Macrophage activation syndrome in systemic juvenile rheumatoid arthritis successfully treated with cyclosporine

A macrophage activation syndrome, possibly related to methotrexate toxicity, developed in a boy with systemic juvenile rheumatoid arthritis. Corticosteroid administration was ineffective, whereas a prompt response to cyclosporine was observed. Two months later, Pneumocystis carinii pneumonia developed.

Circulating levels of interleukin 1 beta and of interleukin 1 receptor antagonist in systemic juvenile chronic arthritis

OBJECTIVE

To measure circulating interleukin 1 beta (IL-1 beta) and IL-1 receptor antagonist (IL-1Ra) levels in patients with systemic juvenile chronic arthritis (JCA) and to evaluate their correlation with disease activity.

METHODS

IL-1 beta and IL-1Ra levels were measured by ELISA in 45 patients with JCA (20 systemic, 10 polyarticular and 15 pauciarticular) and in 15 healthy controls.

RESULTS

Plasma IL-1 beta levels were undetectable in the majority of patients with systemic JCA, and detectable levels were not associated with different treatments or with parameters of disease severity. Serum IL-1Ra levels were markedly increased in patients with systemic JCA and significantly correlated with the persistence of systemic features, the extent and severity of joint involvement, and with C-reactive protein concentrations. Serum IL-1Ra levels were also significantly correlated with IL-6 levels.

CONCLUSION

These results argue against a relevant role of IL-1 in systemic JCA. The increase in IL-1Ra levels does not appear to reflect an increase in IL-1 production, but may rather be induced by IL-6.

Recurrent chest pain as the presenting manifestation of spinal meningioma

We report the case of a 9-year-old boy with a spinal cord meningioma whose only manifestations were recurrent episodes of chest pain lasting for 2 years. This case shows that spinal cord meningioma should be considered among the possible causative factors of chronic chest pain in childhood.

Frequency of relapse after discontinuation of methotrexate therapy for clinical remission in juvenile rheumatoid arthritis

OBJECTIVE

To investigate the outcome of children with juvenile rheumatoid arthritis (JRA) who discontinued taking methotrexate (MTX) therapy after the achievement of clinical remission.

METHODS

We conducted a retrospective review of the clinical course of all consecutive patients with JRA treated with MTX at our department.

RESULTS

Seventeen of the 30 patients who responded to treatment entered clinical remission 6 to 30 mo after beginning MTX therapy. All patients were discontinued from MTX within 2 to 5 mo. Five patients relapsed within 9 mo, whereas 12 patients had sustained remission for 12 mo or longer. Four of 5 children with extended pauciarticular JRA relapsed early after MTX discontinuation. These patients were less responsive to a further cycle of MTX, and 3 showed progression of radiographic joint lesions.

CONCLUSION

These findings suggest that MTX should be continued in patients with extended pauciarticular JRA even after the achievement of clinical remission.

Evaluation of response to methotrexate by a functional index in juvenile chronic arthritis

In juvenile chronic arthritis (JCA) the indices of disease activity, such as joint swelling, pain, tenderness, and limitation of motion, may poorly correlate with the degree of functional impairment. Since the improvement of functional capacity is one of the main objectives of treatment, we evaluated the effect of methotrexate (MTX) in 29 children with JCA by assessing both the articular indices and a functional status measure. After 6 months of therapy, 15 of the 29 patients had a significant (> or = 50%) reduction in the number of joints with active arthritis and/or the articular severity score and were then judged as responders, while 14 did not respond to MTX. In the responder group, the median functional index score decreased from 17 (range: 13-27) at baseline to 13 (range: 13-15) at 6 months (p < 0.001); the median score of the non-responder group was 20 both at baseline and at 6 months (ranges: 14-27, and 13-36, respectively). These results show an improvement of functional impairment in those patients who respond to MTX according to the conventional indices of articular inflammation.

Chronic recurrent multifocal osteomyelitis with unusual features

We describe two children with chronic recurrent multifocal osteomyelitis who showed unusual extraskeletal manifestations. The first patient developed an asymptomatic pulmonary consolidation; the second had an atypic localization of the associated pustulosis, which involved the trunk, groin, thighs and buttocks, but spared the palms and soles. We conclude that this disease is clinically more heterogeneous than previously thought.

Frequency and complications of chronic iridocyclitis in ANA-positive pauciarticular juvenile chronic arthritis

Chronic iridocyclitis (CI) is among the most important extra-articular manifestations of juvenile chronic arthritis (JCA) and is most often observed in young girls with pauciarticular JCA and circulating antinuclear antibodies (ANAs). The frequency of CI found in 39 children with ANA-positive pauciarticular JCA was 56%. None of the patients developed ocular complications during follow-up. We think that this favourable outcome was primarily due to the early diagnosis and to our choice of using atropine as a mydriatic agent and to prolong atropine, after having spaced its administration further apart, up to one year or longer after the remission of ocular manifestations.

Intravenous iron therapy for severe anaemia in systemic-onset juvenile chronic arthritis

The role of iron supplementation in treating the anaemia of systemic-onset juvenile chronic arthritis is not clear. Eight affected children with severe persistent anaemia unresponsive to oral iron therapy were treated with intravenous iron saccharate. From a median post-oral-iron value of 8.0 g/dL (range 6.5-9.5), haemoglobin rose to 11.0 g/dL (10.1-12.1) (p = 0.01). The concentration of serum transferrin receptor, an indicator of iron deficiency, before intravenous therapy correlated with the increase in haemoglobin (r = 0.88, p < 0.01). Intravenous iron saccharate could be an effective treatment for chronic anaemia in this condition, especially with iron deficiency not responsive to oral iron.

High prevalence of antiphospholipid antibodies in children with idiopathic cerebral ischemia

BACKGROUND

The presence of circulating antiphospholipid antibodies (aPLs) is frequently associated with thromboembolic phenomena.

OBJECTIVE

To investigate the prevalence of aPLs, detected as lupus anticoagulant (LA) or anticardiolipin antibody (aCL), in a group of unselected children with idiopathic cerebral ischemia.

DESIGN

Prospective, case series.

SETTING

A pediatric neurology department.

PATIENTS

Thirteen children with cerebral ischemia (eight with stroke, three with transient ischemic attacks, and two with ocular ischemia). Age-matched apparently healthy children served as controls.

MEASUREMENTS

LA and aCL determination was performed within 3 days after the occurrence of the ischemic event and was repeated after 3 to 6 months. To be defined as aPL-positive, patients had to have either a positive LA test or positive IgG and/or IgM aCL at moderate/high level in both determinations.

MAIN RESULTS

Ten (76%) of the 13 patients were positive for either LA or aCL. No differences were found between aPL-positive and aPL-negative patients with respect to clinical manifestations or radiological features. Six (46%) of the 13 patients had a history of multiple ischemic events.

CONCLUSIONS

Our results show a very high prevalence of aPLs in children with idiopathic cerebral ischemia. Because the presence of these antibodies has relevant therapeutic implications, their determination in children with cerebral ischemia is recommended.

Antiphospholipid antibodies in paediatrics

Antiphospholipid antibodies, i.e. circulating auto-antibodies to negatively charged phospholipids, are mainly observed in patients with systemic lupus erythematosus, but may also occur in individuals who lack evidence of a well-defined systemic disease. Several studies have suggested that they may play a direct role in the pathogenesis of recurrent vascular thrombosis, repeated abortions, and thrombocytopenia (so-called antiphospholipid antibody syndrome), although the mechanism by which this occurs is still poorly understood. The management of patients with antiphospholipid antibody-related thrombosis includes anti-aggregants, anticoagulants, corticosteroids, and cytotoxic drugs, but the optimum treatment is still controversial. Here we review the test systems used to detect antiphospholipid antibodies and their significance in paediatrics.

Hypocomplementemic urticarial vasculitis syndrome with severe systemic manifestations

We describe two children with clinical and laboratory features of hypocomplementemic urticarial vasculitis syndrome. Both patients had severe, life-threatening manifestations: rapidly progressive glomerulonephritis (patient 1) and pulmonary hemorrhage (patient 2). We conclude that this syndrome may be a potentially severe multisystem disease.

Factors associated with response to methotrexate in systemic-onset juvenile chronic arthritis

We retrospectively investigated, in 19 children with systemic-onset juvenile chronic arthritis (SoJCA), the possible influence on the outcome of methotrexate (MTX) therapy of several independent variables, including age at onset of juvenile chronic arthritis, disease duration and severity of the disease at baseline. The dosage of MTX ranged from 7.5 to 11.0 mg/m2/week (median 9.3 mg/m2/week) and was given as a single, oral weekly dose. After 6 months of treatment, 12 (63%) patients were judged as responders on grounds of a > or = 50% reduction in the number of joints with active arthritis and/or an articular severity score; 7 (37%) did not respond to therapy. When the baseline values of the selected variables were compared, we found that the responder group had, with respect to the non-responder group, a lower percentage of radiographic lesions (p < 0.005), a shorter duration of the disease (p < 0.05) and a lower number of joints with limitation of motion (p < 0.01), functional limitation score (p < 0.05) and articular severity score (p < 0.05). A threshold value of disease duration of two years and the presence/absence of radiographic lesions gave a correct classification with respect to the treatment outcome of 73.7% and 83.3%, respectively. The predictive value of these two variables was confirmed by a multivariate analysis. We conclude that earlier treatment with MTX, possibly before the appearance of radiographic changes, may favourably influence the outcome of MTX treatment in those patients with SoJCA who require a second-line drug.

Immune responses to the Escherichia coli dnaJ heat shock protein in juvenile rheumatoid arthritis and their correlation with disease activity

Patients with juvenile rheumatoid arthritis frequently have abnormal immune responses to the hsp65 class of bacterial heat shock proteins. However, lymphocytes from children with other inflammatory diseases may also recognize hsp65, and the role of these antigens in juvenile rheumatoid arthritis remains controversial. We have studied humoral and cellular immune responses to a distinct, recently described bacterial heat shock protein, designated dnaJ. The Escherichia coli dnaJ gene was cloned and expressed, and the purified recombinant protein was used as an antigen. Neither normal children nor children with various chronic inflammatory diseases had lymphocyte proliferative responses to recombinant dnaJ. However, lymphocytes from patients with polyarticular, pauciarticular, and systemic manifestations of juvenile rheumatoid arthritis responded strongly to the antigen. Cellular immune responses to dnaJ were higher in synovial fluid than in blood and higher in children with active disease than in children in remission. These data show that increased immune reactivity to dnaJ is characteristic of juvenile rheumatoid arthritis and that the magnitude of the immune response is linked to disease activity. The results suggest that an abnormal immune response to antigens on commensal gut bacteria may contribute to the generation of chronic inflammation in juvenile rheumatoid arthritis.

Anticardiolipin antibodies in pediatric systemic lupus erythematosus

OBJECTIVE

To investigate the prevalence and the clinical significance of anticardiolipin antibodies (ACLs) in a group of children with systemic lupus erythematosus (SLE).

DESIGN

Cross-sectional and longitudinal study.

SETTING

Pediatric Clinic, University of Pavia, Italy.

PARTICIPANTS

Thirty children (aged 4.9 to 16.5 years) with SLE.

MEASUREMENTS AND MAIN RESULTS

Twenty-six (87%) of the 30 patients were initially positive for either IgG or IgM ACLs; 24 (80%) of 30 had IgG ACLs, and 15 (50%) of 30 had IgM ACLs. The cross-sectional analysis showed a trend for IgG ACLs to be positively associated with autoimmune cytopenia and negatively associated with renal disease. The levels of ACLs, particularly of the IgG isotype, tended to correlate with SLE activity as expressed by the complement fraction C3, the erythrocyte sedimentation rate, or the SLE Activity Measure, but not by the SLE Disease Activity Index or the anti-DNA antibodies. Serial determinations of ACL levels in 20 patients revealed frequent fluctuations. High levels of IgG ACLs (> 50 arbitrary units) were observed in nine patients; all nine had active disease and eight had one or more clinical features that have been previously associated with antiphospholipid antibodies: neuropsychiatric manifestations in six patients, autoimmune cytopenia in two patients, and avascular necrosis of bone in one patient. Only one patient experienced an overt episode of vascular thrombosis; IgG ACLs were positive at a medium level 6 months before the thrombotic event, but their level was unchanged when the thrombosis was discovered; the lupus anticoagulant test was positive at time of the thrombosis.

CONCLUSIONS

Our results show that in pediatric SLE, ACLs are frequently found, high levels of IgG ACLs are often associated with central nervous system involvement, and ACLs have a low predictive value in the development of vascular thrombosis.

Frequency and clinical significance of anti-RNP antibodies in Italian SLE patients

The frequency and clinical significance of anti-RNP antibodies in patients with systemic lupus erythematosus (SLE) are still a matter of debate. In this study we report our experience with a series of 123 unselected Italian patients (93 adults and 30 children) suffering from SLE according to the ARA criteria. Anti-RNP were detected by counterimmunoelectrophoresis in 25 patients (20%), 19 of whom did not show other antibodies to extractable antigens (isolated RNP). Our study shows a striking association between anti-RNP and arthritis as well as between anti-RNP and Raynaud's phenomenon. In addition, we found an association between anti-RNP and lack of renal involvement. This association was limited to those patients with isolated RNP and was independent of the presence of anti-dsDNA antibodies. These data were confirmed by a 50 month follow-up study.

Plasma levels after oral methotrexate in children with juvenile rheumatoid arthritis

Plasma levels of methotrexate (MTX) after oral administration of 6.4 to 11.2 mg/m2/week (mean 8.5 mg/m2/week) were studied in 33 children with severe juvenile rheumatoid arthritis (JRA). MTX concentrations were measured by a fluorescence polarization immunoassay (TDx) at 1, 2, 3, and 24 h after administration. The maximum level was observed in most patients after 1 h. No significant correlation was found between MTX dosage and the 1, 2, and 3-h plasma levels. No patient showed values in the range of probable toxicity 24 h after administration. A stepwise multiple regression analysis on 1, 2, and 3-h MTX levels, selected clinical features, dosage and duration of MTX therapy, and concomitant drug treatment showed that MTX concentrations at the different time points tend to be closely related; among the other variables, only concurrent treatment with salicylates was found to affect significantly the 3-h level. Serial determinations performed in 20 patients at the same oral dosage showed a wide interindividual and intraindividual variability of the plasma levels from the first dose to the next. Variable and unpredictable levels were observed also in most of the 8 patients studied after one or more increases of MTX dosage. No difference in MTX concentrations was observed between patients who responded to treatment and those who failed to respond, and between patients who had serum transaminase elevation and those who did not. Our results suggest that, until the pharmacokinetics of low dose MTX is clarified, routine therapeutic monitoring of MTX has a limited value in the clinical management of children with JRA.

Severe retinopathy in systemic lupus erythematosus associated with IgG anticardiolipin antibodies

A six-year-old boy with systemic lupus erythematosus developed insidiously a monolateral serous retinal detachment leading to severe visual loss. Serial determinations of anticardiolipin antibodies showed the presence of IgG anticardiolipin antibodies only at the time of ocular involvement. This case underlines the need for regular ophthalmologic evaluation in children with active systemic lupus erythematosus and supports the previous hypothesis of a relationship between antiphospholipid antibodies and retinal involvement in systemic lupus erythematosus.

[The Schönlein-Henoch syndrome with severe multisystemic involvement]

A case of Henoch-Schönlein purpura (HSP) characterized by several unusual complications and exceedingly prolonged course is reported. A 6-year-old boy, hospitalized with a typical clinical picture of HSP, developed after a few days a severe gastrointestinal vasculitis leading to digestive hemorrhages and food intolerance. The treatment included continuous gastrointestinal infusion, parenteral nutrition, and corticosteroids during the exacerbations of symptoms. Intestinal ultrasonography showed diffuse submucous edema and widespread mural hematomas; hydrops of the gallbladder and edematous swelling of the pancreas were also detected. A gastro-duodenoscopy revealed diffuse and severe mucosal vasculitis with ulcers and petechial lesions. One week after admission the occurrence of weight gain, hyponatremia, and hypoprotidemia in the absence of proteinuria suggested a protein-losing enteropathy. The elevation of serum and urine amylases was consistent with pancreatic involvement. The course was characterized by recurrent exacerbations of gastrointestinal manifestations; symptoms subsided slowly to such a degree that oral feeding could be gradually restarted only seven weeks after admission. The use of high-frequency intestinal ultrasonography proved useful and sensitive in monitoring the evolution of intestinal involvement. During hospitalization the child complained of acute painful scrotal swelling. Ultrasonography showed scrotal hemorrhage and testicular swelling but no signs of testicular torsion, thus helping to avoid surgical exploration. In the recovery phase the child complained of colicky abdominal pain with vomiting. A plain abdominal roentgenogram showed bilateral staghorn pelvic urolithiasis. This finding was confirmed by an intravenous pyelography which also revealed a bilateral pyeloureteritis with edema of the ureteral wall and partial stenosis of the lumen.(ABSTRACT TRUNCATED AT 250 WORDS)

Chronic intoxication by ethane-1-hydroxy-1,1-diphosphonate (EHDP) in a child with myositis ossificans progressiva

A child with myositis ossificans progressiva was treated for 8 years with ethane-1-hydroxy-1,1-diphosphonate (EHDP) 30-40 mg/kg per day. Latterly he complained of severe, progressive bone and joint pain which made standing and walking almost impossible. A radiographic skeletal survey showed diffuse ricket-like lesions. Withdrawal of EHDP therapy produced substantial improvement in his general condition as well as in the radiographic appearance of the bones. Multiple exostoses were observed in this case and, particularly those around the knees, presented a peculiar morphology. This supports the theory that exostoses originate from a defect of metaphyseal modelling.

Antiphospholipid antibody associated thrombosis in juvenile chronic arthritis

A child with systemic onset juvenile chronic arthritis (JCA) who developed a bilateral femuropopliteal vein thrombosis after plaster immobilisation following a tibial fracture is described. When the thrombosis was diagnosed, antiphospholipid antibodies detected either as lupus anticoagulant and anticardiolipin antibodies were found. This suggests that short term prophylatic antithrombotic treatment should be considered in antiphospholipid antibody positive JCA patients who require immobilisation after fractures of demineralised bones.

Recurrent juvenile dermatomyositis and cutaneous necrotizing arteritis with molecular mimicry between streptococcal type 5 M protein and human skeletal myosin

An adult patient had a syndrome associating the features of juvenile dermatomyositis and cutaneous polyarteritis nodosa that followed a cyclic course from childhood; recurrences were always associated with a rise of serum antistreptococcal antibodies. Regions of homology between streptococcal type 5 M protein and skeletal myosin were found. These findings suggest that streptococcal infection, possibly through a molecular mimicry mechanism, played a role in the pathogenesis of the disease in our patient.

Pulmonary function in childhood connective tissue diseases

The term connective tissue diseases (CTD) defines a group of illnesses characterized by the presence of immune abnormalities and by widespread inflammation involving various organs and tissues including the lung. These diseases are not frequent in the paediatric age group. Very few data on pulmonary function are available in paediatric CTD. We investigated possible early lung function abnormalities and any likely relationship with clinical activity of the disease in a group of 81 paediatric CTD patients, without clinical or radiological evidence of pulmonary involvement. Measurement of lung volumes and diffusion lung capacity were performed. A sample of 65 subjects, defined as normal on the basis of history and clinical examination, and matched by age and height with the group of patients, was chosen as control group. CTD patients did not show significant deviations from the control distribution with respect to functional residual capacity (FRC) and maximal expiratory flow at 75% of the forced vital capacity (MEF75) values. On the contrary, both vital capacity (VC) and diffusing capacity of the lungs for carbon monoxide (DLCO) were quite impaired in most CTD during the active phase of the disease. Our results show a functional lung impairment in most children with clinically active CTD, even in absence of abnormalities on chest X-ray pictures.

Pulmonary function in childhood connective tissue diseases

The term connective tissue diseases (CTD) defines a group of illnesses characterized by the presence of immune abnormalities and by widespread inflammation involving various organs and tissues including the lung. These diseases are not frequent in the paediatric age group. Very few data on pulmonary function are available in paediatric CTD. We investigated possible early lung function abnormalities and any likely relationship with clinical activity of the disease in a group of 81 paediatric CTD patients, without clinical or radiological evidence of pulmonary involvement. Measurement of lung volumes and diffusion lung capacity were performed. A sample of 65 subjects, defined as normal on the basis of history and clinical examination, and matched by age and height with the group of patients, was chosen as control group. CTD patients did not show significant deviations from the control distribution with respect to functional residual capacity (FRC) and maximal expiratory flow at 75% of the forced vital capacity (MEF75) values. On the contrary, both vital capacity (VC) and diffusing capacity of the lungs for carbon monoxide (DLCO) were quite impaired in most CTD during the active phase of the disease. Our results show a functional lung impairment in most children with clinically active CTD, even in absence of abnormalities on chest X-ray pictures.

Elevated IgA anti-gliadin antibodies in juvenile chronic arthritis

Increased intestinal permeability secondary to treatment with non-steroidal anti-inflammatory drugs (NSAIDs) and raised levels of anti-gliadin antibodies (AGA) have been reported in adults with rheumatoid arthritis. We have therefore retrospectively investigated the presence of serum AGA of the IgA and IgG classes in 70 patients with juvenile chronic arthritis (JCA). Serum IgA (but not IgG) AGA were found to be higher in JCA patients than in controls (6.2 +/- 8.7 vs 2.1 +/- 1.5 AU/ml; p less than 0.0001). This finding was observed independently of the JCA onset subtype or disease activity; however, lower levels of IgA AGA were found in patients with pauciarticular JCA and in those in remission. No significant differences in IgA AGA serum levels were observed between untreated patients and patients treated with NSAIDs. Five patients who presented the highest levels of IgA AGA were further studied a second time; serum IgA AGA were found to be markedly reduced or normalized and no clinical or laboratory evidence of coexistent coeliac disease was observed. In conclusion, our results suggest that the elevation of IgA AGA seen in our patients is secondary to non-specific immune stimulation rather than to an NSAID-induced increase in intestinal permeability.

Prevalence of anticardiolipin antibodies in juvenile chronic arthritis

The prevalence of anticardiolipin antibodies was evaluated in 70 children with juvenile chronic arthritis (JCA), in 25 adult patients with rheumatoid arthritis, in 42 healthy children and in 40 adult controls. Thirty seven (53%) patients with JCA were positive for IgG or IgM anticardiolipin antibodies, or both, and 30 (43%) for IgG anticardiolipin antibodies. In contrast, only seven (28%) adult patients with rheumatoid arthritis presented anticardiolipin antibodies, which were of IgG class in four (16%) cases. IgG anticardiolipin antibodies were negative in all control subjects while IgM anticardiolipin antibodies were detected in two (5%) children and in four (10%) adult controls. No correlations were found in patients with JCA between the presence or titres of anticardiolipin antibodies and various clinical or laboratory variables. No patient with anticardiolipin antibodies showed any feature of the anticardiolipin syndrome.

Correlation of serum interleukin-6 levels with joint involvement and thrombocytosis in systemic juvenile rheumatoid arthritis

We measured interleukin-6 (IL-6) levels in 70 serum samples obtained from 25 patients with systemic-onset juvenile rheumatoid arthritis (JRA), using the hybridoma cell line B9. Patients with systemic-onset JRA had significantly elevated serum IL-6 levels during active disease (mean +/- SD 92.1 +/- 75.1 hybridoma growth factor units/ml; P less than 0.00001 versus healthy age-matched controls), but not during remission. Serum IL-6 levels correlated with the extent and severity of joint involvement (P less than 0.001) and with platelet counts (P less than 0.05). Our data suggest that IL-6 plays a significant role in the pathogenesis of systemic-onset JRA.

[TMJ in subjects with juvenile rheumatoid arthritis: functional and cephalometric analysis]

The Authors studied 21 patients affected by Juvenilis Rheumatoid Arthritis. The TMJ compromission was evaluated by un objective, clinical and radiographic examination. A teleradiographic with cephalometric analysis was also performed to all subjects. The results show a greater TMJ compromission in earlier arisen disease subjects.

[Juvenile dermatomyositis]

Juvenile dermatomyositis (JDM) is a chronic multisystem inflammatory disease that primarily involves skin and muscles. The clinical picture is mainly characterized by the typical cutaneous rash and by skeletal muscle weakness. Nevertheless the vasculitic process may extend in some cases to other organs such as lung, joints or gastrointestinal system. Calcinosis represents a relatively frequent complication of JDM and occurs in most cases during the late stage of the disease. Usually serum levels of muscle enzymes are elevated and electromyography shows signs of myositis. Muscle biopsy is generally performed only in doubtful cases. JDM should be differentiated from the muscle involvement of other diffuse inflammatory connective tissue diseases and from non inflammatory myopathies. The treatment is mainly based on steroids, whose dosage and regimen depend on disease severity. Steroid therapy has greatly improved the prognosis of JDM.

Multiple inhibitors of mitogen-induced proliferation of normal lymphocytes in juvenile chronic arthritis sera

We evaluated the effect of 47 serum samples obtained from 34 children with juvenile chronic arthritis (JCA) on mitogen-induced proliferation of normal peripheral blood lymphocytes (nPBL). We found that sera from patients with active disease, and particularly those with the systemic form, inhibited significantly PHA-induced proliferation of nPBL at all the PHA concentrations tested. This inhibitory activity was independent of the treatment and was correlated with the value of the erythrocyte sedimentation rate. Part of the JCA sera inhibitory effect could be reversed by the addition of exogenous interleukin 2 (IL-2), but not of interleukin 1 (IL-1) or interferon-gamma, moreover, JCA sera were able to partially inhibit the IL-2 dependent proliferation of CTLL. When we tested serum fractions obtained by Sephadex G-200 chromatography for their inhibitory activity, we observed that: a) two major peaks of inhibitory activity on PHA-induced proliferation were present: peak 1 with MW less than 600,000 and peak 2 with MW between 70,000 and 35,000; b) the inhibitory activity present in the high MW peak was in part IL-2 related; and c) both peaks contained elevated levels of acute phase proteins (APP) which are known to inhibit mitogen-induced lymphocyte proliferation. We conclude that sera from patients with active systemic JCA contain inhibitory activity on mitogen-induced lymphocyte proliferation. We conclude that sera from patients with active systemic JCA contain inhibitory activity on mitogen-induced lymphocyte proliferation. This activity is due to the presence of multiple inhibitors, one of which appears to be IL-2 related; at least part of the inhibitory activity may be due to elevated serum levels of APP.

[Changes in the production of IgM in response to pokeweed mitogen in juvenile rheumatoid arthritis. Correlations with disease activity]

Unstimulated and pokeweed mitogen (PWM)-stimulated "in vitro" IgM synthesis by peripheral blood lymphocytes has been evaluated by an ELISA method in 33 patients with juvenile rheumatoid arthritis (JRA). Lymphocyte PWM responses were significantly reduced in patients with JRA compared with healthy controls. When patients were divided according to disease activity, a significant increase of stimulation index (ratio of IgM synthesis with over that without PWM) has been observed in patients with disease remission compared with those with active disease. These findings confirm the defect in PWM-induced IgM synthesis by peripheral blood lymphocytes of patients with JRA and suggest that these abnormalities may be related to disease activity.

Autoantibodies in juvenile dermatomyositis

Fourteen patients with juvenile dermatomyositis (JDM) have been investigated for the presence of several serum autoantibodies: antinuclear (ANA), anti-single-stranded and double-stranded DNA, anti-histones, anti-Sm, anti-ribonucleoprotein, anti-SSA/SSB, anti-PM-1, anti-Jo-1, anti-mitochondrial, anti-smooth muscle, anti-gastric parietal cells, anti-cardiolipin (ACA) antibodies and rheumatoid factor. Patients were negative for all autoantibodies except for ANA and ACA. ANA were detected in 50% of the patients when tested on rat liver, but the percentage of positivity rose to 86% when HEp-2 cells were used as substrate. This finding suggests that HEp-2 cells represent a more sensitive substrate than rat liver for the detection of ANA in JDM. Three patients were positive for ACA; two of these presented vascular complications, thus suggesting a possible relationship between ACA and vascular involvement in JDM.

Anticardiolipin syndrome in childhood: a report of two cases

We describe two children with an otherwise unexplained deep vein thrombosis associated with high titer anticardiolipin antibodies (ACA) of the IgG class and circulating lupus anticoagulant (LAC). One of these patients had persistent proteinuria but neither had systemic lupus erythematosus. Our observation suggests that ACA and LAC assays should be performed in children with thromboembolic disease even when no underlying autoimmune disease can be found.

[A new computerized file of juvenile rheumatoid arthritis]

A computerized database for patients with juvenile rheumatoid arthritis (JRA) is presented. The program has been developed using PRIST (Patient Record Information System Tool), a flexible tool specifically oriented to clinical data management. The database consists of three main sections: the fixed record devoted to anamnestic data, the periodic record collecting the clinical, laboratory and instrumental data and the balance record devoted to a periodic balance of the disease course. The major advantages of our database are: time saving data handling, elastic procedures and easy retrospective data collection.

Variation of serum IgG subclass concentrations with disease activity in juvenile chronic arthritis

Nineteen patients with juvenile chronic arthritis were followed up and serum IgG subclass concentrations measured at different stages of disease activity. Patients were divided into three groups according to clinical activity of the disease: active disease, partial remission, and remission. The results were compared with normal values obtained in 448 healthy children aged 6 months to 18 years with a homogeneous distribution for each year of age. Serum IgG subclass concentrations of each child were first log transformed and then age corrected, taking the deviation of the log transformed value from that expected for a child of the same age. It was found that patients with partial remission had increased concentrations of IgG2 and decreased concentrations of IgG1 compared with patients with active disease. This suggests that the remission inducing process, at least in juvenile chronic arthritis, is accompanied by a switch of IgG subclass production.

Frequency of autoantibodies in normal children

Very few data have been reported on the frequency of autoantibodies (AAs) in normal children. In the present study we investigated the frequency of 14 AAs in a total of 268 apparently normal children (151 boys and 117 girls; age range, 1 month to 14 years). Forty-one children (22 boys and 19 girls) were positive for at least one AA, usually in a low titer; two children were positive for two AAs. None of these children had a personal or family history of autoimmune diseases. The percentage of children positive for each AA was as follows: antinuclear, 3%; anti-smooth muscle, 2.6%; antireticulin, 2.6%; antimitochondrial, 1.1%; rheumatoid factor, 0.6%; antiribosomal, 0.4%; anti-gastric parietal cells, 5.2%; and anti-thyroid microsomal, 1.3%. Anti-double-stranded DNA, anti-intestinal epithelial cells, antiliver and antikidney microsomal, antithyroglobulin, anti-islet cells, and complement-fixing anti-islet cell antibodies were not detected in any serum. Fifteen of the 41 positive children were checked for the presence of AAs two years later; six (40%) were still positive, always for the same AA, without major differences in titer. Our results suggest that the overall frequency of AAs in apparently healthy children is quite similar to that reported in young adults; this AA positivity seems most often to represent a transient phenomenon.

[Ischemic necrosis of femoral condyles in systemic lupus erythematosus]

Avascular necrosis (AN) of bone is a complication of systemic lupus erythematosus (SLE). In the present paper we describe two patients with SLE who presented an AN of femoral condyles 18 months and 2 years respectively after the diagnosis of the disease. In the second case, together with the destructive change of the symptomatic knee, X-ray films showed an initial involvement, still asymptomatic, of the contralateral knee.

Hypergammaglobulinemic purpura in childhood. Report of two cases and review of the literature

Hypergammaglobulinemic purpura is a rare syndrome characterized by long-standing recurrent purpura of the lower limbs, polyclonal hypergammaglobulinemia, increased erythrocyte sedimentation rate and high titer rheumatoid factor positivity. The syndrome can occur isolated or in association with a systemic disease. Few cases have been described in childhood. We report two cases together with a review of the paediatric literature.

Calcinosis as the presenting sign of juvenile dermatomyositis in a 14-month-old boy

We describe a 14-month-old child with dermatomyositis in whom calcinosis was the first sign of the disease. This case shows that calcinosis, usually a late complication of dermatomyositis, may be the presenting sign of the disease even in young children and when Gottron's sign is still absent and muscular weakness not prominent.

Systemic lupus erythematosus with Jaccoud's arthropathy mimicking juvenile rheumatoid arthritis

We describe a girl who presented at age 5 with objective signs of arthritis and was initially diagnosed as having juvenile rheumatoid arthritis. Over the following years, she developed slowly progressive joint deformities indicative of Jaccoud's arthropathy. When she was 11 years old, symptoms typical of systemic lupus erythematosus appeared, accompanied by anti-DNA antibodies. This case illustrates that in children also, Jaccoud's arthropathy may be a precocious manifestation of systemic lupus erythematosus.

Enhanced interleukin 1 and depressed interleukin 2 production in juvenile arthritis

Blood mononuclear cells from a total of 23 children with juvenile arthritis were stimulated in vitro to produce interleukin 1 (IL-1) and interleukin 2 (IL-2) and compared with age matched healthy controls. Peripheral blood monocytes from patients with juvenile arthritis produced a higher amount of IL-1 than controls, whereas peripheral blood lymphocytes from the same patients produced lower amount of IL-2 than controls. These findings could not be explained by concurrent therapy. The increase of IL-1 production was more marked in patients with active disease and therefore may have been secondary to the pathological process. However, the decrease of IL-2 production did not depend on disease activity, thus suggesting an immunoregulatory abnormality.