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Thomas KN, Aggarwal A. Childhood rheumatic diseases: bites not only the joint, but also the heart. Clin Rheumatol 2023; 42:2703-2715. [PMID: 37160484 PMCID: PMC10169151 DOI: 10.1007/s10067-023-06621-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 04/30/2023] [Accepted: 05/01/2023] [Indexed: 05/11/2023]
Abstract
Cardiovascular involvement in juvenile rheumatic diseases is the primary manifestation in paediatric vasculitis and a major organ manifestation in paediatric connective tissue diseases. Though coronary vasculitis is the prototypical manifestation of Kawasaki disease, it can also be seen in patients with polyarteritis nodosa. Pericarditis is the most common manifestation seen in juvenile rheumatic diseases like systemic onset JIA, and lupus. Cardiac tamponade, valvular insufficiency, aortic root dilatation and arrhythmias are seen rarely. Cardiac involvement is often recognized late in children. The development of cardiac disease in juvenile systemic sclerosis is associated with a poor outcome. In long term, childhood onset of rheumatic diseases predisposes to diastolic dysfunction and premature atherosclerosis during adulthood. Key Points • Pericarditis is the most common cardiac manifestation in SLE and can lead to tamponade. • Conduction defects are common in juvenile mixed connective tissue disease and systemic sclerosis. • Pulmonary hypertension is a significant contributor to mortality in juvenile systemic sclerosis. • In Kawasaki disease, early treatment can reduce risk of coronary artery aneurysms.
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Affiliation(s)
- Koshy Nithin Thomas
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India
| | - Amita Aggarwal
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, 226014, India.
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2
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Yildiz M, Dedeoglu R, Akdeniz B, Adrovic A, Haslak F, Karagozlu F, Koker O, Ulug N, Sahin S, Barut K, Oztunc F, Kasapcopur O. Systolic and Diastolic Cardiac Functions in Juvenile Spondyloarthropathies. J Clin Rheumatol 2022; 28:e175-e179. [PMID: 33337801 DOI: 10.1097/rhu.0000000000001674] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND/OBJECTIVE Juvenile spondyloarthropathies (JSpAs) are a group of inflammatory diseases characterized by asymmetric peripheral arthritis (especially in lower extremities), axial skeleton involvement, and enthesitis. Although cardiovascular findings of inflammatory diseases such as juvenile systemic lupus erythematosus (SLE) and juvenile scleroderma (SD) are well documented, there are only a few studies assessing the cardiovascular consequences of JSpA in the literature. METHODS Forty patients with JSpA and 20 healthy controls were included into this cross-sectional study. Cardiac functions of the participants were evaluated by conventional echocardiography and pulse-wave (PW) tissue Doppler. RESULTS The patients with JSpA had higher mitral lateral S (p = 0.005) and E' wave (p < 0.001), tricuspid A' wave (p = 0.03), ejection fraction (p = 0.03) and shortening fraction (p = 0.01) than the control patients. In contrast, the patients with JSpA had lower left ventricle MPI (p = 0.01) and the ratio of tricuspid E'/A' waves (p = 0.05). Patients with enthesitis detected on magnetic resonance imaging had lower ejection fraction (p = 0.05), the ratio of E/A waves (p = 0.03) and had higher Mitral lateral A' wave (p = 0.01) than those without. There was a significant inverse correlation between the Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) and PW transmitral A velocity (r = -0.256, p = 0.03), the BASDAI score and tricuspid annular plane systolic excursion (r = -0.301, p = 0.04), the BASDAI score and the ratio of E/E' waves (r = -0.276, p = 0.02), and the Juvenile Spondyloarthritis Disease Activity Index and PW transmitral A velocity (r = -0.246, p = 0.04). CONCLUSIONS In this study, we report the possible early signs of RV diastolic dysfunction and possible association between magnetic resonance imaging-confirmed enthesitis and lower LV systolic functions. Early identification of cardiac dysfunctions can help with prevention of long-term cardiovascular complications.
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Affiliation(s)
| | - Reyhan Dedeoglu
- Pediatric Cardiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | | | | | - Fatih Karagozlu
- Pediatric Cardiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Oya Koker
- From the Departments of Pediatric Rheumatology
| | - Nujin Ulug
- Pediatric Cardiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | | | - Kenan Barut
- From the Departments of Pediatric Rheumatology
| | - Funda Oztunc
- Pediatric Cardiology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Abstract
Spondyloarthritis (SpA) is a blanket term encompassing entities such as enthesitis-related arthritis, nonradiographic axial SpA, and ankylosing spondylitis. These diseases share many clinical features, including a predilection for inflammation of the entheses and the sacroiliac joints. The nomenclature is based on the evolution of the classification of the disease and the age of the patient. SpA has a prevalence of approximately 1% of the population of the United States, with 10% to 20% of patients experiencing the onset during childhood. Children with onset of arthritis before age 16 years are classified as having juvenile idiopathic arthritis. Children with enthesitis and/or sacroiliitis are further classified as belonging to the enthesitis-related arthritis subtype of juvenile idiopathic arthritis. The initial manifestations can be subtle and will usually include a peripheral pattern of arthritis and enthesitis. It may take several years for axial disease to develop in children. Except for an association with the human leukocyte antigen (HLA-B27) serotype, there are no laboratory markers for the disease, and the radiographic findings are often negative. A careful clinical evaluation for evidence of inflammation in the entheses and the joints and a search for comorbidities are required. Magnetic resonance imaging facilitates the early detection of sacroiliitis, an important feature that may be clinically silent. Because recent studies indicate that earlier introduction of therapy can help achieve better outcomes, rapid identification and treatment of children with SpA is essential.
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Affiliation(s)
- Lita Aeder
- Department of Pediatrics, Brookdale University Hospital and Medical Center, New York, NY; and State University of New York Health Science Center at Brooklyn, Brooklyn, NY
| | - Karen B Onel
- Department of Pediatric Rheumatology, Hospital for Special Surgery, New York, NY; and Department of Clinical Pediatrics, Weill Cornell Medicine, New York, NY
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Smith JA, Burgos-Vargas R. Outcomes in Juvenile-Onset Spondyloarthritis. Front Med (Lausanne) 2021; 8:680916. [PMID: 34124112 PMCID: PMC8192716 DOI: 10.3389/fmed.2021.680916] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 04/30/2021] [Indexed: 01/31/2023] Open
Abstract
Some studies have suggested children with juvenile onset spondyloarthritis (JoSpA) have a relatively poor outcome compared to other juvenile idiopathic arthritis (JIA) categories, in regards to functional status and failure to attain remission. Thus, in the interest of earlier recognition and risk stratification, awareness of the unique characteristics of this group is critical. Herein, we review the clinical burden of disease, prognostic indicators and outcomes in JoSpA. Of note, although children exhibit less axial disease at onset compared to adults with spondyloarthritis (SpA), 34–62% have magnetic resonance imaging (MRI) evidence for active inflammation in the absence of reported back pain. Furthermore, some studies have reported that more than half of children with “enthesitis related arthritis” (ERA) develop axial disease within 5 years of diagnosis. Axial disease, and more specifically sacroiliitis, portends continued active disease. The advent of TNF inhibitors has promised to be a “game changer,” given their relatively high efficacy for enthesitis and axial disease. However, the real world experience in various cohorts since the introduction of more widespread TNF inhibitor usage, in which greater than a third still have persistently active disease, suggests there is still work to be done in developing new therapies and improving the outlook for JoSpA.
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Affiliation(s)
- Judith A Smith
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, WI, United States
| | - Ruben Burgos-Vargas
- Departamento de Reumatologia, Hospital General de Mexico, Mexico City, Mexico
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5
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Abstract
Juvenile spondyloarthropathy is an umbrella term for a group of childhood rheumatic diseases that can cause chronic arthritis extending to the axial skeleton before the age of 16. Although ankylosing spondylitis has aortic involvement as one of its most important effects, this relationship has not been extensively studied in children with juvenile spondyloarthropathy. Here, a cross-sectional study of the elastic properties of the aorta of 43 patients with juvenile spondyloarthropathy and 19 healthy controls is reported. Aortic stiffness assessed by echocardiography was used to predict the presence of aortitis, supplemented by pulsed-wave tissue Doppler indices. The right ventricular fractional area change was found to be significantly lower in the patients with juvenile spondyloarthropathy than in the healthy controls; aortic strain and distensibility were also significantly lower, and aortic stiffness index β was significantly higher; and the aortic root diameter change was significantly lower. According to HLA-B27 positivity, there was no difference in the stiffness parameters between the two groups. There was a significant correlation between juvenile Ankylosing Spondylitis Disease Activity Index and aortic diameter change, between juvenile Ankylosing Spondylitis Disease Activity Index and aortic stiffness. Thus, juvenile spondyloarthropathy is linked to high aortic stiffness parameters.
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6
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Weiss PF, Roth J. Juvenile-Versus Adult-Onset Spondyloarthritis: Similar, but Different. Rheum Dis Clin North Am 2020; 46:241-257. [PMID: 32340699 DOI: 10.1016/j.rdc.2020.01.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
This article provides an overview of juvenile spondyloarthritis and important differences in the classification criteria, clinical presentation, outcomes, and pathology in juvenile versus adult-onset disease. Key differences in classification criteria between children and adults with spondyloarthritis are important to understand, as they can make transition from pediatric to adult care challenging. MRI and ultrasonography are increasingly relied on for the assessment of adult-onset disease activity and change over time in the pediatric population. The unique features of the maturing axial and peripheral skeleton are described for each modality, as they are key to understand for accurate interpretation of pathology in the pediatric population.
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Affiliation(s)
- Pamela F Weiss
- Perelman School of Medicine UPENN, Philadelphia, PA, USA; Division of Rheumatology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Johannes Roth
- Division of Pediatric Dermatology and Rheumatology, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, Ontario K1H8L1, Canada
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Abstract
Juvenile spondyloarthritis (SpA) is a distinct form of juvenile arthritis characterized by male predominance and adolescent onset. Clinical manifestations include lower extremity and sacroiliac joint arthritis, enthesitis, and subclinical gastrointestinal inflammation. Juvenile SpA is an immune-mediated inflammatory disease long recognized as associated with HLA-B27, which may be related to the microbial environment as suggested by its coexistence with reactive arthritis and psoriasis. Treatment of peripheral arthritis includes nonsteroidal anti-inflammatory drugs, joint injections, and disease-modifying agents, whereas treatment of axial disease may necessitate a tumor necrosis factor inhibitor biologic agent. Fewer than half of children achieve remission off medication 5 years after diagnosis.
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Abstract
PURPOSE OF REVIEW This article provides a comprehensive update of the pathogenesis, diagnostic imaging, treatments, and disease activity measurements of juvenile spondyloarthritis (JSpA). RECENT FINDINGS Genetic and microbiome studies have provided new information regarding possible pathogenesis of JSpA. Recent work suggests that children with JSpA have decreased thresholds for pain in comparison to healthy children. In addition, pain on physical examination and abnormalities on ultrasound of the entheses are not well correlated. Treatment guidelines for juvenile arthritis, including JSpA, were published by the American College of Rheumatology and are based on active joint count and presence of sacroiliitis. Recent studies have established the efficacy of tumor necrosis factor inhibitors in the symptomatic treatment of axial disease, although their efficacy for halting progression of structural damage is less clear. Newly developed disease activity measures for JSpA include the Juvenile Arthritis Disease Activity Score and the JSpA disease activity index. In comparison to other categories of juvenile arthritis, children with JSpA are less likely to attain and sustain inactive disease. SUMMARY Further microbiome and genetic research may help elucidate JSpA pathogenesis. More randomized therapeutic trials are needed and the advent of new composite disease activity measurement tools will hopefully allow the design of these greatly needed trials.
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Bohr AH, Fuhlbrigge RC, Pedersen FK, de Ferranti SD, Müller K. Premature subclinical atherosclerosis in children and young adults with juvenile idiopathic arthritis. A review considering preventive measures. Pediatr Rheumatol Online J 2016; 14:3. [PMID: 26738563 PMCID: PMC4704268 DOI: 10.1186/s12969-015-0061-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2015] [Accepted: 12/18/2015] [Indexed: 12/18/2022] Open
Abstract
Many studies show that Juvenile Idiopathic Arthritis (JIA) is associated with early subclinical signs of atherosclerosis. Chronic inflammation per se may be an important driver but other known risk factors, such as dyslipidemia, hypertension, insulin insensitivity, a physically inactive lifestyle, obesity, and tobacco smoking may also contribute substantially. We performed a systematic review of studies through the last 20 years on early signs of subclinical atherosclerosis in children and adolescents with JIA with the purpose of investigating whether possible risk factors, other than inflammation, were considered.We found 13 descriptive cross sectional studies with healthy controls, one intervention study and two studies on adults diagnosed with JIA. Only one study addressed obesity, and physical activity (PA) has only been assessed in one study on adults with JIA and only by self-reporting. This is important as studies on PA in children with JIA have shown that most patients are less physically active than their healthy peers, and as physical inactivity in several large studies of normal schoolchildren is found to be associated with increased clustering of risk factors for cardiovascular disease. It is thus possible that an inactive lifestyle in patients with JIA is an important contributor to development of the subclinical signs of atherosclerosis seen in children with JIA, and that promotion of an active lifestyle in childhood and adolescence may diminish the risk for premature atherosclerotic events in adulthood.
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Affiliation(s)
- Anna-Helene Bohr
- Department of Paediatrics and Adolescent Medicine, JMC Research Unit, Rigshospitalet Afs. 7821, Tagensvej 22, DK 2200, Copenhagen N, Denmark.
| | | | - Freddy Karup Pedersen
- Department of Paediatrics and Adolescent Medicine, Rigshospitalet, Copenhagen, Denmark
| | | | - Klaus Müller
- Department of Paediatrics and Adolescent Medicine, and Institute for Inflammation Research, Rigshospitalet, Copenhagen, Denmark
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10
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Burgos-Vargas R. Juvenile-onset spondyloarthritis. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00104-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Abstract
Spondyloarthritis (SpA) encompasses a group of disorders linked by overlapping clinical manifestations and genetic predisposition. Newer classification systems developed for adults with SpA focus on identifying individuals with axial or predominantly peripheral involvement. All forms of SpA can begin during childhood, and can be considered on a continuum with adult disease. Nevertheless, there are important differences in presentation and outcome that depend on age at onset. This article highlights these differences, what has been learned about genetics and pathogenesis of SpA, and important unmet needs for future studies.
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Affiliation(s)
- Anusha Ramanathan
- Division of Rheumatology, Children’s Hospital Los Angeles and the University of Southern California, Los Angeles, CA 90027, USA, Tel: 323.361.8232,
| | - Hemalatha Srinivasalu
- Division of Rheumatology, Children’ National Medical Center and George Washington University, Washington, DC 20010, USA, Tel: 202.476.4674,
| | - Robert A. Colbert
- Pediatric Translational Research Branch, National Institute of Arthritis, Musculoskeletal and Skin Diseases (NIAMS), National Institutes of Health, Bethesda, MD 20892, USA Tel: 301.443.8935,
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12
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Paroxysmal Supraventricular Tachycardia and Wolff–Parkinson–White Syndrome in Ankylosing Spondylitis: A Large Cohort Observation Study and Literature Review. Semin Arthritis Rheum 2012; 42:246-53. [DOI: 10.1016/j.semarthrit.2012.04.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Revised: 04/10/2012] [Accepted: 04/19/2012] [Indexed: 11/18/2022]
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13
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Affiliation(s)
- Clara Lin
- University of California San Francisco, Pediatric Rheumatology, 533 Parnassus Avenue, Box 0107, San Francisco, CA 94113, USA
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15
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Singh YP, Aggarwal A. A modified juvenile arthritis damage index to improve articular damage assessment in juvenile idiopathic arthritis--enthesitis-related arthritis (JIA-ERA). Clin Rheumatol 2012; 31:767-74. [PMID: 22234493 DOI: 10.1007/s10067-011-1928-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2011] [Accepted: 12/21/2011] [Indexed: 11/30/2022]
Abstract
Juvenile arthritis damage index (JADI) consists of two parts which measure articular (JADI-A) and extra-articular (JADI-E) damage in patients with juvenile idiopathic arthritis (JIA). It does not include assessment of cardiac dysfunction and joint areas commonly affected in enthesitis-related arthritis (ERA) category of JIA. We have tried to study if modification of JADI will improve its performance in JIA-ERA. We studied 101 consecutive patients of JIA-ERA. JADI-A was modified (JADI-AM) to include damage assessment of tarsal joints and lumbar spine. JADI-E was modified (JADI-EM) to include assessment of symptomatic cardiac dysfunction. The performances of the modified and standard JADI were compared. Ninety-seven patients were male. The median age was 18 years (9-36). At a median disease duration of 6 years (1-24), joint damage was observed in 47 as assessed by JADI-A. JADI-AM could identify 11 more patients (N = 58) with articular damage. JADI-AM had good correlation with number of joints with limitation of movement (Spearman's [rS] = 0.9) and low to moderate correlation (rS < 0.7) with measures of disease activity and functional status. JADI-AM discriminated well among patients with different disability levels. Extra-articular damage was observed in 35, and modification of JADI-E with inclusion of cardiac dysfunction did not identify any additional patient. Thus, we propose a modification of the JADI-A (JADI-AM). In JIA-ERA, modification of JADI-A improves its ability to identify articular damage. Modification of the JADI-E may not be needed as symptomatic cardiac involvement is rare.
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16
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Prati C, Claudepierre P, Pham T, Wendling D. Mortality in spondylarthritis. Joint Bone Spine 2011; 78:466-70. [PMID: 21450507 DOI: 10.1016/j.jbspin.2011.02.012] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/27/2010] [Indexed: 11/29/2022]
Abstract
Ankylosing spondylitis (AS) is a chronic inflammatory joint disease that can lead to chronic pain in axial and peripheral joints and to functional impairments after several years. Excess mortality has been reported in patients with AS. We reviewed recent studies of patients with AS who were treated and monitored according to the improved methods developed in the past few years, without radiation therapy. Our results do not support excess mortality in these patients. Long-term follow-up data from patients enrolled in biologics registries will provide additional information. Cardiovascular disease is the leading cause of death in patients with AS, as in the general population. However, the cardiovascular mortality rate may be slightly increased in patients with AS, probably as a result of dyslipidemia and early endothelial dysfunction. Similarly, and as expected, there is excess mortality related to the spinal disease itself and to renal and gastrointestinal disease. More surprisingly, alcohol abuse and injury or suicide cause excess mortality compared to the general population. In the absence of radiation or radium-224 therapy, and regardless of the other treatments used, the evidence does not support an increased rate of lymphoma or other malignancies compared to the general population. In this review, we discuss the causes and rates of mortality in patients with AS.
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Affiliation(s)
- Clément Prati
- Service de rhumatologie, université de Franche-Comté, CHU, 1, boulevard Fleming, 25030 Besançon, France
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Burgos-Vargas R. The juvenile-onset spondyloarthropathies. Rheumatology (Oxford) 2011. [DOI: 10.1016/b978-0-323-06551-1.00101-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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18
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Gratacós J. [Extra-articular manifestations and complications of ankylosing spondylitis]. REUMATOLOGIA CLINICA 2005; 1:25-31. [PMID: 21794233 DOI: 10.1016/s1699-258x(05)72709-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2004] [Accepted: 11/22/2004] [Indexed: 05/31/2023]
Abstract
Extra-articular manifestations can be defined as all symptoms and signs etiopathogenically related, at least in part, to ankylosing spondylitis (AS) that arise in the various organs and tissues of the locomotor apparatus. Thus, ocular, intestinal and cardiac manifestations, which are common to all spondylarthritides through their association with HLA-B27, are grouped under this heading. Complications include clinical manifestations that result from persistent spondylitic activity and/or treatment. Table 1 provides a list and the main characteristics of these manifestations. Obviously, this classification is far from perfect since, among other factors, knowledge of the etiopathogenesis of AS is still fairly limited.
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Affiliation(s)
- J Gratacós
- Unidad de Reumatología. Hospital de Sabadell. Institut Universitari Parc Taulí. Universidad Autónoma de Barcelona. Sabadell. Barcelona. España
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Aggarwal A, Hissaria P, Misra R. Juvenile ankylosing spondylitis?is it the same disease as adult ankylosing spondylitis? Rheumatol Int 2003; 25:94-6. [PMID: 14655021 DOI: 10.1007/s00296-003-0417-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2003] [Accepted: 10/18/2003] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Juvenile and adult forms of ankylosing spondylitis (AS) have been shown to have different clinical presentation and outcome in Caucasians. We did this retrospective analysis to see if similar differences exist in the Indian population. PATIENTS AND METHODS Case records of 210 Indian patients diagnosed with AS according to modified New York criteria were reviewed. Data were collected regarding age of onset, clinical features, drug treatment, and outcome at last follow-up. Patients with onset before 17 years of age were classified as having juvenile AS (JAS) and the rest with adult AS (AAS). RESULTS There were 150 patients with AAS and 60 with JAS. The latter had higher male preponderance, more frequent onset with peripheral arthritis, and greater involvement of hip and knee joints. Valvular dysfunction was seen only in patients with JAS. CONCLUSION In this group of subjects, juvenile AS had onset more often with oligoarthritis and enthesitis than with spinal disease. Hip and knee joint involvement was more common in JAS than AAS.
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Affiliation(s)
- Amita Aggarwal
- Department of Immunology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow 226 014, India.
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Abstract
The juvenile-onset spondyloarthropathies are a group of pediatric disorders characterized by arthropathy and enthesopathy and a variety of extra-articular symptoms. With the application of new classification criteria, there is an increasing recognition of these diseases. This review summarizes recent advances in etiologic factors, clinical manifestations, therapeutics, and prognosis. Improved recognition of juvenile-onset spondyloarthropathies has allowed systematic and rigorous treatment trials to evaluate clinical outcomes relevant to pediatric medicine. Thus far, current therapeutic options allow for symptomatic control only. Further treatment studies are needed to examine the possibility of disease modification of juvenile-onset spondyloarthropathies.
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Affiliation(s)
- Shirley M L Tse
- Department of Pediatrics, Hospital for Sick Children, University of Toronto, Ontario, Canada.
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21
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Abstract
The juvenile-onset spondyloarthritides comprise a group of HLA-B27-associated disorders, which are mainly characterized by enthesitis and arthritis affecting the lower extremities, and in a variable proportion of cases, the sacroiliac and spinal joints. Additional features include a variety of extra-articular manifestations, and in some cases, bacterial infections as triggers. Except for the prevalence of some clinical features at onset and severity throughout the course of the disease, juvenile-onset SpA resemble their adult counterpart in most clinical aspects, strength of HLA-B27 association, and the role of arthritogenic bacteria in their pathogenesis. Not surprisingly, several aspects, from nomenclature to classification, and diagnostic criteria reflect to some extent those developed in the adult onset populations.
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Affiliation(s)
- Rubén Burgos-Vargas
- Research Division, Hospital General de México, Dr. Balmis 148, 06726 Mexico DF, Mexico.
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22
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Jiménez-Balderas FJ, García-Rubi D, Pérez-Hinojosa S, Arellano J, Yáñez P, Sanchez ML, Camargo-Coronel A, Zonana-Nacach A. Two-dimensional echo Doppler findings in juvenile and adult onset ankylosing spondylitis with long-term disease. Angiology 2001; 52:543-8. [PMID: 11512693 DOI: 10.1177/000331970105200806] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The authors' objective was to determine by 2-dimensional echo Doppler (2DECHO) the cardiac abnormalities in juvenile onset ankylosing spondylitis (JOAS) and adult onset ankylosing spondylitis (AOAS) in male patients with long-term disease. Twenty patients with JOAS, 31 with AOAS, and 20 healthy controls of the same age and gender without cardiopulmonary symptoms were studied. Using 2DECHO, the heart dimensions were determined according to American Society of Echocardiography guidelines. The left ventricle ejection fraction (LVEF) was calculated by Teichholz's formula. Cardiomyopathy was established when 2DECHO had diminished LVEF. Statistics used were the Student t and Fisher test, chi2, and ANOVA. Ninety percent of JOAS and 51% of AOAS patients were B27+ (p=0.005). The disease duration was 19.3 +/- 8.8 years in JOAS and 14.8 +/- 12.8 years in AOAS (p=NS). Age at the time of the study was 30.7 +/- 9.9 years in JOAS vs 40.3 +/- 12.7 in AOAS (p=0.003), and vs 40.2 +/- 17 years in controls (p=NS). There was a higher frequency of cardiomyopathy in AOAS (32.2%) than in JOAS (25%) and the controls (0%) (p=0.01). Patients with JOAS had a higher mitral valve gradient (25%) than AOAS patients (19%, p=NS) and controls (0%, p=0.04). Abnormal aortic ring reflectance was shown in 19% of AOAS vs 0% abnormalities in JOAS and controls (p=0.01). The aortic root diameter was increased in 58% of AOAS, 30% of JOAS, and 0% of controls (p=0.001). The frequency of 2DECHO abnormalities was increased in cardiopulmonary asymptomatic spondylitis patients. Despite the high frequency of B27+, JOAS had a lower frequency of aortic abnormalities than AOAS. Mitral valve gradient was found in JOAS and in AOAS that could contribute to a decreased ejection fraction and to left ventricular dysfunction.
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23
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John A, Glauner C, Warnecke H. Ankylosing Spondylitis and the Mitral Valve. Asian Cardiovasc Thorac Ann 1999. [DOI: 10.1177/021849239900700318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Recurrent valve dehiscence was encountered in a patient with ankylosing spondylitis who had undergone mitral valve replacement. A method of reinforcing the native annulus with bovine pericardium and reattaching the valve is described.
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Affiliation(s)
- Alexander John
- Department of Heart Surgery Schüchtermann Clinic Bad Rothenfelde, Germany
| | - Christoph Glauner
- Department of Heart Surgery Schüchtermann Clinic Bad Rothenfelde, Germany
| | - Henning Warnecke
- Department of Heart Surgery Schüchtermann Clinic Bad Rothenfelde, Germany
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Strobel ES, Fritschka E. Renal diseases in ankylosing spondylitis: review of the literature illustrated by case reports. Clin Rheumatol 1999; 17:524-30. [PMID: 9890685 DOI: 10.1007/bf01451293] [Citation(s) in RCA: 48] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Ankylosing spondylitis (AS) can be accompanied by extraarticular manifestations in the cardiovascular, pulmonary, neurologic and renal organs. Secondary renal amyloidosis is the most common cause of renal involvement in AS (62%) followed by IgA nephropathy (30%), mesangioproliferative glomerulonephritis (5%) as well as rarely membranous nephropathy (1%), focal segmental glomerulosclerosis (1%) and focal proliferative glomeruleonephritis (1%). Treatment associated nephrotoxicity may result from non-steroidal anti-inflammatory drugs or disease modifying agents. The purpose of this paper was to alert for the possibility of renal damage in AS and to analyse the frequencies of different etiologies of renal involvement. Two typical case reports of renal involvement in AS are presented to illustrate the clinical course of such patients. Renal side effects and possible pre-existing renal diseases should be taken into account while choosing the appropriate medication for patients with AS.
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Affiliation(s)
- E S Strobel
- Department of Internal Medicine, Freiburg University Hospital, Germany
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Galve E, Ordi J, Candell J, Soler Soler J. [Pathology of diseases of extracardiac origin. VI. Disease of the connective tissue and heart]. Rev Esp Cardiol 1998; 51:232-42. [PMID: 9577169 DOI: 10.1016/s0300-8932(98)74738-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Connective tissue diseases encompass a wide group of nosologic entities of unknown etiology, characterized by multisystemic organ involvement, sharing an immunologic pathogenetic mechanism, producing a variety of inflammatory manifestations, and whose primary lesion is always a diffuse vasculitis. Any part of the cardiovascular system may be involved, including the pericardium, the myocardium, the endocardium and valves, the coronary arteries, the aorta, the pulmonary vasculature, the peripheral arteries, veins, arterioles, venules, and the capillary beds of almost every organ subsystem. Pathologic studies disclose a high prevalence of heart involvement, but the presence and extent of pathologic findings correlate poorly with clinical manifestations. With the advent of echocardiography-Doppler, milder and earlier cases are now recognized. Although these patients continue under the care of rheumatologists and internists, when cardiac involvement arises, cardiologists must be aware of the characteristics, outcome and management of connective tissue diseases.
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Affiliation(s)
- E Galve
- Servicio de Cardiología, Hospital General Universitario Vall d'Hebron, Barcelona
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Strobel ES, Fritschka E. Case report and review of the literature. Fatal pulmonary complication in ankylosing spondylitis. Clin Rheumatol 1997; 16:617-22. [PMID: 9456016 DOI: 10.1007/bf02247804] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
A 44-year-old non-smoking patient with longstanding ankylosing spondylitis presented in marked respiratory distress with tachypnea, fever, cough, greenish sputum, night sweats, dyspnea and weight loss. Computed tomography showed traction bronchiectases and cavities associated with scarring. The findings were most pronounced in the upper lobes which contained multiple cavities up to 8 cm in diameter harboring fungus balls. The superior segment of the left lower lobe showed two additional cavities. Tuberculosis and atypical mycobacteria were ruled out. Antibiotic therapy resulted in transient improvement. Five months after this acute exacerbation the patient expired from massive haemoptysis. Pulmonary fibrosis is a rare manifestation of ankylosing spondylitis, may be complicated by infection and haemorrhage and determine the dismal prognosis of these patients.
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Affiliation(s)
- E S Strobel
- Department of Medicine, Klinikum der Albert-Ludwigs-Universität Freiburg, Germany
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Abstract
This article discusses the clinical spectrum and characteristics of juvenile-onset spondyloarthropathies and includes a review of the demographic, clinical, radiographic (and other imaging techniques), and laboratory data of conditions, syndromes, and diseases making up this group. The pathogenic role of several factors in the context of adult-onset patients, but also in regards to studies already performed in juvenile-onset patients, is discussed.
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MESH Headings
- Adolescent
- Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
- Arthritis, Psoriatic/etiology
- Arthritis, Psoriatic/pathology
- Arthritis, Psoriatic/therapy
- Arthritis, Reactive/diagnosis
- Arthritis, Reactive/etiology
- Arthritis, Reactive/therapy
- Child
- Colitis, Ulcerative/complications
- Crohn Disease/complications
- Female
- Humans
- Male
- Spondylitis, Ankylosing/diagnosis
- Spondylitis, Ankylosing/etiology
- Spondylitis, Ankylosing/therapy
- Tenosynovitis/diagnosis
- Tenosynovitis/etiology
- Tenosynovitis/therapy
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Affiliation(s)
- R Burgos-Vargas
- Department of Medicine Hospital General de México, México City, DF, México
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28
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Kim TH, Jung SS, Sohn SJ, Park MH, Kim SY. Aneurysmal dilatation of ascending aorta and aortic insufficiency in juvenile spondyloarthropathy. Scand J Rheumatol 1997; 26:218-21. [PMID: 9225879 DOI: 10.3109/03009749709065685] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Aortic insufficiency is a well-recognized complication of adult spondyloarthropathy but rare in juveniles, and no report is associated with aneurysmal dilatation at any age. We describe rapidly progressive aortic insufficiency with aneurysmal dilatation of ascending aorta in a 15-year-old boy with juvenile spondyloarthropathy, necessitating a Bentall operation.
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Affiliation(s)
- T H Kim
- Rheumatism Center, Hanyang University Hospital, Seoul, Korea
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