes should be aware of systemic Behçet disease. Early recognition of ocular involvement is important and such patients should strongly be instructed to visit immediately an ophthalmologist, as uveitis management differs from extraocular involvements with high ocular morbidity from sight-threatening complications due to relapsing inflammatory attacks in the posterior segment of the eye. A single infliximab infusion should be considered for the control of acute panuveitis, whereas repeated long-term infliximab infusions were proved to be more effective in reducing the number of episodes in refractory uveoretinitis with faster regression and complete remission of CME.

Time-course study of the immunotoxic effects of the anticancer drug chlorambucil in the rat

In 2005, the International conference on harmonization (ICH) recommended that all new human pharmaceuticals be tested for unintended immunomodulatory potential via a tiered approach. Included in this approach is a semiquantitative description of changes in the separate compartments of lymphoid tissue (also called enhanced histopathology). Chlorambucil was administered to Hanover Wistar rats at regular time points, followed by a treatment-free (recovery) period. Groups of treated and control animals were sacrificed regularly during both the treatment and recovery periods. Selected tissues were removed, weighed fresh and fixed in formalin, processed, and stained with hematoxylin and eosin. Blood samples and bone marrow smears were also obtained. With the use of enhanced histopathology, a description of the changes in lymphoid tissues and bone marrow was used as a means of assessing the susceptibility, and recovery, of the different lymphoid cell populations over time. A correlation with organ weights, flow cytometry data, and bone marrow cytology was achieved. The administration of chlorambucil in the Hanover Wistar rat provided a useful tool to examine the rate and sequence of changes in the lymphoid organs and bone marrow during treatment with, and the recovery from the effects of, a potent immunosuppressive agent.

Psychiatric disorders in patients with Behçet's disease

Objective. In this study, we aimed to investigate current prevalence and related clinical factors of psychiatric disorders in Behçet patients. Methods. Seventy-three outpatients who applied to a Behçet clinic and whose diagnosis was Behçet's disease according to criteria of the International Study Group for Behçet's disease were recruited in this study. Psychiatric diagnoses were assessed with The Structured Clinical Interview for DSM-IV/Clinical Version (SCID-I/CV). Results. Thirty patients (41.1%) reported at least one current psychiatric disorder. Major depression (17.8%) was the most frequent psychiatric disorder. Specific phobia (16.4%), generalized anxiety disorder (15.1%) and social phobia (9.6%) were other frequent disorders. Prevalence rates of any psychiatric and anxiety disorder were significantly higher in females than males. There was no significant relationship between psychiatric morbidity and clinical characteristics of Behçet's disease. Conclusion. Our study suggests that Behçet patients have high prevalence of psychiatric disorders. Therefore, psychiatric evaluation should be performed in all patients with Behçet's disease.

Increased proportion of CD3+CD4-CD8- double-negative T cells in peripheral blood of children with Behcet's disease

INTRODUCTION

Behcet's disease (BD) is a multi-system inflammatory disorder of poorly understood pathogenesis, which is characterized by oral aphtosis, genital ulcers and uveitis.

OBJECTIVE

To assess the role of CD3+CD4-CD8- double negative (DN) T cells in pathogenesis of Behcet's disease.

PATIENTS

Ten BD patients (age 12.2+/-2.2 years, 7 in remission, 3 in exacerbation state) treated at the Pediatric Rheumatology unit of Soroka University Medical Center and 3 age-matched controls participated in the study.

METHODS

Peripheral blood lymphocytes of study subjects were isolated and stained with fluorescein-labeled anti-CD45, CD3, CD4, CD8 antibodies and analyzed by FACS assay.

RESULTS

Proportion of CD4-CD8- DN T cells was significantly increased in BD patients (n=10) as compared to healthy controls (6.2+/-3.4% vs. 3.2+/-1.1% of total CD3+ cells, p<0.05), this cell group was additionally enhanced in BD exacerbation, compared to patients in remission (10+/-4.1% vs. 4.7+/-1.2%, p<0.05, respectively). DN T cells were significantly increased in BD patients in remission, compared to healthy controls (4.7+1.2% vs. 3.2+1.1% of total CD3+ cells, p<0.05, respectively).

CONCLUSIONS

Behcet's disease is characterized by increased proportion of CD3+CD4-CD8- double negative T cells in peripheral blood. Further studies, that include additional immunophenotyping and analysis of gene expression, aimed at characterization of these cells are currently underway.

Clinical features of late-onset Behçet's disease: Report of nine cases

BACKGROUND

Behçet's disease (BD) is usually diagnosed between the second and fourth decades. Onset after 50 years of age is extremely rare. We aimed to analyze the clinical features of late-onset patients with BD.

METHOD

The study was conducted from 439 patients diagnosed as BD according to criteria of the International Study Group for BD. Clinical features of patients who were asymptomatic or suffered from only recurrent aphthous stomatitis (RAS) until 50 years of age but fulfilled the diagnostic criteria of BD after this age were reviewed.

RESULTS

The age-of-onset was more than 50 years in nine patients (1.56%). Two patients developed erythema nodosum, two developed pathergy positivity, one developed papulopustules, pathergy positivity and ocular symptoms, one developed papulopustules and pathergy positivity, one developed ocular symptoms, one developed papulopustules and ocular symptoms, and one developed erythema nodosum and pathergy positivity as well as oral aphthae and genital ulcerations after the age of 50 years. The neurologic system was involved in two patients. Mucocutaneous symptoms of two patients worsened after interruption of therapy. Two patients with neurologic and ocular involvement flared during the follow up.

CONCLUSION

Since the course of the disease is regarded to be relatively mild in mature patients, it is noteworthy that systemic manifestations such as ocular and neurologic involvement and acute flares developed after the age of 50 years in the limited number of patients with late-onset BD in our series.

Skewed Th1 responses caused by excessive expression of Txk, a member of the Tec family of tyrosine kinases, in patients with Behcet's disease

Behcet's disease (BD) is characterized by recurrent attacks of uveitis, oral aphtha, genital ulcers and skin lesions. The etiology and pathogenesis of BD are largely unknown. It has been reported that excessive Th1 cell function is involved in the pathogenesis of BD. Previously, we found that Txk, a member of the Tec family of tyrosine kinases, acts as a Th1 cell-specific transcription factor that is involved in the effector function of Th1 cells. Thus, we studied Th1 cytokine production and Txk expression of T-lymphocytes in patients with BD. Peripheral blood lymphocytes produced excessive Th1-associated cytokines including interferon-gamma (IFN-gamma) and interleukin (IL)-12 in patients with BD. Circulating CD3+ and purified CD4+ T cells expressed excessive Txk protein. The extent of IFN-gamma production by the lymphocytes correlated with the expression of Txk protein in the immunoblotting analysis. The majority of cells infiltrating into the skin lesions of patients with BD expressed IFN-gamma. IL-12 and IL-18 were found in the mononuclear cell aggregates in the skin and intestinal lesions of those with BD. Lymphocytes accumulating in the skin and intestinal lesions expressed higher levels of Txk as compared with other Th2-associated diseases. IFN-gamma, IL-18 and IL-12 detected in skin lesions may induce preferential development of Th1 cells in patients with BD. Collectively, Th1 cells expressing Txk and Th1-associated cytokines may play a critical role in the development of skin and intestinal lesions in patients with BD. This review may serve as a reminder of the importance of excessive Th1 cell function in the pathogenesis of BD and may contribute to the discovery of new molecular targets for the development of a specific therapeutic strategy for BD.

Complex aphthosis: A large case series with evaluation algorithm and therapeutic ladder from topicals to thalidomide

BACKGROUND

Recurrent aphthous stomatitis is a common problem with 20% to 50% of the population having experienced simple aphthous lesions (ie, canker sores). Complex aphthosis is the diagnosis given to patients with almost constant >3 oral aphthae or recurrent oral and genital aphthae in the absence of Behcet's disease.

METHODS

Eighty-one patients were referred to the Wake Forest University School of Medicine, Department of Dermatology from 1995 to 2001 with the diagnosis of presumptive Behcet's disease. After exclusion of patients with simple recurrent aphthous stomatitis or non-aphthous oral disease, 64 patients remained. Ten of the patients met criteria for Behcet's disease. The remaining 54 patients were evaluated and treated as patients with the diagnosis of complex aphthosis.

RESULTS

The 54 patients with complex aphthosis became the subject of this study. Twelve patients had secondary complex aphthosis with 10/12 having inflammatory bowel disease. The remaining 42 patients had primary (ie, idiopathic) complex aphthosis. The therapeutic ladder for these patients ranged from topical therapy through oral colchicine and combination oral colchicine and oral dapsone therapy to oral thalidomide therapy.

CONCLUSION

Complex aphthosis is an important condition to distinguish from Behcet's disease. Appropriate patient evaluation algorithms and treatment therapeutic ladders are proposed.

Managing the symptoms of Behçet's disease

Behçet's disease (BD) is a chronic, relapsing, systemic inflammatory vasculitis of unknown aetiology with a myriad of immunological and pathological consequences. Patients with BD are clustered along the ancient silk road, extending from Far-East Asia to Turkey. The disease affects both genders of all ages from infants to the elderly. It is a long-term, cyclical disease and such patients may have symptom-free periods of weeks, months or years that are interrupted by exacerbations of varying intensities lasting a few days, weeks or months. Clinical features include oral aphthae, genital ulcers, ocular inflammation, skin lesions, as well as articular, vascular, neurological, pulmonary, gastrointestinal, renal and genitourinary manifestations. The main histopathological finding is a widespread vasculitis of the arteries and veins of any size or thrombophilia according to the site of involvement. BD may start with just one or two small symptoms but other symptoms may gradually appear over the years. Recurrent ocular inflammation, which occurs in approximately 50% of cases, is the major morbidity that may eventually lead to blindness. The treatment of BD is usually symptomatic and palliative. Therefore, the main objectives are to relieve symptoms associated with mucocutaneous lesions and arthritis, to modify the course of the disease, to control inflammatory eye disease, clinically suppress the inflammation and vasculitis, to prevent recurrences and thus, prevent irreversible damage. The choice of treatment is based on the severity of systemic involvement, clinical presentation and the site affected. The preferred treatment modalities are combined drug therapy and include topical therapies as well as systemic corticosteroids, NSAIDs, colchicine, dapsone and immunosuppressive and cytotoxic agents. Such therapies are tailored to the individual patient depending on clinical manifestations. Thalidomide, tacrolimus, IFN-alpha and anti-TNF monoclonal antibody have recently attracted attention as novel therapeutic approaches.

Resistant bipolar disorder precipitated by Behcet's syndrome

OBJECTIVE

To report a case of a patient with Behcet's syndrome who developed treatment resistant bipolar disorder (BD) several years after the onset of Behcet's syndrome.

METHODS

A 62-year-old woman suffering from Behcet's syndrome since the age of 38, who developed a typical BD 6 years after the first manifestations of the syndrome was described.

RESULTS

Once BD occurred, Behcet's syndrome became milder, while BD deteriorated and evolved into a rapid cycling illness. Lithium and carbamazepine were ineffective in controlling the affective symptoms, while sodium valproate combined with low doses of carbamazepine and olanzapine resulted in sufficient stabilization of her mood state.

CONCLUSIONS

Behcet's syndrome may have been the organic substrate for BD in this case. The appearance of BD in the setting of an organic-immune disorder, like Behcet's syndrome, suggests that such disorders may be the neurobiologic substrate or contributor for BD, at least in certain cases.

Polymorphism of the Duffy erythrocyte chemokine receptor in Italian patients with Behçet's disease

This study examined the hypothesis that the polymorphism of Duffy antigen receptor for chemokines (DARC) predisposes to and/or influences the clinical manifestations of Behçet's disease. The serum levels of IL-8 and monocyte chemotactic peptide (MCP)-1, two DARC-binding chemokines, were investigated and related to this polymorphism. Twenty-eight patients with Behçet's disease and 30 healthy blood donors were included in the study. No null phenotypes were found among the patients studied, and the frequencies of the other phenotypes (Fy((a+b-)), Fy((a+b+)), and Fy((a-b+))) did not significantly differ from those found in the blood donor group or reported in the general Caucasian population. No difference was found between the single phenotypes in terms of IL-8 and MCP-1 serum levels, and no relevant association between the clinical characteristics, Behçet's disease-associated human leukocyte antigen (HLA)-B51, and single phenotypes was observed. This investigation indicates that DARC is not a genetic trait significantly associated with or predisposing to Behçet's disease, at least in Caucasian Italians. However, the role of this polymorphism in the development and in the clinical course of the disease awaits further investigation.

Complex aphthosis and Behçet's disease

Complex aphthosis is a disorder in which patients develop recurrent oral and genital aphthous ulcers or almost constant, multiple oral aphthae, without manifestations of systemic disease. Behçet's disease is a multisystem disease characterized clinically by oral and genital aphthae, arthritis, cutaneous lesions, and ocular, gastrointestinal, and neurologic manifestations. This article reviews both disorders, including their clinical and histologic presentations, factors in pathogenesis, and includes an overview of therapeutic modalities.

Posterior segment involvement in ocular Behçet's disease

PURPOSE

Posterior segment involvement, which can lead to blindness with recurrent inflammatory attacks, has a very important prognostic value in ocular Behçet's disease (BD). This study evaluated the frequency and characteristics of posterior segment involvement and the causes of visual impairment in patients with ocular BD.

METHODS

We retrospectively evaluated 257 eyes of the 131 patients who were followed from 1993 to 2001 in the Uveitis and BD division of SSK Ankara Eye Hospital, Turkey.

RESULTS

The mean follow-up was 49.2 +/- 27.4 months. Thirty-one of the palents were female (23.6%) and 100 male (76.4%). The mean age was 25.1 +/- 7.9. Fundus changes were observed in 213 (82.9%) eyes and were bilateral in 87%, and vitritis was present in 239 (93%) eyes. The most frequent fundus changes were vascular sheathing in 61 eyes (23.7%), optic atrophy in 46 (17.9%), macular edema in 29 (11.3%), retinal hemorrhage in 23 (9%), macular scar in 21 (8.2%), optic disc paleness in 19 (7.4%), retinal edema in 17 (6.6%), branch retinal vein occlusion in 15 (5.8%). The most common fluorescein angiography findings were diffuse vascular leakage in 98 (38%), hyperfluorescence of the optic disc in 38 (14.8%) and hyperfluorescence of the macula in 29 eyes (11.3%). Visual acuity was <1/10 in 85 (33%) of the eyes. Optic atrophy was the main cause (54.1%) of permanent visual impairment.

CONCLUSIONS

Posterior segment involvement is the most serious ocular complication of BD, leading to blindness with recurrent attacks. Following patients closely, performing fluorescein angiography in all patients diagnosed as BD even they have no clinical ocular involvement, and early treatment are very important in the prognosis of the disease.

Central retinal artery occlusion associated with ocular Behçet's disease

PURPOSE

To report a case of central retinal artery occlusion associated with ocular Behçet's disease (BD) and briefly discuss retinal vasculitis due to BD.

CASE REPORT

A 52-year-old man, diagnosed as BD 22 years ago and followed up with ocular involvement for six years presented with sudden loss of vision. The clinical diagnosis was central retinal artery occlusion.

RESULTS

No other associated systemic diseases were found and the case was classified as a complication of retinal vasculitis due to BD.

CONCLUSIONS

Although the arteries are rarely affected in retinal vasculitis due to BD, it has to be considered in the differential diagnosis of retinal arterial occlusions especially in countries where the disease is prevalent. To our knowledge, this is the first reported case of ocular BD complicated with central retinal artery occlusion.

Immunopathology of the noninfectious posterior and intermediate uveitides

The posterior and intermediate uveitides share an underlying immune etiology; however, they can be clinically and immunopathologically distinguished. Although the initiating stimuli for posterior and intermediate uveities are not known, it is believed that an exogenous agent (such as a bacterium or a virus) or an endogenous molecule may induce disease. In either case, T-helper lymphocytes in conjunction with human leukocyte antigens are likely to be involved. This review examines the epidemiology, histology, immunopathology, and theories of pathogenesis of several posterior and intermediate uveitides, including sympathetic ophthalmia, Vogt-Koyanagi-Harada syndrome, Behçet's disease, sarcoidosis, intermediate uveitis, white dot syndromes, and birdshot retinochoroidopathy.