Behçet disease

Etiology of Pediatric Uveitis in a Tertiary Pediatric Eye Hospital in Egypt

PURPOSE

To report the causes of childhood-onset uveitis in a tertiary pediatric ophthalmology hospital in Egypt.

METHODS

Retrospective study of the medical records of all uveitis patients following up at a tertiary pediatric ophthalmology hospital in Egypt from January 2017 to December 2020.

RESULTS

The present study included 388 patients. The most common anatomical category was intermediate uveitis (30.4%), and around half of these children had pars planitis. This was followed by panuveitis (25.5%), posterior uveitis (23.5%), and anterior uveitis (20.6%), in decreasing frequency. Juvenile idiopathic arthritis, toxoplasmosis, and Vogt-Koyanagi-Harada syndrome were the most common causes of anterior uveitis, posterior uveitis, and panuveitis respectively. Cataract (40.5%), glaucoma (33.8%), and cystoid macular edema (31.6%) were the most frequent ocular complications.

CONCLUSION

The present report provides the relative prevalence of the different anatomical types of uveitis, as well as their main causes in a cohort of Egyptian patients with childhood-onset uveitis.

Etiology of Uveitis in Upper Egypt

Purpose

To report the causes of uveitis in a referral ocular inflammation clinic in Upper Egypt.

Methods

Retrospective medical chart review of all uveitis cases visiting a referral uveitis clinic during the period between January 2015 and January 2020.

Results

A total of 982 patients were included. Uveitis was bilateral in 51.7% of the patients. Anterior uveitis was the most common type, followed by posterior uveitis, affecting 34.4% and 25.6% of the study cohort, respectively. About one-third of our patients were beneath the age of 18, and among that group, no specific etiology of uveitis could be determined in about a quarter of the patients by the end of the study period, and juvenile idiopathic arthritis was the most common disease entity.

Conclusion

In conclusion, the present report attempted to illustrate the most common causes of uveitis in Upper Egypt. Tuberculosis followed by sarcoidosis were the two leading causes of uveitis in our group of patients.

Clinical Significance of Serum Bilirubin in Behçet's Disease

Background and Objective

Bilirubin (Bb) is the product of the intravascular compartment of catabolic pathway. In a small number of clinical trials, it has been shown that Bb molecules are associated with cardiovascular diseases, diabetes, cancer, autoimmune (lupus, rheumatoid arthritis) diseases and schizophrenia. Behçet's disease is a chronic, multisystemic, inflammatory vasculitis that was first described by Hulusi Behçet in 1937, which affects almost all organs and systems without any known aetiology. Here, we investigated the clinical significance of serum Bb as a biomarker in the patients with Behçet's disease.

Methods

Seventy-one (N = 71) patients with Behcet's diagnosis within the last 1 year were included retrospectively. Control group consisted of 75 subjects with similar age and sex distribution. Serum Bb, indirect Bb, total Bb, aspartate aminotransferase (AST), alanine aminotransferase (ALT), alkaline phosphatase (ALP) and erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) data were recorded from the hospital records.

Results

In the Behçet group, direct Bb was significantly lower (P = 0.011), ESR and CRP were significantly higher (P = 0.00). No significant differences were observed in other parameters. In the whole group, total Bb and indirect Bb were negatively correlated with ESR (P = 0.025, P = 0.01). Direct Bb was negatively correlated with CRP (P = 0.002). For the diagnosis of Behçet, direct Bb with a threshold of < 0.14 can be used as a diagnostic test (P = 0.000) with 70% sensitivity, 68% specificity (area under the curve = 0.69; 95% confidence interval 0.59–0.80) in ROC curve analysis.

Conclusion

According to our study, we found that inflammatory markers were high and direct Bb values were low in patients with Behcet's disease. In addition, Bb parameters were negatively associated with acute phase reactants. As a practical biomarker with anti-oxidative properties, the direct Bb can be used to diagnose and clinical follow-up in cases with Behçet's disease.

Pattern of Childhood Uveitis in Egypt

Purpose: To report the pattern of childhood-onset uveitis observed in Egypt from May 2010 to May 2017 Methods: Retrospective evaluation of the data of all patients with uveitis diagnosed before the age of 16 and visiting uveitis referral clinics in 5 Egyptian Governorates (Alexandria, Cairo, Al Bohayra (Damanhour), Al Gharbeya (Tanta), and Sohag) between May 2010 and May 2017. Results: A total of 413 uveitis patients were enrolled. These included 219 male and 194 female patients. Uveitis was bilateral in 68.3% of the patients. The most frequently observed ocular complications were cataract, glaucoma, and cystoid macular edema. The percentage of children with a visual acuity ≥1.00 logMAR in at least one eye by the final visit was 21.8%. Conclusion: Pediatric uveitis is a vision-threatening condition which caused more than one-fifth of the children in this study to lose vision in one or both eyes.

Uveitis Referral Pattern in Upper and Lower Egypt

Purpose: To report the pattern of uveitis in two referral eye hospitals, one in Upper Egypt and another in Lower Egypt Methods: Retrospective chart review of all uveitis cases visiting the uveitis clinic in Alexandria and Sohag University Hospitals between May 2010 and March 2017. Results: A total of 1315 patients (683 in Upper Egypt and 632 in Lower Egypt) were identified. Uveitis was bilateral in 56.6% of patients in Upper Egypt and in 43.6% of patients in Lower Egypt. Anterior uveitis was the most common in both regions, accounting for 34.7% and 38.2% of cases in Upper Egypt and Lower Egypt respectively. Pediatric cases constituted 18.7% of the cases in Upper Egypt and 18.1% of the cases in Lower Egypt. Specific diagnosis was established in 71.3% and 67.7% of Upper and Lower Egypt cases respectively. Conclusions: Patterns of uveitis differ according to the geographical area in Egypt.

Breaking the Magic: Mouth and Genital Ulcers with Inflamed Cartilage Syndrome

Mouth and genital ulcers with inflamed cartilage (MAGIC) syndrome refers to a condition in which features of Behcet’s disease (BD) and relapsing polychondritis (RP) occur in the same individual. The existence of MAGIC syndrome suggests a potential common etiology for BD and RP. However, connecting these two diseases and referring to this condition as MAGIC syndrome might have been premature, as there is currently insufficient knowledge on BD and RP. In this critical review, we argue that these two clinical entities could possibly be unique disease processes rather than two ends of the same disease spectrum. Distinguishing the clinical difference between BD and RP is critical for the management of patients diagnosed with MAGIC syndrome, as biological therapeutic approaches for BD and RP differ. Also, inaccurate perception regarding the relationship of these two diseases could mislead researchers in their endeavors to unravel the pathophysiological mechanisms behind these two diseases.

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.

Pattern of Childhood-Onset Uveitis in a Referral Center in Tunisia, North Africa

PURPOSE

To analyze the pattern of childhood uveitis in a referral center in Tunisia, North Africa.

METHODS

The study included 64 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1994 to July 2005. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with 3-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis.

RESULTS

The mean age at onset of uveitis was 12.4 years. The male-to-female ratio was 0.68. The process was unilateral in 51.6% of patients. Mean follow-up was 43.2 months. Anterior and intermediate uveitis each represented 31.25% of cases, posterior uveitis 20.3%, and panuveitis 17.2%. Noninfectious uveitis (75%) was the most frequent type of inflammation. Idiopathic uveitis was found in 50% of patients. Infectious uveitis was responsible for 25% of the cases, with toxoplasmosis (14.1%) being the most frequent cause. Twenty percent of the patients had systemic associations; juvenile idiopathic arthritis was found in 6.25%. Ocular complications occurred in 74.7% of affected eyes, of which the most common were posterior synechiae (28.4%), cataract (17.9%), cystoid macular edema (19%), and optic disc edema (32.6%). Fifty-seven affected eyes (60%) had a final visual acuity more than 20/40 and nine (9.5%) had a final visual acuity less than 20/200.

CONCLUSIONS

In a hospital population in Tunisia, a specific cause of uveitis in children was found in half the patients. Idiopathic intermediate uveitis was the leading cause of uveitis in our study, followed by idiopathic anterior uveitis and toxoplasmosis. Uveitis associated with juvenile idiopathic arthritis was rare. Visual prognosis appeared to be good.

Pattern of uveitis in a referral centre in Tunisia, North Africa

AIM

To analyse the pattern of uveitis in a referral centre in Tunisia, North Africa.

METHODS

The study included 472 patients with uveitis examined at the Department of Ophthalmology of Monastir (Tunisia) from January 1992 to August 2003. All patients had a comprehensive ocular and systemic history, including an extensive review of medical systems. Complete ophthalmic examination was performed in all cases, including best-corrected Snellen visual acuity, slit-lamp examination, applanation tonometry, and dilated fundus examination with three-mirror lens. Standard diagnostic criteria were employed for all syndromes or entities of uveitis.

RESULTS

The mean age at onset of uveitis was 34 years. The male-to-female ratio was 1:1.1. Uveitis was unilateral in 282 patients (59.7%) and bilateral in 190 patients (40.3%). Anterior uveitis was most common (166 patients; 35.2%), followed by posterior uveitis (133 patients; 28.2%), panuveitis (100 patients; 21.2%), and intermediate uveitis (73 patients; 15.5%). A specific diagnosis was found in 306 patients (64.8%). The most common cause of anterior uveitis was herpetic uveitis (56 patients; 33.7%). Toxoplasmosis was the most frequent cause of posterior uveitis (51 patients; 38.3%). Intermediate uveitis was most commonly idiopathic (63 patients; 86.3%). Behçet's disease was the most common cause of panuveitis (36 patients; 36%), followed by Vogt-Koyanagi-Harada (VKH) disease (15 patients; 15%). A total of 16 patients (3.4%) suffered from blindness, and 59 (12.5%) from uniocular blindness.

CONCLUSIONS

In a hospital population in Tunisia, the most common causes of uveitis were Behçet's disease, herpes simplex infection, toxoplasmosis, and VKH disease.

Serum levels of soluble P-selectin are increased and associated with disease activity in patients with Behçet's syndrome

Behçet's syndrome (BS) is a relapsing, chronic, inflammatory disease characterized by endothelial dysfunction, atherothromboembogenesis, and leukocytoclastic vasculitis with complex immunologic molecular interactions. Generalized derangements of the lymphocyte and neutrophil populations, activated monocytes, and increased PMNLs motility with upregulated cell surface molecules such as ICAM-1, VCAM-1, and E-selectin, which are found on the endothelial cells, leukocytes, and platelets, have all been demonstrated during the course of BS. Our aim is to investigate the association of serum concentrations of soluble P-selectin in patients with BS, and to evaluate whether disease activity has an effect on their blood levels. This multicenter study included 31 patients with BS (15 men and 16 women) and 20 age- and sex-matched healthy control volunteers (11 men and nine women). Neutrophil count, erythrocyte sedimentation rate, and acute-phase reactants as well as soluble P-selectin levels were determined. The mean age and sex distributions were similar (P > .05) between BS patients (35 years) and control volunteers (36 years). Serum levels of soluble P-selectin in patients with BS (399 +/- 72 ng/mL) were significantly (P < .001) higher when compared with control subjects (164 +/- 40 ng/mL). In addition, active BS patients (453 +/- 37 ng/mL) had significantly (P < .001) elevated levels of soluble P-selectin than those in inactive period (341 +/- 52 ng/mL). This study clearly demonstrated that serum soluble P-selectin levels are increased in BS patients when compared with control subjects, suggesting a modulator role for soluble P-selectin during the course of platelet activation and therefore, atherothrombogenesis formation in BS, especially in active disease.

Transverse myelitis after lumbar steroid injection in a patient with Behcet's disease

STUDY DESIGN

Case report.

OBJECTIVE

We describe a patient who developed transverse myelitis (TM) following a nerve root injection of steroids and anesthetic at L2 for radicular pain.

SETTING

Baltimore, MD, USA.

CLINICAL PRESENTATION

A 42-year-old woman developed progressive lower extremity weakness and paresthesias, a T12 sensory level and urinary urgency 8 h following the injection of Marcaine and Celestone into the left L2 nerve root. Magnetic resonance imaging showed T2 signal abnormality with gadolinium enhancement from T12 to the conus medullaris and there was no evidence of traumatic injury to the spinal cord. The patient had undiagnosed Behcet's disease (BD) and had experienced multiple episodes of pathergy: hyper-responsiveness of the skin to local trauma, resulting in inflammation and edema. Intravenous steroids were initiated and the patient experienced a near total clinical resolution and a complete radiologic resolution.

CONCLUSION

Since the spinal cord inflammation developed after and immediately adjacent to local spinal trauma, we suggest that the TM in this patient was related to BD and was a pathergy response in the spinal cord.

Managing the symptoms of Behçet's disease

Behçet's disease (BD) is a chronic, relapsing, systemic inflammatory vasculitis of unknown aetiology with a myriad of immunological and pathological consequences. Patients with BD are clustered along the ancient silk road, extending from Far-East Asia to Turkey. The disease affects both genders of all ages from infants to the elderly. It is a long-term, cyclical disease and such patients may have symptom-free periods of weeks, months or years that are interrupted by exacerbations of varying intensities lasting a few days, weeks or months. Clinical features include oral aphthae, genital ulcers, ocular inflammation, skin lesions, as well as articular, vascular, neurological, pulmonary, gastrointestinal, renal and genitourinary manifestations. The main histopathological finding is a widespread vasculitis of the arteries and veins of any size or thrombophilia according to the site of involvement. BD may start with just one or two small symptoms but other symptoms may gradually appear over the years. Recurrent ocular inflammation, which occurs in approximately 50% of cases, is the major morbidity that may eventually lead to blindness. The treatment of BD is usually symptomatic and palliative. Therefore, the main objectives are to relieve symptoms associated with mucocutaneous lesions and arthritis, to modify the course of the disease, to control inflammatory eye disease, clinically suppress the inflammation and vasculitis, to prevent recurrences and thus, prevent irreversible damage. The choice of treatment is based on the severity of systemic involvement, clinical presentation and the site affected. The preferred treatment modalities are combined drug therapy and include topical therapies as well as systemic corticosteroids, NSAIDs, colchicine, dapsone and immunosuppressive and cytotoxic agents. Such therapies are tailored to the individual patient depending on clinical manifestations. Thalidomide, tacrolimus, IFN-alpha and anti-TNF monoclonal antibody have recently attracted attention as novel therapeutic approaches.

Endothelial cell activation and hypercoagulability in ocular Behçet's disease

PURPOSE

To investigate the presence of a hypercoagulable state and vascular endothelial dysfunction in patients with ocular Behçet's disease and relate the results to the activity of ocular and systemic involvement.

DESIGN

Cross-sectional laboratory and clinical study.

METHODS

Prospective study of blood samples of 24 patients diagnosed with ocular Behçet's disease, which were analyzed for factor VIII, factor XI, von Willebrand factor antigen and ristocetin (vWF ag and risto), antithrombin III (ATIII), protein C and S, fibrinogen and activated protein C (APC) resistance. The results were compared with 40 healthy controls and analyzed for association with ocular and systemic clinical features.

RESULTS

The mean values of factor VIII, factor XI, vWF ag, vWF risto, ATIII, and fibrinogen were significantly raised compared to healthy population (for all: P <.001). Most striking were factor VIII activity levels above 130% in 79% (19 of 24) of our patients. 67% (16 of 24) had levels of factor VIII above 150%, which correlates with a fivefold increase in risk of thrombosis. Other prothrombogenic factors were negative in all but 2 patients (1 protein C deficiency, 1 factor V Leiden mutation). Endothelial cell activation, measured by vWF activity, revealed elevated levels in 42% (10/24). Complete/incomplete Behçet's disease patients with present or previous macular edema had significantly higher FVIII levels than complete/incomplete Behçet's disease patients who had never shown any signs of macular edema (P =.04). Further correlations between the laboratory results and clinical symptoms were not found.

CONCLUSIONS

We found a generalized hypercoagulable state with endothelial cell activation in ocular Behçet's disease, irrespectively of current ocular disease activity.