Vasculitis in children

Overview of childhood vasculitis

Pediatric vasculitis and adult vasculitis differ in several aspects. While both involve inflammation of blood vessels, pediatric vasculitis tends to present with distinct clinical features and may involve different types of blood vessels compared to adult vasculitis. Despite its relatively rare occurrence compared to adult vasculitis, pediatric vasculitis warrants careful attention due to its potential for profound and diverse clinical manifestations, ranging from mild cutaneous symptoms to life-threatening systemic complications. Childhood vasculitis should be suspected in children who present symptoms attributable to systemic inflammation and complications arising from multi-organ dysfunction. However, achieving a diagnosis necessitates thorough exclusion of alternative conditions manifesting similar symptoms and findings. Hence, children suspected of vasculitis should undergo meticulous history-taking, comprehensive physical examination, and requisite laboratory investigations, imaging studies, and sometimes tissue biopsies to elucidate the diagnosis. Early detection and treatment of childhood vasculitis are crucial, as the condition can affect various organs and potentially lead to life-threatening complications or long-term sequelae in adulthood if left untreated. This review aimed to provide an exhaustive overview of childhood vasculitis, outlining its epidemiology, classification, clinical presentation, diagnostic modalities, therapeutic strategies and outcome.

Assessment of the effect of mesangial hypercellularity in childhood nephropathies to the clinical and laboratory findings

AIM

To assess the relationship between mesangial hypercellularity in various childhood nephropathies and clinical and laboratory parameters.

METHODS AND PATIENTS

The reports of the renal biopsies were evaluated retrospectively. The patients with diagnosis of IgA nephropathy (isolated and Henoch-Schönlein nephritis), IgM nephropathy, or isolated mesangial proliferative glomerulonephritis were included. Each nephropathy group was divided into two subgroups according to the severity of mesangial hypercellularity as mild and severe. The biochemical data and histopathological findings of the patients were recorded.

RESULTS

When the groups were compared, it was found that the patients with IgA nephropathy had hematuria (p = 0.043) and the patients with IgM nephropathy had nephrotic syndrome more frequently than the other patients (p = 0.01). No difference was detected between the groups regarding the severity of mesangial hypercellularity. On the other hand, when the groups were evaluated within themselves, no significant association was detected between the severity of mesangial hypercellularity and clinical and laboratory parameters. It was determined that the renal biopsy was performed earlier in patients with Henoch-Schönlein nephritis compared to the other cases (p = 0.004). Compared to the isolated IgA nephropathy group, it was found that the number of cases with severe mesangial hypercellularity was higher and the level of proteinuria was more prominent in patients with Henoch-Schönlein nephritis. Additionally, when the patients with Henoch-Schönlein nephritis were evaluated, the degree of proteinuria was found to be higher in patients with severe mesangial hypercellularity compared to those of showing mild mesangial hypercellularity (p = 0.002).

CONCLUSION

It was observed that there is no direct relation between the severity of mesangial hypercellularity and clinical and laboratory findings in various childhood nephropathies. However, when Henoch-Schönlein nephritis is compared with IgA nephropathy, it was found that the severity of mesangial hypercellularity was higher in cases with Henoch-Schönlein nephritis and the level of proteinuria was more prominent in those cases. However, no difference was detected in glomerular filtration rates and biochemical data with regard to the level of mesangial hypercellularity.

Other Allergic Skin Disorders

In this chapter we discuss allergic skin disorders other than atopic dermatitis (AD): the urticaria-angioedema syndrome, allergic contact dermatitis (ACD), protein contact dermatitis (PCD), phytodermatitis, allergic photodermatitis and allergic vasculitis.

Pathogenesis-related adhesion molecules in Henoch-Schonlein vasculitis

The aim of this study was to reveal the distribution of various inflammation and endothelium-related adhesion molecules, namely, P-selectin, E-selectin, ICAM-1, ICAM-2, ICAM-3 and VCAM-1, on the skin samples of patients with Henoch-Schonlein purpura. Skin biopsies obtained from 12 pediatric patients at the acute purpura phase and from 5 patients at the convalescent phase of the disease were included in the study. Endothelial expression of P-selectin (P < 0.05), endothelial and inflammatory cellular expressions of ICAM-2 (P < 0.05, P < 0.01) and inflammatory cellular expression of ICAM-3 (P < 0.05) were significantly more intense when compared to patients in the convalescent phase. Although endothelial E-selectin and VCAM-1 expressions, and endothelial and inflammatory cellular ICAM-1 expressions displayed a decrease in the convalesant phase, this difference was not found to be statistically significant (P > 0.05).

An unusual presentation of classic polyarteritis nodosa in a child

Classic polyarteritis nodosa (c-PAN) is a rare disease in adults and extremely rare in children. We report a 3-year-old girl with c-PAN who presented with disturbances of consciousness and hypertension. Cranial tomography showed a subarachnoid hemorrhage. Subsequent magnetic resonance imaging and magnetic resonance angiography demonstrated subarachnoid hemorrhage and acute ischemic lesions. Renal angiography revealed bilateral multiple aneurysms. Due to her constitutional symptoms and hypertension and radiological findings she was diagnosed as having c-PAN. She was successfully treated with hydralazine followed by angiotensin-converting enzyme inhibitor, calcium channel blocker, intravenous pulse methylprednisolone, and subsequently oral prednisolone and oral cyclophosphamide. To our knowledge this is the youngest patient with c-PAN presenting with subarachnoid hemorrhage. Malign hypertension at this young age deserves a meticulous investigation of the vascular origin. Furthermore, treatment with pulse methyl prednisolone followed by oral prednisolone and oral cyclophosphamide is a successful modality of treatment in such a life-threatening presentation of c-PAN in childhood.

Radiologic investigation of rheumatic diseases

This article reviews the current use of the wide variety of imaging modalities now available, presenting the imaging features of common and important causes of acute and chronic rheumatic disorders including juvenile idiopathic arthritis, spondyloarthropathies/enthesitis-related arthritis, sepsis, autoimmune diseases, vasculitis, and osteoporosis.

MDCT angiography of pediatric vascular diseases of the abdomen, pelvis, and extremities

Multi-detector-row computed tomography (MDCT) enables rapid, noninvasive, high-resolution, and three-dimensional imaging of pediatric vascular diseases. In this paper, we explore the adaptation of the MDCT angiographic principles to pediatric patients for vascular diseases of the abdomen, pelvis, and extremities. Special emphasis is placed on the practical aspects of how to perform these studies. Optimizations of scan parameters, contrast medium usage, radiation dose, and three-dimensional image processing are discussed in detail. We provide practical guidance on how to choose between MR angiography and CT angiography. Finally, we review important pediatric vascular diseases, categorized into traumatic injuries, inherited vascular diseases, congenital vascular diseases, vasculitides, and surgical planning and assessment. In each category, we discuss how CT angiography can be tailored to maximize its clinical benefits.

Ischemic small bowel strictures in a case of incomplete Kawasaki disease

The authors describe an atypical case of Kawasaki disease in a 9-month-old girl who presented with fever, coronary artery aneurysms, and acquired ischemic stricture of the proximal jejunum. Histology of the surgical specimen was consistent with mesenteric vasculitis. The infant had only some of the typical clinical signs of Kawasaki disease, suggesting that an atypical or incomplete form of the disease was present. To the best of the authors' knowledge this is only the third case to be reported of incomplete Kawasaki disease associated with ischemic bowel stricture. J Pediatr Surg 36:648-650.

Rapidly progressive antineutrophil cytoplasm antibodies associated with pulmonary-renal syndrome in a 10-year-old girl

CONTEXT

The term pulmonary-renal syndrome has been used frequently to describe the clinical manifestations of a great number of diseases in which pulmonary hemorrhage and glomerulonephritis coexist. The classic example of this type of vasculitis is Goodpasturés syndrome, a term used to describe the association of pulmonary hemorrhage, glomerulonephritis and the presence of circulating antiglomerular basement membrane antibodies (anti-GBM). Among the several types of systemic vasculitides that can present clinical manifestations of the pulmonary-renal syndrome, we focus the discussion on two types more frequently associated with antineutrophil cytoplasm antibodies (ANCA), microscopic polyangiitis and Wegener's granulomatosis, concerning a 10 year old girl with clinical signs and symptoms of pulmonary-renal syndrome, with positive ANCA and rapidly progressive evolution.

CASE REPORT

We describe the case of a 10-year-old girl referred to our hospital for evaluation of profound anemia detected in a primary health center. Five days before entry she had experienced malaise, pallor and began to cough up blood-tinged sputum that was at first attributed to dental bleeding. She was admitted to the infirmary with hemoglobin = 4 mg/dL, hematocrit = 14 %, platelets = 260,000, white blood cells = 8300, 74 % segmented, 4 % eosinophils, 19 % lymphocytes and 3 % monocytes. Radiographs of the chest revealed bilateral diffuse interstitial alveolar infiltrates. There was progressive worsening of cough and respiratory distress during the admission day, when she began to cough up large quantities of blood and hematuria was noted. There was rapid and progressive loss of renal function and massive lung hemorrhage. The antineutrophil cytoplasm antibody (ANCA) test with antigen specificity for myeloperoxidase (anti-MPO) was positive and the circulating anti-GBM showed an indeterminate result.

Cerebral vasculitis in chronic mucocutaneous candidiasis: autopsy case report

An autopsy case of chronic mucocutaneous candidiasis (CMCC) is reported here, in which cerebral vasculitis developed in the final stage. A 32-year-old man who had suffered from superficial candidial infection since his childhood was diagnosed as having CMCC. During the past 7 years the patient had developed various associated disorders including insulin-dependent diabetes mellitus (IDDM), common variable immunodeficiency (CVID), candidial esophagitis, multiple digestive tract ulcers and pyothorax. In 1998, at the age of 32, he developed convulsions that were accompanied by impairment of consciousness, and which were temporarily treated with steroid pulsed-medication. Epileptic status associated with widespread cerebral infarctions occurred subsequently, however, and the patient died of sepsis 2 months later. At autopsy, multiple cerebral infarctions and arterial thrombosis were evident. These were histologically proven to be primary vasculitis which was confined solely to the brain, and this was verified by general pathological examination. Thus, some as yet unknown cerebrovascular factors might be involved in the onset of an autoimmune-related vasculitis in patients with a longstanding immunodeficiency state such as CMCC.

Systemic necrotizing vasculitis: a review, with the personal perspective of a nurse educator

Although its definition is simple, systemic necrotizing vasculitis (SNV) is a complex, potentially life-threatening disease. By reviewing current published literature, this article provides an overview of vasculitis and focuses on what is common to the many individual systemic vascular diseases (vasculitides). A case history of a 10-year-old girl with SNV is included. Parse's Human Becoming theory is reviewed briefly as it applies to this case.

Overview of the radiology of connective tissue disorders in children

This review article describes the imaging finding of the connective tissue disorders in children. The radiological features of the following conditions are described; the spondyloarthropathics, systemic lupus erythematosus (SLE), dermatomyositis, scleroderma, the vasculitides, Kawasaki disease, synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO), and focal myositis. The features on several integrated imaging techniques are described.

Serum hepatocyte growth factor levels in Henoch-Schönlein purpura

BACKGROUND

Henoch-Schönlein purpura (HSP) is the most common form of vasculitis in children. The potential role of hepatocyte growth factor (HGF) in acute immune-mediated vasculitis has not been elucidated.

METHODS

Serum HGF levels were determined in patients with HSP.

RESULTS

In patients with acute-phase HSP, mean (+/- SD) serum HGF levels were 0.32 +/- 0.14 ng/mL and were significantly higher than those in the control group (0.11 +/- 0.10 ng/mL). This elevation of serum HGF levels recovered to control levels in parallel with improvement of the clinical symptoms.

CONCLUSIONS

It is suggested that elevation of serum HGF levels in patients with acute-phase HSP may reflect endothelial cell damage or dysfunction in HSP.

Cerebral vasculitis associated with chronic mucocutaneous candidiasis

Chronic mucocutaneous candidiasis is a heterogenous group of disorders, associated with a variety of autoimmune disorders and a broad spectrum of immune aberrations. We describe 2 patients with chronic mucocutaneous candidiasis who had cerebrovascular disease with severe neurologic sequelae. Results of angiography of cerebral vessels and brain biopsy in one were consistent with the diagnosis of cerebral vasculitis.

Emergency and critical care issues in pediatric rheumatology

The study of critical care issues in pediatric rheumatology is in its infancy, and the available literature is largely case studies and small retrospective series. A child's limited communication skills and the lack of understanding of disease consequences by both parent and child may cause both overuse and underuse of emergency services. To the extent that small case experiences in children with rheumatic diseases do not adequately reflect possible disease presentations or diagnostic and treatment options, pediatric and adult rheumatologists, intensivists, and emergency physicians should readily turn as needed to larger reported experiences in adults with similar conditions.

Systemic lupus erythematosus

Systemic Lupus Erythematosus (SLE) of childhood is a complex and challenging disease which can occur at any age. Identification of disease early in it's course and aggressive, appropriate management leads to improved outcome for an individual child. The history of SLE indicates how much progress has been made in the last quarter century. A discussion of the etiopathogenesis of SLE demonstrates the complexity of the syndrome. This is followed by a description of clinical manifestations, including diagnostic criteria, differential diagnosis and suggested methods for eliciting important symptoms to make the diagnosis. Evaluation of specific organs is next reviewed highlighting critical organ manifestations that are significant for future prognosis. Treatment of SLE includes a variety of medications, including non-steroidal anti-inflammatory medications, steroids and immuno-suppressive drugs. Attention to physical activity, stress and nutrition is equally important. Signs and symptoms that indicate disease flare or infection are described. Lastly, related syndromes are reviewed.