Pathological haemostasis and "prothrombotic state" in Behçet's disease

Computed tomography imaging-based radiologic evaluation of pulmonary artery thrombosis in a series of patients with Behcet's disease

AIM

Pulmonary artery involvement is a severe complication of Behcet's disease (BD). Although venous thrombosis is common in BD, pulmonary embolism is considered to be rare because the inflammatory nature makes the thrombi strongly adherent to the venous walls. This study aimed to define the radiological characteristics of pulmonary artery thrombosis (PAT) on computed tomography (CT) imaging in BD patients.

METHODS

We retrospectively evaluated 165 BD patients with vascular involvement. Among the patients with venous involvement (n = 146), we identified 65 patients who had undergone thorax CT imaging previously. Fourteen patients who were diagnosed with PAT were included in the study. Expert radiologists re-evaluated the patients' initial and control thorax CT scans, classified the PAT as acute or chronic based on their radiological features.

RESULTS

The patients' median age was 35 (min-max: 15-60) years at the time of the initial CT scan, and nine were male. Twelve (85.7%) patients were symptomatic at the time of CT evaluation. Upon re-evaluating the thorax CTs, acute PAT was diagnosed in six (42.8%); chronic PAT was detected in eight (57.1%) patients. Two patients with chronic PAT also had acute PAT. Pulmonary artery aneurysms were present in three (21.4%) patients, and intracardiac thrombus was found in three (21.4%) patients.

CONCLUSION

A significant number of BD patients with venous involvement had radiological findings consistent with acute PAT potentially due to pulmonary emboli in this study. The clinical importance of these lesions has to be defined with future studies.

Thrombosis in vasculitis: An updated review of etiology, pathophysiology, and treatment

Introduction

Thromboembolic disease is a complication of many vasculitides. A common observation is that thromboembolic events coincide with the period of vasculitic disease, but the mechanism by which this occurs remains unclear. Inflammatory thrombosis is now recognized as a symptom of arteritis rheumatic, and vasculitides such as Behçet's syndrome (BS), and anti-neutrophil cytoplasmic antibodies (ANCA)-associated vasculitis (AAV) or giant cell arteritis (GCA). This systematic review aimed to explain recent findings related to etiology, pathophysiology, and treatment methods for BS, AAV, and medium/large-vessel vasculitis.

Methods

A comprehensive literature search on English sources from PubMed, Scopus, MEDLINE, Science Direct, ProQuest, AIM, CINAHIL, and ELDIS databases was used to find the relevant articles and reports. The relevant papers (having full text) were obtained until June 2023. Two independent reviewers screened the titles and abstracts of the obtained articles, and a third arbitrator resolved disputes between the reviewers.

Results and conclusion

It is becoming increasingly clear that certain systemic inflammatory diseases, like vasculitis, are linked to a higher risk of both venous and arterial thrombosis. An increased incidence of thromboembolic disease in AAV has been noted, particularly during times of active disease. Growing evidence supports the use of immunosuppression in the management of venous thrombosis in vasculitis. These patients also have a higher risk of developing ischemic disease.

Oral Lesions as the Primary Manifestations of Behçet's Disease: The Importance of Interdisciplinary Diagnostics-A Case Report

BACKGROUND

Behçet's disease (BD) is a rare chronic auto-inflammatory systemic disease with non-specific oral manifestations, categorised as generalised variable vessel vasculitis that requires an interdisciplinary approach to diagnose due to its phenotypic heterogeneity. Whilst the oral lesions that reoccur in BD underpin the complex diagnostic process, the crucial role of dental professionals is highlighted in a case report summarised herein. We present a case of a 47-year-old male referred to the Oral Medicine Department by a rheumatologist after previous hospitalization for thrombosis of the iliac vein and inferior vena cava. He had elevated inflammatory C-reactive protein biomarker and an increased erythrocyte sedimentation rate. Recurrent episodes of folliculitis, oral and genital ulcers were reported. Clinical examination revealed multiple ulcerations in the oral mucosa. The complementary, histopathological analysis performed to rule out other disorders, based on excisional biopsy, showed non-keratinised stratified squamous epithelium with areas of exocytosis and ulceration. The connective tissue presented an intense mixed inflammatory infiltrate, congested blood vessels, haemorrhage, vasculitis, and HLA-B genotyping identified the expression of HLA-B15, further supporting the BD diagnosis. Treatment was initiated with colchicine, prednisolone, and weekly subcutaneous administration of methotrexate and resulted in the complete remission of oral lesions and no recurrence of other manifestations.

CONCLUSIONS

This BD case report emphasizes the importance of a multidisciplinary approach in diagnosing BD, including the use of histopathological assessment and genetic profiling. It highlights the significance of thorough intraoral assessment and referral to a multidisciplinary team for diagnosis. The oral manifestations of BD as the primary symptoms often indicate underlying major systemic pathologies. The authors stress the need for a structured diagnostic algorithm to facilitate timely and effective management of BD.

Lesion probability map in cerebral vein thrombosis due to Behçet's disease

AIM

Behçet's disease (BD) is a multisystemic inflammatory disease. Cerebral venous sinus thrombosis (CVST) is the second most common form of neuro-BD after parenchymal central nervous system involvement. The purpose of this study was to construct flow-void probability maps of patients with CVST with and without BD to visually illustrate the impacted cerebral venous sinuses, to compare the subgroups of patients, and investigate the effect of thrombus localization on clinical findings.

METHODS

Seventeen patients with a diagnosis of BD-related CVST (CVST-BD) and 23 patients with a diagnosis of CVST related to other etiologies (CVST-O) were included. We collected data including gender, age at onset of BD and CVST, presenting symptoms, neurological findings, and the etiology. High-resolution magnetic resonance venographies obtained during CVST were used to mark and digitalize thrombosed areas. Thrombus probability and subtraction maps were created to reveal the differences between the subgroups.

RESULTS

Remarkably, all patients with CVST-BD had thrombosis in the transverse sinus (TS). However, TS was affected in 73.9% of the CVST-O patients (17/17 in CVST-BD vs 17/23 in CVST-O, P = .03). Thrombosis developed mostly in the superior sagittal sinus (SSS) and TS in the CVST-O group (11/23, 47.8% and 17/23, 73.9%, respectively). The frequency of SSS thrombosis tended to be higher in the CVST-O (47.8% vs 23.5%, P = .19).

CONCLUSION

Venous infarction and hemorrhage were less common in patients with CVST-BD. The only clinical symptom in most of the CSVT patients with BD was headache due to elevated intracranial pressure. TS thrombosis was more common in patients with BD.

Adamantiades-Behçet disease: from clinical heterogeneity to diagnosis during the COVID-19 pandemic

Adamantiades-Behçet Disease (ABD) is a systemic disease with vasculitis, characterised by recurrent oral aphthosis and ocular, cutaneous, articular, vascular, cardiopulmonary manifestations and it is mainly found in the territories of the antique "silk road. ABD pathogenesis remains unknown although genetic, infectious and environmental factors seem to be implicated in the development of the disease, which is considered an auto-inflammatory condition. COVID-19 infection can present some symptoms, in particular at the level of oral and pulmonary mucosa, which require a differential diagnosis with ABD. Furthermore, the immunological alterations of this disease, and the drugs used for its treatment could influence the infection by COVID-19, and its clinical evolution. Nevertheless, vaccination anti-COVID-19 is recommended in ABD patients. The most commonly used diagnostic criteria for ABD are those established in 2014 by the International Team for the Revision of the International Criteria for BD (ITR-ICBD). Furthermore, criteria for disease severity according to the Overall Damage Index of Behçet's syndrome (BODI) have recently been proposed in order to quantify the severity of the disease as well as the evolution during follow-up. In ABD patients it is mandatory to investigate on the presence of active/latent tuberculosis, because of the common organ involvement, such as eyes and bowel. ABD has a high morbidity and low mortality, sometimes linked to the rupture of an arterial aneurysm and/or neurological complications. This article is based on a general review on ABD ranging from the history of ABD to possible causes and clinical manifestations. A specific section has been dedicated to the COVID-19 pandemic.

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.

Two Cases of Vasculitis with Renal Vein Thrombosis

We present a series of two cases of ANCA associated Vasculitis (AAV) presenting as Pulmonary Renal syndrome with associated renal vein thrombosis. Although there are enough evidences suggesting association of venous thrombosis with AAVs, the incidence of renal vein thrombosis is rare. Renal vein thrombosis should be ruled out in cases where there is delay in recovery of renal function in patients with AAV. Positive laboratory values for anti-Proteinase-3 (PR3) and anti-Myeloperoxidase (MPO) ANCA in the cases that presented as Rapidly Progressive Glomerulonephritis, helped in early initiation of treatment with complete recovery of Renal function.

Immunopathogenesis of Behçet Disease

BACKGROUND

Behçet's Disease (BD, OMIM 109650) is a chronic relapsing inflammatory disease of unknown etiology with unpredictable exacerbations and remissions. First described in 1937 by the Turkish dermatologist HulusiBehçet, as a trisympton complex (oral and genital ulcers and uveitis), it is now recognized as a multisystemic disease. The syndrome can manifest in diverse ways and can involve nearly every organ system. Several studies have implicated T cells and monocytes in the pathogenesis of BD especially when these cells are stimulated by heat shock proteins and streptococcal antigen. This article presents a review of the relevant published literature about the immunopathogenesis of BD.

RESULT

The authors used MeSH terms "Behçet's disease" with "pathophysiology," "pathogenesis," "genetic", "epigenetic", "immunogenetic" or "immune response" to search the PubMed database. All the relevant studies identified were included.

Genetics and Epigenetics Mechanism in the Pathogenesis of Behçet's Disease

BACKGROUND

Behçet's Disease (BD) is characterized by numerous systemic manifestations and is known for its ability to affect both, arteries and the veins. However, the etiology of BD is only partially understood, and previous studies have demonstrated a role for genetic and epigenetic factors that contribute to disease pathophysiology. Several studies have implicated T cells and monocytes in the pathogenesis of BD especially when these cells are stimulated by heat shock proteins and streptococcal antigen. Furthermore, during disease exacerbations adenosine deaminase has an important role in activating lymphocyte proliferation, maturation, and differentiation in BD. This article presents a review of the published literature mainly from the last 20 years. The topics of main concern were the role of genetic and epigenetic factors as contributing factors in disease pathophysiology.

RESULT AND CONCLUSION

The authors used MeSH terms "Behçet's disease" with "pathophysiology," "pathogenesis," "genetic" or "epigenetic" to search the PubMed database. All the relevant studies identified were included and are described according to the aforementioned subheadings.

Diagnostic Value of Neutrophil-Lymphocyte Ratios and Mean Platelet Volumes in the Activation of Recurrent Aphthous Stomatitis

Recurrent aphthous stomatitis (RAS) is associated with endothelial dysfunction and chronic inflammation. The neutrophil-to-lymphocyte ratio (NLR) and mean platelet voume (MPV) are markers of inflammation and endothelial dysfunction, respectively. In the present report, we discuss the NLR and MPV values of patients with active and inactive RAS. In total, 42 patients (24 females and 18 males) with inactive RAS, 19 patients (12 females and 7 males) with active RAS and 40 healthy controls (24 females and 16 males) were enrolled. MPVs were measured and NLRs calculated. We sought correlations among the MPV and NLR findings in the active and inactive RAS groups and compared them with those of healthy controls. The MPV and NLR values were significantly higher in patients with active than inactive RAS (MPV, 10.6 ± 2.9 vs. 7.1 ± 2.4 fL, p < 0.001; NLR, 3.74 ± 1.9 vs. 2.1 ± 1.43, p = 0.015). In addition, both MPV and NLR values in patients with inactive RAS didn't differ significantly compared to values observed in the controls (MPV, 7.1 ± 2.4 vs. 6.9 ± 2.1 fL, p = 0.126; NLR, 2.1 ± 1.43 vs. 2.07 ± 0.96, p = 0.525). Both the NLR and MPV were significantly higher in patients with active RAS, emphasising the importance of inflammation and endothelial dysfunction in the pathophysiology of RAS activation.

Diffuse connective tissue disorders in HIV-infected patients

Background:

Human immunodeficiency virus (HIV) infection has been associated with various autoimmune disorders.

Aim:

To review the spectrum of diffuse connective tissue disorders (dCTD) in HIV-infected patients, in the context of highly active anti-retroviral therapy.

Methods:

Electronic search of the literature was performed using the terms HIV, AIDS, autoimmune, rheumatic/rheumatological, immune reconstitution inflammatory syndrome, Systemic Lupus Erythematosus, Diffuse Infiltrative Lymphocytosis Syndrome, Sjogren’s syndrome, vasculitis, Behçet’s disease, cryoglobulins, Henoch-Schönlein purpura, and antiphospholipid syndrome.

Results:

We reviewed the clinical manifestations, natural history and treatment of dCTDs, since the implementation of Highly Active Anti-Retroviral Therapy (HAART), and the emergence of new pathogenic mechanisms, such as the immune reconstitution inflammatory syndrome.

Conclusions:

Caution in differentiating clinical and laboratory findings of dCTDs from non-specific manifestations of acute and chronic HIV infection is warranted due to the common presentation. Patients with chronic infection and access to HAART have a normal life expectancy and dCTDs, although rare, must be correctly addressed. HAART alone or combined with immunosuppressive therapy result in favourable outcomes.

Increased Arterial Stiffness in Behçet's Disease: a Systematic Review and Meta-Analysis

Background and Objectives

Behçet's disease (BD) is a systemic vasculitis that is characterized by genital, oral, or skin lesions, uveitis, and vascular complications. Studies have shown that increased arterial stiffness is common in systemic immune and inflammatory diseases such as rheumatoid arthritis and systemic lupus erythematosus. However, current research has not yet determined whether patients with BD have increased arterial stiffness. This meta-analysis compares arterial stiffness parameters in subjects with a BD diagnosis to normal subjects.

Subjects and Methods

A comprehensive search of the MEDLINE and EMBASE databases was performed from the database beginning through May 2016. Observation studies were included in this analysis if they assessed the association between BD and arterial stiffness in adult subjects. BD patients met the International Study Group criteria for a diagnosis of Behçet's disease. Aortic stiffness was assessed using carotid-femoral pulse wave velocity (PWV) measurements as an indicator. Pooled mean difference (MD) of PWV and 95% confidence intervals (CI) were calculated using a random-effect, generic inverse variance meta-analysis. The between-study heterogeneity of effect-size was quantified using the Q statistic and I².

Results

Data were extracted from four observational studies that included 303 subjects. PWV is significantly higher in patients with Behçet's disease compared with controls (MD=0.74;95%, CI: 0.28-1.20, p=0.002, I²=63%).

Conclusion

In this meta-analysis, we observed that PWV, an ideal indicator of arterial stiffness, is increased in patients with Behçet's disease compared with the controls. Prospective studies in a large population should be done to determine the pathophysiological and prognostic implications of increased arterial stiffness in BD.

Behçet disease: New aspects

Behçet disease is currently considered an "autoinflammatory disease" triggered by infection and environmental factors in genetically predisposed individuals. Although the disease is characterized by recurrent oral and genital aphthous ulcers and ocular involvement, it can affect multiple organ systems. Complex aphthosis is characterized by recurrent oral and/or genital aphthous ulcers. It is important to evaluate the patient with complex aphthosis for Behçet disease and related systemic disorders. We discuss the etiopathogenesis, clinical features, diagnostic criteria, and treatment approaches for complex aphthosis and Behçet disease in light of the current literature.

Decreased Protein Z Concentrations Complicating the Hypercoagulable State of Behqet's Disease

Protein Z is a vitamin-K-dependent plasma protein that serves as a cofactor for the inhibition of factor Xa. Although the precise physiologic function of protein Z is still unknown, abnornal plasma protein Z concentrations have been associated with a number of thrombotic disease states. There is the evidence of universal activation of the hemostatic system in Behqet's disease (BD), which represents a hypercoagulable/prothrombotic state. Circulating protein Z levels in patients with BD were evaluated. Plasma protein Z concentrations were assayed in 24 patients with BD (male/female: 13/11, mean age 35.4 years) and in 24 healthy controls (males/females: 14/10, mean age 59.8 years). The disease duration was 10.6 years (range, 1-30 years). None of the subjects in either group had received anticoagulants within 3 weeks before the study, and none of them had liver dysfunction. Patients complicated with vascular disease were also excluded from the study. Mean plasma concentrations of protein Z were 141 ng/mL (range, 56.8-257) in healthy controls and 107.8 ng/mL (range, 21.2-202) in BD patients (p<0.05). There was a positive correlation between the disease duration and protein Z levels in the study group (p<0.05, r=0.448). Alterations of protein Z concentrations could complicate the pathobiology of the prothrombotic state of BD. Furthermore, the tendency of increment in the protein Z with the passage of time may reflect the diminution of the disease activity.

Extra-medial thickness of carotid artery in patients with Behçet's disease: evaluation of atherosclerotic vessel wall changes with a novel carotid artery ultrasound index

OBJECTIVES

Chronic inflammation and endothelial dysfunction are the characteristic features of Behçet's disease (BD). We researched carotid extra-medial thickness (cEMT), a novel ultrasound parameter for atherosclerotic vessel wall changes, and carotid intima media thickness (cIMT), a widely accepted marker of subclinical atherosclerosis, in patients with BD, and we evaluated the relationship between these two parameters.

MATERIALS AND METHODS

In total, 31 patients with BD were matched to 26 control subjects based on age, gender, and major cardiovascular risk factors. Laboratory parameters, including lipid profile, were measured for both patients and controls. B-mode ultrasonography was used to assess the cEMT and cIMT.

RESULTS

There was no significant difference in the cEMT values between the patients with BD and the control group (P = 0.90). cIMT in the BD group was significantly higher compared with the control group (P = 0.021). There was a significant positive correlation between cIMT and cEMT (r = 0.585, P = 0.001). Both cEMT and cIMT were positively correlated with age and the presence of arthritis. There was linear correlation with sedimentation, C-reactive protein, and cEMT.

CONCLUSIONS

To the best of our knowledge, this is the first study to evaluate both cEMT and cIMT in BD. This study presents morphological evidence of subclinical atherosclerosis in terms of cIMT. Although there was no significant increment in cEMT, it has the potential to assess endothelial dysfunction in BD. Further studies are required to confirm this finding.

Behçet's: A Disease or a Syndrome? Answer from an Expression Profiling Study

Behçet's disease (BD) is a chronic, relapsing, multisystemic inflammatory disorder with unanswered questions regarding its etiology/pathogenesis and classification. Distinct manifestation based subsets, pronounced geographical variations in expression, and discrepant immunological abnormalities raised the question whether Behçet's is "a disease or a syndrome". To answer the preceding question we aimed to display and compare the molecular mechanisms underlying distinct subsets of BD. For this purpose, the expression data of the gene expression profiling and association study on BD by Xavier et al (2013) was retrieved from GEO database and reanalysed by gene expression data analysis/visualization and bioinformatics enrichment tools. There were 15 BD patients (B) and 14 controls (C). Three subsets of BD patients were generated: MB (isolated mucocutaneous manifestations, n = 7), OB (ocular involvement, n = 4), and VB (large vein thrombosis, n = 4). Class comparison analyses yielded the following numbers of differentially expressed genes (DEGs); B vs C: 4, MB vs C: 5, OB vs C: 151, VB vs C: 274, MB vs OB: 215, MB vs VB: 760, OB vs VB: 984. Venn diagram analysis showed that there were no common DEGs in the intersection "MB vs C" ∩ "OB vs C" ∩ "VB vs C". Cluster analyses successfully clustered distinct expressions of BD. During gene ontology term enrichment analyses, categories with relevance to IL-8 production (MB vs C) and immune response to microorganisms (OB vs C) were differentially enriched. Distinct subsets of BD display distinct expression profiles and different disease associated pathways. Based on these clear discrepancies, the designation as "Behçet's syndrome" (BS) should be encouraged and future research should take into consideration the immunogenetic heterogeneity of BS subsets. Four gene groups, namely, negative regulators of inflammation (CD69, CLEC12A, CLEC12B, TNFAIP3), neutrophil granule proteins (LTF, OLFM4, AZU1, MMP8, DEFA4, CAMP), antigen processing and presentation proteins (CTSS, ERAP1), and regulators of immune response (LGALS2, BCL10, ITCH, CEACAM8, CD36, IL8, CCL4, EREG, NFKBIZ, CCR2, CD180, KLRC4, NFAT5) appear to be instrumental in BS immunopathogenesis.

Intracardiac thrombus in patients with Behcet's disease: clinical correlates, imaging features, and outcome: a retrospective, single-center experience

Intracardiac thrombus (ICT) is a rare but serious complication of Behcet's disease (BD). The study was to report the clinical characteristics, imaging features, treatment, and outcomes of BD patients with ICT in a single tertiary center. A series of 626 BD patients admitted to Peking Union Medical College hospital between April 2003 and April 2013 were reviewed. A total of 12 (1.9 %) BD patients with ICT were included. ICT was presenting manifestation of BD in 5 of the 12 patients (41.7 %) and occurred mostly in men (9/12, 75 %) younger than 40 years. Patients with ICT had more arterial (66.7 vs. 7.3 %, p < 0.001) and venous involvement (75.0 vs. 8.1 %, p < 0.001) compared to those without ICT. Right heart was the most frequent site of ICT (11/12, 91.7 %). Thrombus were hyperechogenic and immobile with a broad-based attachment on echocardiography in most cases (11/12, 91.7 %). Cardiac magnetic resonance (CMR) was performed in four patients. All thrombi showed isointense on T1-weighted image, while all but one were hypointense on T2-weighted image without delayed enhancement. Remission of ICT was associated with therapy of anticoagulant, corticosteroid, and immunosuppressant in most cases (10/12, 83.3 %). There was no death, and relapses of ICT occurred in only one patient after tapering of immunosuppressant during follow-up. A diagnosis of BD should be considered when a young male patient presents with a mass in the right-sided heart accompanied by vascular lesions. Medical therapy especially adequate immunosuppressants might be the first choice for BD patients with ICT.

Successful Treatment and Secondary Prevention of Venous Thrombosis Secondary to Behçet Disease with Rivaroxaban

We here present the successful initial treatment and secondary prophylaxis of superficial venous thrombosis secondary to Behçet’s disease by a novel anticoagulant drug, rivaroxaban (Xarelto®). To our knowledge, this is the first case of using an oral direct inhibitor of FXa in this setting. Our findings are promising; the outcome was favourable without any adverse effect noted. We propose that the patients with Behçet’s disease and venous thrombosis might benefit from the advantages of the new anticoagulant drug.

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

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

Right ventricular thrombus with pulmonary artery aneurysm in a young male: A rare presentation of Behçet's disease

We describe an adolescent patient presenting with hemoptysis. Detailed clinical work up of the patient showed right ventricular thrombus and bilateral pulmonary artery aneurysms along with the prescribed criteria for the diagnosis of Behcet's disease. Younger age of the patient was another distinctive feature of this case. Six months of therapy with cyclophosphamide and prednisolone resulted in near complete clinicoradiological response.

Cardiac manifestations in Behcet's disease

Behcet's disease (BD) is a chronic inflammatory disorder, with vasculitis underlying the pathophysiology of its multisystemic effects. Venous pathology and thrombotic complications are hallmarks of BD. However, it has been increasingly recognised that cardiac involvement and arterial complications are also important aspects of the course of the disease. Cardiac lesions include pericarditis, endocarditis, intracardiac thrombosis, myocardial infarction, endomyocardial fibrosis, and myocardial aneurysm. Treatment of cardiovascular involvement in BD is largely empirical, and is aimed towards suppressing the vasculitis. The most challenging aspect seems to be the treatment of arterial aneurysms and thromboses due to the associated risk of bleeding. When the prognosis of cardiac involvement in BD is not good, recovery can be achieved through oral anticoagulation, immunosuppressive therapy, and colchicine use. In this review, we summarise the cardiovascular involvement, different manifestations, and treatment of BD.

Neutrophil–Lymphocyte Ratio and Carotid–Intima Media Thickness in Patients With Behçet Disease Without Cardiovascular Involvement

Behçet disease (BD) is associated with endothelial dysfunction and chronic inflammation. The neutrophil–lymphocyte (N/L) ratio and carotid intima–media thickness (cIMT) are markers of inflammation and vascular risk, respectively. We assessed the relationship between cIMT values and N/L ratio in BD (65 patients and 62 control participants). There were statistically significant differences in N/L ratios and cIMT values between the patients with BD and control group ( P < .001). There were moderate positive correlations between cIMT value, C-reactive protein, and N/L ratio in patients with BD. Receiver–operating characteristic curve analysis suggested that the optimum N/L ratio cutoff point for patients with BD was 1.29, with a sensitivity, specificity, negative predictive value, and positive predictive value of 97, 77, 96, and 75%, respectively (area under curve: 0.691, 95% confidence interval = 0.600-0.782, P < .001). The N/L ratio may be a useful index of BD activity.

Association of Rho-kinase 1 (ROCK1) gene polymorphisms with Behçet's disease

BACKGROUND AND OBJECTIVE

Behçet's disease (BD) is a chronic inflammatory vasculitis presenting with flares and silent periods usually between 15 and 40 years of age. The aim of this study was to evaluate the possible association between Rho-kinase 1 (ROCK1) gene polymorphisms and patients with BD in a Turkish population.

METHODS

A total of 192 BD patients and 255 healthy controls of similar age and sex were enrolled in this study. Polymorphisms were analyzed in genomic DNA using a BioMark HD dynamic array system.

RESULTS

In the presence of CC genotype for rs73963110, CT genotype for rs111874856 (Val355Ile), and TC genotype for rs112130712 (Lys1054Arg) polymorphisms, the risk of BD increased 12.13-, 15.05-, and 16.28-fold, respectively (p < 0.0001). There was a lower frequency of the GA genotype of the rs112108028 (Pro1164Leu) polymorphisms in BD (10.3 %) compared with controls (39.7 %; p < 0.0001). Marked associations between these polymorphisms and the manifestations of BD were recorded.

CONCLUSION

This is the first study to show that ROCK1 gene polymorphisms may have a significant impact on susceptibility to BD.

Mean platelet volume is associated with aortic arterial stiffness in patients with Behçet's disease without significant cardiovascular involvement

BACKGROUND

Behçet's disease (BD), is a chronic, systemic vasculitis, which may affect all types and sizes of blood vessels. BD is associated with endothelial dysfunction and chronic inflammation. Endothelial dysfunction is the critical early step in the process of atherogenesis, and it is commonly investigated by measuring arterial stiffness. Mean platelet volume (MPV) has been investigated in relation with both thrombosis and inflammation. We aimed to investigate the relationship between an increased arterial stiffness and MPV in patients with Behçet's disease without significant cardiovascular involvement.

METHODS

We studied 36 patients (20 males, mean age: 37.6 ± 11.7 years) who were diagnosed by the international diagnostic criteria of BD and 35 healthy controls (15 males, mean age: 35.0 ± 10.6 years), and the two groups were matched by age and gender. MPV levels and arterial stiffness measurements were compared in these groups.

RESULTS

Arterial stiffness was higher in patients with BD compared to control group. (BD and controls; 7.28 m/s, 6.64 m/s; respectively) (p: 0.02). MPV levels were also significantly higher in patients with BD compared to control group. (BD and controls; 8.86 ± 0.81 fl, 8.39 ± 0.96 fl, respectively) (p: 0.02). Additionally, arterial stiffness correlated positively with age, the duration of disease and MPV levels in patients with BD (p: 0.002, 0.03, 0.02 respectively).

CONCLUSIONS

In our study, increased MPV is associated with arterial stiffness in patients with BD without significant cardiovascular involvement. It shows that there is a relationship between thrombosis and chronic inflammation in BD. Furthermore, MPV is also a moderate predictor of cardiovascular disease and represents an increase in platelet activation. These findings provide further evidence of a link between inflammation and thrombosis in patients with BD.

Mean platelet volume in ocular Behçet's disease

Objective. To determine whether mean platelet volume (MPV) is an indicator of disease severity in ocular Behçet's Disease (BD). Materials and Methods. The study population was 30 newly diagnosed ocular BD patients who presented with active uveitis. These patients had no past history of smoking, drug use, or systemic diseases including diabetes mellitus, hypertension, cardiovascular disease, and renal disease. A control group consisting of 34 healthy individuals was included for comparison. MPV measurements were performed serially upon presentation with active uveitis and at one and three month thereafter in BD group whereas only at presentation in the controls. Results. Upon presentation with active uveitis, the mean MPV levels were 7.88 ± 1.14 femtoliters (fL) for BD group. During the posttreatment follow-up period at first and third months, BD patients demonstrated a mean MPV level of 7.71 ± 1.12 fL and 7.65 ± 1.04 fL, respectively. The mean MPV value of control group, was 8.39 ± 0.66 fL at presentation. Fluctuations in MPV values were not significant in the BD group, while there was a significant difference between the initial measurements of the BD and control groups. Conclusion. MPV measurement in ocular BD is not a predictive laboratory test to determine the clinical improvement in early stages following classical immunosuppressive treatment.

Mean Platelet Volume in Recurrent Aphthous Stomatitis and Behçet Disease

Behcet disease (BD) and recurrent aphthous stomatitis (RAS) are systemic inflammatory diseases, but the exact pathogenesis of both the diseases is unknown. Mean platelet volume (MPV) is an indicator of platelet activation. The aim of this study was to investigate the MPV levels in patients with BD, RAS, and healthy participants. A total of 61 patients with BD, 60 patients with RAS, and 60 healthy controls were included in this study. The MPV levels and erythrocyte sedimentation rate in patients with BD and RAS groups were significantly higher than the control groups ( P < .001). In the BD group as well as in the RAS group, the disease activity does not affect the levels of MPV. The MPV levels may be used as a cheap and feasible diagnostic marker in patients with BD and RAS. Nevertheless, the MPV does not have a predictive value in differentiating the diagnosis of BD and RAS.

Atypical Vascular Involvement in a Case of Behçet's Disease

Introduction. Behçet's disease (BD) is a form of vasculitis of unknown etiology which is rare in our environment. It is characterized by a variety of clinical manifestations and usually affects young adults. Recurrent oral and genital ulcers are a characteristic and extremely frequent symptom, but mortality is linked with more significant symptoms such as aortic pseudoaneurysm, pulmonary pseudoaneurysm, and cerebral venous thrombosis. Patient and Method. We present a case of a young male with atypical BD and severe polyvascular involvement (previous cerebral venous thrombosis and current peripheral venous thrombosis, acute ischemia, and peripheral arterial pseudoaneurysm) who required urgent surgical intervention due to a symptomatic external iliac pseudoaneurysm. Result. The pseudoaneurysm was successfully treated, we performed an iliofemoral bypass, and we treated it with steroids and immunosuppressive therapy. Conclusions. These rare clinical manifestations highlight the importance of considering BD in young patients, even in usual cases of vascular intervention, whether arterial or venous in nature.

Ocular Behçet disease: current therapeutic approaches

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Recurrent pseudotumor cerebri in childhood: a case of neuro-Behçet disease complicated with thrombotic risk factors

Pseudotumor cerebri with or without venous sinus thrombosis is a rare clinical presentation of Behçet disease in childhood. We present here a case of childhood pseudotumor cerebri without a previous diagnosis of Behçet disease. The detailed history and physical examination of the case led to the diagnosis of neuro-Behçet disease. The investigation of predisposition to thrombosis revealed heterozygous factor V Leiden mutation along with the high lipoprotein(a) level. The symptoms resolved dramatically by treatment with the combination of immunosuppression and anticoagulation with regard to the detected factor V Leiden mutation and high lipoprotein(a) level. After a symptom-free period of 9 months, the cerebral vein thrombosis recurred. We present this case to draw attention to this rare cause of pseudotumor cerebri in childhood and to emphasize the importance of additional thrombotic risk factors regarding the potential recurrence of thrombotic events in Behçet disease.

Elevated Oxidative Stress Markers and its Relationship With Endothelial Dysfunction in Behçet Disease

Behçet’s disease (BD) is a multisystemic disorder characterized by endothelial dysfunction. However, the relationship between oxidative stress and endothelial function has not been clearly shown. We investigated the relationship between oxidative stress markers and endothelial function in patients with BD. Patients with BD (n = 40) having active disease and sex- and age-matched 40 controls were included. Endothelial function was assessed by flow-mediated dilatation (FMD) technique. Serum gamma-glutamyltransferase (GGT) and high-sensitive C-reactive protein levels (hsCRP) were measured in all participants. Brachial artery FMD was significantly lower in patients with BD than in controls. Gamma-glutamyltransferase and hsCRP levels were higher in patients with BD than in controls. Also, GGT and hsCRP levels were inversely correlated with endothelial function. Oxidative stress markers are elevated in patients with BD having active disease. This may be one of the reasons behind the vasculitis in active BD.

Homocysteine in vascular Behcet disease: a meta-analysis

OBJECTIVE

Behçet disease (BD) is a vasculitis of unknown etiology, characterized by oral or genital aphtosis and uveitis. Homocysteine (hcy) is an independent risk factor for venous and arterial thrombosis. The association between hyperhomocysteinemia and thrombosis has been investigated in some studies in BD patients. However, information on this association is based only on the results of small studies with conflicting results. To overcome such limitations, we performed a metaanalysis comparing the plasma levels of hcy in BD patients with and without history of thrombosis.

METHODS AND RESULTS

We searched for all published studies using the Medline and Embase databases. Two reviewers performed study selection independently. Studies were included if hcy was measured in adult BD patients with and without thrombosis. Two reviewers independently extracted data on study and population characteristics. The mean value of hcy in BD patients and the presence of hyperhomocysteinemia in patients with and without thrombosis were collected. Association between thrombosis and hyperhomocysteinemia, and the mean difference of hcy levels in BD patients with and without thrombosis were calculated. Sixteen studies, for a total of 979 patients, were included. Hyperhomocysteinemia was more prevalent in patients with thrombosis than in those without (odds ratio 3.14; 95% CI 1.26 to 7.80) Mean levels of hcy were significantly higher in patients with thrombosis in comparison with patients without (mean difference 3.30 μmol/L; 95% CI 2.09 to 4.51).

CONCLUSIONS

Our results suggest that hyperhomocysteinemia may be considered to be associated with thrombosis in BD patients.

Might platelet-leucocyte complexes be playing a role in major vascular involvement of Behçet's disease? A comparative study

We determined platelet-leucocyte complexes, which play roles in the thrombosis-inflammation relationship, in Behçet's disease patients with and without major vascular involvement (MVI) and in healthy controls. We included 36 Behçet's disease patients (22 male, 14 female, mean age: 34.4 +/- 8.3 years) and 20 healthy individuals (14 male, six female, mean age: 31.8 +/- 4.4 years). Whole blood count, CRP and ESR were determined in both groups. Clinical data about the patients were obtained from medical charts. Individuals with hypertension, diabetes, coronary artery disease, and smokers were excluded. Behçet's disease patients with MVI were taken as a separate group (8 male, 5 female, mean age: 37 +/- 8 years). MVI was defined as the presence of pulmonary arterial aneurysm, deep venous thrombosis, vena cava inferior or superior thrombosis, or venous sinus thrombosis. Flow cytometry was used to determine platelet-monocyte complexes (PMC), platelet-neutrophil complexes (PNC), basal and adenosine diphosphate (ADP)-stimulated platelet CD62P expression. Behçet's disease patients with MVI had significantly higher PNC than Behçet's disease patients without MVI and healthy controls (P values = 0.01). PMC levels in Behçet's disease patients with MVI were significantly higher than in healthy controls (P = 0.01). The groups were similar in basal and ADP-stimulated platelet CD62P expression (P values >0.05). Basal and ADP-stimulated CD62P expression, PMC and PNC were not significantly different between active Behçet's disease versus inactive Behçet's disease patients. The evaluated parameters were similar in Behçet's disease patients with and without uveitis, and pathergy-positive and pathergy-negative groups. Our results might suggest that the formation of PMC and PNC might play a role in thrombosis and MVI of Behçet's disease.

Behçet's Disease as a Model of Venous Thrombosis

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

Behçet’s Disease as a Model of Venous Thrombosis

Behçet’s disease (BD) is a chronic inflammatory disease of unknown aetiology characterized by recurrent oral, genital aphthous ulcerations, uveitis, skin lesions and other multisystem affections associated with vasculitis. Different types of vessels, predominantly veins, can be affected in BD. The frequency of vascular lesions in BD, such as superficial and deep venous thromboses, arterial aneurysms and occlusions, ranges between 7-29%.

In this review, various factors of thrombogenesis in BD, particularly pro- and antithrombotic endothelial and non-endothelial factors, factors of coagulation, platelet activation and rheological changes are presented and discussed from positions of Virchow’s triad of venous thrombosis.

Despite advances in understanding of thrombogenesis in BD, still many issues of diagnosis and targeted preventive and therapeutic measures remain unresolved. Further studies are needed to clarify the pathobiology of BD-related thrombosis and to provide the clinicians with recommendations over the utility, safety and effectiveness of the antithrombotic therapy in BD.

Behçet's Disease: an Insight from a Cardiologist's Point of View

Behçet's disease (BD) is an enigmatic inflammatory disorder, with vasculitis (perivasculitis) underlying pathophysiology of its multisystemic affections. Venous pathology and thrombotic complications are hallmarks of BD. However, it has been increasingly recognized that cardiac involvement and arterial complications (aneurysms, pseudoaneurysms, rupture and thrombosis) are important part of the course of BD. Pericarditis, myocardial (diastolic and/or systolic dysfunction), valvular and coronary (thrombosis, aneurysms, rupture) involvement, intracardiac thrombi (predominantly right-sided) are, probably, the most frequent cardiac manifestations. Treatment of cardiovascular involvement in BD is largely empirical and aimed at suppression of vasculitis. The most challenging seems to be the treatment of arterial aneurysms and thromboses due to the associated risk of bleedings. Cardiologists should always bear in mind potential threats of (a)symptomatic cardiovascular involvement in BD.

Behçet’s Disease: an Insight from a Cardiologist’s Point of View

Behçet's disease (BD) is an enigmatic inflammatory disorder, with vasculitis (perivasculitis) underlying pathophysiology of its multisystemic affections. Venous pathology and thrombotic complications are hallmarks of BD. However, it has been increasingly recognized that cardiac involvement and arterial complications (aneurysms, pseudoaneurysms, rupture and thrombosis) are important part of the course of BD. Pericarditis, myocardial (diastolic and/or systolic dysfunction), valvular and coronary (thrombosis, aneurysms, rupture) involvement, intracardiac thrombi (predominantly right-sided) are, probably, the most frequent cardiac manifestations. Treatment of cardiovascular involvement in BD is largely empirical and aimed at suppression of vasculitis. The most challenging seems to be the treatment of arterial aneurysms and thromboses due to the associated risk of bleedings. Cardiologists should always bear in mind potential threats of (a)symptomatic cardiovascular involvement in BD.