Secukinumab in the treatment of parenchymal neuro-Behçet's syndrome

Paradoxical Behçet's Disease after Ixekizumab: A Case Report and Literature Review

Behçet's disease is a chronic inflammatory condition that affects multiple organs and systems. It is characterized by recurrent oral and genital ulcers. A previous study reported that the IL-17A inhibitor secukinumab can improve the skin and mucosal manifestations in patients with refractory Behçet's disease. Additionally, secukinumab has been shown to effectively improve neurological symptoms when administered for Behçet's disease. However, we report a case where Behçet's disease occurred after the treatment of psoriasis with the IL-17A inhibitor ixekizumab. To summarize its clinical characteristics and treatment experience, we consulted relevant domestic and international literature and conducted a literature review. We concluded that anti-IL-17A treatment may lead to the development of Behçet's disease. The reported cases are more likely to occur in middle-aged men with varying onset times. The main manifestations include oral and vulvar mucosal ulcers. Furthermore, the gut microbiota may be involved in paradoxical Behçet's disease.

[Update on Behçet syndrome]

BACKGROUND

Behçet syndrome (BS) is a vasculitis of variable vessels with multiple organ manifestations.

OBJECTIVE

This article gives an overview of innovations in the last 2 years.

MATERIAL AND METHODS

A literature search was carried out using the keyword "Behcet" in 2022-2024 in PubMed. The selection of suitable articles was based on the relevance.

RESULTS AND CONCLUSION

With respect to the pathophysiology it is now clear that BS occupies an intermediate position between autoinflammatory and autoimmune clinical pictures. It is now classified as MHC-I-opathy, i.e., a disease that has a strong association with HLA class I antigens, which also play a prominent role in the pathogenesis. The diagnostic international criteria for Behcet's disease (ICBD) from 2014 with a score of 4 points or more that makes the diagnosis of BS probable have become established; however, in countries with a low prevalence of BS, the differential diagnosis of BS from other diseases is difficult and a higher point limit in the diagnostic score seems to make sense in order to avoid incorrect diagnoses. Clusters or phenotypes of the disease have now been described in various countries in which different symptom complexes frequently occur together; however, the clusters differ between the different countries of origin and depending on the age of the patients. Sonography of the common femoral vein with specific wall thickening in BS patients has been established as an additional tool for the differential diagnosis. Typical characteristics of oral aphthae in BS were also described and the frequency of positivity in the pathergy test could be significantly increased using pneumococcal antigens as the reagent. The treatment recommendations of the EULAR from 2018 still apply; in treatment-refractory cases, tocilizumab, secukinumab, Janus kinase inhibitors (JAKi) and ustekinumab have now also been successfully used. The new EULAR treatment recommendations are expected in 2025.

Behçet's syndrome

Behçet's syndrome is a rare, chronic multisystemic inflammatory disorder also known as the Silk Route disease due to its geographical distribution. Behçet's syndrome is a multifactorial disease and infectious, genetic, epigenetic, and immunological factors contribute to its pathogenesis. Its heterogeneous spectrum of clinical features include mucocutaneous, articular, ocular, vascular, neurological, and gastrointestinal manifestations that can present with a relapsing and remitting course. Differential diagnosis is often hampered by the non-specific clinical presentation and the absence of laboratory biomarkers or pathognomonic histological features. The therapeutic approach is tailored on the basis of patient-specific manifestations and relies on glucocorticoids, colchicine, and traditional and biological immunosuppressants. Despite progress in the knowledge and management of the disease, unmet needs in diagnostics, monitoring, prediction, and treatment personalisation challenge clinical practice, making Behçet's syndrome a complex disorder associated with an increased risk of morbidity.