Vasculitis in children

Cochlear and vestibular involvement in children with IgA vasculitis

In this study, our purpose is to evaluate cochlear and vestibular function in juveniles with IgA vasculitis using audiometry, distortion product otoacoustic emissions, and cervical vestibular evoked myogenic potential (cVEMP) tests. Forty children diagnosed with IgA vasculitis from the pediatry clinic and 40 age- and sex-matched healthy children were evaluated with distortion product otoacoustic emissions, audiometry, and cVEMP test in a tertiary hospital. The audiometry average values for both ears of the IgA vasculitis group and the control subjects were compared, and as a result, median 4.7-dB sensorineural hearing loss (SHL) was found for the IgA vasculitis group compared to the control group at 250 Hz and it was statistically significant (p < 0.001). An average of 6.4-dB SHL was detected at 8000 Hz (p < 0.001). There was a statistically significant difference among IgA vasculitis and control groups regarding measurement results of average p1-n1 latency time of both ears (0.9 ms (ms) increase, p = 0.035). In IgA vasculitis patients, the median amplitude difference of both ears' average p1 n1 was found to be 5.6 mV, statistically significantly decreased compared to the control group (p = 0.003).

CONCLUSION

This study, firstly in literature, demonstrated that IgA vasculitis may have association with hearing loss and vestibular dysfunction in children. We think this might be due to autoimmune mechanisms.

WHAT IS KNOWN

• Ig A vasculitis is a leukocytoclastic vasculitis with unknown etiology, involving the skin, joints, gastrointestinal system, kidneys, and rarely other organs. • No study has been reported for the cochlear and vestibular association of Ig A vasculitis in current literature.

WHAT IS NEW

• This study demonstrated that Ig A vasculitis may have association with hearing loss in children. • This study also demonstrated that Ig A vasculitis may have association with vestibular dysfunction in children.

Cardiovascular Sequelae and Genetics of Familial Mediterranean Fever: A Literature Review

INTRODUCTION

Familial Mediterranean fever (FMF) is an autoinflammatory fever syndrome distinguished by recurrent attacks of spontaneous peritonitis, pleuritis, fever, and arthritis. It is specifically seen in the ethnic groups of Mediterranean origin, but sporadic cases have been reported in Eastern Europe and America due to migrations. There is a number of cardiac manifestations associated with FMF.

METHODS

Using PubMed as the search engine, the literature search was done for articles published between 1958 and 2020. To summarize the body of available evidence, a scoping review was carried out to find relevant articles and case reports in patients of FMF with cardiovascular manifestations.

RESULTS

In the literature, there is a number of mechanisms explaining the cause of cardiac involvement in FMF, including the subclinical inflammation and secondary (AA) amyloid deposition in the vessels and the myocardium. There is a variable and often spurious course of these manifestations and it can be associated with a poor prognosis such as an acute myocardial infarction. In FMF patients, polyarteritis nodosa and Henoch-Schönlein purpura are seen more significantly as compared to the general population with increased frequency of mutations in Mediterranean fever (MEFV) gene. Through unclear mechanisms, Behçet's disease is associated with MEFV gene mutations and shares vascular manifestations with FMF. There is an interplay of IL-1 and MEFV gene, which impart an important role in inflammatory attacks of FMF. There is an intima-media thickening of blood vessels AA to persistent inflammation which can lead to atherosclerotic plaque formation resulting in atherosclerotic cardiovascular disease.

CONCLUSION

FMF and its associated cardiovascular diseases are interlinked to 2 main mechanisms: subclinical atherosclerosis and amyloid deposition, and colchicine is the primary treatment of patients with FMF which shows the regression of amyloid deposits and prevents cardiovascular sequelae.

MEFV gene mutations in children with Henoch-Schönlein purpura and their correlations-do mutations matter?

OBJECTIVE

To explore the frequency of MEFV gene mutations in children with Henoch-Schönlein purpura who had no prior familial Mediterranean fever diagnosis and to evaluate the association of MEFV mutations with the clinical and laboratory features of Henoch-Schönlein purpura.

METHODS

Data of 1120 patients diagnosed with Henoch-Schönlein purpura were reviewed retrospectively. The spectrum and degree of organ involvement and acute phase reactant levels were documented for each patient. Blood for MEFV gene mutation analysis was obtained either at the time of the Henoch-Schönlein purpura diagnosis or during follow-up visits. Pathological specimens of patients who underwent biopsy (renal/skin) were evaluated with special consideration for immunofluorescent examinations.

RESULTS

Two hundred and thirty-eight (21.3%) patients were found to have one of the MEFV mutations in which exon 10 mutations were the most common (16.7%). Abdominal pain, joint involvement, scrotal involvement, and relapse were more frequent, and acute-phase reactant levels were significantly high in patients with MEFV mutations. More severe characteristics were observed in the presence of homozygous exon 10 mutations. There was no significant association between exon 2 variants and clinical course of Henoch-Schönlein purpura. Patients carrying MEFV mutations did not have significantly higher levels of IgA deposits in the biopsy materials.

CONCLUSION

Henoch-Schönlein purpura in patients with homozygous exon 10 MEFV mutations seems to be more severe than that in patients carrying other mutations. In patients with exon 10 MEFV mutations, Henoch-Schönlein purpura might be considered as an associated presentation of familial Mediterranean fever rather than a separate clinical entity. Key points • p.M694V mutation is more common in Henoch-Schönlein purpura than in the general population. • p.E148Q variants have no impact on clinical symptoms and laboratory findings in Henoch-Schönlein purpura patients. • The majority of Henoch-Schönlein purpura patients with familial Mediterranean fever have no IgA deposits. • Henoch-Schönlein purpura in familial Mediterranean fever patients may be considered as an integral clinical feature of familial Mediterranean fever.

Influence of Latitude on the Prevalence of Kawasaki Disease: A Retrospective Cohort Study from the Taiwan National Health Insurance Database and Review of the Literature

Background: Countries at higher latitudes have higher incidence rates of Kawasaki disease (KD) than do countries at lower latitudes in the Asian and West Pacific area. However, the precise influence of latitude on KD incidence rates requires further clarification. Methods: We searched the Longitudinal Health Insurance Database 2005 to retrieve patients’ medical records from 1996 to 2009. The patients with KD were categorized as living in northern, middle, and southern Taiwan; the period prevalence of KD for each area was determined. Climate variables, including temperature, sunshine duration, precipitation, and relative humidity, were collected from the Taiwan Central Weather Bureau. The effect of latitude on the period KD prevalence and the correlation between climate variables and KD prevalence were calculated. Results: After patients without complete data excluded, a total of 61,830 children up to 10 years old were retrieved, from which 404 patients with KD were recognized. The period prevalence of KD increased significantly with latitude (p = 0.0004). Climate variables associated with high temperature demonstrated a connection with KD prevalence; however, this correlation was not statistically significant. Conclusions: Our study demonstrated that higher latitude is associated with a higher KD prevalence in Taiwan.

Evaluation of TGF-β1 and MCP-1 expression and tubulointerstitial fibrosis in children with Henoch-Schönlein purpura nephritis and IgA nephropathy: A clinical correlation

OBJECTIVES:

Henoch-Schönlein purpura nephritis and immunoglobulin A nephropathy are two diseases with similar clinical presentations but very different prognoses. Transforming growth factor β1 and monocyte chemoattractant protein-1 have been associated with the development of tissue fibrosis. We examined the development of tubulointerstitial fibrosis and its relationship with Transforming growth factor β1 and monocyte chemoattractant protein-1 expression in these patients.

METHODS:

Renal tissue samples were collected by renal biopsy from 50 children with Henoch-Schönlein purpura nephritis and 50 children with immunoglobulin A nephropathy. Hematoxylin and eosin and Masson's trichrome-stained tissues were examined using light microscopy. Tubulointerstitial fibrosis was graded using the method described by Bohle et al. (1). The immunohistochemical detection of Transforming growth factor β1 and monocyte chemoattractant protein-1 expression was correlated with the tubulointerstitial fibrosis grade. Clinical Trial registration number: ZJCH-2012-0105.

RESULTS:

Transforming growth factor β1 and monocyte chemoattractant protein-1 expression in the renal tissues was significantly greater in the patients with immunoglobulin A nephropathy than in the patients with Henoch-Schönlein purpura nephritis (both p<0.001). The immunoglobulin A nephropathy patients had a higher tubulointerstitial fibrosis grade than the Henoch-Schönlein purpura nephritis patients (p<0.001). The tubulointerstitial fibrosis grade was in accordance with the Transforming growth factor β1 and monocyte chemoattractant protein-1 expression levels in both diseases (both p<0.001).

CONCLUSION:

Transforming growth factor β1 and monocyte chemoattractant protein-1 expression was associated with the development of immunoglobulin A nephropathy and Henoch-Schönlein purpura nephritis. Further studies are needed to better evaluate this association.

[Childhood vasculitis]

BACKGROUND

The primary vasculitides are rare conditions in childhood. The most common disease subtypes are Schönlein-Henoch purpura and Kawasaki's syndrome, which frequently have a self-limiting course. In the majority of vasculitides, the etiology remains unknown. Environmental exposure, including infections, is suspected to trigger an autoinflammatory response in predisposed individuals.

GOAL

The aim of this review is to present the various aspects of childhood vasculitis.

MATERIALS AND METHODS

Reviews and special original papers on childhood vasculitis, published classification criteria and current therapy guidelines were reviewed and summarized.

RESULTS

The classification of vasculitides in childhood has been modified from the previous adult Chapel Hill classification for vasculitides in 2008. Most therapy recommendations for children are adapted from results of studies in adults. This review covers the current classifications, pathogenesis, clinical manifestations and therapy recommendations for children.

DISCUSSION

Although etiology and pathogenesis of many vasculitides in childhood are still unknown, clarifying diagnostic methods and effective therapeutic options are available. The knowledge about various forms of disease manifestation may contribute to an early diagnosis and timely initiation of treatment, which may prevent devastating irreversible impairment.

Developments in large and midsize vasculitis

Childhood vasculitis is a complex and fascinating area in pediatric rheumatology that has experienced an unprecedented surge in research, leading to new knowledge over the past several years. Vasculitis is defined as the presence of inflammatory cell infiltration in blood vessel walls, usually with multisystemic involvement. The most frequent forms of vasculitis in childhood are the small-size vasculitides, of which Henoch-Schoenlein Purpura and other leucocytoclastic vasculitis are the best examples, followed by Kawasaki disease, a midsize vasculitis, and Takayasu arteritis, a large-size vasculitis, both of which are topics in this article.

Increased sensitivity of the European medicines agency algorithm for classification of childhood granulomatosis with polyangiitis

OBJECTIVE

Granulomatosis with polyangiitis (Wegener's; GPA) and other antineutrophil cytoplasmic antibody (ANCA)-associated vasculitides (AAV) are rare in childhood and are sometimes difficult to discriminate. We compared use of adult-derived classification schemes for GPA against validated pediatric criteria in the ARChiVe (A Registry for Childhood Vasculitis e-entry) cohort, a Childhood Arthritis and Rheumatology Research Alliance initiative.

METHODS

Time-of-diagnosis data for children with physician (MD) diagnosis of AAV and unclassified vasculitis (UCV) from 33 US/Canadian centers were analyzed. The European Medicines Agency (EMA) classification algorithm and European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Paediatric Rheumatology European Society (EULAR/PRINTO/PRES) and American College of Rheumatology (ACR) criteria for GPA were applied to all patients. Sensitivity and specificity were calculated (MD-diagnosis as reference).

RESULTS

MD-diagnoses for 155 children were 100 GPA, 25 microscopic polyangiitis (MPA), 6 ANCA-positive pauciimmune glomerulonephritis, 3 Churg-Strauss syndrome, and 21 UCV. Of these, 114 had GPA as defined by EMA, 98 by EULAR/PRINTO/PRES, and 87 by ACR. Fourteen patients were identified as GPA by EULAR/PRINTO/PRES but not by ACR; 3 were identified as GPA by ACR but not EULAR/PRINTO/PRES. Using the EMA algorithm, 135 (87%) children were classifiable. The sensitivity of the EMA algorithm, the EULAR/PRINTO/PRES, and ACR criteria for classifying GPA was 90%, 77%, and 69%, respectively, with specificities of 56%, 62%, and 67%. The relatively poor sensitivity of the 2 criteria related to their inability to discriminate patients with MPA.

CONCLUSION

EULAR/PRINTO/PRES was more sensitive than ACR criteria in classifying pediatric GPA. Neither classification system has criteria for MPA; therefore usefulness in discriminating patients in ARChiVe was limited. Even when using the most sensitive EMA algorithm, many children remained unclassified.

Vascular comorbidities in familial Mediterranean fever

Familial Mediterranean fever (FMF) is a common hereditary autoinflammatory disorder characterized by recurrent febrile attacks and polyserositis. The MEditerranean FeVer (MEFV) gene missense mutations altering the structure and function of pyrin protein play a significant role in the pathophysiology of the disease. Mutated pyrin is associated with the loss of delicate control of the inflammatory pathways, which results in a prolonged or augmented inflammation that predisposes these patients and carriers of the MEFV mutation to a pro-inflammatory state. This increased inflammation might lead to susceptibility to vascular comorbidities in FMF patients and even in carriers. In this review, we aim to discuss the vascular comorbidities seen in FMF patients. For this purpose, a thorough search was done in Web sites such as Pubmed, Web of Science, Scopus and Google Scholar, and the most relevant articles and case reports were evaluated. It seems that various vasculitides and the emerging problem of atherosclerosis have increasingly been recognized in these patients and, on the other hand, cardiac amyloidosis appears as a rare but devastating complication of FMF. Future studies will shed light on the unknown aspects of the emerging vascular problems in patients with FMF.

A review of pediatric uveitis: part II. Autoimmune diseases and treatment modalities

Uveitis is a manifestation of complex processes that can represent an infectious process or a dysfunction of the immune system that may have grave effects on the eye. Although infectious causes, once properly identified, may be successfully treated by addressing the inciting organism with recognized interventions, the immune-modulated chronic forms of uveitis often provide more complex challenges in management. Recent strides in understanding the inflammatory pathway and better bioengineering capabilities have resulted in some new modalities of treatment.

An asthmatic adolescent with a rash and eosinophilia

Children frequently visit emergency departments with asthma exacerbations. Many of these asthmatic children may have fever and/or pneumonia, but when associated with eosinophilia or evidence of vasculitis, other diagnoses should be considered. Churg-Strauss syndrome is a rare form of systemic vasculitis, which usually occurs in patients with asthma in association with eosinophilia. The diagnosis of Churg-Strauss syndrome can be difficult because this syndrome may arise at first as a common association between asthma and allergic rhinitis. A delay in diagnosis and treatment may increase the morbidity from the complications of vasculitis. We report a young asthmatic adolescent who presented with vasculitis, eosinophilia, and peripheral neuropathy.