Association of Long Non-coding RNA C1RL-AS1 and PTPN6 Gene Polymorphisms with Ocular Behcet's Disease in Han Chinese

PURPOSE

To explore the association of the polymorphisms in PTPN6 and LncRNA C1RL-AS1 genes with ocular BD in Han Chinese patients.

METHODS

Correlation study was performed using the iPLEX system on a cohort of ocular BD patients andcontrols. The genotyping of 7 SNPs for LncRNA C1RL-AS1 and PTPN6 genes in ocular BD patients was performed using the iPLEX Gold genotype.

RESULTS

The frequencies of rs4013722 AG genotype/A allele in LncRNA C1RL-AS1 were significantly decreased in BD patients, and the frequency of GG genotype was significantly increased in BD patients. The rs4013722 was associated with ocular BD in male patients, but not in female patients. The AG and GG genotype of rs4013722 were associated with skin lesions in male patients. The gene polymorphisms of PTPN6 were not associated with BD patients.

CONCLUSIONS

The LncRNA C1RL-AS1/rs4013722 polymorphism conferred susceptibility to ocular BD in Han Chinese patients, which was influenced by sex.Abbreviations: LncRNA: Long Non-coding RNA; BD: Behcet's disease; SNP: single nucleotide polymorphism; PBMCs: peripheral blood mononuclear cells; PTPs: Protein tyrosine phosphatases; PTPN6: protein tyrosine phosphatase non-receptor 6; GWAS: genome-wide association study; HWE: Hardy-Weinberg equilibrium; LD: linkage disequilibrium; OR: odds ratio; CI: confidence interval; eQTL: expression quantitative trait loci; IBD: inflammatory bowel disease; RA: rheumatoid arthritis; Padj: Bonferroni corrected P value; NS: non-significant.

COVID 19 vaccination as a trigger of acute genital ulcers in an immunocompromised adolescent-case study and literature review

Acute genital ulcers can affect females of all ages. In children, they often appear as an emergency and remain a diagnostic challenge for pediatricians, gynecologists and dermatologists. Prompt diagnosis and identification of disease- related factors help to implement appropriate treatment. Firstly, it is crucial to properly compile the past medical history of the patient. Past infectious, autoimmune, malignant or traumatic conditions, as well as vaccinations may contribute to the occurrence of acute genital ulcers. Moreover, new infectious agents, such as severe acute respiratory syndrome coronavirus 2 and vaccinations against Coronavirus disease of 2019, may play a significant role in the development of atypical clinical symptoms. Here we present a case of a 12-year-old girl with acute genital ulcers. Additional symptoms accompanying the ulcer included: abdominal pain, nausea, vomiting, dysuria, vulvar pain and fever. Blood test showed leukocytosis, especially neutrophilia and monocytosis and increased levels of c-reactive protein and procalcitonin. Serological tests for the most common infections were negative. Moreover, the patient had a history of autoimmune diseases. She had periodic fever, aphthous stomatitis, pharyngitis, and adenitis syndrome, and IgA vasculitis, also known as Henoch-Schönlein purpura in her past medical history. Additionally, she was vaccinated against SARS-CoV-2 shortly before the lesions appeared.

Patient Experiences and Challenges in the Management of Autoinflammatory Diseases-Data from the International FMF & AID Global Association Survey

BACKGROUND

Autoinflammatory diseases (AIDs) are rare, mostly genetic diseases that affect the innate immune system and are associated with inflammatory symptoms. Both paediatric and adult patients face daily challenges related to their disease, diagnosis and subsequent treatment. For this reason, a survey was developed in collaboration between the FMF & AID Global Association and the Erlangen Center for Periodic Systemic Autoinflammatory Diseases.

METHODS

The aim of the survey was to collect the personal assessment of affected patients with regard to their current status in terms of diagnostic timeframes, the interpretation of genetic tests, the number of misdiagnoses, and pain and fatigue despite treatment.

RESULTS

In total, data from 1043 AID patients (829 adults and 214 children/adolescents) from 52 countries were collected and analyzed. Familial Mediterranean fever (FMF) (521/50%) and Behçet's disease (311/30%) were the most frequently reported diseases. The average time to diagnosis was 3 years for children/adolescents and 14 years for adults. Prior to the diagnosis of autoinflammatory disease, patients received several misdiagnoses, including psychosomatic disorders. The vast majority of patients reported that genetic testing was available (92%), but only 69% were tested. A total of 217 patients reported that no increase in acute-phase reactants was detected during their disease episodes. The intensity of pain and fatigue was measured in AID patients and found to be high. A total of 88% of respondents received treatment again, while 8% reported no treatment.

CONCLUSIONS

AID patients, particularly adults, suffer from significant delays in diagnosis, misdiagnosis, and a variety of symptoms, including pain and fatigue. Based on the results presented, raising awareness of these diseases in the wider medical community is crucial to improving patient care and quality of life.

Investigation of optic nerve function in Behçet's patients with optic disc hyperfluorescence in fundus fluorescein angiography

PURPOSE

The aim was to investigate the changes in optic nerve function that may help in the diagnosis of subclinical optic nerve involvement in patients with Behçet's disease (BD) and isolated optic disc (OD) hyperfluorescence in fluorescein angiography (FA).

MATERIALS AND METHODS

Three groups were formed; BD patients with isolated OD hyperfluorescence in FA, BD patients without ocular involvement (normal FA) and control group. A total of 88 eyes of 45 patients were included. The groups were compared in terms of OCT-RNFL, contrast sensitivity and VEP latency.

RESULTS

When the OCT-RNFL values were compared, there was a significant difference between the control group and Behçet's patients with normal FA. Contrast sensitivity values differed significantly among the groups, and the lowest mean contrast sensitivity was observed in the group with OD hyperfluorescence (p < 0.05).

CONCLUSION

As far as we know, this is the first publication that investigates optic nerve function in BD patients with isolated OD hyperfluorescence in FA. Assessment with FA of asymptomatic BD patients with visual complaints and low contrast sensitivity may be helpful at early detection of inflammatory optic neuropathy by close follow-up in patients with OD hyperfluorescence.

Endovascular repair with a physician-modified fenestrated endograft to treat abdominal aortic pseudoaneurysm with Behcet's disease: a case report

BACKGROUND

Aortic involvement in patients with Behcet's disease (BD) is rare, but it is one of the most severe manifestations. Open surgical repair of aortic aneurysm is challenging considering the high risk of postoperative recurrent anastomotic pseudoaneurysms and is associated with a much higher mortality rate. Recently, endovascular treatment has proven to be a feasible, less invasive alternative to surgery for these patients.

CASE PRESENTATION

We report a total endovascular repair of a paravisceral abdominal aortic pseudoaneurysm in a 25-year-old male patient with BD. The pseudoaneurysm was successfully excluded, and the blood supply of visceral arteries was preserved with a physician-modified three-fenestration endograft under 3D image fusion guidance. Immunosuppressive therapy was continued for 1 year postoperatively. At 18 months, the patient was asymptomatic without abdominal pain. Computed tomography angiography demonstrated the absence of pseudoaneurysm recurrence, good patency of visceral vessels.

DISCUSSION AND CONCLUSIONS

Endovascular repair using physician-modified fenestrated endografts is a relatively safe and effective approach for treating paravisceral aortic pseudoaneurysm in BD patients. This technique enables the preservation of the visceral arteries and prevents aneurysm recurrence at the proximal and distal landing zones, which are common complications of open surgical repair in these patients. Furthermore, we emphasize the importance of adequate immunosuppressive therapy before and after surgical repair in BD patients, which is a major risk factor for recurrence and poor prognosis.

"Deficiency in ELF4, X-Linked": a Monogenic Disease Entity Resembling Behçet's Syndrome and Inflammatory Bowel Disease

Defining monogenic drivers of autoinflammatory syndromes elucidates mechanisms of disease in patients with these inborn errors of immunity and can facilitate targeted therapeutic interventions. Here, we describe a cohort of patients with a Behçet's- and inflammatory bowel disease (IBD)-like disorder termed "deficiency in ELF4, X-linked" (DEX) affecting males with loss-of-function variants in the ELF4 transcription factor gene located on the X chromosome. An international cohort of fourteen DEX patients was assessed to identify unifying clinical manifestations and diagnostic criteria as well as collate findings informing therapeutic responses. DEX patients exhibit a heterogeneous clinical phenotype including weight loss, oral and gastrointestinal aphthous ulcers, fevers, skin inflammation, gastrointestinal symptoms, arthritis, arthralgia, and myalgia, with findings of increased inflammatory markers, anemia, neutrophilic leukocytosis, thrombocytosis, intermittently low natural killer and class-switched memory B cells, and increased inflammatory cytokines in the serum. Patients have been predominantly treated with anti-inflammatory agents, with the majority of DEX patients treated with biologics targeting TNFα.

Imaging characteristics and prognostic factors of Behcet's disease with arterial involvement: A long-term follow-up study

PURPOSE

To investigate the imaging characteristics and prognostic factors for the long-term survival of Behcet's disease (BD) with arterial involvement.

METHODS

In this retrospective study, BD patients with arterial involvement were identified from January 2003 to January 2020. Arterial lesions were detected by ultrasonography, traditional arteriography, and/or computed tomography angiography (CTA). Cox proportional hazards regression analyses were performed to identify the prognostic factors.

RESULTS

Totally, 84 BD patients with arterial involvement were identified (73.8 % males). The mean age at BD diagnosis was 39.1 ± 13.1 years. Arterial involvement was the initial manifestation in 33.3 % of the patients, and the median time from BD diagnosis to arterial involvement was 6 (IQR 1-15.5) years for the rest of patients. Systemic artery involvement and pulmonary artery involvement (PAI) were found in 64 and 27 patients, respectively. Approximately 94.0 % (79/84) of the patients had more than one artery involved concurrently or successively during the course of BD. Aneurysm/dilation was the most prevalent lesion in the aorta (76.0 %), while stenosis/occlusion was the main lesion of the coronary artery (90.9 %) and other aortic branches (74.5 %). Pulmonary hypertension was found in 70.4 % (19/27) of patients with PAI. The 5- and 10-year survival rates of BD patients with arterial involvement were 87.4 % and 84.1 %, respectively. Cardiac involvement (HR: 4.34) and pulmonary artery aneurysm/dilation (HR: 4.89) were independently associated with mortality.

CONCLUSIONS

Arterial lesions associated with BD usually involve multiple arteries and manifest differently in different types of arteries. Cardiac involvement and pulmonary artery aneurysm/dilation are independent prognostic factors of BD patients with arterial involvement.

Shelterin Dysfunction Promotes CD4+ T Cell Senescence in Behçet's Disease

OBJECTIVES

To investigate the potential role of shelterin dysfunction in naïve CD4+ T cells in the pathogenesis of Behçet's disease (BD).

METHODS

Naïve CD4+ T cells were isolated from 40 BD patients and 40 sex- and age-matched healthy controls (HC). Senescent profiles, shelterin subunits expression, telomere length, telomerase activity, and critical DNA damage response (DDR) was evaluated. TRF2 silencing was conducted for further validation.

RESULTS

Compared to HC, BD patients had significantly decreased naïve CD4+ T cells, increased cell apoptosis, senescence, and productions of TNF-α and IFN-γ upon activation. Notably, BD naïve CD4+ T cells had shortened telomere, impaired telomerase activity, and expressed lower levels of shelterin subunits TRF2, TIN2, and RAP1. Furthermore, BD naïve CD4+ T cells exhibited significantly increased DDR, evidenced by elevated phosphorylated ataxia telangiectasia (AT) mutated (pATM), pp53, and p21. Finally, TRF2-silencing markedly upregulated DDR, apoptosis, and proinflammatory cytokines production in HC naïve CD4+ T cells.

CONCLUSION

Our study demonstrated that TRF2 deficiency in BD naïve CD4+ T cells promoted cell apoptosis and senescence, leading to proinflammatory cytokines overproduction. Therefore, restoring TRF2 might be a promising therapeutic strategy for BD.

Integrated analyses delineate distinctive immunological pathways and diagnostic signatures for Behcet's disease by leveraging gene microarray data

Behcet's disease (BD) is a chronic inflammatory vasculitis and clinically heterogeneous disorder caused by immunocyte aberrations. Comprehensive research on gene expression patterns in BD illuminating its aetiology is lacking. E-MTAB-2713 downloaded from ArrayExpress was analysed to screen differentially expressed genes (DEGs) using limma. Random forest (RF) and neural network (NN) classification models composed of gene signatures were established using the E-MTAB-2713 training set and subsequently verified using GSE17114. Single sample gene set enrichment analysis was used to assess immunocyte infiltration. After identifying DEGs in E-MTAB-2713, pathogen-triggered, lymphocyte-mediated and angiogenesis- and glycosylation-related inflammatory pathways were discovered to be predominant in BD episodes. Gene signatures from the RF and NN diagnostic models, together with genes enriched in angiogenesis and glycosylation pathways, well discriminated the clinical subtypes of BD manifesting as mucocutaneous, ocular and large vein thrombosis involvement in GSE17114. Moreover, a distinctive immunocyte profile revealed T, NK and dendritic cell activation in BD compared to the findings in healthy controls. Our findings suggested that EPHX1, PKP2, EIF4B and HORMAD1 expression in CD14+ monocytes and CSTF3 and TCEANC2 expression in CD16+ neutrophils could serve as combined gene signatures for BD phenotype differentiation. Pathway genes comprising ATP2B4, MYOF and NRP1 for angiogenesis and GXYLT1, ENG, CD69, GAA, SIGLEC7, SIGLEC9 and SIGLEC16 for glycosylation also might be applicable diagnostic markers for subtype identification.

Surgical treatment of Behcet's disease with severe aortic regurgitation

Behcet's disease (BD) is a multisystem inflammatory disease that is characterized by oral aphthosis, genital aphthosis, ocular lesions, and cutaneous lesions. Although BD rarely affects the cardiovascular system, its symptoms can be shown as aortic regurgitation (AR), which requires surgical intervention. Due to the special pathogenesis of BD, a low preoperative diagnosis rate and a high incidence of serious complications, such as perivalvular leakage, valve detachment, and pseudoaneurysm after prosthetic valve replacement, surgical treatment of BD with severe AR has a poor prognosis. In recent years, new surgical strategies have been developed to improve treatment efficacy for this disease. This article reviews and summarizes the evolution of surgical techniques for BD with AR and aims to provide a reference for optimizing surgical strategies, improving perioperative management, and assisting prognosis in patients suffering from BD with severe AR.

Flanged Bentall procedure for paravalvular leakage and pseudoaneurysm after root replacement in Behcet's disease and infective endocarditis: a case report

Background

Behcet's disease is a multi-systemic inflammatory disorder. Paravalvular leakage and aortic pseudoaneurysm are rare in patients with Behcet's disease after aortic root replacement. Complicated post-operative infective endocarditis can make the treatment more difficult. We applied a flanged Bentall procedure to treat one such case.

Case summary

A 27-year-old man with aortic regurgitation and Behcet's disease underwent aortic root replacement. Post-operative electrocardiogram showed a complete atrioventricular block. One year after the operation, he underwent percutaneous temporary pacemaker implantation and endovascular stent graft exclusion because of pseudoaneurysm of the ascending aorta. Post-operative fever and blood culture confirmed infective endocarditis. Examination showed paravalvular leakage and pseudoaneurysm recurrence. Then, the patient underwent a third operation in our hospital. Aortic root replacement with a flanged composite valved conduit was performed. Immunosuppressants and antibiotic treatment were given after surgery. After 3 months, the cardiovascular examination was normal, and the patient was in good condition.

Discussion

Surgical treatment of aortic regurgitation caused by Behcet's disease was characterized by a high rate of paravalvular leakage, which led to reoperation and high mortality. Combined infective endocarditis would further increase the difficulty and risk of treatment. It is important to maintain effective immunosuppressive therapy while monitoring serum biomarkers and inflammation indicators. The potential hazards of immunosuppressants are increased risk of infection and poor tissue healing. In our case, targeted antibiotic treatment and appropriate immunosuppressive therapy were well balanced. The flanged Bentall procedure was also the key to success, which could increase aortic effective orifice area and reduce the risk of dehiscence.

Subclinical atherosclerosis in Behcet's disease and its inverse relation to azathioprine use: an updated meta-analysis

To evaluate the intima media thickness of carotid arteries (IMT) and its clinical, laboratory and treatment correlates in Behcet's disease (BD). Systematic search of EMBASE and PubMed databases from January 2016 to October 2022; we employed random effect meta-analyses for continuous outcomes and Peto's odds ratio for rare events. The meta-analysis included 36 case control studies: the IMT was greater in BD (n = 1103) than in controls (n = 832) (p < 0.0001) with wide heterogeneity (I2 = 86.9%); a sensitivity analysis that included mean age of BD participants, gender, disease duration and activity, atherogenic index of plasma, blood pressure, C-reactive protein, ethnicity, smoking status, anti-inflammatory and immune suppressive agents, revealed that male gender, mean age of participants and azathioprine use (the latter two in inverse fashion) partly explained the heterogeneity variance (p = 0.02, p = 0.005, and p = 0.01). The IMT was greater in vascular (n = 114) than in non-vascular BD (n = 214) (p = 0.006). BD patients (n = 782) had a greater pooled prevalence of carotid plaques than controls (n = 537) (13.1% vs. 2.97%, p < 0.0001). Subclinical carotid artery atherosclerosis represents a vascular feature of BD, independently of the traditional cardiovascular risk factors. The inverse correlations between IMT, age and azathioprine use suggest that thicker carotid arteries at disease onset eventually regress with immune suppressive treatment: this assumption needs verification on adequately designed clinical trials.

Validity and reliability of the BODI for assessing damage in Behcet's disease

OBJECTIVE

In the present study, we aimed to validate the Behçet's syndrome Overall Damage Index (BODI) and compare its performance with that of vasculitis damage index (VDI) in Iranian patients with BD.

METHODS

This study included 274 patients with a diagnosis of BD and median follow-up of 40 months. The medical records of the patients were reviewed and the demographic characteristics, disease activity status, clinical manifestations, and data on organs damage were collected from all patients.

RESULTS

To evaluate the construct/convergent validity, BODI and VDI were applied to all participants. We found a good correlation between BODI score and VDI score. There was a significant and strong correlation between physician global assessment with BODI (r = 0.869, P = 0.001) and VDI (r = 0.817, P = 0.001). The ability of BODI to determine the accumulation of damage over time was assessed by analyzing the changes in BODI score over time. The increase in BODI score was occurred in 53 (19.3%) patients. In comparison, the increase in VDI score occurred in 36 (13.1%) patients. The increase in median BODI was significantly more than median VDI (P < 0.001). Multiple linear regression analysis showed that age at disease onset, disease duration, and disease severity were independent predictors of BODI scores. Reliability of BODI was examined by comparing the BODI scores as determined by two independent assessors in 100 patients. Cronbach's α was 0.942.

CONCLUSION

The BODI demonstrated acceptable validity and reliability in assessing BD-related damage in Iranian patients with BD.

Evaluation of the Psychoeducation Program Given to Behcet's Patients in the Context of the Roy Adaptation Model

The physical, social, and psychological effects of Behcet's disease necessitate the person's adaptation in many areas. This study was conducted to examine the effect of psychoeducation provided to people living with Behcet's disease in the context of the Roy adaptation model on illness adjustment, dyadic adjustment, self-esteem, and psychiatric symptoms. The study was quasi-experimental. The study was with 70 patients with Behcet's disease: 35 patients were in the intervention group and the same number in the control group. The data of the study were collected using the Adaptation to Chronic Illness Scale, Dyadic Adjustment Scale, Rosenberg Self-Esteem Scale, and Brief Symptom Inventory. A seven-session psychoeducation program was provided to the intervention group. After the psychoeducation program, adaptation to illness increased significantly and psychiatric symptoms decreased significantly in the intervention group compared with the control group (P < .05).

A rare case of Behcet's disease in Nepal: multisystem manifestations and diagnostic challenges

Behcet's disease (BD) is a chronic inflammatory disorder characterized by a relapsing and remitting course and multisystem involvement. The authors present a case report of a 20-year-old male who presented with bilateral knee joint pain, oral and genital ulcers, and papulopustular skin lesions. The patient's clinical history, physical examination, laboratory findings, and biopsy results were consistent with the diagnosis of BD. The patient tested positive for the HLA-B51 allele, confirming a genetic predisposition. The diagnosis was supported by a positive pathergy test and a skin biopsy showing vasculitis. The diagnostic criteria established by the international study group and the International Criteria for Behcet's Disease were fulfilled. Treatment consisted of colchicine, azathioprine, and topical corticosteroids. This case highlights the importance of recognizing the varied clinical presentations of BD and the need for a multidisciplinary approach to diagnosis and management. Early and accurate diagnosis is crucial to prevent severe complications and improve patient outcomes.

Vascular Involvement in Behcet's Disease: An Evaluation of 147 Cases and Literature Review

Objectives

Behcet's disease (BD) is characterized by systemic vasculitis with inflammation that can affect various body organs. In BD, vasculitis primarily manifests with venous involvement, distinguishing it from other forms of systemic vasculitis.

Methods

We retrospectively analyzed the demographic and clinical characteristics of 147 patients diagnosed with vascular BD in our center.

Results

Vascular BD cases accounted for 25.0% (147 out of 589) of all BD patients. A statistically significant correlation was found between gender and vascular involvement that was seen predominantly in males (76.9%). In 71 patients, a vascular event developed during follow-up for BD, while in 76 patients the disease was diagnosed after the occurrence of a vascular event (51.7%). The most common vascular event was deep vein thrombosis in the lower extremities (69.4%). Arterial involvement was primarily observed in the pulmonary arteries (12.9%). Patients with lower extremity deep vein thrombosis tended to be younger, while those with pulmonary artery involvement were typically older. Overall, veins were affected 4.5 times more frequently than arteries.

Conclusion

The prevalent type of venous involvement was deep vein thrombosis in the lower extremities. Thrombotic events in BD cannot be solely attributed to abnormalities in thrombotic factors. The treatment of thrombotic events in BD remains contentious, with anticoagulant efficacy being debated and immunosuppressive therapy representing the primary treatment approach. Behcet's disease should be considered when a young male patient presents with an arterial or venous vascular event, especially if it is recurrent.

Advances in pathogenesis and treatment of ocular involvement in Behcet's disease

Behcet's disease (BD) is a chronic multi-systemic disease characterized by relapsing-remitting oral ulcers, genital ulcers, ocular inflammatory involvements, and numerous other systemic features. Ocular involvements are quite common in BD and may cause severe tissue damage and potentially blindness. Even though the pathogenesis of BD remains ambiguous, growing evidences have shown that genetic factors, environmental triggers and immunological abnormalities play significant roles in its development and progression. Novel biotherapies targeting IFN-γ, TNF-α and interleukins have been used in recent years. In this review, we mainly pay attention to the ocular involvement of BD, and discuss the current understanding of mechanisms and advances in therapeutic approaches, especially novel biologics. Finally, we discuss the management in patients with pregnancy.

Aortic sinus aneurysm invading ventricular septum and dissection caused by Behcet's disease: a case report and literature review

Few case reports have mentioned the aortic sinus aneurysm invading ventricular septum and dissection caused by Behcet's disease. Here, we reported a 36-year-old male patient with an aortic sinus aneurysm invading the ventricular septum and dissection caused by Behcet's disease, who manifested as recurrent chest tightness and shortness of breath. Cardiac ultrasound showed the rupture of the right aortic sinus and the formation of ventricular septal dissection. Ascending aortic valve prosthesis replacement, mitral valvuloplasty with ring implantation and tricuspid valvuloplasty were performed. Postoperatively, he was treated with hormones, hydroxychloroquine sulfate, mycophenolate mofetil tablets, thalidomide and warfarin, and his symptoms were relieved. This is a rare case easily being misdiagnosed and missed, early diagnosis and in-time treatment are crucial to avoid surgical complications. The diagnostic and therapeutic approaches of this patient were reported and related literature was reviewed in this case report.

Digital Analysis of Clinical Screening Criteria for a Rare Disease - Behcet's Disease

The objective is to identify clinical screening criteria for a rare disease,- Behcet's disease and to analyse the digitally structured and unstructured components of the Identified Clinical criteria, build a clinical archetype using OpenEHR editor to be used by learning health support systems for clinical screening of the disease. Methods/Search Strategy: Literature search was conducted, 230 papers were screened, and finally 5 papers were retained, analysed and summarised. Digital Analysis of the clinical criteria was done and a sandardised clinical knowledge model of the same was built using OpenEHR editor, underpinned by OpenEHR international standards. Results The structured and unstructured components of the criteria analysed to be able to incorporate them in a learning health system to screen patients for Behcet's disease. SNOMED CT and Read codes were assigned to the structured componenets. Possible misdiagnosis were identified, along with their corresponding clinical terminology codes that can be incorporated in the Electronic Health Record systems. Conclusion: The identified clinical screening was digitally analysed which can be embedded into a clinical decision support system that can be plugged onto the primary care systems to give an alert to the clinicians if a patient needs to be screened for a rare disease, for e.g., Behcet's.

Can early-onset acquired demyelinating syndrome (ADS) hide pediatric Behcet's disease? A case report

Behcet's disease (BD) is a rare vasculitis characterized by multisystemic inflammation. Central nervous system (CNS) involvement is rare and heterogeneous, particularly in the pediatric population. A diagnosis of neuro-Behcet could be highly challenging, especially if neurological manifestations precede other systemic features; however, its timely definition is crucial to prevent long-term sequelae. In this study, we describe the case of a girl who, at 13 months of age, presented with a first episode of encephalopathy compatible with acute disseminated encephalomyelitis, followed, after 6 months, by a neurological relapse characterized by ophthalmoparesis and gait ataxia, in association with new inflammatory lesions in the brain and spinal cord, suggesting a neuromyelitis optica spectrum disorder. The neurological manifestations were successfully treated with high-dose steroids and intravenous immunoglobulins. In the following months, the patient developed a multisystemic involvement suggestive of Behcet's disease, characterized by polyarthritis and uveitis, associated with HLA-B51 positivity. The challenge presented by this unique case required a multidisciplinary approach involving pediatric neurologists, neuro-radiologists, and pediatric rheumatologists, with all of these specialists creating awareness about early-onset acquired demyelinating syndromes (ADSs). Given the rarity of this presentation, we performed a review of the literature focusing on neurological manifestations in BD and differential diagnosis of patients with early-onset ADS.

Identification of the immune-related biomarkers in Behcet's disease by plasma proteomic analysis

BACKGROUND

This study aimed to investigate the expression profile of immune response-related proteins of Behcet's disease (BD) patients and identify potential biomarkers for this disease.

METHODS

Plasma was collected from BD patients and healthy controls (HC). Immune response-related proteins were measured using the Olink Immune Response Panel. Differentially expressed proteins (DEPs) were used to construct prediction models via five machine learning algorithms: naive Bayes, support vector machine, extreme gradient boosting, random forest, and neural network. The prediction performance of the five models was assessed using the area under the curve (AUC) value, recall (sensitivity), specificity, precision, accuracy, F1 score, and residual distribution. Subtype analysis of BD was performed using the consensus clustering method.

RESULTS

Proteomics results showed 43 DEPs between BD patients and HC (P < 0.05). These DEPs were mainly involved in the Toll-like receptor 9 and NF-κB signaling pathways. Five models were constructed using DEPs [interleukin 10 (IL10), Fc receptor like 3 (FCRL3), Mannan-binding lectin serine peptidase 1 (MASP1), NF2, moesin-ezrin-radixin like (MERLIN) tumor suppressor (NF2), FAM3 metabolism regulating signaling molecule B (FAM3B), and O-6-methylguanine-DNA methyltransferase (MGMT)]. Among these models, the neural network model showed the best performance (AUC = 0.856, recall: 0.692, specificity: 0.857, precision: 0.900, accuracy: 0.750, F1 score: 0.783). BD patients were divided into two subtypes according to the consensus clustering method: one with high disease activity in association with higher expression of tripartite motif-containing 5 (TRIM5), SH2 domain-containing 1A (SH2D1A), phosphoinositide-3-kinase adaptor protein 1 (PIK3AP1), hematopoietic cell-specific Lyn substrate 1 (HCLS1), and DNA fragmentation factor subunit alpha (DFFA) and the other with low disease activity in association with higher expression of C-C motif chemokine ligand 11 (CCL11).

CONCLUSIONS

Our study not only revealed a distinctive immune response-related protein profile for BD but also showed that IL10, FCRL3, MASP1, NF2, FAM3B, and MGMT could serve as potential immune biomarkers for this disease. Additionally, a novel molecular disease classification model was constructed to identify subsets of BD.

A case series of intracardiac thrombi and vascular involvement in pediatric Behçet's disease

To evaluate the general characteristics of pediatric Behçet's disease (BD) patients with thrombus and to present the clinical features, treatment responses and prognosis of patients with intracardiac thrombus. The clinical characteristics and outcomes of 15 patients with thrombus among 85 pediatric BD patients followed in the Department of Pediatric Rheumatology were evaluated retrospectively. Of the 15 BD patients with thrombus, 12 (80%) were male, 3 (20%) were female. The mean age at diagnosis was 12.9 ± 1.1 years. Thrombus was present at the time of diagnosis in 12 patients (80%), while thrombus developed in three patients within the first three months after diagnosis. The most common site of thrombus was the central nervous system (n = 9, 60%), followed by deep vein thrombus (n = 6, 40%) and pulmonary artery thrombus (n = 4, 26.6%). Three male patients (20%) developed intracardiac thrombus. The overall intracardiac thrombus rate in the 85 patients was 3.5%. Two of the three patients had thrombus in the right, and one had thrombus in the left heart cavity. In addition to steroids, 2 of the 3 patients received cyclophosphamide, while the patient with thrombus localized in the left heart cavity was given infliximab. In the follow-up, the two patients with thrombus in the right heart cavity were switched to infliximab because of resistance to cyclophosphamide. Complete resolution was observed in 2 of the 3 patients on infliximab; a significant reduction in the thrombus of the other patient was achieved. Intracardiac thrombus is a rare presentation of cardiac involvement in BD. It is usually observed in males and in the right heart. Although steroids and immunosuppressive agents such as cyclophosphamide are recommended as first-line treatment, favorable outcomes can be achieved with anti-TNFs in resistant cases.

Combined central retinal vein occlusion and cilioretinal artery occlusion as the initial presentation of frosted branch angiitis: a case report and literature review

PURPOSE

To report a case of combined central retinal vein occlusion (CRVO) with cilioretinal artery occlusion (CLRAO) that heralded the development of frosted branch angiitis (FBA).

CASE REPORT

A 25-year-old healthy male presented with sudden painless visual loss in his left eye with a visual acuity (VA) of 20/300. Fundus exam and fluorescein angiography showed signs of combined CRVO and CLRAO. Without treatment, his vision gradually improved until it reached 20/30 within four months. Five months after initial presentation, he returned with severe visual loss (20/400) in the same eye and a clinical picture of severe occlusive periphlebitis resembling a frosted branch angiitis pattern associated with severe macular edema. This was promptly and successfully treated with systemic steroids and immunosuppressive medications.

CONCLUSION

CRVO in young population can have an unusual course and one should carefully rule out underlying uveitic etiologies in each visit. Clinical suspicion and close follow‑up are required for early detection and timely management of FBA.

Successful treatment of a refractory intestinal Behcet's disease with an oncology history by Vedolizumab: a case report and literature review

Objective

Behçet's Disease (BD) is an intractable systemic vasculitis. When accompanied by intestinal symptoms, the prognosis is usually poor. 5-Aminosalicylic acid (5-ASA), corticosteroids, immunosuppressive drugs, and anti-tumor necrosis factor-α (anti-TNF-α) biologics are standard therapies to induce or maintain remission for intestinal BD. However, they might not be effective in refractory cases. Safety should also be considered when patients have an oncology history. Regarding the pathogenesis of intestinal BD and the specific targeting effect of vedolizumab (VDZ) on the inflammation of the ileum tract, previous case reports suggested that VDZ might be a potential treatment for refractory intestinal BD.

Methods

We report a 50-year-old woman patient with intestinal BD who had oral and genital ulcers, joint pain, and intestinal involvement for about 20 years. The patient responds well to anti-TNF-α biologics but not to conventional drugs. However, biologics treatment was discontinued due to the occurrence of colon cancer.

Results

VDZ was intravenously administered at a dose of 300 mg at 0, 2, and 6 weeks and then every eight weeks. At the 6-month follow-up, the patient reported significant improvement in abdominal pain and arthralgia. We observed complete healing of intestinal mucosal ulcers under endoscopy. However, her oral and vulvar ulcers remained unresolved, which disappeared after adding thalidomide.

Conclusion

VDZ may be a safe and effective option for refractory intestinal BD patients who do not respond well to conventional treatments, especially those with an oncology history.

Challenges in the Timely Diagnosis of Behcet's Disease

Behcet's disease (BD) is a chronic, multi-systemic inflammatory disorder mainly characterized by recurrent oral and genital ulcers, skin lesions, and uveitis. As no pathognomonic laboratory test exists for BD, the diagnosis relies solely on clinical features. Over the years, great efforts have been invested in creating clinical diagnostic and classification criteria. The international study group criteria introduced in 1990 were the first true multinational set of criteria. Despite improving the ability to diagnose BD, these criteria still have limitations, including the inability to diagnose patients presenting without oral ulcers or presenting with rare manifestations of the disease. This led to the introduction of the international criteria for BD in 2013, which improved the sensitivity with minimal compromise on specificity. Despite the efforts made and as our understanding of the clinical manifestations of BD and genetic pathogenesis continue to evolve, efforts should be made to further enhance the currently accepted international classification criteria, perhaps by incorporating genetic testing (e.g., family history or HLA typing) as well as ethnic group-specific features.

Scoping beyond pulmonary artery involvement; pulmonary involvement in Behcet's disease; a retrospective analysis of 28 patients

OBJECTIVES

Pulmonary involvement other than pulmonary artery involvement in Behcet's disease still remains an area of investigation. The aim of this study was to evaluate pulmonary involvement associated with Behcet's disease.

METHOD

We retrospectively investigated all Behcet's disease patients in terms of pulmonary involvement. Twenty-eight patients, whose radiologic examinations were consistent with Behcet's disease-related involvement after excluding other possibilities, were included in this study. Data regarding demographic characteristics, other clinical components of Behcet's disease, treatment modalities, and types of pulmonary involvement were analyzed.

RESULTS

Pulmonary involvement was seen more common in male (82.1% vs 17.9%). Mean age for Behcet's disease diagnosis was found 32 years (SD 10.9) and mean age for pulmonary involvement was calculated 37 years (SD 11.4). Deep vein thrombosis (DVT) was the most common associated vascular involvement (53.6%). In our study population, alveolar hemorrhage and/or ground glass appearance were seen in 46.4% (13/28) of BD patients with pulmonary involvement. Totally, pulmonary artery aneurysm (PAA), small-sized pulmonary vasculitis (sPV), and pulmonary thrombosis (PT) were seen in 7 (25%), 13 (46.3%), and 18 (64.4%) of patients, respectively. Intracardiac thrombosis (ICT) in the right ventricle was present in 5 patients. Cyclophosphamide (CYC) was the most common preferred agent (78%) followed by azathioprine (AZA) in the first line. Warfarin was used in 18 patients. Overall mortality was seen in 3 patients: 1 due to PAA bleeding and others with unknown causes.

CONCLUSION

Despite the importance of pulmonary artery involvement and pulmonary thrombosis in Behcet's disease, small-sized pulmonary vasculitis in the form of small vessel involvement is generally overlooked. Our study findings have shown that alveolar hemorrhage and/or ground-glass appearance in the absence of pulmonary artery aneurysm and pulmonary thrombosis are seen commonly as well. Key Points • The characteristics of pulmonary small vasculature involvement in Behcet's disease which is still an area of investigation warrant further attention. • The clinician should bear in mind that the spectrum of pulmonary involvement in Behcet's disease may be variable, but an extensive work up is still of great importance especially in atypical cases.

Behcet's disease in a patient with primary sclerosing cholangitis: a case report and literature review

Behçet's disease (BD) is a rare, chronic multisystem disease of unknown aetiology. Clinically, it presents with ulceration located on the oral and genital mucosa, skin, uveitis, arthritis and neurological disorders. Most commonly, the disease affects men in the second and third decades of life and occurs endemically. The vast majority of cases have been reported in Asia and the Mediterranean area. The diagnosis of this disease is difficult, especially because of its rare occurrence in Central Europe. In this report, we present the case of BD in a 56-year-old man with primary sclerosing cholangitis, followed by a literature review covering current insights into BD aetiology, diagnostics and treatment.

Recurrent endobronchial occlusion and aorto-bronchial fistula formation in Behcet's disease

BACKGROUND

Behcet's disease is a multi-system inflammatory disorder. A small subset of patients with Behcet's develop relapsing polychondritis which is classified as a separate disease known as Mouth and Genital ulcers with inflamed cartilage (MAGIC syndrome). It has previously been observed that this condition can also affect the cartilaginous tissue in the tracheobronchial tree.

CASE PRESENTATION

We present the case of a 44-year-old lady with Behcet's Disease, Mouth and Genital ulcers with inflamed cartilage (MAGIC) syndrome and an aortic Frozen Elephant Trunk (FET) who presented to hospital with recurrent episodes of left lobar collapse of the lung. During bronchoscopy, we found the presence of multiple inflammatory endobronchial webs occluding segments of the left bronchial tree. Repeated examinations showed evidence that these inflammatory webs were progressing in size, density and location. Furthermore, we noticed herniation of her descending aortic FET into her left bronchial tree forming an aorto-bronchial fistula which was complicated by a graft infection. Her descending aortic FET section was surgically replaced with an open procedure and bronchoscopic interventions attempted to remove the occlusions in her bronchial tree. Despite optimisation of medical management and surgical correction, this patient continued to develop progressive occlusion of her left bronchial tree, resulting in a chronically collapsed left lung.

CONCLUSIONS

A multi-disciplinary team approach is of paramount importance in order to optimally manage patients with Behcet's disease, balancing immunosuppressive regimens that need close monitoring and titration in the context of potential surgical intervention and the risk for intercurrent infection.

Hughes-Stovin Syndrome: An Experience of Management of 3 Cases From a Tertiary Health Care Centre

Three young males with Hugh-Stovin's syndrome presented with cough, haemoptysis, fever, raised inflammatory markers, and pulmonary artery aneurysm. Only one had recurrent oral ulcers suggestive of Behcet's disease, and none were HLA B51 positive. All responded well to immunosuppression but eventually needed either an endovascular procedure or surgery.

Behçet's Disease: A Radiological Review of Vascular and Parenchymal Pulmonary Involvement

Behcet's disease (BD) is a chronic systemic inflammatory disorder characterized by underlying chronic vasculitis of both large- and small-caliber vessels. Thoracic involvement in BD can occur with various types of manifestations, which can be detected with contrast-enhanced MSCT scanning. In addition, MR can be useful in diagnosis. Characteristic features are aneurysms of the pulmonary arteries that can cause severe hemoptysis and SVC thrombosis that manifests as SVC syndrome. Other manifestations are aortic and bronchial artery aneurysms, alveolar hemorrhage, pulmonary infarction, and rarely pleural effusion. Achieving the right diagnosis of these manifestations is important for setting the correct therapy and improving the patient's outcome.

Association of miRNA-146a Gene Polymorphism Rs2910164 with Behcet's Disease: A Meta-analysis

BACKGROUND

A meta-analysis was performed by summarizing relevant researches to evaluate the relationship between miRNA-146a gene polymorphism rs2910164 and Behcet's disease (BD).

METHODS

A systematic search of published studies was conducted in PubMed and Embase. Five eligible studies involving 1167 BD cases and 1662 controls were included in the current meta-analysis.

RESULTS

The results suggested that the polymorphism rs2910164 was correlated with BD susceptibility in all genetic models. In subgroup analysis according to ethnicity, the relationship between this polymorphism and BD was more significant in Caucasians (allele model: OR = 0.49, 95% CI 0.39-0.61; heterozygote model: OR = 0.35, 95% CI 0.26-0.47; homozygote model: OR = 0.29, 95% CI 0.16-0.53; dominant model: OR = 0.34, 95% CI 0.25-0.45; recessive model: OR = 0.56, 95% CI 0.50-0.72) than that in Asians.

CONCLUSION

In conclusion, this meta-analysis indicates that miRNA-146a gene polymorphism rs2910164 G allele confers BD susceptibility, especially in Caucasians.

5Apal, Taql, Fokl, and Bsml polymorphisms and the susceptibility of Behcet's disease: an updated meta-analysis

OBJECTIVE

The aim of this study was to investigate whether the gene polymorphisms of vitamin D receptor (VDR) had a genetic effect on the susceptibility of Behcet's disease (BD).

MATERIAL AND METHODS

We conducted a meta-analysis emphasizing the association between the VDR gene polymorphisms and the risk of BD. The strength of the association in five genetic models was assessed by pooled odds ratios (OR) with a corresponding 95%confidence interval (CI).

RESULTS

A total of seven independent comparisons with 478 cases and 666 healthy controls were included in this meta-analysis. The overall results suggested that a significant association between ApaI polymorphism and BD risk was found in allele comparison, recessive model, and homozygote model among total populations. Subgroup analysis indicated that a significant association of ApaI polymorphism in the development of BD existed under the allelic model among Africans, while for Caucasians, a similar link was identified in the recessive model and homozygote model. Regarding Bsml polymorphism, an obvious relationship was detected to be significant in allele comparison and recessive model in the Caucasian population. Interestingly, the Fokl variant decreased the risk of BD in Africans under five genetic models, while it increased the risk in Caucasians across the recessive model and homozygote model.

CONCLUSION

The results of this meta-analysis provide evidence of the link between the four widely studied polymorphisms in the VDR gene and BD, indicating a robust estimate of the genetic risk.

The association between vitamin D levels and oxidative stress markers in Egyptian Behcet's disease patients

BACKGROUND

Oxidative stress is postulated to have a major role in the pathophysiology of Bechet's Disease (BD). Growing evidence suggests that vitamin D has important roles in enhancing the expression of anti-inflammatory cytokines as well as certain antioxidants. However, there is little evidence currently about the antioxidant properties of vitamin D in BD.

OBJECTIVE

To study the relationship between vitamin D levels and the oxidative stress markers in patients with BD in addition to its association with disease activity and severity.

METHODS

Sixty BD patients (45 males, 15 females; mean age: 34.2 ± 9.6 years) were enrolled in this study and compared to a sex and age matched control group. Plasma 25-Hydroxy vitamin D (25-OH-D) was measured using Human (25-OH-D) ELISA assay. Plasma malondialdehyde (MDA), nitric oxide (NO), reduced glutathione (GSH), superoxide dismutase (SOD) activity, catalase (CAT) activity and total antioxidant capacity (TAC) were determined by spectrophotometric methods in both groups. Plasma calcium (Ca) was measured by ELISA assay.

RESULTS

When compared to controls vitamin D, GSH, CAT activity, TAC and Ca were significantly lower in BD patients, while MDA and NO levels were significantly increased in BD patients. Our Results Found that vitamin D was inversely correlated to BD current Activity form (BDCAF), disease severity score, ESR, CRP, MDA and NO, while vitamin D was significantly positively correlated to GSH, SOD, TAC and Ca.

CONCLUSION

Our study confirms that a lower level of vitamin D is associated with the oxidative stress state in BD patients as detected by MDA and NO elevation as well as decreased GSH, SOD activity, CAT activity and TAC. Hence, Vitamin D fortified foods and beverages or supplementation may improve disease severity and oxidative stress in BD patients.

Endovascular Treatment of the Ruptured Pseudoaneurysm of Common Femoral Artery in Behcet's Disease: Report of a Case with Four Years of Follow-Up

Behcet's disease (BD) is a vasculitic condition that affects arteries and veins of all sizes. Arterial pseudoaneurysm is a rare but life-threatening complication of BD. We reported a 41-year-old man with 20 years history of BD and 5 years history of bilateral blindness. The patient presented with sudden onset of pain and swelling in his left groin and was diagnosed with the ruptured pseudoaneurysm of the left common femoral artery (CFA), which extended into the origins of superficial and deep femoral arteries. The patient was in the active phase of BD; therefore, he was initially treated with corticosteroids and cyclophosphamide pulse therapies and subsequently underwent stent graft placement. Post stenting angiography and postprocedural ultrasonography confirmed the successful exclusion of pseudoaneurysm without any evident complication. Four years of follow-up was uneventful.

Identification of novel genes in Behcet's disease using integrated bioinformatic analysis

Behcet’s disease (BD) is a chronic vascular inflammatory disease. However, the etiology and molecular mechanisms underlying BD development have not been thoroughly understood. Gene expression data for BD were obtained from the Gene Expression Omnibus database. We used robust rank aggregation (RRA) to identify differentially expressed genes (DEGs) between patients with BD and healthy controls. Gene ontology functional enrichment was used to investigate the potential functions of the DEGs. Protein–protein interaction (PPI) network analysis was performed to identify the hub genes. Receiver operating characteristic analyses were performed to investigate the value of hub genes in the diagnosis of BD. GSE17114 and GSE61399 datasets were included, comprising 32 patients with BD and 26 controls. The RRA integrated analysis identified 44 significant DEGs among the GSE17114 and GSE61399 CD4 + T lymphocytes. Functional enrichment analysis revealed that protein tyrosine/threonine phosphatase activity and immunoglobulin binding were enriched in BD. PPI analysis identified FCGR3B as a hub gene in the CD4 + T lymphocytes of BD patients. Our bioinformatic analysis identified new genetic features, which will enable further understanding of the pathogenesis of BD.

Vitamin D Levels in Patients with Behcet's Disease: A Systematic Review and Meta-Analysis

OBJECTIVE

Behcet's disease (BD) is a chronic multisystem inflammatory disease classified as Variable Vessel Vasculitis with unclear etiology. We designed this systematic review and meta-analysis to evaluate vitamin D status in Behcet's disease patients with this background.

METHODS

We performed this systematic review and meta-analysis according to (PRISMA) guidelines. We included all observational studies in humans published in English, evaluating the association of 25(OH)D concentrations in Behcet's patients. Two reviewers (HRK and AE) independently searched the databases and screened articles based on their titles and abstracts. A third reviewer resolved all disagreements. We performed analysis using Cochrane Program Review Manager Version 5.3. The protocol for this review was registered on PROSPERO (CRD42020197426).

RESULTS

A total of 341 publications were initially identified according to the search strategy. Finally, 12 publications were included in the meta-analysis. We performed this meta-analysis on 1265 participants from different studies with a sample size from 63 to 224 individuals. In studies comparing Active and Inactive subgroups of patients with Behcet's Disease, we found a significantly lower serum level of vitamin D in patients with Active BD (-0.4; 95%CI: -0.61, -0.25; p<0.00001). We found that the serum level of vitamin D in Behcet's Disease is significantly higher than Health Controls (0.5; 95%CI: 0.15, 0.50; p=0.00001).

CONCLUSION

We demonstrated that the existing evidence is consistent with the hypothesis that an increased serum level of vitamin D would be associated with substantially lower risk of active Behcet's disease.

Novel Insights Into Gene Signatures and Their Correlation With Immune Infiltration of Peripheral Blood Mononuclear Cells in Behcet's Disease

Background

Behcet’s disease (BD) is a chronic inflammatory disease that involves systemic vasculitis and mainly manifests as oral and genital ulcers, uveitis, and skin damage as the first clinical symptoms, leading to gastrointestinal, aortic, or even neural deterioration. There is an urgent need for effective gene signatures for BD’s early diagnosis and elucidation of its underlying etiology.

Methods

We identified 82 differentially expressed genes (DEGs) in BD cases compared with healthy controls (HC) after combining two Gene Expression Omnibus datasets. We performed pathway analyses on these DEGs and constructed a gene co-expression network and its correlation with clinical traits. Hub genes were identified using a protein–protein interaction network. We manually selected CCL4 as a central hub gene, and gene-set enrichment and immune cell subset analyses were applied on patients in high- and low-CCL4 expression groups. Meanwhile, we validated the diagnostic value of hub genes in differentiating BD patients from HC in peripheral blood mononuclear cells using real-time PCR.

Results

Twelve hub genes were identified, and we validated the upregulation of CCL4 and the downregulation of NPY2R mRNA expression. Higher expression of CCL4 was accompanied by larger fractions of CD8 + T cells, natural killer cells, M1 macrophages, and activated mast cells. Receiver operator characteristic curves showed good discrimination between cases and controls based on the expression of these genes.

Conclusion

CCL4 and NPY2R could be diagnostic biomarkers for BD that reveal inflammatory status and predict vascular involvement in BD, respectively.

Predictive value of erythrocyte sedimentation rate and C-reactive protein in Behcet's disease activity and manifestations: a cross-sectional study

Background

Behcet’s disease (BD) as a chronic inflammatory condition that affects the eyes, skin, central nervous system, gastrointestinal tract and vessels. According to the literature, the exact value of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) in predicting active manifestations of BD remains controversial. In this study, we aim to assess and compare values of ESR and CRP between BD patients with active/inactive BD and active/inactive manifestations of the disease. Moreover, we try to determine the predictive value of ESR and CRP for disease activity.

Methods

Participants (n = 514) were drug-naïve BD patients; Based on last two visits, ESR and CRP values, disease activity, and active manifestations were recorded. The Man-Whitney U test measured the associations, and the binomial logistic regression evaluated the predictive value of ESR and CRP for active disease and each active manifestation. The sensitivity and specificity and the area under the curve (AUC) for each model were determined using receiver operating characteristic curves (ROC). Multiple regressions were run to predict BD activity score from ESR and CRP.

Result

Patients with active oral, genital, joint and dermal manifestations had higher ESR and CRP values (Mann–Whitney U test, p < 0.05 for all). Binomial logistic regressions showed that ESR had valuable predictive value for active BD (OR = 1.09 [1.04–1.13], AUC = 0.79 [0.74–0.83], p < 0.001) and active vascular manifestations (1.03 [1.01–1.05], AUC = 0.85 [0.79–0.92], p < 0.001). CRP had good predictive value for active vascular manifestations (OR 1.98 [1.45–2.72], AUC = 0.86 [0.8–0.91], p < 0.001). The optimal value of ESR ≥ 10.5 and ESR ≥ 42.5 could predict active BD and active vascular manifestations with sensitivity, specificity = 71%, 75% and = 81%, 83% respectively.

Conclusions

ESR and CRP are both associated with active BD and most manifestations of the diseases. They can be used for the prediction of active BD and active vascular manifestations in BD patients. Further studies can help to confirm the findings of the current research.

Global systematic review and meta-analysis of health-related quality of life in Behcet's patients

Background

Behcet's disease (BD) is a chronic fatal illness with a relapsing remitting nature and significant organ-threatening morbidity and mortality. The aim of this research was to examine studies which were conducted on investigation of prevalence of quality of life among patients with Behcet's disease.

Methods

A total of 13 articles were extracted from four main databases including PubMed, EMBASE, Scopus, and Web of Science from the onset of 2000 to January 2021. All studies published in English with the purpose of examining quality of life (QOL) among patients with BD or investigating its main determinants were included.

Results

Totally, 1137 BD patients participated in 13 studies. Based on random effect analysis, the total score of physical health-related QOL was 46.7 (95% CI=41.26 to 52.13) and the total score of mental health-related QOL was 49.01 (95% CI=43.83 to 54.18) representing a moderate level of QOL among BD patients. Furthermore, weighted effect size analyses showed a significant correlation between QOL and variables such as patients' age, gender, disease duration and depression (pvalue: 0.00).

Conclusion

As the symptoms of BD worsen over time, patients confront with more severe body pain, mobility restrictions, and difficulties in chewing, eating, speaking and swallowing which negatively affect social interactions of patients and reduce their QOL. Furthermore, depression was proved to act as a deteriorating factor for Health-Related Quality of Life (HRQOL) among BD patients. Thus, patients need to be psychologically supported by a specialized team and be informed during the course of treatment to gain useful information about the disease, treatment approaches and coping strategies.

Neutrophil Extracellular Traps in Skin Diseases

Neutrophils are the primary innate immune cells, and serve as sentinels for invading pathogens. To this end, neutrophils exert their effector functions via phagocytosis, degranulation, reactive oxygen species generation, and neutrophil extracellular trap (NET) release. Pathogens and pathogen-derived components trigger NET formation, leading to the clearance of pathogens. However, NET formation is also induced by non-related pathogen proteins, such as cytokines and immune complexes. In this regard, NET formation can be induced under both non-sterile and sterile conditions. NETs are enriched by components with potent cytotoxic and inflammatory properties, thereby occasionally damaging tissues and cells and dysregulating immune homeostasis. Research has uncovered the involvement of NETs in the pathogenesis of several connective tissue diseases, such as systemic lupus erythematosus, rheumatoid arthritis, and ANCA-associated vasculitis. In dermatology, several skin diseases clinically develop local or systemic sterile pustules and abscesses. The involvement of neutrophils and subsequent NET formation has recently been elucidated in these skin diseases. Therefore, this review highlights the NETs in these neutrophil-associated diseases.

Isomer-Specific Monitoring of Sialylated N-Glycans Reveals Association of α2,3-Linked Sialic Acid Epitope With Behcet's Disease

Behcet’s disease (BD) is an immune disease characterized by chronic and relapsing systemic vasculitis of unknown etiology, which can lead to blindness and even death. Despite continuous efforts to discover biomarkers for accurate and rapid diagnosis and optimal treatment of BD, there is still no signature marker with high sensitivity and high specificity. As the link between glycosylation and the immune system has been revealed, research on the immunological function of glycans is being actively conducted. In particular, sialic acids at the terminus of glycoconjugates are directly implicated in immune responses, cell–cell/pathogen interactions, and tumor progression. Therefore, changes in sialic acid epitope in the human body are spotlighted as a new indicator to monitor the onset and progression of immune diseases. Here, we performed global profiling of N-glycan compositions derived from the sera of 47 healthy donors and 47 BD patients using matrix-assisted laser desorption/ionization-time of flight mass spectrometry (MALDI-TOF MS) to preferentially determine BD target glycans. Then, three sialylated biantennary N-glycans were further subjected to the separation of linkage isomers and quantification using porous graphitized carbon-liquid chromatography (PGC-LC)/multiple reaction monitoring (MRM)-MS. We were able to successfully identify 11 isomers with sialic acid epitopes from the three glycan compositions consisting of Hex₅HexNAc₄NeuAc₁, Hex₅HexNAc₄Fuc₁NeuAc₁, and Hex₅HexNAc₄NeuAc₂. Among them, three isomers almost completely distinguished BD from control with high sensitivity and specificity with an area under the curve (AUC) of 0.945, suggesting the potential as novel BD biomarkers. In particular, it was confirmed that α2,3-sialic acid at the terminus of biantennary N-glycan was the epitope associated with BD. In this study, we present a novel approach to elucidating the association between BD and glycosylation by tracing isomeric structures containing sialic acid epitopes. Isomer-specific glycan profiling is suitable for analysis of large clinical cohorts and may facilitate the introduction of diagnostic assays for other immune diseases.

Primary adrenal tuberculosis infection in patients with Behcet's disease presenting as isolated adrenal metastasis by 18F-FDG PET/CT: a rare case report and literature review

Primary adrenal tuberculosis (TB) is a rare type of extrapulmonary tuberculosis (EPTB). A pathological biopsy is usually required to make a definite diagnosis due to nonspecific symptoms. Antituberculous chemotherapy is the main treatment regimen, and cortisol replacement therapy should be added when adrenal insufficiency is involved. Here, we present a 59-year-old man who had recurrence of oral and genital aphthosis for 3 years and was diagnosed with Behcet's disease (BD), which was cured by thalidomide. After 10 days of admission, the patient had sudden abdominal pain in the right upper quadrant with high fever and was diagnosed with acute cholecystitis attack, which was treated by percutaneous transhepatic gallbladder drainage (PTGBD). Further contrast-enhanced CT showed a right adrenal mass with a diameter of 2.0 cm, and PET-CT indicated intense ¹⁸F-fluorodeoxyglucose (¹⁸F-FDG) uptake in the right adrenal mass with a maximum standardized uptake value (SUV_max) of 15.2. As a metastatic adrenal mass was suspected, the patient underwent retroperitoneal laparoscopic adrenalectomy. Histopathological and immunohistochemical analysis revealed primary adrenal TB. After routine anti-tuberculosis treatment with isoniazid, rifampin, pyrazinamide and ethambutol for six months, the patient was cured and discharged. In summary, primary unilateral adrenal TB without adrenal insufficiency is difficult to diagnose only on the basis of clinical manifestations and examinations. Further studies are needed to develop an easier and more accurate diagnostic examination.

Coronavirus disease 2019 in patients with Behcet's disease: a report of 59 cases in Iran

OBJECTIVES

To present the clinical characteristics, disease course, management, and outcomes of COVID-19 infection in patients with Behcet's disease (BD).

METHODS

In this retrospective cohort study, we retrieved BD patients with definite diagnosis of COVID-19 infection. Demographic data, comorbidities, features related both to BD and COVID-19 infection, treatments, and outcomes were collected. Comparisons between patients with or without hospitalization were performed. All statistical analyzes were performed using SPSS version 25. We considered p < 0.05 statistically significant.

RESULTS

We identified 61 episodes of COVID-19 infection in 59 BD patients. The prevalence was 0.69%. The median age was 45 years (IQR = 20), and the median disease duration was 162 months (IQR = 195). BD features were similar except for higher rate of arterial involvement and positive pathergy test in infected patients. Thirty-five episodes (62.5%) happened in non-active patients; 39% had a comorbid disease. COVID manifestations were the same as the general population. Flu-like symptoms were the most common (85%), followed by fever (66%), ageusia/anosmia (56%), headache (51%), and pulmonary involvement (48%). There was no change in BD symptoms in 74%. Fifteen patients (25.4%) were hospitalized, and one patient (1.7%) died. Receiving glucocorticoids (p < 0.03) and cytotoxic drugs (p < 0.02) were associated with an increased rate of hospitalization.

CONCLUSION

The incidence of COVID-19 infection in BD patients was not higher than general population in Iran. They showed milder form of disease with lower morbidity and mortality rate. Most were on immunosuppressive drugs, or had a comorbidity apart from BD. No significant effect on BD course was shown. Key Points • The incidence of COVID-19 infection in patients with Behcet's disease is not higher. • They showed milder form of infection with lower morbidity and mortality rate. • No significant effect on Behcet's disease course was shown with COVID19 infection. • BD patients can be managed according to the guidelines used for general population.

Surgical Intervention to Treat Pharyngolaryngeal Stenosis Caused by Behcet's Disease

We aimed to summarize the surgical treatment for pharyngolaryngeal stenosis and discuss prognosis in patients with Behcet's disease. Six cases of pharyngolaryngeal stenosis caused by Behcet's disease were analyzed retrospectively. All underwent surgical treatment for pharyngolaryngeal stenosis after systematic medical treatment. The follow-up time for the 6 patients was between 1 and 12 years. Four of the 6 patients underwent adhesiolysis as their first procedure. Two of these 4 experienced recurrence of stenosis within 6 months and underwent flap repair as their second procedure. The remaining two patients underwent flap reconstruction as their first procedure and maintained good swallowing function. Three of the 6 patients underwent preoperative tracheotomy because of dyspnea. Tracheal decannulation was successful in all patients. None of the patients experienced recurrence after their final surgical procedure and all recovered to a near-normal condition. Pharyngolaryngeal stenosis caused by Behcet's disease is a rare but severe complication; surgical intervention should be considered in patients with dysphagia after systematic medical treatment.

Clinical Effect of Non-Thermal CO2 Laser Therapy (NTCLT) on Pain Relief of Oral Aphthous Ulcers of Behçet's Disease

Introduction: Behçet's disease (BD) is a debilitating and chronic vasculitis which can affect multiple organs. Recurrent oral aphthosis is the most common clinical feature of BD. The remarkable pain associated with painful oral ulcers can exert a major impact on the patients' quality of life. Relieving pain of these oral ulcers is an essential approach in the management of mucocutaneous lesions of BD. Non-thermal CO2 laser therapy (NTCLT) as a novel photobiomodulative approach has recently been used for significant and immediate pain reduction of some types of painful oral lesions such as recurrent aphthous stomatitis, pemphigus vulgaris, and so on. In this procedure by some considerations, the conventional CO2 laser is used as a non-surgical, non- thermal, photobiomodulative laser without any visible thermal adverse effects. In this article, we report our experiences about the analgesic effects of NTCLT on painful oral aphthous ulcers of BD. Case Presentation: We report four cases of BD, whose painful oral aphthous ulcers were irradiated with NTCLT. Immediately after NTCLT, the pain of the lesions was significantly relieved with no visible complications. Conclusion: The results of this study suggest that NTCLT could be proposed as a hopeful procedure for significant and instant pain relief of oral aphthous ulcers of BD without any visible thermal adverse effects.

High mobility group box-1 levels may be associated with disease activity of Behcet's disease

BACKGROUND

High mobility group box- 1 (HMGB- 1) is a nuclear protein acting as a proinflammatory molecule. The serum HMGB- 1 levels were found elevated in chronic inflammatory diseases. In this cross-sectional study, serum HMGB- 1 levels in Behcet's disease (BD) patients and healthy controls (HC) were studied. Also, its association with disease activity scores and clinical findings were evaluated.

METHODS

Ninety BD patients and 50 age-sex matched HC were included in the study. Disease activity scores were assessed by Behcet Disease Current Activity Form (BDCAF) and Behcet Syndrome Activity Score (BSAS). Serum HMGB- 1 levels were measured using a commercial ELISA kit. A p value of < 0.05 was considered to be statistically significant.

RESULTS

Serum HMGB- 1 levels were significantly higher in BD than in HC (43.26 pg/mL and 16.73 pg/mL; p < 0.001, respectively). Serum HMGB- 1 levels were statistically significantly associated with presence of erythema nodosum (EN) and genital ulcers in the last one month prior to recruitment (p = 0.041 and p < 0.001, respectively). BDCAF and BSAS scores were positively correlated with serum HMGB- 1 level ( p = 0.03 and p = 0.02, respectively).

DISCUSSION

HMGB - 1 may play a role in the development of BD. Also, due to its positive correlation with disease activity indices, it can be used as a novel disease activity parameter in BD.

Spectrum Of Ocular Manifestations Of Rheumatic Autoimmune Diseases: A Tertiary Care Experience In Pakistan

BACKGROUND

Eye involvement is a common and potentially devastating complication of various immune related rheumatic diseases. We aimed to determine the spectrum, associations and the impact of ocular manifestations among well characterised autoimmune rheumatic disease patients presenting to ophthalmology and rheumatology clinics in a tertiary care hospital in Lahore, Pakistan.

METHODS

Descriptive cross-sectional study performed in Rheumatology department of Fatima memorial hospital. Only those rheumatic disease patients were included who have been attending ophthalmology department for their ophthalmic conditions. The patients with ophthalmic symptoms who have not attended an ophthalmologist were not included in this study. Proforma was designed and the studied parameters were recorded prospectively from patient's interview and also by reviewing patient's medical and ophthalmologic medical records. Parameters assessed were demographics, symptoms and the diagnosis of eye disease, unilateral or bilateral presentation, duration of eye symptoms along with the duration of the primary rheumatologic disease, and the complications of the eye disease whether due to the eye diagnosis or its treatment.

RESULTS

Eighty-three consecutive patients with mean age 33±11 years, 67.5% being female were recruited. Spondyloarthritis (SpA) comprised 38.6% (n=32) of patients followed by 21.7% (n=18) of Behcet's disease. Majority of patients (68.7%) had bilateral eye symptoms. In our cohort, 70% (n=58) of the patients had uveitis and almost all of these patients had either SpA or Behcet's disease as their primary rheumatologic diagnosis. Scleritis in 15.7% (n=13) patients followed by retinal vasculitis in 9.6% (n=8) patients, while glaucoma and keratopathy were present in 2.4% (n=2) patients each comprised other manifestations. Reassuringly our uveitis patients had no long-term eye related complications either due to the disease or its treatment.

CONCLUSIONS

Uveitis represented the most common ophthalmologic manifestation associated with underlying rheumatologic diseases in our cohort, and it was associated with underlying Behcet's disease and SpA. Uveitis associated with connective tissue diseases has good prognosis with low-risk of significant long-term complications. Moreover, uveitis associated with SpA was noted to present much earlier in its disease course.

Changes in the Gut Microbiome Contribute to the Development of Behcet's Disease via Adjuvant Effects

Behcet’s disease (BD) is associated with considerable gut microbiome changes. However, it still remains unknown how the composition of the gut microbiome exactly affects the development of this disease. In this study, transplantation of stool samples from patients with active ocular BD to mice via oral gavage was performed. This resulted in decreases of three short chain fatty acids (SCFAs) including butyric acid, propionic acid and valeric acid in the feces of the BD-recipient group. Intestinal barrier integrity of mice receiving BD feces was damaged as shown by a decreased expression of tight junction proteins and was associated with the release of Lipopolysaccharides (LPS) in the circulation. The mice also showed a higher frequency of splenic neutrophils as well as an enrichment of genes associated with innate immune responses in the neutrophils and CD4 + T cells as identified by single cell RNA sequencing. Analysis of neutrophils and T cells functions in these mice showed an enhanced mesenteric lymph node and splenic Th1 and Th17 cell differentiation in association with activation of neutrophils. Transplantation of BD feces to mice and subsequent induction of experimental uveitis (EAU) or encephalomyelitis (EAE) led to an exacerbation of disease in both models, suggesting a microbial adjuvant effect. These findings suggest that the gut microbiome may regulate an autoimmune response via adjuvant effects including increased gut permeability and enhancement of innate immunity.