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Review
.2019 Mar;195(3):322-333.
doi: 10.1111/cei.13243. Epub 2018 Dec 18.

Behçet's syndrome as a tool to dissect the mechanisms of thrombo-inflammation: clinical and pathogenetic aspects

Affiliations
Review

Behçet's syndrome as a tool to dissect the mechanisms of thrombo-inflammation: clinical and pathogenetic aspects

M Becatti et al. Clin Exp Immunol.2019 Mar.

Abstract

Behçet's syndrome (BS) is a complex disease with different organ involvement. The vascular one is the most intriguing, considering the existence of a specific group of patients suffering from recurrent vascular events involving the venous and, more rarely, the arterial vessels. Several clinical clues suggest the inflammatory nature of thrombosis in BS, especially of the venous involvement, thus BS is considered a model of inflammation-induced thrombosis. Unique among other inflammatory conditions, venous involvement (together with the arterial one) is currently treated with immunosuppressants, rather than with anti-coagulants. Although many in-vitro studies have suggested the different roles of the multiple players involved in clot formation, in-vivo models are crucial to study this process in a physiological context. At present, no clear mechanisms describing the pathophysiology of thrombo-inflammation in BS exist. Recently, we focused our attention on BS patients as a human in-vivo model of inflammation-induced thrombosis to investigate a new mechanism of clot formation. Indeed, fibrinogen displays a critical role not only in inflammatory processes, but also in clot formation, both in the fibrin network and in platelet aggregation. Reactive oxygen species (ROS)-derived modifications represent the main post-translational fibrinogen alterations responsible for structural and functional changes. Recent data have revealed that neutrophils (pivotal in the pathogenetic mechanisms leading to BS damage) promote fibrinogen oxidation and thrombus formation in BS. Altogether, these new findings may help understand the pathogenetic bases of inflammation-induced thrombosis and, more importantly, may suggest potential targets for innovative therapeutic approaches.

Keywords: Behçet’s syndrome; fibrinogen; neutrophils; oxidative stress; thrombosis.

© 2018 British Society for Immunology.

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Figures

Figure 1
Figure 1
(a) Maintenance of blood fluidity is essential to preserve physiological function of tissues supplying the body with oxygen and other nutrients and removing waste products. Hemostasis consists of a series of enzymatic steps activated in response of vessel injury by forming a fibrin plug that serves to limit bleeding/hemorrhage. It is affected by many factors, including cellular and plasma components. It starts with platelets adhesion to damaged endothelium, and concludes with clot retraction and finally fibrinolysis. Numerous circulating proteins constitutively survey the vasculature to prevent unnecessary clot formation or its premature degradation. Under normal physiological conditions a delicate equilibrium is maintained between the pathological states of hypercoagulability and hypocoagulability in the circulating blood. (b) Oxidative stress and inflammation as interconnected processes that co‐exist in the inflamed milieu. Reactive oxygen species (ROS) are released by vascular and inflammatory cells at the site of inflammation leading to oxidative damage; conversely, ROS production enhances proinflammatory responses. Our experimental data indicate that ROS promote fibrinogen oxidation (carbonylation) leading to fibrinogen secondary structure modifications which affect its biological activity. Fibrinogen oxidation induces the build‐up of an altered thrombogenic clot mainly characterized by a tight fibrin network composed of filaments with slightly decreased fiber size that are resistant to plasmin‐induced lysis. This oxidized fibrin network persists in the vascular bed and contributes to vascular occlusion and thrombus development. In BS, the use of traditional disease‐modifying anti‐rheumatic drugs (DMARDs) (mainly azathioprine and cyclophosphamide) and/or anti‐tumor necrosis factor (TNF)‐α (namely infliximab and adalimumab) is effective for the treatment of both venous and arterial manifestations. The efficacy of immunosuppressants might be due partly to their ability to interfere with the mechanisms described above.
Figure 2
Figure 2
Unoxidized fibrinogen from healthy subjects forms a plasmin‐susceptible fibrin clot. Conversely, in Behçet’s syndrome (BS) patients, ROS promote fibrinogen oxidation and fibrinogen structure modifications, which are responsible for altered fibrinogen clotting ability and reduced fibrin susceptibility to plasmin‐induced lysis. This evidence offers a new model of inflammation‐induced thrombosis and supports current therapeutic concepts regarding the use of immunosuppressive (rather than anti‐coagulation) therapy in BS‐related thrombosis.
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References

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