Major vascular involvement in Behçet's disease: a retrospective study of 796 patients. Clin Rheumatol. 2013;32:845-852. [PMID: 23443336 DOI: 10.1007/s10067-013-2205-7]

Arterial and venous thrombosis in systemic and monogenic vasculitis

Systemic vasculitis, common forms of which include anti-neutrophil cytoplasmic antibody-associated small-vessel vasculitis, large-vessel vasculitis and Behçet syndrome, are frequently complicated by arterial or venous thrombotic events (AVTEs). Newly identified entities such as DADA2 (deficiency of adenosine deaminase 2) and VEXAS (vacuoles, E1 enzyme, X-linked, autoinflammatory, somatic) syndrome, which are driven by genetic mutations, also exhibit vasculitic features and are associated with a high risk of AVTEs. AVTEs in systemic vasculitis, including monogenic forms of vasculitis, are due to the complex interaction of inflammation and coagulation. New insights into the pathogenetic mechanisms implicate endothelial dysfunction, immune complex deposition and the interplay of pro-inflammatory cytokines with prothrombotic factors, which collectively promote thrombus formation. AVTEs impose a substantial disease burden, complicate diagnosis and negatively affect prognosis by increasing the risk of morbidity and mortality. Early diagnosis and treatment are crucial to prevent lasting damage. Management strategies should target both thrombosis and underlying inflammation. Antithrombotic therapies, including low-dose aspirin, or oral anticoagulants should be used on the basis of individual thrombotic risk assessment. Immunosuppressive therapy is the cornerstone of treatment for arterial and venous thrombosis, particularly in Behçet syndrome, in which vascular inflammation has a crucial role in thrombotic complications.

Novel inflammatory biomarkers for discriminating vascular involvement in Behçet's syndrome: evaluating SII, SIRI, and NPAR

OBJECTIVE

This study aims to investigate discriminatory ability of the Systemic Immune-Inflammation Index (SII), Systemic Inflammation Response Index (SIRI), and Neutrophil Percentage-to-Albumin Ratio (NPAR), in differentiating Behçet's Syndrome (BS) organ involvements from mucocutaneous involvement.

METHODS

This retrospective cohort study analyzed 436 patients diagnosed with BS from 2018 to 2023. Patients were categorized into three groups based on organ involvement: vascular, only mucocutaneous, and other organ involvement. Receiver Operating Characteristic (ROC) analysis was used to evaluate the discriminatory ability (mucocutaneous vs rest, vascular vs rest). DeLong's test was used to determine statistical differences in discriminatory power between the models.

RESULTS

Out of 436, 115 patients had vascular involvement. SII, SIRI, and NPAR were notably elevated in the vascular involvement group (p < 0.001). ROC analysis revealed that, SII, SIRI and NPAR showed discriminative ability for vascular involvement with AUCs of 0.87 for SII, 0.87 for SIRI, and 0.88 for NPAR. Pairwise comparisons using DeLong's test indicated that all three models performed similarly.

CONCLUSION

SII, SIRI, and NPAR are promising noninvasive biomarkers for predicting vascular involvement. These indices, derived from routine laboratory tests, could enhance early screening and may improve patient outcomes by enabling timely intervention.

Optimal timing of surgical treatment for Behcet's disease aortic or peripheral artery pseudoaneurysms

OBJECTIVE

The aim of this study was to assess the optimal thresholds of surgical intervention for Behcet's disease (BD) aortic or peripheral artery pseudoaneurysms.

METHODS

This was a retrospective single-center study of 2138 patients with BD, including 96 patients with vascular BD (4.5%) with 151 pseudoaneurysms between January 2002 and December 2021. Factors associated with mortality were assessed using Cox regression model. The growth rate of each pseudoaneurysm was calculated based on available imaging data in a linear mixed effect model.

RESULTS

Patients in the surgical group (2/56) had significantly lower aneurysm-related mortality than those in the medical treatment group (10/33) (χ2 = 10.34; P = .0013). Surgical intervention (P = .009) and diameter of BD pseudoaneurysm (P = .006) were independently associated with BD aneurysm-related mortality. Rapid growth of BD pseudoaneurysm was achieved once diameter exceeded 4.0 cm for aortic pseudoaneurysm, or 2.5 cm for peripheral artery pseudoaneurysm, accompanied with high risk of rupture (Overall rupture rate: BD aortic pseudoaneurysm, ≥4.0 cm vs <4.0 cm: 63.6% vs 15.4%; BD peripheral artery pseudoaneurysm, ≥2.5 cm vs <2.5 cm: 50.9% vs 0).

CONCLUSIONS

This study verified the critical role of surgical intervention in reducing the mortality rate of patients with BD pseudoaneurysms. BD aortic pseudoaneurysms larger than 4.0 cm in diameter and peripheral artery pseudoaneurysms larger than 2.5 cm in diameter require prompt surgical intervention due to the remarkable increase in the growth rate and greater risk of rupture and death.

Risk of Postoperative Complications After Total Hip and Total Knee Arthroplasty in Behcet Syndrome Patients

BACKGROUND

Behcet syndrome (BS), a multisystem autoimmune disorder, has unclear effects on outcomes after total hip arthroplasty (THA) and total knee arthroplasty (TKA). This study assessed the relative risk of perioperative adverse events in patients with BS.

METHODS

This retrospective cohort study used the PearlDiver M157Ortho data set, a large national administrative database. Total hip arthroplasty and TKA patients with BS were identified and matched 1:4 to those without BS based on patient age, sex, Elixhauser Comorbidity Index scores, and procedure performed (THA or TKA). The incidence of 90-day adverse events was determined and compared by multivariate analysis. 5-year survival to revision surgeries was assessed and compared with the log-rank test.

RESULTS

After matching, 282 THA/TKA patients with BS were identified and compared with 1127 without BS. On multivariate analysis, patients with BS were at independently greater risk of aggregated any (odds ratio [OR] 2.16, P < 0.0001), serious (OR 1.78, P = 0.0051), and minor (OR 2.39, P < 0.0001) adverse events compared with those without BS. No significant difference was observed in 5-year survival to revision surgery (P = 0.3).

CONCLUSIONS

Patients with BS undergoing THA or TKA experienced markedly greater 90-day postoperative adverse events. The findings underscore the need for optimized perioperative management for patients with BS undergoing arthroplasty.

Cardiovascular Manifestations in Behçet's Disease

Cardiovascular involvement in Behçet's disease (BD) is considerably related to morbidity and mortality. However, the cardiovascular manifestation is sometimes difficult to distinguish from those of other causes. The suspicion of BD and proper treatment is pivotal in the management of BD. Histology demonstrates perivasculitis. Neutrophil seems to play an important role in the inflammation of BD. It is thought that inflammation causes venous thrombosis and arterial aneurysm. Characteristically, BD involves both arteries and veins of variable size in any region. Venous thrombosis needs immunosuppression, and inferior vena cava thrombosis and Budd-Chiari syndrome require intensive immunosuppressive therapy. Arterial involvement causes aneurysm which usually is treated by surgical or endovascular intervention with immunosuppression. Pulmonary artery aneurysm and cardiac involvement require multimodal managements.

Development and validation of a risk prediction model for valve regurgitation in Behçet's disease

BACKGROUND

In Behçet's disease (BD), mild-to-severe valvular regurgitation (VR) poses a serious complication that contributes significantly to heart failure and eventually death. The accurate prediction of VR is crucial in the early stages of BD subjects for improved prognosis. Accordingly, this study aimed to develop a nomogram that can detect VR early in the course of BD.

METHODS

One hundred seventy-two patients diagnosed with Behçet's disease (BD) were conducted to assess cardiac valve regurgitation as the primary outcome. The severity of regurgitation was classified as mild, moderate, or severe. The parameters related to the diagnostic criteria were used to develop model 1. The combination of stepAIC, best subset, and random forest approaches was employed to identify the independent predictors of VR and thus establish model 2 and create a nomogram for predicting the probability of VR in BD. Receiver operating characteristics (ROC) and decision curve analysis (DCA) were used to evaluate the model performance.

RESULTS

Thirty-four patients experienced mild-to-severe VR events. Model 2 was established using five variables, including arterial involvement, sex, age at hospitalization, mean arterial pressure, and skin lesions. In comparison with model 1 (0.635, 95% CI: 0.512-0.757), the ROC of model 2 (0.879, 95% CI: 0.793-0.966) was improved significantly. DCA suggested that model 2 was more feasible and clinically applicable than model 1.

CONCLUSION

A predictive model and a nomogram for predicting the VR of patients with Behçet's disease were developed. The good performance of this model can help us identify potential high-risk groups for heart failure. Key Points • In this study, the predictors of VR in BD were evaluated, and a risk prediction model was developed for the early prediction of the occurrence of VR in patients with BD. • The VR prediction model included the following indexes: arterial involvement, sex, age at hospitalization, mean arterial pressure, and skin lesions. • The risk model that we developed was better and more optimized than the models built with diagnostic criteria parameters, and visualizing and personalizing the model, a nomogram, provided clinicians with an easy and intuitive tool for practical prediction.

Identification of biomarkers for abdominal aortic aneurysm in Behçet's disease via mendelian randomization and integrated bioinformatics analyses

Behçet's disease (BD) is a complex autoimmune disorder impacting several organ systems. Although the involvement of abdominal aortic aneurysm (AAA) in BD is rare, it can be associated with severe consequences. In the present study, we identified diagnostic biomarkers in patients with BD having AAA. Mendelian randomization (MR) analysis was initially used to explore the potential causal association between BD and AAA. The Limma package, WGCNA, PPI and machine learning algorithms were employed to identify potential diagnostic genes. A receiver operating characteristic curve (ROC) for the nomogram was constructed to ascertain the diagnostic value of AAA in patients with BD. Finally, immune cell infiltration analyses and single-sample gene set enrichment analysis (ssGSEA) were conducted. The MR analysis indicated a suggestive association between BD and the risk of AAA (odds ratio [OR]: 1.0384, 95% confidence interval [CI]: 1.0081-1.0696, p = 0.0126). Three hub genes (CD247, CD2 and CCR7) were identified using the integrated bioinformatics analyses, which were subsequently utilised to construct a nomogram (area under the curve [AUC]: 0.982, 95% CI: 0.944-1.000). Finally, the immune cell infiltration assay revealed that dysregulation immune cells were positively correlated with the three hub genes. Our MR analyses revealed a higher susceptibility of patients with BD to AAA. We used a systematic approach to identify three potential hub genes (CD247, CD2 and CCR7) and developed a nomogram to assist in the diagnosis of AAA among patients with BD. In addition, immune cell infiltration analysis indicated the dysregulation in immune cell proportions.

Increased inferior vena cava wall thickness as a sign of extensive venous inflammation in Behçet's Disease

INTRODUCTION/OBJECTIVES

Behçet's disease (BD) affects both arterial and venous vessels. We have previously shown that common femoral vein wall thickness (WT) is increased in BD and can be used as a diagnostic test. However, there is limited data assessing large veins. Therefore, this study seeks to assess inferior vena cava wall thickness (IVC) by transthoracic echocardiography (TTE) in BD compared to healthy controls (HC).

METHODS

Age- and gender-matched 70 BD patients and 51 HC were included. IVC wall thickness and common femoral vein WT were measured by TTE and Doppler ultrasonography, respectively. All examinations were performed on the same day as the clinical assessment.

RESULTS

The mean IVC wall thickness of BD patients was significantly higher than HC (2.9 mm (0.3) vs 2.6 mm (0.3), p < 0.001). Patients with mucocutaneous involvement (2.8 mm (0.3)) and major organ involvement (2.9 mm (0.3)) had significantly thicker walls compared to HC (p = 0.003, p < 0.001, respectively). IVC wall thickness was higher in patients with vascular involvement compared to those with nonvascular major organ involvement (3.1 mm (0.3) vs 2.8 mm (0.2), p = 0.04). There was a moderate correlation between IVC and common femoral vein WT (r = 0.49 for the right, r = 0.43 for the left, p = 0.01 for both).

CONCLUSION

This study shows that venous wall inflammation is not limited to lower extremity veins and is also present in IVC walls of BD patients regardless of IVC involvement. Vascular wall inflammation is probably a widespread vascular event of all venous walls in BD. Key Points • Venous wall inflammation is not limited to lower extremity veins and is present also in IVC wall in Behçet's disease. • Extensive venous wall inflammation in Behçet's disease includes large venous structures despite not being clinically involved.

A Case Report of Neuro-Behçet Syndrome: Frequent Neurological Manifestations Concurrent With Life-Threatening Illnesses

​​​​Behçet disease (BD) is a recurrent, multisystemic autoimmune vasculitis that affects both small and large vessels. A combination of neurological signs and symptoms in BD is called neuro-Behçet syndrome (NBS). We present the case of a 31-year-old male diagnosed with chronic progressive NBS who presented with multiple relapsing episodes concurrent with infective endocarditis due to intravenous drug abuse, drug-induced hepatitis, acute kidney injury, and septic shock that is not related to BD. Neurological relapsing episodes were treated with steroids azathioprine and colchicine. At the same time, concurrent illnesses were managed appropriately. Infective endocarditis needed valve replacement surgery, and sepsis was treated with selected antibiotics. Fortunately, the patient's brain images and laboratory investigation improved accordingly. On average, patients with parenchymal neuro-Behçet syndrome (P-NBS) have a poor prognosis; within 10 years of diagnosis, 50% of those patients are severely disabled as our patient who became aphasic and quadriplegic.

Hypertension as a prominent manifestation secondary to renal artery lesions in pediatric Behcet's disease

OBJECTIVE

Hypertension caused by vascular Behcet's disease (BD) is an important prognostic factor of paediatric BD. However, much less is known about its clinical features. The objective of this study was to investigate the clinical characteristics of paediatric vascular BD complicated by hypertension.

METHODS

A retrospective study was carried out in paediatric BD patients complicated by hypertension treated in the Children's Hospital Capital Institute of Paediatrics from Jan 2009 to Dec 2022.

RESULTS

Of 65 BD patients, 6 (9.2%) were complicated by hypertension, 5 patients were female, and the median ages of onset and diagnosis were 9.8 years and 11.3 years, respectively. Three patients were found to have cardiac involvement and hypertensive retinopathy secondary to hypertension. Five of the 6 patients with hypertension had right renal artery involvement, and all of them were treated with glucocorticoids and immunosuppressants. Four patients were treated with biological agents. One patient with severe renal artery stenosis underwent unsuccessful vascular interventional therapy. After 3-6 years of follow-up, five patients were found to have renal atrophy, and one patient was at stable condition.

CONCLUSION

Hypertension in paediatric BD is mainly caused by renal artery involvement. Early recognition and treatment of vascular involvement in BD is important to prevent poor prognosis.

Imaging characteristics and prognostic factors of Behcet's disease with arterial involvement: A long-term follow-up study

PURPOSE

To investigate the imaging characteristics and prognostic factors for the long-term survival of Behcet's disease (BD) with arterial involvement.

METHODS

In this retrospective study, BD patients with arterial involvement were identified from January 2003 to January 2020. Arterial lesions were detected by ultrasonography, traditional arteriography, and/or computed tomography angiography (CTA). Cox proportional hazards regression analyses were performed to identify the prognostic factors.

RESULTS

Totally, 84 BD patients with arterial involvement were identified (73.8 % males). The mean age at BD diagnosis was 39.1 ± 13.1 years. Arterial involvement was the initial manifestation in 33.3 % of the patients, and the median time from BD diagnosis to arterial involvement was 6 (IQR 1-15.5) years for the rest of patients. Systemic artery involvement and pulmonary artery involvement (PAI) were found in 64 and 27 patients, respectively. Approximately 94.0 % (79/84) of the patients had more than one artery involved concurrently or successively during the course of BD. Aneurysm/dilation was the most prevalent lesion in the aorta (76.0 %), while stenosis/occlusion was the main lesion of the coronary artery (90.9 %) and other aortic branches (74.5 %). Pulmonary hypertension was found in 70.4 % (19/27) of patients with PAI. The 5- and 10-year survival rates of BD patients with arterial involvement were 87.4 % and 84.1 %, respectively. Cardiac involvement (HR: 4.34) and pulmonary artery aneurysm/dilation (HR: 4.89) were independently associated with mortality.

CONCLUSIONS

Arterial lesions associated with BD usually involve multiple arteries and manifest differently in different types of arteries. Cardiac involvement and pulmonary artery aneurysm/dilation are independent prognostic factors of BD patients with arterial involvement.

A case of Behçet syndrome presenting with acute coronary syndrome

Cardiac involvement (CI) is rare in Behçet syndrome (BS), but the important point is that CI may be the first manifestation of the disease. The presence of CI worsens the prognosis of BS, so early diagnosis and early initiation of immunosuppressive treatment (IST) are vital. Coronary aneurysm may develop spontaneously in these patients, or any vascular intervention may cause aneurysm with a pathergy-like reaction. The risk of restenosis is high after percutaneous coronary intervention or coronary artery bypass surgery applied without IST. Therefore, it should be kept in mind that IST constitutes the main step of treatment. Herein, we present a young male diagnosed with BS after acute coronary syndrome caused by coronary artery aneurysms and thrombosis.

Case report: Deep vein thrombosis as the sole clinical feature of Behcet's syndrome

Introduction

Behcet's syndrome is a rare, chronic, systemic condition often categorized within the group of vasculitides. It presents a diagnostic challenge due to its varied clinical manifestations and the absence of a definitive laboratory test. Its etiology remains unclear but may involve genetic, infectious, and environmental factors.

Case presentation

We report the case of a 16-year-old male who presented with deep vein thrombosis, followed by recurrent episodes of breakthrough thrombosis, despite adequate anticoagulant therapy. The patient did not meet the International Study Group (ISG) criteria nor the International Criteria for Behcet's syndrome (ICBD) due to the absence of characteristic features such as oral aphthous ulcers, genital ulcers, and uveitis. Later in the disease course, after ruling out other causes of breakthrough thrombosis, he tested positive for HLA-B51, an allele associated with Behcet's syndrome, and exhibited a pathergy reaction.

Discussion

The patient's clinical course underlines the diagnostic complexity associated with Behcet's syndrome and highlights the importance of maintaining a broad differential diagnosis in cases of recurrent thrombosis. Although HLA-B51 testing is not routinely recommended, it played a pivotal role in our case, underscoring the value of an integrated diagnostic approach. Furthermore, this case reinforces the potential for atypical presentations of Behcet's syndrome, necessitating vigilant clinical awareness. After establishing the diagnosis, we successfully treated the patient with immunosuppressive therapy, significantly improving his condition.

Surgical treatment of Behcet's disease with severe aortic regurgitation

Behcet's disease (BD) is a multisystem inflammatory disease that is characterized by oral aphthosis, genital aphthosis, ocular lesions, and cutaneous lesions. Although BD rarely affects the cardiovascular system, its symptoms can be shown as aortic regurgitation (AR), which requires surgical intervention. Due to the special pathogenesis of BD, a low preoperative diagnosis rate and a high incidence of serious complications, such as perivalvular leakage, valve detachment, and pseudoaneurysm after prosthetic valve replacement, surgical treatment of BD with severe AR has a poor prognosis. In recent years, new surgical strategies have been developed to improve treatment efficacy for this disease. This article reviews and summarizes the evolution of surgical techniques for BD with AR and aims to provide a reference for optimizing surgical strategies, improving perioperative management, and assisting prognosis in patients suffering from BD with severe AR.

Association of Behçet's disease with the risk of metabolic syndrome and its components: a systematic review and meta-analysis

The present meta-analysis aimed to elucidate the association of Behçet's disease (BD) with the risk of metabolic syndrome (MetS) and its components. Observational cohort studies were searched from the Embase, Web of Science, Medline, and Cochrane Library databases. The primary outcome was the association of BD with the risk of MetS and its relevant components. Effect estimates with odds ratios (ORs) were pooled using either the random-effects or fixed-effects models, according to heterogeneity. Leave-one-out sensitivity analyses were used to determine the stability of the results. Twenty-three studies, comprising 42,834 patients with BD, were included. Overall, a significant association between BD and the risk of MetS was found (pooled OR 2.26; 95% confidence interval [CI] 1.61-3.17; P < 0.0001). Among the components of MetS, significant associations were found between BD and diabetes mellitus (OR 1.21; 95% CI 1.10-1.33; P < 0.0001), BD and hypertension (OR 1.39; 95% CI 1.13-1.70; P = 0.002), and BD and dyslipidemia (OR 1.21; 95% CI 1.01-1.45; P = 0.04). Our study indicated an association between BD and the risk of MetS and some of its components (diabetes mellitus, hypertension, and dyslipidemia). Physician should consider these associations so that specific treatments are available for patients with comorbidities. Moreover, patients with BD should regularly monitor their blood pressure, fasting plasma glucose, and blood lipid levels.

Giant coronary aneurysm of Behcet's disease with sudden syncope: a case report

Behcet's disease(BD) is a chronic inflammatory vasculitis that rarely affects the arteries, making myocardial infarction unlikely. We report a 28-year-old patient who was admitted to our hospital with multiple sudden syncope. Cardiovascular risk factors such as hypertension (HT), diabetes and obesity were not found in her. Preoperatively, imaging examinations suggested thrombosis of the inferior and superior vena cava and right heart combined with coronary artery aneurysm. The patient was finally diagnosed with a huge coronary artery aneurysm proximal to the left anterior descending artery. Syncope is considered to be caused right ventricular outflow tract obstruction. The patient received a successful aneurysm resection and had an uneventful postoperative recovery.

Long-term outcomes of endovascular treatment for aortic pseudoaneurysm in patients with Behçet's disease

OBJECTIVES

Behçet's disease (BD) is a multisystem inflammatory disorder with unknown etiology, and its aneurysmal lesions are associated with high mortality due to the high risk of rupture. This study intended to further explore the long-term safety and efficacy of endovascular therapy for BD-related aortic pseudoaneurysm (BAP).

METHODS

From January 2009 to May 2021, 17 BAP patients who underwent endovascular repair were retrospectively identified and enrolled. Adequate immunosuppressive treatment was instituted before and after endovascular treatment unless emergency surgery was required. The patients were followed up at 3, 6, and 12 months and yearly after the primary endovascular intervention by computed tomography angiography (CTA) examination.

RESULTS

Nineteen BAPs were identified among 17 patients. BAPs located at the aortic arch were found in three patients (17.6%), descending thoracic aorta in 5 (29.4%), and abdominal aorta in 10 (58.8%; suprarenal abdominal aorta in 2 [11.8%], and infrarenal abdominal aorta in 8 [47.1%]). The mean ESR during admission was 56.5 ± 24.9 mm/h (range = 30.0-120.0 mm/h), which fell to 22.7 ± 18.4 mm/h (range = 2.0-74.0 mm/h) before the endovascular intervention (p < 0.001). The rate of favorable immunosuppressive control before intervention is 76.5% (13/17). Technical success was achieved in all patients. Median follow-up time was 57.0 months (interquartile range [IQR] = 21.3-67.3 months). Pseudoaneurysm recurrence was observed in four patients, type I endoleak in one, pseudoaneurysms sac dilation in one, and external iliac artery occlusion in 1. Two patients died of pseudoaneurysm rupture. Five-year accumulated overall rate, recurrence-free rate, and reintervention-free survival rate of BAP patients were 92.8%, 75.4%, and 71.8%, respectively.

CONCLUSION

Endovascular treatment in BAP patients seemed to be associated with long-term safety and efficacy with a 5-year overall survival rate of 92.8%. Adequate immunosuppressive treatment was essential for BAP patients to prevent aortic pseudoaneurysm recurrence and improve the prognosis.

Frail Silk: Is the Hughes-Stovin Syndrome a Behçet Syndrome Subtype with Aneurysm-Involved Gene Variants?

Hughes-Stovin syndrome is a rare disease characterized by thrombophlebitis and multiple pulmonary and/or bronchial aneurysms. The etiology and pathogenesis of HSS are incompletely known. The current consensus is that vasculitis underlies the pathogenic process, and pulmonary thrombosis follows arterial wall inflammation. As such, Hughes-Stovin syndrome may belong to the vascular cluster with lung involvement of Behçet syndrome, although oral aphtae, arthritis, and uveitis are rarely found. Behçet syndrome is a multifactorial polygenic disease with genetic, epigenetic, environmental, and mostly immunological contributors. The different Behçet syndrome phenotypes are presumably based upon different genetic determinants involving more than one pathogenic pathway. Hughes-Stovin syndrome may have common pathways with fibromuscular dysplasias and other diseases evolving with vascular aneurysms. We describe a Hughes-Stovin syndrome case fulfilling the Behçet syndrome criteria. A MYLK variant of unknown significance was detected, along with other heterozygous mutations in genes that may impact angiogenesis pathways. We discuss the possible involvement of these genetic findings, as well as other potential common determinants of Behçet/Hughes-Stovin syndrome and aneurysms in vascular Behçet syndrome. Recent advances in diagnostic techniques, including genetic testing, could help diagnose a specific Behçet syndrome subtype and other associated conditions to personalize the disease management.

Vascular Behçet syndrome: from pathogenesis to treatment

Behçet syndrome is a rare, chronic inflammatory disease of unknown aetiopathogenesis, most commonly presenting with mucocutaneous and ocular manifestations. Vascular involvement, most frequently superficial vein and deep vein thrombosis, can occur in up to 50% of patients with Behçet syndrome. Venous thrombosis at atypical sites (inferior and superior vena cava, suprahepatic veins with Budd-Chiari syndrome, portal vein, cerebral sinuses and right atrium and/or ventricle) and arterial involvement (mostly in situ thrombosis and aneurysms of the pulmonary arteries, as well as aneurysms of the abdominal aorta, and peripheral and visceral arteries) are also unique features of Behçet syndrome. Behçet syndrome is considered a natural model of inflammation-induced thrombosis in humans, with an impaired immune-inflammatory response rather than traditional cardiovascular risk factors contributing to thrombogenesis. Specifically, neutrophil hyperactivation and neutrophil-mediated mechanisms of damage directly promote endothelial dysfunction, platelet activation and thrombogenesis in Behçet syndrome. This unusual pathogenesis directly determines the treatment approach, which relies mostly on immunosuppressants rather than anticoagulants for treatment of thrombosis and for secondary prevention. This Review discusses the main histopathological, pathogenetic and clinical aspects of vascular Behçet syndrome, addressing their implications for therapeutic management. Future perspectives in terms of pathogenetic studies, disease monitoring and treatment strategies are also discussed.

Behcet disease: an undifferentiating and complex vasculitis

Behçet Disease is a relapsing and remitting variable vessel vasculitis characterized by recurrent mucocutaneous ulcers that can involve almost every organ system in the body. Indeed, the presence of recurrent oral or genital ulcers with other auto-inflammatory symptoms should raise suspicion for this elusive disease. It is unique among the vasculitides in that it can affect vessels of small, medium, and large size and tends to involve venous rather than arterial circulation, and its effects on the pulmonary venous circulation are particularly notable for their role in disease mortality. Classically seen in Mediterranean, Middle-Eastern, and eastern Asian countries, and relatively rare in the United States, prevalence has been increasing, prompting an increased need for internists to be aware of Behcet's clinical presentation and treatment. As early recognition and diagnosis of the disease is key to successful treatment and better prognosis, this review provides a brief summary of the current etiological theories, important clinical manifestations, and treatments including newer biologic alternatives.

Frequency of AA amyloidosis has decreased in Behçet's syndrome: a retrospective study with long-term follow-up and a systematic review

OBJECTIVE

A decline in the frequency of AA amyloidosis secondary to RA and infectious diseases has been reported. We aimed to determine the change in the frequency of AA amyloidosis in our Behçet's syndrome (BS) patients and to summarize the clinical characteristics of and outcomes for our patients, and also those identified by a systematic review.

METHODS

We identified patients with amyloidosis in our BS cohort (as well as their clinical and laboratory features, treatment, and outcome) through a chart review. The primary end points were end-stage renal disease and death. The prevalence of AA amyloidosis was estimated separately for patients registered during 1976-2000 and those registered during 2001-2017, in order to determine whether there was any change in the frequency. We searched PubMed and EMBASE for reports on BS patients with AA amyloidosis. Risk of bias was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) tool.

RESULTS

The prevalence of AA amyloidosis was 0.62% (24/3820) in the earlier cohort and declined to 0.054% (3/5590) in the recent cohort. The systematic review revealed 82 cases in 42 publications. The main features of patients were male predominance and a high frequency of vascular involvement. One-third of patients died within 6 months after diagnosis of amyloidosis.

CONCLUSION

The frequency of AA amyloidosis has decreased in patients with BS, which is similar to the decrease observed for AA amyloidosis due to other inflammatory and infectious causes. However, AA amyloidosis is a rare, but potentially fatal complication of BS.

Risk of ischaemic heart diseases and stroke in behçet disease: A systematic review and meta-analysis

BACKGROUND

Behçet disease (BD) is a systemic vasculitis. In addition to the mucocutaneous lesions, the vascular injury of pathophysiology in BD is theoretically correlated with cardiovascular diseases. This study aimed to elucidate the association of BD with ischaemic heart diseases (IHDs) and stroke.

METHODS

A systematic search of PubMed, Embase, Web of Science and Cochrane Library databases was performed for all relevant observational studies from database inception until 10 July 2021. No language restriction was applied. A random-effects model was used for meta-analysis.

RESULTS

A total of six observational studies consisting of three cohort studies, two cross-sectional studies and one study with both study designs were adopted in the meta-analysis. The numbers of patients with BD and healthy controls were 9,813 and 41,802, respectively. The pooled analysis demonstrated no significant association between BD and IHD. By contrast, we found that patients with BD had a significantly higher risk of stroke (adjusted hazard ratio, 2.083; 95% confidence interval, 1.339-3.240; p = 0.001) than healthy controls. We observed substantial heterogeneity across studies in few meta-analyses, but no significant publication bias was detected in any of the meta-analyses.

CONCLUSIONS

BD was significantly associated with stroke but not IHD. Physicians should be aware of possible vascular and neurological complications during care of patients with BD.

Case Report and Literature Review: Behçet's Disease With a Novel TFPI Gene Mutation

We report a case of Behçet's disease (BD) with a newly identified tissue factor pathway inhibitor (TFPI) gene mutation. The patient suffered from recurrent deep vein thrombosis and dural sinus thrombosis which could not be relieved by constant anticoagulation therapy. Slight relapsing oral lesion was the initial manifestation of BD but was neglected. Genital ulcers and ocular symptoms were manifest 8-month later than vascular involvement. The patient was diagnosed with BD at last and a novel mutation in TFPI was identified simultaneously. After administration with azathioprine and dexamethasone, the clinical symptoms were quickly gone and no relapse was found during 7-month follow-up.

A Case Report of Behcet's Disease With Thromboses in the Superior Vena Cava and External Iliac Vein

Behcet's disease (BD), also known as Behcet's syndrome, is a rare, chronic, autoimmune disorder of unknown origin. Its manifestations are thought to be caused by vasculitis, resulting in damage to blood vessels of all sizes throughout the body. We report a 25-year-old Pakistani male who is sexually active and presents with a one-year history of shortness of breath, cough, exertional dyspnea, and neck and facial swelling. On examination, he had severe anemia, mouth ulcers, distended neck and chest veins, prominent abdominal veins, and a scrotal ulcer. After going through mandatory investigations to evaluate the presenting signs and symptoms, thromboses were found in the major veins, including the superior vena cava (SVC) and external iliac vein, as well as a positive pathergy test. Accordingly, a diagnosis of Behcet’s disease with cardiomyopathy and venous thrombosis was made. He was treated with anticoagulants, steroids, and azathioprine for six months and subsequently went into remission.

Multiple concomitant arterial aneurysms in Behçet’s disease

Background

Behçet’s disease (BD) is a rare form of systemic vasculitis that affects small to large vessels. It is characterized by mucocutaneous, pulmonary, cardiovascular, gastrointestinal, and neurological manifestations. Large vessel involvement may occur in a third of cases. Veins are usually more affected than arteries. Furthermore aneurysms are the most frequent arterial complication.

Case presentation

A 41-year-old man presented with multiple arterial aneurysms. He had previous medical history of a right popliteal aneurysm treated with a reversed femoro-popliteal venous bypass, long-term steroids and immunosuppressive treatment. On admission, diagnostic computed tomography angiography revealed multiple aneurysms, including an 87 mm aneurysm of the femoro-popliteal bypass and an abdominal aortic and left common iliac artery aneurysm. He received an intensification of medical treatment with methylprednisolone and infliximab intravenous infusion. Aorto iliac artery aneurysms were treated by infrarenal bifurcated stent graft implantation. The aneurysm of the venous femoro-popliteal bypass was treated by explantation and prosthetic repair. One month later, he presented with acute right limb ischemia related to occlusion of the right limb of the stent graft despite anticoagulation which was treated by mechanical thrombectomy.

Conclusions

Vascular BD can worsen the vascular outcome after surgery. Except in an urgent context, BD must be controlled before surgery. This case report illustrates the importance of combined medical and surgical management, with first BD activity control with corticosteroids and immunosuppressive treatment, then surgical or endovascular treatment.

Arterial and venous involvement in Behçet's syndrome: a narrative review

Behçet syndrome (BS) is a unique type of vasculitis that affects veins and arteries of all sizes, leading to recurrent vascular events, mostly venous thrombosis. The prevalence of venous thromboembolism in BS patients ranges between 15 and 40%. Thrombosis is usually an early manifestation leading to diagnosis of BS in up to 40% of patients. BS is per se a model of inflammation-induced thrombosis. The primary autoimmune response activates lymphocytes that in turn produce a cytokine cascade that activates neutrophils, which modify the secondary structure of fibrinogen making it less susceptible to plasmin-induced lysis. This leads to endothelial dysfunction, platelet activation and overexpression of tissue factor leading to inflammatory thrombi, usually attached to the wall. The pathogenesis of thrombosis is especially relevant to direct the specific treatment, that is based on immunosuppression rather than anticoagulation. Superficial vein thrombosis (SVT) and deep vein thrombosis (DVT) are the most common form of thrombosis in BS, but thrombosis in atypical sites (cava vein, suprahepatic veins, intracardiac thrombus) and arterial involvement can also occur. We assessed the latest update of the European League Against Rheumatism recommendations for the management of BS. Vascular Behçet treatment is usually based of immunosuppressants, and the role of anticoagulation remains controversial. The use of interventional and surgical procedures should be carefully evaluated, due to the risk of triggering a vascular pathergy phenomenon.

Quantitative changes in peripapillary, macular, and choriocapillaris microvasculatures of patients with non-ocular Behçet's disease and relationship with systemic vascular involvement, an optical coherence tomography angiography study

BACKGROUND

To evaluate the changes in the peripapillary, macular and choriocapillaris microvasculatures in the eyes of patients with Behçet's disease (BD) without ocular involvement by optical coherence tomography angiography (OCT-A) and to investigate the relationship with systemic vascular involvement (SVI).

METHODS

The study included 56 eyes of 33 patients with non-ocular BD and 61 eyes of 33 healthy subjects. The macular microvascular (MMV) vessel densities (VDs), FAZ parameters, Choriocapillaris flow area (CCFA), radial peripapillary capillary (RPC) VDs and optic nerve head (ONH) analyses were performed with OCT-A. MMV, RPC, ONH, and CCFA measurements were compared between the non-ocular BD patients and healthy controls. Then, the patient group was divided into two subgroups according to the presence of SVI. MMV, RPC, and CCFA measurements of these subgroups were compared with the healthy controls.

RESULTS

While deep capillary plexus VD and foveal density decreased in MMV analysis in the BD group compared to the control group, CCFA was not different. In the RPC and ONH analysis, the VDs of the inside-disc small vessels and the VDs of the inside-disc all vessels were decreased while the cup/disk area ratio and cup volume were increased in the BD group compared to the healthy controls. Furthermore, the VDs of the inside-disc vessels were reduced in patients without SVI compared to those with SVI and healthy controls.

CONCLUSIONS

The RPC network, ONH and MMV architecture analysis by OCT-A revealed changes in the MMV, RPC, and ONH structures in non-ocular BD patients. Moreover, the decrease in RPC VDs and MMV VDs in patients without SVI suggested that the patients with BD without SVI had subclinical ocular involvement even in the absence of clinical ocular findings.

Computed tomography pulmonary angiography (CTPA) in Behçet's disease patients: a remarkable gender gap and time to refine the treatment strategy

OBJECTIVE

The aim of the work was to delineate the computed tomography pulmonary angiography (CTPA) findings in Behçet's disease (BD) patients with and without chest manifestations.

PATIENTS AND METHODS

The study included 122 BD adults recruited from 5 Teaching University Hospitals in Egypt of those who agreed to perform a CTPA. The Arabic version of BD current activity form (BDCAF) and BD damage index (BDI) were assessed. Detailed pulmonary manifestations, examination, plain radiology chest, and CTPA findings were recorded.

RESULTS

The mean age of patients was 36.9 ± 11.3 years, male:female was 1.8:1, disease duration 9.6 ± 8.2 years, and age at onset 28.3 ± 8.6 years. Their mean BDCAF was 4.4 ± 2.2 and BDI 3.4 ± 1.8. There were chest manifestations in 51 (41.8%) and plain chest x-ray findings in 13 (10.7%) and CTPA findings in 31 (25.4%) in the form of pulmonary thromboembolism in 15 (12.3%), pulmonary aneurysms in 7 (5.7%), pneumonia in 5 (4.1%), interstitial lung disease in 4 (3.3%) and pleural effusion in 3 (2.5%). Patients with chest manifestations had significantly higher frequency of cardiac manifestations (15.7%) compared to those without (2.8%; p = 0.023); chest x-ray findings tended to be higher (17.6% vs 5.6%; p = 0.05) while CTPA findings were significantly detected (51% vs 7%; p < 0.0001). Higher frequency of CTPA findings were in females (p < 0.0001). Yet the rate of serious pulmonary embolisms, aneurysms, and thrombosis was exclusive in males.

CONCLUSION

Meticulous investigation of the chest manifestations is warranted in BD patients to undermine the actual magnitude of pulmonary impact. CTPA provides a realistic estimate of the extent of involvement even in asymptomatic cases. Key Points • Meticulous chest assessment is warranted in Behçet's disease patients to undermine the actual magnitude of pulmonary impact • CTPA provides a realistic estimate of the extent of involvement even in asymptomatic cases.

Association of Large Vessel Aneurysm/Pseudo-Aneurysm/Aortitis and Deep Vein Thrombosis in Patients with Behçet's Disease: A Case Report

BACKGROUND

Behçet's disease (BD) is a complex vasculitis with some vascular manifestations including venous thrombosis, arterial thrombosis/aneurysm/pseudoaneurysm, and co-associated venous thrombosis and arterial lesions. We present two patients with Behçet's disease came with progressive both arterial and venous involvement.

CASE PRESENTATION

The first patient was a young man with recurrent oral aphthosis and skin folliculitis and referred with complaint of new abdominal pain and 2 months severe headache. He had not referred to a physician due to COVID-19 pandemic until that time. In addition, he gradually developed a lower extremity edema and eventually was diagnosed with BD complicated with brain sagittal sinus vein thrombosis, abdominal aortic aneurysms and aortitis and deep vein thrombosis (DVT) of femoral vein. The second patient was a young woman with previous history of uveitis, DVT and recurrent oral and genital aphthosis presented with a large inguinal mass due to large iliac artery pseudoaneurysm impending to rupture, and after the operation, due to poor follow-up, developed a new femoral DVT.

CONCLUSION

It seems the same inflammatory process is responsible for arterial and venous involvement in patients with BD, so it should be considered that involvement in one side (venous/arterial) can be a risk factor for the other side (venous/arterial) and early immunosuppressive treatment should always be considered to improve the prognosis.

Ultrasonographic measurement of the vascular wall thickness and intima-media thickness in patients with Behçet's disease with symptoms or signs of vascular involvement: A cross-sectional study

Objectives

This study aims to measure and compare bilateral carotid intima-media thickness (CIMT), bilateral jugular, common femoral, and main portal vein wall thicknesses (VWTs) in Behçet’s disease (BD) patients with and without vascular involvement to obtain a cut-off value for vascular complications and determine their relationship with disease activity.

Patients and methods

Sixty-three BD patients (41 males, 22 females; median age: 38.0 years; min 20 - max 71 years) and 30 healthy control subjects (14 males, 16 females; median age: 40.3 years; min 21 - max 60 years) were included in this cross-sectional study between February and March 2020. According to imaging findings, BD patients were divided into two groups as those with and without vascular complications. Disease duration, medical treatment and BD manifestations of patients were questioned. Disease activity was evaluated using the Behçet's Disease Current Activity Form (BDCAF) and the Behçet's Syndrome Activity Scale (BSAS). Two radiologists blinded to the diagnosis of BD used ultrasound to measure VWT and CIMT. Receiver operating characteristics were assessed to obtain sensitivity and specificity values for each VWT and CIMT.

Results

The groups were similar in terms of age, sex, and body mass index (p>0.05). There was a significant difference between the BD groups when the BDCAF and BSAS scores were compared, while there was no difference between them in terms of disease duration and medical treatment (p>0.05). All VWTs and CIMTs were significantly higher in patients with BD compared to healthy controls (p<0.05). There was no significant difference between the BD groups in terms of CIMT, jugular and common femoral VWTs (p>0.05). But portal VWT was significantly higher in patients with vascular involvement (p<0.05). A cut-off value of ≥1.35 mm yielded a sensitivity of 79.2% and a specificity of 82.4% for the diagnosis of vascular involvement with the highest Youden's index (area under the curve, 0.869; 95% confidence interval, 0.783 to 0.956).

Conclusion

Portal VWT has high sensitivity and specificity for the screening of vascular involvement in patients with BD.

Pulmonary artery thrombosis as the first presentation of Behçet's syndrome: a case report and review of the literature

BACKGROUND

Behçet's syndrome is a type of systemic chronic vasculitis of unknown etiology, frequently characterized by recurrent oral and genital ulcers and uveitis. It is less commonly characterized by arthritis and skin, vascular, and gastrointestinal involvements. Behçet's syndrome affects various sizes of vessels by perivascular infiltration and vasculitis. Unlike other classic types of vasculitis, Behçet's syndrome patients can present with both arterial and venous involvement. Although vascular Behçet's syndrome is found in only around 15% of Behçet's syndrome patients, it is the major cause of morbidity and mortality among them. Furthermore, although deep venous thrombosis has high incidence in Behçet's syndrome patients, pulmonary artery thrombosis is an uncommon complication. Combining the findings of this and previous case reports of pulmonary artery thrombosis in Behçet's syndrome patients, we sought to determine the best treatment options for pulmonary artery thrombosis in Behçet's syndrome patients.

CASE PRESENTATION

We present the case of a 22-year-old Arabian male who was admitted to an emergency department with acute chest pain, dyspnea, and hemoptysis for 2 weeks. He gave a long history of recurrent oral and genital ulcers for the last 4 months but without seeking medical advice. Spiral computed tomography showed arterial filling defects with a pulmonary nodule for which the presence of a pulmonary artery aneurysm ruled out. The lung perfusion scan showed multiple pulmonary perfusion defects. After excluding common infectious diseases such as tuberculosis and brucellosis, a diagnosis of Behçet's syndrome with pulmonary artery thrombosis was made. Steroids with enoxaparin were initiated. The patient was discharged later on prednisolone (tapering dose) with adalimumab and apixaban. He was on regular follow-up for the next 9 months.

CONCLUSIONS

Vascular involvement in Behçet's syndrome is a major contributor to morbidity and mortality of Behçet's syndrome patients. Consequently, early detection of vascular involvement has a major impact on the prognosis of patients with Behçet's syndrome.

Behcet's disease and multiple arterial aneurysms: 4 case reports

Behcet's disease (BD) is a vasculitis of unknown origin. BD is rare in Western countries and the southern hemisphere and is mainly seen in countries along the Silk Road such as the Middle East and Mediterranean regions including Iran. We report four interesting cases of BD with multiple aneurysms three of which had subclavian aneurysms. We chose different surgical approaches for each of these patients due to the different presentations and unique circumstances of each case. Endovascular stent graft used for patients and we discussed open vs. endovascular treatment for BD aneurysms in the discussion.

Behcet’s disease manifesting as esophageal variceal bleeding: A case report

BACKGROUND

Behcet’s disease (BD) is a chronic disease characterized by oral and vulvar ulcers as well as eye and skin damage and involves multiple systems. It presents as an alternating process of repeated attacks and remissions. Esophageal venous rupture and bleeding caused by BD is rarely reported at home and abroad. This paper reports a case of bleeding from oesophageal varices caused by BD, aiming to provide an additional dimension for considering the cause of bleeding from esophageal varices in the future.

CASE SUMMARY

A 38-year-old female patient was admitted due to a gradual increase in shortness of breath and chest tightness after the activity, and was admitted to our hospital for treatment. After admission, relevant examinations showed that the patient had multiple blood clots. Four days after admission, she suddenly experienced massive hematemesis. Emergency esophagogastroduodenoscopy revealed bleeding from esophageal and gastric varices. The patient had no history of viral hepatitis or drinking habits, and no history of special genetic diseases or congenital vascular diseases. There is no obvious abnormality in liver function. After reviewing the medical history, it was found that the patient had recurred oral ulcers since childhood, ulcers were visible in the perineum during menstruation, and there was an intermittent red nodular rash and uveitis. The current skin acupuncture reaction is positive, combined with the evaluation of the external hospital and our hospital, the main diagnosis is BD. She received methylprednisolone, cyclophosphamide, immunomodulation, acid suppression, gastric protection, and anticoagulation and anti-infection treatments, and was discharged from the hospital. During the 1-year follow-up period, the patient did not vomit blood again.

CONCLUSION

This case highlights bleeding from esophageal varices caused by BD, aiming to provide an additional dimension concerning the cause of bleeding from esophageal varices in the future.

Pulmonary Manifestations of Systemic Vasculitis in Children

Vasculitides are defined according to the vessel size involved, and they tend to affect certain organ systems. Pulmonary involvement is rare in the common childhood vasculitides, such as Kawasaki disease, IgA vasculitis (Henoch Schonlein purpura). On the other hand, lung involvement is common in a rare pediatric vasculitis, granulomatosis with polyangiitis (GPA) (Wegener granulomatosis), where respiratory system findings are common. A criterion in the Ankara 2008 classification criteria for GPA is the presence of nodules, cavities, or fixed infiltrates. The adult data suggest that rituximab may be an alternative to cyclophosphamide in induction treatment.

Cluster analysis of phenotypes of patients with Behçet's syndrome: a large cohort study from a referral center in China

INTRODUCTION

Behcet's syndrome (BS) is a complex, heterogeneous disorder. However, classification of its subgroups is still debated. The purpose of this study was to investigate the clinical features and aggregation of patients with BS in China, based on manifestations and organ involvements.

METHODS

This was a cross-sectional study of BS patients in Huadong Hospital of Fudan University between September 2012 and January 2020. We calculated relative risks (RRs) of clinical variables according to sex. Moreover, we conducted a hierarchical cluster analysis applied according to eighteen variables to determine subgroups of patients.

RESULTS

A total of 860 BS patients were included. Male sex was associated with ocular involvement (RR 2.32, 95% CI 1.67, 3.22, P < 0.0001), vascular involvement (RR 2.00, 95% CI 1.23, 3.23, P = 0.004), cardiac lesion (RR 5.46, 95% CI 2.33, 12.77, P < 0.0001), and central nervous system involvement (RR 2.95, 95% CI 1.07, 6.78, P = 0.007) and was negatively associated with genital ulcers (RR 0.84, 95% CI 0.79, 0.91, P < 0.0001). Five clusters (C1-C5) were observed. C1 (n = 307) showed the skin and mucosa type. In C2 (n = 124), all had articular involvement, barely having major organ involvement except for 18 cases with intestinal lesions. In C3 (n = 156), the gastrointestinal type, 144 patients presented with intestinal involvement, and 36 patients with esophageal ulcers. In C4 (n = 142), all subjects presented with uveitis. C5 (n = 131) consisted of 44 patients with cardiac lesions, 58 with vascular involvement, and 26 cases having central nervous system involvement.

CONCLUSION

Our analysis confirmed sex differences in phenotypes of BS. Cluster analysis identified gastrointestinal, uveitis, and cardiovascular involvement cluster separately in different subsets, which represents the most commonly involved organs. Further research is required to replicate and clarify the patterns of phenotype in BS.

Uveitis as a potential predictor of acute myocardial infarction in patients with Behcet's disease: a population-based cohort study

OBJECTIVES

To investigate whether uveitis is a predictor of acute myocardial infarction (AMI) among patients with Behcet's disease (BD).

DESIGN

Retrospective cohort study.

SETTING

Patients with BD were retrieved from the whole population of the Taiwan National Health Insurance Research Database from 1 January 2001 to 31 December 2013.

PARTICIPANTS

Among the 6508 patients with BD, 2517 (38.7%) were in the uveitis group and 3991 were in the non-uveitis group.

PRIMARY AND SECONDARY OUTCOME MEASURES

Kaplan-Meier curves were generated to compare the cumulative hazard of AMI in the uveitis and non-uveitis groups. Multivariate Cox regression analysis was used to estimate the adjusted HRs and 95% CI of AMI, and was adjusted for age, gender, systemic comorbidities (eg, hypertension, diabetes, hyperlipidaemia, smoking) and clinical manifestation of BD (eg, oral ulcers, genital ulcers, skin lesions, arthritis and gastrointestinal involvement).

RESULTS

The mean age of the BD cohort was 38.1±15.1 years. Compared with non-uveitis patients, uveitis patients were significantly younger and male predominant. There was no significant difference between the two groups for most proportions of systemic comorbidities and clinical manifestations. The Kaplan-Meier method with the log-rank test showed that the uveitis group had a significantly higher cumulative hazard for patients with AMI compared with the non-uveitis group (p<0.0001). In the multivariable Cox regression after adjustment for confounding factors, patients with uveitis had a significantly higher risk of AMI (adjusted HR 1.87; 95% CI 1.52 to 2.29). Other significant risk factors for AMI were age, hypertension, smoking, and skin lesions.

CONCLUSIONS

Statistical analyses from the nationwide database demonstrated that uveitis is a potential predictor of AMI in patients with BD.

Total endovascular treatment for thoraco-abdominal aortic aneurysm in a patient with Behçet's disease: Case report and literature review

INTRODUCTION

To report total endovascular treatment for a rare case of Crawford extent IV thoraco-abdominal aortic aneurysm (TAAA) using custom-designed branched device in a patient with Behçet's disease.

METHODS

A 50 years' old man with history of BD was accidentally diagnosed Crawford extent IV TAAA during computed tomography follow-up after left nephrectomy of renal carcinoma. The aneurysm extended from descending aorta to right common iliac artery with a maximum diameter of 6.2 cm.

RESULTS

The endovascular procedure wassuccessfully performed using custom-designed branched component to cannulate visceral arteries, bifurcated endograft and iliac legs to exclude the aneurysm sac in abdominal aorta and an iliac branched device to preserve the right internal iliac artery. The patient was discharged without any complication. Computed tomography angiogram at one month after endovascular repair demonstrated total exclusion of the aneurysm, patent visceral branches and right internal iliac artery. No complication occurred to six-month follow-up.

CONCLUSION

Endovascular treatment of stable TAAA in patients with Behc?et's disease using custom-designed branched device is feasible, microinvasive and safe. The long-term efficacy needs to be observed.

A case of vascular Behçet's disease complicated with acute myocardial infarction due to spontaneous coronary artery dissection

Spontaneous coronary artery dissection (SCAD) is a rare cause of acute myocardial infarction and occurs predominantly in young women without conventional cardiovascular risk factors. Emotional or physical stress and hormone imbalance are associated with the occurrence of SCAD, but the precise mechanisms have not been sufficiently elucidated. Furthermore, there is a paucity of data regarding the underlying disease in patients with SCAD. We herein report a case involving a 48-year-old man who developed acute myocardial infarction due to SCAD in the distal segment of the left anterior descending artery and was successfully treated with conservative medical therapy. A repeat coronary angiography examination performed 2 weeks later revealed complete angiographic healing. In addition, he was treated for suspected Behçet's disease because he had a history of recurrent aphthous stomatitis, nodular erythema, and genital ulcers. After thorough assessment, he was finally diagnosed with vascular Behçet's disease based on additional evidence of bilateral deep vein thrombosis. This case report highlights a rare case of vascular Behçet's disease complicated with SCAD in a male patient. Physicians should be aware that SCAD may occur in association with systemic inflammatory disease including Behçet's disease, even in male patients. <Learning objective: Spontaneous coronary artery dissection (SCAD) is a rare disease entity that can cause acute myocardial infarction especially in young individuals without significant cardiovascular risk factors. We herein describe a 48-year-old man who was diagnosed with vascular Behçet's disease after undergoing conservative medical therapy for acute myocardial infarction due to SCAD. This case report highlights that SCAD may occur in association with systemic inflammatory disease including Behçet's disease, even in male patients.>.

Acute coronary syndrome in Behcet's syndrome: A systematic review

Behcet syndrome is a rare vasculitis that affects both arteries and veins. Vasculo-Bechet Syndrome (VBS) is seen predominantly in men. Genetic predisposition and immune dysregulation leading to inflammation, endothelial damage, and impaired fibrinolysis contribute to its pathogenesis. Isolated case reports of Behcet syndrome (BS) with associated acute coronary syndrome (ACS) have been reported in the past. In this study, we present the first systematic review of such cases. A systematic search was conducted using Pubmed, Google Scholar, CINAHL, Cochrane CENTRAL, and Web of Science databases from 1980-2018 to identify case reports of myocardial infarction associated with BS. Cases that fulfilled the criteria for BS were selected for analysis. Demographic data, electrocardiography, echocardiography, angiography findings, and management were analyzed when available. We identified 62 case reports. Most subjects were men with a mean age of 37 years. Twenty-one percent were smokers, but other traditional cardiovascular risk factors were less common. Myocardial infarction was confirmed in half of the cases with findings on electrocardiogram (ECG). Echocardiogram revealed wall motion abnormality in 76% of patients, and angiography showed double-vessel disease in more than half of the cases. Mortality was reported in 1.6% of the cases. This systematic review shows that ACS in BS affects young males with low prevalence of coronary artery disease risk factors. Chest pain is the most common presenting feature and ST-segment elevation myocardial infarction (STEMI) was the most common ECG finding. Immunotherapy may be helpful to prevent future ACS in these patients.

Multiple intra-cardiac masses: A life-threatening complication of Behçet's disease

The incidence of multiple intra-cardiac masses is rare, and the differential diagnosis may be challenging sometimes. The most common etiologies of multiple intra-cardiac masses are thrombus, vegetation, and tumors. Intra-cardiac thrombus is more common in patients with central catheters, with a wall-motion abnormality and global hypokinesis. Certain autoimmune disorders may favor the development of intra-cardiac thrombus, and very rarely, multiple thrombi may be seen. Here, a patient with multiple intra-cardiac masses in the right ventricle and diagnosed with Behçet's disease is presented.

Clinical features and management of venous thromboembolism in patients with Behçet's syndrome: a single-center case-control study

Almost one third of patients with Behçet's syndrome (BS) display vascular involvement. However, data regarding the prevalence and management of venous thromboembolism (VTE) in BS are scanty. We assessed the differential characteristics between patients with and without VTE and the factors associated with VTE incidence. A case-control study in a cohort of patients with BS was performed. 57 patients were included (56.1% women) with a mean follow-up of 10.56 (± 10.7) years. Mean age at diagnosis of BS and diagnosis of the first VTE episode was 34.7 (± 12.1) and 31.2 (± 8.9) years, respectively. Erythema nodosum (OR 4.6, CI 95% 1.2-18.1) and fever (OR 8.2, CI 95% 1.6-42.1) were associated with a higher risk of VTE. 26 episodes of VTE were registered in 12/57 (21%) patients. 83.3% of patients were not diagnosed with BS when the first episode of VTE occurred and, among them, the episode of VTE led to the diagnosis of BS in 40% of cases. Half of patients had at least one VTE recurrence. The absence of immunosuppressive treatment was associated with a higher risk of developing a first episode of VTE (OR 20 CI 95% 19.2-166.6). All patients were treated with anticoagulation and 75% were treated with immunosuppressants after the first VTE event. The diagnosis of VTE usually precedes that of BS, with a high frequency of VTE recurrence. Erythema nodosum and fever were associated with a higher risk of VTE, while the immunosuppressants showed a protective role for the development of VTE.

Clinical characteristics and factors influencing the prognosis of Behçet’s disease complicated with vascular involvement

Summary: Background: Vascular Behçet's disease (VBD) might involve all sizes of arterial and venous vessels. Major vascular involvement caused the primary death in Behçet's syndrome (BS). We aimed to investigate the clinical characteristics and factors influencing the prognosis of VBD. Patients and methods: A retrospective analysis of the prospectively collected data of the Shanghai BS database from October 2012 to October 2018 was conducted. Patients who were diagnosed with BS and merged with venous thrombosis, arterial aneurysms, and arterial stenosis/occlusions were enrolled. Results: There were 47 patients with vascular involvement among 836 BS patients, 38 males and 9 females. The numbers of patients with venous thrombosis, arterial aneurysm, and arterial stenosis/occlusion were 25 (53.2 %), 21 (44.7 %), and 12 (25.5 %), respectively. Nearly half of the venous thromboses were located in limbs (n = 22, 46.8 %). Arterial aneurysm was the main form of arterial lesion. Most of the patients (93.6 %) were treated with corticosteroids and immunosuppressants. Late onset of BS or with arterial involvement had lower treatment response. Therapy with biological agents had significantly better results than that in the group without biological treatment (94.1 % vs. 80 %, P = 0.005). Conclusions: VBD showed a male preponderance and more than half of the patients presented with venous thrombosis. Late onset and arterial involvement were associated with poor prognosis. Therapy with biological agents is a viable alternative treatment to improve the prognosis.

Evaluation of atherogenic laboratory markers in Behçet's disease patients with vascular involvement

INTRODUCTION

Behçet's disease is a chronic inflammatory vasculitis presenting with immunological and endothelial changes. The aim of the present study is to evaluate blood levels of diagnostic markers which can be used in Behçet's patients with vascular involvement.

MATERIAL AND METHODS

Fifty Behçet's patients (22 with vascular involvement) and 30 healthy controls were included in the study. High-sensitivity C-reactive protein (hsCRP), erythrocyte sedimentation rate (ESR), tumor necrosis factor-α (TNF-α), apolipoprotein A1 (apoA1), apolipoprotein B (apoB), high-density lipoprotein (HDL), low-density lipoprotein (LDL), triglyceride, total cholesterol, Lp-plA-2, homocysteine and ischemia modified albumin (IMA) levels were analyzed. Statistical analysis was performed with the SPSS program version 11.0. p < 0.05 was accepted as statistically significant.

RESULTS

hsCRP, TNF-α, homocysteine, IMA, apoA1, apoB, HDL, Lp-pla2 and ESR levels in patient and control groups were significantly different (p < 0.001, p = 0.001, p < 0.001, p < 0.001, p = 0.005, p < 0.001, p < 0.001, p < 0.001 and p = 0.003 respectively). In Behçet's patients with vascular involvement, homocysteine, TNF-α and Lp-pla2 levels were significantly higher than in Behçet's patients without vascular involvement (p = 0.035, p = 0.010 and p < 0.001 respectively).

CONCLUSIONS

Increased levels of inflammatory and atherogenic markers in Behçet's patients are an expected outcome due to the inflammatory nature of the disease. Especially, elevated levels of homocysteine, TNF-α and Lp-pla2 make them candidate diagnostic tools to be helpful in clinical evaluation of Behçet's disease patients with vascular involvement.

The Clinical Features, Risk Factors, and Outcome of Aneurysmal Lesions in Behcet's Disease

Objective

To investigate the clinical features and potential risk factors of aneurysmal lesions in Behcet's disease (BD).

Methods

We retrospectively reviewed the clinical data of BD patients with aneurysmal lesions in our institute from 1997 to 2017 and compared them with 207 BD patients without aneurysmal lesions. The treatment and outcome of these patients were also analyzed.

Results

Sixty-nine patients were included with 117 aneurysmal lesions. The average period between BD onset and diagnosis of aneurysmal lesion was 5.4 ± 5.5 years. Thirty-three patients (47.8%) had multiple aneurysmal lesions. Ten patients developed 20 pulmonary artery aneurysms alone. For the other 97 aortic and/or peripheral artery aneurysms in 59 patients, the most commonly affected vessels were abdominal aorta (27/97, 27.8%), coronary artery (10/97, 10.3%), and superficial femoral artery (8/97, 8.2%). Multivariate analysis revealed pathergy reaction (OR = 3.78 (1.70-8.41)), arterial stenosis or occlusion (OR = 44.12 (11.56-168.35)), and arterial thrombosis (OR = 9.27 (2.33-36.93)) as independent predictors of aneurysmal lesions in BD. With a mean follow-up of 5.5 ± 4.0 years, 40 patients (58.0%) achieved clinical improvements, 15 patients (21.7%) relapsed, and 10 patients (14.5%) died. The respective estimated cumulative 1- and 5-year relapse-free rates were 91.3% and 76.3%, and the respective estimated 1- and 5-year survival rates were 95.0% and 87.2%.

Conclusion

Aneurysmal lesions are severe complications in BD. Pathergy reaction, arterial stenosis or occlusion, and arterial thrombosis are the risk factors of aneurysmal lesions in BD. Achieving BD remission and performing surgical or interventional procedures are both important in the treatment of these patients.

Pattern of pulmonary vasculitis and major vascular involvement in Hughes-Stovin syndrome (HSS): brief report of eight cases

To describe the pattern of pulmonary artery vasculitis and the characteristic computed tomographic pulmonary angiography (CTPA) signs in patients with Hughes-Stovin syndrome (HSS). In a retrospective study, the medical records of eight HSS patients (six men), seen between February 2008 and January 2018, were reviewed regarding history, disease characteristics, laboratory investigations, imaging, and treatments. The mean (SD) age was 37.375 ± 8.65 years (range 30-55) and mean (SD) follow-up 30 ± 41.60 months (range 9-132). In all patients, routine laboratory investigations and complete coagulation profile were done. In all, CTPA studies were performed as well as and Doppler ultrasound for suspected deep vein thrombosis (DVT). Four patients had a history of thrombophlebitis, and DVT was observed in all, in two cases bilateral. Arterial thromboses involving popliteal, tibial, common iliac, and femoral arteries were observed in one patient. All patients had mild to moderate hemoptysis, and one had massive hemoptysis. None of the patients had a history of recurrent mouth and/or genital ulcers, uveitis, or arthritis. In all patients, CTPA identified bilateral pulmonary artery aneurysms (PAAs) with adherent in situ thrombosis and mural enhancement in all patients. Lobar PA branches were involved in all patients, segmental in six and main PA in five patients. Proper immunomodulators were initiated early, with favorable outcome; none was treated with TNF-α antagonists. HSS is a systemic vasculitis that may affect virtually all major veins and arteries in patients with normal coagulation profile. PAAs, adherent in situ thrombosis, and mural wall enhancement are characteristic CTPA signs. Early treatment with immunomodulators is essential.Key Points• Hughes Stevin syndrome (HSS) is a systemic vasculitis that may affect virtually all major veins and arteries in patients. It has a normal coagulation profile.• Computed tomography (CT) pulmonary angiography is considered to be the most important diagnostic tool to assess the degree and the extent of the characteristic pulmonary artery aneurysms, and in situ thrombosis, and mural wall enhancement.• It is likely that HSS syndrome is often not recognized and misdiagnosed as deep venous thrombosis (DVT) with pulmonary thromboembolism.• Early treatment with combined immunomodulators is essential to ensure favorable outcome.