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Arya P, Westra SJ, Benavidez OJ, Natter MD, Murali MR. Case 17-2022: A 17-Year-Old Boy with Chest Pain. N Engl J Med 2022; 386:2222-2231. [PMID: 35675180 DOI: 10.1056/nejmcpc1909620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Puneeta Arya
- From the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), Pathology (M.R.M.), and Medicine (M.R.M.), Massachusetts General Hospital, and the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), and Medicine (M.R.M.), Harvard Medical School - both in Boston
| | - Sjirk J Westra
- From the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), Pathology (M.R.M.), and Medicine (M.R.M.), Massachusetts General Hospital, and the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), and Medicine (M.R.M.), Harvard Medical School - both in Boston
| | - Oscar J Benavidez
- From the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), Pathology (M.R.M.), and Medicine (M.R.M.), Massachusetts General Hospital, and the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), and Medicine (M.R.M.), Harvard Medical School - both in Boston
| | - Marc D Natter
- From the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), Pathology (M.R.M.), and Medicine (M.R.M.), Massachusetts General Hospital, and the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), and Medicine (M.R.M.), Harvard Medical School - both in Boston
| | - Mandakolathur R Murali
- From the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), Pathology (M.R.M.), and Medicine (M.R.M.), Massachusetts General Hospital, and the Departments of Pediatrics (P.A., O.J.B., M.D.N.), Radiology (S.J.W.), and Medicine (M.R.M.), Harvard Medical School - both in Boston
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Schutt C, Mirizio E, Salgado C, Reyes-Mugica M, Wang X, Chen W, Grunwaldt L, Schollaert KL, Torok KS. Transcriptomic Evaluation of Juvenile Localized Scleroderma Skin With Histologic and Clinical Correlation. Arthritis Rheumatol 2021; 73:1921-1930. [PMID: 33844442 DOI: 10.1002/art.41758] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 04/01/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Juvenile localized scleroderma (LS) is an autoimmune disease of the skin whose pathogenesis is not well understood due to the rarity of the disease. This study was undertaken to determine the skin transcriptome in skin biopsy tissue from children with juvenile LS compared to pediatric healthy controls, with identification of significant molecular targets using RNA sequencing (RNA-Seq). In this study, differentially expressed genes (DEGs) were assessed for correlations with histopathologic and clinical features in children with juvenile LS, and were used to group the children into distinct genetic clusters based on immunophenotype. METHODS RNA-Seq was performed on sections of paraffin-embedded skin tissue obtained from 28 children with juvenile LS and 10 pediatric healthy controls. RNA-Seq was carried out using an Illumina HTS TruSeq RNA Access library prep kit, with data aligned using STAR and data analysis using a DESeq2 platform. A standardized histologic scoring system was used to score skin sections for the severity of inflammation and levels of collagen deposition. Histologic scoring was completed by 2 pathologists who were blinded with regard to the status of each sample. Spearman's rank correlation coefficients were used to assess significant correlations between DEG expression profiles and skin histologic findings in patients with juvenile LS. RESULTS We identified 589 significant DEGs in children with juvenile LS as compared to healthy controls. Hierarchical clustering was used to demonstrate 3 distinct juvenile LS immunophenotype clusters. The histologic scores of skin inflammation (based on numbers and categories of inflammatory cell infiltrates) were significantly correlated with the expression levels of HLA-DPB1, HLA-DQA2, HLA-DRA, and STAT1 genes (rs > 0.5, P < 0.01). Collagen thickness correlated with the expression levels of collagen organization genes as well as with genes found to be correlated with the severity of inflammation, including genes for major histocompatibility complex (MHC) class I, MHC class II, and interferon-γ signaling. CONCLUSION Among children with juvenile LS, 3 distinct genetic signatures, or clusters, were identified. In one cluster, inflammation-related pathways were up-regulated, corresponding to the histologic skin inflammation score. In the second cluster, fibrosis-related pathways were up-regulated. In the third cluster, gene expression in the skin corresponded to the patterns seen in healthy controls. Up-regulation of HLA class II genes was observed within the first cluster (characterized by predominant inflammation), a feature that has also been observed in the peripheral blood of patients with morphea and in the skin of patients with systemic sclerosis.
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Affiliation(s)
- Christina Schutt
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, and University of Rochester MedicalCenter and Golisano Children's Hospital, Rochester, New York
| | | | - Claudia Salgado
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Miguel Reyes-Mugica
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Xinjun Wang
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Wei Chen
- University of Pittsburgh, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - Lorelei Grunwaldt
- University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | | | - Kathryn S Torok
- University of Pittsburgh, University of Pittsburgh Medical Center, Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania
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Glaser D, Torok KS. Evaluation and Treatment of Pediatric Localized Scleroderma: Pearls and Updates. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021. [DOI: 10.1007/s40674-021-00170-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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4
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Dag A, Tarakci E, Adrovic A, Kasapcopur O. Effects of sense and functionality changes in the hands on activity and participation in patients with juvenile scleroderma. Mod Rheumatol 2020; 31:657-668. [PMID: 32857628 DOI: 10.1080/14397595.2020.1816612] [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: 10/23/2022]
Abstract
OBJECTIVES The purpose of the study was to examine the effects of sense and functionality changes in the hands on activity and participation in patients with juvenile scleroderma (JS). METHODS Sixteen patients with juvenile localized scleroderma (JLS), 14 patients with Juvenile Systemic Sclerosis (JSS), and 30 healthy controls were included. Light touch-deep pressure sensation was assessed by Semmes-Weinstein monofilament test (SWMT). Localization sensation testing was performed by lightly stroking the patient's skin. The hand joint range of motion was measured with a goniometer, hand grip strength with Dynomometer, the pinch gripping force with pinch meter, and the hand mobility with modified Hand Mobility in Scleroderma (mHAMIS). Children completed their activity and participant performance status with 'Childhood Health Assessment Questionnaire (CHAQ)' and 'Jebson Taylor Hand Function Test (JTHFT)' questionnaire tests. The quality of life was evaluated using the 'Scleroderma Health Assessment Questionnaire (SHAQ)'. RESULTS There were significantly differences among evaluated three groups in light of touch-deep pressure sensation, sense of touch localization, range of motion, mHAMIS scores, JTHFT scores, all CHAQ scores, and almost all SHAQ score (p < .05). Over than half of patients with JSS (57.1%) and almost half of patients with JLS stated that their diseases obstructed them from doing any activity (p < .001). A significant percent of JSS patients (64.3%) had hand and wrist joint involvement. CONCLUSION Sensory and functional disorders caused by hand involvement in JS patients result in limitation of daily living activities and affect negatively the effective usage of the hand. Approximately half of the JS patients had disabilities in performing pinch motor skills of hands. The assessment of sensory symptoms that affect the functionality, activity level and participation of JSS and JLS patients should be considered during the routine clinical examination. We suggest the sensory therapies as an important factor in increasing the effectiveness of rehabilitation.
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Affiliation(s)
- Arzu Dag
- Faculty of Health Science, Department of Physiotherapy and Rehabilitation, Istanbul Yeni Yuzyil University, Istanbul, Turkey
| | - Ela Tarakci
- Faculty of Health Science, Division of Physical Therapy and Rehabilitation, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Cerrahpasa Medical School, Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Cerrahpasa Medical School, Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Foeldvari I, Culpo R, Sperotto F, Anton J, Avcin T, Baildam E, Boros C, Chaitow J, Constantin T, Kasapcopur O, Knupp Feitosa de Oliveira S, Pilkington C, Toplak N, van Royen A, Saad Magalhaes C, Vastert SJ, Wulffraat N, Zulian F. Consensus-based recommendations for the management of juvenile systemic sclerosis. Rheumatology (Oxford) 2020; 60:1651-1658. [PMID: 33147624 DOI: 10.1093/rheumatology/keaa584] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 06/18/2020] [Accepted: 07/11/2020] [Indexed: 12/29/2022] Open
Abstract
Abstract
Juvenile systemic sclerosis (JSSc) is a rare disease of childhood and currently no international consensus exists with regard to its assessment and treatment. This SHARE (Single Hub and Access point for paediatric Rheumatology in Europe) initiative, based on expert opinion informed by the best available evidence, provides recommendations for the assessment and treatment of patients with JSSc with a view to improving their outcome. Experts focused attention not only on the skin assessment but also on the early signs of internal organ involvement whose proper treatment can significantly affect the long-term outcome. A score for disease severity is proposed in order to perform a structured assessment of outcome over time but a validation in a wider patient population is recommended. Finally, a stepwise treatment approach is proposed in order to unify the standard of care throughout Europe with the aim to reduce morbidity and mortality in this disease.
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Affiliation(s)
- Ivan Foeldvari
- Hamburger Zentrum für Kinder- und Jugendrheumatologie, Schoen Clinic, Hamburg-Eilbek, Germany
| | - Roberta Culpo
- Department of Woman’s and Child’s Health, University of Padova, Padua, Italy
| | - Francesca Sperotto
- Department of Woman’s and Child’s Health, University of Padova, Padua, Italy
| | - Jordi Anton
- Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Tadej Avcin
- Department of Allergy, Rheumatology and Clinical Immunology, University Children’s Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Eileen Baildam
- Clinical and Academic Paediatric and Adolescent Rheumatology Unit, Alder Hey Children’s NHS Foundation Trust, Liverpool, UK
| | - Christina Boros
- Rheumatology, Women’s and Children’s Hospital, University of Adelaide, Adelaide, Australia
| | - Jeffrey Chaitow
- Rheumatology, The Children's Hospital Westmead, Australia, Sydney
| | - Tamas Constantin
- 2nd Department of Pediatrics, Semmelweis Hospital, Budapest, Hungary
| | - Ozgur Kasapcopur
- Department of Pediatrics, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sheila Knupp Feitosa de Oliveira
- Pediatric Rheumatology Unit, Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Clarissa Pilkington
- Centre for Adolescent Rheumatology, Institute of Child Health University College London, London, UK
| | - Natasa Toplak
- Department of Allergy, Rheumatology and Clinical Immunology, University Children’s Hospital, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Annet van Royen
- Paediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
| | | | - Sebastiaan J Vastert
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- The European Reference Network RITA
| | - Nico Wulffraat
- Department of Paediatric Rheumatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
- The European Reference Network RITA
| | - Francesco Zulian
- Department of Woman’s and Child’s Health, University of Padova, Padua, Italy
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Virdi A, Patrizi A, Cambiaghi S, Diociaiuti A, El Hachem M, Schena D, Bassi A, Bonamonte D, Brazzelli V, Belloni Fortina A, Pepe P, DI Lernia V, Neri I. A retrospective study on clinical subtypes and management of morphea in 10 Italian Dermatological Units. Ital J Dermatol Venerol 2020; 156:446-454. [PMID: 33070566 DOI: 10.23736/s2784-8671.20.06632-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND There are still few dermatological studies on morphea. We evaluated the epidemiological and clinical features and management of pediatric morphea, reporting dermatologists experience. METHODS A multicenter retrospective observational study was carried out on the epidemiological and clinical features and management of the disease between 01/01/2009 and 01/10/2014 in 10 Italian Dermatological Units. RESULTS We collected the data of 69 children affected by: circumscribed morphea (39.1%); linear morphea of trunk and limbs (14.5%); en coupe de sabre morphea (ECDS) (14.5%); progressive facial hemiatrophy (8.7%); generalized form (18.8%); mixed morphea (4.4%). The mean age at onset was 6.86±3.21 years, mainly between 2 and 8 years, but is statistically significantly lower for ECDS (4.5±3.03). Localizations were: head/neck (30.4%), limbs (26.1%), trunk (14.5%), 2 or more sites (29%), most often the trunk plus limbs. Extracutaneous manifestations were observed in 26.1% patients. 10 patients presented a second autoimmune disorder. Treatments were topical in 26.1% cases and systemic (alone or associated with topical treatments) in 68.1%. CONCLUSIONS There was a lack of uniformity in the management of patients and an increasing awareness of dermatologists on the use of systemic therapies, in particular of methotrexate, which is no longer exclusive to rheumatologists. Methotrexate causes stabilization and improvement of the clinical signs, but topical creams are still considered adjuvant or maintenance therapies during/after the use of systemic drugs.
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Affiliation(s)
- Annalucia Virdi
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy -
| | - Annalisa Patrizi
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefano Cambiaghi
- Unit of Pediatric Dermatology, Department of Pathophysiology and Transplantation, Maggiore Polyclinic Hospital, IRCCS Ca' Granda Foundation, University of Milan, Milan, Italy
| | - Andrea Diociaiuti
- Dermatology Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - May El Hachem
- Dermatology Unit, Bambino Gesù Children's Hospital IRCCS, Rome, Italy
| | - Donatella Schena
- Section of Dermatology and Venereology, Department of Medicine, University of Verona, Verona, Italy
| | - Andrea Bassi
- Unit of Pediatric Dermatology Service, Anna Meyer Pediatric Hospital, Florence, Italy
| | - Domenico Bonamonte
- Section of Dermatology, Department of Biomedical Science and Human Oncology, University of Bari, Bari, Italy
| | - Valeria Brazzelli
- Department of Clinical-Surgical, Diagnostic and Pediatric Science, Institute of Dermatology, IRCCS San Matteo Polyclinic Foundation, University of Pavia, Pavia, Italy
| | - Anna Belloni Fortina
- Unit of Pediatric Dermatology, Department of Medicine, University of Padua, Padua, Italy
| | - Patrizia Pepe
- Unit of Dermatology, Surgical, Medical and Dental Sciences, Department of Morphological Sciences Related to Transplant, Oncology and Regenerative Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Vito DI Lernia
- Unit of Dermatology, Arcispedale S. Maria Nuova IRCCS, Reggio Emilia, Italy
| | - Iria Neri
- Division of Dermatology, Department of Experimental, Diagnostic and Specialty Medicine, S. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Kaushik A, Mahajan R, De D, Handa S. Paediatric morphoea: a holistic review. Part 1: epidemiology, aetiopathogenesis and clinical classification. Clin Exp Dermatol 2020; 45:673-678. [PMID: 32472964 DOI: 10.1111/ced.14234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/29/2022]
Abstract
Morphoea, also known as localized scleroderma, is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Paediatric-onset disease is not uncommon and is associated with frequent relapses. The disease has complex pathogenetic mechanisms and multiple clinical subtypes, and affects children of all ages. Recent research has focused on elucidating the disease pathophysiology and identifying measures of disease activity. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected, and results were analysed before being summarized. In the first of this two-part review, we provide a bird's-eye view of the current literature concerning the epidemiology, aetiopathogenesis and clinical classification of paediatric morphoea; in Part 2, we review the diagnosis, markers of disease activity, management and natural history.
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Affiliation(s)
- A Kaushik
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R Mahajan
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - D De
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Handa
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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8
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Kaushik A, Mahajan R, De D, Handa S. Paediatric morphoea: a holistic review. Part 2: diagnosis, measures of disease activity, management and natural history. Clin Exp Dermatol 2020; 45:679-684. [PMID: 32449205 DOI: 10.1111/ced.14236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2020] [Indexed: 12/01/2022]
Abstract
Paediatric morphoea is a debilitating fibrosing disorder of uncertain aetiology, affecting the skin and subcutaneous tissues. Defining optimum management strategies in paediatric morphoea remains an ongoing challenge, owing to the varied presentations and a relative paucity of paediatric-specific studies. We performed a literature search on PubMed, MEDLINE and Google Scholar, using keywords such as 'pediatric morphea', 'juvenile localised scleroderma' and 'juvenile systemic sclerosis'. Relevant studies, including randomized trials, reviews of standard current guidelines and original research articles, were selected and results analysed before summarizing them. In Part 1 of this review, we described the epidemiology, aetiopathogenesis and clinical classification; in this part, we discuss the diagnosis, markers of disease activity, management and natural history in paediatric morphoea.
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Affiliation(s)
- A Kaushik
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - R Mahajan
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - D De
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - S Handa
- Department of Dermatology, Venereology, and Leprology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
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Mertens J, de Jong E, van den Hoogen L, Wienke J, Thurlings R, Seyger M, Hoppenreijs E, Wijngaarde C, van Vlijmen-Willems I, van den Bogaard E, Giovannone B, van Wijk F, van Royen-Kerkhof A, Marut W, Radstake T. The identification of CCL18 as biomarker of disease activity in localized scleroderma. J Autoimmun 2019; 101:86-93. [DOI: 10.1016/j.jaut.2019.04.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Revised: 04/06/2019] [Accepted: 04/08/2019] [Indexed: 01/10/2023]
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10
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Jung JY, Kim MY, Suh CH, Kim HA. Off-label use of tocilizumab to treat non-juvenile idiopathic arthritis in pediatric rheumatic patients: a literature review. Pediatr Rheumatol Online J 2018; 16:79. [PMID: 30547812 PMCID: PMC6295005 DOI: 10.1186/s12969-018-0296-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 12/04/2018] [Indexed: 12/13/2022] Open
Abstract
Tocilizumab, an anti-interleukin-6 (IL-6) agent, is indicated as a treatment for several autoimmune or inflammatory diseases, including rheumatoid arthritis and juvenile idiopathic arthritis (JIA). IL-6 plays roles in both immune system dysregulation and inflammation, and thus efforts to extend the utility of tocilizumab in patients with autoinflammatory conditions are ongoing. Here, we survey the literature on the off-label use of tocilizumab in patients with juvenile-onset rheumatic diseases including juvenile systemic lupus erythematosus (SLE), juvenile dermatomyositis (DM), vasculitis, juvenile scleroderma, and other autoinflammatory diseases. There is no real evidence that tocilizumab is useful for patients with SLE and juvenile DM, but several cases of childhood Takayasu arteritis have experienced promising outcomes. In juvenile-onset scleroderma, for which no therapy that can halt disease progression is available, tocilizumab may stop progression and the associated functional impairment. Tocilizumab prevents systemic inflammation in patients with Kawasaki's disease, but may develop coronary aneurysms. Tocilizumab has been used to treat several pediatric autoinflammatory diseases, including JIA-associated uveitis and Castleman's disease. Further work in larger populations is necessary to confirm the effects of tocilizumab in patients with pediatric rheumatic diseases.
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Affiliation(s)
- Ju-Yang Jung
- 0000 0004 0532 3933grid.251916.8Department of Rheumatology, Ajou University of medical school, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499 Republic of Korea
| | - Moon-Young Kim
- 0000 0004 0532 3933grid.251916.8Department of Rheumatology, Ajou University of medical school, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499 Republic of Korea
| | - Chang-Hee Suh
- 0000 0004 0532 3933grid.251916.8Department of Rheumatology, Ajou University of medical school, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499 Republic of Korea
| | - Hyoun-Ah Kim
- Department of Rheumatology, Ajou University of medical school, 164 Worldcup-ro, Yeongtong-gu, Suwon, 16499, Republic of Korea.
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11
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Extensive Bone Lengthening for a Patient with Linear Morphea. Case Rep Orthop 2018; 2018:4535804. [PMID: 30210887 PMCID: PMC6120294 DOI: 10.1155/2018/4535804] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2018] [Revised: 07/14/2018] [Accepted: 07/24/2018] [Indexed: 12/03/2022] Open
Abstract
Localized scleroderma, also known as morphea, is a rare condition characterized by progressive sclerosis of the skin and associated atrophy of the underlying tissues. The linear type of localized scleroderma is the most frequent form in childhood, usually affecting unilateral extremities. Fibrosclerosis of the fasciae and muscles can spread across joints and impair the range of motion of the joint. Dysplastic and/or atrophic bones of the affected lower extremity can lead to clinically significant leg length discrepancy (LLD). Limb reconstruction surgery has rarely been indicated for LLD in patients with linear morphea. We report on a case of extensive bone lengthening for appreciable LLD in a pediatric patient with linear morphea. A Japanese girl with linear morphea underwent staged simultaneous lengthening of the femur and tibia twice at seven and eleven years of age using a unilateral external fixator. A healing index exceeded 100 days/cm except for the first femoral lengthening that was complicated by regenerate fracture. At the final follow-up, LLD of 38 mm remained, but she could walk independently without a brace or a crutch. Due to soft tissue tightness and poor regenerative ability in the affected limb, cautions should be taken to prevent regenerate fracture and/or malalignment of the limb.
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12
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Ferreli C, Gasparini G, Parodi A, Cozzani E, Rongioletti F, Atzori L. Cutaneous Manifestations of Scleroderma and Scleroderma-Like Disorders: a Comprehensive Review. Clin Rev Allergy Immunol 2018; 53:306-336. [PMID: 28712039 DOI: 10.1007/s12016-017-8625-4] [Citation(s) in RCA: 104] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Scleroderma refers to an autoimmune connective tissue fibrosing disease, including three different subsets: localized scleroderma, limited cutaneous systemic sclerosis, and diffuse cutaneous systemic sclerosis with divergent patterns of organ involvement, autoantibody profiles, management, and prognostic implications. Although systemic sclerosis is considered the disease prototype that causes cutaneous sclerosis, there are many other conditions that can mimic and be confused with SSc. They can be classified into immune-mediated/inflammatory, immune-mediated/inflammatory with abnormal deposit (mucinoses), genetic, drug-induced and toxic, metabolic, panniculitis/vascular, and (para)neoplastic disorders according to clinico-pathological and pathogenetic correlations. This article reviews the clinical presentation with emphasis on cutaneous disease, etiopathogenesis, diagnosis, and treatment options available for the different forms of scleroderma firstly and for scleroderma-like disorders, including scleromyxedema, scleredema, nephrogenic systemic fibrosis, eosinophilic fasciitis, chronic graft-versus-host disease, porphyria cutanea tarda, diabetic stiff-hand syndrome (diabetic cheiroartropathy), and other minor forms. This latter group of conditions, termed also scleroderma mimics, sclerodermiform diseases, or pseudosclerodermas, shares the common thread of skin thickening but presents with distinct cutaneous manifestations, skin histology, and systemic implications or disease associations, differentiating each entity from the others and from scleroderma. The lack of Raynaud's phenomenon, capillaroscopic abnormalities, or scleroderma-specific autoantibodies is also important diagnostic clues. As cutaneous involvement is the earliest, most frequent and characteristic manifestation of scleroderma and sclerodermoid disorders, dermatologists are often the first-line doctors who must be able to promptly recognize skin symptoms to provide the affected patient a correct diagnosis and appropriate management.
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Affiliation(s)
- Caterina Ferreli
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy.
| | - Giulia Gasparini
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Aurora Parodi
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Emanuele Cozzani
- Section of Dermatology, Department of Health Sciences, DISSAL, IRCSS-AOU S. Martino-IST, University of Genoa, Genoa, Italy
| | - Franco Rongioletti
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
| | - Laura Atzori
- Section of Dermatology, Department of Medical Sciences and Public Health, University of Cagliari, Cagliari, Italy
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Stasiulis E, Gladstone B, Boydell K, O'Brien C, Pope E, Laxer RM. Children with facial morphoea managing everyday life: a qualitative study. Br J Dermatol 2018; 179:353-361. [PMID: 29451694 DOI: 10.1111/bjd.16449] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/06/2018] [Indexed: 01/15/2023]
Abstract
BACKGROUND Facial morphoea is a chronic inflammatory skin disorder, typically presenting in childhood and adolescence, which can be disfiguring, and which has been suggested to cause mild-to-moderate impairment in quality of life. OBJECTIVES To explore the everyday experiences of children with facial morphoea by examining the psychosocial impact of living with facial morphoea and how children and their families manage its impact. METHODS We used a qualitative, social constructionist approach involving focus groups, in-depth interviews and drawing activities with 10 children with facial morphoea aged 8-17 years and 13 parents. Interpretive thematic analysis was utilized to examine the data. RESULTS Children and parents reported on the stress of living with facial morphoea, which was related to the lack of knowledge about facial morphoea and the extent to which they perceived themselves as different from others. Self-perceptions were based on the visibility of the lesion, different phases of life transitions and the reactions of others (e.g. intrusive questioning and bullying). Medication routines, and side-effects such as weight gain, added to the stress experienced by the participants. To manage the impact of facial morphoea, children and their parents used strategies to normalize the experience by hiding physical signs of the illness, constructing explanations about what 'it' is, and by connecting with their peers. CONCLUSIONS Understanding what it is like to live with facial morphoea from the perspectives of children and parents is important for devising ways to help children with the disorder achieve a better quality of life. Healthcare providers can help families access resources to manage anxiety, deal with bullying and construct adequate explanations of facial morphoea, in addition to providing opportunities for peer support.
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Affiliation(s)
- E Stasiulis
- Child and Youth Mental Health Research Unit, The Hospital for Sick Children, Toronto, ON, Canada.,Institute of Medical Science, Toronto, ON, Canada
| | - B Gladstone
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - K Boydell
- Child and Youth Mental Health Research Unit, The Hospital for Sick Children, Toronto, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Black Dog Institute, University of South Wales, Randwick, NSW, Australia
| | - C O'Brien
- Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Rehabilitation Services, The Hospital for Sick Children, Toronto, ON, Canada
| | - E Pope
- Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
| | - R M Laxer
- Division of Rheumatology, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada.,Department of Medicine, The Hospital for Sick Children, Toronto, ON, Canada
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15
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Morfea en la infancia: actualización. ACTAS DERMO-SIFILIOGRAFICAS 2018; 109:312-322. [DOI: 10.1016/j.ad.2017.06.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2017] [Revised: 06/12/2017] [Accepted: 06/25/2017] [Indexed: 10/18/2022] Open
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Juvenile Scleroderma: A Referral Center Experience. Arch Rheumatol 2018; 33:344-351. [PMID: 30632525 DOI: 10.5606/archrheumatol.2018.6578] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/13/2017] [Indexed: 12/23/2022] Open
Abstract
Objectives This study aims to evaluate the demographic and clinical features, laboratory data, treatment modalities, and outcomes of juvenile systemic sclerosis (JSS) and juvenile localized scleroderma (JLS) patients at a referral pediatric rheumatology center in Turkey. Patients and methods Medical records of a total of 57 patients, including 29 with JSS (1 male, 28 females; mean age 18.3±3.2 years; range 14 to 27 years) and 28 with JLS (6 males, 22 females; mean age 14.4±4.8 years; range 6 to 23 years), diagnosed betweenJanuary 2006 and Mart 2015 and followed-up for at least six months were evaluated in this retrospective longitudinal study. All medical records were retrospectively analyzed for demographic, clinical, and laboratory findings. Results Mean age at disease onset was 9.9±4.2 years and 7.7±3.9 years for JSS and JLS, respectively. Mean ages at diagnosis and at the time of study were lower in JLS: 9.1±3.5 years vs. 11.7±3.7 years and 14.4±4.8 years vs. 18.3±3.2 years, respectively. Mean disease duration was 7.8±5.2 years and 8.0±4.3 years for JSS and JLS, respectively. Among JSS patients, interstitial lung disease was seen in eight (27%), pulmonary hypertension in three (10%), and arrhythmia in one (3%). One JSS patient (3%) died as a consequence of cardiac sclerosis. Corticosteroids with methotrexate were used in 29 JSS patients (100%) and in 21 JLS patients (75%). Patients with vasculopathy were treated with nifedipine (n=18, 62%) and bosentan (n=12, 41%). Internal organ involvement was treated with high-dose cyclophosphamide (n=10, 34%) or biological agent (n=3, 10%). Conclusion Close monitoring of internal organ involvement is of great importance in preventing disease-related complications in JSS and JLS. Although rare, vital organ involvement has a devastating effect on prognosis. Biological agents represent an option for patients resistant to standard immunosuppressive treatment.
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Schoch JJ, Schoch BS, Werthel JD, McIntosh AL, Davis DMR. Orthopedic complications of linear morphea: Implications for early interdisciplinary care. Pediatr Dermatol 2018; 35:43-46. [PMID: 29119592 DOI: 10.1111/pde.13336] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Linear morphea of the limb primarily affects children, and extracutaneous manifestations are common. Orthopedic surgeons are often essential in the care of patients with linear morphea, yet there are few reports outlining specific orthopedic complications in this population. We sought to improve the understanding of orthopedic complications in linear morphea of the limb. Between 1999 and 2014, 51 children were evaluated for linear morphea of an extremity. Twenty-six (51%) had documented orthopedic manifestations. Outcome measures included limb length discrepancy, angular malalignment, limb atrophy, and orthopedic surgical intervention. Joint contractures were most common, affecting 88% of patients, followed by limb atrophy, angular deformity, and limb length discrepancy; 14% required surgical intervention. Despite the use of systemic immunosuppressive therapy in many patients, approximately half of patients with linear morphea of an extremity have orthopedic disease. Early orthopedist involvement is crucial to improve limb alignment and preserve function.
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Affiliation(s)
- Jennifer J Schoch
- Department of Dermatology, University of Florida, Gainesville, Florida
| | - Bradley S Schoch
- Department of Orthopedic Surgery, University of Florida, Gainesville, Florida
| | | | - Amy L McIntosh
- Department of Orthopedic Surgery, Texas Scottish Rite Hospital, Dallas, Texas
| | - Dawn M R Davis
- Department of Dermatology, Mayo Clinic, Rochester, MN, USA
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Esophageal abnormalities in juvenile localized scleroderma: is it associated with other extracutaneous manifestations? REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:521-525. [PMID: 29173689 DOI: 10.1016/j.rbre.2016.09.011] [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: 03/17/2016] [Accepted: 07/30/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To assess esophageal involvement (EI) in juvenile localized scleroderma (JLS) population and the possible association between this gastrointestinal manifestation and demographic data, clinical features, laboratory exams, treatments and outcomes. METHODS For a period of 30 years, 5881 patients with rheumatic diseases were followed in our Pediatric Rheumatology Division. EI was defined by the presence of symptoms (solid/liquid dysphagia, heartburn, esophageal regurgitation, nausea/vomiting and epigastralgia) and confirmed by at least one EI exam abnormality: barium contrast radiography, upper gastrointestinal endoscopy and 24-hour esophageal pH-monitoring. RESULTS JLS was observed in 56/5881 patients (0.9%), mainly linear morphea subtype. EI was observed in 23/56(41%) of JLS patients. Eight(35%) of 23 EI patients with JLS were symptomatic and presented heartburn(5/8), solid and liquid dysphagia(3/8), nausea and epigastralgia(1/8). The frequency of any cumulative extracutaneous manifestations (calcinosis, arthritis/arthralgia, central nervous system, interstitial pneumonitis, mesangial nephritis and/or arrhythmia) was significantly higher in JLS patients with EI compared to those without this complication (56% vs. 24%, p=0.024). No differences were evidenced in demographic data, JLS subtypes and in each extracutaneous manifestation in both groups (p>0.05). The frequency of methotrexate use was significantly higher in JLS patients with EI compared to those without (52% vs. 12%, p=0.002). Autoantibody profile (antinuclear antibodies, anti-SCL-70, rheumatoid factor, anticentromere, anti-cardiolipin, anti-Ro/SSA and anti-La/SSB) was similar in both groups (p>0.05). CONCLUSIONS Our study demonstrated that EI was frequently observed in JLS patients, mainly in asymptomatic patients with linear subtype. EI occurred in JLS patients with other extracutaneous manifestations and required methotrexate therapy.
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Couto SB, Sallum AM, Henriques LS, Malheiros DM, Silva CA, Vaisbich MH. Nephrotic syndrome as the first manifestation of juvenile systemic scleroderma. REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:613-615. [PMID: 29173697 DOI: 10.1016/j.rbre.2014.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/17/2014] [Indexed: 11/30/2022] Open
Affiliation(s)
- Saulo B Couto
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Unidade de Nefrologia Pediátrica, São Paulo, SP, Brazil
| | - Adriana M Sallum
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Unidade de Nefrologia Pediátrica, São Paulo, SP, Brazil
| | - Luciana S Henriques
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Unidade de Nefrologia Pediátrica, São Paulo, SP, Brazil
| | - Denise M Malheiros
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Departamento de Patologia, São Paulo, SP, Brazil
| | - Clovis A Silva
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Departamento de Patologia, São Paulo, SP, Brazil
| | - Maria H Vaisbich
- Universidade de São Paulo (USP), Faculdade de Medicina, Hospital das Clínicas, Instituto da Criança, Unidade de Nefrologia Pediátrica, São Paulo, SP, Brazil.
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Valões CC, Novak GV, Brunelli JB, Kozu KT, Toma RK, Silva CA. Anormalidades esofágicas na esclerodermia localizada juvenil: associação com outras manifestações extracutâneas? REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Abstract
Morphea, also known as localized scleroderma, encompasses a group of idiopathic sclerotic skin diseases. The spectrum ranges from relatively mild phenotypes, which generally cause few problems besides local discomfort and visible disfigurement, to subtypes with severe complications such as joint contractures and limb length discrepancies. Eosinophilic fasciitis (EF, Shulman syndrome) is often regarded as belonging to the severe end of the morphea spectrum. The exact driving mechanisms behind morphea and EF pathogenesis remain to be elucidated. However, extensive extracellular matrix formation and autoimmune dysfunction are thought to be key pathogenic processes. Likewise, these processes are considered essential in systemic sclerosis (SSc) pathogenesis. In addition, similarities in clinical presentation between morphea and SSc have led to many theories about their relatedness. Importantly, morphea may be differentiated from SSc based on absence of sclerodactyly, Raynaud’s phenomenon, and nailfold capillary changes. The diagnosis of morphea is often based on characteristic clinical findings. Histopathological evaluation of skin biopsies and laboratory tests are not necessary in the majority of morphea cases. However, full-thickness skin biopsies, containing fascia and muscle tissue, are required for the diagnosis of EF. Monitoring of disease activity and damage, especially of subcutaneous involvement, is one of the most challenging aspects of morphea care. Therefore, data harmonization is crucial for optimizing standard care and for comparability of study results. Recently, the localized scleroderma cutaneous assessment tool (LoSCAT) has been developed and validated for morphea. The LoSCAT is currently the most widely reported outcome measure for morphea. Care providers should take disease subtype, degree of activity, depth of involvement, and quality-of-life impairments into account when initiating treatment. In most patients with circumscribed superficial subtypes, treatment with topical therapies suffices. In more widespread disease, UVA1 phototherapy or systemic treatment with methotrexate (MTX), with or without a systemic corticosteroid combination, should be initiated. Disappointingly, few alternatives for MTX have been described and additional research is still needed to optimize treatment for these debilitating conditions. In this review, we present a state-of-the-art flow chart that guides care providers in the treatment of morphea and EF.
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Musculoskeletal MRI findings of juvenile localized scleroderma. Pediatr Radiol 2017; 47:442-449. [PMID: 28091699 DOI: 10.1007/s00247-016-3765-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 10/17/2016] [Accepted: 12/06/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Juvenile localized scleroderma comprises a group of autoimmune conditions often characterized clinically by an area of skin hardening. In addition to superficial changes in the skin and subcutaneous tissues, juvenile localized scleroderma may involve the deep soft tissues, bones and joints, possibly resulting in functional impairment and pain in addition to cosmetic changes. OBJECTIVE There is literature documenting the spectrum of findings for deep involvement of localized scleroderma (fascia, muscles, tendons, bones and joints) in adults, but there is limited literature for the condition in children. We aimed to document the spectrum of musculoskeletal magnetic resonance imaging (MRI) findings of both superficial and deep juvenile localized scleroderma involvement in children and to evaluate the utility of various MRI sequences for detecting those findings. MATERIALS AND METHODS Two radiologists retrospectively evaluated 20 MRI studies of the extremities in 14 children with juvenile localized scleroderma. Each imaging sequence was also given a subjective score of 0 (not useful), 1 (somewhat useful) or 2 (most useful for detecting the findings). RESULTS Deep tissue involvement was detected in 65% of the imaged extremities. Fascial thickening and enhancement were seen in 50% of imaged extremities. Axial T1, axial T1 fat-suppressed (FS) contrast-enhanced and axial fluid-sensitive sequences were rated most useful. CONCLUSION Fascial thickening and enhancement were the most commonly encountered deep tissue findings in extremity MRIs of children with juvenile localized scleroderma. Because abnormalities of the skin, subcutaneous tissues and fascia tend to run longitudinally in an affected limb, axial T1, axial fluid-sensitive and axial T1-FS contrast-enhanced sequences should be included in the imaging protocol.
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Zulian F, Balzarin M, Birolo C. Recent advances in the management of juvenile systemic sclerosis. Expert Rev Clin Immunol 2016; 13:361-369. [DOI: 10.1080/1744666x.2017.1243467] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Francesco Zulian
- Pediatric Rheumatology Unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Marta Balzarin
- Pediatric Rheumatology Unit, Department for Woman and Child Health, University of Padua, Padua, Italy
| | - Carolina Birolo
- Pediatric Rheumatology Unit, Department for Woman and Child Health, University of Padua, Padua, Italy
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[Morphea or juvenile localised scleroderma: Case report]. ACTA ACUST UNITED AC 2016; 87:279-83. [PMID: 26976080 DOI: 10.1016/j.rchipe.2016.01.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 01/19/2016] [Accepted: 01/31/2016] [Indexed: 11/21/2022]
Abstract
INTRODUCTION Morphea or juvenile localised scleroderma (JLS) is an autoimmune, inflammatory, chronic, slowly progressive connective tissue disease of unknown cause that preferably affects skin and underlying tissues. OBJECTIVE To report a case of Juvenil Localised scleroderma in an 8-year old girl, contributing to an early diagnosis and treatment. CLINICAL CASE The case is presented of an 8 year-old girl who presented with indurated hypopigmented plaques, of linear distribution in the right upper extremity of two years onset, together with papery texture hyperpigmented indurated plaques with whitish areas of thinned skin in right lower extremity, and leg and ankle swelling. The clinical features and diagnostic tests, including histology were compatible with linear and pansclerotic JLS. She started with immunosuppressive therapy, physiotherapy, and occupational therapy. CONCLUSIONS We report a case of linear and pansclerotic ELJ type, in which there was a 2 year delay in diagnosis, however the response to treatment was positive as expected.
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McCann LJ, Pain CE. A Practical Approach to Juvenile Dermatomyositis and Juvenile Scleroderma. Indian J Pediatr 2016; 83:163-71. [PMID: 26489640 DOI: 10.1007/s12098-015-1907-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 09/09/2015] [Indexed: 01/15/2023]
Abstract
Juvenile dermatomyositis and juvenile scleroderma are rare multisystem autoimmune disorders. Although they share some pathognomonic hallmarks with adult onset myositis or scleroderma, there are significant differences in presentation, characteristics and associated features when the diseases present in childhood. In view of this, and the rarity of the conditions, it is important for care to be led by teams with expertise in pediatric rheumatology conditions. Prognosis has improved significantly in the West; likely due to early diagnosis and aggressive treatment with immunosuppressive medications. However, this trend is not replicated in the developing world. Early recognition of these diseases is crucial to achieve rapid and sustained remission and prevent disease or medication associated complications. This article aims to provide a practical overview for recognition, diagnosis and treatment of these conditions.
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Adrovic A, Oztunc F, Barut K, Koka A, Gojak R, Sahin S, Demir T, Kasapcopur O. The frequency of pulmonary hypertension in patients with juvenile scleroderma. Bosn J Basic Med Sci 2015; 15:30-5. [PMID: 26614849 DOI: 10.17305/bjbms.2015.596] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Revised: 07/25/2015] [Accepted: 07/26/2015] [Indexed: 01/15/2023] Open
Abstract
Juvenile scleroderma (JS) represents a rarely seen group of connective tissue diseases with multiple organ involvement. Cardiac involvement in JSS is well known and, although rare in children, it may be an important cause of mortality and morbidity. Therefore, an early determination of cardio-vascular and pulmonary involvement is of the most relevance to reduce the mortality in patients with juvenile scleroderma. The aim of the study was to explore the non-invasive methods (Doppler echocardiography, pulmonary function tests), Forced vital capacity (FVC) and Carbon monoxide diffusion capacity (DLCO) in the assessment of the cardiopulmonary involvement in patients with JS. The assessment of pulmonary arterial pressure (PAP) and risk factors for pulmonary arterial hypertension (PAH) were made by the measurement of maximum tricuspid insufficiency (TI), end-diastolic pulmonary insufficiency (PI), ratio of acceleration time (AT) to ejection time (ET) (AT/ET), right atrial pressure (RAP) and contraction of vena cava inferior during inspiration. Thirty-five patients with confirmed JS were included in the study. The mean age of onset of the disease was 9.57 years (median 10 years, range 2-18 years). The mean disease duration and follow-up time was 2 years (median 1 year, range 0.5-8 years) and 3.57 years (median 2 years, range 0.5-14.5 years), respectively.The values of all the analyzed parameters including TI, PI, AT/ET, PAP, FVC and DLCO were found to be within normal ranges in all the patients tested, confirming an uncommonness of cardiopulmonary involvement in patients with juvenile scleroderma.
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Affiliation(s)
- Amra Adrovic
- Department of Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey.
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Spencer CH, Patwardhan A. Pediatric Rheumatology for the Primary Care Clinicians-Recognizing Patterns of Disease. Curr Probl Pediatr Adolesc Health Care 2015. [PMID: 26205101 DOI: 10.1016/j.cppeds.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This review presents a diagnostic approach to musculoskeletal and rheumatic diseases in children for primary care clinicians. The focus is on juvenile idiopathic arthritis (JIA) as the major arthritis disease in children. It is necessary to know the personalities of these JIA categories. It is also crucial to be able to recognize the common infectious, orthopedic and mechanical, malignant, genetic, other rheumatic diseases, and other miscellaneous syndromes that can mimic JIA. To do so requires recognition of clinical patterns using a thorough musculoskeletal and rheumatic history and repeated complete physical exams with emphasis on the musculoskeletal exam. It also requires targeted and limited laboratory testing with careful follow-up over time.
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Yun D, Stein SL. Review of the cutaneous manifestations of autoimmune connective tissue diseases in pediatric patients. World J Dermatol 2015; 4:80-94. [DOI: 10.5314/wjd.v4.i2.80] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2014] [Revised: 02/25/2015] [Accepted: 04/07/2015] [Indexed: 02/06/2023] Open
Abstract
Autoimmune connective tissue diseases are chronic inflammatory disorders associated with complex genetic and environmental interplay resulting in a variety of cutaneous and systemic manifestations. Pediatric onset of these disorders carries a unique diagnostic pressure for the clinician due to the potential years of disease burden and complications. Mortality and morbidity from these disorders has fallen dramatically over the past fifty years due to increasing awareness of these disease sequelae and utilization of systemic treatment modalities when necessary. This review highlights the clinical features that are unique to pediatric presentations of lupus erythematosus, juvenile idiopathic arthritis, juvenile dermatomyositis, juvenile onset systemic sclerosis and morphea. Each of these disorders has a distinct appearance corresponding to a particular cutaneous and systemic clinical course and prognosis. Awareness of the associated potential systemic complications can also alert the clinician to make astute management decisions when confronted with a probable rheumatologic case. Cutaneous symptoms may predate onset of systemic symptoms and by keeping the rheumatologic differential diagnoses in mind, the dermatologist can play a key role in potentially offsetting autoimmune disease burden in children.
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Tolkachjov SN, Patel NG, Tollefson MM. Progressive hemifacial atrophy: a review. Orphanet J Rare Dis 2015; 10:39. [PMID: 25881068 PMCID: PMC4391548 DOI: 10.1186/s13023-015-0250-9] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 03/09/2015] [Indexed: 11/23/2022] Open
Abstract
Background Progressive Hemifacial Atrophy (PHA) is an acquired, typically unilateral, facial distortion with unknown etiology. The true incidence of this disorder has not been reported, but it is often regarded as a subtype of localized scleroderma. Historically, a debate existed whether PHA is a form of linear scleroderma, called morphea en coup de sabre (ECDS), or whether these conditions are inherently different processes or appear on a spectrum (; Adv Exp Med Biol 455:101–4, 1999; J Eur Acad Dermatol Venereol 19:403–4, 2005). Currently, it is generally accepted that both diseases exist on a spectrum of localized scleroderma and often coexist. The pathogenesis of PHA has not been delineated, but trauma, autoimmunity, infection, and autonomic dysregulation have all been suggested. The majority of patients have initial manifestations in the first two decades of life; however, late presentations in 6th and 7th decades are also described [J Am Acad Dermatol 56:257–63, 2007; J Postgrad Med 51:135–6, 2005; Neurology 61:674–6, 2003]. The typical course of PHA is slow progression over 2-20 years and eventually reaching quiescence. Systemic associations of PHA are protean, but neurological manifestations of seizures and headaches are common [J Am Acad Dermatol 56:257–63, 2007; Neurology 48:1013–8, 1997; Semin Arthritis Rheum 43:335–47, 2013]. As in many rare diseases, standard guidelines for imaging, treatment, and follow-up are not defined. Methods This review is based on a literature search using PubMed including original articles, reviews, cases and clinical guidelines. The search terms were “idiopathic hemifacial atrophy”, “Parry-Romberg syndrome”, “Romberg’s syndrome”, “progressive hemifacial atrophy”, “progressive facial hemiatrophy”, “juvenile localized scleroderma”, “linear scleroderma”, and “morphea en coup de sabre”. The goal of this review is to summarize clinical findings, theories of pathogenesis, diagnosis, clinical course, and proposed treatments of progressive hemifacial atrophy using a detailed review of literature. Inclusion- and exclusion criteria Review articles were used to identify primary papers of interest while retrospective cohort studies, case series, case reports, and treatment analyses in the English language literature or available translations of international literature were included.
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Affiliation(s)
| | - Nirav G Patel
- Mayo Clinic, 13400 E. Shea Blvd, Scottsdale, AZ, 85259, USA.
| | - Megha M Tollefson
- Mayo Clinic, Department of Dermatology, 200 First Street SW, Rochester, MN, 55905, USA.
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A rare cause of gingival recession: morphea with intra-oral involvement. Oral Surg Oral Med Oral Pathol Oral Radiol 2015; 119:e257-64. [PMID: 25864825 DOI: 10.1016/j.oooo.2015.02.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 02/04/2015] [Indexed: 12/11/2022]
Abstract
Morphea is an inflammatory disorder of the skin and underlying tissues characterized by an overabundance of collagen leading to fibrosis. The prevalence of this disease is estimated at around 0.4-2.7/100,000 people. When the process occurs in the gingival tissues, it induces traction, which can cause gingival recession. A 19-year-old woman was referred to the clinic for a progressive recession on teeth 11 and 12. A pale, atrophic, linear region extending from her nose to her upper lip on the right-hand side of her face was diagnosed as morphea en coup de sabre. Cone beam computed tomography, quantitative polymerase chain reaction and histologic evaluation were used to assess the pathology. Treatment with methotrexate was conducted. After 12 months, no progression of the recession could be observed.
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Couto SB, Sallum AM, Henriques LS, Malheiros DM, Silva CA, Vaisbich MH. [Nephrotic syndrome as the first manifestation of juvenile systemic scleroderma.]. REVISTA BRASILEIRA DE REUMATOLOGIA 2014; 57:S0482-5004(14)00188-0. [PMID: 25440709 DOI: 10.1016/j.rbr.2014.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 08/17/2014] [Indexed: 10/24/2022] Open
Abstract
Renal involvement occurs in 1%-12% in juvenile systemic sclerosis (JSSc) patients, mainly with arterial hypertension, proteinuria and scleroderma renal crisis. We report herein a patient who presented nephrotic syndrome (NS) as the first manifestation of JSSc with focal segmental glomerulosclerosis (FSGS). A female patient presented steroid-sensitive NS at the age of 12 years. At 14 years, she had orbital and lower limbs edema, arterial hypertension, sclerodactyly and proximal skin sclerosis. Moderate capillary dilation and mild focal devascularization were observed in nailfold capillaroscopy, compatible with early stage of scleroderma (scleroderma pattern). Percutaneous renal biopsy guided by ultrasound revealed focal segmental glomerulosclerosis and direct immunofluorescence were negative. Therefore, she fullfilled the provisional classification criteria for JSSc. Patient was treated with oral 25-hydroxyvitamin D (800 IU/day), methotrexate (0.5mg/kg/week) and amlodipin (0.15 mg/kg). Prednisone (60 mg/m2/day) was administered for 4 consecutive weeks, followed by alternate-day (40mg/m2) for 2 consecutive months, with tapering for 4 months and then stopping this medication. Currently she is being treated with methotrexate 15 mg/week, without edema and proteinuria. In conclusion, we reported a rare case of NS with FSGS as the first manifestation of scleroderma. Therefore, renal biopsy is mandatory in JSSc patients with sustained proteinuria or NS.
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Affiliation(s)
- Saulo B Couto
- Unidade de Nefrologia Pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brasil
| | - Adriana M Sallum
- Unidade de Nefrologia Pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brasil
| | - Luciana S Henriques
- Unidade de Nefrologia Pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brasil
| | - Denise M Malheiros
- Departamento de Patologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brasil
| | - Clovis A Silva
- Departamento de Patologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brasil
| | - Maria H Vaisbich
- Unidade de Nefrologia Pediátrica do Instituto da Criança do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HC-FMUSP), São Paulo, SP, Brasil.
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Saad Magalhães C, Fernandes TDAP, Fernandes TD, Resende LADL. A cross-sectional electromyography assessment in linear scleroderma patients. Pediatr Rheumatol Online J 2014; 12:27. [PMID: 25053924 PMCID: PMC4105867 DOI: 10.1186/1546-0096-12-27] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 07/07/2014] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Muscle atrophy and asymmetric extremity growth is a common feature of linear scleroderma (LS). Extra-cutaneous features are also common and primary neurologic involvement, with sympathetic dysfunction, may have a pathogenic role in subcutaneous and muscle atrophy. The aim was investigate nerve conduction and muscle involvement by electromyography in pediatric patients with LS. METHODS We conducted a retrospective review of LS pediatric patients who had regular follow up at a single pediatric center from 1997-2013. We selected participants if they had consistently good follow up and enrolled consecutive patients in the study. We examined LS photos as well as clinical, serological and imaging findings. Electromyograms (EMG) were performed with bilateral symmetric technique, using surface and needle electrodes, comparing the affected side with the contralateral side. Abnormal muscle activity was categorized as a myopathic or neurogenic pattern. RESULTS Nine LS subjects were selected for EMG, 2 with Parry-Romberg/Hemifacial Atrophy Syndrome, 7 linear scleroderma of an extremity and 2 with mixed forms (linear and morphea). Electromyogram analysis indicated that all but one had asymmetric myopathic pattern in muscles underlying the linear streaks. Motor and sensory nerve conduction was also evaluated in upper and lower limbs and one presented a neurogenic pattern. Masticatory muscle testing showed a myopathic pattern in the atrophic face of 2 cases with head and face involvement. CONCLUSION In our small series of LS patients, we found a surprising amount of muscle dysfunction by EMG. The muscle involvement may be possibly related to a secondary peripheral nerve involvement due to LS inflammation and fibrosis. Further collaborative studies to confirm these findings are needed.
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Affiliation(s)
- Claudia Saad Magalhães
- Pediatric Rheumatology Unit, Pediatrics Division, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | | | - Thiago Dias Fernandes
- Electrophysiology Section, Neurology Division, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Luis Antonio de Lima Resende
- Electrophysiology Section, Neurology Division, Botucatu Medical School, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
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