[Case report : Rare case of a spontaneous pseudoaneurysm of the superficial femoral artery revealing Behçet's disease in a young patient]

Behçet's disease is a chronic inflammatory vascular disorder that can affect arteries and veins of various sizes. Arterial involvement, which plays a significant prognostic role, requires a treatment approach involving corticosteroids, immunosuppressants, and potentially surgical or endovascular procedures. This article presents the case of a young man diagnosed with Behçet's disease, manifested by a spontaneous pseudoaneurysm in the superficial femoral artery. The patient underwent surgical intervention to remove the pseudoaneurysm and restore circulation using a venous graft. This case underscores the importance of considering Behçet's disease in vascular manifestations.

Are the specific and nonspecific ANA staining patterns of Behçet's Disease patients important?

BACKGROUND

The autoinflammatory character of Behçet's Disease has led researchers to investigate the role of autoantibodies. However, no significant positive result has been reported for autoantibody tests for the disease.

AIMS

To investigate the specific and nonspecific staining patterns of Behçet's Disease (BD) patients.

METHODS

140 patients (87 females, 53 males) with an average of 41.9±3 years who were being followed up for Behçet's Disease, and a control group consisting of a total of 736 (464 females, 272 males) healthy volunteers made up of blood donors without any disease whose average age was 50.2±4 years were included in the study. Peripheral venous blood was collected from the patients and the sera were separated. Patient sera were studied by indirect immunofluorescence antibody test (IFA) at a dilution of 1/40 and 1/100.

RESULTS

A total of 140 (87 females, 53 males) Behçet's Disease patients and 736 (464 females, 272 males) healthy controls were examined. The rate of ANA positivity was 11.6% in the control group and 10.7% in the Behçet's Disease group. In general, no difference was detected between the patients and the healthy controls in terms of autoantibody positivity (p>0.05). However, when examined in terms of patterns, the low detection of DFS70 and the observation of centriole staining type patterns in Behçet's Disease patients was noteworthy (p<0.05).

CONCLUSION

Autoantibody tests, which hold an important place in classic autoimmune diseases, are not necessary for Behçet's patients, but they should be examined in terms of nonspecific patterns.

Evaluation and Comparison of Choroidal Thickness in Patients with Behçet Disease with versus without Ocular Involvement

Purpose

To assess the subfoveal choroidal thickness (SFCT) in patients with Behçet disease (BD) and compare the SFCT in patients with and without ocular BD (OBD) and between patients with active and quiescent phases of the Behçet's posterior uveitis.

Methods

This prospective cross-sectional study was conducted on patients with BD (n = 51) between October 2016 and October 2018. Complete ocular examinations including slit lamp biomicroscopy and fundus examination with dilated pupils were performed for all patients. The SFCT values were compared between patients with and without OBD. Enhanced depth imaging optical coherence tomography (EDI–OCT) was done to measure the SFCT, and wide field fundus fluorescein angiography (WF-FAG) was performed to evaluate the ocular involvement and determine the active or quiescent phases of the Behçet's posterior uveitis. The correlation between the changes of SFCT and the WF-FAG scores was assessed.

Results

One hundred and two eyes of 51 patients with BD, aged 29 to 52 years were studied. Of these, 23 patients were male. The mean age ± standard deviation in patients with OBD and patients without ocular involvement was 38.71 ± 7.8 and 36.22 ± 10.59 years (P = 0.259) respectively. The mean SFCT in patients with OBD was significantly greater than in patients without OBD (364.17 ± 93.34 vs 320.43 ± 56.70 µm; P = 0.008). The difference of mean SFCT between the active compared to quiescent phase was not statistically significant when only WF-FAG criteria were considered for activity (368.12 ± 104.591 vs 354.57 ± 58.701 µm, P = 0.579). However, when the disease activity was considered based on both WF-FAG and ocular exam findings, SFCT in the active group was higher than the inactive group (393.04 ± 94.88 vs 351.65 ± 58.63 µm, P = 0.060). This difference did not reach statistical significance, but it was clinically relevant.

Conclusion

Choroidal thickness was significantly increased in BD patients with ocular involvement; therefore, EDI-OCT could be a noninvasive test for evaluation of ocular involvement in patients with BD. The increased SFCT was not an indicative of activity in OBD; however, it could predict possible ocular involvement throughout the disease course.

Are the Specific and Nonspecific ANA Staining Patterns of Behçet's Disease Patients Important?

BACKGROUND

The autoinflammatory character of Behçet's Disease has led researchers to investigate the role of autoantibodies. However, no significant positive result has been reported for autoantibody tests for the disease.

AIMS

To investigate the specific and nonspecific staining patterns of Behçet's Disease (BD) patients.

METHODS

140 patients (87 females, 53 males) with an average of 41.9±3 years who were being followed up for Behçet's Disease, and a control group consisting of a total of 736 (464 females, 272 males) healthy volunteers made up of blood donors without any disease whose average age was 50.2±4 years were included in the study. Peripheral venous blood was collected from the patients and the sera were separated. Patient sera were studied by indirect immunofluorescence antibody test (IFA) at a dilution of 1/40 and 1/100.

RESULTS

A total of 140 (87 females, 53 males) Behçet's Disease patients and 736 (464 females, 272 males) healthy controls were examined. The rate of ANA positivity was 11.6% in the control group and 10.7% in the Behçet's Disease group. In general, no difference was detected between the patients and the healthy controls in terms of autoantibody positivity (p>0.05). However, when examined in terms of patterns, the low detection of DFS70 and the observation of centriole staining type patterns in Behçet's Disease patients was noteworthy (p<0.05).

CONCLUSION

Autoantibody tests, which hold an important place in classic autoimmune diseases, are not necessary for Behçet's patients, but they should be examined in terms of nonspecific patterns.

Identification of an Unconventional Subpeptidome Bound to the Behçet's Disease-associated HLA-B*51:01 that is Regulated by Endoplasmic Reticulum Aminopeptidase 1 (ERAP1)

Human leukocyte antigen (HLA) B*51:01 and endoplasmic reticulum aminopeptidase 1 (ERAP1) are strongly genetically associated with Behçet's disease (BD). Previous studies have defined two subgroups of HLA-B*51 peptidome containing proline (Pro) or alanine (Ala) at position 2 (P2). Little is known about the unconventional non-Pro/Ala2 HLA-B*51-bound peptides. We aimed to study the features of this novel subpeptidome, and investigate its regulation by ERAP1. CRISPR-Cas9 was used to generate an HLA-ABC-triple knockout HeLa cell line (HeLa.ABC-KO), which was subsequently transduced to express HLA-B*51:01 (HeLa.ABC-KO.B51). ERAP1 was silenced using lentiviral shRNA. Peptides bound to HLA-B*51:01 were eluted and analyzed by mass spectrometry. The characteristics of non-Pro/Ala2, Pro2, and Ala2 peptides and their alteration by ERAP1 silencing were investigated. Effects of ERAP1 silencing on cell surface expression of HLA-B*51:01 were studied using flow cytometry. More than 20% of peptides eluted from HLA-B*51:01 lacked Pro or Ala at P2. This unconventional group of HLA-B*51:01-bound peptides was relatively enriched for 8-mers (with relatively fewer 9-mers) compared with the Pro2 and Ala2 subpeptidomes and had similar N-terminal and C-terminal residue usages to Ala2 peptides (with the exception of the less abundant leucine at position Ω). Knockdown of ERAP1 increased the percentage of non-Pro/Ala2 from 20% to ∼40%, increased the percentage of longer (10-mer and 11-mer) peptides eluted from HLA-B*51:01 complexes, and abrogated the predominance of leucine at P1. Interestingly knockdown of ERAP1 altered the length and N-terminal residue usage of non-Ala2&Pro2 and Ala2 but not the Pro2 peptides. Finally, ERAP1 silencing regulated the expression levels of cell surface HLA-B*51 in a cell-type-dependent manner. In conclusion, we have used a novel methodology to identify an unconventional but surprisingly abundant non-Pro/Ala2 HLA-B*51:01 subpeptidome. It is increased by knockdown of ERAP1, a gene affecting the risk of developing BD. This has implications for theories of disease pathogenesis.

Increased Serum Antibody Titer against HPV-16 Antigen in Patients with Behçet's Disease

Quadrivalent human papillomavirus (HPV) vaccine has been reported to be significantly associated with Behçet's disease (BD). However, no reports have described HPV infection as a possible cause for the development of BD. The objective of this study was to evaluate whether anti-HPV immunoglobulin G (IgG) antibody titer is increased in BD. Serum samples from 93 Korean BD patients, who fulfilled the diagnostic criteria of the International Study Group for BD, were used in an enzyme-linked immunosorbent assay (ELISA). The clinical activity of BD was evaluated at the time of blood sampling. HPV-16 L1 virus-like particle (VLP) antigen was used in this study for the ELISA. Patients with BD had significantly higher antibody titers against HPV-16 (optical density [OD], 0.210-3.675; mean 0.992) than that of healthy controls (OD, 0.248-0.762; mean 0.517; P < 0.001). Using a receiver operating characteristic (ROC) analysis, a cut-off value of 0.578 OD for the anti-HPV antibody titer was determined that differentiated BD patients from healthy controls. When we compared the clinical features of BD between the 2 groups, articular involvement of BD was more likely in patients with an anti-HPV-16 antibody titer < 0.578 OD (P = 0.035). In addition, patients with an anti-HPV-16 antibody titer < 0.578 were significantly younger than those with a titer ≥ 0.578 OD. HPV itself may be a possible extrinsic triggering infectious agent causing the development of BD.

Polymorphisms of Promoter Region of TNF-α Gene in Iranian Azeri Turkish Patients with Behçet's Disease

Behçet's disease (BD) is a complex chronic relapsing inflammatory disorder of unknown etiology. Alterations of the tumor necrosis factor (TNF) expression related to the polymorphic alleles of TNF gene may implicate a pathogenetic role in increased activity of this cytokine in BD. A current study aimed at investigating the possible association between BD and its clinical features in Iranian Azeri Turks with two functional TNF-α gene polymorphisms (at the positions of -238 and -857). A total number of 166 Iranian subjects were enrolled into two different groups; patients with BD (n = 64), and ethnically matched healthy controls (n = 101). The genotype distributions of BD patients and healthy controls were determined. The frequency of TNF-α -857C allele was significantly higher in Behçet's patients than that of healthy controls (P = 0.001; odds ratio [OR] = 2.616; 95% confidence interval [CI] = 1.129-6.160), whereas the frequency of TNF-α -238A allele was similar in both groups. The sole TNF-α haplotype-857C-1031C, was associated with an increase in the risk of developing BD. The TNF-α -857C allele was considerably associated with BD in this cohort. The findings of this study, collectively, indicate that TNF-α -857C-1031C haplotype located in the promoter region of the gene could exert major influence on the susceptibility to BD.

Pattern of uveitis at a referral center in Iraq

PURPOSE

To determine the etiologies of uveitis and the causes of visual loss in uveitis patients at a referral center in Baghdad, Iraq.

PATIENTS AND METHODS

A 4-year prospective study was performed at the uveitis clinic at Ibn Al-Haetham teaching eye hospital in Baghdad, Iraq. Referral cases of active uveitis were included. A complete ophthalmic examination was performed in all cases. If clinical picture did not indicate a specific etiology, patients were sent for a routine set of tests while ancillary tests were conducted when indicated.

RESULTS

Out of 318 patients included in this study, 236 patients (74.2%) had bilateral uveitis, and 212 patients (66.7%) had non-granulomatous uveitis. Posterior uveitis was recorded in 123 cases (38.7%) followed by panuveitis in 97 cases (30.5%), anterior uveitis in 78 cases (24.5%), and intermediate uveitis in 20 cases (6.3%). A diagnosis was established in 210 cases (66%) while etiology could not be determined in the remaining 108 cases (34%). Most common infectious causes were toxoplasmosis (13.8%) and presumed ocular tuberculosis (11.4%) while most common non-infectious causes were Vogt-Koyanagi-Harada disease (12.3%), Behηet's disease (8.2%), and pars planitis (5.7%). Out of 49 eyes with irreversible blindness, macular degenerations, or scars (46.9%) and optic nerve atrophy (34.7%) were the most important causes.

CONCLUSION

At this referral center, toxoplasmosis and presumed ocular tuberculosis were the most common infectious causes of uveitis while Vogt-Koyanagi-Harada disease, Behηet's disease, and pars planitis were, in that order, the most common non-infectious causes. Macular degenerations or scars and optic nerve atrophy were the most important causes of irreversible blindness.

A systematic approach to emergencies in uveitis

Uveitis is a common cause of preventable blindness although it is consider a sight-threatening condition particularly in cases with posterior segment inflammation. To deal with emergency conditions in uveitis, we must aware of the essential signs and symptoms that reflect a true uveitic emergency. Failure to recognize these essential signs and symptoms of a true uveitic emergency may result in a devastating visual outcome. This review provides general ophthalmologists and residents, clinical guidelines for the main uveitic entities that require immediate recognition and urgent intervention in the emergency room to prevent severe permanent visual loss.

Secondary Syphilis with Nodular Vasculitis Mimicking Behçet's Disease

Although, erythema nodosum is a common skin manifestation associated with syphilis, nodular vasculitis is a rare feature. Here, we describe a case of a 22-year-old, human immunedeficiency virus negative, non-immunocompromised man who developed recurrent oral and scrotal ulcers with nodular lesions of the lower extremitie. Behçet's disease was initially suspected, however, his serologic test for syphilis was positive, and he was thus diagnosed with secondary syphilis, with a skin biopsy showing nodular vasculitis. The patient was treated with benzathine penicillin, and the skin lesions disappeared after treatment.

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.