Behçet's disease physiopathology: a contemporary review

Tintelnotia destructans, the Rare Opportunist of a Behçet's Disease Patient

Behçet's disease is a systemic vasculitis characterized by recurrent oral and genital ulcers that can have ophthalmologic, cutaneous, neurologic, vascular, and thromboembolic manifestations. Treatment usually involves immunosuppressant medication, which leads to an increased risk of opportunistic infections. Only recently identified, Tintelnotia destructans is a rare fungus that can cause eye and nail infections in humans, usually refractory to standard antifungal therapy. Ocular infections are most commonly associated with ocular trauma or the use of contact lenses and may cause permanent damage without adequate treatment. We present a case of a 40-year-old man with Behçet's disease, treated with adalimumab, who developed an ocular abscess due to Tintelnotia destructans. This clinical case serves the purpose of alerting for an opportunistic infection caused by a newly described and rare microorganism, which is hard to identify.

Behçet's disease: incidence, prevalence, and real-word data on the use of biologic agents in Japan

BACKGROUND

Behçet's disease (BD) is an autoinflammatory disease that can affect multiple organs, including the gastrointestinal tract. Conventional management comprises anti-inflammatory drugs such as glucocorticoids (GCs) and/or immunomodulators that alleviate symptoms. The introduction of biological agents that target tumor necrosis factor α (TNF-α) has improved disease management. The goal of this work was to analyze the current prevalence and incidence of total BD and gastrointestinal Behçet's disease (GIBD) in Japan, and examine treatment trends, especially regarding the use of TNF-α inhibitors (TNFαi).

METHODS

We performed a retrospective descriptive observational study in which BD and GIBD demographic trends, medical treatment patterns, and reported adverse events (AEs) were assessed among patients with data recorded between 2017 and 2021 in the Japan Medical Data Center Claims Database (now JMDC Inc.).

RESULTS

Prevalence of BD and GIBD in Japan during the observation period increased at an annual rate of + 3% and + 4%, respectively, while incidence decreased by - 5% and - 2%, with a more prominent decline in confirmed GIBD cases (- 15%). Although GCs were the most common initial treatment administered, use of TNFαi for BD and GIBD management increased by + 5.6% and + 8.1%, respectively. Severe AEs (mainly pneumonia and GI-associated AEs) were reported in 40% of patients receiving TNFαi; however, a high retention rate (of up to 80%) was observed 3 years after treatment initiation.

CONCLUSION

The use of TNFαi for GIBD treatment has increased in Japan in recent years. Additional research is necessary to further evaluate TNFαi effectiveness in GIBD and other BD subtypes.

Assessment of IL-6 Pathway Inhibition in Gastrointestinal Behçet's Disease from Immunological and Clinical Perspectives

Behçet's disease is an autoinflammatory disorder characterized by relapsing and remitting vasculitis that can manifest in various forms, including gastrointestinal Behçet's disease (GIBD). Its complications (e.g., intestinal perforation) are among the primary causes of morbidity and mortality. GIBD pathogenesis involves the enhanced production of certain cytokines, e.g., tumor necrosis factor α and interleukin-6 (IL-6), which could serve as a target for potential therapies. This review provides an overview of GIBD, including the diagnosis and immunopathogenesis as it is currently understood, and evaluates the emerging role of the inhibition of IL-6 (classic and trans-signaling) as an alternative treatment option for patients with GIBD. Given the current paucity of data, we reflected on the potential of IL-6 inhibitors such as tocilizumab and olamkicept based on immunopathogenic considerations and available clinical data in patients with inflammatory bowel disease (IBD), in whom clinical response or remission was induced. The selective inhibition of IL-6 trans-signaling may bring new impetus to the development of this drug class, particularly regarding safety. Still, the benefits of IL-6 inhibitors for patients with GIBD need to be evaluated in appropriate proof-of-concept studies. The clinical outcomes of IL-6 inhibitors in IBD are promising and may suggest their potential relevance in GIBD.

Clinical Activity of Behcet's Disease Associated with SARS-CoV-2 and Herpes Simplex Virus: Insights from Three Case Reports

Introduction

The Behçet's Disease Current Activity Form (BDCAF) is crucial for monitoring the progression and treatment efficacy of Behçet's Disease (BD), an autoimmune disorder that can be triggered or exacerbated by viral infections. Herpes simplex virus type 1 (HSV-1) has long been recognized as a potential trigger for BD, as it can induce systemic inflammation and exacerbate symptoms. In contrast, Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has recently emerged and may also initiate or worsen BD symptoms. This report examines three BD cases with oral manifestations specifically triggered by HSV-1 and SARS-CoV-2, comparing their clinical activity and treatment responses.

Case

Three female patients, aged 29, 24, and 41 years, presented to the Oral Medicine Department with complaints of canker sores, along with genital and skin lesions and red eyes. Intraoral examination showed ulcerative, erosive, and white plaque lesions throughout the oral mucosa. The first patient was confirmed to have COVID-19 by the SARS-CoV-2 RNA test. The second and third patients had a two-year history of recurrent oral ulcerations with reactive IgG anti-HSV-1 tests. All patients were diagnosed with BD according to the International Criteria for Behcet's Disease. The BDCAF measurements were conducted, showing a BD activity index score of 4 for the COVID-19-positive patient, while scores of 6 and 7 were recorded for the other two patients with seropositive HSV-1.

Case Management

Medications provided include corticosteroid, antimetabolite, analgesic, antiviral, antifungal, antiseptic mouthwash, and multivitamin. All patients showed good clinical improvement after treatment.

Conclusion

The BD activity index scores of a BD patient with COVID-19 were lower than those with HSV-1 infection. This difference may be due to the recent SARS-CoV-2 infection in the patient, whereas reactivation of chronic latent HSV-1 in the other patients likely contributed to a longer history of clinical manifestations, resulting in increased disease activity.

Reclassification of the overlap syndrome of Behçet's disease and antineutrophil cytoplasmic antibody-associated vasculitis in patients with Behçet's disease

BACKGROUND/AIMS

This study applied the 2022 American College of Rheumatology/European Alliance of Associations for Rheumatology (ACR/EULAR) criteria for antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) to patients with Behçet's disease (BD) to investigate the proportion and clinical implications of the reclassification to the overlap syndrome of BD and AAV (OS-BD-AAV).

METHODS

We included 280 BD patients presenting with ANCA positivity but without medical conditions mimicking AAV at diagnosis. Demographic data, items from the 2014 revised International Criteria for BD and 2022 American College of Rheumatology and European Alliance of Associations for Rheumatology criteria for AAV, ANCA positivity, and laboratory results were recorded as clinical data at diagnosis. A total score ≥ 5 indicated microscopic polyangiitis (MPA) and granulomatosis with polyangiitis (GPA), whereas a total score ≥ 6 indicated a diagnosis of eosinophilic GPA (EGPA).

RESULTS

The overall reclassification rate of OS-BD-AAV was 8.6%. Of the 280 patients, 16 (5.7%) and 8 (2.9%) were reclassified as having OS-BD-MPA and OS-BD-GPA, respectively; none were classified as having OS-BD-EGPA. ANCA, myeloperoxidase-ANCA (P-ANCA), proteinase 3-ANCA (C-ANCA) positivity, hearing loss, and interstitial lung disease (ILD) at diagnosis were more common in patients with OS-BD-AAV than in those without. ANCA positivity and ILD at BD diagnosis contributed to the reclassification of OS-BD-AAV. However, hearing loss was not considered a major contributor to BD due to its possibility of developing as a manifestation of BD.

CONCLUSION

To our knowledge, this is the first study to demonstrate the reclassification rate (8.6%) of patients with BD and ANCA results at diagnosis as OS-BD-AAV.

Behçet's disease: recurrent ischemic stroke as an initial presentation - a case based review

Behçet's disease (BD) is a rare systemic vasculitis that is characterized by recurrent oral and genital ulcers, uveitis, and skin lesions. Although neurological involvement is a known complication, ischemic stroke remains uncommon. Herein, we report a 37-year-old Kuwaiti woman who experienced recurrent ischemic stroke with no traditional risk factors. Imaging studies, including magnetic resonance imaging and angiography, confirmed the diagnosis of recurrent ischemic stroke and identified the underlying vasculitic changes. A detailed examination revealed a history of recurrent orogenital ulcers, leading to a diagnosis of BD. High-dose corticosteroids, azathioprine, and antiplatelet treatment were effectively used to manage her acute strokes and underlying vasculitis, thus preventing further thrombotic events. Our case report underscores the difficulties of diagnosing BD with ischemic stroke as the initial manifestation and emphasizes the importance of a multidisciplinary approach that involves rheumatologists, neurologists, and radiologists to create an effective treatment plan. Our findings also underscore the need for medical practitioners to be more knowledgeable about ischemic stroke in young patients without risk factors from endemic areas of BD, and to develop effective therapy plans. Our review of the English literature indicates that this is only the fifth report of stroke as the first presentation of BD.

HLA-B*51:01 in Iranian patients with Behcet uveitis syndrome

BACKGROUND

Behcet's disease (BD) is a multisystem disorder prevalent along the historic Silk Road, with Behcet's uveitis (BU) representing a significant complication contributing to disability. Various studies have linked different HLA alleles with BD across diverse populations.

METHODS

In this study, we investigated the association between HLA-B51:01/x and HLA-B27/x genotypes with Behcet's uveitis in 50 unrelated Iranian patients diagnosed with Behcet's uveitis, comparing them to a control group of 70 healthy individuals. Our analysis aimed to determine the susceptibility conferred by these alleles and assess their clinical relevance.

RESULTS

Our findings indicate a notable susceptibility conferred by the HLA-B51:01/x genotype for Behcet's uveitis (P=0.0001). Conversely, the B27/x genotype did not demonstrate significant associations with Behcet's uveitis. Furthermore, we employed prevalence-corrected positive predictive value (PcPPV) calculations to gauge the clinical utility of testing for these alleles within the Iranian Behcet's uveitis patient population. The PcPPV for B27/x genotype testing was determined to be 0.05%, while the PcPPV for B51:01/x genotype testing in the same population was 0.065%. These results suggest that carriers of the B*51:01 allele, when presenting with clinical symptoms, exhibit a heightened risk for Behcet's uveitis compared to the general population.

CONCLUSION

Individuals carrying the B51:01 allele, when symptomatic, face an elevated Behcet's uveitis risk. This insight aids in targeted clinical assessments for at-risk populations.

Approaches based on miRNAs in Behçet's Disease: Unveiling pathogenic mechanisms, diagnostic strategies, and therapeutic applications

Behçet's Disease (BD) is an intricate medical puzzle, captivating researchers with its enigmatic pathogenesis. This complex ailment, distinguished by recurrent mouth and genital lesions, eye irritation, and skin injuries, presents a substantial obstacle to therapeutic research. This review explores the complex interaction of microRNAs (miRNAs) with BD, highlighting their crucial involvement in the disease's pathophysiology. miRNAs, recognized for regulatory influence in diverse biological processes, hold a pivotal position in the molecular mechanisms of autoimmune diseases, such as BD. The exploration begins with examining miRNA biogenic pathways and functions, establishing a foundational understanding of their regulatory mechanisms. Shifting to the molecular landscape governing BD, the review highlights miRNA-mediated impacts on critical signaling pathways like Notch, nuclear factor kappa-light-chain-enhancer of activated B cells (NF-κB), and protein kinase B (AKT)/mammalian target of rapamycin (mTOR), offering insights into intricate pathophysiological mechanisms. Dissecting the immunological landscape reveals the profound influence of miRNAs on BD, shedding light on the intricate modulation of immune responses and offering novel perspectives on disease etiology and progression. Beyond molecular intricacies, the review explores the clinical relevance of miRNAs in BD, emphasizing their potential as diagnostic and prognostic indicators. The discussion extends to the promising realm of miRNA-based therapeutic interventions, highlighting their potential in alleviating symptoms and altering disease progression. This comprehensive review, serving as a valuable resource for researchers, clinicians, and stakeholders, aims to decipher the intricate molecular tapestry of BD and explore the therapeutic potential of miRNAs.

Causal relationship between gut microbiota and Behçet's disease: a Mendelian randomization study

Background

While observational epidemiological studies have suggested an association between gut microbiota and Behçet's disease (BD), the causal relationship between the two remains uncertain.

Methods

Statistical data were obtained from gut microbiome Genome-Wide Association Studies (GWAS) published by the MiBioGen consortium, and genetic variation points were screened as instrumental variables (IV). Mendelian randomization (MR) study was performed using inverse variance weighted (IVW), weighted median, MR-Egger regression, simple mode, and weighted mode methods to evaluate the causal relationship between gut microbiota (18,340 individuals) and BD (317,252 individuals). IVW was the main method of analysis. The stability and reliability of the results were verified using the leave-one-out method, heterogeneity test, and horizontal genetic pleiotropy test. Finally, a reverse MR analysis was performed to explore reverse causality.

Results

Inverse variance weighted (IVW) results showed that the genus Parasutterella (OR = 0.203, 95%CI 0.055-0.747, p = 0.016), Lachnospiraceae NC2004 group (OR = 0.101, 95%CI 0.015-0.666, p = 0.017), Turicibacter (OR = 0.043, 95%CI 0.007-0.273, p = 0.001), and Erysipelatoclostridium (OR = 0.194, 95%CI 0.040-0.926, p = 0.040) were protective factors against BD, while Intestinibacter (OR = 7.589, 95%CI 1.340-42.978, p = 0.022) might be a risk factor for BD.

Conclusion

Our study revealed the causal relationship between gut microbiota and BD. The microbiota that related to BD may become new biomarkers; provide new potential indicators and targets for the prevention and treatment of BD.

Treatment of non-systemic Sjögren's syndrome: Potential prevention of systematization with immunosuppressant agent/biotherapy

Sjögren's syndrome (SS) is a systemic autoimmune pathology manifested mainly by a dry syndrome, intense asthenia and arthromyalgia. Systemic manifestations may also occur. Since 2019, immunosuppressant agents (IS) or biotherapies are recommended only for patients with systemic involvement. However, before 2019, in some cases, paucisymptomatic patients had been treated with IS/biotherapies, often off-label. Objective: We propose to evaluate the benefit and safety of using IS/biotherapy in patients with SS without systemic involvement. Methods: We retrospectively collected the clinical records of all patients with SS diagnosed according to ACR/EULAR diagnostic criteria followed up between January 1980 and October 2023 at Grenoble University Hospital (France). Results: Eighty-three patients were included: 64 with an initially non-systemic form. Of these patients with an initially non-systemic form, 24 were treated with IS/biotherapy. None of them developed secondary systematization, whereas 11 out of 40 patients in the untreated group did (p < 0.05). On the other hand, IS/biotherapy did not appear to improve dry syndrome. There were no serious adverse events. Conclusion: Early introduction of an IS/biotherapy treatment appears to provide a benefit for the patient without side effects.

Novel genetic variants of HLA gene associated with Thai Behcet's disease (BD) patients using next generation sequencing technology

Behçet's disease (BD) manifests as an autoimmune disorder featuring recurrent ulcers and multi-organ involvement, influenced by genetic factors associated with both HLA and non-HLA genes, including TNF-α and ERAP1. The study investigated the susceptible alleles of both Class I and II molecules of the HLA gene in 56 Thai BD patients and 192 healthy controls through next-generation sequencing using a PacBio kit. The study assessed 56 BD patients, primarily females (58.9%), revealing diverse manifestations including ocular (41.1%), vascular (35.7%), skin (55.4%), CNS (5.4%), and GI system (10.7%) involvement. This study found associations between BD and HLA-A*26:01:01 (OR 3.285, 95% CI 1.135-9.504, P-value 0.028), HLA-B*39:01:01 (OR 6.176, 95% CI 1.428-26.712, P-value 0.015), HLA-B*51:01:01 (OR 3.033, 95% CI 1.135-8.103, P-value 0.027), HLA-B*51:01:02 (OR 6.176, 95% CI 1.428-26.712, P-value 0.015), HLA-C*14:02:01 (OR 3.485, 95% CI 1.339-9.065, P-value 0.01), HLA-DRB1*14:54:01 (OR 1.924, 95% CI 1.051-3.522, P-value 0.034), and HLA-DQB1*05:03:01 (OR 3.00, 95% CI 1.323-6.798, P-value 0.008). However, after Bonferroni correction none of these alleles were found to be associated with BD. In haplotype analysis, we found a strong linkage disequilibrium in HLA-B*51:01:01, HLA-C*14:02:01 (P-value 0.0, Pc-value 0.02). Regarding the phenotype, a significant association was found between HLA-DRB1*14:54:01 (OR 11.67, 95% CI 2.86-47.57, P-value 0.001) and BD with ocular involvement, apart from this, no distinct phenotype-HLA association was documented. In summary, our study identifies specific HLA associations in BD. Although limited by a small sample size, we acknowledge the need for further investigation into HLA relationships with CNS, GI, and neurological phenotypes in the Thai population.

An investigation of the relationship between Behçet's disease and tenascin-C

Objectives

The study aimed to investigate serum tenascin-C levels and its relationship with pathogenesis of Behçet's disease (BD) with inflammatory processes.

Patients and methods

This prospective and analytical study included 34 BD patients (19 males, 15 females; mean age: 31.5±8.2 years; range, 18 to 48 years) who met the 2014 International Criteria for Behçet's Disease and had no comorbidities and 37 healthy volunteers (21 females, 16 males; mean age: 29.6±5.3 years; range, 21 to 45 years). Sex, age, age at diagnosis, clinical and laboratory data, medication use, and smoking history of the participants were recorded. Serum tenascin-C levels were measured using a commercially available tenascin-C enzyme-linked immunosorbent assay kit.

Results

There was no significant difference between the groups in terms of age (p=0.262) and sex (p=0.287). Serum tenascin-C levels were significantly lower in the BD group (10,824±7,612 pg/mL) compared to the control group (27,574±14,533 pg/mL, p<0.001). In the receiver operating characteristic analysis performed for the diagnostic value of tenascin-C level in BD, the sensitivity was determined as 79.4% and the specificity as 82.5% (p<0.001). No statistically significant difference was observed in tenascin-C levels in correlation with clinical characteristics, laboratory values, medication use, and smoking in the BD group.

Conclusion

In contrast to other chronic inflammatory diseases, lower levels of tenascin-C were observed in patients with BD than in the healthy individuals, which can be attributed to the absence of prolonged chronic inflammatory course in BD. The fact that tenascin-C levels are high in other rheumatic inflammatory diseases but low in BD may be useful in the differential diagnosis of BD.

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.

The Microbiome and Uveitis: A Narrative Review

The human intestinal microbiome is composed of hundreds of species and has recently been recognized as an important source of immune homeostasis. While dysbiosis, an altered microbiome from the normal core microbiome, has been associated with both intestinal and extraintestinal autoimmune disorders, including uveitis, causality has been difficult to establish. There are four proposed mechanisms of how the gut microbiome may influence the development of uveitis: molecular mimicry, imbalance of regulatory and effector T cells, increased intestinal permeability, and loss of intestinal metabolites. This review summarizes current literature on both animal and human studies that establish the link between dysbiosis and the development of uveitis, as well as provides evidence for the above mechanisms. Current studies provide valuable mechanistic insights as well as identify potential therapeutic targets. However, study limitations and the wide variability in the intestinal microbiome among populations and diseases make a specific targeted therapy difficult to establish. Further longitudinal clinical studies are required to identify any potential therapeutic that targets the intestinal microbiome.

Association between Serum α-Klotho Levels and Behçet Disease

BACKGROUND

Endothelial dysfunction (ED) has a well-known role in promoting vascular inflammation in Behçet disease (BD). α-klotho is involved in regulation of endothelial function, and its reduction has been reported to be associated with ED.

OBJECTIVE

To assess serum α-klotho in patients with BD, compared with healthy control individuals.

METHODS

In a cross-sectional study, 55 patients with BD and 30 age- and sex-matched healthy controls were enrolled, and their serum levels of α-klotho were measured.

RESULTS

Common clinical symptoms in patients with BD were oral aphthous ulcers, uveitis, and genital ulcers. Median (IQR) serum α-klotho levels in the BD and control groups were 0.30 (0.20-0.70) and 1.00 (0.70-2.52) ng/mL, respectively. The difference was statistically significant (P = .005). No significant correlation was observed between serum α-klotho and age (r = 0.194; P = .14). Serum α-klotho levels in patients with uveitis were significantly lower.

CONCLUSION

α-klotho may have a role in the pathogenesis of ED and is a potential biomarker for uveitis in BD.

Pulmonary Arterial Aneurysms and Thrombosis in a Young Male: A Rare Presentation of Behcet's Disease

Behcet's disease (BD) is a chronic systemic inflammatory vasculitis with a relapsing and remitting course. The disease predominantly affects males between the ages of 20 and 40 years. The disease is more prevalent in Middle Eastern and Asian countries but is less common in North American countries. BD typically presents as recurrent oro-genital ulcers and ocular inflammation. Pulmonary vasculitis with pulmonary arterial involvement is a unique manifestation, with most pulmonary manifestations occurring later in the disease course. Here, we report a case with pulmonary arterial aneurysms and variable arterial-venous thrombosis in a young African American Male diagnosed with BD after he presented with pulmonary manifestations. This report emphasizes that a high index of suspicion is needed to diagnose a rare condition with such variable manifestations as Behcet's disease and that early detection and immunosuppression therapy can confer improved prognosis.

Autoimmune Dysphagia Related to Rheumatologic Disorders: A Focused Review on Diagnosis and Treatment

Autoimmune dysphagia is defined as dysphagia caused by autoimmune processes affecting various components of the swallowing process such as muscle, neuromuscular junction, nerves, roots, brainstem, or cortex. These autoimmune causes can be classified into gastroenterological, dermatological, rheumatologic, and neurologic. Rheumatological disorders, such as scleroderma, Sjogren's syndrome, systemic lupus erythematosus, rheumatoid arthritis, sarcoidosis, Behcet's disease, anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis, or granulomatosis with polyangiitis, have been associated with dysphagia. Autoimmune dysphagia in the context of rheumatological disorders is particularly significant because it can occur as a sole manifestation or as part of a symptom complex associated with the underlying disorder and often responds to immunosuppressive therapies. However, diagnosing autoimmune dysphagia can be challenging as it requires the exclusion of structural and primary motility disorders through procedures such as endoscopy and manometry. Early diagnosis is important to improve the quality of life and prevent significant mortality and morbidity. Management focuses on treating the underlying disease activity, and a multidisciplinary approach involving various medical specialties may be necessary to achieve success. This article aims to review the autoimmune rheumatological conditions that can lead to dysphagia and discuss the associated pathophysiological mechanisms. We also outline the clinical clues and laboratory testing methods that facilitate early diagnosis, with the goal of improving patient outcomes through timely intervention and appropriate management.

Successful treatment of a refractory intestinal Behcet's disease with an oncology history by Vedolizumab: a case report and literature review

Objective

Behçet's Disease (BD) is an intractable systemic vasculitis. When accompanied by intestinal symptoms, the prognosis is usually poor. 5-Aminosalicylic acid (5-ASA), corticosteroids, immunosuppressive drugs, and anti-tumor necrosis factor-α (anti-TNF-α) biologics are standard therapies to induce or maintain remission for intestinal BD. However, they might not be effective in refractory cases. Safety should also be considered when patients have an oncology history. Regarding the pathogenesis of intestinal BD and the specific targeting effect of vedolizumab (VDZ) on the inflammation of the ileum tract, previous case reports suggested that VDZ might be a potential treatment for refractory intestinal BD.

Methods

We report a 50-year-old woman patient with intestinal BD who had oral and genital ulcers, joint pain, and intestinal involvement for about 20 years. The patient responds well to anti-TNF-α biologics but not to conventional drugs. However, biologics treatment was discontinued due to the occurrence of colon cancer.

Results

VDZ was intravenously administered at a dose of 300 mg at 0, 2, and 6 weeks and then every eight weeks. At the 6-month follow-up, the patient reported significant improvement in abdominal pain and arthralgia. We observed complete healing of intestinal mucosal ulcers under endoscopy. However, her oral and vulvar ulcers remained unresolved, which disappeared after adding thalidomide.

Conclusion

VDZ may be a safe and effective option for refractory intestinal BD patients who do not respond well to conventional treatments, especially those with an oncology history.

Challenges in the Timely Diagnosis of Behcet's Disease

Behcet's disease (BD) is a chronic, multi-systemic inflammatory disorder mainly characterized by recurrent oral and genital ulcers, skin lesions, and uveitis. As no pathognomonic laboratory test exists for BD, the diagnosis relies solely on clinical features. Over the years, great efforts have been invested in creating clinical diagnostic and classification criteria. The international study group criteria introduced in 1990 were the first true multinational set of criteria. Despite improving the ability to diagnose BD, these criteria still have limitations, including the inability to diagnose patients presenting without oral ulcers or presenting with rare manifestations of the disease. This led to the introduction of the international criteria for BD in 2013, which improved the sensitivity with minimal compromise on specificity. Despite the efforts made and as our understanding of the clinical manifestations of BD and genetic pathogenesis continue to evolve, efforts should be made to further enhance the currently accepted international classification criteria, perhaps by incorporating genetic testing (e.g., family history or HLA typing) as well as ethnic group-specific features.

Utility of neutrophil/albumin ratio and C-reactive protein/albumin ratio as novel inflammatory markers in Behcet's disease

INTRODUCTION AND OBJECTIVES

Behcet's disease (BD) is an autoimmune systemic inflammatory disease, and its exact pathogenesis is unknown. There are currently no specific tests to evaluate the disease activity of BD, making its management more difficult. This study aims to determine the neutrophil/albumin ratio (NAR) and C-reactive protein (CRP) to albumin ratio (CAR) and investigate their associations with clinical findings in patients with BD and to determine optimum cutoff levels of CAR and NAR.

METHODS

The study included 75 consecutively recruited patients with BD with a mean age of 33.29±6.23 years and disease duration of 7.21±4.64 years, as well as 75 healthy participants. Clinical characteristics and laboratory data were obtained. Disease activity was assessed using the BD current activity form score (BDCAF).

RESULTS

NAR and CAR were elevated in patients with BD compared with those of healthy controls (NAR: 1.08±0.34 vs. 0.607±0.06, CAR: 2.49±1.73 vs. 0.39±0.142; p<0.0001), as well as in active BD versus inactive BD. Both NAR and CAR were significantly correlated with CRP, active uveitis, and BDCAF score (p≤0.05). In patients with active BD, the cutoff value of NAR was >0.9744 (sensitivity: 89.74%, specificity: 80.56%), while that of CAR was >2.04 (sensitivity: 74.36%, specificity: 83.33%).

CONCLUSIONS

NAR and CAR are both elevated in patients with BD and may contribute to its active state. NAR and CAR can be feasible and inexpensive markers for predicting BD activity.

The Role of Colchicine in Different Clinical Phenotypes of Behcet Disease

PURPOSE

Behcet disease (BD) is a multisystemic disorder characterized by variable clinical manifestations that affect nearly all systems and organs. Colchicine, an alkaloid plant extract, is considered as the first-line therapy for gout, pericarditis, and familial Mediterranean fever. However, the role of colchicine in the treatment of different clinical phenotypes of BD has not been clearly described. This narrative review summarizes the clinical use of colchicine in BD.

METHODS

All relevant literature from 1980 to March 2021 was searched in PubMed, MEDLINE, and Cochrane Library. The Medical Subject Heading terms and related words that were searched are as follows: Behcet's disease, Behcet's syndrome, BD, colchicine, management, treatment, and therapy.

FINDINGS

BD is an autoimmune systemic vasculitis with various clinical phenotypes, with involvement of skin mucosa, joints, eyes, and gastrointestinal, vascular, and neurologic systems. Colchicine has been used for centuries, acts by binding to tubulin to prevent the mitotic process, and has anti-inflammatory, antitumor, and antifibrotic properties. Colchicine has been reported to be an effective option for the treatment of skin, mucosal, and joint involvement in patients with certain BD clinical phenotypes.

IMPLICATIONS

Colchicine reduces the severity of certain clinical phenotypes and may improve the overall disease activity index in patients with BD. More randomized clinical trials are needed to confirm the value of colchicine in the treatment of BD, and further elucidation of the mechanisms is also needed, which may reveal new application of colchicine that has been used for centuries.

Effects of breast milk on Behçet's disease clinical features

BACKGROUND

The etiology of Behçet's disease (BD) is not clearly known, however, abnormal activity in T helper (Th) 1, Th 17, and regulatory T cells (Treg) has critical importance in pathogenesis. It has been shown that the intestinal microbiome can be effective in the modulation of these immune abnormalities in BD patients. Breastfeeding increases the maturation of the infant's intestinal permeability by affecting the newborn's immature intestinal microbiome and metagenome. We aimed to examine the effects of breastfeeding on disease related symptoms, organ involvements and course of the disease in BD patients.

METHODS

This study was designed as a cross-sectional study in Ankara City Hospital rheumatology clinic between December 2021 and March 2022. Patients who were diagnosed with BD by meeting the criteria of the 'International Study Group' and whose information we could access by agreeing to participate in the study were enrolled. The mothers of the patients were also contacted and asked whether these patients were breastfed, the duration of breastfeeding, and the mode of birth. Demographic and clinical data of the patients, comorbid diseases, and drugs used for BD were collected from the records in the hospital database. The presence of sacroiliitis in patients was evaluated with sacroiliac X-ray and/or magnetic resonance imaging (MRI), which was requested because of low back pain symptoms and only patients with previous sacroiliac imaging for low back pain were included in the study. BD-related organ damage was measured by the Vasculitis Damage Index (VDI) and Behçet's syndrome Overall Damage Index (BODI) scores.

RESULTS

: A total of 304 patients were included in the study. The percentage of patients who were reported to have ever breastfed (median duration (IQR): 12(12) months, 33.5% < 6 months, 66.4% ≥ 6 months, and 59.6% ≥ 12 months) is 92%. When the breastfed and nonbreastfed patients were compared, 6.8% of the breastfed patients needed TNF-i against 18.2% of the nonbreastfed patients (p = 0.052). While the rate of having at least one comorbidity was 26.4% for those who were breastfed, this rate was 50% for those who had never been breastfed. When the organ and system involvements of the patients were compared, the incidence of sacroiliitis was statistically significantly higher in the nonbreastfed group (p = 0.025). Patients who were breastfed for less than 6 months were diagnosed with BD at an earlier age than those who were breastfed for more than 6 months, and those who were breastfed for less than 12 months compared to those who were breastfed for more than 12 months (respectively, p = 0.039, p = 0.035).

DISCUSSION

Our results imply that history of breastfeeding may have some positive effects on the course of the disease in BD patients.

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.

Interleukin 37; a possible marker of arterial stiffness in Behçet's disease

BACKGROUND

Interleukin 37 (IL-37) is an anti-inflammatory cytokine previously studied in Behçet's disease (BD) and atherosclerosis. However, little is known about its relation to macro and microcirculations in BD. Previous studies relied mainly on common carotid artery (CCA) intima-media thickness (IMT) and ankle brachial index (ABI) to study atherosclerosis in BD with conflicting results. This study evaluated flow parameters of CCA, ABI and nailfold videocapillaroscopy in relation to serum IL-37 in BD.

METHODS

Forty BD patients and 30 healthy controls were included. IMT, peak-systolic, end-diastolic velocities, resistivity index of CCA and ABI were measured by duplex ultrasound. Capillary loop, length, diameter and morphology were recorded by nailfold videocapillaroscopy. Serum IL-37 levels were measured using enzyme-linked immunosorbent assay (ELISA).

RESULTS

Compared to controls, patients had higher mean CCA IMT (p < 0.0001), resistivity index (p < 0.001) and peak-systolic velocity (p=0.09) and lower mean CCA end-diastolic velocity (p=0.002), capillary loop, length, arterial, venous limbs diameter and serum IL-37 (p < 0.001). Patients with ABI ≥ 1.4 "indicating stiff arteries" had higher serum IL-37 (p < 0.05 on left, p>0.05 right sides). Serum IL-37 correlated negatively with left CCA end-diastolic velocity "denoting atherosclerosis" and positively with left posterior tibial artery ABI and CRP (p < 0.03) "denoting inflammation". Multiple regression analysis showed only association with left CCA end-diastolic velocity.

CONCLUSIONS

IL-37 may be related to arterial stiffness in BD and could be used as a possible marker of arteriosclerosis in the disease for further investigations. Changes of CCA peak-systolic, end-diastolic velocities, resistivity index and IMT refer to increased atherosclerosis in larger elastic arteries. In smaller muscular "crural" arteries, vasculitis with possible medial disease may be more evident.

Behcet's disease: Diagnosed as isolated recurrent oral aphthae; a case report

Background

Case report

Discussion

Conclusion

•Background: A case of Behcet syndrome presenting initially with isolated oral aphthous.

•

Case Report: A 32-year-old male with recurrent oral aphthous. A complete resolution of the lesions with no reproduction.

•

Conclusion: A case of Behcet's syndrome affected the oral mucosa and later caused uveitis and the genitalia aphthae.

•

Keywords: Oral aphthae, Behcet's Disease, Dapsone treatment .

The pro-inflammatory effect of triglyceride on human CD4+ T cells and experimental autoimmune uveitis

Aberrant lipid metabolism plays a role in inflammation and progression of autoimmune diseases but the definite mechanism remains unclear. In this study we investigate lipidomic profiles in Behçet's disease (BD) and the role of triglyceride (TAG) in the pathogenesis of autoimmune uveitis. Lipidomics revealed a distinct lipid metabolite profile including increased TAG metabolites in plasma of active BD patients. TAG could stimulate the proliferation, IL-17 and IFN-γ expression by CD4⁺ T cells and Th1, Th17 cell differentiation in vitro, but did not influence neutrophils. A922500 inhibited the TAG generation, ameliorated the EAU severity, decreased Th17 frequency and IL-17 expression by CD4⁺ T cells in vivo. The proteomocis analysis showed an up-regulation of apoptosis-related protein, Pik3r2, in CD4⁺ T cells from A922500-treated mice. In conclusion, TAG can stimulate human CD4⁺ T cells and the inhibition of its generation could significantly ameliorate EAU activity in association with down-regulated Th17 cell response.

Selected plasma oxysterols as a potential multi-marker biosignature panel for Behçet's Disease

Clinical, genetic, and medical evidence has shown the inflammatory vasculitis aspect of Behçet's Disease (BD). Whereas oxysterols are vital factors in inflammation and oxidative stress, it is still unknown whether they are involved in the pathophysiology of BD. The current study aims to explore the profile of oxysterols in plasma of BD patients. Thirty patients diagnosed with BD and forty healthy controls matched for age and gender were included. Results showed that the cholestane-3β,5α,6β-triol, 27-hydroxycholesterol (27-OHC) and cholestanol levels were higher in BD than controls. In addition, plasma levels of 7-ketocholesterol (7-KC) and 25-hydroxycholesterol (25-OHC) were lower in BD patient. However, levels of 24S-hydroxycholesterol (24-OHC) did not significantly differ. For BD patients, the plasma 7-KC level was negatively correlated with the BD activity index (BDAI) while 27-OHC was positively correlated with high-sensitivity C-reactive protein (hs-CRP) in patients with active course of the disease. According to ROC analysis, a remarkable increase in the area under the curve (AUC) with a higher sensitivity (Se) and specificity (Sp) for 7-KC, 25-OHC and 27-OHC combined markers was observed. The present study indicated that the identification of the predictive value of these three-selected biomarkers related to oxidative stress and inflammation in patients should lead to a better identification of the etiological mechanism of BD.

Gut microbiome profiles and associated metabolic pathways in patients of adult-onset immunodeficiency with anti-interferon-gamma autoantibodies

Autoantibodies against interferon-gamma (AutoAbs-IFN-γ) can cause the immunodeficiency condition following various opportunistic infections. Gut microbiota can affect the human immune system in many ways. Many studies have shown that gut dysbiosis was associated with some immune diseases, such as autoimmune diseases and human immunodeficiency virus (HIV) infection, while its relationship at anti-IFN-γ AAbs remains unknown. We aimed to identify the anti-IFN-γ AAbs specific microbiome and the possible association with immunodeficiency. We profiled fecal microbiome for two cohorts of forty subjects, including seven patients with anti-IFN-γ AAbs and 33 individuals with competent immune. The study shows that patients with anti-IFN-γ AAbs have characterized the gut microbiome and have lower alpha diversity indexes than healthy controls (HC). There are significant differences in the microbiome structure at both the family and genera level between the two cohorts. The anti-IFN-γ AAbs cohort featured some microbiome such as Clostridium, including the possible opportunistic pathogen and fewer genera including Bacteroides, Ruminococcus, and Faecalibacterium, some of them with possible immune-related genera. The PICRUSt2 pathway demonstrated the decreased abundance of some immune-related pathways and one potential pathway related to the immune alternations in the anti- IFN-γ AAbs cohort. This was the first study to examine the gut microbiome characteristics in patients with anti-IFN-γ AAbs. It could be involved in the pathogenesis of anti-IFN-γ AAbs and contribute to the derived immune condition in this disease. This could lead to new strategies for treating and preventing patients suffering from this disease.

Regulation of NLRP3 inflammasome by zinc supplementation in Behçet's disease patients: A double-blind, randomized placebo-controlled clinical trial

BACKGROUND

Overproduction of NLRP3 inflammasome complex is one of the causes of Behcet's disease's (BD) auto-inflammatory nature. The aim of current study was to examine the effect of zinc supplementation on NLRP3 inflammasome expression; as well as clinical manifestations of BD.

METHODS

In this double-blind parallel placebo-controlled randomized clinical trial, 50 BD patients were randomly allocated into either zinc gluconate (30 mg/day elemental zinc) or placebo groups for 12 weeks. The mRNA expression of NLRP3 and caspase-1 in the leukocytes, serum level of zinc and IL-1β, anthropometric measures, and clinical manifestations of patients were collected at pre- and post-intervention phase. The Iranian Behçet's disease dynamic activity measure (IBDDAM) was scored to measure the treatment effect using the calculation of number needed to treat (NNT). Analysis of covariance was performed to obtain the corresponding effect sizes.

RESULTS

Zinc gluconate led to a significant improvement in genital ulcer (P = 0.019). Zinc supplementation decreased NLRP3 and caspase-1 genes expression compared with placebo group (baseline-adjusted P-value = 0.046 for NLRP3 and P-value = 0.003 for caspase-1), even after adjustment for the effect of confounding factors (baseline- and confounders-adjusted P-value = 0.032 for NLRP3 and P-value = 0.004 for caspase-1). Baseline and confounders adjusted effect size demonstrated that zinc was effective in reducing the serum level of IL-1β (P = 0.046). The NNT [95 %CI] for the rate of IBDDAM improvement was 3 [1.7-8.5].

CONCLUSIONS

Zinc gluconate supplementation (30 mg/day) for a 3-month period can be considered as an adjuvant therapy in alleviating inflammation and genital ulcer among BD patients.

Clinical Features of Aortitis with Gastrointestinal Involvement

Few vascultides have a predilection for the aorta. Among those are Takayasu arteritis, Behcet's disease, giant cell arteritis, and infectious aortitis. Diagnosis of aortitis requires a high index of suspicion since clinical features are atypical and nonspecific. However, many patients present with gastrointestinal manifestations owing to mesenteric involvement, intestinal infarction, and hepatitis. The most common vascultides that involve the aorta are Takayasu arteritis, Behcet's disease, giant cell arteritis, and infectious arteritis. Herewith, we review the literature on epidemiology, gastrointestinal manifestations, and management of each form of aortitis that affects the gastrointestinal tract.

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.

Expression of lncRNAs NEAT1 and lnc-DC in Serum From Patients With Behçet’s Disease Can Be Used as Predictors of Disease

Background: Behçet’s disease (BD) is a chronic autoimmune disease. The early diagnosis of BD is very important to avoid serious and/or fatal complications such as eye damage, severe neurological involvement, and large vessel occlusion. New, sensitive biomarkers would aid in rapid diagnosis, the monitoring of disease activity, and the response to treatment.

Methods: This study’s aim is to identify two immune system-related BD biomarkers. We measured long non-coding RNAs (lncRNAs) NEAT1 (nuclear-enriched abundant transcript 1), and lnc-DC (lncRNA in dendritic cells) in serum by real-time polymerase chain reaction (RT-PCR) in 52 BD patients and 52 controls. We analyzed the association between NEAT1 and lnc-DC and the clinical parameters of BD. Receiver operating characteristic (ROC) curve analysis was performed to explore the diagnostic performance of the studied genes.

Results: Compared to controls, the significant upregulation of NEAT1 {median [interquartile range (IQR)] = 1.68 (0.38–7.7), p < 0.0001} and downregulation of lnc-DC [median (IQR) = 0.2 (0.12–1.39), p = 0.03] were detected in the sera collected from BD patients. Higher serum expression levels of NEAT1 and lnc-DC were significantly associated with the following clinical presentations: cutaneous lesions, vascular manifestations, articular manifestations, neurological manifestations, and higher disease activity score. Also, high NEAT1 levels were significantly associated with a negative pathergy test, while higher lnc-DC was significantly associated with a positive family history. ROC curves showed that NEAT1 and lnc-DC levels in serum could be used as predictors of BD with high specificity and fair sensitivity. NEAT1 had an area under the curve (AUC) of 0.692 (95% CI: 0.591–0.794, p = 0.001), and lnc-DC had an AUC of 0.615 (95% CI: 0.508–0.723, p = 0.043).

Conclusion: Serum lncRNAs NEAT1 and lnc-DC are biomarkers for BD.

Cadherin Signaling in Cancer and Autoimmune Diseases

Cadherins mediate cell–cell adhesion through a dynamic process that is strongly dependent on the cellular context and signaling. Cadherin regulation reflects the interplay between fundamental cellular processes, including morphogenesis, proliferation, programmed cell death, surface organization of receptors, cytoskeletal organization, and cell trafficking. The variety of molecular mechanisms and cellular functions regulated by cadherins suggests that we have only scratched the surface in terms of clarifying the functions mediated by these versatile proteins. Altered cadherins expression is closely connected with tumorigenesis, epithelial–mesenchymal transition (EMT)-dependent fibrosis, and autoimmunity. We review the current understanding of how cadherins contribute to human health and disease, considering the mechanisms of cadherin involvement in diseases progression, as well as the clinical significance of cadherins as therapeutic targets.

Epigenetic Modifications and Therapy in Uveitis

Uveitis is a sight-threatening intraocular inflammation, and the exact pathogenesis of uveitis is not yet clear. Recent studies, including multiple genome-wide association studies (GWASs), have identified genetic variations associated with the onset and progression of different types of uveitis, such as Vogt–Koyanagi–Harada (VKH) disease and Behcet’s disease (BD). However, epigenetic regulation has been shown to play key roles in the immunoregulation of uveitis, and epigenetic therapies are promising treatments for intraocular inflammation. In this review, we summarize recent advances in identifying epigenetic programs that cooperate with the physiology of intraocular immune responses and the pathology of intraocular inflammation. These attempts to understand the epigenetic mechanisms of uveitis may provide hope for the future development of epigenetic therapies for these devastating intraocular inflammatory conditions.

Serum Levels of Interleukin-36 Alpha and Interleukin-36 Receptor Antagonist In Behcet’s Syndrome

Background Behcet’s syndrome (BS) is a systemic vasculitic disorder. This study aimed to investigate the levels of serum IL-36α and IL-36Ra in patients with BS.

Material and Methods A total of 80 subjects (60 BS patients and 20 healthy controls [HC]) were included.

Results The median IL-36α level was 0.11 ng/ml in the BS group and 0.09 ng/ml in the HC group (p=0.058). The mean IL-36Ra level was 13.62 pg/ml in the BS group and 13.26 pg/ml in the HC group (p=0.348). Serum IL-36Ra levels of the active group were significantly higher (p=0.037). Patients with oral ulcers and central nervous system involvement had higher serum IL36Ra levels. In the BS group, a positive correlation was found between serum IL-36Ra and CRP. In a multivariate analysis, the IL-36Ra level (OR=1.067; 95% CI=1.001–1.137; p=0.045) was independently associated with disease activity.

Conclusion According to these findings, it is not clear whether such a slight difference is clinically significant, but they suggest that the IL-36 cytokine family may play a role in the course of the disease.

Clinical Effect of Non-Thermal CO2 Laser Therapy (NTCLT) on Pain Relief of Oral Aphthous Ulcers of Behçet's Disease

Introduction: Behçet's disease (BD) is a debilitating and chronic vasculitis which can affect multiple organs. Recurrent oral aphthosis is the most common clinical feature of BD. The remarkable pain associated with painful oral ulcers can exert a major impact on the patients' quality of life. Relieving pain of these oral ulcers is an essential approach in the management of mucocutaneous lesions of BD. Non-thermal CO2 laser therapy (NTCLT) as a novel photobiomodulative approach has recently been used for significant and immediate pain reduction of some types of painful oral lesions such as recurrent aphthous stomatitis, pemphigus vulgaris, and so on. In this procedure by some considerations, the conventional CO2 laser is used as a non-surgical, non- thermal, photobiomodulative laser without any visible thermal adverse effects. In this article, we report our experiences about the analgesic effects of NTCLT on painful oral aphthous ulcers of BD. Case Presentation: We report four cases of BD, whose painful oral aphthous ulcers were irradiated with NTCLT. Immediately after NTCLT, the pain of the lesions was significantly relieved with no visible complications. Conclusion: The results of this study suggest that NTCLT could be proposed as a hopeful procedure for significant and instant pain relief of oral aphthous ulcers of BD without any visible thermal adverse effects.

Behcet's disease in an adult male from Nepal: A case report

This case report highlights considering Behcet's disease as a diagnosis in orogenital ulcers and uveitis, although its prevalence is unknown in Nepal due to underreporting. Also, collaboration for patient care among relevant specialties is required.

Changes in the Gut Microbiome Contribute to the Development of Behcet's Disease via Adjuvant Effects

Behcet’s disease (BD) is associated with considerable gut microbiome changes. However, it still remains unknown how the composition of the gut microbiome exactly affects the development of this disease. In this study, transplantation of stool samples from patients with active ocular BD to mice via oral gavage was performed. This resulted in decreases of three short chain fatty acids (SCFAs) including butyric acid, propionic acid and valeric acid in the feces of the BD-recipient group. Intestinal barrier integrity of mice receiving BD feces was damaged as shown by a decreased expression of tight junction proteins and was associated with the release of Lipopolysaccharides (LPS) in the circulation. The mice also showed a higher frequency of splenic neutrophils as well as an enrichment of genes associated with innate immune responses in the neutrophils and CD4 + T cells as identified by single cell RNA sequencing. Analysis of neutrophils and T cells functions in these mice showed an enhanced mesenteric lymph node and splenic Th1 and Th17 cell differentiation in association with activation of neutrophils. Transplantation of BD feces to mice and subsequent induction of experimental uveitis (EAU) or encephalomyelitis (EAE) led to an exacerbation of disease in both models, suggesting a microbial adjuvant effect. These findings suggest that the gut microbiome may regulate an autoimmune response via adjuvant effects including increased gut permeability and enhancement of innate immunity.

Behçet's Disease in a Polish Patient: A Case Report

Behçet's disease (BD) is a systemic autoinflammatory vasculitis. It occurs predominantly in Turkey but very rarely in Europe. The clinical manifestations of BD involve the skin and mucosal membranes; cardiovascular, gastrointestinal and nervous systems; and the eyes and joints. A 26-year-old man was repeatedly hospitalized at the Department of Dermatology of the Medical University of Bialystok. He had a family history of family members' deaths from unknown cause and a long personal history of recurring headaches and nonspecific pain in the chest as well as a 2-year history of recurring painful erosions on the oral mucosa. Recently, before admission to hospital, another erosion had appeared on the scrotum, which rapidly evolved into a painful ulceration. The patient also presented a large erosion in the area of the right hip and acne lesions. He consulted doctors of different specialties and underwent laboratory and imaging tests. Considering the symptoms, BD was diagnosed. Azathioprine was introduced, along with topical treatment. Great improvement of the skin lesions was achieved. He was later admitted to the department a few times for follow-up visits and remains in good general condition. BD is an extremely rare disease in Europe, especially in Poland. The fact that BD is a rare disease outside Asia leads to lower awareness and the possibility of not considering it in the differential diagnosis. The great diversity of symptoms also causes difficulties in tracking this disease. The various manifestations of BD require a broad spectrum of additional tests and an interdisciplinary approach to the patient.

Lesional activation of Tc 17 cells in Behçet's disease and psoriasis supports HLA-class I-mediated autoimmune responses

BACKGROUND

Behçet's disease (BD) presents with lymphocytic and neutrophilic vasculitis of unknown aetiology. HLA-B*51 ERAP1 and IL12R/IL23R are genetic risk factors. IL-23 regulates IL-17A, which controls recruitment and activation of neutrophils.

OBJECTIVES

To determine pathological changes in BD skin lesions related to the complex genetic predisposition METHODS: We characterised the expression of IL-17A and IL-23A in various cell types by immunohistological double staining of sections from papulopustular skin lesions (PPL) of acute attacks of BD and lesions of psoriasis vulgaris (PV), another HLA-class I-associated T-cell mediated autoimmune disease in which excessive T-cell derived IL-17A production promotes neutrophil activation.

RESULTS

We found that in BD lesions, as in psoriasis, actively expanding CD8⁺ T cells were the predominant source of IL-17A. IL-17A⁺ CD8⁺ T (Tc17) cells outnumbered infiltrating IL-17A⁺ CD4⁺ T cells. Unlike the epidermal localisation of CD8⁺ T cells in psoriasis, Tc17 cells in BD lesions infiltrated mainly the perivascular tissue and also the blood vessel walls of dermis and subcutaneous tissue. They colocalised with a marked IL-23A expression by CD11c⁺ dendritic cells (DCs) and CD68⁺ macrophages. IL-17A expression was associated with extensive recruitment of neutrophils around blood vessels that formed neutrophil extracellular traps (NETs).

CONCLUSIONS

In BD, the genetic predisposition may mediate antigen-specific activation and differentiation of a T_c 17 response, possibly targeting endothelial antigens. Neutrophils recruited by IL-17A in this process may enhance tissue damage by extensive NET formation (NETosis). Thus, the IL-23/IL-17 axis presumably controls neutrophilic inflammation in BD vasculitis in the context of a predominant antigen-specific CD8⁺ T-cell response.

Coronary Vasculitis

The term coronary “artery vasculitis” is used for a diverse group of diseases with a wide spectrum of manifestations and severity. Clinical manifestations may include pericarditis or myocarditis due to involvement of the coronary microvasculature, stenosis, aneurysm, or spontaneous dissection of large coronaries, or vascular thrombosis. As compared to common atherosclerosis, patients with coronary artery vasculitis are younger and often have a more rapid disease progression. Several clinical entities have been associated with coronary artery vasculitis, including Kawasaki’s disease, Takayasu’s arteritis, polyarteritis nodosa, ANCA-associated vasculitis, giant-cell arteritis, and more recently a Kawasaki-like syndrome associated with SARS-COV-2 infection. This review will provide a short description of these conditions, their diagnosis and therapy for use by the practicing cardiologist.

Somatic symptoms with psychogenic or psychiatric background: Characteristics and pitfalls

Introduction:

The characteristics of somatic symptoms seen at the first hospital visit in patients with psychogenic backgrounds remain poorly elucidated till date.

Methodology:

A total of 277 patients who visited the Department of General Medicine at a single university hospital with somatic symptoms were prospectively enrolled in this study. The eventual definite diagnoses were classified into the following three groups: non-psychogenic disease (n = 128), psychogenic symptoms (n = 131), and mental illness (n = 18). Subsequently, the chief complaints and other background information of the patient obtained at the first visit were compared among the three groups.

Results:

More than half of the patient with non-psychogenic diseases (60.2%) presented with a single complaint at their first hospital visit; contrarily, less than half of the patients with psychogenic symptoms (23.7%) or mental illnesses (22.2%) presented with a single complaint at the first visit. Approximately, <10% of the patients with non-psychogenic diseases had four or more multisystemic presentations at the first visit. The results of the receiver operating characteristic curve analysis revealed a fair discriminatory ability of the number of complaints to identify patients with psychogenic diseases or psychiatric backgrounds. Almost half of the non-psychogenic patients with four or more multisystemic presentations were eventually diagnosed with autoimmune-related disorders, such as Sjögren's syndrome or Behçet's disease. In conclusion, the general notion that patients with psychogenic somatic symptoms are likely to present with more complaints than patients with non-psychogenic diseases is correct. However, not a few patients who present with multiple indefinite complaints would certainly have organic diseases such as autoimmune-related disorders or neuromuscular diseases. A careful diagnostic process is required in such patients before attributing their symptoms to psychogenic or psychiatric factors.

An association study between FokI, BsmI, miR-146a, and miR-155 and Behcet’s disease in the Egyptian population

Background

Behcet’s disease (BD) is a systemic inflammatory disease of the blood vessels and affects various body parts. This study aimed to determine the association of four single-nucleotide polymorphisms (SNPs) and BD in the Egyptian population using multiple statistical models and show the resulting associations along with previous studies of different populations. Four SNPs were examined for their association with BD: two SNPs from vitamin D receptor gene (FokI and BsmI) were selected and the other two were selected from miR-146a and miR-155. These four SNPs were selected for their association and role with BD in different populations and in the immune system. A marker check was conducted using the Hardy-Weinberg equilibrium and minor allele frequency. The associations were tested using four different statistical models: multiplicative, dominant, recessive, and codominant models. All statistical models used the odd’s ratio (OR) with confidence interval (CI) of 95% to evaluate the association of each SNP.

Results

BsmI showed association using the four models, while FokI did not show any association through any model. miR-155 showed association using the multiplicative and recessive models. miR-146a showed association using the multiplicative model only.

Conclusions

As a result, BsmI, miR-155, and miR-146a SNPs could have a role in the development of BD in the Egyptian population, while FokI could have a weak role, if any, in the development of BD in the Egyptian population.

Association between metabolic syndrome and Behçet's disease: A nationwide population-based study

Metabolic syndrome (MetS) is characterized by insulin resistance, high blood pressure/sugar, dyslipidemia, and obesity. Whether MetS and its components affect the development of Behçet's disease (BD) remains unclear. This study was performed to investigate the associations between metabolic syndrome and risk of BD using nationwide population data. We conducted a retrospective cohort study of 10 505 818 Korean subjects who received health checkups in 2009-2012. Patients were classified into a MetS and its components group and were followed-up until 2016 for new-onset BD. A Cox proportional hazards model was used to assess the independent or synergistic effects of MetS and its components on the risk of incident BD. Compared to subjects without MetS components, the hazard ratio (HR) for development of BD in patients with MetS was 0.874 (95% confidence interval [CI]: 0.819-0.933) and this association was more prominent when all components of MetS were present (HR = 0.675, 95% CI = 0.571-0.798). Subjects with low high density lipoprotein (HDL) has a significantly increased risk of the development of BD (HR = 1.51, 95% CI = 1.4-1.594) compared to controls. This study showed that the incidence of Behçet's disease was reduced in subjects with MetS. Moreover, the presence of MetS components, with the exception of HDL, was negatively related to the development of BD.

Behcet's Syndrome resembling complex perianal Crohn's Disease

Behcet’s syndrome is a systemic inflammatory disorder that involves several organ systems and is exceptionally rare in the Western world. The diagnosis is frequently difficult as it resembles several other disease processes. A 23-year-old male with a previous presumptive diagnosis of Crohn’s disease presented to our unit with genital ulceration. This is on a background of recurrent perianal abscesses requiring surgical drainage and seton placement. He subsequently developed a complex perianal fistula extending from the rectum to the perineum and left groin. After drainage and an unsuccessful trial of biologic immunosuppressive therapy, he developed several papulopustular cutaneous lesions and oral ulcerations. The diagnostic criteria for Behcet’s syndrome was met and he was referred to a rheumatologist for ongoing management.

Inflammatory status might direct ILC and NK cells to IL-17 expressing ILC3 and NK subsets in Behcet's disease

Innate lymphoid cells (ILCs) are lymphoid cells that have important effector and regulatory functions in innate immunity and tissue remodeling. Uncontrolled activation and proliferation of ILCs can contribute to inflammatory autoimmune diseases. Behcet's disease (BD) is a complex systemic inflammatory disorder of unknown etiology. It has been shown that natural killer (NK) cells may play an immunoregulatory role in BD, however the role of ILCs is unknown. In this study, the levels and functions of ILCs and NK cell subsets in BD patients were investigated. Cell surface and cytotoxic granules (perforin and granzyme) expression of NK cells and ILCs were evaluated and labeled according to whole blood lysing protocol in peripheral blood samples obtained from the patients and healthy subjects. Cytokine levels of NK cells were investigated in stimulated peripheral blood mononuclear cells. All data were analyzed by flow cytometry. Total ILC and ILC3⁺ cells were increased in active BD patients compared to inactive BD patients and healthy subjects. There was no significant difference between the patients and healthy subjects regarding NK cell surface and intracellular molecule expression. Although, an increase in IFN-γ and IL-17, and a decrease in IL-4 levels were observed in CD56^dim NK cell subset of BD patients. Recent studies showed increased neutrophilic infiltration and IL-17 secreting Th17 cells in BD patients. It is known that ILC3⁺cells are similar to Th17 subset regarding their cytokine profile and transcription factor expression patterns. Results of current study may suggest that inflammatory microenvironment in BD patients might direct ILC cells to differentiate into ILC3⁺ subset, and IL-17 released by NK cells might have a role in neutrophilic infiltration.

Case Report: Repeated Low-Dose Rituximab Treatment Is Effective in Relapsing Neuro Behçet's Disease

Neuro Behçet's disease (NBD) is a rare but most aggressive manifestation of Behçet's disease (BD) with a poor prognosis, and some patients even present a relapsing and treatment-resistant progressive course. In some relapsing NBD cases, traditional corticosteroids and immunosuppressive drugs show limited efficacy, while benefits of biological agents, such as anti-B-lymphocyte CD20 biological agent rituximab (RTX), gradually represent potential therapeutic advantages with clinical rapid remission and long-time maintenance. However, up to now, the optimal dosage of RTX in NBD is still elucidated. Here, we report two patients with relapsing NBD, despite continuous high dose steroids and sufficient azathioprine treatment, still presenting severe and relapsing meningoencephalitis or brainstem involvement. Repeated low-dose RTX (100 mg × 3/1 week apart, 100 mg repeated every 6 months) is then attempted with rapid recovery and sustained remission. The approach in our cases may expand therapeutic options and provide helpful references for relapsing NBD treatment.