Suleyman Ozbek

Smoking and Behçet’s Disease

Abstract: It has recently been claimed that some of the symptoms in patients with Behçet’s disease (BD) can be activated after the patient has stopped smoking. In this study we investigated the effect of smoking on the symptoms of Behçet’s disease. Fifty asymptomatic current smokers (CS) who promised to stop smoking (group 1) and 60 current non-smokers (NS) (group 2) (21 of them ex-smokers) with BD were examined at the beginning and a week later for the presence of symptoms of BD. Forty-seven of the 50 CS completed the study. Oral aphthous ulcers were observed in 31 (65.9%) of them at the end of the study period. Besides oral aphthous lesions, genital ulcers were detected in two and erythema nodosum in two other patients. Only 15 (25%) group 2 patients developed oral aphthous ulcers during the study period. The difference between the frequencies of oral aphthous lesions in these groups was significant (p = 0.0002). We concluded that cessation of cigarette smoking can activate the mucocutaneous symptoms, especially oral aphthous lesions, in patients with BD.

Methylenetetrahydrofolate reductase gene C677T mutation and plasma homocysteine level in Behçet's disease

ObjectiveThe aim of this study was to assess whether homozygosity for the 5, 10-methylenetetrahydrofolate reductase (MTHFR) C677T mutation and plasma homocysteine concentration are related to deep vein thrombosis in Behçets disease (BD) patients.MethodsForty BD patients (23 males, 17 females; mean age 40.2±8.4 years) and 60 healthy controls (HC) (34 males, 26 females; mean age 41.6±6.9 years) were included in the study. Fourteen of the BD patients had a history of deep venous thrombosis (DVT), as confirmed by Doppler ultrasound.ResultsThe rates of homozygosity for the MTHFR C677T mutation in the BD and HC groups were 7.5% and 10%, respectively. The distribution of MTHFR genotypes was similar in the two groups (p>0.05), and analysis showed that homozygosity for the mutation was not a risk factor for DVT. The mean plasma homocysteine levels were 13.4±4.2 µmol/l for the overall BD patients and 12.6±3.8 µmol/l for HC (p>0.05). However, the mean plasma homocysteine level in the BD patients with DVT history (15.9±4.6 µmol/l) was significantly higher than the level in the BD patients with no DVT history (12.1±3.3 µmol/l) (p=0.013) and the level in the HC group (12.6±3.8 µmol/l) (p=0.025).ConclusionThe study results suggest that elevated plasma homocysteine level may play a role in the pathogenesis of venous thrombosis in BD.

Renal vascular resistance in progressive systemic sclerosis: evaluation with duplex Doppler ultrasound.

The study was planned to evaluate renal vascular resistance by means of duplex Doppler ultra sonography in patients with progressive systemic sclerosis (PSS) with or without signs of renal involvement. Twenty-two female patients with PSS (mean age 38.5 ± 17.3 years) and 20 age-matched (mean age 36.7 ±7.2 years) female healthy controls participated to the study. Doppler indices of renal vascular resistance—resistive index (RI), pulsative index (PI), and systolic-to-diastolic flow velocities ratio (S/D ratio)—were determined on main renal artery and interlobar artery. RI, PI and S/D ratio were found to be increased in PSS patients with signs of renal involvement as compared to those without renal manifestations and healthy controls (p<0.0001 for all groups). Doppler indices of renal vascular resistance were closely related to the duration of the disease, age, and plasma renin activity. Doppler ultrasound is a useful and informative technique in the monitoring of PSS patients with renal involvement.

Delay in the diagnosis of SLE: the importance of arthritis/arthralgia as the initial symptom.

Despite the current diagnostic and serologic testing for SLE, the interval between the onset of symptoms and the diagnosis is still long. In this study, we aimed to show the interval between the initial symptoms and the diagnosis of SLE and to investigate the presence of any relationship between the interval and the initial symptoms. One hundred and thirty-six patients were diagnosed with SLE using the 1982 ARA criteria. The mean age of the patients at diagnosis was 29.9 +/- 10.5 years. The mean interval between the onset of symptoms and the diagnosis of SLE was 21.82 +/- 30.32 months. The subjects were evaluated twice, at intervals of < or = 3 and < or = 12 months after the onset of symptoms. Although arthritis and/or arthralgia were the most common initial symptoms (60.3%), only 26.8% of the patients with these symptoms were diagnosed earlier than 3 months after the onset. If the first initial symptoms were butterfly rash or pericarditis, pleuritis, spontaneous abortion or cognitive dysfunction, they led to early diagnosis. In conclusion, since arthritis and/or arthralgia are the most common initial symptoms of the disease, every young woman with these symptoms should be carefully evaluated for SLE.

Is there any relationship between toxoplasma infection and reactive arthritis

BACKGROUND The diagnosis of reactive arthritis is a challenging clinical problem in daily practice. Although there are many triggering infectious agents for reactive arthritis, Toxoplasmosis, a worldwide parasitic infection has not been reported. AIM We investigated the serologic evidence of Toxoplasma gondii ( T. gondii ) infection in patients with newly diagnosed reactive arthritis after six weeks of the onset of the first symptom but no demonstrable triggering agent for reactive arthritis. SETTING AND DESIGN Clinical controlled study. MATERIALS AND METHODS We screened serologically the serum toxoplasma IgM and IgG antibody (Ab) titers which revealed toxoplasma infection in 50 patients with reactive arthritis (40 female, 10 men) and no demonstrable triggering agent and control subjects (32 female, 8 male). STATISTICAL ANALYSIS SPSS 10.0 software package program was used. RESULTS The mean age of the patients and controls was similar (41.3+/- 12.0 vs. 39.6+/-11.8 years) respectively. The prevalence of IgG Ab titers of T. gondii in patients and controls were found to be 52% and 47.5%, respectively. Mean serum Toxoplasma IgG Ab levels were found to be 16.5+/-14.5 IU/ml, and 16.9+/-13.8 IU/ml in patients and control subjects respectively ( P> 0.05). We did not find any Toxoplasma IgM Ab titer demonstrating the acute or sub-acute infection in the serum of patients or controls. CONCLUSION Although past Toxoplasma infection was prevalent in both groups, we did not find any subject with acute Toxoplasma infection in patients with newly diagnosed reactive arthritis and healthy controls. Despite the fact that our study group was small, we suggest that T. gondii does not seem to be a triggering agent for reactive arthritis and past infection may be a coincidental finding.

Is sildenafil effective in secondary pulmonary hypertension due to systemic lupus erythematosus? A case report

It has been reported that more than 60% of patients with systemic lupus erythematosus (SLE) have pulmonary involvement, and 1–14% of them have pulmonary hypertension (PH). Both primary and secondary hypertension can be seen in patients with SLE [1, 2]. Recently, it was reported that sildenafil could reduce pulmonary artery pressure and increase quality of life in patients with SLE [2, 3]. In March 2003, a 40-year-old nonsmoker female patient was admitted to the outpatient clinic of Chest Disease, Çukurova University School of Medicine. She had been followed at the Department of Rheumatology with a diagnosis of SLE for 10 years. She had complained of exercise-induced dyspnea for the last 8 years. During this period, the patient had no other pulmonary problem and received methylprednisolone and cyclophosphamide treatment for SLE. She had progressive dyspnea during the last 3 years, and echocardiographic examination revealed PH. Treatment with regular methylprednisolone and calcium channel blocker had been started. In spite of this treatment, the patient suffered from dyspnea (New York Heart Association functional class III). On physical examination, there was no pathological finding except Raynaud’s phenomenon in her hands and feet and hepatomegaly. The detection of antinuclear antibody was found to be (+++), anti-DNA ( ), and anticardiolipin antibody IgM and IgG ( ). Pulmonary function tests revealed mild airflow obstruction while bronchodilation test with salbutamol 200 lg was negative [FEV1: 1.71 l (67% of predicted), FVC: 2.49 l (83% of predicted), and FEV1/FVC: 69 (85% of predicted)]. High-resolution computed tomography (HRCT) of the thorax was normal. Systolic pulmonary artery pressure (PASP) was 110 mmHg measured by Doppler echocardiogram, and right heart dilatation was determined. Oral sildenafil 50 mg (Viagra, Pfizer) was started after written consent of the patient was obtained. Echocardiography was repeated 90 min after administration of the drug, revealing that pulmonary artery pressure had declined to 81 mmHg. Sildenafil was given at a dose of 25 mg b.i.d. for 1 month. After 1 month, no improvement was observed in the severity of dyspnea. A Doppler echocardiogram revealed a PASP of 105 mmHg and the treatment of sildenafil was discontinued. During this period, no side effect related with sildenafil was determined. A variety of vasodilator agents have been studied in patients with PH. It has been reported that continuous infusion of prostacyclin (epoprostenol) and/or its analogs, oral (beraprost) and inhaler (iloprost), bosentan (endothelin receptor antagonist), and nitric oxide have been shown to reduce pulmonary vascular resistance and PASP in patients with SLE or interstitial lung diseases [4, 5, 6]. However, this treatment has several problems due to using the mentioned drugs. In some studies, it was determined that PASP is reduced and exercise tolerance and quality of life are increased with sildenafil treatment for primary PH [7, 8]. Littera et al. reported that a patient with thalassemia and secondary PH who received sildenafil treatment of 50 mg twice a day during 15 months had both clinical and laboratory improvement [9]. Molina et al. gave daily 400 mg sildenafil for 7 months to a patient with SLE and PH and observed improvement in the quality of life I. Hanta (&) Æ A. Kocabas Department of Chest Medicine, Çukurova University, School of Medicine, Adana, Balcali, 01330, Turkey E-mail: ihanta@cu.edu.tr Tel.: +90-322-338-6851

Superior vena cava syndrome: a rare clinical manifestation of Behcet's disease.

Behçet’s disease is a multisystemic, chronic inflammatory disease of unknown etiology characterized by recurrent episodes [1, 2]. Arterial and venous thrombosis due to Behçet’s disease, although not frequent, can be seen in clinical presentation [3]. The involvement of larger vessels such as the vena cava superior was reported to be less than 2% [4]. A 37-year-old male patient was admitted with swelling around the neck and dyspnea during exercise in April 2003. In a detailed conversation, the patient reported that he had experienced recurrent ulcers in his mouth and genital area within the last year. Physical examination revealed swelling at the supraclavicular region bilaterally, enlargement of the frontal chest wall and upper extremity vessels bilaterally, papillomatous, pustular lesions on the skin, and ulcer scars at the genital region. Laboratory data were normal. Chest X-ray revealed mediastinal enlargement. However, magnetic resonance imaging (MRI) of the thorax revealed total obstruction of the bilateral jugular veins and superior vena cava (Fig. 1). Arterial and venous color Doppler ultrasonography of the upper and lower extremities demonstrated thrombosis in the left subclavian vein, and in both right and left popliteal veins. The patient was diagnosed as Behçet’s disease based on these clinical findings. Methylprednisolone, cyclophosphamide, and low molecular weight heparin were initiated. Four months later, repeated MRI of the thorax revealed that the thrombosis in the superior vena cava had dissolved and recanalized. Vascular involvement due to Behçet’s disease can affect all the vessels in the body. Occlusion of upper and lower extremity veins with superior and inferior cava veins and aneurysms of pulmonary arteries and aorta can be seen [2]. MRI is the suggested diagnostic method [1]. In the treatment of superior vena cava syndrome due to Behçet’s disease, prednisolone, cyclophosphamide, heparin, or a combination of these are recommended [3]. Thrombolytic treatment options can be used in superior vena cava syndrome [4, 5]. In our case, prednisolone and cyclophosphamide were given, and 4 months later when MRI of the thorax was repeated, it was shown that the thromboses had disappeared.

Histopathological changes of cervical tissue in women with systemic sclerosis

Systemic sclerosis is a connective tissue disease that can affect almost any organ of the body. The clinical aspects of systemic sclerosis on the reproductive system have been studied in large series, and an increased rate of cesarean section has been reported. For this reason, in the present study the histopathological features of cervical specimens of hysterectomyzed women with systemic sclerosis were evaluated. An increased frequency of vascular and stromal abnormalities in cervical specimens of women with systemic sclerosis were observed. Vascular medial hypertrophy, intimal thickening, and fibrosis were more often encountered in the cervical specimens of the patients with systemic sclerosis. Some of the histopathological features also showed correlation with the clinical profile of the disease. The patients with vascular medial hypertrophy in their cervical specimens were older, had a higher Rodnan score, and had longer duration of the disease. In contrast to vascular medial hypertrophy, periadventitial edema was found in the cervical specimens of the patients who were younger, had a lower Rodnan score, and had shorter duration of the disease. It was concluded that the problems that are seen in common obstetric and gynecological practices in patients with systemic sclerosis may be explained by these tissue abnormalities.