Rheumatic manifestations of Bartonella infection in 2 children

We describe 2 patients with very unusual rheumatological presentations presumably caused by Bartonella infection: one had myositis of proximal thigh muscles bilaterally, and the other had arthritis and skin nodules. Both patients had very high levels of antibody to Bartonella that decreased in association with clinical improvement. Bartonella infection should be considered in the differential diagnosis of unusual myositis or arthritis in children.

The effects of stereotype activation on behavior: a review of possible mechanisms

Considerable recent research has examined the effects that activated stereotypes have on behavior. Research on both self-stereotype activation and other-stereotype activation has tended to show that people behave in ways consistent with the stereotype (e.g., walking more slowly if the elderly stereotype is activated). Interestingly, however, the dominant account for the behavioral effects of self-stereotype activation involves a hot motivational factor (i.e., stereotype threat), whereas the dominant account for the behavioral effects of other-stereotype activation focuses on a rather cold cognitive explanation (i.e., ideomotor processes). The current review compares and contrasts the behavioral research on self- and other-stereotype activation and concludes that both motivational and cognitive explanations might account for effects in each domain.

The effects of stereotype activation on behavior: a review of possible mechanisms

Considerable recent research has examined the effects that activated stereotypes have on behavior. Research on both self-stereotype activation and other-stereotype activation has tended to show that people behave in ways consistent with the stereotype (e.g., walking more slowly if the elderly stereotype is activated). Interestingly, however, the dominant account for the behavioral effects of self-stereotype activation involves a hot motivational factor (i.e., stereotype threat), whereas the dominant account for the behavioral effects of other-stereotype activation focuses on a rather cold cognitive explanation (i.e., ideomotor processes). The current review compares and contrasts the behavioral research on self- and other-stereotype activation and concludes that both motivational and cognitive explanations might account for effects in each domain.

Acute rheumatic fever and poststreptococcal reactive arthritis: diagnostic and treatment practices of pediatric subspecialists in Canada

OBJECTIVE

We conducted a survey of pediatric specialists in rheumatology, cardiology, and infectious diseases to ascertain present Canadian clinical practice with respect to diagnosis and treatment of acute rheumatic fever (ARF) and poststreptococcal reactive arthritis (PSReA), and to determine what variables influence the decision for or against prophylaxis in these cases.

METHODS

A questionnaire comprising 6 clinical case scenarios of acute arthritis occurring after recent streptococcal pharyngitis was sent to members of the Canadian Pediatric Rheumatology Association, and to heads of divisions of pediatric cardiology and pediatric infectious diseases at the 16 university affiliated centers across Canada.

RESULTS

There is considerable variability with respect to diagnosis in cases of ReA following group A streptococcal (GAS) infection both within and across specialties. There is extensive variability regarding the decision to provide prophylaxis in cases designated as ARF or PSReA. Findings indicated that physicians are most comfortable prescribing antibiotic prophylaxis in the presence of clear cardiac risk and are less inclined to such intervention for patients diagnosed with PSReA. When prophylaxis was recommended for cases of PSReA, the majority of respondents prescribed longer term courses of antibiotics.

CONCLUSION

The lack of observed consistency in diagnosis and treatment in cases of reactive arthritis post-GAS infection likely reflects the lack of universally accepted criteria for diagnosis of PSReA and insufficient longterm data regarding carditis risk within this population. There is a need for clear definitions and treatment guidelines to allow greater consistency in clinical practice across pediatric specialties.

Echocardiography and pulmonary function testing in childhood onset systemic lupus erythematosus

The aim of this paper was to investigate the frequency of echocardiography (ECHO) and pulmonary function test (PFT) abnormalities in childhood onset systemic lupus erythematosus (SLE), and to determine the relationship of these abnormalities to disease activity. The charts of 50 patients with childhood onset SLE attending a pediatric rheumatology clinic were reviewed for ECHO and PFT studies. The frequency and description of ECHO and PFT abnormalities were documented. Possible associations of PFT and ECHO abnormalities with clinical cardiopulmonary disease, radiographic findings, and measures of lupus disease activity were evaluated. Forty patients (80%) had at least one ECHO study. Twenty-seven (68%) had an abnormal initial study. Nine of 14 patients with an initial abnormal ECHO had normal findings on repeated study. Three abnormalities were considered moderately severe. Thirty-three patients (66%) had at least one PFT performed. Sixteen (48%) were abnormal initially. Four of these 'abnormal' studies were repeated and the abnormalities persisted. Nine patients (27%) were considered to have a severe abnormality. Thirty-one children (62%) had both studies performed. An initial abnormal ECHO and abnormal PFT was found in 10 (32%) of these children. No relationship between ECHO or PFT abnormality and any measure of disease activity (physician's global assessment, anti DNA, C3 or ESR) could be found. Occult cardiac and pulmonary disease as demonstrated by ECHO or PFT occurs frequently in childhood onset SLE. If we wish to understand the natural history of these abnormal heart and lung findings, it will be necessary to do serial testing with ECHO and PFTs in this population.

Lipodystrophy in patients with juvenile dermatomyositis--evaluation of clinical and metabolic abnormalities

OBJECTIVE

Lipodystrophy and associated metabolic abnormalities are being increasingly recognized as complications of juvenile dermatomyositis (JDM). We investigated the prevalence of lipodystrophy and the extent of metabolic abnormalities related to lipoatrophic diabetes mellitus in patients with JDM.

METHODS

Twenty patients with JDM were evaluated for evidence of lipodystrophy and associated lipoatrophic diabetes mellitus. All patients underwent clinical assessment, laboratory investigations, and metabolic studies (oral glucose tolerance test, lipid studies, insulin antibodies).

RESULTS

We found clinical evidence of lipodystrophy and lipoatrophic diabetes mellitus in 4 of 20 patients with JDM and metabolic abnormalities known to be associated with lipodystrophy in another 8 patients. The 20 patients with JDM were categorized as follows: Group 1 (Patients 1-4) consisted of patients with lipodystrophy and either diabetes mellitus (2 patients) or impaired glucose tolerance (2 patients); Group 2 (Patients 5-12): no lipodystrophy but abnormal glucose and/or lipid studies; Group 3 (Patients 13-20): no lipodystrophy and no abnormalities of glucose and lipid studies.

CONCLUSION

We found 25% of patients with JDM have lipodystrophy, and 50% present with hypertriglyceridemia and insulin resistance. Screening for metabolic abnormalities in JDM should be included in routine followup because of the effect of lipodystrophy on longterm prognosis.

Extending the bases of subjective attitudinal ambivalence: interpersonal and intrapersonal antecedents of evaluative tension

Researchers have conceptualized ambivalence as resulting from the conflicting positive and negative thoughts and feelings that a person holds toward an attitude object (intrapersonal discrepancy). The authors investigated the hypothesis that perceived interpersonal attitudinal discrepancies can also contribute to feelings of subjective ambivalence beyond that determined by intrapersonal discrepancy. Study 1 revealed that the perception of attitudinal discrepancy with one's parents was associated with greater feelings of ambivalence. Studies 2 and 3 found increased ambivalence as a function of manipulated interpersonal discrepancies. Study 4 replicated and reversed the effect, revealing that interpersonal attitudinal discrepancy with a disliked other was associated with less ambivalence. Together, these studies provide support for the proposition that, because of balance processes, interpersonal relationships influence feelings of subjective ambivalence.

Isolated tuberculous monoarthritis mimicking oligoarticular juvenile rheumatoid arthritis

Isolated monoarthritis caused by Mycobacterium tuberculosis in the absence of clinical pulmonary disease is extremely rare in North America. After decades of consistent declines in incidence, a remarkable resurgence of tuberculosis (TB) is occurring in North America. It must always be considered in the differential diagnosis of chronic monoarthritis if devastating sequelae are to be avoided. We describe 2 cases of tuberculous arthritis in young children presenting with monoarthritis of the knee. The presumptive diagnosis in each case was oligoarticular onset juvenile rheumatoid arthritis (JRA). Each had an atypical course for JRA, with lack of response to intraarticular corticosteroid. The diagnosis of TB arthritis was made only with synovial biopsy.

Overview and report on international registry of sarcoid arthritis in childhood

Interest in childhood sarcoidosis prompted the formation of an international registry in 1991. Over the next 5 years, 53 patients were registered by 23 physicians from 14 countries. All the patients had definite histologic evidence of sarcoidosis: noncaseating granulomas of the skin (31), synovium (15), liver (10), lymph node (eight), lung (five), muscle (four), conjunctiva (three), or kidney (one). All but nine patients developed polyarthritis; 38 of 44 had persistent arthritis. Of those with persistent polyarthritis, arthritis occurred at presentation in 16 of 38 patients and inflammation of the uveal tract of the eye occurred in 44 with involvement of both anterior and posterior segments in 21. One patient was blind at the time of the report. Other ocular complications included chorioretinitis, glaucoma, and phthisis bulbi. Laboratory abnormalities included mild anemia and elevated erythrocyte sedimentation rate (39 out of 45). Angiotensin converting enzyme levels were elevated in 14 out of 37 patients. Information on these patients with sarcoidosis helps develop a better understanding of this rare childhood disease. These patients are discussed in conjunction with an overview of sarcoid arthropathy.

Beyond valence in the perception of likelihood: the role of emotion specificity

Positive and negative moods have been shown to increase likelihood estimates of future events matching these states in valence (e.g., E. J. Johnson & A. Tversky, 1983). In the present article, 4 studies provide evidence that this congruency bias (a) is not limited to valence but functions in an emotion-specific manner, (b) derives from the informational value of emotions, and (c) is not the inevitable outcome of likelihood assessment under heightened emotion. Specifically, Study 1 demonstrates that sadness and anger, 2 distinct, negative emotions, differentially bias likelihood estimates of sad and angering events. Studies 2 and 3 replicate this finding in addition to supporting an emotion-as-information (cf. N. Schwarz & G. L. Clore, 1983), as opposed to a memory-based, mediating process for the bias. Finally, Study 4 shows that when the source of the emotion is salient, a reversal of the bias can occur given greater cognitive effort aimed at accuracy.

Comparison of criteria for the classification of childhood arthritis

OBJECTIVE

To evaluate the applicability of the ILAR criteria for classification of childhood arthritis in an outpatient pediatric rheumatology clinic population, and to determine the proportion of children who met standard classification criteria, but failed to meet ILAR criteria for specific arthritides, and therefore became unclassifiable.

METHODS

We reviewed the charts of 70 consecutive patients who had arthritis for at least 6 months, and attended the clinic between September and November 1997. Sixty-nine patients were categorized according to one of the traditional classifications [ACR for juvenile rheumatoid arthritis (JRA), European Spondylarthropathy Study Group (ESSG) for spondyloarthropathy, Vancouver Criteria for juvenile psoriatic arthritis (JPsA)], and the ILAR classification system.

RESULTS

Sixty-one patients (88.4%) were classifiable by the ILAR system; 8 others failed to fulfill ILAR criteria for any specific category, and were assigned to the "other arthritis" category. Of the 29 patients with oligoarticular onset JRA, 6 were unclassified, 5 because of exclusions, and one because he fulfilled criteria for 2 categories. Presence of a family history of psoriasis accounted for most of the exclusions in the oligoarthritis and enthesitis related arthritis categories. All patients with polyarticular onset or systemic onset JRA were classified in the corresponding category in the ILAR system. One 9-year-old patient with spondyloarthropathy was reclassified as "other arthritis" because of exclusions. All 6 children with definite JPsA met ILAR criteria for PsA. Of 4 patients with probable JPsA, only 2 met ILAR criteria for PsA, a third was classified as rheumatoid factor negative polyarthritis, and the fourth was classified as "other arthritis" because of exclusions.

CONCLUSION

The ILAR classification criteria applied to a group of children with chronic arthritis classified by traditional criteria results in reassignment of 11.6% of the patients, predominantly in the oligoarticular group. It will be important to determine the role of the presence of a family history of psoriasis in classifying these patients.

Beyond valence in the perception of likelihood: the role of emotion specificity

Positive and negative moods have been shown to increase likelihood estimates of future events matching these states in valence (e.g., E. J. Johnson & A. Tversky, 1983). In the present article, 4 studies provide evidence that this congruency bias (a) is not limited to valence but functions in an emotion-specific manner, (b) derives from the informational value of emotions, and (c) is not the inevitable outcome of likelihood assessment under heightened emotion. Specifically, Study 1 demonstrates that sadness and anger, 2 distinct, negative emotions, differentially bias likelihood estimates of sad and angering events. Studies 2 and 3 replicate this finding in addition to supporting an emotion-as-information (cf. N. Schwarz & G. L. Clore, 1983), as opposed to a memory-based, mediating process for the bias. Finally, Study 4 shows that when the source of the emotion is salient, a reversal of the bias can occur given greater cognitive effort aimed at accuracy.

Knee magnetic resonance imaging in childhood chronic monarthritis

OBJECTIVE

To describe the usefulness of magnetic resonance imaging (MRI) of the knee in the evaluation of chronic monarthritis of uncertain cause in childhood.

METHODS

We retrospectively reviewed 21 children referred to our clinic with a putative diagnosis of chronic inflammatory monarthritis of the knee who had MRI performed between May 1993 and June 1997. The median age was 13 years (range 2-17) and 11 were girls.

RESULTS

The clinical diagnosis prior to MRI assessment was inflammatory arthritis in 16 patients, and a primary noninflammatory cause in 5. MRI was done in the patients with presumptive inflammatory arthritis when there were atypical symptoms, signs, or radiographs (n = 14), or when they failed to respond to therapy (n = 2). In the patients with a presumptive noninflammatory diagnosis, MRI was performed to clarify the diagnosis. Twelve children (57%) had MRI evidence of a noninflammatory diagnosis. In 4 children (19%) the MRI study indicated the presence of arthritis, and in 5 children (24%) the MRI studies were normal. The noninflammatory diagnoses included: lipoma arborescens (n = 1), vascular malformation [intraarticular (n = 1), extraarticular (n = 1)], synovial chondromatosis (n = 2), partial anterior cruciate ligament tear (n = 2), traumatic bone contusion (n = 2), possible meniscal tear (n = 1), osteochondritis dissecans (n = 1), and a soft tissue mass of uncertain significance in the suprapatellar pouch (n = 1).

CONCLUSION

Inflammatory arthritis is usually diagnosed by clinical assessment alone. Uncommonly, when a single joint is involved, and atypical features are identified by a pediatric rheumatologist, other causes of chronic pain and swelling need to be excluded. In this selected patient population, MRI is a useful tool either to confirm the presence of inflammatory arthritis or to investigate a wide range of pathology that can mimic knee joint arthritis.

Prognosis in children with rheumatic diseases: justification for consideration of new therapies

It is evident that current approaches to the treatment of childhood arthritis, although much improved in the past decade, are still insufficient to halt the destructive progress of these diseases in many children. Furthermore, the treatment itself is associated with toxicity which may be prohibitive. The need for new and innovative treatments is urgent. ABMT is one possible avenue that offers hope to children with severe unresponsive disease. It will be important to select carefully those children who are likely to benefit from such an approach. An appreciation of the prognosis and possible predictors of disease severity should aid in this task.

Stigmatized sources and persuasion: prejudice as a determinant of argument scrutiny

Two experiments examined the viability of several explanations for why majority group individuals process persuasive messages from stigmatized sources more than those from nonstigmatized sources. In each study, majority group participants who either were high or low in prejudice or were high or low in ambivalence toward a stigmatized source's group were exposed to a persuasive communication attributed to a stigmatized (Black, Experiment 1; homosexual, Experiment 2) or nonstigmatized (White, Experiment 1; heterosexual, Experiment 2) source. In both studies, source stigmatization increased message scrutiny only among those who were low in prejudice toward the stigmatized group. This finding is most consistent with the view that people scrutinize messages from stigmatized sources in order to guard against possibly unfair reactions by themselves or others.

Stigmatized sources and persuasion: prejudice as a determinant of argument scrutiny

Two experiments examined the viability of several explanations for why majority group individuals process persuasive messages from stigmatized sources more than those from nonstigmatized sources. In each study, majority group participants who either were high or low in prejudice or were high or low in ambivalence toward a stigmatized source's group were exposed to a persuasive communication attributed to a stigmatized (Black, Experiment 1; homosexual, Experiment 2) or nonstigmatized (White, Experiment 1; heterosexual, Experiment 2) source. In both studies, source stigmatization increased message scrutiny only among those who were low in prejudice toward the stigmatized group. This finding is most consistent with the view that people scrutinize messages from stigmatized sources in order to guard against possibly unfair reactions by themselves or others.

HLA-B27 does not affect invasion of arthritogenic bacteria into human cells

OBJECTIVE

To investigate the effect of HLA-B27 expression on entry of Salmonella typhimurium and Yersinia enterocolitica into human cells.

METHODS

We performed standard bacterial invasion assays with S. typhimurium and Y enterocolitica to analyze isogenic pairs of HeLa (epithelial), U937 (promonocyte), C1R (B lymphocyte), and Jurkat (T lymphocyte) human cell lines and their respective HLA-B27 transfectants. Invasion of peripheral blood derived T lymphocytes, monocytes, and B lymphocytes/dendritic cell fraction (corresponding to peripheral blood cells depleted of monocytes and T lymphocytes) from patients with ankylosing spondylitis and healthy donors was also analyzed. The percentage of internalized bacteria was quantified, and the differences between HLA-B27 positive and negative samples were compared.

RESULTS

The percentages of intracellular S. typhimurium and Y enterocolitica in HeLa, U937, and C1R with or without B27 were not statistically different (independent t test). We also found that the percentage of internalized bacteria did not differ significantly between HLA-B27 positive and negative samples in the different populations of peripheral blood derived cells.

CONCLUSION

The presence of HLA-B27 on the surface of human cells does not alter the degree of bacterial invasion into either cultured human cell lines or peripheral blood derived human cells, and the influence of HLA-B27 expression on bacterial invasion should not be implicated in the pathogenesis of reactive arthritis related to Salmonella and Yersinia.

Neonatal dendritic cells

The capacity of lymphoid dendritic cells from human cord blood or adult peripheral blood to support a mixed leukocyte reaction in cord blood and adult T cells has been compared. Cord blood dendritic cells have a limited ability to induce either adult or cord blood T cells to proliferate in response to typical concentration of phytohemagglutinin or concanavalin A. Adult blood dendritic cells, on the other hand, induce equivalent mitogen responses in cord blood and adult blood T cells. This relative deficiency can be overcome by increasing the concentration of mitogen or the numbers of dendritic cells in the culture. Neonatal primary immune responses may, in part, reflect the reduced function of dendritic cells.