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Auanassova A, Yessirkepov M, Zimba O, Ahmed S, Mruthyunjaya P. Diagnostic delays in systemic vasculitides. Rheumatol Int 2024; 44:1003-1011. [PMID: 38587659 DOI: 10.1007/s00296-024-05582-9] [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: 01/02/2024] [Accepted: 03/12/2024] [Indexed: 04/09/2024]
Abstract
Systemic vasculitides are among the less common disorders encountered in routine rheumatology practice. The low incidence and heterogeneous presentation at onset can potentially lead to delayed diagnosis. Not recognizing these in the early phase may prove detrimental, as some vasculitis may progress to a catastrophic course with major morbidity or mortality. The causes of diagnostic delay may vary among different types of vasculitis and may also be disease-, patient-, or physician-related. Disease-related factors include the myriad presentations with diverse and non-specific symptoms, mimicking other conditions like infections. In addition, some forms have prolonged prodromal phases before evident organ damage. Limited awareness among healthcare professionals, particularly outside rheumatology, and a lack of readily available diagnostic tools contribute to missed diagnoses. Delays in seeking care due to non-specific symptoms or lack of access to specialist care can worsen outcomes. The economic burden also increases with delayed diagnosis and damage accrual when the disease remains unrecognized or untreated for prolonged periods. Although the causes of vasculitis are numerous, including secondary causes, in this review, we focus on diagnostic delays in primary vasculitides and suggest potential steps to identify and treat these diseases early. These include educating both healthcare professionals and the public about the signs and symptoms of vasculitis; expanding the rheumatology workforce and facilitating timely referrals; implementing readily available and reliable tests for early detection; and streamlining care and diagnostic pathways. Such measures have the potential to improve the overall outcomes of the disease, with prolonged remission, minimal damage accrual, and improved quality of life.
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Affiliation(s)
- Akerke Auanassova
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Marlen Yessirkepov
- Department of Biology and Biochemistry, South Kazakhstan Medical Academy, Shymkent, Kazakhstan
| | - Olena Zimba
- Department of Clinical Rheumatology and Immunology, University Hospital in Krakow, Krakow, Poland
- National Institute of Geriatrics, Rheumatology and Rehabilitation, Warsaw, Poland
- Department of Internal Medicine #2, Danylo Halytsky Lviv National Medical University, L'viv, Ukraine
| | - Sakir Ahmed
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, 751024, India
| | - Prakashini Mruthyunjaya
- Department of Clinical Immunology and Rheumatology, Kalinga Institute of Medical Sciences, KIIT University, Bhubaneswar, 751024, India.
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2
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Hassold N, Dusser P, Laurent A, Lemelle I, Pillet P, Comarmond C, Mekinian A, Lambert M, Mirault T, Benhamou Y, Belot A, Jeziorski E, Reumaux H, Sibilia J, Desdoits A, Espitia O, Faye A, Quartier P, Saadoun D, Koné-Paut I. Clinical spectrum and outcome of Takayasu's arteritis in children. Joint Bone Spine 2024; 91:105735. [PMID: 38631524 DOI: 10.1016/j.jbspin.2024.105735] [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: 03/20/2024] [Revised: 03/29/2024] [Accepted: 04/08/2024] [Indexed: 04/19/2024]
Abstract
OBJECTIVES We aimed to compare clinical spectrum and outcome between adults and children with Takayasu's arteritis (TAK) in a European population. METHODS We made a nationwide retrospective observational study between 1988 and 2019. All adult patients met the ACR diagnostic criteria for TAK and all children met the EULAR/PRINTO/PRES criteria for paediatric TAK. RESULTS We identified 46 children and 389 adults with TAK. The male to female ratio was 34/46 (0.74) in the paediatric group compared to 241/274 (0.88) in the adult group (P<0.05). Children presented with significantly more systemic symptoms; i.e., fever (P<0.05), fatigue (P<0.001), weight loss (P<0.001), abdominal pain (P<0.05), and myalgia (P<0.05) while adults had more upper limb claudication (P<0.01). Topography of the lesions differed significantly between the two groups: adults had more damage at the cerebral vasculature (P<0.01), upper and lower limbs (P<0.001) while children had more kidney lesions (P<0.05). Children TAK had more frequent (P<0.01) and higher (P<0.001) biological inflammation than adults. Children received higher dose-weight of corticosteroids (P=0.001) and less biotherapy (P<0.010) at diagnosis. Relapses (P<0.05) and death (8.6% vs 4.9%) were more frequent in children TAK than in adults. CONCLUSION Paediatric TAK seems more severe than adult TAK. Therefore, paediatrics patients may require closer monitoring and systemic use of biological treatment.
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Affiliation(s)
- Nolan Hassold
- Department of paediatric rheumatology and CEREMAIA, Kremlin-Bicêtre Hospital, AP-HP, université de Paris Saclay, Kremlin-Bicêtre, France.
| | - Perrine Dusser
- Department of paediatric rheumatology and CEREMAIA, Kremlin-Bicêtre Hospital, AP-HP, université de Paris Saclay, Kremlin-Bicêtre, France
| | - Audrey Laurent
- Department of paediatric rheumatology, Femme-Mère-Enfant Hospital, HCL, Lyon, France
| | - Irene Lemelle
- Department of paediatric oncology, Hôpitaux de Brabois, CHU, Nancy, France
| | - Pascal Pillet
- Department of paediatrics, Pellegrin Hospital, CHU, Bordeaux, France
| | - Cloé Comarmond
- Department of internal medicine, Lariboisière Hospital, AP-HP, Paris, France
| | - Arsene Mekinian
- Department of internal medicine, Saint-Antoine Hospital, AP-HP, Sorbonne université, Paris, France
| | - Marc Lambert
- Department of internal medicine, Claude-Huriez Hospital, CHU, Lille, France
| | - Tristan Mirault
- Department of vascular medicine, George-Pompidou Hospital, AP-HP, Paris, France
| | - Ygal Benhamou
- Department of internal medicine, Charles-Nicolle Hospital, CHU, Rouen, France
| | - Alexandre Belot
- Department of paediatric rheumatology, Femme-Mère-Enfant Hospital, HCL, Lyon, France
| | - Eric Jeziorski
- Department of paediatrics, Arnaud-de-Villeneuve Hospital, CHU, Montpellier, France
| | - Héloïse Reumaux
- Department of paediatrics, Jeanne-de-Flandre Hospital, CHRU, Lille, France
| | - Jean Sibilia
- Department of rheumatology, Arlin d'Alsace Hospital, CHU, Strasbourg, France
| | - Alexandra Desdoits
- Department of paediatrics, Hôpital de la Côte-de-Nacre, CHU, Caen, France
| | - Olivier Espitia
- Nantes Université, CHU Nantes, Department of internal and vascular medicine, 44000 Nantes, France
| | - Albert Faye
- Department of general paediatrics, infectious diseases and internal medecine, Robert-Debré Hospital, AP-HP, Université Paris Cité, Paris, France
| | - Pierre Quartier
- Department of paediatric rheumatology, Necker Hospital, AP-HP, Paris, France
| | - David Saadoun
- Department of internal medicine, La Pitié-Salpétrière Hospital, AP-HP, Sorbonne université, Paris, France
| | - Isabelle Koné-Paut
- Department of paediatric rheumatology and CEREMAIA, Kremlin-Bicêtre Hospital, AP-HP, université de Paris Saclay, Kremlin-Bicêtre, France
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3
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Rathore U, Chandwar K, Singh K, Misra DP. Pediatric-onset Takayasu arteritis is associated with greater risk of mortality than adult-onset Takayasu arteritis-A systematic review with meta-analysis of observational cohort studies. Semin Arthritis Rheum 2024; 65:152355. [PMID: 38183753 DOI: 10.1016/j.semarthrit.2023.152355] [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: 09/27/2023] [Revised: 12/09/2023] [Accepted: 12/18/2023] [Indexed: 01/08/2024]
Abstract
A subset of Takayasu arteritis (TAK) has onset in the pediatric age group (≤18 years). The differences in mortality between pediatric-onset and adult-onset TAK are unclear. Therefore, we undertook a systematic review with meta-analysis to compare mortality risk in pediatric-onset with adult-onset TAK. Scopus, Pubmed (MEDLINE and Pubmed Central), recent conference abstracts, clinicaltrials.gov, and the Cochrane database were searched up to August 2023 for relevant studies. Five studies (all of moderate or high quality on the Newcastle Ottawa scale) were identified which had compared mortality between 151 pediatric-onset and 499 adult-onset TAK. Pediatric-onset TAK was associated with a significantly higher risk of death than adult-onset TAK (pooled risk ratio 2.27, 95% confidence interval 1.05 - 4.85, I2=0%). Cardiovascular disease and infections were the major causes of death in both pediatric-onset and adult-onset TAK. Sub-group analyses identified a greater mortality risk with pediatric-onset TAK in retrospective (but not prospective) studies and in studies of high quality (but not in those of moderate quality). Meta-regression did not reveal a significant influence of differences in sex distribution or age or the proportions of patients with pediatric-onset or adult-onset TAK on the pooled mortality risk. An increased mortality risk with pediatric-onset TAK on meta-analysis is consistent with more frequent severe organ manifestations of pediatric-onset TAK (heart failure, renal failure) when compared with adult-onset TAK. Future studies should systematically evaluate differences in the pathogenesis between pediatric-onset and adult-onset to understand the reasons for such observed differences in the mortality risk.
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Affiliation(s)
- Upendra Rathore
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Kunal Chandwar
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Kritika Singh
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India
| | - Durga Prasanna Misra
- Department of Clinical Immunology and Rheumatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, India.
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Jin J, Zhao Y, Gao X, Wang P, Liu Y, Pan Y, Fan Z, Yu H. A retrospective study of infantile-onset Takayasu arteritis: experience from a tertiary referral center in China. Front Cardiovasc Med 2024; 11:1249305. [PMID: 38357518 PMCID: PMC10864990 DOI: 10.3389/fcvm.2024.1249305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 01/17/2024] [Indexed: 02/16/2024] Open
Abstract
Objective Takayasu artery (TAK) is a chronic inflammatory disease that mainly affects the aorta and its major branches and is rarely reported in infants. We aimed to summarize the clinical features of infant TA (I-TA) in a tertiary care center. Methods We performed a retrospective study involving 10 infants diagnosed with TAK. A comprehensive evaluation of clinical, laboratory, radiographic features, disease activity, treatment and outcomes was carried out. Results A consecutive cohort was composed of 8 girls and 2 boys, with an age at diagnosis of 11.1 (1.7-36) months. The median time to diagnosis and the average time to follow-up were 9.5 days (2-235 days) and 10.9 (1-21) months, respectively. The most common initial manifestations were malaise (80%), fever (70%), hypertension (50%) and rash (30%). The mean Pediatric Vasculitis Activity Score (PVAS), Takayasu Clinical Activity Score (ITAS-2010) and ITAS-A scores were 2.8/63, 2.6/51, and 5.6/54, respectively. All patients had aberrant laboratory parameters. The most common lesions were in the thoracic aorta (60%) and abdominal aorta (60%). Corticosteroids combined with cyclophosphamide followed by long-term mycophenolate mofetil were initiated in most cases (70%). Biologics were attempted in 5 cases. Mortality was 40%. Conclusions It is challenging to diagnose TAK in infants in a timely manner. Considering the more vessels involved, more severe inflammation and higher mortality, aggressive treatment is warranted in infants. GCs and CYC treatment seem to be effective.
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Affiliation(s)
- Jing Jin
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Yan Zhao
- Department of Ultrasonography, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Xiucheng Gao
- Department of Image, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Panpan Wang
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Yingying Liu
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Yuting Pan
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Zhidan Fan
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, China
| | - Haiguo Yu
- Department of Rheumatology and Immunology, Children’s Hospital of Nanjing Medical University, Nanjing, China
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Sener S, Basaran O, Kaya Akca U, Atalay E, Kasap Cuceoglu M, Balik Z, Aliyev E, Bayindir Y, Batu ED, Hazirolan T, Bilginer Y, Ozen S. Treatment of childhood-onset Takayasu arteritis: switching between anti-TNF and anti-IL-6 agents. Rheumatology (Oxford) 2022; 61:4885-4891. [PMID: 35262635 DOI: 10.1093/rheumatology/keac149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 03/01/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES Biologics are new treatment alternatives in Takayasu arteritis (TA), although data in childhood are limited. The aim of this study was to share our experience in seven childhood-onset TA patients who received a TNF-α inhibitor (adalimumab) or an IL-6 receptor inhibitor (tocilizumab) and the effect of switching therapy. METHODS We retrospectively evaluated the medical treatment records of seven patients with TA, followed between August 2005 and January 2021 at the Pediatric Rheumatology Department of Hacettepe University Faculty of Medicine. RESULTS The median age of patients was 14 (IQR 4) years, and six were female. All of the patients had severe disease and high acute-phase reactants. The patients initially received only steroids or steroids+CYC. Prednisone was decreased, and biologic agents were started once the acute phase reactants decreased, and the Indian Takayasu Activity Score (ITAS) returned to normal. Initially, four patients received tocilizumab (TCZ) [median 25.5 (IQR 41) months] and three patients received adalimumab (ADA) [median 13 (IQR 31) months]. However, due to the progression of MR angiography findings or persistent elevation in acute-phase reactants, the biologic agents were switched from TCZ to ADA in four patients and from ADA to TCZ in three patients. The patients' median follow-up time after changing was 50 (IQR 77) months, and median ITAS was evaluated as '0' after 2 (IQR 4) months. CONCLUSIONS In conclusion, both TNF-α and IL-6 inhibitors are effective alternatives in treating patients with childhood-onset TA. However, prospective randomized controlled trials are needed for the comparison of their effectiveness.
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Affiliation(s)
- Seher Sener
- Division of Pediatric Rheumatology, Department of Pediatrics
| | - Ozge Basaran
- Division of Pediatric Rheumatology, Department of Pediatrics
| | | | - Erdal Atalay
- Division of Pediatric Rheumatology, Department of Pediatrics
| | | | - Zeynep Balik
- Division of Pediatric Rheumatology, Department of Pediatrics
| | - Emil Aliyev
- Division of Pediatric Rheumatology, Department of Pediatrics
| | - Yagmur Bayindir
- Division of Pediatric Rheumatology, Department of Pediatrics
| | - Ezgi Deniz Batu
- Division of Pediatric Rheumatology, Department of Pediatrics
| | | | - Yelda Bilginer
- Division of Pediatric Rheumatology, Department of Pediatrics
| | - Seza Ozen
- Division of Pediatric Rheumatology, Department of Pediatrics
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6
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Aeschlimann FA, Yeung RSM, Laxer RM. An Update on Childhood-Onset Takayasu Arteritis. Front Pediatr 2022; 10:872313. [PMID: 35498790 PMCID: PMC9043359 DOI: 10.3389/fped.2022.872313] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/03/2022] [Indexed: 11/21/2022] Open
Abstract
Takayasu Arteritis (TAK) is a rare large vessel vasculitis affecting the aorta and its major branches. The heterogeneous and often severe clinical manifestations result from systemic and local inflammation as well as end-organ ischemia. Disease flares are common and contribute to accrued damage over time with significant morbidity and mortality. Newer understanding of the pathogenesis in TAK has paved the way for the use of pathway targeting agents such as tumor necrosis factor (TNF)α- or interleuking (IL)-6-inhibitors with improved disease control. Nevertheless, long-term data are lacking, particularly in children; prognosis often remains guarded and the disease burden high. This article aims at providing a comprehensive review of childhood-onset TAK with a focus on recent publications.
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Affiliation(s)
- Florence A. Aeschlimann
- Pediatric Immunology, Hematology and Rheumatology Unit, Hôpital Necker-Enfants Malades, Paris, France
| | - Rae S. M. Yeung
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Pediatrics, University of Toronto, Toronto, ON, Canada
- Department of Immunology, University of Toronto, Toronto, ON, Canada
| | - Ronald M. Laxer
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, ON, Canada
- Department of Medicine, University of Toronto, Toronto, ON, Canada
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Haslak F, Yildiz M, Sahin S, Adrovic A, Barut K, Kasapcopur O. Pediatric Takayasu Arteritis: A Review of the Literature. Curr Pediatr Rev 2022; 18:243-250. [PMID: 35249495 DOI: 10.2174/1573396318666220304205518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2021] [Revised: 11/03/2021] [Accepted: 12/16/2021] [Indexed: 11/22/2022]
Abstract
Takayasu arteritis (TA) is the third most common vasculitis of childhood and is extremely rare. It is mainly characterized by chronic, autoimmune, and granulomatous inflammation of the aorta and its major branches. Women under 40 years of age are mostly affected. It occurs for the first time in childhood in about 30% of affected individuals. Initially, it presents nonspecific constitutional findings. Since there is no specific laboratory finding, diagnosis is challenging. The gold standard imaging method for diagnosis is conventional angiography. Delay in diagnosis can cause devastating consequences. Therefore, in cases presenting with nonspecific findings, with hypertension and high acute phase reactants, the diagnosis should be suspected and confirmed with appropriate imaging method, and treatment should be started immediately. Immunosuppressive agents are the mainstay of the treatment. Biological agents are successful in refractory cases, and endovascular revascularization methods are used in the treatment of complications.
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Affiliation(s)
- Fatih Haslak
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Kenan Barut
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Istanbul University-Cerrahpasa, Cerrahpasa Medical School, Istanbul, Turkey
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8
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Renovascular hypertension in pediatric patients: update on diagnosis and management. Pediatr Nephrol 2021; 36:3853-3868. [PMID: 33851262 DOI: 10.1007/s00467-021-05063-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/11/2021] [Accepted: 03/19/2021] [Indexed: 01/03/2023]
Abstract
Renovascular hypertension (RVH) is defined as an elevated blood pressure caused by kidney hypoperfusion, generally as a result of anatomic stenosis of the renal artery with consequent activation of the Renin Angiotensin-Aldosterone System. The main causes include genetic and inflammatory disorders, extrinsic compression, and idiopathic alterations. RVH is often asymptomatic and should be suspected in any child with refractory hypertension, especially if other suggestive findings are present, including those with severe hypertension, abdominal bruit, and abrupt fall of glomerular filtration rate after administration of angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. There is a consensus that digital subtraction angiography is the gold standard method for the diagnosis of RVH. Nevertheless, the role of non-invasive imaging studies such as Doppler ultrasound, magnetic resonance angiography, or computed tomographic angiography remains controversial, especially due to limited pediatric evidence. The therapeutic approach should be individualized, and management options include non-surgical pharmacological therapy and revascularization with percutaneous transluminal renal angioplasty (PTRA) or surgery. The prognosis is related to the procedure performed, and PTRA has a higher restenosis rate compared to surgery, although a decreased risk of complications. This review summarizes the causes, physiopathology, diagnosis, treatment, and prognosis of RVH in pediatric patients. Further studies are required to define the best approach for RVH in children.
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Nozawa H, Ogura M, Miyasaka M, Suzuki H, Ishikura K, Ishiguro A, Ito S. Ultrasonography as a Diagnostic Support Tool for Childhood Takayasu Arteritis Referred to as Fever of Unknown Origin: Case Series and Literature Review. JMA J 2021; 4:358-366. [PMID: 34796290 PMCID: PMC8580698 DOI: 10.31662/jmaj.2020-0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2020] [Accepted: 06/02/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction Childhood Takayasu arteritis (c-TA) often shows nonspecific symptoms, such as fever of unknown origin (FUO). Delay of diagnosis may result in organ dysfunction by arterial occlusion; therefore, early diagnosis is very important. Although ultrasonography is the first-line screening tool for children with FUO, its diagnostic efficacy of evaluation of systemic arteries in c-TA that presents as FUO remains unclear. We evaluated the suitability of ultrasonography evaluation that included systemic vessels for the early diagnosis of c-TA initially presenting as FUO. Methods We review five patients who received a diagnosis of c-TA in our institution and also performed a literature review regarding TA cases with FUO and diagnosed on the basis of initial ultrasonography. Results As in our cases, the median period from onset to diagnosis was 25 days (interquartile range [IQR], 21-35). Comparing the initial ultrasonography findings with later contrast-enhanced computed tomography (CECT) findings in the abdominal aorta, celiac artery, superior mesenteric artery, bilateral renal arteries, and bilateral common carotid arteries, the concordance rate between ultrasonography and CECT was moderate (Kappa coefficient was 0.50). All the patients were successfully treated without severe vascular damage. The literature review revealed 12 articles; although 9 of the 13 patients did not show the characteristic features (such as blood pressure discrepancy, bruit, or pulse deficiency), the median time to diagnosis was still 5 months (IQR, 3-12). Conclusions During initial screening for patients with FUO, ultrasonography including evaluation of systemic vessels could contribute to earlier diagnosis of c-TA.
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Affiliation(s)
- Hisataka Nozawa
- Center for Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| | - Masao Ogura
- Division of Pediatric Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Mikiko Miyasaka
- Department of Radiology, National Center for Child Health and Development, Tokyo, Japan
| | - Hiromichi Suzuki
- Department of Health Policy, National Research Institute for Child Health and Development, Tokyo, Japan
| | - Kenji Ishikura
- Division of Pediatric Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
| | - Akira Ishiguro
- Center for Postgraduate Education and Training, National Center for Child Health and Development, Tokyo, Japan
| | - Shuichi Ito
- Division of Pediatric Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan.,Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Japan
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10
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Cannon L, Wu EY. Recent Advances in Pediatric Vasculitis. Rheum Dis Clin North Am 2021; 47:781-796. [PMID: 34635304 DOI: 10.1016/j.rdc.2021.07.007] [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: 10/20/2022]
Abstract
This article provides an overview of the clinical presentation and diagnosis of select pediatric primary systemic vasculitides. Important advances in understanding the pathogenesis of these rare diseases also are discussed and efforts to harmonize treatment through consensus-based guidelines and multicenter and international collaborations highlighted.
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Affiliation(s)
- Laura Cannon
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, 2301 Erwin Road, DUMC Box 3212, Durham, NC 27710, USA
| | - Eveline Y Wu
- Division of Pediatric Rheumatology, Department of Pediatrics, The University of North Carolina Chapel Hill, 030 MacNider Hall, CB #7231, Chapel Hill, NC 27599, USA; Division of Allergy/Immunology, Department of Pediatrics, The University of North Carolina Chapel Hill, Chapel Hill, NC.
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11
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Sener S, Basaran O, Ozen S. Wind of Change in the Treatment of Childhood-Onset Takayasu Arteritis: a Systematic Review. Curr Rheumatol Rep 2021; 23:68. [PMID: 34218346 DOI: 10.1007/s11926-021-01032-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE OF REVIEW We lack evidence-based data for the treatment of childhood-onset Takayasu arteritis (c-TA) since it is a rare disease in children. In this systematic literature review, we aimed to evaluate the treatment choices in c-TA patients and integrate our experience for the treatment of our patients in the recent years/in the biologic era. RECENT FINDINGS We reviewed 24 articles addressing treatments of 413 c-TA patients. Steroids were given to 352 patients (85.2%) as the main immunosuppressive therapy. Other immunosuppressive agents included methotrexate (37.3%), cyclophosphamide (24.5%), azathioprine (16.9%), and mycophenolate mofetil (7.9%). Besides, various biological agents were used, including tumor necrosis factor-alpha inhibitors in 70 of 107 c-TA patients (65.4%) and interleukin-6 inhibitors in 33 of them (30.8%). Biologics are increasingly used in our center as well. Even in severe patients, CYC is switched to either anti-TNF or antiIL6 once disease control is achieved. Recently, in addition to conventional immunosuppressants, biologics are increasingly used in c-TA. We have revised our treatment protocol to start with 1-3 doses of high-dose steroids and CYC, in a child with TA with types III-V involvement and high acute phase reactants; once clinical features subside and CRP normalizes, biologics should be started to replace CYC while decreasing the steroid dose.
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Affiliation(s)
- Seher Sener
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Ozge Basaran
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey
| | - Seza Ozen
- Division of Rheumatology, Department of Pediatrics, Hacettepe University Faculty of Medicine, 06100, Ankara, Turkey.
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Sönmez HE, Demir F, Özdel S, Karadağ ŞG, Bağlan E, Bülbül M, Çakan M, Ayaz NA, Sözeri B. Neuroimaging of Children With Takayasu Arteritis. J Child Neurol 2021; 36:642-647. [PMID: 33591239 DOI: 10.1177/0883073821991287] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Takayasu arteritis is a rare granulomatous chronic vasculitis that affects the aorta and its main branches. Neurologic manifestations can accompany the disease; however, there is no study on neuroimaging in children with Takayasu arteritis. Therefore, we aimed to evaluate cranial magnetic resonance imaging (MRI) in pediatric Takayasu arteritis patients. MATERIALS AND METHODS Demographic, clinical, and laboratory data were obtained retrospectively. RESULTS The study included 15 pediatric Takayasu arteritis patients. All patients presented with constitutional symptoms. Additionally, 6 patients suffered from headache, 2 had syncope, 1 had loss of consciousness, and 1 had convulsion. All patients underwent cranial and diffusion MRI a median 12 months after diagnosis. Cranial MRI findings were normal in 12 patients, whereas 3 patients had abnormal findings, as follows: stenosis in the M1 and M2 segments of the left middle cerebral artery (n = 1); diffuse thinning of the right internal carotid, middle cerebral, and right vertebral and basilar artery (n = 1); as a sequela, areas of focal gliosis in both the lateral ventricular and posterior periventricular regions (n = 1). Among these 3 patients, 1 had no neurologic complaints. CONCLUSION Abnormal MRI findings can be observed in pediatric Takayasu arteritis patients, even those that are asymptomatic; therefore, clinicians should carefully evaluate neurologic involvement in all pediatric Takayasu arteritis patients.
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Affiliation(s)
- Hafize Emine Sönmez
- Division of Pediatrics, Department of Pediatric Rheumatology, 52980Kocaeli University, Kocaeli, Turkey
| | - Ferhat Demir
- Department of Pediatric Rheumatology, Ümraniye Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Semanur Özdel
- Department of Pediatric Rheumatology, Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Şerife Gül Karadağ
- Department of Pediatric Rheumatology, Sadi Konuk Research and Training Hospital, University of Health Science, Istanbul, Turkey
| | - Esra Bağlan
- Department of Pediatric Rheumatology, Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Mehmet Bülbül
- Department of Pediatric Rheumatology, Sami Ulus Research and Training Hospital, Ankara, Turkey
| | - Mustafa Çakan
- Department of Pediatric Rheumatology, Zeynep Kamil Research and Training Hospital, University of Health Sciences, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Department of Pediatric Rheumatology, Istanbul University Medical School, Istanbul, Turkey
| | - Betül Sözeri
- Department of Pediatric Rheumatology, Ümraniye Research and Training Hospital, University of Health Science, Istanbul, Turkey
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13
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A hypertensive girl with failure to thrive accompanied by gastrointestinal symptoms: Answers. Pediatr Nephrol 2021; 36:2125-2128. [PMID: 33646393 DOI: 10.1007/s00467-021-05004-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 02/01/2021] [Accepted: 02/05/2021] [Indexed: 10/22/2022]
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14
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Astley C, Gil S, Clemente G, Terreri MT, Silva CA, Campos LMA, Aikawa NE, de Sá Pinto AL, Pereira RMR, Roschel H, Gualano B. Poor physical activity levels and cardiorespiratory fitness among patients with childhood-onset takayasu arteritis in remission: a cross-sectional, multicenter study. Pediatr Rheumatol Online J 2021; 19:39. [PMID: 33752674 PMCID: PMC7986021 DOI: 10.1186/s12969-021-00519-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 03/04/2021] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND It is currently unknown whether patients with childhood-onset Takayasu disease (c-TA) are prone to physical inactivity and poor aerobic capacity. In this study, we assessed physical activity levels and cardiorespiratory fitness along with health-related quality of life (HRQL) and various traditional and non-traditional risk factors in patients with c-TA vs. healthy controls. METHODS c-TA patients with non-active disease (n = 17) and age- and sex-matched healthy controls (n = 17) were enrolled in the study. We assessed physical activity levels, aerobic capacity, body composition, systemic inflammation, cardiometabolic markers, disease-related parameters, and HRQL. RESULTS c-TA patients showed greater time spent in sedentary behavior (P = 0.010), and lower moderate-to-vigorous physical activity (P > 0.001) and lower step counts per day (P > 0.001). VO2peak (P < 0.001) and chronotropic response (P = 0.016) were significantly lower in patients with c-TA and they had worse HRQL in physical domain (P < 0.001), lower bone mineral content and density, and higher insulin levels vs. healthy controls (all P ≤ 0.05). CONCLUSIONS c-TA patients exhibited reduced physical activity levels and aerobic capacity, worse cardiometabolic risk factors and HRQL parameter compared with healthy peers. Physical inactivity and aerobic deconditioning emerge as potentially novel risk factors for c-TA. The role of physical activity interventions in preventing poor outcomes and improving HRQL in c-TA remains to be explored.
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Affiliation(s)
- Camilla Astley
- Applied Physiology & Nutrition Research Group, Laboratory of Assessment and Conditioning in Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP, Sao Paulo, Brazil
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Saulo Gil
- Applied Physiology & Nutrition Research Group, Laboratory of Assessment and Conditioning in Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP, Sao Paulo, Brazil
| | - Gleice Clemente
- Division of Paediatric Rheumatology, Department of Paediatrics, Federal University of Sao Paulo, SP, Sao Paulo, Brazil
| | - Maria Teresa Terreri
- Division of Paediatric Rheumatology, Department of Paediatrics, Federal University of Sao Paulo, SP, Sao Paulo, Brazil
| | - Clovis Artur Silva
- Paediatric Rheumatology Unit of Children and Adolescents' Institute, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Lucia Maria Arruda Campos
- Paediatric Rheumatology Unit of Children and Adolescents' Institute, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Nadia Emi Aikawa
- Paediatric Rheumatology Unit of Children and Adolescents' Institute, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Ana Lúcia de Sá Pinto
- Applied Physiology & Nutrition Research Group, Laboratory of Assessment and Conditioning in Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP, Sao Paulo, Brazil
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Rosa Maria R Pereira
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Hamilton Roschel
- Applied Physiology & Nutrition Research Group, Laboratory of Assessment and Conditioning in Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP, Sao Paulo, Brazil
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Bruno Gualano
- Applied Physiology & Nutrition Research Group, Laboratory of Assessment and Conditioning in Rheumatology, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, SP, Sao Paulo, Brazil.
- Rheumatology Division, Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
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15
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Childhood-onset versus adult-onset Takayasu arteritis: A study of 141 patients from Turkey. Semin Arthritis Rheum 2020; 51:192-197. [PMID: 33383295 DOI: 10.1016/j.semarthrit.2020.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/27/2020] [Accepted: 10/30/2020] [Indexed: 11/20/2022]
Abstract
AIM To compare childhood-onset (c-TAK) versus adult-onset Takayasu arteritis (a-TAK) patients for vascular involvement, disease activity, damage, and treatment. METHODS Patient charts from two tertiary-care centers of a pediatric and adult rheumatology clinic were reviewed. Adult patients diagnosed before the age of 18 years were included in the childhood-onset group. The activity was assessed with the physician's global assessment (PGA) and Indian Takayasu Clinical Activity Score (ITAS). The damage was evaluated with Takayasu Arteritis Damage Score (TADS) and Vasculitis Damage Index (VDI). RESULTS Twenty-four c-TAK (follow-up duration: 53 months) and 117 a-TAK patients (follow-up duration: 68 months) were analyzed. Aorta involvement was more prevalent (79% vs. 33%), and the median PGA score was higher in the c-TAK group (9 vs. 7), whereas the mean Indian Takayasu Arteritis Score was similar (14 vs. 13) among both groups. Median VDI score was lower for c-TAK patients (4 vs. 5), whereas TADS was similar for children and adults (8 vs. 8). Higher incidence of glucocorticoid related side-effects, a longer time to diagnosis and upper extremity claudication seemed to account for higher VDI scores in adults. CONCLUSION Aorta involvement was more common among children with TAK, whereas upper extremities were relatively spared. Biologic agents were used more commonly among children which may be explained by higher rates of aortic involvement. However, c-TAK patients did not have greater cumulative damage.
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16
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Singer TG, Bray MA, Chan A, Ikeda S, Walters B, Fuller MY, Falco C. Chronic Ulcers and Malnutrition in an African Patient. Pediatrics 2020; 146:e20201717. [PMID: 33115794 PMCID: PMC8061712 DOI: 10.1542/peds.2020-1717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/10/2020] [Indexed: 11/24/2022] Open
Abstract
An 11-year-old girl with a congenitally malformed left hand, sickle cell trait, asthma, and history of appendicitis was transferred from Zambia for evaluation and treatment of widespread suppurative and ulcerative skin lesions that typically appeared after trauma to her skin. The ulcers first presented 3 years earlier but had markedly worsened in the 9 months before transfer, spreading circumferentially on her extremities and abdomen at the site of an appendectomy. They were painful and did not resolve with multiple courses of intravenous antibiotics and close management by a pediatric infectious disease specialist working for a nongovernmental organization (NGO) in her home country. Per NGO records, she had previously been average weight-for-age. On presentation after international transfer, she was severely malnourished, with lesions covering ∼35% of her body. In initial workup, leukocytosis of 21 × 103 cells per μL (79% neutrophils), hemoglobin of 6.1 g/dL, and mean corpuscular volume of 66 fL were found. Iron studies revealed an iron level of 18 μg/dL, ferritin level of 55 ng/mL, total iron binding capacity of 222 μg/dL, and transferrin saturation of 8%. Inflammatory markers were elevated, C-reactive protein was 20.1 mg/dL, and the erythrocyte sedimentation rate was 131 mm/h. A chest computed tomography scan revealed bilateral pulmonary nodules, the largest in her left upper lobe measuring 2.4 × 2.0 × 1.9 cm. Our panel of experts reviews the evaluation and treatment of this patient with extensive suppurative and ulcerative skin lesions and the factors considered in offering charity care to international patients.
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Affiliation(s)
| | | | | | | | - Brittany Walters
- International and Destination Medicine, Texas Children's Hospital, Houston, Texas
| | - Maren Y Fuller
- Pathology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas; and
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17
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Trapani S, Rubino C, Indolfi G. Gastrointestinal involvement in childhood vasculitides. Acta Paediatr 2020; 109:2226-2236. [PMID: 32479665 DOI: 10.1111/apa.15381] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/18/2020] [Accepted: 05/26/2020] [Indexed: 02/01/2023]
Abstract
AIM The aim of this narrative review was to provide a comprehensive summary of the characteristics of gastrointestinal (GI) involvement in the most common paediatric primary vasculitides. METHODS We used PubMed to primarily identify papers, reviews, case series and editorials published in English from 2000 until 31 January 2020. Based on this, we report the prevalence, clinical manifestations, diagnostic approaches and management of GI involvement in each vasculitis. RESULTS Vasculitides are inflammatory blood vessel diseases, and the majority can affect the GI system with vascular, GI tract or solid organ involvement. GI involvement can sometimes complicate and delay the correct diagnosis. Clinical findings are usually nonspecific symptoms, such as fever, abdominal pain, nausea, vomiting and diarrhoea. Bleeding should alert paediatricians to the possibility of severe complicated vasculitis. Diagnosis relies mostly on imaging. If it goes unrecognised, GI involvement in paediatric vasculitis is a serious cause of morbidity and even mortality, related to bowel ischaemia and perforation. Treatment of GI symptoms depends on the type of vasculitis and usually involves high-dose steroids and immunosuppressants. CONCLUSION GI manifestations in the most common paediatric primary vasculitides were usually nonspecific, diagnosis mostly relied on imaging, and treatment usually involved high-dose corticosteroids and immunosuppressants.
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Affiliation(s)
- Sandra Trapani
- Department of Health Sciences, University of Florence and Meyer Children's University Hospital, Florence, Italy
| | - Chiara Rubino
- Post-graduate School of Pediatrics, University of Florence, Florence, Italy
| | - Giuseppe Indolfi
- Meyer Children's University Hospital and Department, NEUROFARBA, University of Florence, Florence, Italy
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18
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Aydin F, Acar B, Uncu N, BaŞaran Ö, Adalet Yildiz E, GÜven A, Çakar N. Takayasu Arteritis: A Case Presenting With Neurological Symptoms and Proteinuria. Arch Rheumatol 2020; 35:287-291. [PMID: 32851381 DOI: 10.46497/archrheumatol.2020.7402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2019] [Accepted: 07/01/2019] [Indexed: 11/03/2022] Open
Abstract
In this article, we present an 18-year-old female patient who was initially diagnosed as central nervous system vasculitis and focal segmental glomerulosclerosis but later diagnosed as Takayasu arteritis.
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Affiliation(s)
- Fatma Aydin
- Department of Pediatric Rheumatology, Ankara Child Health, Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Banu Acar
- Department of Pediatric Rheumatology, Ankara Child Health, Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Nermin Uncu
- Department of Pediatric Rheumatology, Ankara Child Health, Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Özge BaŞaran
- Department of Pediatric Rheumatology, Ankara Child Health, Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Elçin Adalet Yildiz
- Department of Pediatric Radiology, Ankara Child Health, Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Alev GÜven
- Department of Pediatric Neurology, Ankara Child Health, Hematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Nilgün Çakar
- Department of Pediatric Rheumatology and Nephrology, Ankara University School of Medicine, Ankara, Turkey
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Aeschlimann FA, Twilt M, Yeung RSM. Childhood-onset Takayasu Arteritis. Eur J Rheumatol 2020; 7:S58-S66. [PMID: 35929861 PMCID: PMC7004266 DOI: 10.5152/eurjrheum.2019.19195] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 12/04/2019] [Indexed: 09/02/2023] Open
Abstract
Childhood-onset Takayasu Arteritis (cTAK) is a rare, large-vessel type of vasculitis seen in children, mainly affecting the aorta and its major branches. Clinical manifestations are often severe and arise as a result of systemic and local inflammation, along with end-organ ischemia. Disease flares are common and the disease burden is high, with a significant rate of morbidity and mortality. Recent advances in understanding the underlying disease pathobiology resulted in the use of pathway-targeting agents, such as TNF- or IL-6 inhibitors with improved disease control. Nonetheless, the prognosis often remains guarded and the accrued damage is significant. This review aims at summarizing the recent evidence and observations regarding this condition, with a focus on pediatric publications.
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Affiliation(s)
- Florence A Aeschlimann
- Paediatric Immunology, Hematology and Rheumatology Unit, Hôpital Necker - Enfants Malades, Paris, France; Division of Paediatrics, Kantonsspital Winterthur, Winterthur, Switzerland
| | - Marinka Twilt
- Division of Rheumatology, Department of Paediatric, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Alberta, Canada; Department of Paediatrics, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Rae S M Yeung
- Division of Rheumatology, Department of Paediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada; Department of Immunology, University of Toronto, Toronto, Ontario, Canada
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Abstract
Childhood-onset Takayasu arteritis (c-TA) is the third most common systemic vasculitic disorder in children. Vascular stenosis is the main complication, and aneurysms are reported in 19-65% of cases, often in combination with stenotic lesions. Management of patients with c-TA is largely based on studies involving predominantly patients with adult-onset TA (a-TA). More widely used criteria for patients with c-TA have been devised by the joint European League Against Rheumatism, Pediatric Rheumatology International Trials Organization, and Pediatric Rheumatology European Society. Of the available imaging modalities, those that do not use radiation (color Doppler ultrasound and magnetic resonance angiogram) are preferred over 18F-labeled fluoro-2-deoxyglucose (18F-FDG) positron-emission tomography, computed tomography (CT), and CT angiogram in children. Remission rates have been reported to be lower in c-TA than in a-TA, and published mortality rates in c-TA range from 16 to 40%, which is much higher than reported in patients with a-TA. The usual drug therapy options include steroids plus steroid-sparing second-line immunosuppressants, such as mycophenolate, azathioprine, methotrexate, cyclophosphamide, and cyclosporine, along with antiplatelet agents. Interleukin-6 inhibitors such as tocilizumab, as well as the tumor necrosis factor inhibitors, are other aggressive therapeutic options. As yet, no randomized controlled trials have been conducted in c-TA.
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Affiliation(s)
- Ruchika Goel
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India
| | - T Sathish Kumar
- Department of Child Health, Christian Medical College, Vellore, India
| | - Debashish Danda
- Department of Clinical Immunology and Rheumatology, Christian Medical College, Vellore, India.
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