An exacerbation of Behçet's syndrome presenting with bilateral papillitis

Optic neuritis as a presenting feature of Behçet's disease: case-based review

Behçet's disease (BD) is vasculitis affecting vessels of variable sizes characterized with recurrent oral and/or genital aphthous ulcers accompanied by cutaneous, ocular, articular, gastrointestinal, and/or central nervous system inflammatory lesions. The disease is characterized by recurrent attacks and remissions of different durations, which is one of the reasons why the diagnosis is, in most cases, made several years after the onset of first symptoms. We present a 24-year old male, with South Eastern European heritage, with relapsing bilateral optic neuritis as a first symptom of the disease, followed by aseptic meningitis 2 years, and vascular manifestation 3 years after onset, which finally led to the diagnosis of Behçet's disease. Vascular symptoms were thromboembolism of the right leg and aneurism of the right popliteal artery that due to the size required surgical treatment. The patient was treated with glucocorticoids, azathioprine and anti-tumor necrosis factor-alpha therapy, that proved to be the best treatment options for all manifestations of the disease. Based on our literature review, optic neuritis is a known and rare clinical feature of BD. To our knowledge, there are only several literature reports in which optic neuritis is the initial symptom of BD. Our case report and literature review emphasize the importance of recognizing optic neuritis without inflammatory eye disease as a possible presenting symptom of BD and accentuate detailed medical history review at each patient's visit.

Pre-papillary vitreous opacities associated with Behçet's disease: a case series and review of the literature

PURPOSE

To present pre-papillary vitreous opacity as an uncommon manifestation of inflammation in Behçet's disease that may be specific to this uveitic entity.

METHODS

We retrospectively reviewed the charts of 67 patients with Behçet's disease examined at our clinic between 2005 and 2016. Behçet's disease was diagnosed based on established clinical criteria of inflammation involving the eyes, mucocutaneous junctions, and skin. Patients with Behçet's disease who presented with papillitis and a pre-papillary vitreous opacity were identified. Response to anti-inflammatory treatment on examination and optical coherence tomography imaging were evaluated. PubMed searches were performed for (1) other cases with pre-papillary vitreous opacities in uveitic entities and (2) reports of optic nerve involvement specifically in Behçet's disease.

RESULTS

We identified three patients with Behçet's disease who presented with unilateral papillitis and a pre-papillary vitreous opacity. The pre-papillary vitreous opacity had a funnel-shaped appearance on optical coherence tomography. All patients were initially treated with steroids, which led to resolution of the opacity clinically and on imaging. We identified one previous report of such a pre-papillary opacity in a patient with Behçet's disease, and no reports of this finding in other uveitic entities.

CONCLUSION

This study expands the number of Behçet's disease cases presenting with a pre-papillary vitreous opacity and demonstrates novel optical coherence imaging of this finding. This finding may be specific to Behçet's disease as it was not identified in other uveitic entities in a review of the existing literature.

Bilateral optic neuritis in a patient with Behçet's disease who respond to therapeutic plasma exchange

Bilateral optic neuritis has been reported very rarely as a manifestation of neuro-Behçet’s disease. We present a 50 year old woman who had 20-year history of Behçet’s disease presented with acutely blurred vision associated with orbital pain in both eyes. Visual acuity was 0.4 in the right eye and light perception in the left eye; afferent pupillary defect was detected in the left eye. Bilateral swelling of the optic disk was found. The cerebrospinal fluid sample tests were within normal limits. Brain magnetic resonance imaging, magnetic resonance venography and fundus fluorescein angiography were normal. She was diagnosed with bilateral optic neuritis and treated with intravenous methyl prednisolone for 10 days. As there was no response to the treatment, therapeutic plasma exchange was started and the patient’s visual acuities improved moderately. We suggest that when high dose steroid is failed to treat ON in BD, treatment with TPE may be considered.

[Parenchymal neuro-Behcet's disease. Clinical and paraclinical characteristics, a report of 40 cases]

OBJECTIVE

Describe the clinical and paraclinical characteristics of parenchymal neuro-Behcet's disease.

METHODS

This is a prospective, descriptive study, concerning 40 patients with parenchymal neuro-Behcet's disease. The patients were followed during 3 years, benefited a thorough physical examination and paraclinical made of inflammatory laboratory tests, infectious serology, serum/CSF autoimmunity assessment, brain/spine MRI and evoked potentials. We also evaluated the frequency of HLA-B51.

RESULTS

We identified 22 men and 18 women. The average age was 32 years. The beginning was poly-symptomatic in 65% cases. Twenty-eight patients (70%) reported a decrease in visual acuity, 40% (16 cases) associated with uveitis, 33 cases (82.5%) complained of headache and 11 cases (27.5%) with dizziness. Inaugural signs consisted of motor disorders (50%) and balance disorders (40%). The inflammatory serum markers were positive in 75% and oligoclonal bands present in CSF were found in 7 patients. Infracentimetric demyelinating lesions in MRI study were located in the brainstem (52.5%), the subcortical white matter (40%), the periventricular region (42.5%), cerebellum (32.5%), basal ganglia (30%), internal capsule (25%) and corpus callosum (12.5%). The HLA-B51 was found in 53% of cases.

CONCLUSION

Behçet's disease mainly affects young male. The neurological complications are highly polymorphic, involving severe vital or functional prognosis.

Epidemiology of Behçet disease

Behçet disease (BD) is a multisystem inflammatory disorder that is an important cause of morbidity worldwide. BD is most common along the ancient "Silk Road" route in the Far East and Mediterranean basin. The eye is the most commonly involved organ in BD patients.The prototypical form of involvement is a relapsing remitting panuveitis and retinal vasculitis. Less commonly, BD may present in the form of conjunctivitis, conjunctival ulcers, keratitis, episcleritis, scleritis, and extraocular muscle paralysis. Uveitis in BD carries significant implications for the patient, because it is a chronic recurrent disease characterized by explosive attacks of severe inflammation that may cause significant, cumulative damage to the intraocular structures. This review summarizes the epidemiology of systemic and ocular clinical features of BD with particular focus on risk factors, clinical characteristics, complications, and prognosis of BD-associated uveitis.

Behçet's Uveitis

Behçet's disease is a multisystem inflammatory disorder that is most common in countries along the ancient “Silk Road”. The eye is the most commonly involved vital organ in Behçet's patients and the typical form of involvement is a relapsing remitting panuveitis and retinal vasculitis. Uveitis is the initial manifestation of the disease in 10-15% of the patients. Anterior uveitis is always nongranulomatous. Diffuse vitritis, retinal infiltrates, sheathing of predominantly retinal veins, and occlusive vasculitis are the typical signs of posterior segment inflammation. Spontaneous resolution of acute inflammatory signs is a diagnostic feature. Fundus fluorescein angiography is the gold standard in monitoring inflammatory activity. Laser flare photometry is a useful noninvasive tool since flare readings correlate with fluorescein angiographic leakage. The most common complications are cataract, maculopathy, and optic atrophy. Male patients have a more severe disease course and worse visual prognosis. Immunomodulatory therapy is indicated in all patients with posterior segment involvement. Corticosteroids combined with azathioprine and/or cyclosporine is used initially. Biologic agents, including interferon alfa and infliximab, are used in resistant cases. Visual prognosis has improved in recent years with an earlier and more aggressive use of immunomodulatory therapy and the use of biologic agents in resistant cases.