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Abatacept in the treatment of localized scleroderma: A pediatric case series and systematic literature review. Semin Arthritis Rheum 2020; 50:645-656. [DOI: 10.1016/j.semarthrit.2020.03.020] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 11/18/2022]
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52
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Mostmans Y, Richert B, Badot V, Nagant C, Smith V, Michel O. The importance of skin manifestations, serology and nailfold (video)capillaroscopy in morphea and systemic sclerosis: current understanding and new insights. J Eur Acad Dermatol Venereol 2020; 35:597-606. [PMID: 32656859 DOI: 10.1111/jdv.16813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 06/24/2020] [Indexed: 11/29/2022]
Abstract
Since the field around morphea and systemic sclerosis (SSc) is evolving rapidly, this review approaches conventional as well as more recent clinical developments from a dermatological point of view. Skin manifestations are critical in sub-classifying these diseases ensuring a correct prognosis for these patients. They can be discretely present, and therefore, diagnosis can be challenging sometimes, implicating a thorough dermatological examination is mandatory. Furthermore, a growing amount of dermatologists perform nailfold videocapillaroscopy (NVC), a more recent reliable non-invasive imaging technique used for in vivo assessment of the microcirculation at the nailfold. After all, specific NVC-changes are present in a majority of patients with SSc. This way, dermatologists not only take part in the diagnosis process through clinical investigation but also through the use of a modern state of the art imaging technique that is becoming the golden standard in SSc multidisciplinary workup. In this review, current understandings for NVC in morphea and SSc are revised. So far, the role of NVC in the diagnosis/prognosis/classification of morphea patients has not been thoroughly investigated to make proper conclusions. As for SSc, it is well known that NVC contributes to the diagnosis and can make a fundamental difference especially when obvious clinical SSc signs are absent. This review emphasizes the (somewhat underestimated) role of dermatologists in the process of diagnosis and follow-up, and thus, the difference we can make for our patients and fellow colleagues in the multidisciplinary workup of SSc and morphea.
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Affiliation(s)
- Y Mostmans
- Department of Immunology-Allergology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Department of Dermatology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - B Richert
- Department of Dermatology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - V Badot
- Department of Immunology-Allergology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium.,Department of Rheumatology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - C Nagant
- Department of Immunology IRIS Laboratory, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - V Smith
- Department of Rheumatology, Ghent University Hospital, University Hospital (UZ) Ghent, Ghent, Belgium
| | - O Michel
- Department of Immunology-Allergology, CHU Brugmann, Université Libre de Bruxelles (ULB), Brussels, Belgium
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Abstract
PURPOSE OF REVIEW Treatment of scleroderma in children is challenging since little is known about its pathogenesis. Herein, we review the most recent evidence regarding the treatment of juvenile scleroderma. RECENT FINDINGS According to the recent recommendations for Pediatric Rheumatology in Europe (SHARE), systemic treatment in localized scleroderma is needed when there is a risk for disability, such as in generalized or pansclerotic morphea and progressive linear scleroderma. In juvenile systemic sclerosis, the introduction of the severity score, J4S, has standardized the assessment of the patients in the daily practice and allowed a more tailored therapeutic approach. Since, to date, no clinical trial is available in JSSc, due to its rarity, the treatment is based on adults' experience. The recent recommendations for juvenile scleroderma represent an important instrument to standardize the treatment approach, confirm the role of methotrexate, and open new windows for effective experimental treatments, such as mycophenolate mofetil and biological agents, for severe or refractory cases.
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Affiliation(s)
- Francesco Zulian
- Department of Woman's and Child's Health, University of Padua, Via Giustiniani 3, 35128, Padua, Italy.
| | - Francesca Tirelli
- Department of Woman's and Child's Health, University of Padua, Via Giustiniani 3, 35128, Padua, Italy
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Kaushik A, Mahajan R, De D, Handa S. Paediatric morphoea: a holistic review. Part 1: epidemiology, aetiopathogenesis and clinical classification. Clin Exp Dermatol 2020; 45:673-678. [PMID: 32472964 DOI: 10.1111/ced.14234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/29/2022]
Abstract
Morphoea, also known as localized scleroderma, is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Paediatric-onset disease is not uncommon and is associated with frequent relapses. The disease has complex pathogenetic mechanisms and multiple clinical subtypes, and affects children of all ages. Recent research has focused on elucidating the disease pathophysiology and identifying measures of disease activity. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected, and results were analysed before being summarized. In the first of this two-part review, we provide a bird's-eye view of the current literature concerning the epidemiology, aetiopathogenesis and clinical classification of paediatric morphoea; in Part 2, we review the diagnosis, markers of disease activity, management and natural history.
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Affiliation(s)
- A Kaushik
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R Mahajan
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - D De
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Handa
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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55
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Kaushik A, Mahajan R, De D, Handa S. Paediatric morphoea: a holistic review. Part 2: diagnosis, measures of disease activity, management and natural history. Clin Exp Dermatol 2020; 45:679-684. [PMID: 32449205 DOI: 10.1111/ced.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/01/2022]
Abstract
Paediatric morphoea is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Defining optimum management strategies in paediatric morphoea remains an ongoing challenge, owing to the varied presentations and a relative paucity of paediatric-specific studies. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected and results analysed before summarizing them. In Part 1 of this review, we described the epidemiology, aetiopathogenesis and clinical classification; in this part, we discuss the diagnosis, markers of disease activity, management and natural history in paediatric morphoea.
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Affiliation(s)
- A Kaushik
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R Mahajan
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - D De
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Handa
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Weibel L, Theiler M, Howell K, Denton C, Waelchli R, Atherton D, Woo P, Harper J. Prospective evaluation of treatment response and disease reversibility of paediatric localized scleroderma (morphoea) to steroids and methotrexate using multi‐modal imaging. J Eur Acad Dermatol Venereol 2020; 34:1609-1616. [DOI: 10.1111/jdv.16308] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/07/2020] [Indexed: 11/30/2022]
Affiliation(s)
- L. Weibel
- Department of Dermatology Pediatric Skin Center University Children's Hospital Zurich Zurich Switzerland
| | - M. Theiler
- Department of Dermatology Pediatric Skin Center University Children's Hospital Zurich Zurich Switzerland
| | - K.J. Howell
- Microvascular Diagnostics Royal Free Hospital Institute of Immunity and Transplantation London UK
| | - C.P. Denton
- Centre for Rheumatology and Connective Tissue Disease UCL Division of Medicine Royal Free London NHS Foundation Trust London UK
| | - R. Waelchli
- Department of Dermatology Pediatric Skin Center University Children's Hospital Zurich Zurich Switzerland
| | - D. Atherton
- Department of Dermatology Great Ormond Street Hospital for Children London UK
| | - P. Woo
- Centre for Adolescent Rheumatology University College London London UK
| | - J.I. Harper
- Department of Dermatology Great Ormond Street Hospital for Children London UK
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Navallas M, Inarejos Clemente EJ, Iglesias E, Rebollo-Polo M, Antón J, Navarro OM. Connective Tissue Disorders in Childhood: Are They All the Same? Radiographics 2020; 39:229-250. [PMID: 30620697 DOI: 10.1148/rg.2019180078] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Systemic connective tissue disorders are characterized by the presence of autoantibodies and multiorgan system involvement. Juvenile systemic lupus erythematosus with or without associated antiphospholipid syndrome; juvenile dermatomyositis; sclerodermiform syndromes, including systemic and localized sclerodermas and eosinophilic fasciitis; mixed connective tissue disease; and Sjögren syndrome are the disorders that affect children most frequently. Diagnosis is difficult, because the clinical presentation of patients is diverse, from mild to severe disease. In addition, all organs may be affected. However, a variety of imaging techniques are now available to investigate rheumatic disease in children. These imaging modalities offer the potential for earlier diagnosis and improved assessment of therapeutic response. This article reviews the main connective tissue disorders that affect children, highlighting their key imaging features on images acquired with different diagnostic imaging modalities and correlating these features with clinical and pathologic findings, when available. ©RSNA, 2019.
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Affiliation(s)
- María Navallas
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Emilio J Inarejos Clemente
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Estíbaliz Iglesias
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Mónica Rebollo-Polo
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Jordi Antón
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
| | - Oscar M Navarro
- From the Departments of Radiology (M.N., E.J.I.C., M.R.P.) and Rheumatology (E.I., J.A.), Hospital Sant Joan de Déu, Passeig Sant Joan de Déu 2, 08950 Esplugues de Llobregat, Barcelona, Spain; Department of Medical Imaging, University of Toronto, Toronto, ON, Canada (M.N., O.M.N.); and Department of Diagnostic Imaging, The Hospital for Sick Children, Toronto, ON, Canada (M.N., O.M.N.)
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Associations between Disease Activity/Severity and Damage and Health-Related Quality of Life in Adult Patients with Localized Scleroderma-A Comparison of LoSCAT and Visual Analogue Scales. J Clin Med 2020; 9:jcm9030756. [PMID: 32168819 PMCID: PMC7141310 DOI: 10.3390/jcm9030756] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 03/07/2020] [Accepted: 03/09/2020] [Indexed: 11/28/2022] Open
Abstract
Localized scleroderma (LoS) is a chronic fibrosing disorder of the skin and, less commonly, subcutaneous tissues. As the disease causes subjective symptoms, cosmetic defects, and, at times, functional disability, subjects with LoS experience deterioration of their health-related quality of life (HRQoL). The influence of disease activity/severity and damage status on HRQoL measures in patients with LoS is scarcely known. Physician-reported measures (modified LoS skin severity index, LoS skin damage index, physician global assessments of the disease activity/severity and damage) and patient-derived measures (patient global assessments of the disease activity/severity and damage) were obtained in adult LoS patients. Their HRQoL was measured with Skindex-29 and Short Form-36. The patients’ assessments of disease activity/severity and damage in LoS differed from the assessments by the physicians. The patients’ predominant concerns centered on LoS-related damage, whereas the physicians’ concerns focused on features of disease activity. Visual analogue scales bore some relation to the HRQoL, and they seem to be important in a holistic approach to the patient and should not be omitted in LoS evaluation.
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59
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George R, George A, Kumar TS. Update on Management of Morphea (Localized Scleroderma) in Children. Indian Dermatol Online J 2020; 11:135-145. [PMID: 32477969 PMCID: PMC7247622 DOI: 10.4103/idoj.idoj_284_19] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Juvenile localized scleroderma (morphea) is the predominant scleroderma in childhood which affects the skin and may extend to the underlying fascia, muscle, joints and bone. The assessment of activity and damage can be done with a validated instrument like LoSCAT. Disease classified as “low severity” which includes superficial plaque morphea can be treated with topical mid potent- potent steroids, tacrolimus, calcipotriol or imiquimod in combination with phototherapy. Methotrexate is recommended for linear, deep and generalized morphea. Steroids are effective in the early inflammatory stage and used in combination with methotrexate. Methotrexate is continued for at least 12 months after adequate response is achieved. Mycophenolate mofetil is given in cases where methotrexate is contraindicated or for those who do not respond to methotrexate. There are also reports of improvement of disease with ciclosporine and hydroxychloroquine. In severe cases, recalcitrant to standard therapy there may be a role for biologics, JAK inhibitors, and IVIG. Supportive measures like physiotherapy and psychiatric counseling are also important in the management of morphea. Orthopedic surgery and other measures like autologous fat transfer may be advocated once the disease is inactive.
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Affiliation(s)
- Renu George
- Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
| | - Anju George
- Department of Dermatology, Venereology and Leprosy, Christian Medical College, Vellore, Tamil Nadu, India
| | - T Sathish Kumar
- Department of Child Health, Christian Medical College, Vellore, Tamil Nadu, India
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Flores Quispe SKJ, Cavaliere A, Weber M, Stramare R, Zuliani M, Quaia E, Zulian F, Giraudo C. Sarcopenia in juvenile localized scleroderma: new insights on deep involvement. Eur Radiol 2020; 30:4091-4097. [PMID: 32144460 DOI: 10.1007/s00330-020-06764-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Revised: 02/13/2020] [Accepted: 02/19/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Juvenile localized scleroderma (JLS) is a rare chronic autoimmune disease which can also affect bones and muscles. Nevertheless, muscle loss was not previously investigated in patients with JLS. Thus, the aim of this study was to retrospectively evaluate deep involvement and assess and quantify sarcopenia in JLS patients using magnetic resonance imaging (MRI). METHODS Fourteen children with JLS (nine females, mean age ± SD, 7.1 ± 3.6 years) referring to our tertiary center from January 2012 to January 2018 who underwent at least one MRI examination including axial T1-weighted and short tau inversion recovery images were included. Two readers assessed in consensus superficial and deep involvement. Muscle edema, muscle fatty infiltration, and sarcopenia were independently scored (absent, moderate, or severe) and the Cohen's kappa coefficient computed. Skin perimeter, subcutaneous area, muscle area, and muscle volume were independently measured using the contralateral unaffected extremity as reference (paired Student's t test, p < 0.05). The intraclass correlation coefficient (ICC) was used to investigate the reliability of the measurements. RESULTS All patients showed superficial involvement with subcutaneous fat atrophy being the most common finding (13 patients). Bone marrow edema occurred in five patients. Muscle edema affected ten children (moderate in seven, severe in three; k = 0.89), muscle fatty replacement occurred in one case (severe; k = 1.00), and sarcopenia was detected in eight patients (severe in two; k = 0.78). All quantitative parameters were lower on the affected side than on the unaffected contralateral limb (p < 0.05, each) and all measurements showed a high reliability (ICC > 0.750, each). CONCLUSION Patients with JLS can be affected by sarcopenia and quantitative analyses allow a robust characterization of such finding. KEY POINTS • Deep involvement in juvenile localized scleroderma is frequently characterized by sarcopenia. • In juvenile localized scleroderma, muscle edema and sarcopenia are mostly moderate while fatty infiltration, even if rare, can be severe. • Sarcopenia can be reliably quantified in children with juvenile localized scleroderma using MRI.
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Affiliation(s)
| | - Annachiara Cavaliere
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Michael Weber
- Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Roberto Stramare
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Monica Zuliani
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | - Emilio Quaia
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy
| | | | - Chiara Giraudo
- Department of Medicine - DIMED, Radiology Institute, University of Padova, Via Giustiniani 2, 35100, Padua, Italy.
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Zigler C, Ardalan K, Hernandez A, Caliendo A, Magee K, Terry M, Mann C, Torok K. Exploring the impact of paediatric localized scleroderma on health‐related quality of life: focus groups with youth and caregivers. Br J Dermatol 2020; 183:692-701. [DOI: 10.1111/bjd.18879] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/14/2020] [Indexed: 11/27/2022]
Affiliation(s)
- C.K. Zigler
- Center for Health Measurement Department of Population Health Sciences Duke University School of Medicine Durham NC USA
| | - K. Ardalan
- Division of Rheumatology Departments of Pediatrics and Medical Social Sciences Ann & Robert H. Lurie Children's Hospital of Chicago/Northwestern University Feinberg School of Medicine Chicago IL USA
| | - A. Hernandez
- Center for Health Measurement Department of Population Health Sciences Duke University School of Medicine Durham NC USA
| | - A.E. Caliendo
- Northwestern University Feinberg School of Medicine Chicago IL USA
| | - K.E. Magee
- Department of Psychological Sciences Case Western Reserve University Cleveland OH USA
| | - M.A. Terry
- Behavioral and Community Health Services Public Health University of Pittsburgh Pittsburgh PA USA
| | - C.M. Mann
- Center for Health Measurement Department of Population Health Sciences Duke University School of Medicine Durham NC USA
| | - K.S. Torok
- Division of Rheumatology Department of Pediatrics Children's Hospital of Pittsburgh of UPMC Pittsburgh PA USA
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Zigler CK, Ardalan K, Lane S, Schollaert KL, Torok KS. A novel patient-reported outcome for paediatric localized scleroderma: a qualitative assessment of content validity. Br J Dermatol 2020; 182:625-635. [PMID: 31498874 PMCID: PMC7050359 DOI: 10.1111/bjd.18512] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND According to current standards, no existing patient-reported outcome (PRO) measures have high-quality validity evidence for use with individuals diagnosed with paediatric localized scleroderma (LS). This severely hinders patient-centred LS-focused research, including much needed clinical trials. OBJECTIVES To develop a valid health-related quality of life measure for individuals with paediatric LS and to qualitatively evaluate its content validity using a patient-centred approach. METHODS Previously collected qualitative data from youth with LS and their caregivers was used to develop items. The resulting item set was administered in a clinical setting to participants aged 8-18 years old. Cognitive interviews were used to evaluate time to survey completion, readability/understanding of the items, appropriateness of the recall period and construct representation. RESULTS Seventeen children and adolescents with LS participated in the study. Interviews supported readability, understanding of the items and appropriateness of the recall period in individuals > 10 years old. Revisions were made to simplify the instructions and to be more inclusive of different subtypes of LS. Three items were added to improve content representation. CONCLUSIONS Content validity was supported by the patient-centred development process of the outcome measure and via direct feedback from individuals with LS and their families. Although an important first step, the resulting PRO, termed the Localized Scleroderma Quality of Life Instrument, should be further evaluated in a larger sample before being implemented. What's already known about this topic? No current health-related quality of life (HRQoL) measures have been created using direct input from children and adolescents with localized scleroderma (LS). When compared with qualitative reports of HRQoL impact in youth with all LS subtypes, no existing patient-reported outcome (PRO) measures have appropriate content validity for individuals with paediatric LS. What does this study add? This study proposes a novel LS-specific PRO and is the first qualitative assessment of content validity for any PRO measure in this population. Results from cognitive interviews with children and adolescents support the content validity of the newly developed item set and its ability to capture HRQoL impact in a clinical context. What are the clinical implications of this work? Incorporating a content-valid PRO of HRQoL impact into clinical practice would allow for the valid, ongoing capture of patient experience in LS. Although content validity is an important and necessary step in the process of evaluating validity, items within this novel measure will undergo additional psychometric evaluation before implementation in research and clinical settings.
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Affiliation(s)
- C K Zigler
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, U.S.A
| | - K Ardalan
- Division of Rheumatology, Departments of Paediatrics and Medical Social Sciences, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, U.S.A
- Northwestern University Feinberg School of Medicine, Chicago, IL, U.S.A
| | - S Lane
- School of Education and 5School of Medicine, University of Pittsburgh, Pittsburgh, PA, U.S.A
| | | | - K S Torok
- Division of Rheumatology, Department of Paediatrics, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, U.S.A
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63
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Do N, Ringold S, Sullivan E, Brandling-Bennett H. A retrospective study: Impact of consensus treatment plans on systemic therapy of pediatric morphea. Pediatr Dermatol 2020; 37:278-283. [PMID: 31967352 DOI: 10.1111/pde.14074] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Morphea is an inflammatory and fibrosing condition that affects the skin and subcutaneous structures. Morphea is managed by dermatologists, rheumatologists, or both. Prior studies have suggested there is significant variability in approach to treatment. In 2012, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) published consensus treatment plans (CTPs) for pediatric morphea to develop more standardized treatment plans for patients requiring systemic therapy. We aimed to assess whether the publication of CTPs has impacted care of patients with morphea at our institution. METHODS Data were collected via a retrospective review of medical records of 61 pediatric patients diagnosed with morphea at Seattle Children's Hospital (SCH) from January 1, 2005, to December 12,2017. RESULTS Prior to the publication of CTPs, 2 out of 24 patients (8.3%) were treated with a regimen that matched a subsequent CTP. After publication of CTPs, 29 out of 37 patients (78.4%) were treated with a regimen that matched a CTP (P < 0.001). A subanalysis was performed to assess the number of patients who needed second- or third-line therapies. Of those who followed a CTP therapy plan (n = 26), 3 patients (11.5%) needed a second-line therapy compared with 11 patients (44%) in the no-CTP followed group (n = 25), (P = 0.012). CONCLUSIONS The publication of CTPs led to a significant change in treatment approach for patients with morphea requiring systemic therapy at SCH. Patients treated with one of the treatment plans recommended by the CTPs were less likely to need second-line systemic therapy.
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Affiliation(s)
- Ngan Do
- University of Washington School of Medicine, Seattle, Washington
| | - Sarah Ringold
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, Seattle, Washington
| | - Erin Sullivan
- Children's Core for Biomedical Statistics, Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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Li SC, Zheng RJ. Overview of Juvenile localized scleroderma and its management. World J Pediatr 2020; 16:5-18. [PMID: 31786801 DOI: 10.1007/s12519-019-00320-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 09/26/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Juvenile localized scleroderma (JLS) is a rare pediatric disease characterized by inflammation and skin thickening. JLS is associated with deep tissue and extracutaneous involvement that often results in functional impairment and growth disturbances. This article provides an overview of the disease with a focus on active features and treatment. DATA SOURCES We searched databases including PubMed, Elsevier and MedLine and Wanfang, reviewing publications from 2013 to 2019. Selected earlier publications were also reviewed. RESULTS Linear scleroderma is the most common JLS subtype. Several lines of evidence suggest that JLS is an autoimmune disease. Extracutaneous involvement is common and can present before the onset of skin disease. Multiple skin features are associated with disease activity, and activity can also manifest as arthritis, myositis, uveitis, seizures, and growth impairment. Systemic immunosuppressive treatment, commonly methotrexate with or without glucocorticoids, greatly improves outcome and is recommended for treating JLS patients with active disease and moderate or higher severity. Long term monitoring is needed because of the disease's chronicity and the high frequency of relapses off of treatment. CONCLUSIONS JLS is associated with a risk for disabling and disfiguring morbidity for the growing child. Identifying active disease is important for guiding treatment, but often difficult because of the paucity of markers and lack of a universal skin activity feature. More studies of JLS pathophysiology are needed to allow the identification of biomarkers and therapeutic targets. Comparative effectiveness treatment studies are also needed to work towards optimizing care and outcome.
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Affiliation(s)
- Suzanne C Li
- Department of Pediatrics, Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, 30 Prospect Avenue, Imus 337, Hackensack, 07601, NJ, USA.
- Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall University, Clifton, 07110, NJ, USA.
| | - Rong-Jun Zheng
- Department of Rheumatology, Immunology, and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310003, China
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Reiff D, Crayne CB, Mannion ML, Cron RQ. Characteristics of coexisting localized scleroderma and inflammatory arthritis. Eur J Rheumatol 2020; 7:S67-S71. [PMID: 31804172 PMCID: PMC7004265 DOI: 10.5152/eurjrheum.2019.19147] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 11/07/2019] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Localized scleroderma (LS), including morphea and linear scleroderma, is an autoimmune disease where excessive subcutaneous collagen deposits lead to thickening, scarring, and fibrosis of the tissues. LS coexisting with inflammatory arthritis is less well-described but has been reported in as many as 20% of 53 LS patients in a recent cohort. Herein, we describe a cohort of 8 children with both LS and inflammatory arthritis. The objective of this study is to determine the characteristics of inflammatory arthritis in children with LS and their response to treatment regimens. METHODS A retrospective chart review was completed on patients less than 19 years of age who were diagnosed with either morphea or linear scleroderma at the Children of Alabama center from 2004-2018. Patients were identified using ICD-9 and ICD-10 diagnostic codes. Records were reviewed for additional diagnostic codes, exams, and laboratory findings confirming coexisting inflammatory arthritis and LS. RESULTS A total of 87 patients with a diagnosis of either morphea or linear scleroderma were identified. Eight (9%) had coexisting inflammatory arthritis according to the diagnostic codes with documented active arthritis. Median age of initial rheumatic disease diagnosis was 7.5 years. A majority of patients with both LS and inflammatory arthritis were female (62.5%). Half of the patients (n=4, 50%) had LS lesions over arthritic joints. All of the identified patients were diagnosed with a form of juvenile idiopathic arthritis (JIA). The JIA diagnoses varied widely in 3 (37.5%) patients with rheumatoid factor (RF) negative polyarticular JIA, 2 (25%) with oligoarticular JIA, 2 (25%) with psoriatic JIA, and 1 (12.5%) with enthesitis-related JIA. The timing of onset of LS and inflammatory arthritis varied widely. Three (37.5%) patients had LS lesions preceding clinical arthritis, and three (37.5%) had arthritis before the appearance of LS. Two (25%) patients had both LS and arthritis at the time of diagnosis. All patients received methotrexate (MTX) during their disease course with only 3 (37.5%) receiving systemic steroids during treatment. All 8 patients showed resolution of LS lesions. However, 6 of the 8 patients demonstrated active arthritis on combination MTX and TNFi therapy. CONCLUSION In this cohort of pediatric LS, 9% of patients had coexisting inflammatory arthritis. The characteristics of this cohort varied widely. All patients received MTX initially and showed a resolution of LS lesions. However, in the majority of patients, the arthritis failed to respond to MTX and TNFi combination therapy. These results suggest that inflammatory arthritis coexisting with LS may be less likely to respond to traditional inflammatory arthritis or JIA therapies.
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Affiliation(s)
- Daniel Reiff
- Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Courtney B. Crayne
- Division of Rheumatology, Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Melissa L. Mannion
- Division of Rheumatology, Department of Pediatrics, University of Alabama, Birmingham, AL, USA
| | - Randy Q. Cron
- Division of Rheumatology, Department of Pediatrics, University of Alabama, Birmingham, AL, USA
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Giani T, Madera A, Cimaz R. Association of juvenile idiopathic arthritis and morphea: a case series. Clin Rheumatol 2019; 39:1341-1345. [PMID: 31838640 DOI: 10.1007/s10067-019-04850-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 10/21/2019] [Accepted: 11/08/2019] [Indexed: 11/30/2022]
Abstract
The association of different autoimmune diseases in the same subject is not uncommon, also in the pediatric age. The coexistence of morphea and juvenile idiopathic arthritis (JIA) is however exceptional. We report four such cases. Unlike the few other reported cases, in 3/4 of our patients, morphea appeared well after the onset of JIA, when the articular disease was in full clinical remission. Based on the epidemiology of pediatric morphea in the general population, this association is unlikely to be fortuitous. Pediatric rheumatologists should be aware of this possible association, and follow clinically patients who achieve long-term clinical remission. Key Points ⦁ Morphea is an unusual occurrence in the context of JIA. These conditions have a common autoimmune background, but are very rarely reported together. ⦁ It is important to follow JIA patients even during long-term remission since other autoimmune phenomena can occur.
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Affiliation(s)
- Teresa Giani
- Pediatric Rheumatology, AOU Meyer, Florence, Italy.,Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Anna Madera
- Pediatric Rheumatology, AOU Meyer, Florence, Italy
| | - Rolando Cimaz
- Department of Clinical Sciences and Community Health, University of Milano, Milan, Italy. .,ASST G Pini, Via Pini 9, 20122, Milan, Italy.
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Abstract
Juvenile localized scleroderma (jLS) is an orphan disease that can lead to cosmetic disfiguration and orthopedic problems. Two recent publications review the current recommendations regarding diagnosis, assessment, follow up and treatment of pediatric localized scleroderma cases, both of which suggest the Localized Scleroderma Cutaneous Assessment Tool as an important instrument to assess activity and damage. This review focuses on the systemic treatment of jLS. Systemic treatment includes synthetic and biologic disease-modifying antirheumatic drugs. Systemic therapy is indicated if the lesion crosses any joint, or leads to potential cosmetic disfiguration or orthopedic problems. The only controlled trial of systemic treatment has shown the efficacy of methotrexate, which is the first choice of treatment. It appears superior to phototherapy according to a recently published meta-analysis. In case of methotrexate intolerance, mycophenolate mofetil is an option. In case of methotrexate nonresponse, addition of mycophenolate mofetil, tocilizumab or abatacept seems to be effective. Future treatment options derived and extrapolated from adult trials regarding treatment of skin involvement of systemic scleroderma or fibrosis are promising, as the final pathway in the skin seems to be similar in both diseases.
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Affiliation(s)
- Ivan Foeldvari
- Hamburg Centre for Pediatric and Adolescence Rheumatology, Centre for Treatment of Scleroderma and Uveitis in Childhood and Adolescence, Teaching Unit of the Asklepios Campus of the Semmelweis Medical School, Budapest, An der Schön Klinik Hamburg-Eilbek, Dehnhaide 120, 22081, Hamburg, Germany.
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Yamasaki R, Yonekawa T, Inamizu S, Shinoda K, Ochi H, Matsushita T, Isobe N, Tsuji G, Sadashima S, Kuma Y, Oda Y, Iwaki T, Furue M, Kira JI. A case of overlapping adult-onset linear scleroderma and Parry-Romberg syndrome presenting with widespread ipsilateral neurogenic involvement. Neuropathology 2019; 40:109-115. [PMID: 31775183 DOI: 10.1111/neup.12614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/22/2019] [Accepted: 09/23/2019] [Indexed: 11/29/2022]
Abstract
Linear scleroderma is a variant of localized scleroderma. We report a 43-year-old woman who had developed left arm weakness and linear scleroderma on her back during pregnancy at 25 years of age, followed by left hemifacial atrophy and left leg weakness. She had multiple linear scleroderma lesions on her trunk and left limbs, left eyelid ptosis, impairment of vertical movement and abduction of the left eye, left hemifacial atrophy, and weakness and atrophy of the sternocleidomastoid, trapezius, and proximal limb muscles on the left side. On serology, antibodies to U1-ribonucleoprotein and Jo-1 were positive; anti-scleroderma-70 antibody was negative. Skin biopsy demonstrated increased hypertrophic collagen fibers without inflammatory infiltrates. Needle electromyography of left limb muscles revealed mild neurogenic patterns; left quadriceps muscle biopsy showed chronic neurogenic changes. Brain magnetic resonance imaging revealed mild left hemispheric atrophy. This is a rare case of linear scleroderma and Parry-Romberg syndrome presenting with widespread ipsilateral neurogenic manifestations.
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Affiliation(s)
- Ryo Yamasaki
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Tomomi Yonekawa
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Saeko Inamizu
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Koji Shinoda
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Hirofumi Ochi
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Takuya Matsushita
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Noriko Isobe
- Department of Neurological Therapeutics, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Gaku Tsuji
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Shoko Sadashima
- Department of Neuropathology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Yuki Kuma
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan.,Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Toru Iwaki
- Department of Neuropathology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Masutaka Furue
- Department of Dermatology, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
| | - Jun-Ichi Kira
- Department of Neurology, Neurological Institute, Graduate School of Medical Sciences, Kyushu University, Higashi-ku, Fukuoka, Japan
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Li SC, Torok KS, Rabinovich CE, Dedeoglu F, Becker ML, Ferguson PJ, Hong SD, Ibarra MF, Stewart K, Pope E, Higgins GC, Laxer RM, Mason T, Fuhlbrigge RC, Andrews T. Initial Results from a Pilot Comparative Effectiveness Study of 3 Methotrexate-based Consensus Treatment Plans for Juvenile Localized Scleroderma. J Rheumatol 2019; 47:1242-1252. [DOI: 10.3899/jrheum.190311] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 12/27/2022]
Abstract
Objective.To perform a comparative effectiveness feasibility study in juvenile localized scleroderma (LS), using standardized treatment regimens (consensus treatment plans; CTP).Methods.A prospective, multicenter 1-year pilot observational cohort study was performed by Childhood Arthritis and Rheumatology Research Alliance (CARRA) LS workgroup members. Patients with active, moderate to severe juvenile LS were treated with one of 3 CTP: methotrexate alone, or in combination with intravenous (30 mg/kg/dose for 3 mos) or oral corticosteroids (2 mg/kg/day tapered by 48 weeks).Results.Fifty patients, with demographics typical for juvenile LS, were enrolled, and 44 (88%) completed the study. Most had extracutaneous involvement. Patients improved in all 3 CTP, with > 75% having a major or moderate level of improvement compared to baseline. Damage accrued in some patients. Major deviations from prescribed regimen resulted from medication intolerance (n = 6; 14%) or treatment failure (n = 11; 25%); failures occurred in all 3 CTP. Significant responses to treatment were demonstrated by LS skin scoring measures and overall physician assessments, with differences in response level identified in some patient subsets. Response differences were associated with baseline disease activity level, LS subtype, skin disease extent, and extracutaneous involvement.Conclusion.This study demonstrates the feasibility of conducting juvenile LS comparative effectiveness studies. The CTP were found to be safe, effective, and tolerable. Our assessments performed well. Because damage is common and may progress despite effective control of activity, we recommend initial treatment efficacy be evaluated primarily by activity measures. Potential confounders for response were identified that warrant further study.
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Li SC, Fuhlbrigge RC, Laxer RM, Pope E, Ibarra MF, Stewart K, Mason T, Becker ML, Hong S, Dedeoglu F, Torok KS, Rabinovich CE, Ferguson PJ, Punaro M, Feldman BM, Andrews T, Higgins GC. Developing comparative effectiveness studies for a rare, understudied pediatric disease: lessons learned from the CARRA juvenile localized scleroderma consensus treatment plan pilot study. Pediatr Rheumatol Online J 2019; 17:43. [PMID: 31307476 PMCID: PMC6632199 DOI: 10.1186/s12969-019-0350-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/08/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND We designed and initiated a pilot comparative effectiveness study for juvenile localized scleroderma (jLS), for which there is limited evidence on best therapy. We evaluated the process we used, in relation to the specific protocol and to the general task of identifying strategies for implementing studies in rare pediatric diseases. METHODS This was a prospective, multi-center, observational cohort study of 50 jLS patients initiating treatment, designed and conducted by the jLS group of the Childhood Arthritis and Rheumatology Research Alliance (CARRA) from 2012 to 2015. A series of virtual and physical meetings were held to design the study, standardize clinical assessments, generate and refine disease activity and damage measures, and monitor the study. Patients were initiated on one of three standardized methotrexate-based treatment regimens (consensus treatment plans, CTPs) and monitored for 1 year. An optional bio-banking sub-study was included. RESULTS The target enrollment of 50 patients was achieved over 26 months at 10 sites, with patients enrolled into all CTPs. Enrolled patients were typical for jLS. Study eligibility criteria were found to perform well, capturing patients thought appropriate for treatment studies. Minor modifications to the eligibility criteria, primarily to facilitate recruitment for future studies, were discussed with consensus agreement reached on them by the jLS group. There were marked differences in site preferences for specific CTPs, with half the sites treating all their patients with the same CTP. Most patients (88%) completed the study, and 68% participated in the bio-banking substudy. CONCLUSIONS We demonstrate the feasibility of our approach for conducting comparative effectiveness research in a rare pediatric disease. Multi-center collaboration by dedicated investigators who met regularly was a key factor in the success of this project. Other factors that facilitate these studies include having a sufficient number of investigators to enroll in each regimen, and streamlining study approval and management.
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Affiliation(s)
- Suzanne C. Li
- Joseph M. Sanzari Children’s Hospital, Hackensack University Medical Center, Imus PC337, 30 Prospect Ave, Hackensack, NJ 07061 USA
- Hackensack Meridian School of Medicine at Seton Hall University, Clifton, NJ USA
| | | | - Ronald M. Laxer
- University of Toronto and The Hospital for Sick Children, Toronto, Canada
| | - Elena Pope
- University of Toronto and The Hospital for Sick Children, Toronto, Canada
| | | | - Katie Stewart
- Texas Scottish Rite Hospital and UT Southwestern, Dallas, TX USA
| | | | | | - Sandy Hong
- University of Iowa Stead Family Children’s Hospital, Iowa City, IA USA
| | | | | | | | | | - Marilynn Punaro
- Texas Scottish Rite Hospital and UT Southwestern, Dallas, TX USA
| | - Brian M. Feldman
- University of Toronto and The Hospital for Sick Children, Toronto, Canada
| | - Tracy Andrews
- Rutgers School of Public Health, Rutgers University, Newark, NJ USA
| | - Gloria C. Higgins
- The Ohio State University and Nationwide Children’s Hospital, Columbus, OH USA
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Khatri S, Torok KS, Mirizio E, Liu C, Astakhova K. Autoantibodies in Morphea: An Update. Front Immunol 2019; 10:1487. [PMID: 31354701 PMCID: PMC6634257 DOI: 10.3389/fimmu.2019.01487] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 06/14/2019] [Indexed: 01/15/2023] Open
Abstract
Skin autoimmune conditions belong to a larger group of connective tissue diseases and primarily affect the skin, but might also involve underlying tissues, such as fat tissue, muscle, and bone. Autoimmune antibodies (autoantibodies) play a role in autoimmune skin diseases, such as localized scleroderma also termed morphea, and systemic scleroderma, also called systemic sclerosis (SSc). The detailed studies on the biological role of autoantibodies in autoimmune skin diseases are limited. This results in a few available tools for effective diagnosis and management of autoimmune skin diseases. This review aims to provide an update on the detection and most recent research on autoantibodies in morphea. Several recent studies have indicated the association of autoantibody profiles with disease subtypes, damage extent, and relapse potential, opening up exciting new possibilities for personalized disease management. We discuss the role of existing autoantibody tests in morphea management and the most recent studies on morphea pathogenesis. We also provide an update on novel autoantibody biomarkers for the diagnosis and study of morphea.
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Affiliation(s)
- Sangita Khatri
- Department of Chemistry, Technical University of Denmark, Kongens Lyngby, Denmark
| | - Kathryn S. Torok
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Emily Mirizio
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Christopher Liu
- Division of Rheumatology, Department of Pediatrics, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kira Astakhova
- Department of Chemistry, Technical University of Denmark, Kongens Lyngby, Denmark
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Mertens J, de Jong E, van den Hoogen L, Wienke J, Thurlings R, Seyger M, Hoppenreijs E, Wijngaarde C, van Vlijmen-Willems I, van den Bogaard E, Giovannone B, van Wijk F, van Royen-Kerkhof A, Marut W, Radstake T. The identification of CCL18 as biomarker of disease activity in localized scleroderma. J Autoimmun 2019; 101:86-93. [DOI: 10.1016/j.jaut.2019.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 01/10/2023]
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Torok KS, Li SC, Jacobe HM, Taber SF, Stevens AM, Zulian F, Lu TT. Immunopathogenesis of Pediatric Localized Scleroderma. Front Immunol 2019; 10:908. [PMID: 31114575 PMCID: PMC6503092 DOI: 10.3389/fimmu.2019.00908] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 04/09/2019] [Indexed: 01/03/2023] Open
Abstract
Localized scleroderma (LS) is a complex disease characterized by a mixture of inflammation and fibrosis of the skin that, especially in the pediatric population, also affects extracutaneous tissues ranging from muscle to the central nervous system. Although developmental origins have been hypothesized, evidence points to LS as a systemic autoimmune disorder, as there is a strong correlation to family history of autoimmune disease, the presence of shared HLA types with rheumatoid arthritis, high frequency of auto-antibodies, and elevated circulating chemokines and cytokines associated with T-helper cell, IFNγ, and other inflammatory pathways. This inflammatory phenotype of the peripheral blood is reflected in the skin via microarray, RNA Sequencing and tissue staining. Research is underway to identify the key players in the pathogenesis of LS, but close approximation of inflammatory lymphocytic and macrophage infiltrate with collagen and fibroblasts deposition supports the notion that LS is a disease of inflammatory driven fibrosis. The immune system is dynamic and undergoes changes during childhood, and we speculate on how the unique features of the immune system in childhood could potentially contribute to some of the differences in LS between children and adults. Interestingly, the immune phenotype in pediatric LS resembles to some extent the healthy adult cellular phenotype, possibly supporting accelerated maturation of the immune system in LS. We discuss future directions in better understanding the pathophysiology of and how to better treat pediatric LS.
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Affiliation(s)
- Kathryn S. Torok
- Division of Pediatric Rheumatology, Department of Pediatrics, Childrens's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, PA, United States
| | - Suzanne C. Li
- Division of Pediatric Rheumatology, Department of Pediatrics, Hackensack University Medical Center, Hackensack, NJ, United States
- Hackensack Meridian School of Medicine at Seton Hall University, Clifton, NJ, United States
| | - Heidi M. Jacobe
- Department of Dermatology, UT Southwestern Medical Center, Dallas, TX, United States
| | - Sarah F. Taber
- Division of Pediatric Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York, NY, United States
- Department of Pediatrics, Weill Cornell Medicine, New York, NY, United States
| | - Anne M. Stevens
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Washington, Seattle, WA, United States
- Seattle Children's Research Institute, University of Washington, Seattle, WA, United States
| | - Francesco Zulian
- Pediatric Rheumatology Unit, Department of Woman's and Child's Health, University of Padua, Padua, Italy
| | - Theresa T. Lu
- Division of Pediatric Rheumatology, Department of Rheumatology, Hospital for Special Surgery, New York, NY, United States
- HSS Research Institute, Hospital for Special Surgery, New York, NY, United States
- Department of Microbiology and Immunology, Weill Cornell Medicine, New York, NY, United States
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Kunzler E, Florez-Pollack S, Teske N, O'Brien J, Prasad S, Jacobe H. Linear morphea: Clinical characteristics, disease course, and treatment of the Morphea in Adults and Children cohort. J Am Acad Dermatol 2019; 80:1664-1670.e1. [PMID: 31005342 DOI: 10.1016/j.jaad.2019.01.050] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 12/05/2018] [Accepted: 01/21/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Prospective, longitudinal studies examining the features of linear morphea are limited. OBJECTIVE To utilize the Morphea in Adults and Children cohort to determine clinical characteristics, impact on life quality, and disease course of linear morphea in a prospective, longitudinal manner. METHODS Characteristics of linear morphea versus other subtypes were compared in a cross-sectional manner. Next, linear morphea participants were examined in depth over a 3-year period. RESULTS Linear morphea was the most common morphea subtype (50.1%, 291/581) in the cohort. Deep involvement was more common in linear (64.3%, 187/291) than other morphea subtypes. Linear morphea participants with deep involvement were more likely to have a limitation in range of motion (28.6%, 55/192) than those without (11.1%, 11/99, P < .001). Adult-onset disease occurred in 32.6% (95/291) of those with linear morphea. Frequency of deep involvement was similar between pediatric (66.8%, 131/196) and adult-onset linear morphea (58.9%, 56/95, P = .19). Quality of life and disease activity scores improved over time, while damage stabilized with treatment. LIMITATIONS Results of the study are associative, and the University of Texas Southwestern Medical Center is a tertiary referral center. CONCLUSION A substantial number of linear morphea patients have adult-onset disease. In all age groups, linear morphea with deep involvement was associated with functional limitations.
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Affiliation(s)
- Elaine Kunzler
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas; Northeast Ohio Medical University, Rootstown, Ohio
| | | | - Noelle Teske
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jack O'Brien
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Smriti Prasad
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Heidi Jacobe
- Department of Dermatology, University of Texas Southwestern Medical Center, Dallas, Texas.
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Wu EY, Li SC, Torok KS, Virkud YV, Fuhlbrigge RC, Rabinovich CE. Baseline Description of the Juvenile Localized Scleroderma Subgroup From the Childhood Arthritis and Rheumatology Research Alliance Legacy Registry. ACR Open Rheumatol 2019; 1:119-124. [PMID: 31777788 PMCID: PMC6858014 DOI: 10.1002/acr2.1019] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective Localized scleroderma (LS) is a chronic inflammatory and fibrosing skin disorder. We present baseline data on the juvenile LS (jLS) cohort from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Legacy Registry, a multicenter observational registry of pediatric rheumatologic disorders. Methods This is a cross-sectional analysis of children with jLS enrolled in the CARRA Legacy Registry between May 2010 and April 2014. Descriptive statistics were used for demographic, clinical, and laboratory features. Data analysis included two-sample t test, χ2 test, Fisher's exact test, linear/logistic regression, and analysis of variance. Results Of 381 children with jLS, 76% were female and 80% Caucasian. Mean onset age was 8.2 years, with 17% having a 2-year or greater delay to first pediatric rheumatology (PRH) visit. Linear scleroderma was the most common subtype (54%). Antinuclear antibody (ANA) positivity was associated with joint contracture (P = 0.04), muscle atrophy (P = 0.014), and extremity shortening (P = 0.007). Elevated aldolase was associated with joint contracture (P = 0.008) and elevated creatine kinase (CK) with muscle atrophy (P = 0.028) and extremity shortening (P = 0.016). Children with functional limitation (27%) had earlier first PRH visit compared with those without (P = 0.01). Poorer function correlated with muscle atrophy, joint contracture, and extremity shortening (P < 0.001). Methotrexate (97%) and corticosteroids (68%) were the most common medications used. Conclusion Children with jLS without joint limitation are referred later, highlighting the insidious onset and need for educating referring providers. Poorer function correlated with muscle atrophy, joint contracture, and limb shortening. ANA positivity and elevated CK or aldolase were associated with muscle atrophy, joint contracture, and/or limb shortening, suggesting predictors of muscle involvement.
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Affiliation(s)
| | - Suzanne C Li
- Hackensack University Medical Center Hackensack New Jersey
| | - Kathryn S Torok
- Children's Hospital of Pittsburgh of UPMC Pittsburgh Pennsylvania
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Zulian F, Culpo R, Sperotto F, Anton J, Avcin T, Baildam EM, Boros C, Chaitow J, Constantin T, Kasapcopur O, Knupp Feitosa de Oliveira S, Pilkington CA, Russo R, Toplak N, van Royen A, Saad Magalhães C, Vastert SJ, Wulffraat NM, Foeldvari I. Consensus-based recommendations for the management of juvenile localised scleroderma. Ann Rheum Dis 2019; 78:1019-1024. [PMID: 30826775 PMCID: PMC6691928 DOI: 10.1136/annrheumdis-2018-214697] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2018] [Revised: 01/17/2019] [Accepted: 02/13/2019] [Indexed: 01/04/2023]
Abstract
In 2012, a European initiative called Single Hub and Access point for paediatric Rheumatology in Europe (SHARE) was launched to optimise and disseminate diagnostic and management regimens in Europe for children and young adults with rheumatic diseases. Juvenile localised scleroderma (JLS) is a rare disease within the group of paediatric rheumatic diseases (PRD) and can lead to significant morbidity. Evidence-based guidelines are sparse and management is mostly based on physicians' experience. This study aims to provide recommendations for assessment and treatment of JLS. Recommendations were developed by an evidence-informed consensus process using the European League Against Rheumatism standard operating procedures. A committee was formed, mainly from Europe, and consisted of 15 experienced paediatric rheumatologists and two young fellows. Recommendations derived from a validated systematic literature review were evaluated by an online survey and subsequently discussed at two consensus meetings using a nominal group technique. Recommendations were accepted if ≥80% agreement was reached. In total, 1 overarching principle, 10 recommendations on assessment and 6 recommendations on therapy were accepted with ≥80% agreement among experts. Topics covered include assessment of skin and extracutaneous involvement and suggested treatment pathways. The SHARE initiative aims to identify best practices for treatment of patients suffering from PRDs. Within this remit, recommendations for the assessment and treatment of JLS have been formulated by an evidence-informed consensus process to produce a standard of care for patients with JLS throughout Europe.
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Affiliation(s)
| | - Roberta Culpo
- Pediatric Rheumatology, University of Padova, Padua, Italy
| | | | - Jordi Anton
- Pediatric Rheumatology, Hospital and Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Tadej Avcin
- Pediatric Rheumatology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Eileen M Baildam
- Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Christina Boros
- Discipline of Paediatrics, Women's and Children's Hospital, University of Adelaide, North Adelaide, New South Wales, Australia
| | - Jeffrey Chaitow
- Pediatrics, Sydney Children's Hospital Network Randwick and Westmead, Sydney, New South Wales, Australia
| | - Tamàs Constantin
- Unit of Paediatric Rheumatology, Semmelweis University, Budapest, Hungary
| | - Ozgur Kasapcopur
- Pediatric Rheumatology, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey
| | | | | | - Ricardo Russo
- Servicio de Inmunología/Reumatología, Hospital de Pediatria Juan P Garrahan, Buenos Aires, Argentina
| | - Natasa Toplak
- Pediatric Rheumatology, University Children's Hospital Ljubljana, Ljubljana, Slovenia
| | - Annet van Royen
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Claudia Saad Magalhães
- Departamento de Pediatria, Faculdade de Medicina de Botucatu, Hospital das Clínicas, UNESP, Botucatu, Brazil
| | - Sebastiaan J Vastert
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Nico M Wulffraat
- Department of Paediatric Immunology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Ivan Foeldvari
- Klinikum Eilbek, Hamburger Zentrum für Kinder-und Jugendrheumatologie, Hamburg, Germany
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77
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Beukelman T, Xie F, Foeldvari I. The prevalence of localised scleroderma in childhood assessed in the administrative claims data from the United States. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2019; 4:77-78. [PMID: 35382148 PMCID: PMC8922586 DOI: 10.1177/2397198318798588] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Accepted: 08/09/2018] [Indexed: 08/26/2024]
Abstract
Juvenile localised scleroderma is believed an orphan autoimmune disease, which occurs 10 times more often than systemic sclerosis in childhood and is believed to have a prevalence of 1 per 100,000 children. To gain data regarding the prevalence of juvenile localised scleroderma, we assessed the administrative claims data in the United States using the International Classification of Diseases, Ninth Revision diagnosis codes. We found an estimated prevalence in each year ranging from 3.2 to 3.6 per 10,000 children. This estimate is significantly higher as found in previous studies.
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Affiliation(s)
- Timothy Beukelman
- Department of Pediatrics, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Fenglong Xie
- School of Medicine, The University of Alabama at Birmingham, Birmingham, AL, USA
| | - Ivan Foeldvari
- Hamburg Center for Pediatric and Adolescent Rheumatology, Am Schön Klinik Eilbek, Hamburg, Germany
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Lythgoe H, Almeida B, Bennett J, Bhat C, Bilkhu A, Brennan M, Deepak S, Dawson P, Eleftheriou D, Harrison K, Hawley D, Heaf E, Leone V, Long E, Maltby S, McErlane F, Rafiq N, Ramanan AV, Riley P, Rangaraj S, Varnier G, Wilkinson N, Pain CE. Multi-centre national audit of juvenile localised scleroderma: describing current UK practice in disease assessment and management. Pediatr Rheumatol Online J 2018; 16:80. [PMID: 30563543 PMCID: PMC6299547 DOI: 10.1186/s12969-018-0295-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 12/02/2018] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To describe current United Kingdom practice in assessment and management of patients with juvenile localised scleroderma (JLS) compared to Paediatric Rheumatology European Society (PRES) scleroderma working party recommendations. METHODS Patients were included if they were diagnosed with JLS and were under the care of paediatric rheumatology between 04/2015-04/2016. Retrospective data was collected in eleven UK centres using a standardised proforma and collated centrally. RESULTS 149 patients were included with a median age of 12.5 years. The outcome measures recommended by the PRES scleroderma working party were not utilised widely. The localised scleroderma cutaneous assessment tool was only used in 37.6% of patients. Screening for extracutaneous manifestations did not meet recommendations that patients with head involvement have regular screening for uveitis and baseline magnetic resonance imaging (MRI) brain: only 38.5% of these patients were ever screened for uveitis; 71.2% had a MRI brain. Systemic treatment with disease-modifying anti-rheumatic drugs (DMARDs) or biologics was widely used (96.0%). In keeping with the recommendations, 95.5% of patients were treated with methotrexate as first-line therapy. 82.6% received systemic corticosteroids and 34.2% of patients required two or more DMARDs/biologics, highlighting the significant treatment burden. Second-line treatment was mycophenolate mofetil in 89.5%. CONCLUSION There is wide variation in assessment and screening of patients with JLS but a consistent approach to systemic treatment within UK paediatric rheumatology. Improved awareness of PRES recommendations is required to ensure standardised care. As recommendations are based on low level evidence and consensus opinion, further studies are needed to better define outcome measures and treatment regimens for JLS.
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Affiliation(s)
- Hanna Lythgoe
- 0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK ,0000 0004 0421 1374grid.417858.7NIHR Alder Hey Clinical Research Facility, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK ,0000 0004 1936 8470grid.10025.36Department of Women’s and Children’s, Institute of Translational Medicine, University of Liverpool, Liverpool, UK
| | - Beverley Almeida
- 0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK ,0000 0004 5902 9895grid.424537.3Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Joshua Bennett
- 0000 0004 4904 7256grid.459561.aDepartment of Paediatric Rheumatology, Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Chandrika Bhat
- 0000 0004 0399 4960grid.415172.4Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - Amarpal Bilkhu
- 0000 0004 0624 7987grid.496757.eDepartment of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Mary Brennan
- 0000 0004 0624 7987grid.496757.eDepartment of Paediatric Rheumatology, Royal Hospital for Sick Children, Edinburgh, UK
| | - Samundeeswari Deepak
- 0000 0001 0440 1889grid.240404.6Department of Rheumatology, Nottingham Children’s Hospital, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Pamela Dawson
- 0000 0004 0399 7272grid.415246.0Department of Rheumatology, Birmingham Children’s Hospital, Birmingham, UK
| | - Despina Eleftheriou
- 0000 0004 5902 9895grid.424537.3Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Kathryn Harrison
- 0000 0004 0399 7272grid.415246.0Department of Rheumatology, Birmingham Children’s Hospital, Birmingham, UK
| | - Daniel Hawley
- 0000 0004 0641 6082grid.413991.7Department of Paediatric Rheumatology, Sheffield Children’s Hospital, Sheffield, UK
| | - Eleanor Heaf
- 0000 0001 0235 2382grid.415910.8Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Valentina Leone
- 0000 0000 9965 1030grid.415967.8Department of Paediatric Rheumatology, Leeds Children’s Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Ema Long
- 0000 0004 4904 7256grid.459561.aDepartment of Paediatric Rheumatology, Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Sarah Maltby
- 0000 0004 0641 6082grid.413991.7Department of Paediatric Rheumatology, Sheffield Children’s Hospital, Sheffield, UK
| | - Flora McErlane
- 0000 0004 4904 7256grid.459561.aDepartment of Paediatric Rheumatology, Great North Children’s Hospital, Newcastle upon Tyne, UK
| | - Nadia Rafiq
- 0000 0000 9965 1030grid.415967.8Department of Paediatric Rheumatology, Leeds Children’s Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Athimalaipet V. Ramanan
- 0000 0004 1936 7603grid.5337.2Department of Paediatric Rheumatology, Bristol Royal Hospital for Children & Bristol Medical School, University of Bristol, Bristol, UK
| | - Phil Riley
- 0000 0001 0235 2382grid.415910.8Department of Paediatric Rheumatology, Royal Manchester Children’s Hospital, Manchester, UK
| | - Satyapal Rangaraj
- 0000 0001 0440 1889grid.240404.6Department of Rheumatology, Nottingham Children’s Hospital, Nottingham University Hospital NHS Trust, Nottingham, UK
| | - Giulia Varnier
- 0000 0004 5345 7223grid.483570.dDepartment of Rheumatology and Chronic Pain, Evelina London Children’s Hospital, Guy’s and St Thomas’s NHS Foundation Trust, London, UK
| | - Nick Wilkinson
- 0000 0004 5345 7223grid.483570.dDepartment of Rheumatology and Chronic Pain, Evelina London Children’s Hospital, Guy’s and St Thomas’s NHS Foundation Trust, London, UK
| | - Clare E. Pain
- 0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust, Eaton Road, Liverpool, L12 2AP UK
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Kurzinski KL, Zigler CK, Torok KS. Prediction of disease relapse in a cohort of paediatric patients with localized scleroderma. Br J Dermatol 2018; 180:1183-1189. [PMID: 30315656 DOI: 10.1111/bjd.17312] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/05/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND Localized scleroderma (LS) is an autoimmune condition of the skin and underlying tissue. Active or recurring disease can lead to cumulative tissue damage, especially in paediatric-onset disease. OBJECTIVES To highlight the rate of relapse of LS activity in a cohort of paediatric patients and to evaluate for potential clinical and laboratory predictors of disease relapse. METHODS Clinical and laboratory data were gathered prospectively. Patients were categorized as experiencing relapse or not, and clinical and laboratory parameters were compared. A logistic regression was fit to predict odds of relapse while controlling for multiple predictors. A subgroup of patients was also evaluated to determine the average time from treatment completion to relapse. RESULTS Seventy-seven patients were followed for the identified study duration of > 2 years and had achieved disease remission, with 35 (45%) experiencing LS relapse. Patients who were older at disease onset, antinuclear antibody (ANA) positive and without an extracutaneous manifestation (ECM) were more likely to relapse. All three variables remained significant in the multivariable logistic regression model. Results of the subgroup mirrored the larger sample. The average time between treatment completion and relapse was 21 months. CONCLUSIONS Assessment of patients with LS experiencing a relapse of disease activity has shown older age of initial LS onset and ANA positivity to be potential markers for risk of relapse. Patients meeting these parameters may require greater clinical vigilance. The presence of one or more ECM may be protective. Clinicians treating patients with LS should provide significant long-term follow-up to monitor for relapse.
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Affiliation(s)
- K L Kurzinski
- Children's Hospital of Pittsburgh of Univeristy of Pittsburgh Medical Center, University of Pittsburgh Scleroderma Center, Pittsburgh, PA, U.S.A
| | - C K Zigler
- Department of Physical Medicine and Rehabilitation, School of Medicine, University of Pittsburgh, Pittsburgh, PA, U.S.A.,Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA, U.S.A
| | - K S Torok
- Children's Hospital of Pittsburgh of Univeristy of Pittsburgh Medical Center, University of Pittsburgh Scleroderma Center, Pittsburgh, PA, U.S.A
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81
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The correlation between serum E-selectin levels and soluble interleukin-2 receptors with relation to disease activity in localized scleroderma. Postepy Dermatol Alergol 2018; 35:614-619. [PMID: 30618531 PMCID: PMC6320493 DOI: 10.5114/ada.2018.77613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 05/02/2018] [Indexed: 02/02/2023] Open
Abstract
Introduction Scleroderma is a chronic connective tissue disease resulting in fibrosis. Aim The aim of the study was to determine the connection between sE-selectin and sIL-2R and the severity of skin lesions in various subtypes of LoS. Evaluation of disease severity, the location of skin lesions, the duration of symptoms and disease activity were assessed in relation to the three different LoS subtypes in patients with localized scleroderma. Material and methods The study included 42 patients with localized scleroderma and the control group consisted of 41 healthy subjects. All patients in the LoS study group had a confirmed diagnosis via skin biopsy and underwent serology testing for sE-selectin and sIL-2R concentrations by enzyme-linked immunosorbent assay (ELISA). Results Significantly higher levels of sE-selectin and sIL-2R were observed in the LoS study group when compared with the control group (p < 0.001). The analysis showed a result close to statistical significance (p = 0.058) between sE-selectin concentration during the time of active disease in the LoS study group. The highest concentrations of sE-selectin and sIL-2R were observed in patients with the generalized subtype of LoS. A positive, statistically significant, curvilinear relationship was shown amid the modified Localized Skin Severity Index (mLoSSI) and sE-selectin and sIL-2R concentrations in the LoS study group. Conclusions Concentrations of the circulating form of sE-selectin appear to be an adequate marker of the endothelial function, positively correlating with the severity of the disease. The proven correlation of sIL-2R concentrations with the severity of the disease indicates that it is a valuable prognostic factor for predicting the impending course of the disease.
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82
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Bali G, Szilvási A, Inotai D, Varga Á, Sárdy M, Kárpáti S, Medvecz M, Szegedi A, Hidvégi B. Comorbidity of localized scleroderma and primary biliary cholangitis. J Dtsch Dermatol Ges 2018; 16:1323-1327. [DOI: 10.1111/ddg.13693] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Revised: 04/28/2018] [Accepted: 05/04/2018] [Indexed: 01/13/2023]
Affiliation(s)
- Gábor Bali
- Department of Dermatology; Venereology and Dermato-Oncology; Faculty of Medicine; Semmelweis University; Budapest Hungary
| | - Anikó Szilvási
- Hungarian National Blood Transfusion Service; Transplantation Immunogenetics Laboratory; Budapest Hungary
| | - Dóra Inotai
- Hungarian National Blood Transfusion Service; Transplantation Immunogenetics Laboratory; Budapest Hungary
| | - Ágnes Varga
- Hungarian National Blood Transfusion Service; Transplantation Immunogenetics Laboratory; Budapest Hungary
| | - Miklós Sárdy
- Department of Dermatology; Venereology and Dermato-Oncology; Faculty of Medicine; Semmelweis University; Budapest Hungary
| | - Sarolta Kárpáti
- Department of Dermatology; Venereology and Dermato-Oncology; Faculty of Medicine; Semmelweis University; Budapest Hungary
| | - Márta Medvecz
- Department of Dermatology; Venereology and Dermato-Oncology; Faculty of Medicine; Semmelweis University; Budapest Hungary
| | - Anna Szegedi
- Department of Dermatology; Venereology and Dermato-Oncology; Faculty of Medicine; Semmelweis University; Budapest Hungary
| | - Bernadett Hidvégi
- Department of Dermatology; Venereology and Dermato-Oncology; Faculty of Medicine; Semmelweis University; Budapest Hungary
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Mansour M, Liy Wong C, Zulian F, Li S, Morishita K, Yeh EA, Stewart K, Laxer RM, Pope E. Natural history and extracutaneous involvement of congenital morphea: Multicenter retrospective cohort study and literature review. Pediatr Dermatol 2018; 35:761-768. [PMID: 30187959 DOI: 10.1111/pde.13605] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Congenital morphea is a form of localized scleroderma that presents at birth. There is limited information on its presentation and progression. METHODS Patients with congenital morphea were identified from five pediatric dermatology and rheumatology tertiary care centers in Canada, the United States, and Italy from 2001 to 2016. Cases from the literature were identified by searching Ovid (EMBASE and MEDLINE) from inception to June 30, 2017. Disease characteristics and prevalence of extracutaneous involvement were analyzed. RESULTS Thirteen patients were identified from the five centers, and 13 cases were described in the literature, representing 25 patients, with one duplication. Fourteen patients (56%) were female. Median age at diagnosis was 2.9 years (interquartile range 1.2-5.1 years). Linear morphea, including en coup de sabre and Parry-Romberg syndrome, was the most common subtype observed (n = 19, 76%), followed by circumscribed (n = 5, 20%), generalized (n = 2, 8%), and mixed (n = 2, 8%). The face (n = 14, 56%), scalp (n = 8, 32%), and trunk (n = 6, 24%) were the most common locations affected. Most lesions were active at diagnosis (n = 19, 76%), but all patients with follow-up later became inactive. Extracutaneous involvement was seen in 12 (48%) patients, all of whom had linear morphea. Musculoskeletal sequelae were seen in those with linear morphea of the extremities (4/5, 80%), and neurologic involvement was seen in those with linear morphea of the head (8/13, 62%). CONCLUSION Congenital morphea is associated with extracutaneous manifestations and delayed diagnosis. More research is needed to determine whether early recognition, monitoring, and treatment can alter the disease course.
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Affiliation(s)
- Mark Mansour
- Section of Dermatology, Division of Paediatric Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Carmen Liy Wong
- Section of Dermatology, Division of Paediatric Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Francesco Zulian
- Pediatric Rheumatology Unit, Department of Women's and Children's Health, University of Padua, Padua, Italy
| | - Suzanne Li
- Department of Pediatrics, Joseph M. Sanzari Children's Hospital, Hackensack Meridian Health, Hackensack, New Jersey
| | - Kimberly Morishita
- Department of Pediatrics, British Columbia Children's Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Eluen Ann Yeh
- Division of Neurology, Department of Pediatrics, Neuroscience and Mental Health, SickKids Research Institute, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Katie Stewart
- Division of Rheumatology, Department of Pediatrics, Texas Scottish Rite Hospital for Children, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ronald M Laxer
- Division of Rheumatology, Departments of Paediatrics and Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Elena Pope
- Section of Dermatology, Division of Paediatric Medicine, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
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Identifying the Signature Immune Phenotypes Present in Pediatric Localized Scleroderma. J Invest Dermatol 2018; 139:715-718. [PMID: 30616925 DOI: 10.1016/j.jid.2018.09.025] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 09/20/2018] [Accepted: 09/24/2018] [Indexed: 11/23/2022]
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85
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Moinzadeh P, Kreuter A, Krieg T, Hunzelmann N. Morphea/lokalisierte Sklerodermie und extragenitaler Lichen sclerosus. Hautarzt 2018; 69:892-900. [DOI: 10.1007/s00105-018-4266-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Li SC, Li X, Pope E, Stewart K, Higgins GC, Rabinovich CE, O’Neil KM, Haines KA, Laxer RM, Punaro M, Jacobe H, Andrews T, Wittkowski K, Nyirenda T, Foeldvari I, Torok KS. New Features for Measuring Disease Activity in Pediatric Localized Scleroderma. J Rheumatol 2018; 45:1680-1688. [DOI: 10.3899/jrheum.171381] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/25/2018] [Indexed: 11/22/2022]
Abstract
Objective.To identify clinical features that define disease activity in pediatric localized scleroderma (LS), and determine their specificity and importance.Methods.We conducted a multicenter prospective study of patients with active and inactive LS skin lesions. A standardized evaluation of a single designated study lesion per subject was performed at 3 visits. We evaluated the pattern and correlation between assessed features and physician’s global assessments of activity (PGA-A).Results.Ninety of 103 subjects had evaluable data; 66 had active and 24 inactive disease. Subjects had similar age of onset, sex, and disease patterns. Linear scleroderma was the most common subtype. Features specific for active disease included erythema, violaceous color, tactile warmth, abnormal skin texture, and disease extension. Scores for these variables changed over time and correlated with PGA-A of the lesion. Active and inactive lesions could not be distinguished by the presence or level of skin thickening, either of lesion edge or center. However, in active lesions, skin thickening scores did correlate with PGA–A scores. Regression analysis identified the combination of erythema, disease extension, violaceous color, skin thickening, and abnormal texture as predictive of PGA-A at study entry. Damage features were common irrespective of activity status.Conclusion.We identified variables strongly associated with disease activity, expanding upon those used in current measures, and determined their relative importance in physician activity scoring. Skin thickening was found to lack specificity for disease activity. These results will help guide development of a sensitive, responsive activity tool to improve care of patients with LS.
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Abstract
Scleroderma is a rare disease that has two main forms: localized scleroderma (LS) and systemic sclerosis (SSc). Both are chronic diseases, can present in different patterns (subtypes), and are associated with extracutaneous involvement in pediatric patients. Morbidity and mortality is much worse for juvenile SSc with patients at risk for life-threatening lung, heart, and other visceral organ fibrosis and vasculopathy. Mortality is extremely rare in juvenile LS, but morbidity is common, with patients at risk for severe disfigurement and functional impairment. Scleroderma treatment is directed towards controlling inflammation and managing specific problems. Early diagnosis can greatly improve outcome.
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Affiliation(s)
- Suzanne C Li
- Department of Pediatrics, Hackensack Meridian School of Medicine at Seton Hall University, 30 Prospect Avenue, Hackensack, NJ 07601, USA; Division of Pediatric Rheumatology, Joseph M. Sanzari Children's Hospital, Hackensack University Medical Center, 30 Prospect Avenue, Hackensack, NJ 07601, USA.
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Ophthalmic findings in linear scleroderma manifesting as facial en coup de sabre. Eye (Lond) 2018; 32:1688-1696. [PMID: 29973692 DOI: 10.1038/s41433-018-0137-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 05/15/2018] [Accepted: 05/18/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND To evaluate ophthalmic involvement in a long-term series of patients with en coup de sabre (ECS) close to the eye based on the hypothesis that this is not commonly affected, or simply under-reported. METHODS An observational study of ophthalmological findings in patients from Copenhagen University Dermatology Clinics. A standard eye examination further included exophthalmometry, axial length and keratometry (IOLMaster), and horizontal eye muscle thickness (B-scan ultrasonography). RESULTS Thirty-one consecutive patients were included from 2014 to 2015 (25 females, 6 males; median age, 33 years; range, 11-71 years). Twenty-seven patients had undergone ophthalmic evaluation more than once (observation time, 1-31 years; median, 7 years). Most eyes were normal or had currently adapted to eventual adnexal lesions and to insidious changes in eye position and/or motility. However, significant ipsilateral complications had developed related to 8 eyes, where two patients had more than one disorder. The ophthalmic pathologies were: blind eye (n = 2) due to adult age keratopathy/perforation and to Coats-like retinal detachment in childhood; restricted eye motility and diplopia (n = 2); acquired corneal astigmatism (n = 2); and dense cataract with light sense only (n = 1). Two patients had optic neuritis-like presentations, and lacrimal sac pathology occurred in one. CONCLUSIONS The main ophthalmic focus possibly explained the high proportion of significant lesions in this patient series (in 8 of 31). In addition to the established feature of enophthalmos, the oculometric evidence suggested smaller eye and rectus muscle involvement, interpreted as a secondary (late) negative trophic effect of the overlying skin disorder on eye structures.
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Ferreli C, Gasparini G, Parodi A, Cozzani E, Rongioletti F, Atzori L. Cutaneous Manifestations of Scleroderma and Scleroderma-Like Disorders: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:306-336. [PMID: 28712039 DOI: 10.1007/s12016-017-8625-4] [Citation(s) in RCA: 106] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Scleroderma refers to an autoimmune connective tissue fibrosing disease, including three different subsets: localized scleroderma, limited cutaneous systemic sclerosis, and diffuse cutaneous systemic sclerosis with divergent patterns of organ involvement, autoantibody profiles, management, and prognostic implications. Although systemic sclerosis is considered the disease prototype that causes cutaneous sclerosis, there are many other conditions that can mimic and be confused with SSc. They can be classified into immune-mediated/inflammatory, immune-mediated/inflammatory with abnormal deposit (mucinoses), genetic, drug-induced and toxic, metabolic, panniculitis/vascular, and (para)neoplastic disorders according to clinico-pathological and pathogenetic correlations. This article reviews the clinical presentation with emphasis on cutaneous disease, etiopathogenesis, diagnosis, and treatment options available for the different forms of scleroderma firstly and for scleroderma-like disorders, including scleromyxedema, scleredema, nephrogenic systemic fibrosis, eosinophilic fasciitis, chronic graft-versus-host disease, porphyria cutanea tarda, diabetic stiff-hand syndrome (diabetic cheiroartropathy), and other minor forms. This latter group of conditions, termed also scleroderma mimics, sclerodermiform diseases, or pseudosclerodermas, shares the common thread of skin thickening but presents with distinct cutaneous manifestations, skin histology, and systemic implications or disease associations, differentiating each entity from the others and from scleroderma. The lack of Raynaud's phenomenon, capillaroscopic abnormalities, or scleroderma-specific autoantibodies is also important diagnostic clues. As cutaneous involvement is the earliest, most frequent and characteristic manifestation of scleroderma and sclerodermoid disorders, dermatologists are often the first-line doctors who must be able to promptly recognize skin symptoms to provide the affected patient a correct diagnosis and appropriate management.
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Affiliation(s)
- Caterina Ferreli
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| | - Giulia Gasparini
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Aurora Parodi
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Emanuele Cozzani
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Franco Rongioletti
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Laura Atzori
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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90
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Kashem SW, Correll CK, Vehe RK, Hobday PM, Binstadt BA, Maguiness SM. Inflammatory arthritis in pediatric patients with morphea. J Am Acad Dermatol 2018; 79:47-51.e2. [PMID: 29535035 DOI: 10.1016/j.jaad.2018.03.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 02/27/2018] [Accepted: 03/03/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Morphea or localized scleroderma is an inflammatory disorder resulting in fibrosis of the skin and subcutaneous tissues. Joint contractures, arthralgias, and functional compromise are recognized associations of pediatric morphea. The co-existence of inflammatory arthritis and morphea is not well-described in the literature. OBJECTIVE To investigate the relationship between pediatric morphea and inflammatory arthritis with regards to cutaneous, musculoskeletal, and laboratory findings and treatment regimens. METHODS A systematic retrospective chart review of 53 patients with pediatric morphea was performed and analyzed for morphea subtypes, arthritic joint involvement, serum autoantibodies, and therapeutic interventions. RESULTS Eleven out of 53 patients had polyarthritis that involved joints unrelated to the site of the cutaneous morphea. These patients were mostly girls with either the linear or generalized subtypes of morphea. Serum levels of antinuclear antibodies were more significantly elevated in patients with arthritis. All children were treated with methotrexate in addition to other systemic or topical immunosuppressive agents. LIMITATIONS This was a small, single-center retrospective study. CONCLUSION Pediatric morphea co-existed with inflammatory arthritis in 11 of 53 children. Further understanding and appreciation of this relationship may direct more intensive therapy and musculoskeletal screening.
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Affiliation(s)
- Sakeen W Kashem
- Division of Pediatric Dermatology, Department of Dermatology, University of Minnesota, Minneapolis, Minnesota
| | - Colleen K Correll
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Richard K Vehe
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Patricia M Hobday
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Bryce A Binstadt
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Minnesota, Minneapolis, Minnesota
| | - Sheilagh M Maguiness
- Division of Pediatric Dermatology, Department of Dermatology, University of Minnesota, Minneapolis, Minnesota.
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91
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Martini G, Fadanelli G, Agazzi A, Vittadello F, Meneghel A, Zulian F. Disease course and long-term outcome of juvenile localized scleroderma: Experience from a single pediatric rheumatology Centre and literature review. Autoimmun Rev 2018; 17:727-734. [DOI: 10.1016/j.autrev.2018.02.004] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/11/2018] [Indexed: 12/20/2022]
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92
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Constantin T, Foeldvari I, Pain CE, Pálinkás A, Höger P, Moll M, Nemkova D, Weibel L, Laczkovszki M, Clements P, Torok KS. Development of minimum standards of care for juvenile localized scleroderma. Eur J Pediatr 2018; 177:961-977. [PMID: 29728839 DOI: 10.1007/s00431-018-3144-8] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Revised: 02/25/2018] [Accepted: 04/04/2018] [Indexed: 11/27/2022]
Abstract
UNLABELLED Juvenile localized scleroderma (jLS), also known as morphea, is an orphan disease. Pediatric guidelines regarding diagnosis, assessment, and management are lacking.Our objective was to develop minimum standards of care for diagnosis, assessment, and management of jLS. A systematic review was undertaken to establish the pediatric evidence for assessment and monitoring of jLS. An expert panel, including members of the Pediatric Rheumatology European Society (PRES) Scleroderma Working Group, were invited to a consensus meeting where recommendations were developed based on evidence graded by the systematic review and, where evidence was lacking, consensus opinion. A nominal technique was used where 75% consensus was taken as agreement. Recommendations for diagnosis, assessment, and management were developed. Due to a lack of pediatric evidence, these were primarily consensus driven. Careful assessment for extra-cutaneous manifestations including synovitis, brain involvement, and uveitis were key features together with joint assessments between Dermatology and Rheumatology to improve and standardize care. CONCLUSION Management of jLS is varied. These recommendations should help provide standardization of assessment and care for those with this rare and potentially debilitating condition. What is Known: • Children with juvenile localized scleroderma (jLS) are managed by a number of specialties including pediatric rheumatologists and dermatologists, sometimes in shared clinics. Studies have shown that management varies considerably and that there are notable differences between specialties [1]. • There is very little published guidance on management of jLS. What is new: • These recommendations aim to standardize diagnosis, assessment, and management through review of pediatric evidence and consensus agreement. • Joint review of patients by both pediatric rheumatologists and dermatologists is recommended.
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Affiliation(s)
| | - Ivan Foeldvari
- Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg, Germany
| | - Clare E Pain
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | | | - Peter Höger
- Department of Paediatric Dermatology, Catholic Children's Hospital Wilhelmstift, Hamburg, Germany
| | - Monika Moll
- University Childrens Hospital, Tuebingen, Germany
| | | | - Lisa Weibel
- Department of Dermatology, University Children's Hospital Zurich, Zurich, Switzerland
| | | | - Philip Clements
- David Geffen School of Medicine at UCLA, Division of Rheumatology, Los Angeles, CA, USA
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93
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Tabata N, Nagano Inoue C. Juvenile Localized Scleroderma with Hyaline Deposits in the Renal Arteriole. Case Rep Dermatol 2018; 10:89-95. [PMID: 29805370 PMCID: PMC5968237 DOI: 10.1159/000488901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 03/29/2018] [Indexed: 11/25/2022] Open
Abstract
We report a 10-year-old boy with localized scleroderma of the linear and plaque type, who showed proteinuria and hematuria. In this patient, skin, articular, and renal manifestations appeared successively and then began to resolve in the same order. A renal biopsy specimen demonstrated mild mesangial cell proliferation, exudate of immunoglobulin in the glomerular capillary, and large electron-dense deposits in the afferent arteriole. We consider that there were some transient factors that had caused the skin and articular manifestations, which also induced renal vascular inflammatory responses.
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Affiliation(s)
- Nobuko Tabata
- Department of Dermatology, Japanese Red Cross Sendai Hospital, Taihaku-ku, Sendai, Japan
| | - Chiyoko Nagano Inoue
- Department of Pediatrics, Japanese Red Cross Sendai Hospital, Taihaku-ku, Sendai, Japan
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94
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Samuelsen S, Jørgensen CD, Mellins ED, Torok KS, Astakhova K. Detection of autoimmune antibodies in localized scleroderma by synthetic oligonucleotide antigens. PLoS One 2018; 13:e0195381. [PMID: 29641558 PMCID: PMC5895021 DOI: 10.1371/journal.pone.0195381] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 03/21/2018] [Indexed: 01/08/2023] Open
Abstract
In this study, we developed a series of synthetic oligonucleotides that allowed us to investigate the details on the antigen recognition by autoimmune antibodies in localized scleroderma subjects. Besides dramatically improved analytical specificity of the assay, our data suggests a potential linking for antibodies to DNA to the biological status of disease state in localized scleroderma. Moreover, introducing chemical modifications into short synthetic deoxyribonucleic acid (DNA) and ribonucleic acid (RNA) molecules completely changed the binding titers of corresponding antibodies and their clinical relevance. The strongest observed effect was registered for the localized scleroderma skin damage index (LoSDI) on the IgG antibodies to TC dinucleotide-rich double-stranded antigen (p < 0.001). In addition to providing valuable tools for diagnosis of clinically relevant biomarkers, we believe that this work opens up new opportunities for research on antibodies to nucleic acids in localized scleroderma and other autoimmune diseases.
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Affiliation(s)
- Simone Samuelsen
- Department of Chemistry, Technical University of Denmark, Kongens Lyngby, Region Hovedstaden, Denmark
| | | | - Elizabeth D. Mellins
- Department of Pediatrics, Program in Immunology, Stanford University School of Medicine, Stanford, California, United States of America
| | - Kathryn S. Torok
- Department of Pediatrics, Division of Rheumatology, Children’s Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America
| | - Kira Astakhova
- Department of Chemistry, Technical University of Denmark, Kongens Lyngby, Region Hovedstaden, Denmark
- * E-mail:
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95
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Ardalan K, Switzer GE, Zigler CK, Hershey NM, Torok KS. Psychometric properties of the Children’s Dermatology Life Quality Index in pediatric localized scleroderma. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2018; 3:175-181. [DOI: 10.1177/2397198318760768] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 01/31/2018] [Indexed: 11/16/2022]
Abstract
Introduction: The Children’s Dermatology Life Quality Index has been used to measure quality of life in studies of pediatric localized scleroderma, which suggested only modest effects on quality of life. However, the Children’s Dermatology Life Quality Index psychometric performance has not been examined in localized scleroderma and it was validated in populations lacking localized scleroderma’s distinctive clinical features, possibly underestimating the quality of life impact. This study assessed psychometric properties of the Children’s Dermatology Life Quality Index in a cohort of pediatric localized scleroderma patients. Methods: Existing Children’s Dermatology Life Quality Index data from a large pediatric localized scleroderma cohort were analyzed. Children’s Dermatology Life Quality Index score distributions were examined and internal consistency was evaluated with Cronbach’s alpha for the entire Children’s Dermatology Life Quality Index and after deletion of individual items. Construct validity was assessed by calculating Spearman’s correlations between Children’s Dermatology Life Quality Index scores and disease severity/impact measures. Dimensionality was examined using exploratory factor analysis with sequential item elimination. Results: Children’s Dermatology Life Quality Index scores suggested modest adverse effects on quality of life. Internal consistency was adequate (Cronbach’s alpha = 0.727) but increased after eliminating items regarding friendships, sleep, and treatment burdens. Children’s Dermatology Life Quality Index scores were not associated with physician-scored disease severity measures but were moderately associated with patient/parent assessments of disease impact. Exploratory factor analysis yielded a three-factor solution encompassing functional limitations, psychosocial effects, and skin symptoms/treatment burden. Conclusion: The Children’s Dermatology Life Quality Index may capture functional and psychosocial domains of quality of life in localized scleroderma, but likely underestimates the quality of life impact given that it includes some items with limited relevance in localized scleroderma, incompletely explores skin symptoms and treatment burdens, and demonstrates limited construct validity. Further study to optimize quality of life measurement in pediatric localized scleroderma is warranted.
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Affiliation(s)
- Kaveh Ardalan
- Division of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
- Department of Medical Social Sciences, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Galen E Switzer
- Division of General Internal Medicine, Department of Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Psychiatry, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Christina K Zigler
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh School of Medicine, Pittsburgh PA
- Human Engineering Research Laboratories, VA Pittsburgh Healthcare System, Pittsburgh, PA
| | - Nicole M Hershey
- Division of Pediatric Rheumatology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Kathryn S Torok
- Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
- Division of Pediatric Rheumatology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
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96
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Jamalpur I, Mogili HR, Koratala A. Disabling pansclerotic morphoea of childhood. BMJ Case Rep 2018; 2018:bcr-2017-222132. [PMID: 29455178 DOI: 10.1136/bcr-2017-222132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Disabling pansclerotic morphoea (DPM) of childhood is a severe and often fatal variant of deep morphoea. It usually starts in childhood and rarely seen in adults. The course of the disease is progressive with lifelong morbidity in the form of joint contractures and immobility. The causes of mortality include complications such as sepsis, gangrene and cardiopulmonary involvement. Herein, we discuss the case of a 15-year-old girl with limb deformity and finger contractures, that is, bone involvement. The diagnosis of DPM of childhood was fortuitously made after the correction of limb deformity, when the patient was seen in the dermatology department for evaluation of skin discolouration on the thighs.
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Affiliation(s)
- Indirakshi Jamalpur
- Department of Dermatology, Kurnool Medical College, Kurnool, Andhra Pradesh, India
| | - Harikrishna Reddy Mogili
- Department of Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India
| | - Abhilash Koratala
- Department of Nephrology, University of Florida College of Medicine, Gainesville, Florida, USA
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97
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Khamaganova I. Progressive Hemifacial Atrophy and Linear Scleroderma En Coup de Sabre: A Spectrum of the Same Disease? Front Med (Lausanne) 2018; 4:258. [PMID: 29445726 PMCID: PMC5798413 DOI: 10.3389/fmed.2017.00258] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2017] [Accepted: 12/26/2017] [Indexed: 11/25/2022] Open
Abstract
Similar clinical and histhopathological features in progressive hemifacial atrophy and linear scleroderma en coup de sabre are well known. Trauma may predispose to the development of both diseases. The lack of association with anti-Borrelia antibodies was shown in both cases as well. The otolaryngological and endocrine disorders may be associated findings in both diseases. However, there are certain differences in neurological and ophthalmological changes in the diseases.
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Affiliation(s)
- Irina Khamaganova
- Pirogov Russian National Research Medical University, Moscow, Russia
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98
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Esophageal abnormalities in juvenile localized scleroderma: is it associated with other extracutaneous manifestations? REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:521-525. [PMID: 29173689 DOI: 10.1016/j.rbre.2016.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2016] [Accepted: 07/30/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess esophageal involvement (EI) in juvenile localized scleroderma (JLS) population and the possible association between this gastrointestinal manifestation and demographic data, clinical features, laboratory exams, treatments and outcomes. METHODS For a period of 30 years, 5881 patients with rheumatic diseases were followed in our Pediatric Rheumatology Division. EI was defined by the presence of symptoms (solid/liquid dysphagia, heartburn, esophageal regurgitation, nausea/vomiting and epigastralgia) and confirmed by at least one EI exam abnormality: barium contrast radiography, upper gastrointestinal endoscopy and 24-hour esophageal pH-monitoring. RESULTS JLS was observed in 56/5881 patients (0.9%), mainly linear morphea subtype. EI was observed in 23/56(41%) of JLS patients. Eight(35%) of 23 EI patients with JLS were symptomatic and presented heartburn(5/8), solid and liquid dysphagia(3/8), nausea and epigastralgia(1/8). The frequency of any cumulative extracutaneous manifestations (calcinosis, arthritis/arthralgia, central nervous system, interstitial pneumonitis, mesangial nephritis and/or arrhythmia) was significantly higher in JLS patients with EI compared to those without this complication (56% vs. 24%, p=0.024). No differences were evidenced in demographic data, JLS subtypes and in each extracutaneous manifestation in both groups (p>0.05). The frequency of methotrexate use was significantly higher in JLS patients with EI compared to those without (52% vs. 12%, p=0.002). Autoantibody profile (antinuclear antibodies, anti-SCL-70, rheumatoid factor, anticentromere, anti-cardiolipin, anti-Ro/SSA and anti-La/SSB) was similar in both groups (p>0.05). CONCLUSIONS Our study demonstrated that EI was frequently observed in JLS patients, mainly in asymptomatic patients with linear subtype. EI occurred in JLS patients with other extracutaneous manifestations and required methotrexate therapy.
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99
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Valões CC, Novak GV, Brunelli JB, Kozu KT, Toma RK, Silva CA. Anormalidades esofágicas na esclerodermia localizada juvenil: associação com outras manifestações extracutâneas? REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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100
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Merlin E, Breton S, Fraitag S, Stéphan JL, Wouters C, Bodemer C, Bader-Meunier B. Fibrous Arthropathy Associated With Morphea: A New Cause of Diffuse Acquired Joint Contractures. Pediatrics 2017; 140:peds.2016-1899. [PMID: 28954874 DOI: 10.1542/peds.2016-1899] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/14/2017] [Indexed: 11/24/2022] Open
Abstract
Etiologies for childhood-onset diffuse joint contractures encompass a large group of inherited disorders and acquired diseases, in particular a subtype of juvenile idiopathic arthritis called "dry polyarthritis," dermatomyositis, and systemic sclerosis. We report on 2 boys, aged 5 and 8 years, who developed acquired symmetric painless joint contractures preceding the development of superficial plaques of morphea by 7 to 13 months. There was no other clinical involvement, biological inflammation, or autoantibodies. No urinary mucopolysaccharidosis was seen. In both patients, wrist MRI showed no joint effusion, no bone erosion, and no or mild synovial thickening with slight enhancement after gadolinium infusion. One patient underwent a synovial biopsy, which showed dense fibrosis with a sparse inflammatory infiltrate, similar to the pathologic pattern observed in the skin biopsy. With methotrexate and systemic steroids, joint contractures slowly improved in the first patient and remained stable in the second. These 2 cases suggest that fibrous synovitis should be considered in children with acquired diffuse, symmetric, painless contractures and without elevation of acute-phase reactants, even in the absence of cutaneous manifestations. Articular MRI with gadolinium and careful cutaneous examination at onset and during follow-up should provide clues for diagnosing this entity.
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Affiliation(s)
- Etienne Merlin
- Inserm CIC 1405, Centre Hospitalier Universitaire de Clermont-Ferrand, Clermont-Ferrand, France
| | - Sylvain Breton
- Radiologie Pédiatrique, Hôpital Necker Enfants Malades, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Sylvie Fraitag
- Service d'Anatomie et de Cytologie Pathologiques, Hôpital Necker Enfants Malades, Assistance Publique - Hopitaux de Paris, Paris, France
| | - Jean-Louis Stéphan
- Service d'hématologie immunologie et rhumatologie pédiatrique, Centre Hospitalier Universitaire de Saint-Etienne, Saint-Priest-en-Jarez, France
| | - Carine Wouters
- Department of Pediatric Rheumatology, University Hospital Leuven, Leuven, Belgium
| | - Christine Bodemer
- Service de Dermatologie, Hôpital Necker Enfants Malades, Institut IMAGINE, Assistance Publique - Hopitaux de Paris, Paris, France; and
| | - Brigitte Bader-Meunier
- Unité d'Immuno-Hématologie et Rhumatologie Pédiatrique, Hôpital Necker Enfants Malades, Institut IMAGINE, Assistance Publique - Hopitaux de Paris, Paris, France
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