Classification of childhood arthritis: a work in progress

The classification of chronic childhood arthritis has challenged physicians for a century. Currently used classifications are all based on clinical characteristics and because they are frequently used imprecisely, communication of scientific data has been difficult. The new classification of the International League of Associations of Rheumatologists (ILAR) represents the results of an international effort to clarify the classification of this group of diseases based on identification of clinically homogeneous groups. This classification process is ongoing, and will reflect the results of scientifically based studies as they become available.

Etiology and pathogenesis of rheumatic diseases of adolescence

The pathogenesis of SLE is multifactorial. Immune complexes, autoantibodies, and abnormal T-lymphocyte responses all play a part. Genetic predispositions are present, but not as strongly expressed as in the spondylarthropathies. Environmental agents and the effects of sex hormones also contribute.

Clinical and therapeutic aspects of juvenile-onset spondyloarthropathies

Relatively little is written about the juvenile spondyloarthropathies. The literature of the past year has included data on the frequency of juvenile spondyloarthropathies, which indicate that these are almost certainly a more common form of childhood arthropathy than formerly believed. Although clinical differences exist between juvenile spondyloarthropathies and juvenile rheumatoid arthritis, there is only limited information about differences in the pathophysiology of these diseases. One study suggests some differences in the expression of tumor necrosis factor and its receptors. Evidence also presented this year suggests that juvenile psoriatic arthritis is probably a separate condition from the spondyloarthropathies. It is hoped that better understanding of the epidemiology and pathophysiology of the juvenile spondyloarthropathies will lead to better treatment strategies.

Viruses and childhood arthritis

The role of viral infections in the aetiology of acute and chronic arthritides of childhood is incompletely understood. The fact that some viruses cause acute arthritis is certain, although in most instances of presumed viral arthritis no agent is identified. The associations of viruses with diseases such as juvenile chronic arthritis (JCA) are limited, and have been difficult to prove with certainty. Rubella, parvovirus B19 and influenza AH2N2 have been shown by culture, serology or epidemiology to be related to at least some cases of JCA in some studies, but not in others. A rationale for pursuing investigations of viral aetiology of chronic arthritis is discussed, and a strategy involving early disease detection and close collaboration between clinicians and scientists is proposed.

Rheumatoid factor positive, oligoarticular onset juvenile rheumatoid arthritis

We describe 2 children with oligoarticular onset juvenile rheumatoid arthritis (JRA) with early erosive disease. Both patients were rheumatoid factor (RF) positive, but neither had HLA-DR4. These findings suggest RF is associated with early erosive disease, independent of HLA-DR4. RF positive oligoarticular onset JRA should probably be recognized as a separate subgroup of JRA.

Anti-RNP antibody in a child with undifferentiated carcinoma and no evidence of mixed connective tissue disease

We describe a young girl who presented with musculoskeletal symptoms and who was found to have high titres of antinuclear antibody with anti-RNP antibody. She was initially suspected of having mixed connective tissue disease, but ultimately was found to have metastatic undifferentiated carcinoma with an unknown primary site. This is a very uncommon malignancy of childhood and an association with anti-RNP antibody has, to our knowledge, not been described. The clinical significance of this finding is discussed.

Intestinal pseudo-obstruction as an initial presentation of systemic sclerosis in two children

Two children are reported in whom intestinal pseudo-obstruction was the initial manifestation of systemic sclerosis. Gastrointestinal symptoms and skin changes resolved or improved in both children following treatment with prednisone and penicillamine (case 1) or methotrexate (case 2), although radiological changes of the gastrointestinal tract persisted at 3 and 2 yr of follow-up, respectively.

Attitudes and attitude change

We review empirical and conceptual developments over the past four years (1992-1995) on attitudes and persuasion. A voluminous amount of material was produced concerning attitude structure, attitude change, and the consequences of holding attitudes. In the structure area, particular attention is paid to work on attitude accessibility, ambivalence, and the affective versus cognitive bases of attitudes. In persuasion, our review examines research that has focused on high effort cognitive processes (central route), low effort processes (peripheral route), and the multiple roles by which variables can have an impact on attitudes. Special emphasis is given to work on cognitive dissonance and other biases in message processing, and on the multiple processes by which mood influences evaluations. Work on the consequences of attitudes focuses on the impact of attitudes on behavior and social judgments.

The gradual threshold model of ambivalence: relating the positive and negative bases of attitudes to subjective ambivalence

This research examined the relationship between the measured (Study 1) and manipulated (Studies 2 and 3) positive and negative bases of attitudes and the psychological experience of attitudinal ambivalence. On the basis of these studies, the gradual threshold model of ambivalence (GTM) was advanced. The GTM holds that: (a) ambivalence increases in a negatively accelerating manner as the number of conflicting reactions (whichever of the positive or negative reactions are fewer in number) increases, (b) ambivalence is a negative function of the extent of dominant reactions, and (c) as the number of conflicting reactions increases, the impact of dominant reactions on ambivalence gradually decreases such that at some level of conflicting reactions (i.e, the threshold), the number of dominant reactions no longer has an impact on subjective ambivalence.

Pneumocystis carinii pneumonia in childhood systemic lupus erythematosus

OBJECTIVE

Although Pneumocystis carinii pneumonia (PCP) is known to occur in adults with systemic lupus erythematosus (SLE), this infection has rarely been described in childhood SLE. We describe 3 children with SLE who developed PCP and describe risk factors for this complication.

METHODS

A retrospective case review.

RESULTS

All 3 children had severe active SLE with organ involvement requiring immunosuppressive therapy, but the clinical presentations of PCP differed in each patient. They shared some of the known risk factors for opportunistic infection in adults with SLE, including lymphopenia, but severe lymphopenia (< 0.35 x 10(9)/1) was not seen.

CONCLUSION

PCP is an uncommon but serious complication of childhood SLE, and should be considered in the presence of respiratory symptoms, however subtle. The role of oral chemoprophylaxis is discussed.

Juvenile psoriatic arthritis: followup and evaluation of diagnostic criteria

OBJECTIVE

To describe the course of juvenile psoriatic arthritis (JPsA) defined by the "Vancouver Criteria."

METHODS

A retrospective review of JPsA in 63 children, (44 girls, median age at onset 4.5 yrs; 19 boys, median age at onset 10.1 yrs) who fulfilled the Vancouver Criteria, as follows. Definite JPsA: arthritis with psoriasis, or arthritis with 3 of 4 minor criteria (nail pits, dactylitis, psoriasis-like rash, family history of psoriasis); probable JPsA: arthritis with 2 of the minor criteria.

RESULTS

At last followup, 50 children had definite JPsA and 13 had probable JPsA. Rheumatoid factor was absent in all; antinuclear antibody was present in 50%. Thirty-eight children were followed for > 5 yrs, 18 for > 10 yrs, and 7 for > 15 yrs. Forty-four children had active arthritis; 32% were in functional class I, 38% in class II, 22% in class III, and 8% in class IV. Of the 46 patients with oligoarticular onset, 21 remained oligoarticular, and 25 became polyarticular. Arthritis in the small joints of the hands and feet increased in frequency, with arthritis eventually occurring in proximal interphalangeal joints in 63%, metacarpophalangeal or metatarsophalangeal joints in 55%, and distal interphalangeal joints in 27%. Dactylitis occurred in 35%, most commonly in 2nd toes and index fingers. Nine patients (14%) developed chronic anterior uveitis. Eleven of 24 patients (46%) who initially had probable JPsA evolved to definite JPsA after a median of 2.1 yrs. Five developed psoriasis and the remainder developed additional minor criteria. The 13 patients with a current diagnosis of probable JPsA did not differ significantly from the 50 patients with definite JPsA with respect to number of joints involved at onset or during the disease course. Patients with psoriasis (n = 41) did not differ from those with definite JPsA without psoriasis (n = 9) with respect to the number of joints involved at onset or during the disease course, functional class, or need for 2nd line therapy.

CONCLUSION

JPsA defined by the Vancouver Criteria is a relatively common chronic arthropathy of childhood that differs clinically, serologically, and genetically from both juvenile rheumatoid arthritis and juvenile ankylosing spondylitis.

Spondyloarthropathies of childhood

The term spondyloarthropathy, currently used to describe some forms of idiopathic arthritis of childhood, may be inappropriate because most children included in this category do not have arthritis of the spine, and inflammatory disease of the sacroiliac joints is an infrequent or late finding. Juvenile AS, the archetype, or "complete" disease may account for only one fifth of the so-called "spondyloarthropathies". "Incomplete" or "early" spondyloarthropathies are most frequent. Such children may not develop axial symptoms and signs for 5 to 10 years after onset, and they may be better characterized as having enthesitis-related arthritis, a term proposed by a recent task force of the International League Against Rheumatism (ILAR). Reactive arthritis, although etiologically linked with the spondyloarthropathies, uncommonly progresses to AS in childhood; most patients have peripheral arthritis with or without enthesitis resolving in the relatively short term. The arthritis associated with IBD is more commonly peripheral than axial. Although axial disease undoubtedly occurs in JPsA, in the authors' experience it is very uncommon.

Positive mood can increase or decrease message scrutiny: the hedonic contingency view of mood and message processing

Currently dominant explanations of mood effects on persuasive message processing (i.e., cognitive capacity and feelings as information) predict that happy moods lead to less message scrutiny than neutral or sad moods. The hedonic contingency view (D. T. Wegener & R. E. Petty, 1994) predicts that happy moods can sometimes be associated with greater message processing activity because people in a happy mood are more attentive than neutral or sad people to the hedonic consequences of their actions. Consistent with this view, Experiment 1 finds that a happy mood can lead to greater message scrutiny than a neutral mood when the message is not mood threatening. Experiment 2 finds that a happy mood leads to greater message scrutiny than a sad mood when an uplifting message is encountered, but to less message scrutiny when a depressing message is encountered.

An unusual case of mixed sclerosing bone dystrophy presenting with morning stiffness and joint swelling in childhood: a case report

We describe a case of a 16 year old native Indian girl with pain, morning stiffness and foot swelling who had radiographic changes consistent with mixed sclerosing bone dystrophy (MSBD) combined with fibrous dysplasia.

Positive mood can increase or decrease message scrutiny: the hedonic contingency view of mood and message processing

Currently dominant explanations of mood effects on persuasive message processing (i.e., cognitive capacity and feelings as information) predict that happy moods lead to less message scrutiny than neutral or sad moods. The hedonic contingency view (D. T. Wegener & R. E. Petty, 1994) predicts that happy moods can sometimes be associated with greater message processing activity because people in a happy mood are more attentive than neutral or sad people to the hedonic consequences of their actions. Consistent with this view, Experiment 1 finds that a happy mood can lead to greater message scrutiny than a neutral mood when the message is not mood threatening. Experiment 2 finds that a happy mood leads to greater message scrutiny than a sad mood when an uplifting message is encountered, but to less message scrutiny when a depressing message is encountered.

Personality moderators of mood congruency effects on cognition: the role of self-esteem and negative mood regulation

The authors report 3 experiments on negative mood regulation in which whether mood-congruency or mood-incongruency effects of negative mood on cognition were observed was dependent on an individual's self-esteem (SE). We found that most of our 224 participants tended toward mood-congruent recall under control conditions in which mood was relatively neutral. However, when a negative emotional state was induced, participants low in SE exhibited mood-congruent recall, but high-SE participants did not. In fact, the more negative high-SE participants felt, the more positive were their cognitions (mood-incongruent recall). This pattern was replicated in 3 experiments that included variations in the negative mood inductions and the type of information that was generated or retrieved. Our results suggest a strong link between SE and the regulation of negative emotional states.

Atlantoaxial subluxation in children with seronegative enthesopathy and arthropathy syndrome: 2 case reports and a review of the literature

We describe 2 HLA-B27 positive children with seronegative enthesopathy and arthropathy (SEA) syndrome who developed spontaneous (nontraumatic) atlantoaxial subluxation early in their disease course. Neither child had evidence of spinal cord compression but both had progressive atlantoaxial subluxation in spite of conservative treatment. Both underwent elective posterior cervical (C1-C2) fusion.

Flexible correction processes in social judgment: the role of naive theories in corrections for perceived bias

Unlike many models of bias correction, our flexible correction model posits that corrections occur when judges are motivated and able to adjust assessments of targets according to their naive theories of how the context affects judgments of the target(s). In the current research, people flexibly correct assessments of different targets within the same context according to the differing theories associated with the context-target pairs. In Study 1, shared theories of assimilation and contrast bias are identified. Corrections consistent with those theories are obtained in Studies 2 and 3. Study 4 shows that idiographic measures of theories of bias predict the direction and magnitude of corrections. Implications of this work for corrections of attributions and bias removal in general are discussed.

Studies of human cord blood dendritic cells: evidence for functional immaturity

We have isolated low-density, nonadherent, nonphagocytic, HLA-DR+ve cells with the morphology of dendritic cells (DCs) from the cord blood of full-term newborn infants. Relative to adult DCs, cord blood DCs were poor stimulators of the mixed leukocyte reaction when either adult or cord blood mononuclear cells (MNCs) or T lymphocytes were used as responder cells. In contrast, cord blood T cells and MNCs responded normally to allogeneic adult DCs. Cord blood DCs performed poorly as accessory cells for T-lymphocyte mitogenic responses at suboptimal concentrations of concanavalin A (Con A) and phytohemagglutinin A or at optimal concentrations of mitogen and low numbers of DCs. Addition of recombinant interleukin-2 (rIL-2) or recombinant interferon-gamma (rIFN-gamma) to cord blood DC-T-cell cultures containing a suboptimal concentration of Con A potentiated the proliferative response. In contrast, rIL-2 and rIFN-gamma exerted little effect on the proliferative response of adult T cells cultured with Con A and DCs. Flow cytometric studies showed that levels of intercellular adhesion molecule-1 (ICAM-1; CD54) and major histocompatibility complex (MHC) class I HLA-ABC and class II HLA-DR antigens on cord blood DCs were significantly lower than those on adult blood DCs. These findings suggest that the relative inefficiency of cord blood DCs in the activation of T cells may be related to their low cell surface expression of MHC and cell adhesion molecules. The demonstrated impairment of cord blood DC function could be of importance in understanding the immunologic relationship between the fetus and mother and could contribute to the susceptibility of newborns to infection.

Visual prognosis in children with chronic anterior uveitis and arthritis

OBJECTIVE

To determine the visual and ocular prognosis for children with uveitis and chronic arthritis and in patients with uveitis with juvenile rheumatoid arthritis (JRA) or juvenile psoriatic arthritis (JPsA) and to evaluate risk factors associated with ocular complications.

METHODS

We studied 49 children with chronic arthritis having greater than 2 years ophthalmological followup from onset of uveitis. Visual acuity and ocular complications (band keratopathy, synechiae, cataracts, glaucoma, or phthisis bulbi) were documented. For the 45 patients with JRA/JPsA, the antinuclear antibody and HLA status, time and mode of onset, and the course of uveitis, were evaluated as risk factors for developing complications.

RESULTS

Mean followup was 9.4 years from diagnosis of uveitis (82 affected eyes). Ocular complications developed in 27 eyes (33%). Visual impairment (corrected acuity 20/50 or worse), occurring only in the presence of complicated uveitis, was present in 12 eyes (15%). Of 45 patients with JRA/JPsA, over 95% developed uveitis within 5 years of onset of arthritis. Those with complicated uveitis (n = 13, mean followup 8.6 years) and uncomplicated uveitis (n = 32, mean followup 10 years) were compared: factors significantly associated with complicated uveitis were (1) a chronic course of uveitis (2) JPsA (3) diagnosis of uveitis prior to, or at the time of arthritis onset (4) symptomatic onset.

CONCLUSION

The risk of developing uveitis 5 years after the onset of JRA/JPsA is small. Although ocular complications were common (33%) among patients with uveitis, normal vision was maintained or correctable for over half of them. Those with uveitis and risk factors for developing ocular complications may need close ophthalmological scrutiny.

Juvenile psoriatic arthritis, or juvenile arthritis with psoriasis?

Juvenile psoriatic arthritis (JPsA) has traditionally been considered to be one of the spondyloarthropathies. Clinical and laboratory evidence had shed doubt on the appropriateness of its inclusion in this classification, however. It is suggested that included under the rubric of JPsA there are two or more conditions: one in which arthritis and psoriasis occur coincidentally, and a second in which psoriasis occurs with a characteristic pattern of joint involvement: asymmetric oligoarthritis affecting large and small joints, with or without dactylitis, chronic uveitis, and antinuclear antibodies. Whether it is appropriate to consider JPsA as a variant of juvenile rheumatoid arthritis, or as an entirely separate disorder is uncertain.

Mood management across affective states: the hedonic contingency hypothesis

Mood management in positive and negative moods is relevant to a variety of social phenomena and has been especially important in the helping literature. Theorists have predicted that sad people strategically engage in mood management activities more than happy people. However, application of learning principles across affective states led the authors to hypothesize that hedonic rewards are more contingent on scrutiny of hedonic consequences in happy than sad states. Thus, happy people should scrutinize the hedonic consequences of potential behaviors more than sad people. A selective exposure paradigm was used to test this hedonic contingency hypothesis. People in whom happy, sad, or neutral states were induced were asked to choose activities in which to engage. In 3 experiments, happy people based their choices on the affective consequences of those activities more than sad or neutral individuals. Implications for interpreting past work are discussed.

Experimental arthritis and uveitis in rats associated with Mycobacterium butyricum

OBJECTIVE

To determine if the anterior uveitis associated with adjuvant arthritis (AA) in the rat can be passively transferred with arthritis to syngeneic recipients using spleen cells or T cell lines prepared from animals given complete Freund's adjuvant (CFA) and Mycobacterium butyricum (M. butyricum) in incomplete Freund's adjuvant (IFA).

METHODS

Spleen cells from Lewis or Lewis SsN rats given IFA, CFA, type I collagen in IFA (CI-IFA), or type II collagen in IFA (CII-IFA) were administered to naive rats or rats treated with pertussis toxin or bacterial endotoxin. Three CD4+ T cell lines, propagated from CFA injected rats and maintained in vitro with M. butyricum (M-1), bovine proteoglycan (PR-1) or an extract of M. butyricum (MBE-1) were administered to naive or immunosuppressed rats. The arthritogenic and uveitogenic properties of these cell preparations and intradermal MBE-IFA, CII-IFA and intraperitoneal (ip) M. butyricum without adjuvant were evaluated.

RESULTS

Uveitis was observed in 15/69 (22%) arthritic rats given CFA. Spleen cells prepared from CFA injected rats caused arthritis in 55 (82%) and uveitis in 2 (3%) of 67 cell recipients. Uveitis occurred in 2/6 cell recipients pretreated with bacterial endotoxin. Neither uveitis nor arthritis was observed in rats given IFA (0/6) or spleen cells prepared from rats given IFA (0/27), CI-IFA (0/6), or CII-IFA (0/28). CII-IFA produced polyarthritis in 5/6 rats, but no uveitis. CII-IFA induced arthritis associated uveitis in 1/15 animals receiving spleen cells from rats given CII-IFA, but not those given CI-IFA (0/3) or IFA (0/13). Uveitis was observed in one recipient of the M-1 T cell line and in 2 recipients of the PR-1 T cell line. Immunization with 400 micrograms of MBE-IFA induced uveitis but not arthritis in 3/11 animals. The MBE specific T cell line was neither arthritogenic nor uveitogenic. A high frequency (5/6) of uveitis accompanied arthritis in male Lewis rats given ip M. butyricum. Arthritis occurred in 4/10 female Lewis rats given ip M. butyricum and 2 arthritic animals also developed uveitis.

CONCLUSION

Uveitis occurs infrequently in arthritic rats given spleen cells from CFA injected animals. The ip administration of M. butyricum constitutes a novel disease model in which the immunopathological relationships between arthritis and uveitis may be more reliably studied.