Case report: Refractory intestinal Behçet’s syndrome successfully treated with tofacitinib: A report of four cases

Multisystemic Manifestations of Behcet's Disease and Its Treatment Outcome: A Case Report and Review of the Literature

Behcet's disease is a rare multisystem vasculitis that demands early diagnosis and prompt treatment. Clinicians must maintain a high index of suspicion, especially in patients presenting with recurrent oral and genital ulcers with systemic symptoms and adopt a multidisciplinary approach for the optimal management.

Case Report: Successful Remission With Upadacitinib in Behçet's Syndrome Following a History of PFAPA Syndrome

Recent studies have revealed a shared genetic background and pathogenesis between Behçet's syndrome (BS) and periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome. This study suggests genetic similarities between recurrent aphthous stomatitis, PFAPA syndrome, and BS and proposes the concept of Behçet's spectrum disorders. An 18-year-old female with a history of PFAPA syndrome who had experienced repeated attacks until puberty visited our hospital complaining of oral ulcers, arthralgia, rash, and abdominal pain that had persisted for 2 weeks. Colonoscopy revealed a deep ulcer in the ileocecal region. Pathological findings showed no evidence suggestive of viral infection, malignancy, or vasculitis, and only nonspecific inflammatory cell infiltration. After ruling out various autoinflammatory diseases through genetic testing, the patient was diagnosed with Behçet's spectrum disorder. The patient was refractory to adalimumab and achieved remission after upadacitinib therapy. Genetic similarities have been reported between PFAPA syndrome and BS, involving genes such as IL-10 and IL-12A. Since the IL-10, IL-12, and IL-23 pathways can be blocked by JAK inhibitors, JAK inhibition therapy may be a potentially effective treatment option for Behçet's syndrome in a patient with a history of PFAPA syndrome.

Behçet syndrome with eye involvement

Behçet's uveitis (BU) is a significant form of major organ involvement in Behçet syndrome and is associated with considerable morbidity. Ocular examination is crucial for diagnosing BS and detecting vitreous cells, even in asymptomatic patients. The primary goals in managing BU are to rapidly suppress ocular inflammation and prevent relapses. Initial treatment for posterior segment involvement in BU typically involves immunosuppressive agents combined with glucocorticoids. Biologic agents are increasingly used in BU management, including as first-line treatments for patients with poor prognostic risk factors or sight-threatening uveitis. There is no established consensus on when to discontinue or taper immunosuppressive therapy. Once remission is achieved, the absence of retinal vasculitis should be confirmed with fluorescein angiography, which should be utilized throughout the process of tapering immunosuppressive therapy. In addition to monoclonal tumor necrosis factor-alpha antagonists and tocilizumab, Janus kinase inhibitors may offer the potential for managing BU in the future.

Tofacitinib for Refractory Uveitis and Scleritis in Children: A Case Series

PURPOSE

This study analyzes the efficacy and safety of tofacitinib in pediatric patients presenting with treatment-resistant uveitis and scleritis.

METHOD

Retrospective Chart Review.

RESULT

Nine children diagnosed with uveitis and one with scleritis received oral tofacitinib treatment. The median age of these patients was 9 years, with bilateral involvement observed in nine of them. Juvenile idiopathic arthritis was the most identifiable cause of uveitis, with anterior uveitis (50%) being the most frequent subtype of inflammation among these children. The median duration of immunosuppressive treatment before switching to tofacitinib was 18 (16-49) months. Remission of uveitis was achieved in all but two children, who experienced recurrence - manifesting as anterior uveitis. The median duration of follow-up in these children after tofacitinib treatment was 277.5 (183-549) days. At the end of follow-up, topical steroids could be withdrawn in six children, and two children were on topical steroids once a day. None of the children developed any systemic side-effect during the follow-up period. The mean BCVA at presentation was 0.62 ± 0.55, which improved to a mean of 0.27 ± 0.325 at the final follow-up (p = 0.0014).

CONCLUSION

Treatment of pediatric uveitis with tofacitinib can be a valuable second-line treatment option and useful alternative in low- and middle-income countries.

Tofacitinib for the treatment of severe rare skin diseases: a narrative review

PURPOSE

Autoimmune bullous diseases, connective tissue diseases, and vasculitis represent a group of severe rare skin diseases. While glucocorticoids and immunosuppressive agents serve as standard treatments for these diseases, their efficacy is limited due to adverse side effects, indicating the need for alternative approaches. Biologics have been used in the management of some rare skin diseases. However, the use of biologics is associated with concerns, such as infection risk and high costs, prompting the quest for efficacious and cost-effective alternatives. This study discusses the safety issues associated with tofacitinib and its potential in treating rare skin diseases.

METHODS

This narrative review focuses on the pharmacodynamic properties of tofacitinib and its impact on the JAK/STAT pathway. In addition, we present a comprehensive discussion of the effects and mechanism of action of tofacitinib for each severe rare skin disease.

RESULTS

This role of tofacitinib in treating severe rare skin diseases has been discussed, shedding light on its promising prospects as a treatment modality. Few reports of serious adverse events are available in patients treated with tofacitinib.

CONCLUSION

We explored the mechanism of action, efficacy, and safety considerations of tofacitinib and found that it can be used as a treatment option for rare skin diseases. However, multicenter clinical studies are needed to confirm the efficacy and safety of JAK inhibitors.

Behçet's disease with intestinal involvement: a case report and review of the literature

BACKGROUND

Behçet's disease (BD) is a chronic systemic disease characterized by vasculitis as the basic pathological change. BD is rare, and gastrointestinal involvement occurs in 3% to 25% of affected patients. This article describes a rare case of intestinal BD along with a literature review of intestinal involvement in BD.

CASE PRESENTATION

A 50-year-old Han woman from China presented with a > 6-month history of distending pain in the right upper abdomen. Because of mechanical obstruction secondary to stricture formation from an ileocecal ulcer, she underwent radical right colon resection, and postoperative pathologic examination indicated an ileocecal ulcer. The patient was readmitted to the hospital 6 months postoperatively for recurrence of the same symptoms. Colonoscopy indicated obvious narrowing of the anastomosis with an oval-shaped deep ulcer that could not be passed by the endoscope. Pathologic examination showed acute and chronic inflammation of the anastomotic mucosa and granulation tissue. In addition, gastroscopy showed a 3.0- × 4.0-cm giant ulcer at the junction of the descending bulb along with a sinus tract. Moreover, total gastrointestinal computed tomography angiography showed significant thickening of the intestinal wall near the transverse colon, forming a sinus tract at the junction of the antrum and duodenum with a length of about 1.3 cm and width of about 0.2 cm. Further inquiry regarding the patient's medical history revealed that she had developed repeated oral ulcers 3 years previously and repeated eye inflammation 5 years previously. Specimens of the right half of the colon removed 6 months previously were sent to Run Run Shaw Hospital Affiliated to Zhejiang University for consultation. The pathologic examination revealed vasculitis in the submucosa and subserosa, and the patient was finally diagnosed with BD. She began treatment with adalimumab, and repeat gastroenteroscopy revealed that the intestinal ulcer had significantly improved.

CONCLUSIONS

An oval-shaped deep intestinal ulcer is a characteristic lesion in patients with BD and may involve the intestinal muscle layer. This case emphasizes that BD is a vasculitis affecting multiple organs and can present with a single, deep, clean-edged intestinal ulcer that penetrates the bowel wall to form a sinus tract. Therefore, careful examination and differential diagnosis should be carried out to prevent a poor prognosis. Adalimumab is effective for patients with intestinal BD.

Challenges and management of childhood non-infectious chronic uveitis

INTRODUCTION

Childhood uveitis is a sight-threatening condition, because if not properly recognized and treated can lead to several ocular complications and blindness. It represents a real challenge not only from an etiologic/diagnostic point of view, but also for management and therapy.

AREAS COVERED

In this review we will discuss the main etiologies, the diagnostic approach, risk factors associated to childhood non-infectious uveitis (cNIU), and the difficulties in eye examination in childhood. Moreover, we will discuss the treatment of cNIU in term of therapeutic choice, timing of initiation and withdrawal.

EXPERT OPINION

Identification of specific diagnosis is mandatory to prevent severe complications, thus a thorough differential diagnosis is essential. Pediatric eye examination may be extremely challenging due to the scarce collaboration, but novel techniques and biomarkers will help in identify low grade of inflammation, eventually modify long-term outcomes. Once identified the appropriate diagnosis, recognition of children who may benefit of a systemic treatment is crucial. What, When and how long are the key questions to address in this field. Current evidence and future results of ongoing clinical trials will help in driving treatment. A proper ocular screening, not only in the context of systemic disease, should be discussed by experts.