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Koru L, Esen F, Turkyilmaz O, Kucuk E, Kaya F, Aydin Z, Haslak F, Ozturk K. Clinical characteristics of pediatric noninfectious uveitis and risk factors for severe disease: a single-center study. Clin Rheumatol 2024; 43:2933-2942. [PMID: 39066867 PMCID: PMC11330385 DOI: 10.1007/s10067-024-07072-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 07/09/2024] [Accepted: 07/10/2024] [Indexed: 07/30/2024]
Abstract
OBJECTIVES We aimed to present the demographic, clinical, laboratory, and treatment data of children with non-infectious uveitis and to evaluate the risk factors for the development of complications and the need for biological treatment. METHOD Patients diagnosed with non-infectious uveitis in childhood and followed up for at least 1 year were included in the study. Demographic data, including age, gender, age at diagnosis, uveitis in first-degree relatives, and rheumatologic diseases, were obtained retrospectively from medical records. The presence of complications or the need for biologic therapy was considered a composite outcome suggesting severe disease. RESULTS The study included 123 patients (female: n = 59, 48%). The mean age at diagnosis was 14.89 ± 4.86 years. Uveitis was symptomatic in 104 patients (84.6%). Approximately one-quarter of the patients had at least one rheumatic disease (n = 35, 28.5%), the most common being juvenile idiopathic arthritis. Thirty-three patients (26.8%) had anti-nuclear antibody positivity. Biologic agents were needed in 60 patients (48.8%). Complications developed in 14 patients (11.4%). Early age at disease onset (aOR, 0.875; 95% C.I. 0.795-0.965, p = 0.007) and female gender (aOR, 2.99; 95% C.I. 1.439-6.248, p = 0.003) were significantly associated with the need for biologic treatment, while Behçet's disease (BD) was strongly associated with uveitis-related complications (aOR, 14.133; 95% C.I. 2.765-72.231, p = 0.001). CONCLUSION We suggest that among pediatric patients with non-infectious uveitis, females, those with an early age of disease onset, and those with BD need to be closely monitored due to a significantly increased risk of severe disease. Key Points • Limited data exist on the clinical course of non-infectious uveitis in children and the associated risk factors for severe disease. • Our study reveals that nearly a quarter of pediatric patients with non-infectious uveitis also have a rheumatic disease. • Among pediatric patients diagnosed with non-infectious uveitis, we observed an increased risk of severe disease in those with an earlier onset age, in female patients, and in those diagnosed with Behçet's disease.
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Affiliation(s)
- Lutfiye Koru
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Fehim Esen
- Department of Ophthalmology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Ozlem Turkyilmaz
- Department of Ophthalmology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Elif Kucuk
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Feray Kaya
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Zelal Aydin
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Fatih Haslak
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, Istanbul, Turkey
| | - Kubra Ozturk
- Department of Pediatric Rheumatology, Istanbul Medeniyet University, Istanbul, Turkey.
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Abstract
Musculoskeletal (MSK) pain is a common pediatric problem and can occur due to many etiologies. A pediatrician should be clinically equipped to identify the cause of musculoskeletal pain by a meticulous history, a detailed physical examination and judicious use of appropriate investigations. In this review, the authors attempt to delineate the approach and discuss a few common causes of musculoskeletal pain.
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Affiliation(s)
- Anju Gupta
- Department of Pediatrics, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Pratap Patra
- Department of Pediatrics, All India Institute of Medical Sciences, Patna, India
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3
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Yiu MK, Ho M, Ho ACH, Chan WKY, Yung W, Yip WWK, Young AL. Paediatric Uveitis - the uniqueness in clinical presentation and the efficacy of biologics treatment. J Ophthalmic Inflamm Infect 2024; 14:34. [PMID: 39017721 PMCID: PMC11254883 DOI: 10.1186/s12348-024-00415-z] [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: 04/16/2024] [Accepted: 06/10/2024] [Indexed: 07/18/2024] Open
Abstract
AIMS To evaluate unique clinical characteristics of paediatric uveitis in our locality and treatment outcomes especially the efficacy of biologics. METHODS This was a retrospective cohort. RESULTS 37 paediatric uveitis cases involving 67 eyes were included. Male-to-female ratio was 1:1.3. Mean age of uveitis onset was 11 ± 3.7 (4-18). 81.1% cases suffered from bilateral uveitis. 75.7% cases were chronic uveitis. Nearly half of the cases (40.5%) presented with anterior uveitis. The predominant diagnosis of uveitis in our cohort was idiopathic. Unlike studies from other populations, the associated systemic conditions in this mostly Chinese cohort were Behçet's disease (8.1%), tubulointerstitial nephritis and uveitis (8.1%) and HLA-B27 associated uveitis (8.1%). Steroid response was a common phenomenon, observed in 40.5% of cases. The most common complication was posterior synechiae (45.9%), followed by cataract (37.8%), glaucoma (27.0%), band keratopathy (18.9%) and macular oedema (13.5%). 3/37 patients encountered either first attack of uveitis or flare after receiving COVID-19 vaccine. 54.1% of patients required systemic steroid for disease control. The majority required steroid sparing immunotherapy, including Methotrexate (43.2%), Mycophenolate Mofetil (24.3%), Cyclosporine A (8.1%), Azathioprine (5.4%) and Tacrolimus (2.7%). Resistant cases required biologics including tumour necrosis factor alpha inhibitors (Adalimumab 32.4%, Infliximab 2.7%) and interleukin-6 inhibitors (Tocilizumab 2.7%). CONCLUSIONS Clinical presentation of the local paediatric uveitis differs from previously described features in Caucasian and other populations. According to our experience as a tertiary eye centre, Behçet's disease, tubulointerstitial nephritis and uveitis and HLA-B27 associated uveitis were more often encountered than Juvenile Idiopathic Arthritis associated uveitis. Our report evaluated the efficacy of immunomodulatory therapy and biologics in controlling uveitis and reducing ocular complications.
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Affiliation(s)
- Mei Kwan Yiu
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Mary Ho
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China.
| | - Assunta C H Ho
- Department of Paediatrics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Winnie K Y Chan
- Department of Paediatrics, Queen Elizabeth Hospital, Hong Kong SAR, China
| | - Wing Yung
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Wilson W K Yip
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
| | - Alvin L Young
- Department of Ophthalmology & Visual Sciences, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, New Territories, Hong Kong SAR, China
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Ede K, Shishov M, Wershba E, Goswami N, Gorry S, Joseph M, Mirea L, O'Neil J. Screening for juvenile idiopathic arthritis associated uveitis with laser flare photometry in the pediatric rheumatology office: a prospective observational study. Pediatr Rheumatol Online J 2024; 22:22. [PMID: 38279120 PMCID: PMC10811873 DOI: 10.1186/s12969-024-00961-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 01/19/2024] [Indexed: 01/28/2024] Open
Abstract
BACKGROUND Juvenile Idiopathic Arthritis (JIA) Associated Uveitis (JIA-U) remains one of the most serious complications of JIA in children. Historically, pediatric JIA is diagnosed by an Optometrist or Ophthalmologist; however, barriers to scheduling increase wait times that may delay diagnosis and treatment. The purpose of this study was to evaluate laser flare photometry (LFP) use to diagnose JIA-U in the Pediatric Rheumatology clinic for patients with JIA. METHODS This prospective, observational study assessed pediatric patients diagnosed with JIA without a previous history of uveitis between January 2020 and September 2022. All patients underwent at least one evaluation of both eyes using a Kowa FM-600 laser flare photometer during a routine Rheumatology appointment, as well as a standard slit lamp examination (SLE) by optometry or ophthalmology during routine clinical care. Data collected at patient visits included demographics, JIA characteristics, treatment, LFP readings, and anterior chamber (AC) cell grade score utilizing the SUN grading system. Data were summarized using descriptive analyses and the uveitis false positive rate was calculated. RESULTS The study cohort included 58 pediatric patients diagnosed with JIA. The mean age was 8.4 years (1.2-16.3 years) at diagnosis and 11.9 (4.8-16.5 years) at enrollment. The mean duration of disease at time of enrollment was 42 months (range; 0-157 months). Participants were predominantly female (n = 43, 74.1%) and white/Caucasian race (n = 37, 63.8%). The most common JIA subtypes included persistent oligoarticular JIA (n = 19, 32.8%), and RF negative polyarticular JIA (n = 12, 20.7%). There were 12 ANA positive patients (20.7%). At enrollment, 16 patients (27.6%) were not on medications, with 20 (34.5%) on methotrexate, 20 (34.5%) on adalimumab, 6 (10.3%) on tocilizumab, and 5 (8.6%) on etanercept. During the study period, no eye exams detected active uveitis based on SLE with a SUN grade over 0. However, of the 135 LFP readings, 131 (97.0%) were normal, yielding a false positive rate of 3% (95% CI: 0.8%, 7.4%). CONCLUSIONS LFP is a non-invasive tool that can be utilized in the pediatric rheumatology clinic to evaluate for JIA-U. There is a low false positive rate of LFP when compared with standard slit lamp exam.
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Affiliation(s)
- Kaleo Ede
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA.
| | - Michael Shishov
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Elisa Wershba
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Nikita Goswami
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Sabrina Gorry
- Division of Pediatric Rheumatology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Malin Joseph
- Department of Biostatistics, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - Lucia Mirea
- Department of Biostatistics, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
| | - James O'Neil
- Division of Pediatric Ophthalmology, Phoenix Children's Hospital, 1919 E Thomas Rd, 85016, Phoenix, AZ, USA
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Palmieri R, Albano V, Guerriero S, Craig F, La Torre F, Filoni S, Sardella D, Petruzzelli MG, Lecce P, De Giacomo A. Beyond Diagnosis: Preliminary Study of Impact on Children and Parents in Neurodevelopmental Disorders and Juvenile Idiopathic Arthritis-Associated Uveitis. Diagnostics (Basel) 2024; 14:275. [PMID: 38337791 PMCID: PMC10855410 DOI: 10.3390/diagnostics14030275] [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: 01/03/2024] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Chronic diseases are a growing problem for global health due to the large number of people they involve, the repercussions they have on the mental and physical well-being of those affected, and the costs to society. Particularly, chronic illnesses of childhood have important psychological implications, not only for affected children but also for their parents. Among these pathologies, neurodevelopmental disorders (NDDs) and uveitis associated with juvenile idiopathic arthritis (JIA-U) may affect mental and physical health, emotions, memory, learning, and socializing. This study evaluates the psychological and behavioral/emotional impact of NDDs and JIA-U on children and parents. Specifically, 30 children with active JIA-U and 30 children with NDDs and their parents completed the Child Behavior Checklist (CBCL) and Parent Stress Index-Short Form (PSI) questionnaires. Children with NDDs have statistically significant differences in all the emotional and behavioral variables compared to JIA-U children, and parents of children with NDDs experience an increased stress load compared to parents of children with JIA-U. This study emphasizes the wide range of emotional and behavioral challenges that parents face with NDDs. This study emphasizes that parents of children with NDDs not only experience higher levels of stress compared to parents of normally developing children but also experience higher levels of stress compared to parents of children with potentially debilitating chronic diseases such as JIA-U.
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Affiliation(s)
- Roberta Palmieri
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari “Aldo Moro”, 70124 Bari, Italy; (D.S.); (M.G.P.); (P.L.); (A.D.G.)
| | - Valeria Albano
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, Institute of Ophthalmology, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (V.A.); (S.G.)
| | - Silvana Guerriero
- Department of Basic Medical Sciences, Neurosciences and Sense Organs, Institute of Ophthalmology, University of Bari, Piazza Giulio Cesare 11, 70124 Bari, Italy; (V.A.); (S.G.)
| | - Francesco Craig
- Department of Cultures, Education and Society (DICES), University of Calabria, 87036 Cosenza, Italy;
| | - Francesco La Torre
- Department of Pediatrics, Pediatric Rheumatology Center, “Giovanni XXIII”, Pediatric Hospital, Via Giovanni Amendola 207, 70126 Bari, Italy;
| | - Serena Filoni
- I.R.C.C.S. Casa Sollievo della Sofferenza, 71013 San Giovanni Rotondo, Italy;
| | - Dario Sardella
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari “Aldo Moro”, 70124 Bari, Italy; (D.S.); (M.G.P.); (P.L.); (A.D.G.)
| | - Maria Giuseppina Petruzzelli
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari “Aldo Moro”, 70124 Bari, Italy; (D.S.); (M.G.P.); (P.L.); (A.D.G.)
| | - Paola Lecce
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari “Aldo Moro”, 70124 Bari, Italy; (D.S.); (M.G.P.); (P.L.); (A.D.G.)
| | - Andrea De Giacomo
- Translational Biomedicine and Neuroscience Department (DiBraiN), University of Bari “Aldo Moro”, 70124 Bari, Italy; (D.S.); (M.G.P.); (P.L.); (A.D.G.)
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Adeeb S, Arabi TZ, Shah H, Alsalameh S, Abu-Shaar M, El-Sibai AM, Alkattan K, Yaqinuddin A. Unveiling the Web: Exploring the Multifaceted Role of Neutrophil Extracellular Traps in Ocular Health and Disease. J Clin Med 2024; 13:512. [PMID: 38256646 PMCID: PMC10816449 DOI: 10.3390/jcm13020512] [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: 11/17/2023] [Revised: 01/02/2024] [Accepted: 01/09/2024] [Indexed: 01/24/2024] Open
Abstract
Neutrophil extracellular traps (NETs) play an essential role in antimicrobial defense. However, NETs have also been shown to promote and mediate a wide spectrum of diseases, including cancer, diabetes mellitus, cardiovascular diseases, and ocular diseases. Data regarding NETs in ocular diseases remain limited. In physiological conditions, NETs protect the eye from debris and cleave proinflammatory cytokines, including several interleukins. On the other hand, NETs play a role in corneal diseases, such as dry eye disease and ocular graft-versus-host disease, where they promote acinar atrophy and delayed wound healing. Additionally, NET levels positively correlate with increased severity of uveitis. NETs have also been described in the context of diabetic retinopathy. Although increased NET biomarkers are associated with an increased risk of the disease, NETs also assist in the elimination of pathological blood vessels and the regeneration of normal vessels. Targeting NET pathways for the treatment of ocular diseases has shown promising outcomes; however, more studies are still needed in this regard. In this article, we summarize the literature on the protective roles of NETs in the eye. Then, we describe their pathogenetic effects in ocular diseases, including those of the cornea, uvea, and retinal blood vessels. Finally, we describe the therapeutic implications of targeting NETs in such conditions.
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Affiliation(s)
| | | | | | | | | | | | | | - Ahmed Yaqinuddin
- College of Medicine, Alfaisal University, Riyadh 11533, Saudi Arabia; (S.A.); (T.Z.A.); (H.S.); (S.A.); (M.A.-S.); (A.M.E.-S.); (K.A.)
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Gentile P, Ragusa E, Bolletta E, De Simone L, Gozzi F, Cappella M, Fastiggi M, De Fanti A, Cimino L. Epidemiology of Pediatric Uveitis. Ocul Immunol Inflamm 2023; 31:2050-2059. [PMID: 37922466 DOI: 10.1080/09273948.2023.2271988] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 10/12/2023] [Indexed: 11/05/2023]
Abstract
Uveitis is uncommon in children and its diagnosis and treatment are challenging. Little is known of the epidemiology of pediatric uveitis. Indeed, population-based studies in the literature are rare. However, there are many tertiary referral center reports that describe the patterns of uveitis in childhood, although few are from developed countries, and their comparison presents some issues. Anterior uveitis is the most frequent entity worldwide, especially in Western countries, where juvenile idiopathic arthritis is diffuse. Most cases of intermediate uveitis do not show any association with infectious or noninfectious systemic diseases. In low- and middle-income countries, posterior uveitis and panuveitis are prevalent due to the higher rates of infectious etiologies and systemic diseases such as Behçet disease and Vogt-Koyanagi-Harada disease. In recent decades, idiopathic uveitis rate has decreased thanks to diagnostic improvements.
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Affiliation(s)
- P Gentile
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - E Ragusa
- Institute of Ophthalmology, University of Modena and Reggio Emilia, Modena, Italy
| | - E Bolletta
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - L De Simone
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - F Gozzi
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - M Cappella
- Pediatric Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - M Fastiggi
- Pediatric Rheumatology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - A De Fanti
- Pediatrics Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - L Cimino
- Ocular Immunology Unit, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
- Department of Surgery, Medicine, Dentistry and Morphological Sciences, with Interest in Transplants, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
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8
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van Meerwijk C, Kuiper J, van Straalen J, Ayuso VK, Wennink R, Haasnoot AM, Kouwenberg C, de Boer J. Uveitis Associated with Juvenile Idiopathic Arthritis. Ocul Immunol Inflamm 2023; 31:1906-1914. [PMID: 37966463 DOI: 10.1080/09273948.2023.2278060] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2023] [Accepted: 10/27/2023] [Indexed: 11/16/2023]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common cause of uveitis in children. While symptoms are usually mild, persistent eye inflammation could lead to severe complications and impaired vision. It is essential that JIA patients at risk are diagnosed with uveitis early, receive adequate treatment, and avoid developing complications, such as cataract, glaucoma, and amblyopia. The purpose of this mini-review is to summarize the screening strategies and clinical management for JIA-associated uveitis (JIA-U) as well as the current state of molecular markers linked to this condition. Because glaucoma is one of the most common causes of visual loss in JIA-U, special focus will be put on this serious complication. We conclude by describing the current evidence regarding the long-standing question of whether chronic anterior uveitis without arthritis may be the same disease entity as JIA-U.
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Affiliation(s)
- Charlotte van Meerwijk
- Department of Ophthalmology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Jonas Kuiper
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joeri van Straalen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Viera Kalinina Ayuso
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Roos Wennink
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Anne-Mieke Haasnoot
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Carlijn Kouwenberg
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Joke de Boer
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
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9
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Shen Y, Gong Y, Su L. Diagnostic Challenges in PD-1 Inhibitor Induced Panuveitis in a Teenage Girl with Chest Soft Tissue Sarcoma - A Case Report. Ocul Immunol Inflamm 2023; 31:2065-2068. [PMID: 37442377 DOI: 10.1080/09273948.2023.2233015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/12/2023] [Accepted: 06/30/2023] [Indexed: 07/15/2023]
Abstract
PURPOSE To report a case of programmed cell death receptor-1 (PD-1) inhibitor induced panuveitis. METHOD Observational case report of a 13-year-old Chinese girl presented as panuveitis. The clinical course, imaging performance, laboratory examination, differential diagnosis, treatment and prognosis were described. RESULT Patient presented with bilateral anterior granulomatous uveitis, vitritis, papillitis, and various creamy yellow nodular lesions in the mid-peripheral fundus. She had a history of biopsy proven alveolar soft tissue sarcoma on the chest wall and pulmonary metastasis, and a PD-1 inhibitor (sintilimab) was intravenously administered. Blood tests, magnetic resonance imaging of the cranium and the orbit, aqueous humor assay of inflammatory cytokines and microbial DNA were performed to distinguish infectious and non-infectious uveitis, choroidal metastases, and intravenous injection-related endophthalmitis. The oncologist evaluated that the sarcoma was stable and terminated sintilimab dosage. After sintilimab withdrawal, the blurred vision improved. Then, the patient received oral corticosteroids, resulted in resolution of the panuveitis. A diagnosis of PD-1 inhibitor induced panuveitis was made. CONCLUSION For patients taking PD-1 inhibitors, the major diagnostic challenge is to identify whether the cause of the uveitis is due to the antitumor treatment or not. It is suggested to be screened by eye care specialist and timely referral to uveitis specialist with any suspicion of intraocular inflammation for these patients.
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Affiliation(s)
- Yinchen Shen
- Department of Ophthalmology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yuanyuan Gong
- Department of Ophthalmology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Li Su
- Department of Ophthalmology, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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10
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Liu Y, Tang X. Identification of key biomarkers in RF-negative polyarticular and oligoarticular juvenile idiopathic arthritis by bioinformatic analysis. Pediatr Rheumatol Online J 2023; 21:143. [PMID: 38001449 PMCID: PMC10675924 DOI: 10.1186/s12969-023-00926-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 11/09/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE Juvenile idiopathic arthritis (JIA) is a broad term used to describe arthritis of unknown origin. JIA commonly persists into adulthood, often causing substantial morbidity such as restricted joint function, which can lead to challenges in employment and independence. This study aims to identify diagnostic biomarkers and investigate the role of immune cells in the pathogenesis of rheumatoid factor-negative polyarticular juvenile idiopathic arthritis (RF-negative pJIA) and oligoarticular juvenile idiopathic arthritis (oJIA). METHODS We retrieved a JIA dataset from the GEO database and conducted an analysis of differentially expressed genes (DEGs). Subsequently, functional enrichment analysis was performed on the DEGs. Weighted gene co-expression network analysis (WGCNA) was utilized to identify key modules. Additionally, we constructed a protein‒protein interaction network to identify hub genes that serve as signature genes. Furthermore, we employed CIBERSORT to classify immune cell infiltration. RESULTS From the GSE20307 dataset, we identified a total of 1438 DEGs in RF-negative pJIA and 688 DEGs in oJIA. WGCNA clustered the data into 6 modules in pJIA and 4 modules in oJIA. Notably, the ME5 and ME2 modules exhibited significant associations with pJIA and oJIA, respectively. In both pJIA and oJIA, we identified six hub genes, four of which demonstrated high diagnostic sensitivity and specificity in pJIA, while five showed high diagnostic sensitivity and specificity in oJIA. CIBERSORT analysis suggested the potential involvement of these signature genes in immune cell infiltration. CONCLUSION In this study, we identified JUN, CXCL8, SOCS3, and KRAS as biomarkers for RF-negative pJIA and JUN, CXCL8, SOCS3, PTGS2, and NFKBIA as biomarkers for oJIA. Furthermore, our findings suggest that Tfh cells may play a role in the early onset of both RF-negative pJIA and oJIA.
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Affiliation(s)
- Yun Liu
- Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, 400010, China
| | - Xuemei Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, 400010, China.
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11
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Ulu K, Çakan M, Çağlayan Ş, Yiğit RE, Demir F, Coşkuner T, Kardeş E, Sözeri B. Real-life data on efficacy and safety of original Adalimumab and biosimilar Adalimumab (ABP 501) in pediatric rheumatic diseases. Expert Opin Biol Ther 2023; 23:833-839. [PMID: 36101926 DOI: 10.1080/14712598.2022.2123703] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 09/08/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND We aimed to compare the efficacy and safety of the original product (OP) and biosimilar product (BP) of adalimumab in pediatric rheumatic diseases. RESEARCH DESIGN AND METHODS The study group consisted of patients who had received original or biosimilar adalimumab (ABP 501) therapy for at least 3 months. The patients were divided into uveitis and arthritis groups based on the indication of adalimumab treatment. Assessment of disease activity was performed by Juvenile Arthritis Disease Activity Score in patients with juvenile idiopathic arthritis, and by standardization of uveitis nomenclature criteria in patients with uveitis. RESULTS The study included 140 patients, of which 87 were treated with OP and 53 with BP. In the arthritis group, 26 (63.4%) and 20 (57.1%) patients reached inactive disease according to JADAS-27 in the original and biosimilar adalimumab groups, respectively. In the uveitis group the mean number of exacerbations throughout the treatment period was 0.84 ± 1.07 in the OP group, and 0.58 ± 0.79 in the BP group. There were 71 treatment-emergent adverse events in the OP group and 38 in the BP group. CONCLUSION There was no significant difference between the biosimilar and the original product in efficacy and safety.
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Affiliation(s)
- Kadir Ulu
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Şengül Çağlayan
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Ramazan Emre Yiğit
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Ferhat Demir
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Taner Coşkuner
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Esra Kardeş
- Department of Ophthalmology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, University of Health Sciences, Ümraniye Training and Research Hospital, Istanbul, Turkey
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12
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Zhang C, Liu X, Xiao J, Jiang F, Fa L, Jiang H, Zhou L, Su W, Xu Z. γδ T cells in autoimmune uveitis pathogenesis: A promising therapeutic target. Biochem Pharmacol 2023; 213:115629. [PMID: 37257721 DOI: 10.1016/j.bcp.2023.115629] [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: 03/16/2023] [Revised: 05/24/2023] [Accepted: 05/24/2023] [Indexed: 06/02/2023]
Abstract
Autoimmune uveitis is a non-infectious, inflammatory intraocular disease that affects the uveal and adjacent tissues. It frequently causes varying degrees of visual loss. Evidence for the strong association between activated γδ T cells and the development of autoimmune uveitis is growing. The innate and adaptive immune response are connected in the early phases by the γδ T cells that contain the γ and δ chains. γδ T cells can identify antigens in a manner that is not constrained by the MHC. When activated by various pathways, γδ T cells can not only secrete pro-inflammatory factors early on (such as IL-17), but they can also promote Th17 cells responses, which ultimately exacerbates autoimmune uveitis. Therefore, we review the mechanisms by which γδ T cells affect autoimmune uveitis in different activation and disease states. Moreover, we also prospect for immunotherapies targeting different γδ T cell-related action pathways, providing a reference for exploring new drug for the treatment of autoimmune uveitis.
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Affiliation(s)
- Chun Zhang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Xiuxing Liu
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou 510060, China
| | - Jing Xiao
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Fanwen Jiang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Luzhong Fa
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Hui Jiang
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Lin Zhou
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China
| | - Wenru Su
- State Key Laboratory of Ophthalmology, Zhongshan Ophthalmic Center, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Ophthalmology and Visual Science, Guangzhou 510060, China.
| | - Zhuping Xu
- Department of Ophthalmology, West China Hospital, Sichuan University, Chengdu, Sichuan 610041, China.
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13
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Triggianese P, Fatica M, Caso F, Costa L, D'Antonio A, Tasso M, Greco E, Conigliaro P, Bergamini A, Fabiani C, Cantarini L, Chimenti MS. Rheumatologist's Perspective on Non-Infectious Uveitis: Patterns from Tertiary Referral Rheumatologic Clinics in Italy. Int J Mol Sci 2023; 24:ijms24119690. [PMID: 37298638 DOI: 10.3390/ijms24119690] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/05/2023] [Accepted: 05/27/2023] [Indexed: 06/12/2023] Open
Abstract
Non-infectious uveitis (NIU) can be an early or even the first extra-articular manifestation of systemic rheumatic diseases, or the first one; thus, rheumatologists are often involved in the diagnostic and therapeutic assessment of NIU. We evaluated 130 patients with a diagnosis of NIU who were admitted to two Italian rheumatologic clinics (Tor Vergata University Hospital in Rome, and Federico II University in Naples) from January 2018 to December 2021. Anterior uveitis (AU) occurred in 75.4% of patients, followed by posterior uveitis (PU, 21.5%); acute (54.6%) and recurrent (35.4%) NIU were more documented than chronic NIU (10%), and a bilateral involvement was observed in 38.7% of cases. Half of NIU cases were associated with spondyloarthritis (SpA); the remaining were affected by Behçet disease (BD)-related uveitis (13.9%) and idiopathic NIU (9.2%). HLA-B27+ patients (34.8%) had a higher prevalence of anterior and unilateral NIU (p = 0.005) with acute course (p = 0.04) than HLA-B27- patients. On the contrary, HLA-B51+ patients (19.6%) had mostly PU and bilateral NIU (p < 0.0001) and recurrent course (p = 0.04) than HLA-B51- patients. At the first rheumatologic referral, 117 patients (90%) received systemic treatments. Findings from this study demonstrate that rheumatologic referral has a pivotal role in the diagnostic work-up of NIU and may dramatically influence NIU-treatment strategies.
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Affiliation(s)
- Paola Triggianese
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Mauro Fatica
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Francesco Caso
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Luisa Costa
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Arianna D'Antonio
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Marco Tasso
- Department of Clinical Medicine and Surgery, School of Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Elisabetta Greco
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Paola Conigliaro
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Alberto Bergamini
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
| | - Claudia Fabiani
- Ophthalmology Unit, Department of Medicine, Surgery and Neurosciences, University of Siena, 53100 Siena, Italy
| | - Luca Cantarini
- Department of Medical Sciences, Surgery and Neurosciences, Research Center of Systemic Autoinflammatory Diseases and Behcet's Disease Clinic, University of Siena, 53100 Siena, Italy
| | - Maria Sole Chimenti
- Rheumatology, Allergology and Clinical Immunology, Department of "Medicina dei Sistemi", PhD in Immunology, Molecular Medicine and Applied Biotechnology, University of Rome Tor Vergata, 00133 Rome, Italy
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14
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Zhou A, Babiker F, Philip AM, Anesi SD, Foster CS. Response to "Similarities in clinical course and outcome between juvenile idiopathic arthritis (JIA)-associated and ANA-positive idiopathic anterior uveitis: data from a population-based nationwide study in Germany". Arthritis Res Ther 2023; 25:41. [PMID: 36918966 PMCID: PMC10012478 DOI: 10.1186/s13075-023-03021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/27/2023] [Indexed: 03/16/2023] Open
Abstract
We have read the article entitled "Similarities in clinical course and outcome between juvenile idiopathic arthritis (JIA)-associated and ANA-positive idiopathic anterior uveitis: data from a population-based nationwide study in Germany" by Heiligenhaus et al. While we appreciate the work conducted by the authors, we have several comments we would like to address. First, the follow-up interval of 2 years is too short to conclude that the clinical course between two chronic pathologies is not significantly different. Second, remission status was determined by uveitis inactivity during the 2-year follow-up visit without any mention of flare frequency or length of remission, which is not a reliable measure of uveitis control. Third, ANA-positive idiopathic anterior uveitis is not a classification with a distinct clinical phenotype, and additional reports of serologic investigations would have been helpful.
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Affiliation(s)
- Avery Zhou
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Massachusetts Eye Research and Surgery Institution, 1440 Main St. Ste. 201, Waltham, MA, 02451, USA
| | - Fatima Babiker
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Massachusetts Eye Research and Surgery Institution, 1440 Main St. Ste. 201, Waltham, MA, 02451, USA
| | - Andrew M Philip
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Massachusetts Eye Research and Surgery Institution, 1440 Main St. Ste. 201, Waltham, MA, 02451, USA
| | - Stephen D Anesi
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
- Massachusetts Eye Research and Surgery Institution, 1440 Main St. Ste. 201, Waltham, MA, 02451, USA
| | - C Stephen Foster
- The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA.
- Massachusetts Eye Research and Surgery Institution, 1440 Main St. Ste. 201, Waltham, MA, 02451, USA.
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA.
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15
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Arslanoglu Aydin E, Ozdel S, Cakar Ozdal P, Bagrul İ, Baglan E, Tuncez S, Bulbul M. Changing face of non-infectious pediatric uveitis in the pre-pandemic and pandemic periods: a comparison study. Postgrad Med 2023; 135:418-423. [PMID: 36851832 DOI: 10.1080/00325481.2023.2184092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
OBJECTIVE Our aim in this study was to reveal the clinical features of pediatric uveitis in the pandemic period and to compare it with the pre-pandemic era. METHODS This retrospective study included 187 children diagnosed with uveitis between the 11th of March 2017 and the 11th of March 2022. The patients were divided into two groups based on the date of diagnosis as follows; Group 1: Patients diagnosed in the pre-pandemic period (11th March 2017-11th March 2020); Group 2: Patients diagnosed in the pandemic period (12th March 2020-11th March 2022). Demographic data, characteristics of uveitis, underlying diseases, systemic treatment modalities, and complications were compared between the two groups. RESULTS A total of 187 (pre-pandemic 71, and pandemic 114) pediatric uveitis patients were recruited to the study. Fifty one percent (51%) of the patients were female. The number of patients diagnosed with uveitis increased approximately twice during the pandemic period compared to the pre-pandemic period. The frequency of anterior uveitis was found to be significantly higher in the pandemic period than in the pre-pandemic period (p = 0.037). It was mostly presented as symptomatic uveitis. There was a decrease in the diagnosis of JIA-related uveitis. ANA positivity increased in the pandemic period (p = 0.029). The response to treatment was better and the complication rate decreased in the pandemic period. CONCLUSION The present study involved a large number of pediatric patients with uveitis. There are some differences in the characteristics of pediatric uveitis cases comparing the pandemic period and the pre-pandemic period. This increased frequency and changing clinical features of pediatric uveitis seems to be a result of COVID-19 infection.
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Affiliation(s)
- Elif Arslanoglu Aydin
- Department of Pediatric Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Semanur Ozdel
- Department of Pediatric Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Pinar Cakar Ozdal
- Service of Uveitis and Retinal Diseases, Ankara Ulucanlar Eye Research Hospital, Ankara, Turkey
| | - İlknur Bagrul
- Department of Pediatric Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Esra Baglan
- Department of Pediatric Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Serife Tuncez
- Department of Pediatric Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Mehmet Bulbul
- Department of Pediatric Nephrology and Rheumatology, Dr. Sami Ulus Maternity and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
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16
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Tocilizumab in Juvenile Idiopathic Arthritis Associated Uveitis, a Narrative Review. CHILDREN 2023; 10:children10030434. [PMID: 36979992 PMCID: PMC10047268 DOI: 10.3390/children10030434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 02/25/2023]
Abstract
Juvenile idiopathic arthritis (JIA) associated uveitis (JIA-U) is the most common extra-articular manifestation of JIA, affecting 10–15% of patients, especially in oligoarticular JIA where its course may be faint. Therefore, JIA-U is one of the most challenging pediatric uveitis, associated with major ocular morbidity and possibly leading to irreversible structural ocular damage and to vision-threatening complications. Adequate management is crucial for avoiding visual impairment complications. Since the introduction of biologic disease modifying anti-rheumatic drugs (bDMARDS), the visual prognosis of JIA-U has dramatically improved over the decades. Tumor necrosis factor-α (TNF-α) blockers are the most used bDMARDs in treating JIA-U with large evidence of efficacy. However, inadequate response to these agents, either due to intolerance or inefficacy, may be observed, requiring a swap to other classes of immunosuppressive agents, including anti-IL-6, anti-CD20, and, more recently, JAK inhibitors. Tocilizumab is a humanized monoclonal antibody to the interelukin-6 receptor preventing IL-6 from binding to its soluble and membrane-bound receptors. A growing body of literature provides promising results about the efficacy of intravenous and subcutaneous tocilizumab in the treatment of JIA-U. A narrative review of the literature on this topic will improve our knowledge on the potential use of tocilizumab in JIA-U.
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17
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Guo Y, Fang Y, Zhang T, Pan Y, Wang P, Fan Z, Yu H. Axial involvement in enthesitis-related arthritis: results from a single-center cohort. Pediatr Rheumatol Online J 2023; 21:13. [PMID: 36747282 PMCID: PMC9903626 DOI: 10.1186/s12969-023-00792-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 01/15/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Axial involvement in children with enthesitis-related arthritis (ERA) has characteristics that differ from those of peripheral involvement. This study characterized their clinical characteristics and treatment. METHODS Patients with ERA at the Children's Hospital of Nanjing Medical University between January 2018 and December 2020 were included. The ERA cohort was divided into two based on the presence or absence of axial joint involvement. Demographic characteristics, clinical features, and treatments were described and compared. RESULTS In total, 105 children with ERA were enrolled (axial ERA, n = 57; peripheral ERA, n = 48). The age at disease onset of the axial group tended to be higher (11.93 ± 1.72 vs. 11.09 ± 1.91 years) and the diagnosis delay was bigger in patients with axial ERA (10.26 ± 11.66 months vs. 5.13 ± 7.92 months). The inflammatory marker levels were significantly higher in patients with axial. There were no differences in HLA-B27 positivity between the groups (34 [59.65%] vs. 28 [58.33%], P > 0.05). Hip involvement was more frequent in the axial group (52.63% vs 27.08%; X2 = 7.033). A total of 38 (66.67%) and 10 (20.83%) patients with axial and peripheral ERA, respectively, were treated with biological disease-modifying anti-rheumatic drugs (DMARDs) at diagnosis. The administration of biologics increased gradually in the axial ERA group, peaking at 18 months and decreasing thereafter, whereas that in the peripheral ERA group peaked at 6 months and began to decline thereafter. CONCLUSIONS Axial ERA is a persistent active disease and requires a more aggressive treatment. Classification and early recognition of axial involvement may help with timely diagnosis and appropriate management.
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Affiliation(s)
- Yanli Guo
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Yuying Fang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Tonghao Zhang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Yuting Pan
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Panpan Wang
- grid.452511.6Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, 210008 China
| | - Zhidan Fan
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children's Hospital of Nanjing Medical University, Nanjing, 210008, China.
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Marelli L, Dallos T, Miserocchi E, Nucci P, Tombolini B, De Lucia O, Gattinara M, Caporali R, Marino A. Case report: Prader-Willi syndrome and inflammatory arthritis-An important consideration. Front Pediatr 2023; 11:1102382. [PMID: 37009284 PMCID: PMC10063871 DOI: 10.3389/fped.2023.1102382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 02/20/2023] [Indexed: 04/04/2023] Open
Abstract
Background Prader-Willi syndrome (PWS) is a multisystemic genetically determined disorder. Musculoskeletal manifestations are common in most patients. We report the cases of two children with PWS who developed inflammatory arthritis, complicated with chronic anterior bilateral uveitis in one case. To our knowledge, no previous reports of such an association exist. Case presentation Case 1 was of a 3-year-old girl diagnosed with PWS who developed arthritis of the right knee with morning stiffness, joint swelling, and limited range of motion. Other causes of arthritis were ruled out. Increased inflammatory markers, antinuclear antibody (ANA) positivity, and hypertrophic synovitis on ultrasound confirmed the diagnosis of inflammatory arthritis compatible with juvenile idiopathic arthritis (JIA). Despite the treatment with methotrexate, arthritis progressed, and etanercept was added. The patient reached and maintained articular remission while on combined MTX and etanercept treatment during 9 years of follow-up. Case 2 was of a 6-year-old boy diagnosed with PWS who developed arthritis of the right knee. Laboratory investigations showed mildly increased acute phase reactants, microcytic anemia, and ANA positivity at high titer (titer 1:1,280). Infectious and other causes of arthritis were excluded. Ultrasound confirmed the presence of joint effusion and synovial thickening, and synovial fluid analysis was consistent with inflammatory arthrosynovitis (white blood cell count of 14,200/µl) compatible with JIA. Shortly after the diagnosis, the ophthalmologic evaluation revealed the presence of bilateral anterior uveitis. Despite MTX and topical corticosteroid, ocular inflammation persisted and adalimumab was added. At the last follow-up, 9 months later, the child experienced inactivity of arthritis and uveitis with normal growth. Conclusions We aim to raise awareness of this possible association among pediatricians since arthritis might be underestimated due to high pain tolerance, behavioral disturbances, and other musculoskeletal abnormalities in PWS patients.
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Affiliation(s)
- Luca Marelli
- Eye Clinic San Giuseppe Hospital, IRCCS Multimedica Scientific Institute, Milan, Italy
| | - Tomáš Dallos
- Second Department of Pediatrics, Comenius University Medical School, Bratislava, Slovakia
| | - Elisabetta Miserocchi
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
- Correspondence: Elisabetta Miserocchi
| | - Paolo Nucci
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Milan, Italy
| | - Beatrice Tombolini
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Division of Head and Neck, Ophthalmology Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Orazio De Lucia
- Division of Clinical Rheumatology, ASST G.Pini-CTO, Milano, Italy
| | | | - Roberto Caporali
- Division of Clinical Rheumatology, ASST G.Pini-CTO, Milano, Italy
- Unit of Pediatric Rheumatology, ASST G.Pini-CTO, Milan, Italy
- Department of Clinical Sciences and Community Health and Research Center for Pediatric and Adult Rheumatic Diseases (RECAP.RD), University of Milan, Milan, Italy
| | - Achille Marino
- Unit of Pediatric Rheumatology, ASST G.Pini-CTO, Milan, Italy
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19
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Wennink RA, Kalinina Ayuso V, Pameijer EM, Dekkers CC, Bozkir I, de Boer JH. Improved clinical outcomes in patients with juvenile idiopathic arthritis associated uveitis in the last decade. Acta Ophthalmol 2022; 100:781-787. [PMID: 35076174 PMCID: PMC9786763 DOI: 10.1111/aos.15097] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Revised: 11/24/2021] [Accepted: 12/29/2021] [Indexed: 12/30/2022]
Abstract
PURPOSE The purpose of the study was to analyse the development of ocular complications and visual prognosis in juvenile idiopathic arthritis associated uveitis (JIA-uveitis) compared to the previous decade in the light of new treatment guidelines. METHODS In this retrospective cohort, 143 patients with JIA-uveitis were stratified into two cohorts based on the year of diagnosis of uveitis, <2010 (n = 61) and ≥2010 (n = 82). Development of ocular complications and visual outcomes were analysed by univariate and multivariate methods. Treatment with systemic corticosteroids and immunomodifying medication (IMT) were documented. RESULTS In total, 109 and 133 affected eyes, respectively, for cohort 1 (<2010) and cohort 2 (≥2010) were included for analysis. In the multivariate analysis with correction for paired eyes, patients in cohort 1 were at higher risk for cataract surgery (p = 0.03) and secondary glaucoma (p = 5.15 × 10-3 ). Also, the number of eyes that were legally blind and visually impaired at 5 years of follow-up was significantly higher in cohort 1 (7% versus 2% and 8% versus 0%, p = 0.01 respectively). The number of patients that started IMT was significantly higher in cohort 2 (57% versus 98%, p = 2.17 × 10-6 ). In cohort 2, both methotrexate and anti-TNF-α therapy were prescribed earlier in the disease course (1.41 versus 0.05 years, p = 8.31 × 10-6 and 6.07 versus 1.84 years, p = 5.14 × 10-5 respectively). CONCLUSIONS The prognosis of JIA-uveitis has improved during the last decade. There is a reduction in the number of cataract surgeries and secondary glaucoma and fewer patients lose their vision parallel with earlier access to tertiary care and earlier introduction of IMT.
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Affiliation(s)
- Roos A.W. Wennink
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Viera Kalinina Ayuso
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Els M. Pameijer
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Coco C. Dekkers
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Irem Bozkir
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
| | - Joke H. de Boer
- Department of OphthalmologyUniversity Medical Center UtrechtUtrecht UniversityUtrechtthe Netherlands
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20
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Montag LJ, Horneff G, Hoff P, Klein A, Kallinich T, Foeldvari I, Seipelt E, Tatsis S, Peer Aries MD, Niewerth M, Klotsche J, Minden K. Medication burden in young adults with juvenile idiopathic arthritis: data from a multicentre observational study. RMD Open 2022; 8:rmdopen-2022-002520. [PMID: 36283758 PMCID: PMC9608545 DOI: 10.1136/rmdopen-2022-002520] [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: 06/17/2022] [Accepted: 09/26/2022] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess the medication and disease burden of young adults with juvenile idiopathic arthritis (JIA). METHODS Young adults with JIA prospectively followed in the Juvenile Arthritis Methotrexate/Biologics long-term Observation reported on their health status and medication use. All medications taken (disease-modifying antirheumatic drugs (DMARDs)/prescription/over-the-counter drugs, but excluding most local therapies) classified according to the Anatomical Therapeutic Chemical Classification System were included in this analysis. Medication use at last follow-up was evaluated by sex, JIA category and time from symptom onset to the first biological DMARD (bDMARD) start. RESULTS A total of 1306 young adults (68% female) with JIA and a mean disease duration of 13.6±6 years were included in the study. Patients reported using on average 2.4±2.1 medicines and 1.5±1.7 non-DMARD medicines, respectively, at the last follow-up. Almost a quarter of the patients reported polypharmacy. The higher the number of medications used was, the higher the disease activity, pain and fatigue, and the lower the quality of life of patients. Medication usage differed significantly between sexes and JIA categories, being highest in patients with rheumatoid factor-positive polyarthritis and systemic JIA. The number of medications used was significantly associated with the time from symptom onset to bDMARD start. Patients taking opioids or antidepressants had a particularly high disease burden and had received bDMARDs an average of 2 years later than patients not taking these medications. CONCLUSION Medication use in adults with JIA varies depending on sex, JIA category, and the time between symptom onset and initiation of treatment with bDMARD.
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Affiliation(s)
- Laura J Montag
- Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Programme area Epidemiology and Health Services Research, Deutsches Rheuma-Forschungszentrum Berlin, Leibniz Institute, Berlin, Germany
| | - Gerd Horneff
- Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany,Department of Paediatric and Adolescent Medicine, University Hospital Cologne, Cologne, Germany
| | - Paula Hoff
- Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Department of Rheumatology, MVZ Endokrinologikum Berlin, Berlin, Germany
| | - Ariane Klein
- Department of Paediatrics, Asklepios Clinic Sankt Augustin, Sankt Augustin, Germany
| | - Tilmann Kallinich
- Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany,Programme area Pathophysiology of Rheumatic Inflammation, Deutsches Rheuma-Forschungszentrum Berlin, Leibniz Institute, Berlin, Germany
| | - Ivan Foeldvari
- Klinikum Eilbek, Hamburger Zentrum für Kinder- und Jugendrheumatologie, Hamburg, Germany
| | - Eva Seipelt
- Immanuel Krankenhaus Berlin-Buch, Berlin, Germany
| | | | | | - Martina Niewerth
- Programme area Epidemiology and Health Services Research, Deutsches Rheuma-Forschungszentrum Berlin, Leibniz Institute, Berlin, Germany
| | - Jens Klotsche
- Programme area Epidemiology and Health Services Research, Deutsches Rheuma-Forschungszentrum Berlin, Leibniz Institute, Berlin, Germany
| | - Kirsten Minden
- Programme area Epidemiology and Health Services Research, Deutsches Rheuma-Forschungszentrum Berlin, Leibniz Institute, Berlin, Germany,Department of Pediatric Respiratory Medicine, Immunology and Critical Care Medicine, Charité Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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Zeng L, Deng Y, He Q, Yang K, Li J, Xiang W, Liu H, Zhu X, Chen H. Safety and efficacy of probiotic supplementation in 8 types of inflammatory arthritis: A systematic review and meta-analysis of 34 randomized controlled trials. Front Immunol 2022; 13:961325. [PMID: 36217542 PMCID: PMC9547048 DOI: 10.3389/fimmu.2022.961325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 08/22/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To evaluate Safety and efficacy of probiotic supplementation in inflammatory arthritis. Methods The literature on the treatment of inflammatory arthritis with probiotics has been collected in databases such as CNKI, Pubmed, Cochrane library, Embase, etc. The search time is for them to build the database until May 2022. The included literatures are randomized controlled trials (RCTs) of probiotics in the treatment of hyperuricemia and gout. The Cochrane risk assessment tool was used for quality evaluation, and the Rev Man5.3 software was used for meta-analysis. Results A total of 37 records were finally included, involving 34 RCTs and 8 types of autoimmune disease (Hyperuricemia and gout, Inflammatory bowel disease arthritis, juvenile idiopathic arthritis [JIA], Osteoarthritis [OA], Osteoporosis and Osteopenia, Psoriasis, rheumatoid arthritis (RA), Spondyloarthritis). RA involved 10 RCTs (632 participants) whose results showed that probiotic intervention reduced CRP. Psoriasis involved 4 RCTs (214 participants) whose results showed that probiotic intervention could reduce PASI scores. Spondyloarthritis involved 2 RCTs (197 participants) whose results showed that probiotic intervention improved symptoms in patients. Osteoporosis and Ostepenia involving 10 RCTs (1156 participants) showed that probiotic intervention improved bone mineral density in patients. Hyperuricemia and gout involving 4 RCTs (294 participants) showed that probiotic intervention improved serum uric acid in patients. OA involving 1 RCTs (433 participants) showed that probiotic intervention improved symptoms in patients. JIA involving 2 RCTs (72 participants) showed that probiotic intervention improved symptoms in patients. Inflammatory bowel disease arthritis involving 1 RCTs (120 participants) showed that probiotic intervention improved symptoms in patients. All of the above RCTs showed that probiotics did not increase the incidence of adverse events. Conclusion Probiotic supplements may improve Hyperuricemia and gout, Inflammatory bowel disease arthritis, JIA, OA, Osteoporosis and Osteopenia, Psoriasis, RA, Spondyloarthritis. However, more randomized controlled trials are needed in the future to determine the efficacy and optimal dosing design of probiotics. Systematic Review Registration https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021286425, identifier CRD42021286425.
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Affiliation(s)
- Liuting Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
| | - Ying Deng
- People’s Hospital of Ningxiang City, Ningxiang, China
| | - Qi He
- People’s Hospital of Ningxiang City, Ningxiang, China
| | - Kailin Yang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Jun Li
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | - Wang Xiang
- The First People's Hospital of Changde City, Changde, China
| | - Huiping Liu
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha, China
| | | | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
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Waseem S, Ahmed SH, Fatima S, Shaikh TG, Ahmed J. SARS-CoV-2 vaccination and uveitis: Are they linked? Ann Med Surg (Lond) 2022; 81:104472. [PMID: 36060437 PMCID: PMC9420081 DOI: 10.1016/j.amsu.2022.104472] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Revised: 08/18/2022] [Accepted: 08/19/2022] [Indexed: 11/27/2022] Open
Abstract
In 2019, the discovery of a new strain of Coronavirus, later referred to as SARS-CoV2 took the world by storm, leading to a pandemic and shutting down all global activities. Several measures were taken adequately to combat the viral havoc, including developing numerous vaccines. All the vaccines currently available for the general population went through rigorous screenings and trials to ensure maximum safety and were only approved after that. However, once they were rolled out in the markets and administered to the population, some adverse reactions were reported, one of which included uveitis. It is an ocular inflammatory condition of the uveal tract, choroid, or iris. If untreated, it can lead to severe consequences, including blindness. It is further divided into four categories based on its anatomical location. Despite the rare incidence of uveitis following COVID-19 vaccination, it may contribute to vaccine hesitancy; hence addressing and digging into the pathophysiological cause is crucial. This study evaluates all the pathophysiological and demographical links between COVID-19 vaccination and uveitis, suggesting appropriate management plans.
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Affiliation(s)
| | | | | | | | - Jawad Ahmed
- Dow University of Health Sciences, Karachi, Pakistan
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23
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Huguet Rodríguez B, Ortueta Olartecoechea AI, Seoane Sanz A, Tejada Palacios P, de Inocencio Arocena J. Morbidity of uveitis associated with juvenile idiopathic arthritis: The silent disease. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2022; 97:356-358. [DOI: 10.1016/j.anpede.2022.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 04/09/2022] [Indexed: 10/14/2022] Open
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Dini G, Dell'Isola GB, Beccasio A, Di Cara G, Verrotti A, Cagini C. Biologic therapies for juvenile idiopathic arthritis-associated uveitis. FRONTIERS IN OPHTHALMOLOGY 2022; 2:954901. [PMID: 38983531 PMCID: PMC11182104 DOI: 10.3389/fopht.2022.954901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 07/27/2022] [Indexed: 07/11/2024]
Abstract
Juvenile idiopathic arthritis (JIA) is the most frequent rheumatic disease of childhood and uveitis is its most common extra-articular manifestation. JIA-associated uveitis (JIA-U) is one of the main causes of visual impairment in children and represents a major challenge for pediatrician and ophthalmologist, due to its insidious onset and sight-threatening complications. Topical glucocorticoids are the first line of treatment, followed by conventional disease-modifying anti-rheumatic drugs (DMARDs), usually methotrexate (MTX). In recent years, new biological drugs targeting specific molecules involved in disease pathogenesis, have significantly improved the prognosis of the disease, especially for cases refractory to conventional therapies. In this review we discuss the role of biological agents in JIA-U, focusing on cytokine blockers and cell-targeted therapies aimed to control ocular inflammation.
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Affiliation(s)
- Gianluca Dini
- Department of Pediatrics, University of Perugia, Perugia, Italy
| | | | - Alfredo Beccasio
- Department of Medicine and Surgery, Section of Ophthalmology, University of Perugia, Perugia, Italy
| | | | | | - Carlo Cagini
- Department of Medicine and Surgery, Section of Ophthalmology, University of Perugia, Perugia, Italy
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How does age determine the development of human immune-mediated arthritis? Nat Rev Rheumatol 2022; 18:501-512. [PMID: 35948692 PMCID: PMC9363867 DOI: 10.1038/s41584-022-00814-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2022] [Indexed: 11/08/2022]
Abstract
Does age substantially affect the emergence of human immune-mediated arthritis? Children do not usually develop immune-mediated articular inflammation during their first year of life. In patients with juvenile idiopathic arthritis, this apparent ‘immune privilege’ disintegrates, and chronic inflammation is associated with variable autoantibody signatures and patterns of disease that resemble adult arthritis phenotypes. Numerous mechanisms might be involved in this shift, including genetic and epigenetic predisposing factors, maturation of the immune system with a progressive modulation of putative tolerogenic controls, parallel development of microbial dysbiosis, accumulation of a pro-inflammatory burden driven by environmental exposures (the exposome) and comorbidity-related drivers. By exploring these mechanisms, we expand the discussion of three (not mutually exclusive) hypotheses on how these factors can contribute to the differences and similarities between the loss of immune tolerance in children and the development of established immune-mediated arthritis in adults. These three hypotheses relate to a critical window in genetics and epigenetics, immune maturation, and the accumulation of burden. The varied manifestation of the underlying mechanisms among individuals is only beginning to be clarified, but the establishment of a framework can facilitate the development of an integrated understanding of the pathogenesis of arthritis across all ages. In this Review, the authors discuss age-related arthropathy and the similarities and differences between childhood loss of immune tolerance and adult development of immune-mediated arthritis, and develop three hypotheses describing age-related mechanisms that contribute to the onset of arthritis. The arthritis-free ‘immune privilege’ of early childhood is overridden by multiple mechanisms, progressively and age-dependently, generating recognizable patterns of chronic inflammatory arthritis. The emergence of arthritis involves interconnected mechanisms related to immune priming, to a situational susceptibility and to the accumulation of an inflammatory burden. The accumulation of epigenetic drift may contribute to differences across ages. The exposome is expected to contribute to arthritis emergence in adults as well as in children.
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Zeng L, Yang T, Yang K, Yu G, Li J, Xiang W, Chen H. Efficacy and Safety of Curcumin and Curcuma longa Extract in the Treatment of Arthritis: A Systematic Review and Meta-Analysis of Randomized Controlled Trial. Front Immunol 2022; 13:891822. [PMID: 35935936 PMCID: PMC9353077 DOI: 10.3389/fimmu.2022.891822] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 04/22/2022] [Indexed: 12/20/2022] Open
Abstract
BackgroundModern pharmacological research found that the chemical components of Curcuma longa L. are mainly curcumin and turmeric volatile oil. Several recent randomized controlled trials (RCT) have shown that curcumin improves symptoms and inflammation in patients with arthritis.MethodsPubmed, Cochran Library, CNKI, and other databases were searched to collect the randomized controlled trials (RCTs). Then, the risk of bias of RCTs were assessed and data of RCTs were extracted. Finally, RevMan 5.3 was utilized for meta-analysis.ResultsTwenty-nine (29) RCTs involving 2396 participants and 5 types of arthritis were included. The arthritis included Ankylosing Spondylitis (AS), Rheumatoid Arthritis (RA), Osteoarthritis (OA), Juvenile idiopathic arthritis (JIA) and gout/hyperuricemia. Curcumin and Curcuma longa Extract were administered in doses ranging from 120 mg to 1500 mg for a duration of 4-36 weeks. In general, Curcumin and Curcuma longa Extract showed safety in all studies and improved the severity of inflammation and pain levels in these arthritis patients. However, more RCTs are needed in the future to elucidate the effect of Curcumin and Curcuma longa Extract supplementation in patients with arthritis, including RA, OA, AS and JIA.ConclusionCurcumin and Curcuma longa Extract may improve symptoms and inflammation levels in people with arthritis. However, due to the low quality and small quantity of RCTs, the conclusions need to be interpreted carefully.
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Affiliation(s)
- Liuting Zeng
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- *Correspondence: Hua Chen, ; Liuting Zeng, ; Tiejun Yang, ; Kailin Yang,
| | - Tiejun Yang
- Department of Orthopedics, People’s Hospital of Ningxiang City, Ningxiang City, China
- *Correspondence: Hua Chen, ; Liuting Zeng, ; Tiejun Yang, ; Kailin Yang,
| | - Kailin Yang
- Key Laboratory of Hunan Province for Integrated Traditional Chinese and Western Medicine on Prevention and Treatment of Cardio-Cerebral Diseases, Hunan University of Chinese Medicine, Changsha City, China
- *Correspondence: Hua Chen, ; Liuting Zeng, ; Tiejun Yang, ; Kailin Yang,
| | - Ganpeng Yu
- Department of Orthopedics, People’s Hospital of Ningxiang City, Ningxiang City, China
| | - Jun Li
- Department of Orthopedics, People’s Hospital of Ningxiang City, Ningxiang City, China
| | - Wang Xiang
- Department of Rheumatology, The First People's Hospital Changde City, Changde City, China
| | - Hua Chen
- Department of Rheumatology and Clinical Immunology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, National Clinical Research Center for Dermatologic and Immunologic Diseases (NCRC-DID), Key Laboratory of Rheumatology and Clinical Immunology, Ministry of Education, Beijing, China
- *Correspondence: Hua Chen, ; Liuting Zeng, ; Tiejun Yang, ; Kailin Yang,
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McKenna D, McLaughlin D, Campbell C, Mulholland M, Thompson A, Loughran C, Jackson P, Rooney M. Fifteen-minute guide to managing oligoarticular juvenile idiopathic arthritis. Arch Dis Child Educ Pract Ed 2022; 107:175-181. [PMID: 34083213 DOI: 10.1136/archdischild-2020-321088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/18/2021] [Accepted: 03/22/2021] [Indexed: 11/03/2022]
Abstract
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease affecting children and young people today. However, it is not a single disease entity, but an umbrella term that gathers together a heterogeneous collection of complex, chronic inflammatory conditions with oligoarticular JIA the most common form in both Europe and North America. Due to its relative rarity in daily practice and potential to mimic other conditions, oligoarticular JIA can present a diagnostic and management challenge to healthcare professionals in both primary care and general paediatrics. The aim of this article is to provide a summary of the key aspects of diagnosis, investigation and management of this condition, with the hopes of building clinicians' confidence when facing a possible case of oligoarticular JIA.
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Affiliation(s)
| | | | - Cathy Campbell
- Paediatric Rheumatology, Musgrave Park Hospital, Belfast, UK
| | - Melissa Mulholland
- General Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Andrew Thompson
- General Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Clare Loughran
- General Paediatrics, Royal Belfast Hospital for Sick Children, Belfast, UK
| | - Paul Jackson
- Paediatric Rheumatology, Musgrave Park Hospital, Belfast, UK
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Research progress in drug therapy of juvenile idiopathic arthritis. World J Pediatr 2022; 18:383-397. [PMID: 35364799 DOI: 10.1007/s12519-022-00530-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Accepted: 02/17/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in children. With the gradual expansion of the incidence of JIA in the population, the pathogenesis and treatment of JIA were further explored and analyzed, and JIA has achieved some success in drug therapy. DATA SOURCES A systemic literature search was conducted on PubMed, Cochrane Library, EMBASE, ISI Web of Science, the US National Institutes of Health Ongoing Trials Register, and the EU Clinical Trials Register. Through the searching of clinical trials of JIA in recent years, we summarized the progress of the clinical treatment of JIA. RESULTS The main treatment drugs for JIA include non-steroidal anti-inflammatory drugs, glucocorticoids, disease-modifying antirheumatic drugs and biological agents. So far, a variety of biological agents targeting the cytokines and receptors involved in its pathogenesis have been gradually approved for JIA in many countries. The application of biological agents in JIA showed good efficacy and safety, bringing unprecedented experience to children and adolescents with JIA. CONCLUSIONS The potential and advantages of biologic agents in the treatment of JIA are significant, and the application of biologic agents in the treatment of JIA will be more and more common.
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Huguet Rodríguez B, Ortueta Olartecoechea AI, Seoane Sanz A, Tejada Palacios P, de Inocencio Arocena J. Morbilidad de la uveítis asociada a artritis idiopática juvenil: la enfermedad silente. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Implications of Evolving Disease Classification for Drug Approval in Juvenile Idiopathic Arthritis. Paediatr Drugs 2022; 24:185-191. [PMID: 35364780 PMCID: PMC10389810 DOI: 10.1007/s40272-022-00496-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/21/2022] [Indexed: 10/18/2022]
Abstract
The classification of inflammatory arthritis incorporates a sharp divide between diseases of childhood onset, grouped together as juvenile idiopathic arthritis, and diseases such as rheumatoid arthritis that begin by definition in adulthood. An important consequence of this divide is that regulatory authorities and many rheumatologists regard pediatric and adult arthritides as truly different, with the implication that drugs should be evaluated separately for each category. However, it is now clear that most forms of arthritis transcend the pediatric/adult boundary and that agents generally exhibit comparable success irrespective of age of onset, offering new opportunities in drug development and regulation focused on pharmacology and safety rather than efficacy. This paradigm shift will enable advances in arthritis treatment, originating either with adults or children, to translate more rapidly across the age spectrum.
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Paroli MP, Del Giudice E, Giovannetti F, Caccavale R, Paroli M. Management Strategies of Juvenile Idiopathic Arthritis-Associated Chronic Anterior Uveitis: Current Perspectives. Clin Ophthalmol 2022; 16:1665-1673. [PMID: 35663189 PMCID: PMC9159812 DOI: 10.2147/opth.s342717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/18/2022] [Indexed: 12/14/2022] Open
Abstract
Juvenile idiopathic arthritis (JIA) is the most common extraocular disease associated with pediatric uveitis. Despite the growing knowledge about the pathogenetic and clinical characteristics of the disease, it still remains a challenge for both the pediatric rheumatologist and ophthalmologist. Since uveitis is asymptomatic in most cases, it is generally detected by parents in a late phase of the disease when complications have occurred with consequent severe vision loss. Improvement in attentive screening and early treatment initiation to suppress inflammation has considerably reduced the sight-threatening outcomes of JIA-associated chronic anterior uveitis (JIA-CAU). Initial treatment with topical steroids is effective in most cases. However, more severe cases require the use of periocular or systemic corticosteroids, possibly leading to long-term complications. These include growth retardation, cataract and glaucoma. Systemic immunosuppressive agents are then employed in patients resistant to first-line therapy or to reduce steroid-associated complications. In this review, we will discuss the immunosuppressant agents currently employed for the treatment of the disease, including anti-tumor necrosis factor (TNF)α biologics approved or not by the regulatory agencies. We will also highlight how new therapeutic options like biologic targeting cytotoxic T-lymphocyte antigen-4 (CTLA-4) co-stimulatory molecule, interleukin-6 receptor (IL-6R) or B lymphocytes might represent exciting new options for patients resistant to conventional therapy. Finally, the potential use of janus kinase (JAK) inhibitors recently approved for the treatment of several inflammatory rheumatic diseases in adults will be also discussed.
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Affiliation(s)
- Maria Pia Paroli
- Uveitis Service, Ophthalmologic Unit, Department of Sense Organs, Sapienza University of Rome, Rome, Italy
- Correspondence: Maria Pia Paroli, Uveitis Service, Ophthalmologic Unit, Department of Sense Organs, Sapienza University of Rome, Rome, Italy, Tel/Fax +39-06-519-3220, Email
| | - Emanuela Del Giudice
- Pediatric Rheumatology Unit, Department of Maternal Infantile and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - Francesca Giovannetti
- Uveitis Service, Ophthalmologic Unit, Department of Sense Organs, Sapienza University of Rome, Rome, Italy
| | - Rosalba Caccavale
- Clinical Immunology Unit, Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
| | - Marino Paroli
- Clinical Immunology Unit, Department of Clinical, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Rome, Italy
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Sun N, Wang C, Linghu W, Li X, Zhang X. Demographic and clinical features of pediatric uveitis and scleritis at a tertiary referral center in China. BMC Ophthalmol 2022; 22:174. [PMID: 35436862 PMCID: PMC9017000 DOI: 10.1186/s12886-022-02404-z] [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: 02/16/2022] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background To analyse demographic, clinical features, treatment and therapeutic outcomes of pediatric uveitis and scleritis patients. Subjects The clinical records of pediatric uveitis and scleritis cases between January 2012 and December 2020 at a tertiary uveitis service center in Tianjin Medical University Eye Hospital (TMUEH) were reviewed. Results In total, 209 patients (337 eyes) were included, 49.3% were male. The median onset age was 9.0 (IQR, 7.0–12.0) years. Chronic uveitis and scleritis accounted for 86.1%. Panuveitis (29.2%), anterior uveitis(29.2%), and intermediate uveitis (22.0%) were the most common presentations. The most common diagnoses were idiopathic (71.3%), JIA (8.1%), and infectious uveitis (4.8%). At baseline, 40.7% patients received oral corticosteroid therapy; during follow-up, corticosteroids (66.0%), disease-modifying antirheumatic drugs (61.2%), and biologic agents (35.4%) were the mainstay. Posterior synechia (26.1%) and cataracts (25.5%) were the most common complications. In acute cases, the median best corrected visual acuity (BCVA) was 0.99 (IQR, 0.5–1.0) at baseline and 0 (IQR, 0–0) at last follow-up; in chronic cases, the median BCVA improved from 1.09 (IQR, 0.5–2.0) to 0.27 (IQR, 0–0.5), with anterior chamber cell grade significantly declining. Ten eyes underwent cataract surgery during regular follow-up and achieved satisfactory long-term visual outcomes and decreased burden of immunosuppressants. The incidence of steroid-induced ocular hypertension was 41.0%, and children with frequent instillation of eyedrops were at high risk. Conclusions Most cases were of chronic uveitis and scleritis requiring long-term systemic immunosuppressive therapies in pediatric uveitis and scleritis in China. Good management of complications is important for long-term prognosis.
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Affiliation(s)
- Nan Sun
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Chunxi Wang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Wenrui Linghu
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Xiaorong Li
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China
| | - Xiaomin Zhang
- Tianjin Key Laboratory of Retinal Functions and Diseases, Tianjin Branch of National Clinical Research Center for Ocular Disease, Eye Institute and School of Optometry, Tianjin Medical University Eye Hospital, Tianjin, China.
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Abstract
Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis of unknown origin, lasting for >6 weeks with onset before 16 years of age. JIA is the most common chronic inflammatory rheumatic condition of childhood. According to the International League Against Rheumatism (ILAR) classification, seven mutually exclusive categories of JIA exist based on disease manifestations during the first 6 months of disease. Although the ILAR classification has been useful to foster research, it has been criticized mainly as it does not distinguish those forms of chronic arthritis observed in adults and in children from those that may be unique to childhood. Hence, efforts to provide a new evidence-based classification are ongoing. Similar to arthritis observed in adults, pathogenesis involves autoimmune and autoinflammatory mechanisms. The field has witnessed a remarkable improvement in therapeutic possibilities of JIA owing to the availability of new potent drugs and the possibility to perform controlled trials with support from legislative interventions and large networks availability. The goal of drug therapy in JIA is to rapidly reduce disease activity to inactive disease or clinical remission, minimize drug side effects and achieve a quality of life comparable to that of healthy peers. As JIA can influence all aspects of a child's and their family's life, researchers increasingly recognize improvement of health-related quality of life as a key treatment goal.
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Arve-Butler S, Mossberg A, Kahn F, Najibi SM, Berthold E, Król P, Månsson B, Kahn R. Identification of novel autoantigens as potential biomarkers in juvenile idiopathic arthritis associated uveitis. Front Pediatr 2022; 10:1091308. [PMID: 36699287 PMCID: PMC9869058 DOI: 10.3389/fped.2022.1091308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2022] [Accepted: 12/16/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Many children with juvenile idiopathic arthritis (JIA) have autoantibodies, targeting nuclear components (anti-nuclear antibodies, ANA). ANA in JIA is associated with uveitis, an eye inflammation which may cause permanent vision impairment if not detected and treated. However, ANA-testing is neither specific nor sensitive enough to be a clinically reliable predictor of uveitis risk, and the precise autoantigens targeted by ANA in JIA are largely unknown. If identified, specific autoantibodies highly associated with uveitis could be used as biomarkers to facilitate identification of JIA patients at risk. METHODS Antibodies from six ANA-positive, oligoarticular JIA patients, with and without uveitis, were explored by two large-scale methods: (1) screening against 42,100 peptides on an autoimmunity profiling planar array, and (2) immunoprecipitations from cell lysates with antigen identification by mass spectrometry. Three hundred thirty-five peptide antigens, selected from proteins identified in the large-scale methods and the scientific literature were investigated using a bead-based array in a cohort of 56 patients with oligoarticular- or RF-negative polyarticular JIA, eight of which were having current or previous uveitis. RESULTS In the planar array, reactivity was detected against 332 peptide antigens. The immunoprecipitations identified reactivity towards 131 proteins. Only two proteins were identified by both methods. In the bead-based array of selected peptide antigens, patients with uveitis had a generally higher autoreactivity, seen as higher median fluorescence intensity (MFI) across all antigens, compared to patients without uveitis. Reactivity towards 17 specific antigens was significantly higher in patients with uveitis compared to patients without uveitis. Hierarchical clustering revealed that patients with uveitis clustered together. CONCLUSION This study investigated autoantigens in JIA and uveitis, by combining two exploratory methods and confirmation in a targeted array. JIA patients with current or a history of uveitis had significantly higher reactivity towards 17 autoantigens and a generally higher autoreactivity compared to JIA patients without uveitis. Hierarchical clustering suggests that a combination of certain autoantibodies, rather than reactivity towards one specific antigen, is associated with uveitis. Our analysis of autoantibodies associated with uveitis in JIA could be a starting point for identification of prognostic biomarkers useful in JIA clinical care.
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Affiliation(s)
- Sabine Arve-Butler
- Department of Rheumatology, Clinical Sciences Lund, Lund University, Lund, Sweden.,Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden
| | - Anki Mossberg
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Fredrik Kahn
- Department of Infection Medicine, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Seyed Morteza Najibi
- Department of Rheumatology, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Elisabet Berthold
- Department of Rheumatology, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Petra Król
- Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Bengt Månsson
- Department of Rheumatology, Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Robin Kahn
- Wallenberg Center for Molecular Medicine, Lund University, Lund, Sweden.,Department of Pediatrics, Clinical Sciences Lund, Lund University, Lund, Sweden
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Kostik MM, Gaidar EV, Sorokina LS, Avrusin IS, Nikitina TN, Isupova EA, Chikova IA, Korin YY, Orlova ED, Snegireva LS, Masalova VV, Dubko MF, Kalashnikova OV, Chasnyk VG. Uveitis Is a Risk Factor for Juvenile Idiopathic Arthritis' Significant Flare in Patients Treated With Biologics. Front Pediatr 2022; 10:849940. [PMID: 35783325 PMCID: PMC9240648 DOI: 10.3389/fped.2022.849940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 05/12/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Uveitis is the most frequent extra-articular manifestation of juvenile idiopathic arthritis (JIA). Our study is aimed to evaluate the possible difference in arthritis course depending on uveitis presence in patients with JIA, treated with biologics. METHODS From our database of patients with JIA treated with biologics, we extracted patients to whom the first agent was administrated with or without MTX. The exclusion criteria included treatment with current systemic corticosteroids, infliximab, rituximab, observation period <3 years, and no missing data. After selection, 175 patients were eligible for analysis. We evaluated clinically significant flare with joint involvement (which required change of biologic or non-biologic DMARD) and time to flare. We compared two groups: (i) patients with uveitis (n = 32) and (ii) patients without uveitis (n = 143). For statistical analysis, we used Cox's regression models, the log-Rank test, x 2 test, and the Mann-Whitney test. RESULTS There was no difference in gender distribution and achievement of arthritis remission between groups. Patients in the non-uveitis group predominantly received etanercept (64.3%). In the uveitis group, the most prescribed biologic agent was adalimumab (71.9%). The presence of uveitis increased the risk of JIA flare, OR = 3.8 (95% CI: 1.7; 8.7), and the cumulative probability of joint flare, RR = 4.5 (95% CI: 1.7; 12.1), p =.003, after adjustment on methotrexate, RR = 3.1 (1.6; 6.), p =.0008. In the subgroup of patients treated with adalimumab, the absence of methotrexate increased the cumulative probability of flare [RR = 6.5 (95% CI: 1.4; 31.1), p = 0.02]. CONCLUSION The presence of uveitis proved to be a risk factor in JIA flare. Methotrexate can decrease the cumulative flare probability. Further trials are required.
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Affiliation(s)
- Mikhail M Kostik
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Ekaterina V Gaidar
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Lubov S Sorokina
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Ilya S Avrusin
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Tatiana N Nikitina
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Eugenia A Isupova
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Irina A Chikova
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Yuri Yu Korin
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Elizaveta D Orlova
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia.,Pediatric Research and Clinical Center for Infection Diseases, Saint Petersburg, Russia
| | - Ludmila S Snegireva
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Vera V Masalova
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Margarita F Dubko
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
| | - Olga V Kalashnikova
- Saint-Petersburg State Pediatric Medical University, Saint Petersburg, Russia
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Role of Janus Kinase (JAK) Inhibitor in Autoimmune Ocular Inflammation: A Systematic Review. J Immunol Res 2021; 2021:2324400. [PMID: 34966823 PMCID: PMC8712175 DOI: 10.1155/2021/2324400] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/09/2021] [Accepted: 11/19/2021] [Indexed: 02/05/2023] Open
Abstract
Purpose To evaluate the effectiveness of Janus kinase (JAK) inhibitors for the treatment of patients with autoimmune disease and associated inflammatory ocular diseases. Methods We identified relevant literature by screening the MEDLINE, PubMed, and Cochrane databases for randomized controlled trials, cohort studies, case controls, and case reports. Results Seven studies, including 11 patients, were included in the final systematic analysis. Of the 11 patients, there were 5 cases of juvenile idiopathic arthritis- (JIA-) associated uveitis, 1 case of rheumatoid arthritis- (RA-) associated keratitis, 1 case of RA-associated scleritis, 1 case of psoriasis-associated conjunctivitis, 2 cases of noninfectious scleritis, and 1 case of uveitis with suspected autoimmune disease. None of these 11 patients responded adequately to conventional treatments, including biological agents; these were all refractory cases and switched to JAK inhibitor therapy. Irrespective of whether they were suffering from uveitis, scleritis, or other types of ocular inflammation, all 11 patients showed an improvement to JAK inhibitors without significant side effects. Different types of JAK inhibitors might be associated with different responses when used to treat ocular inflammation. Conclusions JAK inhibitors may represent an alternative treatment option for patients with autoimmune ocular inflammation.
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Lanz S, Seidel G, Skrabl-Baumgartner A. Golimumab in juvenile idiopathic arthritis-associated uveitis unresponsive to Adalimumab. Pediatr Rheumatol Online J 2021; 19:132. [PMID: 34419092 PMCID: PMC8380315 DOI: 10.1186/s12969-021-00630-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 07/24/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To assess the efficacy of golimumab (GLM) as a treatment option for juvenile idiopathic arthritis (JIA)-associated uveitis refractory to adalimumab (ADA). METHODS Retrospective single-centre study including patients with JIA receiving GLM for active uveitis after failing ADA. JIA- and uveitis-related data, including intraocular inflammation, best-corrected visual acuity, corticosteroid-sparing potential, and ocular complications were evaluated at start of GLM treatment, at 1 month and 3 months, and every 3 months thereafter during GLM administration. We further investigated the association of response to GLM with primary and secondary failure of ADA treatment. RESULTS Ten patients were studied, all female (17 affected eyes, mean age 14.3 + 6.7 yrs., mean follow-up 25.2 + 21.7 mos). Two patients were switched to GLM because of primary non-response to ADA. Eight were switched because of loss of response (LOR). In 5 of the latter LOR was associated with neutralizing anti-ADA-antibodies. Response to GLM was observed in all 8 patients with LOR, while the 2 patients with primary non-response to ADA also did not respond to GLM. Three of the 8 responders experienced LOR. At the end of follow-up 4 of the 5 remaining responders had achieved complete response. One had achieved partial response. CONCLUSION GLM is an efficacious therapeutic option in patients who experience LOR to ADA. Our data indicate that patients without primary response to ADA should be rather switched to a biologic agent with a different mode of action instead of further blocking the TNF-alpha pathway.
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Affiliation(s)
- Sofia Lanz
- grid.11598.340000 0000 8988 2476Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria
| | - Gerald Seidel
- grid.11598.340000 0000 8988 2476Department of Ophthalmology, Medical University Graz, Graz, Austria
| | - Andrea Skrabl-Baumgartner
- Division of General Pediatrics, Department of Pediatrics and Adolescent Medicine, Medical University Graz, Graz, Austria.
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Wennink RAW, de Boer JH, Hiddingh S, Haasnoot AMJW, Kalinina Ayuso V, de Hoop T, van Setten J, Spierings E, Kuiper JJW. Next-Generation HLA Sequence Analysis Uncovers Shared Risk Alleles Between Clinically Distinct Forms of Childhood Uveitis. Invest Ophthalmol Vis Sci 2021; 62:19. [PMID: 34254975 PMCID: PMC8287043 DOI: 10.1167/iovs.62.9.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Purpose Classical alleles of the human leukocyte antigen (HLA) complex have been linked to specific entities of pediatric noninfectious uveitis, yet genetic predisposition encoded by the HLA super-locus across the patient population remains understudied. Methods We performed next-generation full-length sequencing of HLA-A, HLA-B, HLA-C, HLA-DPB1, HLA-DQB1, and HLA-DRB1 in 280 cases. Dense genotype data from 499 Dutch controls from Genome of the Netherlands were imputed using an HLA-specific reference panel (n = 5225 samples from European ancestry). Cases and controls were compared using logistic regression models adjusting for sex. Results In total, 179 common and rare alleles were detected. Considering all cases and controls, HLA-DQB1*04:02 and HLA-DRB1*08:01 were identified as the principal HLA association, which was mainly driven by 92 cases with juvenile idiopathic arthritis-associated uveitis (JIA-U). The HLA-DQB1*04:02-HLA-DRB1*08:01 haplotype was also the primary association for the phenotypically similar idiopathic chronic anterior uveitis without arthritis (CAU). Also, HLA-DQB1*05:03 was an independent risk allele for CAU, but not in JIA-U. Analysis of 185 cases with other forms of uveitis revealed HLA-wide associations (P < 2.79 × 10−4) for HLA-DRB1*01:02, HLA-DRB1*04:03, and HLA-DQB1*05:03, which could be primarily attributed to cases with panuveitis. Finally, amino acid substitution modeling revealed that aspartic acid at position 57 that distinguishes the risk allele HLA-DQB1*05:03 (for CAU and panuveitis) from nonrisk alleles, significantly increased the binding capacity of naturally presented ligands to HLA-DQ. Conclusions These results uncovered novel shared HLA associations among clinically distinct phenotypes of pediatric uveitis and highlight genetic predisposition affecting the antigen presentation pathway.
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Affiliation(s)
- Roos A W Wennink
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands.,Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Joke H de Boer
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Sanne Hiddingh
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Anne-Mieke J W Haasnoot
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Viera Kalinina Ayuso
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Talitha de Hoop
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jessica van Setten
- Department of Cardiology, Division Heart and Lungs, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Eric Spierings
- Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
| | - Jonas J W Kuiper
- Department of Ophthalmology, University Medical Center Utrecht, Utrecht University, The Netherlands.,Center of Translational Immunology, University Medical Center Utrecht, Utrecht University, The Netherlands
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Clarke SLN, Mageean KS, Carlton H, Simonini G, Sharp GC, Relton CL, Ramanan AV. "Environmental risk factors associated with juvenile idiopathic arthritis associated uveitis: a systematic review of the literature". J Ophthalmic Inflamm Infect 2021; 11:15. [PMID: 34027581 PMCID: PMC8141477 DOI: 10.1186/s12348-021-00247-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 05/10/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Juvenile idiopathic arthritis associated uveitis (JIA-U) is the most common extra-articular manifestation of juvenile idiopathic arthritis (JIA) and carries considerable risk to vision. The aim of this systematic review was to synthesise evidence of environmental risk factors for JIA-U and identify risk factors which may be modifiable or used to stratify JIA patients. METHODS This systematic review was carried out in accordance with PRISMA guidelines. Four online databases - Cumulative Index of Nursing and Allied Health Literature, Web of Science, MEDLINE and Embase - were searched from database inception to 12th August 2020. Identified studies were screened by two independent reviewers against pre-defined inclusion and exclusion criteria. Data was extracted from all primary studies meeting inclusion criteria and independently checked. RESULTS We identified three studies from 895 unique records which met the inclusion criteria, each examining a different environmental risk factor. This systematic review includes 973, predominantly female, participants with JIA across these three studies. The use of allergy medication or documentation of "allergy"/"allergic" in the medical records was associated with an increased risk of JIA-U in all models presented. Vitamin D sufficiency was associated with reduced risk of JIA-U. There was insufficient evidence to support an association between seasonality and JIA-U. CONCLUSIONS This review identifies a potential role for allergy and vitamin D in JIA-U. It also illustrates the paucity of data regarding environmental risk factors for JIA-U and highlights the need for further research to both identify additional risk factors and replicate existing findings.
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Affiliation(s)
- Sarah L N Clarke
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK.
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK.
| | - Katie S Mageean
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - Henry Carlton
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Gabriele Simonini
- Rheumatology Unit, Meyer Children Hospital, NEUROFARBA Department, University of Florence, Florence, Italy
| | - Gemma C Sharp
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Caroline L Relton
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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40
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Abstract
PURPOSE OF REVIEW To give an overview of recently published articles covering risk factors, novel biomarkers and treatment for noninfectious uveitis in children. RECENT FINDINGS In the last few years, several genetic markers, serum biomarkers, aqueous humor markers, tear biomarkers and clinical factors have been identified, which are associated with childhood noninfectious uveitis. We describe the most important reports in this field that may help to tailor the screening and monitoring of this population in the future and might become the target of novel therapies. The advances in the biologic therapy of paediatric uveitis, thanks to evidence provided by the SYCAMORE, ADJUVITE and APTITUDE trials, offer new possibilities for the treatment of patients who fail methotrexate with adalimumab and tocilizumab. We discuss the importance of comprehensive outcome measures as proposed by the Multinational Interdisciplinary Working Group for Uveitis in Childhood (MIWGUC). SUMMARY Paediatric noninfectious uveitis is a sight-threatening condition and the identification of risk factors and novel biomarkers is critical for tailored management. Biologic therapies are revolutionizing the outcomes of patients resistant to conventional therapy. Increasing our knowledge of disease pathogenesis is crucial to improve targeting of screening to those at highest risk and stratification of treatments.
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Chen JL, Abiri P, Tsui E. Recent advances in the treatment of juvenile idiopathic arthritis-associated uveitis. Ther Adv Ophthalmol 2021; 13:2515841420984572. [PMID: 33681703 PMCID: PMC7897841 DOI: 10.1177/2515841420984572] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 12/04/2020] [Indexed: 12/14/2022] Open
Abstract
Juvenile idiopathic arthritis-associated uveitis has an estimated prevalence of 10-20% in patients with juvenile idiopathic arthritis, making it the most common cause of chronic anterior uveitis in children. Prompt treatment is important to prevent development of ocular complications and permanent vision loss. In this review, we will discuss the use of immunosuppression in treatment of juvenile idiopathic arthritis-associated uveitis. This will include the use of conventional immunosuppressants, such as methotrexate, biologic anti-tumor necrosis factor agents, such as adalimumab, as well as other anti-tumor necrosis factor agents, including infliximab and golimumab. In addition, we will discuss medications currently in clinical trials or under consideration for juvenile idiopathic arthritis-associated uveitis, including interleukin-6 inhibitors (tocilizumab) and Janus kinase inhibitors (tofacitinib, baricitinib).
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Affiliation(s)
- Judy L Chen
- Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Parinaz Abiri
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Edmund Tsui
- Assistant Professor of Ophthalmology, Stein Eye Institute, Department of Ophthalmology, David Geffen School of Medicine at UCLA, 200 Stein Plaza, Los Angeles, CA 90095-7003, USA
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Marelli L, Romano M, Pontikaki I, Gattinara MV, Nucci P, Cimaz R, Miserocchi E. Long Term Experience in Patients With JIA-Associated Uveitis in a Large Referral Center. Front Pediatr 2021; 9:682327. [PMID: 34262889 PMCID: PMC8273291 DOI: 10.3389/fped.2021.682327] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 06/02/2021] [Indexed: 01/26/2023] Open
Abstract
Objectives: To describe demographic, clinical and therapeutic findings of a large cohort of patients with JIA-associated uveitis in a nationwide referral pediatric rheumatology and uveitis center in Northern Italy. Methods: Retrospective study of 125 patients with JIA-associated uveitis followed from 2009 to 2019. Demographic and rheumatologic features including JIA ILAR classification, age at onset, and laboratory data were recorded. Ocular findings collected were: anatomic location of uveitis, laterality, type, recurrence rate, visual acuity, ocular complications, and local therapy. Systemic therapy with conventional and biologic immunosuppressants, occurrence of adverse events, and duration of treatments were recorded. Results: One hundred and twenty-five patients with JIA-associated uveitis were followed for a meantime of 9.2 (±1.7) years. Oligoarticular JIA was present in 92.8% of patients and anterior uveitis in 96%. The most common ocular complications recorded in our sample were posterior synechiae (37.6%), cataract (20.8%), band keratopathy (19.2%), glaucoma (7.2%), and macular edema (5.6%). Conventional immunosuppressants were used in 75.2% of patients with a mean duration of 9.1 years (±5.4), while biologics were administered in 47.2% of them for a period of 5.4 years. Adverse events (AE) were seen in 23% of patients being treated with Methotrexate, in 10.4% of patients treated with Adalimumab, in 38.5% of patients in therapy with Infliximab, and in 14.3% of patients being treated with Tocilizumab. No AE were reported in patients treated with Golimumab, Certolizumab, Abatacept and Rituximab. Conclusions: An aggressive treatment approach for patients with JIA-associated uveitis ensured a low number of ocular complications with a good safety profile.
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Affiliation(s)
- Luca Marelli
- Eye Clinic San Giuseppe Hospital, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Multimedica, Milan, Italy
| | - Micol Romano
- Pediatric Rheumatology Unit, Azienda Socio-Sanitaria Territoriale (ASST) G. Pini-Centro Traumatologico Ortopedico (CTO), Milan, Italy
| | - Irene Pontikaki
- Pediatric Rheumatology Unit, Azienda Socio-Sanitaria Territoriale (ASST) G. Pini-Centro Traumatologico Ortopedico (CTO), Milan, Italy
| | - Maurizio Virgilio Gattinara
- Pediatric Rheumatology Unit, Azienda Socio-Sanitaria Territoriale (ASST) G. Pini-Centro Traumatologico Ortopedico (CTO), Milan, Italy
| | - Paolo Nucci
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Rolando Cimaz
- Pediatric Rheumatology Unit, Azienda Socio-Sanitaria Territoriale (ASST) G. Pini-Centro Traumatologico Ortopedico (CTO), Milan, Italy.,Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Elisabetta Miserocchi
- Department of Ophthalmology, San Raffaele Scientific Institute, University Vita-Salute, Milan, Italy
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Maccora I, Fusco E, Marrani E, Ramanan AV, Simonini G. Changing evidence over time: updated meta-analysis regarding anti-TNF efficacy in childhood chronic uveitis. Rheumatology (Oxford) 2020; 60:568-587. [DOI: 10.1093/rheumatology/keaa595] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2020] [Revised: 07/19/2020] [Accepted: 07/31/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
Objective
To summarize evidence regarding efficacy of anti-TNFα in childhood chronic uveitis, refractory to common DMARDs.
Methods
An updated systematic search was conducted between November 2012 and January 2020. Studies investigating the efficacy of anti-TNFα therapy, in children of ages <16 years, as the first biologic treatment for childhood chronic uveitis, refractory to topical and/or systemic steroid and at least one DMARD were eligible for inclusion. The primary outcome measure was the improvement of intraocular inflammation according to Standardization of Uveitis Nomenclature Working Group criteria. A combined estimate of the proportion of children responding to etanercept (ETA), infliximab (INF), and adalimumab (ADA) was determined.
Results
We identified 1677 articles of which 37 articles were eligible. Three were randomized controlled trials, one on ETA and two on ADA, and were excluded from pooled analysis. From the observational studies, a total of 487 children were identified: 226 received ADA, 213 INF and 48 ETA. The proportion of responding children was 86% (95% CI: 76%, 95%) for ADA, 68% (95% CI: 50%, 85%) for INF and 36% (95% CI: 9%, 67%) for ETA. Pooled analysis showed clear differences (χ2 = 32.2, P < 0.0001): ADA and INF were both significantly superior to ETA (χ2 = 26.8, P < 0.0001, and χ2 = 7.41, P < 0.006, respectively), ADA significantly superior to INF (χ2 = 13.4, P < 0.0002).
Conclusion
This meta-analysis, consistent with recent randomized controlled trial data, suggests the efficacy of ADA and INF in childhood chronic uveitis treatment. However, ADA results were superior to those of INF in this clinical setting.
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Affiliation(s)
- Ilaria Maccora
- Rheumatology Unit, Meyer Children's Hospital, School of Human Health Science, University of Florence, Florence, Italy
| | - Eleonora Fusco
- Rheumatology Unit, Meyer Children's Hospital, School of Human Health Science, University of Florence, Florence, Italy
| | - Edoardo Marrani
- Rheumatology Unit, Meyer Children's Hospital, School of Human Health Science, University of Florence, Florence, Italy
| | - Athimalaipet V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
- Translational Health Sciences, University of Bristol, Bristol, UK
| | - Gabriele Simonini
- Rheumatology Unit, NEUROFARBA Department, Meyer Children's Hospital, University of Florence, Florence, Italy
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Maleki A, Manhapra A, Asgari S, Chang PY, Foster CS, Anesi SD. Tocilizumab Employment in the Treatment of Resistant Juvenile Idiopathic Arthritis Associated Uveitis. Ocul Immunol Inflamm 2020; 29:14-20. [PMID: 33021415 DOI: 10.1080/09273948.2020.1817501] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM To determine the efficacy and safety of intravenous tocilizumab in refractory juvenile idiopathic arthritis associated uveitis. PATIENTS AND METHODS This was a retrospective observational case series. Patients with refractory juvenile idiopathic arthritis associated uveitis, who had received tocilizumab were included in this study. RESULTS 8 patients (14 eyes) were included in this study. The average age of the patients at the first visit was 16.8 ± 11.2 years (7-40). The average duration of follow-up period after starting treatment was 28.6 ± 24.6 months (9-70). Intravenous tocilizumab infusions induced and maintained remission in 5 patients (8 eyes). Vasculitis was resolved within 8 months in all but one patient. The presence of papillitis before starting treatment was directly correlated with visual acuity improvement. No side effects were observed. CONCLUSION Intravenous tocilizumab infusion can be an effective and safe method of treatment to induce and maintain remission in resistant juvenile idiopathic arthritis associated uveitis.
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Affiliation(s)
- Arash Maleki
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Ambika Manhapra
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - Soheila Asgari
- Noor Ophthalmology Research Center, Noor Eye Hospital, Tehran, Iran
| | - Peter Y Chang
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
| | - C Stephen Foster
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA.,Department of Ophthalmology, Harard Medical School, Boston, MA, USA
| | - Stephen D Anesi
- Massachusetts Eye Research and Surgery Institution, Waltham, MA, USA.,The Ocular Immunology and Uveitis Foundation, Waltham, MA, USA
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