Vascular involvement in Behçet's disease: 8-year audit

Porto-sinusoidal vascular disorder and nephrotic-range proteinuria due to venous vasculitis in Behçet's disease

Behçet's disease (BD) is an autoinflammatory disease with multifactorial and polygenic etiology, potentially involving arteries and veins of any size resulting in variable vessel vasculitis. We report a case of an Iranian male who presented with porto-sinusoidal vascular disorder due to venous vasculitis as initial manifestation of BD. Despite immunosuppression, anticoagulation and venous recanalization, he subsequently developed severe nephrotic-range proteinuria mimicking a primary renal disease which was completely and immediately ameliorated by stenting of the vena cava. This demonstrates that the proteinuria was caused by increased intraglomerular pressure due to venous outflow obstruction as a consequence of venous vasculitis. To our knowledge, this is the first report of massive proteinuria caused by venous obstruction of the caval vein in the context of BD. Altogether, this case demonstrates the extensive spectrum of vascular disease in BD.

Multiple Venous Thromboses and Renal Failure in Behcet's Disease: A Case Report and Review of the Literature

Behcet's disease (BD) is a systemic condition of unknown etiology, characterized by a wide clinical polymorphism. Vascular involvement in BD is rare and can be revealing in many cases. We present an advanced case of BD with multiple venous thromboses associated with urgent dialysis-dependent end-stage chronic renal failure. This case highlights the complexity of managing BD, emphasizing the challenges associated with multiple thromboses and the crucial importance of early diagnosis to optimize the management of this systemic disease.

Long Term Outcomes and Potential Risk Factors for Endovascular Repair of Aortic Pseudoaneurysms in Vascular Behçet's Disease

OBJECTIVE

This study aimed to analyse long term outcomes and risk factors for endovascular repair of aortic pseudoaneurysms in patients with vascular Behçet's disease (BD).

METHODS

Medical records of 26 aortic vascular BD patients who underwent endovascular treatment at the vascular department of Peking Union Medical College Hospital between January 2002 and December 2021 were reviewed retrospectively. Erythrocyte sedimentation rate (ESR) and C reactive protein were used to assess BD activity. Computed tomography angiography (CTA) was obtained pre- and post-operatively for almost all patients. Univariable logistic regression analysis was used to analyse risk factors for endovascular repair, such as inflammatory indicators, drug usage, and stent graft parameters.

RESULTS

The abdominal aorta (n = 17) was the most common site of 27 vascular BD pseudoaneurysms in this study. CTA also revealed one aortic arch pseudoaneurysm, seven descending thoracic aortic pseudoaneurysms, one thoraco-abdominal aortic pseudoaneurysm, and one pseudoaneurysm at the aortic bifurcation. Most of the pseudoaneurysms were treated with covered stent grafts. The technical success rate was 96% and no deaths occurred during hospital stay. The mean follow up was 5.8 ± 5.5 years and 31% (8/26) experienced post-operative complications. Overall one, three, and five year event free survival rates were 87%, 78%, and 74%, respectively. Univariable logistic regression analysis revealed that pre-operative ESR ≥ 16.0 mm/h (p = .040), pre-operative glucocorticoid (GC) use ≤ 11.5 days (p = .024), pre-operative immunosuppressant use ≤ 15.5 days (p = .028), and length of proximal landing zone ≤ 1.95 cm (p = .034) were associated with a worse prognoses following endovascular treatment. Proximal oversize ≥ 9.5% (p = .074) was also regarded as a risk factor, although not statistically significant.

CONCLUSION

This study further confirmed the feasibility of endovascular repair for aortic vascular BD patients. Risk factors predicting poor prognoses included elevated pre-operative ESR, insufficient pre-operative GC use or immunosuppressant use, inadequate proximal landing zone, and larger proximal oversize percentage.

Unilateral Internal Jugular Vein Thrombosis Revealing Behçet's Disease: Through the Eyes of the Ophthalmologist

Behçet's disease (BD) is a rare autoimmune disease with an unknown aetiology. It is mostly found in the ancient "silk route" (from the Mediterranean region to the Far East). BD is a vasculitis that can involve veins and arteries of all sizes. Clinical features are dominated by oral and genital aphthous ulcers and uveitis. Central nervous system manifestations include parenchymal (80%) and non-parenchymal involvement (20%). Non-parenchymal forms can include cerebral venous thrombosis. Treatment is based on anti-inflammatory, immunosuppressive and anticoagulant agents, but it remains controversial. We report a rare case of a unilateral jugular being thrombosis revealing BD in a young Moroccan male. He was admitted due to neuro-ophthalmological manifestations (diplopia, and bilateral papilloedema). A good outcome occurred after treatment with anti-inflammatory drugs and anti-coagulation.

Adjunctive proximal aortic and aortodistal prosthetic wrapping of vascular anastomoses for Adamantiadis-Behçet's aortic/aortoiliac aneurysms: A revisit

BACKGROUND

We described our local experiences with a single-layer wrapping technique for the vascular anastomoses in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms using InterGard Silver-impregnated Dacron® patch prosthesis.

METHODS

Between January 2013 to December 2019, we retrospectively reviewed 20 patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. All patients presented with Adamantiadis-Behçet's aortic/aortoiliac aneurysms. Two groups were analyzed, Group I, considered as a control group (n = 20). While group II (n = 20), of which prosthetic wrapping was performed. Follow up took place for a maximum of 24 months.

RESULTS

during a six-year retrospective study period, 20 patients were recruited. They included 15 males and five females (ratio 3:1). The median age was 30.5 ± 4.2 years. Anastomotic pseudoaneurysms were reported in group I (control, [non-wrapping group]). While group II doesn't (wrapping group). Paired samples t test revealed a significant difference between those underwent wrapping and those with non-wrapping (p = .019 and .038). False aneurysms were reported in 80% of the non-wrapping group as estimated by the Kaplan-Meier curves. While Log-rank test results revealed a significant difference between both the studied groups (p < .008). Primary graft patency was 90% at 24 months as reported by the Kaplan-Meier survival method.

CONCLUSIONS

adjunctive wrapping for vascular anastomoses using Intergard Silver-impregnated Dacron® patch in patients with Adamantiadis-Behçet's aortic/aortoiliac aneurysms is an applicable, simple, and reliable technique. It was associated with low morbidity and mortality rates. Moreover, we discussed a relatively old technique aiming to explore its success and safety in treating arterial aneurysms in Adamantiadis-Behçet's disease patients.

Analysis of vascular involvement in 460 patients with Behçet's syndrome: Clinical characteristics and associated factors

OBJECTIVES

To describe demographic and clinical characteristics of vascular involvement in patients with Behçet's syndrome (BS) and to evaluate associations with such involvement.

METHODS

We retrospectively evaluated records of 2118 BS patients. In total, 460 patients diagnosed with superficial thrombophlebitis (ST) and/or major vascular events (venous and/or arterial involvements) were included in current analysis. Isolated ST with no accompanying deep venous thrombosis might be accepted as part of skin involvement; therefore, we defined two different outcomes for vascular involvement ("any vascular event" and "major vascular events") and performed univariable and multivariable logistic regression to assess factors associated with these outcome variables.

RESULTS

Overall, 68 (14.8%) patients had isolated ST, and 392 (85.2%) had major vascular events. The mean age of vascular BS was 33.8 (SD: 10.5) years and median follow-up was 13.9 (Q1-Q3: 8.3-22.9) years. The primary sites of major vascular events were deep venous thrombosis (n=358, 77.8%), pulmonary arterial involvement (n=66, 14.3%), extrapulmonary arterial involvement (n=52, 11.3%), and intracardiac thrombosis (n=14, 3.0%), respectively. Male sex was significantly associated with a higher risk for both outcome variables. When it was added to analysis, ST itself was the strongest explanatory variable that was associated with major vascular events in all multivariable models (ORs=11.9, 12.0, 13.0, and 18.9). While HLA-B51 was significantly associated with any vascular event, there was no similar observation for major vascular events.

CONCLUSION

Male sex is a well-known risk factor for major vascular events in BS, but our study established that presence of ST was the strongest risk factor.

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 pattern of cardiovascular manifestations in Egyptian Behçet’s patients and its relation to disease activity

Background

Behçet’s disease (BD) is also referred to as vascular BD when it frequently involves the heart and vessels. This study aimed to describe the cardiovascular manifestations in patients with BD and its correlation to disease activity. We conducted a cross-sectional study on 40 patients diagnosed with BD according to the International Criteria for Behçet’s Disease 2014. All the patients were subjected to detailed history taking, full clinical examination, lab investigations, resting electrocardiogram, trans-thoracic echocardiography, and carotid artery duplex for measuring intimal thickness, peripheral arterial and venous duplex, computed tomography pulmonary angiography, and full ophthalmological examination. Regarding the activity of the disease, it was assessed according to the score of Behçet’s Disease Current Activity Form (BDCAF).

Results

The most common cardiac manifestation was valvular lesion (67.5%) where the most frequently affected valve was the tricuspid valve (27.5%). Although 25% of patients had left ventricular diastolic dysfunction, only 5% had intracardiac masses. Approximately 52.5% of patients had vascular lesion (deep venous thrombosis 45%, arterial involvement 7.5% [as pulmonary artery thrombosis 5% and aneurysm 2.5%]). Increase in intima media thickness (IMT) was observed in 7.5% of patients, while 60% had abnormal lipid profiles. Hypercholesterolemia was the most common lipid abnormality (50%). BDCAF score range was 4–12, which was significantly correlated to multiple cardiovascular parameters as a mitral, tricuspid valve, and vascular venous involvement (p < 0.05), while not significantly correlated to lipid profile (p > 0.05).

Conclusion

Cardiovascular complications are frequent among patients with BD, even those who are asymptomatic; therefore, these complications must be screened for early detection and proper management.

Behçet's Syndrome Apart From the Triple Symptom Complex: Vascular, Neurologic, Gastrointestinal, and Musculoskeletal Manifestations. A Mini Review

Behçet‘s Syndrome (BS) is a variable vessel vasculitis according to the Chapel Hill Consensus Nomenclature (1) and may thus affect any organ, including major and minor arterial and venous vessels to a varying degree and with varying frequency. Although the main features of BS are recurrent oral and genital aphthous ulcers, cutaneous lesions, ocular inflammation and arthritis—major vessel and life—or organ threatening involvement of internal organs and the central and peripheral nervous system occur. In general, BS in Europe appears to form six phenotypes of clinical manifestations (2), which are (1) mucocutaneous only, (2) predominant arthritis/articular involvement, (3) vascular phenotype, (4) ocular manifestations, which are most likely associated with CNS manifestations and HLA-B51, (5) dominant parenchymal CNS manifestations (being associated with the ocular ones), and (6) gastrointestinal involvement. Mucocutaneous manifestations are present in almost all patients/all phenotypes. In the following review, we summarize the current knowledge concerning vascular, neurologic, gastrointestinal and musculoskeletal manifestations of the disease.

[Unusual complication of Behcet's disease]

Arterial involvement in Behcet's disease is rare and the tibioperoneal trunk localisation is exceptional. We report the case of a young men with Behcet's disease and in whom the evolution to angiobehcet was unusual. The medical treatment and the therapeutic abstention were decided according to a bundle of argument.

Clinical course of acute deep vein thrombosis of the legs in Behçet's syndrome

OBJECTIVES

Lower extremity deep vein thrombosis (LEDVT) is a serious complication of Behçet's syndrome. Management constitutes mainly of administration of immunosuppressives, but the predictors of relapse and the optimal choice of immunosuppressives remain unclear. In this prospective study, we aimed to detect the risk and predictors of relapse and treatment response to different modalities.

METHODS

All Behçet's syndrome patients who presented with a first episode of acute LEDVT between 2010 and 2014 were prospectively followed with a standard protocol. Acute LEDVT was confirmed by Doppler ultrasonography. Serial planned Doppler ultrasonography assessments were performed during follow-up and additionally repeated in case of clinical suspicion. Recanalization rate was assessed at each visit. Our first-line treatment strategy consisted of AZA and CSs. IFN-alpha was used in patients who were refractory to or could not tolerate AZA or had concomitant eye involvement requiring further treatment.

RESULTS

Thirty-three patients with LEDVT (26 M/7 F) were prospectively followed for 40.7 ± 13.4 months. Among the 33 patients, 23 relapses were observed in 15 patients. Relapse rates were 29%, 37% and 45% at 6, 12 and 24 months, respectively. Among the possible predictors of relapse, poor recanalization was the only significant factor [hazard ratio 4.34 (95% CI 1.96, 10.0)]. Overall 29 patients were treated with AZA and 17 with IFN-alpha. The relapse rate was lower and recanalization rate was higher with IFN-alpha compared with AZA (12% vs 45% and 86% vs 45%).

CONCLUSION

The relapse rate for LEDVT in Behçet's syndrome is high despite AZA treatment. IFN-alpha seems to be a promising agent for preventing LEDVT relapses and achieving good recanalization.

Behcet's Disease With Budd-Chiari Syndrome and Challenges in Its Management

Budd-Chiari syndrome may rarely occur as a complication of Behcet's disease, and presentation with thrombosis of both inferior vena cava (IVC) and hepatic veins is rarer still. We present a young woman with Behcet's disease who presented with acute Budd-Chiari syndrome, with thrombosis of IVC and all 3 hepatic veins. An IVC stent was placed, followed by a transjugular intrahepatic portosystemic shunt through the IVC stent. On follow-up, despite oral anticoagulants and oral steroids, she developed recurrent thrombosis twice within a 1-year span. Her symptoms resolved with stent revision and increasing immunosuppression.

[Spontaneous aortic isthmus aneurysm: Exceptional revelation of Behçet's disease]

Arterial involvement in Behçet's disease is rare. The exceptional aortic isthmus location is difficult to treat. We report the case of a young man in whom an aortic isthmus aneurysm revealed Behçet's disease. In this exceptional situation, we opted for classical open surgical repair despite current preference for endovascular treatment.

Giant abdominal aortic aneurysm of uncommon etiology due to Behçet disease

Behçet disease is a multisystem disorder presenting with recurrent oral and genital ulcerations as well as with ocular involvement. Vascular involvement can occur in up to 50% of affected patients. Arterial aneurysms are often multiple and are characterized by a saccular configuration with increased risk of unexpected rupture, thrombosis, and aneurysm recurrence. Here we report a case of giant infrarenal abdominal aortic aneurysm in a 34-year-old man with Behçet disease who underwent aneurysmorrhaphy and aortobifemoral bypass.

Detection of Inflammatory Aortopathies Using Multimodality Imaging

Diagnosis of the inflammatory aortopathies and importantly, their distinction in the later stages of disease from genetically mediated or acquired (degenerative) aortopathy remains a challenging clinical problem. Historically, the diagnosis of inflammatory aortopathy has required tissue sampling and pathological assessment. Although histological diagnosis remains an important diagnostic criterion, the ability to obtain sufficient tissue samples is problematic and requires invasive approaches that pose important risk. Continuing refinement in the capabilities of multimodality imaging, including ultrasound, computed tomography, magnetic resonance imaging, and positron emission tomography provides important insights into the broad spectrum of disease which comprise the inflammatory aortopathies. This review examines the current and emerging role of multimodality imaging in the evaluation of aortitis.

Open surgical repair of abdominal aortic aneurysms in Behçet's disease

BACKGROUND

Behçet's disease (BD) is a multisystem chronic autoimmune inflammatory disorder that involves multiple organs. Arterial involvement in BD is rare. Aortic involvement is one of the most severe manifestations and is associated with a much higher mortality. In this article, we will present our experience in open surgical repair of abdominal aortic aneurysm combined with immunosuppressive therapy.

METHODS

Between January 2010 and December 2017, 7 patients were treated for abdominal aortic aneurysms (5 infra-renal and 2 supra-renal, in 1 woman and 6 men). All patients were Moroccan, the age range being 25-59 years, mean age 43.2 years. Three Dacron tube grafts, two Dacron aortobiiliac grafts and two patch closures were used. All 7 patients received immunosuppresive therapy after surgery.

RESULTS

All patients underwent successful open surgical repair without major complications during the 30 days immediately after the procedure. During a mean follow-up of 36 months, there was no recurrent aneurysmal localization, but one patient had lost their sight. Until now, we have been following 6 patients and they continue to receive immunosuppressive therapy.

CONCLUSION

Long-term immunosuppressive therapy after aneurysm repair is important to limit pseudoaneurysm recurrence. Through our serie, we describe the results of the combination of surgical treatment and adjunctive immunosuppressive therapy, with a literature review.

Acquired peripheral pulmonary artery aneurysms: morphological spectrum of disease and multidetector computed tomography angiography findings-cases series and literature review

BACKGROUND

Acquired peripheral or intraparenchymal pulmonary artery aneurysms (PPAA) are rare entities but are important to recognize because of the associated morbidity. Hemoptysis is their principal complication and is a potentially fatal condition.

PURPOSE

To illustrate the causes, multidetector CT angiography (MDCTA) findings and differential diagnosis of acquired PPAA.

MATERIALS AND METHODS

The institutional review boards approved this study. We conducted a retrospective review of the demographic data and the results of clinical and laboratory examinations, and imaging studies of patients managed between January 2012 and January 2017 in two institutions.

RESULTS

A total of 19 patients had acquired PPAA that were detected at MDCTA, 9 patients with normal pulmonary artery pressures and 10 with pulmonary hypertension. Nine patients developed PPAA-related acute symptoms. MDCTA features of PPAA include: a lobulated vascular mass, an indistinct irregular arterial wall, aneurysmal thrombosis or wall calcification, findings of impending rupture including perianeurysmal edema, gas or a soft tissue mass.

CONCLUSION

PPAA are rare. In our series, endocarditis and pulmonary hypertension are the PPAA leading causes. The treatment modality preferred is embolization, especially as surgery poses a very high risk for patients with severe pulmonary hypertension. Further clarification of the natural history of these rare arterial aneurysms is needed.

[False aneurysm of the carotid artery revealing Behçet disease]

Vascular involvement in Behçet's disease often present as venous thrombosis. Arterial damage is rare. We report a case of Behçet's disease occurring in a 40-year-old woman revealed by a false aneurysm of the left common carotid artery. The intervention consisted in a prosthetic graft after endovascular control. After a 2-year follow-up period, the patient did not develop any postoperative complication.

Characteristics of Macular Edema in Behcet Disease after Intravitreal Bevacizumab Injection

Purpose:

To investigate the effect of intravitreal bevacizumab (IVB) injection on macular edema (ME) secondary to Behcet's disease.

Methods:

This prospective case series included 15 patients with bilateral ME due to Behcet's disease. Intravitreal bevacizumab was injected into the more severely involved eye; the contralateral eye was evaluated as the control. Patients were followed up with comprehensive ocular examination, optical coherence tomography, and fluorescein angiography (FA) for a minimum of 6 months by a single ophthalmologist.

Results:

Patients with a mean age of 30.6 ± 7.4 years received a mean number of 3.3 IVB injections during the 6 months. The mean preinjection vision was 0.6 ± 0.3 and 0.4 ± 0.4 LogMAR in the case and control groups, respectively, with no significant improvement at 6 months. Mean central foveal thickness was 375.3 ± 132.1 and 307.2 ± 84.5 μm in the case and control groups, respectively, and these changed to 401 ± 199.9 (P = 0.65) and 307.7 ± 82.8 μm (P = 0.73) at month 6, respectively. A statistically nonsignificant improvement in ME was observed during the first 3 months in the case group. However, it did not persist up to month 6 on an as-needed basis. IVB injections caused a disproportionate decrease in the thickness of macular subfields. A reduction in disc leakage was observed on FA (P = 0.058). Logistic regression analysis revealed no statistically significant predictive factor for an improvement in visual acuity (VA) and a reduction in foveal thickness.

Conclusion:

During a 6-month period, IVB injections based on an as-needed protocol provided no statistically significant improvement in VA and ME.

Toe Amputation After Minor Surgery in a Patient with Behçet's Disease: A Case Report

Behçet's disease is a systemic autoimmune vasculitis. Although various clinical findings can be observed depending on the pathologic features caused by the blood vessels involved, the classic triad of the disease includes oral aphthae, genital ulcers, and uveitis. Although complications involving the aorta or the vena cava inferior can prove fatal, thrombophlebitis in the superficial veins of the lower extremities are more commonly observed. Some patients can remain asymptomatic for a long period after the diagnosis. In patients with positive pathergy test findings, trauma can trigger the inflammatory cascade. This case report presents a patient with vasculitis that occurred subsequent to minor surgery and led to amputation of the great toe in a female patient with a 14-year old history of Behçet's disease.

How I treat catastrophic thrombotic syndromes

Catastrophic thrombotic syndromes are characterized by rapid onset of multiple thromboembolic occlusions affecting diverse vascular beds. Patients may have multiple events on presentation, or develop them rapidly over days to weeks. Several disorders can present with this extreme clinical phenotype, including catastrophic antiphospholipid syndrome (APS), atypical presentations of thrombotic thrombocytopenic purpura (TTP) or heparin-induced thrombocytopenia (HIT), and Trousseau syndrome, but some patients present with multiple thrombotic events in the absence of associated prothrombotic disorders. Diagnostic workup must rapidly determine which, if any, of these syndromes are present because therapeutic management is driven by the underlying disorder. With the exception of atypical presentations of TTP, which are treated with plasma exchange, anticoagulation is the most important therapeutic intervention in these patients. Effective anticoagulation may require laboratory confirmation with anti–factor Xa levels in patients treated with heparin, especially if the baseline (pretreatment) activated partial thromboplastin time is prolonged. Patients with catastrophic APS also benefit from immunosuppressive therapy and/or plasma exchange, whereas patients with HIT need an alternative anticoagulant to replace heparin. Progressive thrombotic events despite therapeutic anticoagulation may necessitate an alternative therapeutic strategy. If the thrombotic process can be controlled, these patients can recover, but indefinite anticoagulant therapy may be appropriate to prevent recurrent events.

Left ventricular intracardiac thrombus in a patient with Behçet disease successfully treated with immunosuppressive agents without anticoagulation: a case report and review of the literature

Behçet disease (BD) is a chronic multisystem disorder with vasculitis underlying its systemic manifestations. Cardiac involvement and particularly left ventricular intracardiac thrombus are rarely diagnosed in the course of BD and are often associated with poor prognosis. The causes of intracardiac thrombi are unknown. It is plausible that specific proinflammatory pathways resulting in the endothelial cell injury and hypercoagulation contribute to the formation of thrombotic masses in the heart. Known thrombophilic factors such as methylenetetrahydrofolate reductase gene mutations, factor V Leiden mutation, proteins S and C, antithrombin III, activated protein C resistance, and antiphospholipid antibodies may contribute to the formation of intracardiac thrombi in BD. We report a case of a 24-year-old male patient with BD presented with left ventricular thrombus. Transthoracic echocardiography allowed to describe and monitor such a rare cardiac manifestation of the disease. A combination of high-dose corticosteroid and azathioprine successfully dissolved intracardiac thrombus within ten days without anticoagulation.

Internal jugular vein thrombosis in Behcet's disease: a rare complication

Behcet's disease (BD) is a systemic inflammatory disorder characterised by oral/genital ulcers, ocular lesions, and gastrointestinal, musculoskeletal, neurological and major vessel involvements. Venous manifestations are more common than arterial involvements. In this case report, we present a patient with internal jugular vein thrombosis, which is a very rare complication of BD.

Abdominal aortic aneurysm causing lumbar vertebral erosion in Behçet's disease presenting by low back pain

Behçet's disease (BD) is a chronic multi-system disorder commonly seen in Mediterranean, middle east and far eastern populations. In this report, we describe a case of a 55-year-old male with Behçet's disease who presented with a low back pain and sciatica. Imaging studies showed that he had a destruction of the third lumbar vertebra because of abdominal aortic aneurysm-related Behçet's disease. Aortic aneurysms with vertebral body erosion have been rarely reported, but this vascular complication is a life-threatening clinical picture. Therefore, among the causes of chronic lumbar pain in a BD patient, abdominal aortic aneurysm should be remembered.

Behçet disease in association with Budd-Chiari syndrome and multiple thrombosis -- case report

Behçet's disease is a chronic inflammatory disease of unknown aetiology, characterized by recurrent oral and genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in Behçet's disease. The frequency of vascular lesions in Behçet's disease, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%. Budd-Chiari syndrome is a rare and serious complication of Behçet's disease and implies thrombosis of the hepatic veins and/or the intrahepatic or suprahepatic inferior vena cava. We report a case of a 25-year-old man with Behçet's disease that developed Budd-Chiari syndrome. The correlation of dermatological, pathological and imaging studies confirmed the diagnosis.

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.

Anterior mediastinal fat in Behçet's disease: qualitative and quantitative CT analysis

The fat-rich anterior mediastinum could be a sensitive window for monitoring minute changes in vascularity induced by systemic vasculitis. To evaluate this hypothesis, an analysis of anterior mediastinal fat in patients with Behçet's disease and a control group was conducted. This study included 43 patients diagnosed with Behçet's disease within the last 11 years who underwent CT scan; 55 patients were selected as a control population. Mediastinal fat was classified according to CT morphology. Comparison of serum inflammatory markers was performed for evaluation of disease activity according to morphologic types, and average Hounsfield unit of the anterior mediastinum was measured. Significantly higher mean CT attenuation was observed in the Behçet's disease group, compared with the control group (-48.5 ± 33.5 vs. -67.7 ± 18.7, respectively, P < 0.05). Mediastinal fat types were classified as follows: pure fatty tissue (2 vs. 31 % [Behçet's disease vs. control group]), diffuse soft tissue infiltration (16 vs. 29 %), tubular structures (21 vs. 4 %), mixed infiltration with tubular structures (42 vs. 15 %), and evident thymic tissue (19 vs. 22 %). The value for mean mediastinal attenuation was significantly higher in the group with a high level of C-reactive protein than in the normal level group. The mean CT attenuation of anterior mediastinal fat is significantly higher in the Behçet's disease group, compared with the normal group. Although pathologic confirmation is needed, the cause is postulated to be either inflammatory neovascularization or minimal thymic hyperplasia induced by Behçet's disease.

Surgical treatment of peripheral aneurysms in patients with Behcet's disease

INTRODUCTION

Our aim was to report our experience with 23 patients presenting with 32 peripheral aneurysms secondary to Behcet's disease (BD) and their outcome after vascular surgery.

METHODS

The study was retrospective in nature. Except for those presenting with aneurysm rupture, patients underwent surgery after treatment of acute inflammatory lesions. All aneurysms appeared to be pseudo-aneurysms. Graft interposition with polytetrafluoroethylene or saphenous vein was most commonly employed. Postoperatively, all patients were put on immunosuppressive and antiplatelet therapy. Follow-up was done every 6-12 months, complications recorded and managed appropriately.

RESULTS

All the patients were males. The mean age at diagnosis of a peripheral aneurysm was 41.0 ± 9 years. There were 17 (53%) femoral, 8 (25%) popliteal, two carotid, two external iliac, two brachial and one internal iliac aneurysms. Fourteen (61%) patients had a single peripheral aneurysm while nine had two. Surgery was performed for all initially presenting 23 aneurysms. Six patients with multiple peripheral aneurysms had surgery for their second asymptomatic aneurysm. The mean follow-up period was 84 ± 62 months. Of 29 aneurysms operated on, 7 (24%) anastomotic pseudo-aneurysms and 11 (38%) graft occlusions developed. Five (22%) patients underwent major lower extremity amputations. Six (26%) mortalities were recorded.

CONCLUSION

Surgery for peripheral aneurysms in BD is warranted in many instances. Results of operation can be improved by prolonged monitoring. However, despite all efforts, peripheral aneurysm involvement in BD worsens the prognosis.

A case of Behçet's disease with widespread perforating enteric ulcers preceded by a long history of peripheral gangrene

Patients suffering from Behçet's disease (BD) with intestinal involvement often have an atypical disease course. The disease in many patients does not fully meet the diagnostic criteria defined by the International Study Group for Behçet's Disease, and instead such patients are diagnosed as having an incomplete type of BD according to the criteria of the BD Research Committee of Japan. The patient reported here developed uveitis and gangrene of the extremities as the initial symptoms and was treated with corticosteroid. After 16 years, the gangrene relapsed and multiple deep ulcers suddenly developed in the gastrointestinal tract, with oral ulcer and uveitis. The intestinal perforation was acute, progressive, severe, and extensive. With a diagnosis of incomplete BD with intestinal involvement, she was treated with high-dose glucocorticoid. However, uncontrollable gastrointestinal bleeding led to her death. Histopathological examination revealed that she suffered from intestinal and vascular BD, although gangrene of the extremities has rarely been reported as a manifestation of vascular BD. Thus, the disease course of this patient was characterized by the reappearance of peripheral gangrene after a long interval that preceded the devastating intestinal lesions.

Aortic transection and diverting bypass as treatment of repetitive recurrent abdominal aortic false aneurysm rupture in a patient with Behcet's disease

Abdominal aortic false aneurysms in patients with Behcet's disease have been reported frequently and repaired successfully by various procedures; however, anastomotic false aneurysms have often been reported to occur after the operation. In this article, we report a case of four-time repetitive, recurrent suprarenal abdominal aortic false aneurysm ruptures that lasted for 7 years. The location of this aneurysm was not easy to repair not only by open surgical procedures but by endovascular stent because the aortic defect was too close to the visceral arterial branches. The last operation consisted of primary repair of aortic defect, transection of abdominal aorta at the level of supraceliac aorta with end closure, and a thoracic aorta to abdominal aorta bypass with Dacron graft. An 8-year follow-up revealed no more abdominal aortic aneurysm recurrence.

Major arterial aneurysms and pseudoaneurysms in Behçet's disease: results from a single centre

OBJECTIVE

Behçet's disease (BD) with arterial involvement is closely correlated with mortality and morbidity due to life-threatening complications such as arterial occlusion and aneurysm rupture. We aimed to determine the clinical characteristics of BD patients with aneurysms and pseudoaneurysms in the major arterial systems.

METHODS

Medical records of 30 BD patients diagnosed with aneurysms or pseudoaneurysms in the major arterial systems were reviewed to determine the clinical characteristics of BD, the sites and types of arterial aneurysms or pseudoaneurysms, laboratory test results, and response to treatment.

RESULTS

A total of 47 aneurysms and pseudoaneurysms (32 saccular aneurysms, eight fusiform aneurysms, and seven pseudoaneurysms) were detected in 30 patients. Most aneurysms and pseudoaneurysms (27 patients, 90%) had not ruptured. Symptomatic lesions presented in 21 patients (70%), and asymptomatic lesions were incidentally detected in nine (30%). Ten of the 30 patients (33.3%) presented two or more aneurysmal lesions. Recurrence was observed in five patients (16.7%) after treatment with stent graft (n = 3), graft interposition (n = 1), or graft embolization (n = 1).

CONCLUSION

We suggest that BD patients diagnosed with major arterial aneurysms should be further evaluated to detect possible associated venous or arterial thrombosis formations or aneurysmal lesions at other sites.

Detection of cardiovascular system involvement in Behçet's disease using fluorodeoxyglucose positron emission tomography

OBJECTIVES

Behçet's disease (BD) theoretically affects all sizes and types of vessels; however, there have been few reports describing the clinical efficacy of using (18)F-fluorodeoxyglucose positron emission tomography (FDG-PET) in patients with BD.

METHODS

Eight patients who were registered at the BD Specialty Clinic of Severance Hospital between 2004 and 2008 underwent FDG-PET scans to evaluate the cardiovascular presentations associated with BD. Medical records and FDG-PET images of the patients were retrospectively reviewed to determine the clinical significance of the cardiovascular findings.

RESULTS

The median quantitative FDG uptake index was 1.46 (range, 0.58-2.61). FDG uptake was detected in multiple pseudoaneurysms, aortitis and arteritis associated with aortic regurgitation, and aneurysmatic dilation of the sinus of Valsalva, atherosclerotic change of the proximal ascending aorta associated with aortic regurgitation, and multiple pulmonary artery aneurysms. The quantitative FDG uptake intensity was significantly associated with the ESR level.

CONCLUSIONS

FDG-PET scans may have clinical value as a workup study for patients with BD who have cardiovascular presentations.

Femoral profunda artery aneurysm as an unusual first presentation of Behcet disease

Behcet disease is a multisystem inflammatory disorder, rarely found in African Americans. Arterial involvement occurs in less than 8% of patients. Profunda femoral artery aneurysms (PFAAs) are extremely rare and often occur with synchronous aneurysms. We present a case of an African American man diagnosed with Behcet disease from his presentation with PFAA. He was also found to have a synchronous hypogastric artery aneurysm. The patient was immediately treated with corticosteroids and infliximab to control systemic and vascular inflammation, returning 1 month later for surgery. He had a repair of the left PFAA with a common femoral to profunda femoris artery bypass with reversed saphenous vein graft and aneurysmorrhaphy. When a patient presents with an aneurysm in an unusual location, it is important to evaluate for other aneurysms. A careful history and physical examination is also required to see if the aneurysm may be part of an underlying systemic syndrome.

Behçet's Disease as a Model of Venous Thrombosis

Behçet's disease (BD) is a chronic inflammatory disease of unknown aetiology characterized by recurrent oral, genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in BD. The frequency of vascular lesions in BD, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%. In this review, various factors of thrombogenesis in BD, particularly pro- and antithrombotic endothelial and non-endothelial factors, factors of coagulation, platelet activation and rheological changes are presented and discussed from positions of Virchow's triad of venous thrombosis. Despite advances in understanding of thrombogenesis in BD, still many issues of diagnosis and targeted preventive and therapeutic measures remain unresolved. Further studies are needed to clarify the pathobiology of BD-related thrombosis and to provide the clinicians with recommendations over the utility, safety and effectiveness of the antithrombotic therapy in BD.