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Held M, Sestan M, Kifer N, Jelusic M. Cerebrovascular involvement in systemic childhood vasculitides. Clin Rheumatol 2023; 42:2733-2746. [PMID: 36884156 DOI: 10.1007/s10067-023-06552-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/02/2023] [Accepted: 02/15/2023] [Indexed: 03/09/2023]
Abstract
Pediatric vasculitides sometimes involve central nervous system (CNS). The manifestations are diverse, ranging from headache, seizures, vertigo, ataxia, behavioral changes, neuropsychiatric symptoms, consciousness disorders, and even cerebrovascular (CV) accidents that may lead to irreversible impairment and even death. Stroke, on the other hand despite the great progress in prevention and treatment, is still one of the leading causes of morbidity and mortality in the general population. The aim of this article was to summarize CNS manifestations and CV issues observed in primary pediatric vasculitides and the current knowledge of etiology and CV risk factors, preventive strategies, and therapeutic options in this target patient population. Pathophysiological links reveal similar immunological mechanisms involved in both pediatric vasculitides and CV events with endothelial injury and damage being the central point. From the clinical point of view, CV events in pediatric vasculitides were associated with increased morbidity and poor prognosis. If damage has already occurred, the therapeutic approach consists of good management of the vasculitis itself, antiplatelet and anticoagulation therapy, and early rehabilitation. Risk factors for acquiring cerebrovascular disease (CVD) and stroke, particularly hypertension and early atherosclerotic changes, already begin in childhood, with vessel wall inflammation contributing itself, once more emphasizing that appropriate preventive measures are certainly necessary in pediatric vasculitis population to improve their long-term outcome.
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Affiliation(s)
- Martina Held
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Mario Sestan
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Nastasia Kifer
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Marija Jelusic
- Department of Pediatrics, University of Zagreb School of Medicine, University Hospital Centre Zagreb, Zagreb, Croatia.
- Division of Clinical Immunology, Rheumatology and Allergology, Centre of Reference for Paediatric and Adolescent Rheumatology of Ministry of Health of the Republic Croatia, University Hospital Centre Zagreb, Kispaticeva 12, 10 000, Zagreb, Croatia.
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Kasap Cuceoglu M, Sener S, Batu ED, Kaya Akca U, Demir S, Sag E, Atalay E, Balık Z, Basaran O, Bilginer Y, Ozen S. Systematic review of childhood-onset polyarteritis nodosa and DADA2. Semin Arthritis Rheum 2021; 51:559-564. [PMID: 33901990 DOI: 10.1016/j.semarthrit.2021.04.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/15/2021] [Accepted: 04/15/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Diagnosis of childhood polyarteritis nodosa (PAN) has become challenging after the definition of deficiency of adenosine deaminase 2 (DADA2). We aimed to define the differential features of pediatric PAN and DADA2 patients in our center and in the literature. METHODS The charts of pediatric PAN and DADA2 patients followed at the Pediatric Rheumatology Unit of Hacettepe University between 2010-2020 were analyzed. A systematic literature review was conducted for articles regarding pediatric PAN or DADA2. RESULTS Thirty-four pediatric PAN and 18 pediatric DADA2 patients were included. The age at onset was younger, parental consanguinity, livedo reticularis, neurologic involvement (especially strokes), lymphopenia, and hypogammaglobulinemia were more frequent, while thrombocytosis and panniculitis were less frequent in DADA2 patients. The primary treatment was anti-tumor necrosis factor (anti-TNF) in DADA2. For induction treatment, all systemic PAN patients received corticosteroids, and cyclophosphamide (n=11) or mycophenolate mofetil (MMF) (n = 3). Cyclophosphamide was replaced with MMF in nine once remission was confirmed with PVAS. In the literature, 28 articles describing 613 pediatric PAN patients and 26 articles describing 207 pediatric DADA2 patients were identified. Neurologic, gastrointestinal, and cardiac involvements were more frequent in DADA2, while constitutional symptoms and testis involvement were more common in PAN. CONCLUSION In a child with PAN-like phenotype, DADA2 should be considered in the presence of young age at disease onset, parental consanguinity, strokes, lymphopenia, and lack of thrombocytosis during active disease. Anti-TNF treatment is indicated for vasculitic DADA2. Cyclophosphamide could be switched to MMF when remission is confirmed with PVAS in severe PAN.
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Affiliation(s)
- Muserref Kasap Cuceoglu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Seher Sener
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ezgi Deniz Batu
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ummusen Kaya Akca
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Selcan Demir
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Erdal Sag
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Erdal Atalay
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Zeynep Balık
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Ozge Basaran
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Yelda Bilginer
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey
| | - Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, and Hacettepe University Vasculitis Research Center, Ankara, 06100, Turkey.
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Mao Y, Yin L, Xia H, Huang H, Zhou Z, Chen T, Zhou W. Incidence and clinical features of paediatric vasculitis in Eastern China: 14-year retrospective study, 1999-2013. J Int Med Res 2016; 44:710-7. [PMID: 27009025 PMCID: PMC5536695 DOI: 10.1177/0300060515621446] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Accepted: 11/13/2015] [Indexed: 12/29/2022] Open
Abstract
Objectives To determine the incidence and clinical features of paediatric primary vasculitis in patients from one centre in Eastern China. Methods Medical records of paediatric patients diagnosed with primary vasculitis between January 1999 and December 2013 were retrospectively reviewed. For Henoch–Schönlein purpura (HSP) and Kawasaki disease (KD), patients included in the analyses had data available for the previous 5 years. Results In total, 1896 patients were identified, of whom 1100 had HSP, 760 had KD, 23 had Takayasu arteritis, five had polyarteritis nodosa, four had cutaneous polyarteritis, three had Behçet’s disease and one had microscopic polyangiitis. Of the 615 patients with HSP included in the analyses, 49.8% had HSP nephritis (for 90% of whom it occurred within 1 week of disease onset). Of the 470 patients with KD included in the analyses, 13.8% were diagnosed with incomplete KD and 29.0% had a concurrent coronary artery lesion. For the 23 patients with Takayasu arteritis, the common clinical symptoms were hypertension, asphygmia/weak pulse and heart failure; only one of these patients had been diagnosed at an early disease stage. The five patients with polyarteritis nodosa received immunosuppressant therapy following diagnosis. Other vasculitides were uncommon. Conclusions The most common primary vasculitides in this population of children from Eastern China were HSP and KD; other vasculitides were rare. Paediatricians should be suspicious of vasculitis when there is evidence of systemic inflammation and multisystem disease that cannot be explained by one specific disorder.
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Affiliation(s)
- Youying Mao
- Nephrology and Rheumatology Department, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lei Yin
- Nephrology and Rheumatology Department, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hui Xia
- Nephrology and Rheumatology Department, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hua Huang
- Nephrology and Rheumatology Department, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhengyu Zhou
- Nephrology and Rheumatology Department, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Tongxin Chen
- Nephrology and Rheumatology Department, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Wei Zhou
- Nephrology and Rheumatology Department, Shanghai Children's Medical Centre, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Jiang G, Jiang S, Yang CS, Lei TC. Purple livedo reticularis. Int J Dermatol 2015; 55:e121-2. [PMID: 26519108 DOI: 10.1111/ijd.13134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2015] [Revised: 05/29/2015] [Accepted: 06/09/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Guan Jiang
- Department of Dermatology, Renmin Hospital of Wuhan University, Wuhan, China.,Department of Dermatology, Affiliated Hospital of Xuzhou Medical College, Xuzhou, China
| | - Shan Jiang
- Department of Dermatology, Renmin Hospital of Wuhan University, Wuhan, China
| | - Chun-Sheng Yang
- Department of Dermatology, Affiliated Huai'an Hospital of Xuzhou Medical College, Huai'an, China
| | - Tie-Chi Lei
- Department of Dermatology, Renmin Hospital of Wuhan University, Wuhan, China
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Mondal R, Sarkar S, Pal P, Nandi M, Hazra A, Sabui TK. Childhood Polyarteritis Nodosa: a prospective multicentre study from eastern India. Indian J Pediatr 2014; 81:371-4. [PMID: 24113882 DOI: 10.1007/s12098-013-1256-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 09/19/2013] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To delineate the spectrum of clinical presentation and system involvement in childhood Polyarteritis Nodosa (PAN) in a multicentre follow up. METHODS This prospective observational study included all children less than 12 y attending pediatric rheumatological clinic of four different institutes in West Bengal or admitted with rheumatological symptoms and were diagnosed as childhood PAN by ACR and EULAR/PRES/PRINTO criteria. During the study period of 8 y, 15 cases were categorized as childhood PAN with organ involvement. The children diagnosed as microscopic polyangiitis or cutaneous PAN were excluded. RESULTS The mean age of presentation was 8.6 ± 2.09 y with male to female ratio of 7:8. All had prolonged fever, severe myalgia, skin involvement and elevated acute phase reactants. Hypertension (93 %) and peripheral neuropathy (46 %) were notable findings. Nine had typical peripheral gangrene with ulceration, whereas rash of livedo reticularis was seen in 6 patients. None had renal, pulmonary or testicular involvement. Diagnosis was established in all patients by skin biopsy which showed necrotizing vasculitis of the medium sized vessels. The clinical presentations and diagnostic parameters were compared between the genders and no statistically significant difference was noted. All patients required corticosteroids while 10 patients needed additional immunosuppressives where there were uncontrolled symptoms of peripheral neuropathy or progressive gangrene despite treatment with corticosteroids. Cyclophosphamide was used most commonly (n = 7). Two required methyl prednisolone. Two children were lost to follow up. One patient had two relapses within three years. No mortality was observed. CONCLUSIONS This multicentric study on childhood PAN, first of its kind from India, demonstrated a distinctive pattern of system involvement and clinical presentations.
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Affiliation(s)
- Rakesh Mondal
- Pediatric Rheumatology Clinic, Department of Pediatric Medicine, North Bengal Medical College Hospital (NBMCH), Darjeeling, India,
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