Behçet’s disease in Egypt: a multicenter nationwide study on 1526 adult patients and review of the literature

Expression of miR-127 and miR-29 in Egyptian patients with Behçet disease and its clinical significance and relationship with disease activity

BACKGROUND

Behçet's disease (BD) is characterized by a variety of clinical involvements and unpredictable courses of remission and exacerbation. BD cannot be diagnosed based on any particular laboratory, histopathologic, or genetic data. After excluding other possible causes, the diagnosis of BD is mostly made based on clinical manifestations. This research aims to assess the expression of miR-127 and miR-29 in Behçet patients and to correlate this expression with different disease manifestations and disease activity.

METHODS

Seventy adult patients with Behçet disease and 30 matched controls were enlisted. Behçet's Disease Current Activity Form (BDCAF) was used to determine the patients' activity scores. Gene expressions of miR-127 and miR-29 were assessed using real-time PCR.

RESULTS

miR-29 was statistically significantly higher in cases when compared to controls with p < 0.001. Patients with oral ulcers, genital ulcers, and neurological manifestations had a significantly higher levels of miR-29b (p = 0.005, 0.008, 0.003, respectively). Expression level of miR-29b was higher in patients with active disease compared with those who were in inactive state (p = 0.003). Patients with high and moderate severity score had a statistically significant higher expression level of miR-29 when compared to patients with mild severity score. There was a statistically significant positive correlation between miR-29 and several study parameters including BDCAF (r = 0.440, p < 0.001) and severity score (r = 0.243, p = 0.043). miR-127 was statistically significantly lower in cases when compared to controls with p < 0.001. There were statistically significant negative correlations between miR-127 and each of ESR (r = - 0.361, p = 0.002) and BDCAF (r = - 0.350, p = 0.003).

CONCLUSIONS

miR-29 expression level was statistically significantly higher while miR-127 was statistically significantly lower in patients with Behçet disease compared with control individuals. Furthermore, miR-29 was significantly positively correlated whereas miR-127 was significantly negatively correlated with BDCAF denoting their association with disease activity. Key Points • Behçet's disease (BD) is a systemic inflammatory disease with uncertain etiology. There is currently no diagnostic test for Behçet disease. Several miRNAs have been identified as powerful diagnostic biomarkers in many diseases. • Measuring the expression levels of miR-29 and miR-127 in serum of sample of patients with Behçet disease was performed in the current study. • miR-29 expression level was statistically significantly higher while miR-127 was statistically significantly lower in patients with Behçet disease compared with control individuals. Furthermore, miR-29 was significantly positively correlated whereas miR-127 was significantly negatively correlated with BDCAF denoting their association with disease activity.

Influence of gender on Behçet's disease phenotype and irreversible organ damage: Data from the International AIDA Network Behçet's Disease Registry

OBJECTIVES

Gender impact on phenotypical expression of Behçet's disease (BD) has been specifically investigated only in a few large-scale studies. The main goal of the study was to examine gender differences in a large cohort of patients affected by BD.

METHODS

Data were retrieved from the International AIDA Network Registry for BD. We assessed differences between males and females in terms of Behçet's syndrome Overall Damage Index (BODI), differences in the disease manifestations at onset and in the cumulative manifestations throughout disease course, as well as differences in the cardiovascular risk. Finally, predictive factors leading to major organ involvement were investigated.

RESULTS

In total, 1024 BD patients (567 males, 457 females) were enrolled in the study, with a male-to-female ratio of 1.24/1. Males displayed a significantly higher mean±SD BODI (1.92±2.09) at the last follow-up, compared to female patients (1.25±1.87) (P<0.0001). Uveitis (P<0.0001) and vascular involvement (P=0.0076) were significantly more frequent among males whereas female patients were significantly over-represented in arthralgia (P<0.0001), arthritis (P=0.00025), isolated headache (P<0.0001), central nervous system (CNS) involvement (P=0.040), and gastrointestinal involvement (P=0.00046). Regarding cardiovascular risk, no differences between the two groups emerged (P=0.617). Four variables were associated with the development of major organ involvement: male gender (OR=2.104, P=0.001), current treatment with biologic agents (OR=2.257, P=0.0003), origin from endemic countries (OR=2.661, P=0.0009), and disease duration (OR=1.002, P=0.024).

CONCLUSION

BD displays a more severe course among males. This subgroup develops more irreversible damage and presents more frequently ocular and vascular involvement during disease course. On the other hand, female patients are prone to experience articular involvement, headache, CNS and gastrointestinal involvement. These data suggest the existence of a gender-driven disease expression.

Uveitis in paediatric Behçet disease: a large multicentric Italian cohort

Background

Behçet disease (BD) is a rare disease in childhood and its uveitis may lead to blindness if not properly treated.

Objectives

We aim to describe a cohort of paediatric BD patients with uveitis.

Design

This is a multicentric retrospective study.

Methods

Six paediatric rheumatology units in Italy were involved including children with a diagnosis of paediatric BD according to the International Criteria for BD Criteria and/or to the International Study Group Criteria for BD, or Paediatric BD classification criteria if they had uveitis. Demographic, laboratory and clinical data were collected and followed up to March 2023. Ocular characteristics and treatment response were assessed according to Standardization Uveitis Nomenclature.

Results

Among the 97 children with BD followed, 33 (34%) had uveitis (22 males, 66.7%). The median age at onset of BD and uveitis were, respectively, 11.5 years (2.5-17.1) and 11 years (3-17.3). Uveitis preceded BD diagnosis in 18 children (54.5%). Seventeen children had HLA B51 positivity (51.5%). Uveitis was bilateral in 25 (75.8%), and panuveitis in 16 (48.5%). All the patients received at least 1 systemic treatment for uveitis: 25 adalimumab, 2 tocilizumab, 1 abatacept, 3 infliximab, 4 azathioprine, 1 methotrexate and 1 corticosteroid. The remission was achieved with 30/35 treatments (85.7%) after a median time of 8 months (6-24). Six children had a relapse in therapy after the achievement of remission (20%). Fourteen patients stopped the therapy for persistent remission, but 5 relapsed (35.7%) after a median time of 9 months (range 1-48).

Conclusion

Uveitis in BD is a sight-threatening condition, and it is more frequently a panuveitis. Biologic treatments seem to be often required to control ocular inflammation.

A proliferation-inducing ligand (APRIL) level among risk factors of ocular involvement in patients with Behçet's disease

Introduction

Ocular involvement is quite common in Behçet's disease (BD) and may cause crucial functional complications. Even though the mechanisms of BD remain unclear, advances in genetic and immunological fields have improved our understanding of the immunopathogenesis of BD ocular involvement. Little is known about the expression of a proliferation-inducing ligand (APRIL) in terms of ocular involvement in BD. The objective of this study was to determine whether serum APRIL concentrations are associated with ocular involvement in patients with BD.

Material and methods

The study included 60 patients diagnosed with BD matched by age and sex to 30 healthy individuals. Every patient underwent a clinical evaluation, and the Behçet's Disease Current Activity Form (BDCAF) was utilized to quantify disease activity. All patients underwent a comprehensive ophthalmological assessment. Serum APRIL was assessed for patients as well as controls.

Results

One or more ocular manifestations were found in 42 BD patients (70%), while 18 patients (30%) had no ocular involvement. The mean level of serum APRIL levels was markedly elevated in BD patients, particularly those with ocular involvement, compared to both BD patients without ocular involvement and healthy individuals. A statistically significant association was determined between high APRIL concentration and development of uveitis, cataract, and hypopyon. Cutaneous lesions and arthritis were strong independent predictors for ocular involvement in BD patients.

Conclusions

Overexpression of APRIL in patients with BD, particularly in terms of uveitis, cataract, and hypopyon, lends credence to the idea that B cell activating factors have an important function in BD. These findings may indicate that serum APRIL concentrations can differentiate a clinical subgroup of BD patients with ocular disease. As a result, finding a new therapeutic strategy targeting the APRIL pathway might be beneficial in BD patients suffering from ocular involvement.

Clinical characteristics of Behçet's syndrome in Shanghai database: Baseline data of a cross-sectional cohort study

OBJECTIVE

Behçet's syndrome (BS) is a variant vessel vasculitis that can involve multiple organs, with highly heterogeneous clinical manifestations. This study aims to analyze baseline data of BS patients to enhance the comprehension of its clinical features.

METHODS

This study included 1216 registered cases of BS patients referred to Huadong Hospital affiliated with Fudan University. Each patient was thoroughly assessed and recorded for demographic data, clinical manifestations, gastrointestinal endoscope, imaging, etc. RESULTS: Significant gender differences were observed in clinical manifestations. Pseudofolliculitis (p < .001), uveitis (p = .003), vascular (p < .001), and cardiovascular involvement (p < .001) were significantly more prevalent in male BS patients, while genital ulcers (p = .011) and erythema nodosum (p = .009) were more common among the female. Furthermore, pseudofolliculitis (44.3%, 37.4% vs. 25.0%, p < .001), pathergy test positivity (37.0%, 24.5% vs. 12.6%, p < .001), and uveitis (18.8%, 18.4% vs. 11.2%, p < .001) showed higher incidence rates in the 16-35 years age group. Vascular involvement (11.1%, 18.0% vs. 15.8%, p < .001) notably increased in the 36-50 years age group. Additionally, the ISG diagnostic criteria were more likely to be met in the 16-35 age group (OR: 2.039, 95% CI: 1.581-2.631, p < .001), whereas the ICBD criteria were less likely to be met in the 16-35 age group (OR: 0.266, 95% CI: 0.150-0.474, p < .001).

CONCLUSIONS

This study provided data on the baseline of clinical features of BS in a single center, BS patients presented significant heterogeneity, showing different manifestations across various genders and age groups. This diversity might contribute to a better understanding of BS clinical features and pave the way for future multi-center studies.

Clinical phenotypes of adult-onset Behçet's syndrome: a comprehensive cross-sectional study in China

Behçet's syndrome (BS) is a variant vasculitis that can involve multiple organs with inflammatory manifestations. This study aimed to provide a more comprehensive analysis of the clinical phenotypes and characteristics of BS patients. We enrolled 2792 BS patients referred from China nationwide to Huadong Hospital Affiliated to Fudan University from October 2012 to December 2022. Detailed assessments of demographic information, clinical manifestations, laboratory results, gastroscopy, and medical imaging were conducted. Cluster analysis was performed based on 13 variables to determine the clinical phenotypes, and each phenotype was characterized according to the features of BS patients. A total of 1834 BS patients were included, while 958 invalid patients were excluded. The median age at onset was 31 years (IQR, 24-40 years), and the median disease duration was 10 years (IQR, 5-15 years). Eight clusters were identified, including mucocutaneous (n =  655, 35.7%), gastrointestinal (n =  363, 19.8%), articular (n =  184, 10%), ocular (n =  223, 12.2%), cardiovascular (n =  119, 6.5%), neurological (n =  118, 6.4%), vascular (n =  114, 6.2%), and hematological phenotype (n =  58, 3.2%). Ocular (RR =  1.672 (95% CI, 1.327-2.106); P <  0.001), gastrointestinal (RR = = 1.194 (95% CI, 1.031-1.383); P =  0.018), cardiovascular (RR = = 2.582 (95% CI, 1.842-3.620); P <  0.001), and vascular (RR = = 2.288 (95% CI, 1.600-3.272); P <  0.001) involvement were more prevalent in male BS patients, while the hematological (RR =  0.528 (95% CI, 0.360-0.776); P =  0.001) involvement was more common among female patients. BS presents significant heterogeneity and gender differences. The eight phenotypes of BS patients we propose hold the potential to assist clinicians in devising more personalized treatment and follow-up strategies. Key Points • This cluster analysis divided adult-onset BS into eight clinical phenotypes. • BS demonstrates a high level of clinical heterogeneity and gender differences. • Hematologic phenotypes of BS present distinctive clinical characteristics.

Ocular Manifestations in Juvenile Behçet's Disease: A Registry-Based Analysis from the AIDA Network

INTRODUCTION

This study aims to characterize ocular manifestations of juvenile Behçet's disease (jBD).

METHODS

This was a registry-based observational prospective study. All subjects with jBD from the Autoinflammatory Diseases Alliance (AIDA) Network BD Registry showing ocular manifestations before 18 years were enrolled.

RESULTS

We included 27 of 1000 subjects enrolled in the registry (66.7% male patients, 45 affected eyes). The median (interquartile range [IQR]) age at ocular involvement was 14.2 (4.7) years. Uveitis affected 91.1% of eyes (anterior 11.1%, posterior 40.0%, panuveitis 40.0%), retinal vasculitis 37.8% and other manifestations 19.8%. Later onset (p = 0.01) and male predominance (p = 0.04) characterized posterior involvement. Ocular complications occurred in 51.1% of eyes. Patients with complications had earlier onset (p < 0.01), more relapses (p = 0.02) and more prolonged steroidal treatment (p = 0.02). The mean (standard deviation [SD]) central macular thickness (CMT) at the enrolment and last visit was 302.2 (58.4) and 293.3 (78.2) μm, respectively. Fluorescein angiography was pathological in 63.2% of procedures, with a mean (SD) Angiography Scoring for Uveitis Working Group (ASUWOG) of 17.9 (15.5). At the last visit, ocular damage according to the BD Overall Damage Index (BODI) was documented in 73.3% of eyes. The final mean (SD) best corrected visual acuity (BCVA) logMAR was 0.17 (0.47) and blindness (BCVA logMAR < 1.00 or central visual field ≤ 10°) occurred in 15.6% of eyes. At multivariate regression analysis, human leukocyte antigen (HLA)-B51 + independently predicted a + 0.35 change in the final BCVA logMAR (p = 0.01), while a higher BCVA logMAR at the first assessment (odds ratio [OR] 5.80; p = 0.02) independently predicted blindness.

CONCLUSIONS

The results of this study may be leveraged to guide clinical practice and future research on this rare sight-threatening condition.

Diabetes mellitus in rheumatic diseases: clinical characteristics and treatment considerations

New pathophysiological insights are now available on comorbidities in rheumatic diseases (RDs). Several nationwide studies point to the fact that comorbid diabetes mellitus (DM) increases the risk of adverse outcomes in patients with various RDs. Genetic factors, intensity of systemic inflammation, anti-inflammatory potential of therapeutic agents, and duration of RDs have been insufficiently explored in the context of comorbidities. Some disease-modifying antirheumatic drugs (DMARDs) have demonstrated a potential to improve the glycemic control while glucocorticoids (GCs) have worsened it, particularly in systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA). Anti-TNFalpha agents in combination with hydroxychloroquine (HCQ) have been associated with a reduced risk of DM in patients with RA, ankylosing spondylitis (AS), Sjögren syndrome (SS), and SLE. Better understanding of confounding factor of currently available antirheumatic therapies in patients with DM and RDs will pave the way for a tailored approach, limiting the severity of clinical manifestations and reducing the mortality risk.

Ocular involvement in pediatric Behçet's disease: is it different than in adults? (a short case series and mini review)

BACKGROUND

Pediatric Behçet's disease (PBD) is rarer than BD and can be a challenging diagnosis as clinical picture may be incomplete. As in adult patients, sight-threatening ocular manifestations may lead to diagnosis. In this study, we aimed to report a series of cases of PBD with ocular manifestations and provide a review of the literature.

METHODS

Retrospective case series of PBD patients with ocular manifestations. Demographic, ophthalmological and systemic data at presentation and during follow-up were collected and analyzed.

RESULTS

Four patients, aged 13.0 ± 2.9 years (9-16) were included. Posterior uveitis with retinal vasculitis, papillitis and macular edema was present in all patients, with associated anterior uveitis in 2 cases. Other features included occlusive vasculitis (2/4) and necrotizing retinitis (2/4). All patients were improved by systemic treatments except one patient with severe bilateral optic neuropathy. Ocular manifestations were the presenting symptoms in 3/4 cases.

CONCLUSION

Ocular manifestations and systemic associations of PBD are comparable to those encountered in adult patients. The lack of complains in pediatric patients may lead to a longer diagnosis delay, especially in unilateral uveitis. Aggressive and long-term treatment is mandatory to prevent vision loss and recurrences.

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.

Clinical Characteristics and Outcomes of Mexican Patients With Behçet's Syndrome

OBJECTIVE

The aim of this study was to describe the clinical characteristics and outcomes of Mexican patients with Behçet syndrome (BS) from a single center.

METHODS

This medical records review study included patients with established BS diagnosis, followed up in a tertiary care center in Mexico City from 2000 to 2020. Demographics, clinical characteristics, laboratory and imaging studies, disease activity, damage, treatment, and outcomes were assessed and compared according to sex and with other international cohorts. Descriptive statistics were used, and differences between groups were evaluated using the χ2 or Mann-Whitney U tests.

RESULTS

Thirty-eight patients were included, 23 (60%) women and 15 (40%) men; the median age at BS diagnosis was 33 years (range, 24-39 years). The most frequent manifestations at diagnosis were recurrent oral and genital ulcers in 34 (89%) and 29 (76%), respectively, musculoskeletal in 21 (55%), and cutaneous in 15 (39%). The most frequent phenotype was the joint involvement. Treatment comprised prednisone in all, colchicine (24 [63%]), pentoxifylline (12 [32%]), and thalidomide (10 [26%]). During a median follow-up time of 12.5 years (range, 7-23 years), relapses were frequent (97%), severe infections were present in 5 patients (13%), and 2 patients (5%) died due to sepsis and pneumonia. Men showed a higher frequency of arterial hypertension (47% vs. 13%, p = 0.03) and thrombosis (20% vs. 0, p = 0.05), and a lower frequency of genital ulcers (40% vs. 78%, p = 0.03) than women.

CONCLUSIONS

This cohort of Mexican patients with BS showed a predominance of female sex, joint involvement phenotype, frequent relapses, and favorable outcomes. Differences in comorbidities and clinical manifestations were identified according to sex.

Damage accrual in Behçet disease: Behçet's Syndrome Overall Damage Index (BODI) versus Behçet's Disease Damage Index (BDI)

OBJECTIVES

To assess the validity of Behçet's Syndrome Overall Damage Index (BODI) and Behçet's Disease Damage Index (BDI) as tools for the detection of damage accrual in Behçet's patients compared to Vasculitis Damage Index (VDI). Also, to evaluate the correlation and the interclass correlation among the 3 indices to find out their consistency.

METHOD

A prospective cohort study was carried out on 102 adult Behçet's disease (BD) patients who were diagnosed according to the International Study Group criteria for BD. Disease severity and organ damage were assessed for each patient by VDI, BDI and BODI at baseline and 1-year follow-up visits. Damage accrual for each index was defined when there was an increase of at least 1 point (∆ ≥ 1) among the baseline and the follow-up visits.

RESULTS

Correlations among the 3 indices were significant, with (r = 0.835, P < 0.001) between VDI and BODI, (r = 0.835, P < 0.001) between VDI and BDI, and (r = 0.844, P < 0.001) between BODI and BDI scores. A highly significant positive correlation existed between the 3 indices and age and disease duration. In contrast, the correlation with the BD Current Activity Form was non-significant, which indicates good discriminative validity of the 3 indices. Neuropsychiatric and ocular systems showed a strong interclass correlation among the 3 indices. Regarding detecting damage accrual, BDI was more sensitive than BODI and showed more agreement with VDI.

CONCLUSION

BD damage indices, VDI, BODI and BDI, had good convergent and discriminative validity for the assessment of BD damage. BDI had more sensitivity than BODI to the detection of damage accrual.

Treatment Options in Pediatric Behçet's Disease

Behçet's disease is a rare and poorly understood vasculitis affecting blood vessels of all types and sizes. Uveitis and oral and genital ulcers represent the typical clinical triad. Populations along the ancient trading route connecting the Mediterranean basin with the Middle and Far East are most affected. Up to a quarter of the cases has a pediatric onset, typically around puberty. The aim of the treatment is early intervention to control inflammation, with symptom relief and prevention of relapses, damage, and complications. The heterogeneous clinical presentation often requires a multidisciplinary and tailored approach. Ocular, neurological, gastrointestinal, and vascular involvement is associated with a worse prognosis and needs more aggressive treatments. In young patients with expected prolonged disease, treatment should also focus on preventive measures and lifestyle advice. In recent years, the pharmacological armamentarium has grown progressively, although only a limited number of drugs are currently authorized for pediatric use. Most evidence for these drugs still derives from adult studies and experience; these are prescribed as off-label medications and are only available as adult formulations. Corticosteroids frequently represent the mainstay for the management of the initial acute phases, but their potential serious adverse effects limit their use to short periods. Different conventional disease-modifying anti-rheumatic drugs have long been used. Many other biologic drugs targeting different cytokines such as interleukin-1, interleukin-6, and interleukin-17 and treatments with small molecules including the phosphodiesterase 4 and Janus kinase inhibitors are emerging as novel promising therapeutic agents. In recent years, a growing interest has developed around anti-tumor necrosis factor agents that have often proven to be effective in severe cases, especially in those with a gastrointestinal and ocular involvement.

Development of machine learning models for detection of vision threatening Behçet's disease (BD) using Egyptian College of Rheumatology (ECR)-BD cohort

BACKGROUND

Eye lesions, occur in nearly half of patients with Behçet's Disease (BD), can lead to irreversible damage and vision loss; however, limited studies are available on identifying risk factors for the development of vision-threatening BD (VTBD). Using an Egyptian college of rheumatology (ECR)-BD, a national cohort of BD patients, we examined the performance of machine-learning (ML) models in predicting VTBD compared to logistic regression (LR) analysis. We identified the risk factors for the development of VTBD.

METHODS

Patients with complete ocular data were included. VTBD was determined by the presence of any retinal disease, optic nerve involvement, or occurrence of blindness. Various ML-models were developed and examined for VTBD prediction. The Shapley additive explanation value was used for the interpretability of the predictors.

RESULTS

A total of 1094 BD patients [71.5% were men, mean ± SD age 36.1 ± 10 years] were included. 549 (50.2%) individuals had VTBD. Extreme Gradient Boosting was the best-performing ML model (AUROC 0.85, 95% CI 0.81, 0.90) compared with logistic regression (AUROC 0.64, 95%CI 0.58, 0.71). Higher disease activity, thrombocytosis, ever smoking, and daily steroid dose were the top factors associated with VTBD.

CONCLUSIONS

Using information obtained in the clinical settings, the Extreme Gradient Boosting identified patients at higher risk of VTBD better than the conventional statistical method. Further longitudinal studies to evaluate the clinical utility of the proposed prediction model are needed.

Autophagy-related genes in Egyptian patients with Behçet's disease

Background

Behçet's disease (BD) is a chronic, multi-systemic, recurrent condition that affects the vascular, ocular, mucocutaneous, and central nervous systems. The diagnosis of this disease depends on its clinical features, which are similar to those observed in several diseases, such as Parkinson’s disease, pemphigus vulgaris, systemic lupus erythematosus, Crohn ҆s disease, and Sjӧgren’s syndrome. Lysosome-mediated autophagy is a catabolic, cytoprotective mechanism that maintains cell homeostasis by degrading undesired long-lived proteins and recycling nutrients. The aim of this study was to evaluate the correlations between some autophagy-related genes (ATG5, ATG7, ATG12, LC3b, mTOR) and the pathogenesis and immunopathology of BD. The expression levels of the genes were evaluated by quantitative polymerase chain reaction (qPCR) in 101 individuals that are classified into two groups. Group 1: (n = 71) BD patients, Group 2: (n = 30) healthy controls.

Results

Patients with BD had lower mRNA expression levels of ATG5 and mTOR and higher levels of LC3b mRNA than the controls. No significant differences in the levels of both ATG7 and ATG12 were observed between the two groups. According to the area under the curve analysis, LC3b was considered the best candidate biomarker among the selected markers for the diagnosis of BD. The mRNA expression of ATG5 was significantly correlated with patient age and the presence of oral ulcers. The mRNA expression of ATG7 was significantly associated with age and the presence of erythema nodosum and vascular lesions, whereas that of LC3b was significantly correlated with the presence of pustules.

Conclusion

These findings indicated that elevated levels of LC3b were strongly associated with BD. Likewise, the levels of ATG5 and ATG7 were associated with the complications and outcomes of this disease. Additional assessments of the mRNA expression levels of these autophagy-related genes might prove beneficial in diagnosing this autoimmune disorder.

Natural History of Behçet's Disease Focusing on Remission of Oral Ulcers

OBJECTIVES

To describe the long-term clinical course of each manifestation of Behçet's disease (BD) and clarify factors involved in oral ulcer (OU) remission using clinical information of BD patients.

METHODS

We retrospectively studied 155 BD patients visiting our hospital (1989-2020). We defined remission criteria for each manifestation and examined long-term clinical changes. Classification and regression trees and multivariable analyses were performed to investigate OU prognostic factors; hazard ratios were used to assign scores to prognostic factors deemed significant (OU prognosis score: OuP score). Risk stratification was examined by dividing the OuP scores into four stages.

RESULTS

OUs appeared earliest, with the slowest decline in prevalence observed post-BD diagnosis. OU presence was the most common factor inhibiting complete remission. Young age at OU onset, never smoker, presence of genital ulcers, positive pathergy test, no usage of tumour necrosis factor inhibitors or of immunosuppressants, and long-term non-treatment or symptomatic treatment for OUs were poor OU prognostic factors. Based on multivariable analysis, the area under the curve of the OuP score to predict OU prognosis was 0.678.

CONCLUSIONS

Remission criteria for each symptom clarified that OU had the greatest impact on complete BD remission. Faster OU remission was associated with earlier OU therapeutic intervention other than symptomatic treatment.

Anti-tubulin-alpha-1c antibody as a marker of value in Behçet syndrome

Background

Behçet’s syndrome (BS) is a multi-systemic vasculitis characterized by recurrent oral ulcers, genital ulcers, ocular lesions, and other systemic manifestations. As there is no laboratory diagnostics of BS, the diagnosis is mainly clinical.

Objective

To investigate the utility of the autoantibody against tubulin-α-1c in diagnosis of BS and its clinical significance.

Methods

Sixty BS patients and sixty healthy controls were enrolled in this study. We assessed all patients by Behçet disease current activity form (BDCAF), routine laboratory investigations, and immunological markers (ANA, anti-DNA, ANCA). Anti-endothelial cell antibodies (AECA) and anti-tubulin-alpha-1c antibodies were performed for all participants.

Results

Regarding duration of illness, Birmingham Vasculitis Activity Score (BVAS), and BDCAF, the mean value was 4.77 ± 4.239, 19.80 ± 10.020, and 9.52 ± 5.476, respectively. On comparing laboratory investigations, there was only significant increase in anti-tubulin-alpha-1c antibody in BS patients compared to healthy controls. Regarding AECA, there was no any significant correlation except with CRP. Anti-tubulin-alpha-1c detected significant direct correlation with the presence of posterior uveitis, panuveitis, and venous thrombosis as well as BVAS, C4, and protein/creatinine ratio. Regarding diagnostic performance of both AECA and anti-tubulin-alpha-1c, the cutoff value of AECA for diagnosis was 27.250, with sensitivity and specificity of 93.3% and 96.7%, respectively. The cutoff value of the anti-tubulin-alpha-1c for diagnosis was 22.300, with sensitivity and specificity of 100% and 96.7% respectively.

Conclusion

Anti-tubulin-α-1c antibodies are of diagnostic value in BS and are indicative of activity with 100% sensitivity and 96.7% specificity.

Key Points • There is lack of specific laboratory, radiological, or histological diagnostics for Behcet syndrome. • We aimed to evaluate the significance of tubulin-α-1c autoantibody in diagnosis of Behcet syndrome. • There is elevation of tubulin-α-1c autoantibody with sensitivity and specificity of 100% and 96.7%, respectively.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10067-021-06025-7.

Quality of life and diet: A paired match study on Behçet’s disease

BACKGROUND: It has been reported that the quality of life and diet quality in individuals with rheumatological diseases are poor and may adversely affect the course of the disease. OBJECTIVE: This study aims to compare the quality of life and diet of individuals with Behçet’s Disease (BD) compared to healthy controls. METHODS: This study was planned as a case-control study, and 60 adult patients with BD were compared with age (±1) and sex paired match healthy controls concerning the quality of life and diet. Diet quality was assessed using nutrient adequacy ratio (NAR) and the mean adequacy ratio (MAR) values calculated from 24 h dietary food recall and obesity was also evaluated by various anthropometric measurements. The Short Form-36 Health Survey (SF-36) was used to evaluate the quality of life (QoL). In addition, the 24-hour physical activities were recorded to calculate physical activity levels (PAL). Data were analyzed by SPSS 25.0 via paired sample t-test and McNemar (and McNemar-Bowkers) test. p <  0.05 was deemed significant. RESULTS: The findings showed that cases were more obese (p = 0.005), less physically active (p <  0.001), had lower QoL (p <  0.01 for all subscales) and had higher Beck depression scores (p = 0.001). Controls had higher means of energy (p <  0.001), CHO% (p = 0.025), fat% (p = 0.004), and fiber (p = 0.007) intake and mean MAR value (p <  0.001). CONCLUSIONS: Compared to healthy controls, patients with BD were more obese, had lower QoL and lower diet quality. Therefore, people with BD should be evaluated for comorbid diseases and be supported by health professionals, such as dietitians and psychologists.

Clinical profile and evolution of patients with juvenile-onset Behçet's syndrome over a 25-year period: insights from the AIDA network

Behçet's syndrome (BS) represents an understudied topic in pediatrics: the main aims of our study were to characterize demographic and clinical features of a cohort of BS patients with juvenile-onset managed in three tertiary referral centers in Italy, evaluate their evolution in the long-term, and detect any potential differences with BS patients having an adult-onset. Medical records of 64 juvenile-onset and 332 adult-onset BS followed-up over a 2-year period were retrospectively analyzed and compared. Mean age ± SD of first symptom-appearance was 10.92 ± 4.34 years with a female-to-male ratio of 1.06:1. Mucocutaneous signs were the most frequent initial manifestations, followed by uveitis. Throughout the disease course, genital aphthae (76.56%) and pseudofolliculitis (40.63%) prevailed among the mucocutaneous signs, while major organ involvement was represented by gastrointestinal and ocular involvement (43.75 and 34.38%, respectively). No significant differences emerged for both mucocutaneous signs and specific major organ involvement between juvenile-onset and adult BS patients. After excluding nonspecific abdominal pain, juvenile-onset BS patients were less frequently characterized by the development of major organ involvement (p = 0.027). Logistic regression detected the juvenile-onset as a variable associated with reduced risk of long-term major organ involvement (OR 0.495 [0.263-0.932], p = 0.029). In our cohort, juvenile-onset BS resembled the clinical spectrum of adult-onset patients. Pediatric patients with a full-blown disease at onset showed a more frequent mucocutaneous involvement. In addition, patients with juvenile-onset seemed to develop less frequently major organ involvement and had an overall less severe disease course.

Behçet's syndrome in children and young people in the United Kingdom and the Republic of Ireland: a prospective epidemiological study

OBJECTIVES

To define the incidence and prevalence of Behçet's syndrome (BS) in children and young people (CYP) up to the age of 16 years in the United Kingdom (UK) and Republic of Ireland (ROI).

METHODS

A prospective epidemiological study was undertaken with the support of the British Paediatric Surveillance Unit (BPSU) and the British Society of Paediatric Dermatologists (BSPD). Consultants reported anonymised cases of BS seen. A follow-up study at one year examined progression of disease and treatment.

RESULTS

Over a two-year period, 56 cases met the International Criteria for Behçet's Disease. For children under 16 years of age, the two-year period prevalence estimate was 4.2 per million (95% CI: 3.2, 5.4) and the incidence was 0.96 per million person years (95% CI: 0.66, 1.41). Mucocutaneous disease was the most common phenotype (56/100%), with ocular (10/56; 17.9%), neurological (2/56; 3.6%) and vascular involvement (3/56; 5.4%) being less common. Median age at onset was 6.34 years and at diagnosis was 11.72 years. There were slightly more female than male children reported (32/56; 55.6%). The majority of cases (85.7%) were white Caucasian. Apart from genital ulcers, which were more common in females, there were no significant differences in frequency of manifestations between male or females, nor between ethnicities. Over 83% of cases had three or more non-primary care healthcare professionals involved in their care.

CONCLUSION

BS is extremely rare in CYP in the UK and ROI and most have mucocutaneous disease. Healthcare needs are complex, and coordinated care is key.

Epidemiology and treatment of Behçet's disease in the USA: insights from the Rheumatology Informatics System for Effectiveness (RISE) Registry with a comparison with other published cohorts from endemic regions

BACKGROUND

Behçet's disease (BD), a chronic systemic vasculitis, has distinct geographical and ethnic variation. Data regarding the epidemiology of patients with BD in the U.S. are limited; therefore, we sought to describe BD patient characteristics and medication use in the U.S., and compared them with data from patients from endemic regions.

METHODS

We conducted a cross-sectional study using data from the RISE registry (2014-2018). Patients aged ≥ 18 years with BD were included. Sociodemographic and treatment information was extracted. We compared patients from the RISE registry to data from other published studies of patients with BD from endemic areas.

RESULTS

One thousand three hundred twenty-three subjects with BD from the RISE registry were included. Mean age was 48.7 ± 16.3 years, female to male ratio was 3.8:1, and 66.7% were White. The most frequently used medications included glucocorticoids (67.6%) and colchicine (55.0%). Infliximab and adalimumab were the most used biologics (14.5% and 14.1%, respectively); 3.2% of patients used apremilast. The RISE registry had more women (79.3%), and patients were older compared to previously published BD studies from endemic areas. Methotrexate and TNFi were more commonly reported in RISE (21.8% and 29.4%) compared to studies from Egypt and Turkey. Colchicine, cyclosporine, and cyclophosphamide were more commonly used in cohorts from Egypt, Turkey, and Iran.

CONCLUSIONS

Findings from the largest BD dataset in the U.S. suggest that BD patients are predominantly female. Further research is needed to explore the reasons for the higher prevalence of BD among women in the U.S. and its possible impact on disease severity and management.

Development and validation of a Behçet's Disease Damage Index for adults with BD: An Explicit, Composite and Rated (ECR) tool

BACKGROUND

Behçet's disease (BD) is a chronic multisystem variable vessel vasculitis. Disease damage is irreversible and permanent. Validated tools evaluating damage are limited. Enhancements in the clinical treatment of vasculitis will take place from the development of refined and exclusive indices for individual vasculitic syndromes including BD and attempting their international validation.

OBJECTIVES

This aim was to develop and validate a simple BD Damage Index (BDI).

METHODS

This was a nationwide study including 1252 BD patients. The work consisted of 3 stages. Stage 1: items generation for score content. Stage 2: items selection for the draft score was performed by an expert rheumatologist. Stage 3: the content validity of the draft score was assessed and BDI, Vasculitis Damage Index (VDI), Antineutrophil cytoplasmic antibody-associated Vasculitis Index of Damage (AVID) and Combined Damage Assessment Index (CDAI) were calculated and compared.

RESULTS

The mean age of the BD patients was 36.1 ± 9.9 years. Stages 1 and 2 resulted in a BDI instrument containing 73 items with a maximum score of 100. Stage 3, the VDI, CDAI, AVID, and BDI were 2.9 ± 2.2, 3.1 ± 2.3, 3.1 ± 2.3 and 5.1 ± 2.9, respectively. High correlations (r = .9) between comparable damage scores assured acceptable concurrent validity.

CONCLUSION

The proposed BDI represents a new robust and potentially useful tool when dealing with BD chronic status.

Development of an Arabic version of the Behçet's Disease Current Activity Form (Ar-BDCAF): cross-cultural adaptation and validation initiative in Egypt

BACKGROUND

Behçet's disease (BD), commonly seen in the Silk road countries, is a variable vessel vasculitis with no specific investigation that reflects disease activity. The Behçet's Disease Current Activity Form (BDCAF) is the most famous and acceptable clinical activity score.

PURPOSE

To develop a cross-cultural adaptation of the BDCAF to the Arabic language (Ar-BDCAF)-Egyptian dialect-across the country and to consider preliminary evaluation of its reliability in assessment of BD activity.

PATIENTS AND METHODS

The score was translated to Arabic language and revised by 3 rheumatology consultants. Reliability of Ar-BDCAF was tested among 88 BD patients from 9 Egyptian main city centers. Patients were questioned by two specialists at 30 min interval to evaluate inter-observer rating and twice by the same physician within 24 h to assess the intra-observer rating.

RESULTS

Patients were 64 males and 24 females (2.7:1) with a mean age of 35 ± 10.3 years. The average time required by the consultant to fill in the form was 5.1 ± 2.2 min (1.5-15 min). The mean Ar-BDCAF scores were 9.81 ± 6.22 (0-25) and 9.53 ± 6.13 (0-28) with an intra-observer concordance (p = 0.28) and was 9.95 ± 6.47 (0-29) for the inter-observer rating (p = 0.89 and p = 0.66, respectively).

CONCLUSION

The Ar-BDCAF is a measurable, easy to calculate, and reliable index for assessing disease activity in Egyptian BD. The Ar-BDCAF score can be used in daily clinical practice to assess BD activity and its use can be extended to other Arab countries for possible regional validation and adaptations. Key Points • The Arabic version of the BDCAF can be extended to other Arab countries for development of a Pan-Arab score. • This is the first study to provide a reliable and valid Arabic version of the BDCAF-Egyptian dialect for measuring current disease activity in BD patients.

Patients characteristics in Behçet's Syndrome and their associations with major organ involvement: a single-centre experience of 2118 cases

Objectives: To evaluate the demographic and clinical characteristics of patients with Behçet's syndrome (BS), and to define their associations with the presence of major organ involvement (MOI).Method: Medical records of 2118 patients (964 males, 1154 females) were analysed retrospectively. MOI was defined as the presence of at least one of vascular, eye, nervous, or gastrointestinal system involvement. Univariable and multivariable binary and ordinal logistic regression analyses were applied to assess the factors that were potentially associated with MOI.Results: The mean ± sd age at diagnosis was 30.5 ± 9.4 years. Genital ulcer and joint involvement were more common in females (both p < 0.001), while MOI was more frequent in males (p < 0.001). Genital ulcer (p < 0.001) and vascular involvement (p = 0.006) were more common in patients with a younger age at diagnosis, while joint involvement was more common in older patients. A total of 1097 patients (51.8%) had at least one MOI, 322 (15.2%) at least two MOIs, and 48 (2.3%) at least three MOIs. Male gender, smoking history, and absence of genital ulcer were significantly associated with MOI in multivariable binary logistic regression. Multivariable ordinal regression analyses confirmed the association between MOI and male gender and smoking, but not the protective effect of genital ulcers. In both regression analyses, we found no significant effects of age, human leucocyte antigen-B51, skin involvement, or joint involvement on MOI.Conclusion: Male gender and positive smoking history have a significant influence on the presence of MOI in patients with BS.

Distinct clinical characteristics of pediatric Behçet's syndrome: A study from a referral center in China

OBJECTIVES

To describe the clinical features and patterns of phenotype aggregation in pediatric Behçet's syndrome (BS) in a tertiary center in China.

METHODS

This was a cross-sectional study of consecutive BS patients in Huadong Hospital, Fudan University between September 2012 and January 2020. Pediatric BS was defined as diagnosed before 16 years old. We compared clinical variables between pediatric and adult patients. We calculate relative risks (RRs) of clinical variables according to sex. Moreover, a hierarchical cluster analysis was undertaken according to 29 clinical variables to determine homogeneous subgroups.

RESULTS

From 1596 consecutive BS cases, we identified 69 pediatric BS. Compared with adult-diagnosed BS, pediatric-diagnosed patients had a higher frequency of folliculitis [RR 1.57 (95% CI 1.12, 2.20)], a lower frequency of arthralgia [RR 0.15 (95% CI 0.02, 1.07)] and panuveitis [RR 0.43 (95% CI 0.18, 1.03)], no cardiac lesion. There was an association between male and arterial thrombosis or aneurysms (p = .006). A cluster analysis stratified three sub-clusters (C1-C3): C1 (n = 30) showed a disease type merely affecting skin and mucosa. C2 (n = 20) represented the gastrointestinal type; most patients presented with intestinal involvement, and two cases with esophageal ulcers. In C3 (n = 19), showing a mixture of uveitis, vascular and central nervous system (CNS) involvement, six patients presented with uveitis and nine had vascular lesions, and three cases had CNS lesions.

CONCLUSION

We conducted a comprehensive statistical analysis in a cohort of pediatric patients with BS in China. Less ocular involvement and no cardiac lesions were observed in childhood-diagnosed patients. For the first time, three distinct phenotype subgroups in pediatric-diagnosed patients were identified by cluster analysis.Key messagesThis study demonstrated the phenotype discrepancy between childhood and adult-diagnosed BS.Three distinct clusters were identified, with skin-mucosa, gastrointestinal, panuveitis, vascular and CNS subgroups.

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.

Impact of disease activity on health related quality of life in patients with Behçet's disease: A cross-sectional study

Background

Behçet's syndrome (BD) is a systemic inflammatory vasculitis of unknown aetiology, affecting vessels of different types, sizes and locations and characterized by recurrent episodes of acute inflammation, including mucocutaneous manifestations (oral aphthous ulcers, genital ulcers and skin lesions) and gastrointestinal, musculoskeletal, neurological, ophthalmic and vascular involvement which lead to a significant morbidity and impaired health related quality of life (HRQoL). Few studies reported impact of disease activity on HRQoL.

Objective

To assess the impact of BD activity on HRQoL.

Patients and methods

This cross sectional study included patients with Behçet's disease diagnosed according to the International Study Group criteria 1990 for BD. Age of the patients, sex, smoking status, educational level, disease duration, organ involvement, age at disease onset, and medications used were recorded. Behçet's Disease Disease activity was assessed using Behçet's Disease Current Activity Form (BDCAF) and HRQoL was evaluated using The Short Form-36 (SF-36).

Results

A total of 71 patients (45 males, 26 females) with Behçet's disease were enrolled in this study. Mean age of patients was 36.0 ± 10.8 years, Males represented the majority of patients (63.4%). BDCAF was significantly and negatively correlated with total SF-36 score (standardized β = − 0.520, p < 0.0001). The mean BDCAF was significantly more in females compared to males (6.154 ± 2.444 vs 4.467 ± 2.785, p = 0.012). While the mean SF36 was significantly more in males compared to females (57.722 ± 21.627 vs 41.435 ± 18.993, p = 0.002). After multiple linear stepwise regression analysis, still BDCAF significantly and negatively affected HRQoL in BD (partial r = −0.255, p = 0.043). Male gender, cyclosporine users, infliximab users, and Adalimumab users had significant positive impact on total SF-36 score (partial r = 0.293, p = 0.020; partial r = 0.256, p- = 0.043, partial r = 0.414; p = 0.00, partial r = 0.399, p = 0.001 respectively). While disease duration, and MMF users (partial r = −0.295, p = 0.019; partial r = −0.250, p = 0.043) had significant negative impact on total SF-36 score, and there was weak positive correlation between vascular involvement and total SF36 score (partial r = 0.244,p = 0.053) and a negative weak correlation between the use of anticoagulant with total SF-36 score (partial r = −0.233, p = 0.066).

Conclusions

Behçet's disease activity has a significant negative impact on HRQoL This may suggest that treating activity of disease may improve HRQoL.

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Behcets disease activity has significantly negative impact on HQoL.

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This may suggest that treating activity of disease may improve HRQoL.

Juvenile-onset Behçet's syndrome and mimics

Behçet's syndrome (BS) presents in childhood in up to 20% of reported cases. Diagnosis is clinical and multiple classification criteria have been developed. Presentation is heterogenous with recurrent oral ulceration often being the presenting feature. Mucocutaneous disease including genital ulceration and skin involvement is a common phenotype. Vascular and neurological manifestations are rarer, particularly in childhood. Musculoskeletal and gastro-intestinal involvement which do not form part of commonly used classification criteria, appear more frequent in children. Treatment approaches are extrapolated from studies of adult onset disease. The pathogenesis of BS is not well defined although dysregulation in both innate and adaptive immune systems, together with abnormal antigen presentation have been described. The recent discovery of monogenic mimics of BS requires further genetic studies to understand the burden of monogenic autoinflammatory conditions affecting those with a BS phenotype.