Nitric oxide levels in Behçet''s disease

Behçet's disease(BD) is a chronic multisystemic disorder which is characterized by a relapsing systemic inflammatory process. In certain inflammatory conditions such as rheumatoid arthritis, over production of nitric oxide (NO) could damage host cells and tissues, either directly and/or following reaction with other free radicals, such as superoxide anion to form species including peroxynitrite or hydroxyl radicals. Excessive superoxide radical production and impaired antioxidant mechanism in both the neutrophils and plasma of patients with BD have been reported. Our study was designed to investigate the role of NO in BD. NO is an extremely unstable molecule and rapidly converted in vivo and in vitro to nitrate () and nitrite (). For this reason serum and have been used as an index of NO generation. We measured serum nitrate + nitrite levels, by using an enzymatic one‐step methodology based on the reduction of nitrate to nitrite by nitrate reductase from Aspergillus species, in the presence of β‐NADPH. When compared to healthy controls, serum nitrate + nitrite levels were found to be higher in active periods of BD patients (P < 0.01). It was concluded that increased NO production in patients with BD might have critical biological activities relevant to vasculitic events in the active period of disease.     

Peripheral insulin resistance in patients with Behçet''s disease

In this study, we examined peripheral insulin resistance in patients with Behçet's disease (BD) characterized by chronic inflammation and endothelial dysfunction. Fourteen patients with BD and 15 healthy controls were recruited to the study. Insulin resistance was investigated by the hyperinsulinaemic–euglycaemic glucose clamp technique. BD patients displayed an enhanced rate of insulin resistance compared to healthy controls (P = 0.014). The insulin sensitivity (M), measured as the glucose utilization rate under steady‐state conditions of euglycaemia, was significantly decreased (P = 0.001) in BD patients compared to the controls (4.09 ± 0.16 vs. 5.60 ± 0.27 mg/kg/min). The C‐reactive protein (CRP) level, but not the erythrocyte sedimentation rate (ESR), was significantly related to the presence of insulin resistance (CRP: r_s = 0.589, P = 0.27; ESR: r_s = 0444, P = 0112), whereas no relationship was found between the M‐value and ESR or CRP. We conclude that patients with BD exhibit peripheral insulin resistance; this could be explained as the diverse consequences of inflammation and endothelial dysfunction in BD.     

An update on Behçet''s disease

Behçet's disease (Adamantiades‐Behçet's disease, ABD) is a multisystemic inflammatory disease, the pathogenesis of which is still a mystery. Many questions are still to be answered and the available diverse data need to be brought together to be compared and analysed. There is at least consensus on the effect of possible, but currently unknown, environmental triggering factor(s) against a background of genetic susceptibility. The possible aetiological factors form a broad spectrum, with infectious agents being the most probable ones. Whatever the stimulus is, the target tissue seems to be the small blood vessels, with various consequences of either vasculitis and/or thrombosis in many organ systems. The endothelium seems to be the primary target in this disease; however, it may just be the subject of the bizarre behaviour of the immune system. The diverse existing data could be interpreted in favour of either explanation. A similar confusion exists about the thrombotic tendency in Adamantiades‐Behçet's disease, in terms of whether a primary hypercoagulability is present or whether it is secondary to inflammation. Recent interesting immunological data promise a way out of the existing dilemma. These findings will be outlined within the context of possible hypotheses and attention will be paid to further investigations that are needed.     

Lack of association between leptin G2548A gene polymorphism and Behçet''s disease

Background Behçet's disease is a chronic, multisystem, inflammatory disease characterized by the predominance of T‐helper 1 cytokines. The disease is also characterized by infiltration of lymphocytes and neutrophils into the affected tissues. Because cytokines are involved in the regulation of lymphocyte and phagocyte functions, they may play an important role in the pathogenesis of Behçet's disease. Leptin, a member of the gp 130 family of cytokines, induces a strong T‐helper 1 response and is regarded as a proinflammatory inducer. Recent studies have shown that serum leptin concentration was increased in patients with Behçet's disease and correlated with disease activity. Objectives We aimed to investigate the role of G2548A polymorphism of leptin gene in patients with Behçet's disease and compare the results with healthy controls. Patients and methods A total of 93 subjects with Behçet's disease and 125 healthy controls were included in this study. Analyses of G‐2548A polymorphism of the LEP gene were performed using the PCR‐restriction fragment length polymorphism technique. The genotypes (GG, GA, and AA of leptin G2548A) and alleles (G and A of leptin 2548) were scored and the frequency was estimated. The frequencies of the alleles and genotypes in patients and controls were compared. We analysed the correlation between leptin gene polymorphism and the clinical features of BD. Results Both genotype and allele frequencies were not significantly different between controls and Behçet's disease patients [OR = 0.67, 95% CI (0.35–1.29), P = 0.197 and OR = 0.77, 95% CI (0.52–1.15), P = 0.184]. We did not find any significant relationship between leptin gene polymorphism and the clinical features of BD (P > 0.05). Conclusion In the present case‐control study, we found no evidence of an association between the G‐2548A variant of the leptin gene and BD among Turks. Further studies are needed to investigate serum leptin level to explain the mechanisms behind the lack of association between leptin G2548A gene polymorphism and BD.     

Fas (CD95) and bcl-2 expression in active skin lesions of Behçet''s disease

Over‐expression of bcl‐2 in lymphocytes has an important role in some immunological and inflammatory diseases. Fas (CD95) is a cell surface molecule that mediates receptor‐triggered apoptosis in various cells including autoreactive T cells. In this study we investigated bcl‐2 and Fas (CD95) expression in dermal lymphocytes in active skin lesions of Behçet's disease (BD) and in skin biopsy samples with chronic, non‐specific inflammations. Tissue sections of 29 skin lesions of Behçet's disease and of 10 chronic non‐spesific inflammatory process cases from the archives of the Ondokuz May?s University's Pathology Department were immunohistochemically stained for bcl‐2 and Fas (CD95), and lymphocytes in the dermal infiltrate were evaluated for cytoplasmic staining. bcl‐2 staining was observed in the skin lesions of 22 cases (75.8%) of Behçet's disease. bcl‐2 staining was detected in two (20%) control skin biopsy samples with non‐specific chronic inflammation. Fas (CD95) positivity was not detected in lymphocytes in Behçet's disease‐related skin lesions. Fas (CD95) staining was observed in only three skin biopsy samples with non‐specific chronic inflammation. bcl‐2 and Fas (CD95) staining values in Behçet's and non‐specific inflammation groups were significantly different (P < 0.01); differences in the bcl‐2 staining values between Behçet's patients with mucocutaneous involvement only and mucocutaneous and other systemic involvements were not significant (P > 0.05). Expression of bcl‐2 and loss of Fas (CD95) expression in dermal lymphocytes may play a role in the development of skin lesions and may account for the chronic course with periodic exacerbations in BD.     

The alteration of sister chromatid exchange frequencies in Behçet''s disease with and without HLA-B51

Background The analysis of sister chromatid exchange (SCE) is a cytogenetic technique used to show DNA damage as a result of an exchange of DNA fragments between sister chromatids. It is known that there is an increased SCE frequency in Behçet's disease (BD). Objective To investigate whether human leucocyte antigen (HLA)‐B51‐positive patients with Behçet's disease exhibit higher SCE frequencies than those without HLA‐B51. Methods Lymphocytes from 75 patients (38 women, 37 men) and from 50 controls (28 women, 22 men) were cultured in darkness for 72 h in the presence of bromodeoxyuridine. Metaphase chromosomes were stained with a fluorescence plus Giemsa technique after a standard harvest procedure. For HLA‐B51 typing, DNA was extracted from ethylenediaminetetraacetic acid blood samples and HLA‐B5 allele genotyping was performed by the polymerase chain reaction (PCR)–sequence specific primer method. Results Thirty‐nine of 75 patients with BD (52%) and 15 of 50 controls (30%) were found HLA‐B51‐positive. The SCE frequencies in HLA‐B51‐positive patients were higher than in HLA‐B51‐negative ones (P < 0.001), whereas no difference was detected in the control group. Conclusion This study revealed that there was a significant association between elevated SCE frequencies and existence of HLA‐B51 patients with BD.     

Stressful life events, anxiety, depression and coping mechanisms in patients with Behçet''s disease

Background Behçet's disease is a systemic immunoinflammatory disease of young adults characterized by systemic vasculitis of arteries and veins. Although many studies have been published since its discovery in 1937, the etiopathogenesis of this unique disorder is still unclear. Objective To assess the relationship between stress factors, psychological and somatic symptoms, and coping mechanisms in patients with Behçet's disease. Method Thirty‐four patients with Behçet's disease and 43 control subjects were compared by using sociodemographic data collection forms, a psychosocial and environmental problems list, the Beck Anxiety Inventory (BAI), Hamilton Depression Rating Scale (HAM‐D) and Toronto Alexithymia Scale (TAS). Results Twenty‐four patients (70.6%) defined stress factors in the first stage of the disease. Twenty‐seven (79.4%) out of 34 patients stated that the recurrence period of the disease was related to the stress factors. Fear was expressed by 10 (29.4%) patients, sadness by 11 (32.3%), and fear plus sadness by 13 (38.2%) when they first learnt the diagnosis. While coping with these emotions 14 (41.2%) revealed active‐reliance strategy. A statistically significant difference was present between the Behçet's patients and control subjects regarding TAS (P < 0.05), HAM‐D (P < 0.001) and BAI (P < 0.001) scores. Conclusion It seems that stressful life events have important implications in both relapsing and remission periods of Behçet's disease via secondary problems.     

Serum interleukin-6, procalcitonin and C-reactive protein levels in subjects with active Behçet''s disease

Background Erythrocyte sedimentation rate (ESR), C‐reactive protein (CRP) and cytokines, including serum interleukin (IL)‐6, IL‐8 and IL‐10, and tumour necrosis factor‐alpha (TNF‐α) have been proposed as disease activity markers in Behçet's disease (BD), although studies have shown conflicting results for IL‐6. Serum procalcitonin (PCT) levels in active BD have not yet been investigated. Objective The aim of the present study was to determine the reliability of serum IL‐6 and PCT levels as well as CRP as biological markers for activity of BD. Methods Serum PCT, IL‐6 and CRP protein levels were measured in patients with active BD (n = 15) and in healthy control subjects (n = 15). IL‐6 and PCT levels were measured in serum by chemiluminescent assay. In addition, a nephelometric method was used to analyse CRP concentrations in serum. Results Serum CRP and IL‐6 values were significantly higher in the subjects with active disease than in the healthy controls (P < 0.05), but there was no significant difference in the levels of PCT in the two groups. Conclusion The results of our study suggest that serum CRP and IL‐6 levels are elevated in patients with active BD, but that serum PCT values are not elevated in these patients.     

Topical granulocyte colony-stimulating factor for the treatment of oral and genital ulcers of patients with Behçet''s disease

Background Recurrent and painful ulcers of the oral mucosa and genital skin/mucosa are the most commonly observed manifestations in patients with Behçet's disease (BD). They affect patients’ quality of life. Because of the effectiveness of granulocyte colony‐stimulating factor (G‐CSF) in wound healing, it may also be useful for the treatment of oral ulcers (OU) and genital ulcers (GU) of BD. Objective We aimed to determine the efficacy of topically applied G‐CSF in the treatment of OU and GU of BD. Methods Seven patients with BD diagnosed according to the criteria of the International Study Group for Behçet's Disease were involved in the study. The patients were observed for 3 months before the study, and all occurrences were recorded during this period. Patients were given topical G‐CSF for OU (4 × 120 µg/day, for 5 days) and/or GU (4 × 30 µg/day, for 5 days) and followed‐up for 3 months after treatment. No concurrent disease‐specific or immunosuppressive topical or systemic drugs were given during the study period. Results G‐CSF treatment decreased the healing time and pain of OU and GU in six of seven patients compared with the pretreatment period. However, the effectiveness of the G‐CSF treatment on OU and GU healing time and pain severity did not continue during the post‐treatment period. Conclusions G‐CSF has beneficial effects on the healing duration and pain severity of OU and GU of patients with BD. However, given the high cost, impractical preparation and inability to cure the disease, G‐CSF treatment should be chosen only in selected patients.     

Adamantiades–Behçet''s disease, deep venous thrombosis and anticardiolipin antibodies: report of two cases

Vascular thrombosis was found in different proportions of patients with Adamantiades–Behçet's disease (ABD), depending on the ethnicity of the population under study. Various thrombophilic factors, including the levels of anticardiolipin antibodies (ACA), were investigated for their role in the thrombotic process with conflicting results. The prevalence of ACA varies considerably in different studies, but their presence has not been associated with increased risk for vascular thrombosis. We present two cases with ABD, deep venous thrombosis (DVT) and elevated levels of ACA that fulfil the criteria for both ABD and antiphospholipid syndrome (APS).     

Relationship between periodontal findings and the TNF-α Gene 1031T/C polymorphism in Turkish patients with Behçet's disease†

Background  Genetic factors that predispose individuals to Behçet's disease (BD) and periodontal disease. Tumour necrosis factor-alpha (TNF-α) has been implicated in the pathogenesis of both BD and periodontal disease. The relationship with periodontitis and the pathogenesis of BD has not yet been determined.
Objective  The aim of the present study was to investigate the possible relation of the periodontal scores and single nucleotide polymorphism of TNF-α-1031T/C with BD compared with healthy controls (HC) and recurrent aphtous stomatitis (RAS). We also sought to determine the effects of periodontal condition and TNF-α-1031T/C polymorphism on clinical severity of BD.
Methods  Eighty-two unrelated patients with BD, 42 RAS patients and 77 HC were enrolled in the study. Periodontal status of all subjects was evaluated according to the World Health Organization community periodontal index of treatment needs (CPITN). For genotyping, polymerase chain reaction-restriction fragment length polymorphism was employed.
Results  The mean CPITN was observed to be higher in patients with BD compared with HC and RAS ( P <  0.001). TNF-α-1031C allele was significantly higher in patients with BD ( P =  0.023) and RAS ( P =  0.007) compared with HC. Mean CPITN was higher in CC genotype compared with other genotypes ( P =  0.004). Moreover, CPITN and CC genotype was found to be correlated with the severity of the disease.
Conclusions  Our data indicate that the TNF-α-1031T/C gene polymorphism (CC genotype) is a risk factor for periodontitis, RAS and BD patients and also suggests that long-term periodontal follow-up and education of oral hygiene in patients with BD may help to prevent the development and/or progression of the disease.     

Late-onset Behçet's disease does not correlate with indolent clinical course: report of seven Taiwanese patients

Background Behçet's disease (BD) is a recurrent multisystem disease of uncertain aetiology. The young adults are most often affected, usually during the third decade. Late occurrence of the disease is considered uncommon and less frequently investigated. Objective The aim of this study was to examine the clinical features of BD patients with disease onset at a later age and compare them with the usual age of onset group. Methods Retrospective review of clinical charts of BD patients was conducted. Patients with age of onset at or after 40 years of age were identified. The clinical profiles and medications required to control the disease activity were documented. Comparisons of clinical features and the medications used were made between patients with disease onset before and after 40 years of age. Results Seven late‐onset BD patients were identified. Among them, five patients required the use of systemic immunosuppressant in addition to colchicine and corticosteroid for adequate disease control. There is no significant difference in clinical profiles between patients with disease onset before and after 40 years of age, but the incidence of uveitis, an indicator of unfavourable prognosis, was surprisingly high. More specifically, it was noted in four of seven patients identified. Conclusion Our findings indicate that the clinical course of BD is not indolent in the patients with late‐onset BD. More importantly, physicians should be aware that BD can occur in older patients, and close attention regarding their disease activities is warranted as their clinical courses may not be as benign as previously believed.     

The significance of immunohistochemistry in the skin pathergy reaction of patients with Behçet''s syndrome

Background Behçet's syndrome is a chronic systemic immuno‐inflammatory disorder affecting multiple organs with generalized vasculitis of arteries and veins. Although the aetiology is still unknown, endothelial dysfunction is one of the most prominent features in Behçet's syndrome. The skin pathergy reaction (SPR) is a non‐specific hyperreactive lesion formation that is one of the major features and diagnostic criteria of the disease. It develops after 24–48 h at the site of the needle‐prick, especially in the exacerbation period, and it is very similar to the erythematous papules or pustules that appear spontaneously in patients with Behçet's syndrome. Therefore, an investigation into the formation of the SPR lesion may contribute to the pathophysiology of skin lesions of this unique disorder. Objective To evaluate the immunological features of SPR formation by assessing the immunohistochemical staining of cell adhesion molecules and endothelial growth factor markers such as E‐selectin, P‐selectin and endoglin (CD 105). Methods Patients with Behçet's syndrome showing positive (n = 15) or negative (n = 10) SPR and 15 age‐ and sex‐matched hospital‐based healthy control subjects from a similar ethnic background were included in this study. Patients were divided into active and inactive stage by clinical findings and acute‐phase reactant parameters including erythrocyte sedimentation rate (ESR) and neutrophil count. Punch biopsy specimens were obtained both from the lesion site on the forearms at 48 h and from normal skin approximately 5 cm adjacent to the SPR site. A biopsy was also obtained from the test application site in Behçet's syndrome patients with negative SPR and healthy volunteers. Biopsy specimens were then evaluated by immunohistochemical staining. Results Immunohistochemical examination demonstrated a mixed inflammatory cell infiltrate around the vessels and skin appendages that extended somewhat into the deep dermis. A positive segmental staining of E‐selectin and P‐selectin was noted in the endothelial cells of biopsies obtained from the patients with positive SPR. A positive segmental staining of CD 105 in the endothelial cells was also observed in the same group of patients. However, the immunostaining of the same markers was found to be negative in the biopsies obtained from normal skin of SPR‐positive patients, SPR‐negative patients and healthy control subjects. Both acute‐phase reactant levels were significantly higher in the active stage than in inactive patients or healthy controls. Conclusion Interaction of cellular adhesion molecules together with endothelial proliferation may play an important role in the formation of SPR lesions in patients with Behçet's syndrome. The involvement of the vascular endothelium in a large number of diseases including Behçet's syndrome supports the importance of vascular‐specific adhesion molecules for their aetiopathogenesis.     

Bone mineral density and bone turnover markers of patients with Behçet's disease

Background Behçet's disease (BD) is a systemic inflammatory disease of unknown aetiology. The pathogenesis of rheumatological findings and the status of bone metabolism in this disease are unknown. Inflammatory diseases may predispose to a decrease in bone mineral density (BMD) and there are many studies concerning osteoporosis in chronic inflammatory diseases. Objective The aim of this study was to investigate BMD and bone turnover markers in patients with BD. Methods Thirty BD patients (17 male and 13 female patients, mean age 36.9 ± 12.6 years) and a total of 30 age‐ and sex‐matched healthy controls (17 male and 13 female controls, mean age 34.9 ± 8.95 years) recruited from the general population were enrolled in the study. Bone mineral density was measured at the lumbar spine (L1‐4) and the left hip (total hip) using dual energy X‐ray absorptiometry. Serum samples were collected between 8 and 10 am after overnight fasting. Serum calcium (Ca), phosphate (P), parathormone (PTH), total alkaline phosphatase (ALP), osteocalcin (OC), erythrocyte sedimentation rate (ESR), and C‐reactive protein (CRP) were measured. Free deoxypyridinoline cross‐links (DPD) in second‐void urine and total daily urinary calcium excretion were analysed. Results No statistically significant difference in lumbar spine or femoral BMD and bone turnover markers were found between BD patients and control groups (P > 0.05). Conclusion Although it is difficult to draw definite conclusions because of the limited number of patients involved, our study indicates that bone mineral density and bone turnover markers in Behçet's disease were no different than in healthy subjects.     

The multiple faces of Behçet's disease and its aetiological factors

Behçet’s disease (BD) is a chronic, inflammatory multisystemic condition of unknown aetiology. It is clinically characterized by recurrent orogenital ulcerations and skin eruptions; ocular manifestations; arthritis; vasculitis and in some cases neurological and large vessel involvement. Aetiology has not been defined, but genetic, environmental, viral, bacterial and immunological factors have been proposed as causative agents. Treatment includes colchicine, thalidomide, steroids and immunosuppressive agents and it is based on the severity of systemic manifestations, such as central nervous system involvement, arterial aneurysms and thrombosis of the major veins. Mortality is related to major system involvement. In this article the different clinical features, the multiple faces of BD and a list of currently suspected aetiological factors of the disease are discussed, and treatment modalities summarized.     

Study on association between polymorphism of HLA-DRB1 alleles and Behçet's disease

Background  Behçet's disease (BD) is known to be associated with human leucocyte antigen (HLA)-B*51 in many ethnic groups. However, the association of HLA class II gene with BD has been described to be different according to different countries and regions.
Objective  This study aims to investigate the association between polymorphism of HLA-DRB1 alleles and BD.
Methods  Forty patients with BD and 100 healthy controls were typed for HLA-DRB1 alleles by the LABType^TM SSO method.
Results  The frequency of HLA-DRB1*14 was significantly higher in BD patients than in controls ( P <  0.05), while the frequency of HLA-DRB1*15 was markedly lower in BD patients ( P <  0.05). Regarding clinical manifestations, the frequency of HLA-DRB1*15 was significantly decreased in BD patients with genital ulcerations compared with controls ( P <  0.05); the frequency of HLA-DRB1*14 was significantly increased in BD patients with erythema nodosum–like lesions and in BD patients with folliculitis-like lesions when compared to controls ( P <  0.05, respectively). Moreover, the frequency of HLA-DRB1*14 was significantly increased in BD patients under 20 years of age at the onset of disease ( P <  0.01), while the frequency of HLA-DRB1*15 was significantly decreased in them ( P <  0.05), compared with controls.
Conclusion  The results suggested that HLA-DRB1 alleles might play an important role in the onset and clinical manifestations of BD.     

Experimental studies on the antiviral agent famciclovir in Behçet's disease symptoms in ICR mice

Background Chronic oral aphthae, recurrent genital ulcers and uveitis are the three main manifestations of Behçet's disease (BD). The aetiopathogenesis of BD is still obscure, but herpes simplex virus (HSV) is one of the possible causal factors. Various kinds of drugs, including immunosuppressants and aciclovir have been used in treatment, but effectiveness is variable. Objectives To demonstrate the efficacy of famciclovir, an antiviral compound that acts against HSV, varicella‐zoster virus and hepatitis B virus, in a murine model of BD. Methods Using the HSV‐induced BD mouse model, famciclovir was administered variously before and after inoculation or from the day of lesion occurrence, with appropriate controls. Ulceration of the mouth and genital skin and eye involvement were monitored. In addition, spleen cytokine expression was measured by polymerase chain reaction. Results Pretreatment and concurrent treatment did not affect the occurrence of BD, but treatment from the appearance of lesions was effective in improving BD and preventing recurrence. After famciclovir, interleukin 2 expression correlated with the recurrence of BD symptoms. Conclusions This model suggests the possible role of immune response to viral infection in the development and activation of BD. The study provides a rationale for clinical trials of famciclovir in the human form of BD.     

A comparison between the effects of low (1 µg) and standard dose (250 µg) ACTH stimulation tests on adrenal cortex functions with Behçet's disease

Introduction Behçet's disease is a rare, chronic disorder. The cause of Behçet's disease is unknown. It is believed to be caused by an autoimmune reaction. As in other chronic autoimmune diseases, Behçet's disease may show a subclinical adrenal failure and some changes in cortisol levels. We aimed to evaluate adrenal gland function in Behçet's disease patients. Material and method This study included 18 Behçet's disease patients and 15 healthy controls. Patient and control groups were administered i.v. 1 µg low dose test (LDT) and 250 µg standard dose test (SDT) adrenocorticotropic hormone (ACTH) stimulation test after 12 h of night fasting with an interval of 3‐days and cortisol responses in the 0th, 30th and 60th minutes were evaluated. Results There was no statistically significant difference between basal cortisol values of Behçet's disease and control groups. Cortisol values in the 60th minute in LDT were significantly lower in Behçet's disease group than in the control group. In the peak cortisol responses to LDT, a significant decrease was found in Behçet's disease group. Conclusion These findings suggest that hypothalamo‐pituitary adrenal axis is partially suppressed in Behçet's disease.