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Abstract
Idiopathic inflammatory myopathies (IIMs) are a diverse group of diseases characterized by proximal muscle weakness and inflammation in skeletal muscle. Phenotypically, the subtypes include dermatomyositis, polymyositis, inclusion body myositis, and amyopathic dermatomyositis. The most common IIM in children is juvenile dermatomyositis (JDM). In contrast to adult dermatomyositis (DM), children are likely to have frequent relapses, vasculopathy, and long-term metabolic and other complications like lipodystrophy, insulin resistance, and calcinosis. Significant advances in our understanding of pathogenesis, disease course, and treatment of JDM has changed the therapeutic landscape and improved outcomes in children. Myositis-specific autoantibodies and myositis-associated autoantibodies have unique clinical associations, disease course and help predict response to therapy. A multidisciplinary approach including exercise programs and psychosocial support is essential. The first line of treatment is a combination of corticosteroids and methotrexate (MTX). Other targeted immunosuppressive therapy is used in refractory cases. Early recognition and timely referral to a specialist center remain pivotal to improving the mortality and morbidity associated with this disease.
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Affiliation(s)
- Suma Balan
- Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi, Kerala, 682 041, India.
| | - Sumanth Madan
- Department of Rheumatology and Clinical Immunology, Amrita Institute of Medical Sciences and Research Centre, Ponekkara, Kochi, Kerala, 682 041, India
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Veldkamp SR, van Wijk F, van Royen-Kerkhof A, Jansen MH. Personalised medicine in juvenile dermatomyositis: From novel insights in disease mechanisms to changes in clinical practice. Best Pract Res Clin Rheumatol 2024; 38:101976. [PMID: 39174374 DOI: 10.1016/j.berh.2024.101976] [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: 04/26/2024] [Revised: 06/12/2024] [Accepted: 07/15/2024] [Indexed: 08/24/2024]
Abstract
Juvenile dermatomyositis is characterized by childhood-onset chronic inflammation of the muscles and skin, with potential involvement of other organs. Patients are at risk for long-term morbidity due to insufficient disease control and steroid-related toxicity. Personalised treatment is challenged by a lack of validated tools that can reliably predict treatment response and monitor ongoing (subclinical) inflammation, and by a lack of evidence regarding the best choice of medication for individual patients. A better understanding of the involved disease mechanisms could reveal potential biomarkers and novel therapeutic targets. In this review, we highlight the most relevant immune and non-immune mechanisms, elucidating the effects of interferon overexpression on tissue alongside the interplay between the interferon signature, mitochondrial function, and immune cells. We review mechanism-based biomarkers that are promising for clinical implementation, and the latest advances in targeted therapy development. Finally, we discuss key steps needed for translating these discoveries into clinical practice.
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Affiliation(s)
- Saskia R Veldkamp
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Femke van Wijk
- Center for Translational Immunology, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Annet van Royen-Kerkhof
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Marc Ha Jansen
- Department of Pediatric Immunology and Rheumatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, Utrecht, the Netherlands.
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Carriquí-Arenas S, Mosquera JM, Quesada-Masachs E, López M, Clemente D, Boteanu A, Udaondo C, de Inocencio J, Nieto JC, Riancho L, Núñez E, Sánchez-Manubens J, Lirola MJ, Roldán R, Camacho M, Martínez M, Medrano M, Alcañiz P, Antón J, Iglesias E. Clinical characteristics and prognostic factor in juvenile dermatomyositis: data of the Spanish registry. Pediatr Rheumatol Online J 2024; 22:66. [PMID: 39039532 PMCID: PMC11265073 DOI: 10.1186/s12969-024-00999-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 06/16/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND Juvenile Dermatomyositis (JDM) is the most common chronic idiopathic inflammatory myopathy in children. The diagnosis is clinical. Baseline laboratory and complementary studies trace the phenotype of these patients. The objective of this study was to describe epidemiological, clinical and laboratory characteristics at diagnosis of JDM patients included in the Spanish JDM registry, as well as to identify prognostic factors on these patients. METHODS We retrospectively reviewed clinical features, laboratory tests, and complementary studies at diagnosis of JDM patients included on the Spanish JDM registry. These data were analyzed to assess whether there was a relationship with the development of complications and time to disease inactivity. RESULTS One hundred and sixteen patients from 17 Spanish paediatric rheumatology centres were included, 76 girls (65%). Median age at diagnosis was 7.3 years (Interquartile range (IQR) 4.5-10.2). All patients had pathognomonic skin lesions at the beginning of the disease. Muscle weakness was present in 86.2%. Median Childhood Muscle Assessment Scale was 34 (IQR 22-47). Twelve patients (34%) had dysphagia and 3,5% dysphonia. Anti-p155 was the most frequently detected myositis specific antibody, followed by anti-MDA5. Twenty-nine patients developed calcinosis and 4 presented with macrophage activation syndrome. 70% reached inactivity in a median time of 8.9 months (IQR 4.5-34.8). 41% relapsed after a median time of 14.4 months (IQR 8.6-22.8) of inactivity. Shorter time to treatment was associated with better prognosis (Hazard ratio (HR) = 0.95 per month of evolution, p = 0.02). Heliotrope rash at diagnosis correlates with higher risk of development complications. CONCLUSIONS We describe heliotrope rash as a risk factor for developing complications in our cohort of JDM patients, an easy-to-evaluate clinical sign that could help us to identify the group of patients we should monitor closely for this complication.
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Affiliation(s)
- Sonia Carriquí-Arenas
- Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain.
- Institut de Recerca Sant Joan de Déu, Barcelona, Spain.
| | - Juan Manuel Mosquera
- Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu, Barcelona, Spain
| | - Estefanía Quesada-Masachs
- Rheumatology Department, Pediatric Rheumatology Unit, Vall d'Hebron University Hospital, Barcelona Hospital Campus, Barcelona, Spain
| | - Mireia López
- Rheumatology Department, Pediatric Rheumatology Unit, Vall d'Hebron University Hospital, Barcelona Hospital Campus, Barcelona, Spain
| | - Daniel Clemente
- Pediatric Rheumatology Unit, Niño Jesús Hospital, Madrid, Spain
| | - Alina Boteanu
- Rheumatology Department, Ramón y Cajal University Hospital, Madrid, Spain
| | - Clara Udaondo
- Pediatric Rheumatology Unit, La Paz University Children's Hospital, CIBERINFEC (CIBER research network, Carlos III research institute), Madrid, Spain
| | - Jaime de Inocencio
- Pediatric Rheumatology Unit, University Hospital 12 de octubre, Madrid, Spain
- Pediatrics Complutense, University of Madrid, Madrid, Spain
| | - Juan Carlos Nieto
- Rheumatology Department, Gregorio Marañón General University Hospital, Madrid, Spain
| | - Leyre Riancho
- Rheumatology Department, Valdecilla Hospital, Santander, Spain
| | - Esmeralda Núñez
- Pediatric Rheumatology Unit, Pediatric Unit. Maternal and Child Hospital, Regional University Hospital of Malaga, Málaga, Spain
| | - Judith Sánchez-Manubens
- Pediatric Rheumatology Unit, Pediatric Department, Parc Taulí University Hospital, Sabadell, Spain
- Investigation and innovation Institute I3PT, University Autónoma, Barcelona, Spain
| | - María José Lirola
- Pediatric, Universtiy Hospital Macarena. IHP Group (Hispalense Institute of Pediatrics), Sevilla, Spain
| | - Rosa Roldán
- Pediatric Rheumatology Unit, Rheumatology Department, University Hospital Reina Sofía, Córdoba, Spain
| | - Marisol Camacho
- Pediatric Rheumatology Unit, Virgen del Rocío University Hospital, Sevilla, Spain
| | - Melania Martínez
- Rheumatology Department, Germans Trias i Pujol University Hospital, Badalona, Spain
| | - Marta Medrano
- Rheumatology Department, Miguel Servet University Hospital, Zaragoza, Spain
| | - Paula Alcañiz
- Pediatra. Pediatric Rheumatology Unit, Virgen de la Arrixaca University Clinical Hospital, Murcia, Spain
| | - Jordi Antón
- Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu, Universitat de Barcelona (UB), Barcelona, Spain
| | - Estíbaliz Iglesias
- Pediatric Rheumatology Department, Hospital Sant Joan de Déu, Barcelona, Spain
- Institut de Recerca Sant Joan de Déu, Barcelona, Spain
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Shukla A, Gaur P. Observational longitudinal study to assess the outcome of patients with idiopathic inflammatory myositis using validated tools. Int J Rheum Dis 2023; 26:2163-2169. [PMID: 37681396 DOI: 10.1111/1756-185x.14903] [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: 06/23/2023] [Revised: 07/29/2023] [Accepted: 08/22/2023] [Indexed: 09/09/2023]
Abstract
INTRODUCTION There have been major changes in the classification and treatment of patients with idiopathic inflammatory myositis (IIM) in the last 2 decades. A major challenge is to identify the parameters that can affect the outcome and prognosis of these patients. Here, we have longitudinally followed a well-characterized cohort of IIM patients in a rheumatology center and reported the outcome using the validated tools. METHOD Patients with a clinical diagnosis of IIM and a follow-up duration of greater than 2 years were prospectively included in the study. The duration of the study was 6 years: July 2016-July 2022. Clinical details and follow-up were recorded using pro-formas and outcomes were noted using validated tools. Ethics approval and written informed consent were taken. RESULTS Forty patients had a clinical diagnosis of IIM. Mean follow-up duration was 43.8 (15) months. Out of 40 patients, 32 (80%) achieved remission (8 patients each were off corticosteroid and off treatment for >6 months), 5 (12%) expired and 3 (8%) had active disease. Disease course was non-relapsing in 22/35 (73%) patients. Mean manual muscle testing-8 score (n = 29) and myositis disease activity assessment tool score (n = 35) at the final visit were 75.6 (6.8) and 0.048 (0.07) respectively. Thirteen patients had damage (37%). Patients with disease duration >1 year at the time of presentation were more likely to develop chronic-continuous disease course (P = .023, odds ratio [OR] = 7.6), more frequently required second-line or third-line immunosuppression (P = .001, OR = 24) with higher myositis damage index score (p = .0002, OR = 47). CONCLUSIONS IIM patients had good outcomes with the majority achieving remission and near-complete muscle recovery. However, the patients presenting late to the rheumatologists were more likely to have smoldering disease, more immunosuppressive medicines, and greater accumulated damage.
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Gebreamlak A, Sawicka KM, Garrett R, Goh YI, Baker KM, Feldman BM. Currently recommended skin scores correlate highly in the assessment of patients with Juvenile Dermatomyositis (JDM). Pediatr Rheumatol Online J 2023; 21:63. [PMID: 37381026 DOI: 10.1186/s12969-023-00844-5] [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: 03/10/2023] [Accepted: 06/14/2023] [Indexed: 06/30/2023] Open
Abstract
BACKGROUND Juvenile Dermatomyositis (JDM) is a rare, chronic, and life-threatening childhood autoimmune disease. Currently, there are recommended, reliable and validated measurement tools for assessment of skin disease activity in JDM including the Disease Activity Score (skinDAS), Cutaneous Assessment Tool (CAT), and the Cutaneous Dermatomyositis Disease Area and Severity Index (CDASI). The Physician's global assessment skin visual analog scale (Skin VAS) is also widely used for skin activity in JDM. For the purpose of comparative international studies, we wanted to compare these tools to the Physician's skin VAS (as a standard) to identify which performs better. OBJECTIVES We sought to compare the correlations of these scoring tools, and separately assess the responsiveness each tool demonstrates following patient treatment, in order to see if one tool may be preferred. This was determined by assessing how well these tools correlate with each other, and the Physician's skin VAS over time, as well as the responsiveness of each tool after patient treatment. METHODS Skin scores were recorded at a baseline (first visit after June 1st, 2018) and all follow-up office visits at the Juvenile Dermatomyositis Clinic. Following baseline visits, patients were followed up as clinically indicated. A subset of newly diagnosed patients (inception cohort) was identified. Correlations were assessed at the baseline visit and over time for the whole cohort. The correlations over time were derived using Generalized Estimating Equations (GEEs). Standardized response means with 95% confidence intervals were calculated to test score responsiveness for the nested inception cohort. RESULTS The skinDAS, CAT and CDASI all correlated highly with each other and with the Physician's skin VAS. The three scoring tools accurately reflected Physician's skin VAS scores over time. In addition, all tools showed moderate to high responsiveness following treatment. CONCLUSION All studied skin score tools performed well in our study and appear to be useful. Since no tool far outperforms the others, arbitrary consensus will be needed to select a single standard measurement tool for the purposes of efficiency and global comparability.
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Affiliation(s)
- Alexander Gebreamlak
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Canada
- Division of Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Katherine M Sawicka
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Canada
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
- Department of Medicine, Division of Neurology, University of Toronto, Toronto, Canada
| | - Rose Garrett
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Canada
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Y Ingrid Goh
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Canada
- Department of Pediatrics, Division of Rheumatology, The Hospital for Sick Children, University of Toronto, 555 University Ave, 555 University Ave, Toronto, Canada
| | - Kayla M Baker
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Canada
- Department of Pediatrics, Division of Rheumatology, The Hospital for Sick Children, University of Toronto, 555 University Ave, 555 University Ave, Toronto, Canada
| | - Brian M Feldman
- Child Health Evaluative Sciences Program, SickKids Research Institute, Toronto, Canada.
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.
- Department of Pediatrics, Division of Rheumatology, The Hospital for Sick Children, University of Toronto, 555 University Ave, 555 University Ave, Toronto, Canada.
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Papadopoulou C, Chew C, Wilkinson MGL, McCann L, Wedderburn LR. Juvenile idiopathic inflammatory myositis: an update on pathophysiology and clinical care. Nat Rev Rheumatol 2023; 19:343-362. [PMID: 37188756 PMCID: PMC10184643 DOI: 10.1038/s41584-023-00967-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/06/2023] [Indexed: 05/17/2023]
Abstract
The childhood-onset or juvenile idiopathic inflammatory myopathies (JIIMs) are a heterogenous group of rare and serious autoimmune diseases of children and young people that predominantly affect the muscles and skin but can also involve other organs, including the lungs, gut, joints, heart and central nervous system. Different myositis-specific autoantibodies have been identified that are associated with different muscle biopsy features, as well as with different clinical characteristics, prognoses and treatment responses. Thus, myositis-specific autoantibodies can be used to subset JIIMs into sub-phenotypes; some of these sub-phenotypes parallel disease seen in adults, whereas others are distinct from adult-onset idiopathic inflammatory myopathies. Although treatments and management have much improved over the past decade, evidence is still lacking for many of the current treatments and few validated prognostic biomarkers are available with which to predict response to treatment, comorbidities (such as calcinosis) or outcome. Emerging data on the pathogenesis of the JIIMs are leading to proposals for new trials and tools for monitoring disease.
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Affiliation(s)
- Charalampia Papadopoulou
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH), London, UK
- Rare Diseases Theme NIHR Biomedical Research Centre at GOSH, London, UK
| | - Christine Chew
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, UK
| | - Meredyth G Ll Wilkinson
- Rare Diseases Theme NIHR Biomedical Research Centre at GOSH, London, UK
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, London, UK
- Infection Immunity and Inflammation Research and Teaching Department, UCL GOS Institute of Child Health, London, UK
| | - Liza McCann
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, UK
| | - Lucy R Wedderburn
- Department of Paediatric Rheumatology, Great Ormond Street Hospital for Children NHS Foundation Trust (GOSH), London, UK.
- Rare Diseases Theme NIHR Biomedical Research Centre at GOSH, London, UK.
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, London, UK.
- Infection Immunity and Inflammation Research and Teaching Department, UCL GOS Institute of Child Health, London, UK.
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Suzon B, Goulabchand R, Louis-Sidney F, Maria A, Najjari R, Chauvet E, Le Quellec A, Bessis D, Guilpain P. Subcutaneous tissue involvement in idiopathic inflammatory myopathies: Systematic literature review including three new cases and hypothetical mechanisms. Autoimmun Rev 2023; 22:103284. [PMID: 36736986 DOI: 10.1016/j.autrev.2023.103284] [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: 01/03/2023] [Accepted: 01/29/2023] [Indexed: 02/04/2023]
Abstract
INTRODUCTION Involvement of subcutaneous tissue in idiopathic inflammatory myopathies (IIM) is poorly known. METHODS We conducted a systematic review of the literature regarding panniculitis and lipodystrophy/lipoatrophy in juvenile and adult IIM via PubMed/Medline, Embase and Scopus databases. Three local observations are included in this review. Epidemiological, clinical, paraclinical and therapeutic data were collected. RESULTS Panniculitis appears to be more common in adults than in juveniles. It was mainly localised in the upper and lower limbs. Panniculitis improved in most cases with steroids and panniculitis and myositis had a similar course in 83.3% and 72.2% of cases in juveniles and adults, respectively. Lipodystrophy appeared to be more frequent in juveniles and was only observed in dermatomyositis in both juveniles and adults. Lipodystrophy was mainly partial in juveniles and adults. The median time from myositis to the diagnosis of lipodystrophy was 6 years [0-35] and 2.5 years [0-10] in juveniles and adults, respectively. Lipodystrophy was associated with anti-TIF1 gamma auto-antibody positivity, a polycyclic/chronic course of myositis and the occurrence of calcinosis and might be an indicator of poor disease control. CONCLUSION Adipose tissue involvement, particularly lipodystrophy, occurs almost exclusively in dermatomyositis. The insidious onset and lack of awareness of the diagnosis may underestimate its prevalence. Larger studies are needed to identify possible risk factors in these patients, to better potential underlying pathophysiological process, in order to discuss potential therapeutic targets.
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Affiliation(s)
- Benoit Suzon
- Department of Internal Medicine, Martinique University Hospital, Fort-de-France, Martinique, France; EpiCliV Research Unit, University of French West Indies, Fort-de-France, Martinique, France
| | - Radjiv Goulabchand
- Department of Internal Medicine, Nîmes University Hospital, France; Institute for Regenerative Medicine and Biotherapy, INSERM U1183, Montpellier, France
| | - Fabienne Louis-Sidney
- EpiCliV Research Unit, University of French West Indies, Fort-de-France, Martinique, France; Department of Rheumatology, Martinique University Hospital, France
| | - Alexandre Maria
- Institute for Regenerative Medicine and Biotherapy, INSERM U1183, Montpellier, France; Department of Internal Medicine and Immuno-Oncologie (MedI(2)O), Montpellier University Hospital, France; Montpellier-1 University, Faculty of Medicine, France
| | - Redwann Najjari
- Department of Internal Medicine and Multi-Organic Diseases, Montpelier University Hospital, France
| | - Elodie Chauvet
- Department of Internal Medicine and Multi-Organic Diseases, Montpelier University Hospital, France
| | - Alain Le Quellec
- Department of Internal Medicine and Multi-Organic Diseases, Montpelier University Hospital, France
| | - Didier Bessis
- Department of Dermatology, Montpellier University Hospital, France
| | - Philippe Guilpain
- Institute for Regenerative Medicine and Biotherapy, INSERM U1183, Montpellier, France; Montpellier-1 University, Faculty of Medicine, France; Department of Internal Medicine and Multi-Organic Diseases, Montpelier University Hospital, France.
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Pinotti CS, Cannon L, Dvergsten JA, Wu EY. Calcinosis in juvenile dermatomyositis: Updates on pathogenesis and treatment. Front Med (Lausanne) 2023; 10:1155839. [PMID: 36936211 PMCID: PMC10017873 DOI: 10.3389/fmed.2023.1155839] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 02/13/2023] [Indexed: 03/06/2023] Open
Abstract
Calcinosis, or the deposition of insoluble calcium salts in the skin, subcutaneous tissue, fascia, tendons, and muscles, is a feared complication of juvenile dermatomyositis. Calcinosis is estimated to affect up to 40% of patients with juvenile dermatomyositis and contributes to significant disease morbidity. Calcinosis can be challenging to treat, and the most effective treatment remains unknown because of a lack of comparative studies. We aim to review the literature published in the last 5 years to summarize updates on the pathogenesis and treatment of calcinosis in juvenile dermatomyositis and describe future areas for research.
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Affiliation(s)
- Caitlan S. Pinotti
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, NC, United States
- *Correspondence: Caitlan S. Pinotti,
| | - Laura Cannon
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina, Chapel Hill, Chapel Hill, NC, United States
| | - Jeffrey A. Dvergsten
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, NC, United States
| | - Eveline Y. Wu
- Division of Pediatric Rheumatology, Department of Pediatrics, University of North Carolina, Chapel Hill, Chapel Hill, NC, United States
- Division of Pediatric Allergy and Immunology, Department of Pediatrics, University of North Carolina Chapel Hill, Chapel Hill, NC, United States
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Pediatric Rheumatic Disease in Lower to Middle-Income Countries: Impact of Global Disparities, Ancestral Diversity, and the Path Forward. Rheum Dis Clin North Am 2021; 48:199-215. [PMID: 34798947 DOI: 10.1016/j.rdc.2021.09.001] [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: 11/21/2022]
Abstract
Pediatric rheumatology subspecialists treat chronic autoimmune diseases with onset in childhood. Prompt diagnosis and ongoing management of these conditions are imperative to prevent damage from ongoing inflammation. Here, we aim to describe the current landscape of pediatric rheumatic disease in lower to middle-income countries (LMICs) and explore current barriers to understanding global disease burden. We then examine innovative strategies to promote a more equitable future for children and young people living with rheumatic diseases worldwide.
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Livermore P, Gibson F, Mulligan K, Wedderburn LR, McCann LJ, Gray S. Mapping the current psychology provision for children and young people with juvenile dermatomyositis. Rheumatol Adv Pract 2021; 5:rkab062. [PMID: 34671713 PMCID: PMC8522803 DOI: 10.1093/rap/rkab062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 08/16/2021] [Indexed: 11/13/2022] Open
Abstract
Objectives Juvenile Dermatomyositis (JDM) is a rare, chronic autoimmune condition of
childhood, with known psychosocial implications. In this study, we sought to
establish current psychological support for children and young people across
the UK with rheumatic conditions, with a specific focus on those with
JDM. Methods Electronic surveys were distributed to the 15 centres that belong to the JDM
Research Group in the UK, collecting responses from health-care
professionals in the fields of medicine, nursing and psychology. Results One hundred per cent of professionals from medicine and nursing replied from
all 15 centres. Of these, 7 (47%) did not have a named psychologist
as part of their rheumatology team, despite the majority [13 (87%)]
having >200 paediatric rheumatology patients. Of the remaining
centres, hospital psychology provision varied considerably. When rating
their service, only 3 (8%) of 40 professionals scored their service
as five (where one is poor and five is excellent); there were wide
discrepancies in these scores. Many challenges were discussed, including
limited psychology provision, lack of time and difficulties in offering
support across large geographical areas. Conclusion Many of the challenges discussed are applicable to other centres worldwide.
Suggestions have been proposed that might help to improve the situation for
children and young people with rheumatic conditions, including JDM. Based on
these findings, we suggest that rheumatology teams maximize use of these
data to advocate and work toward more comprehensive psychology provision and
support in their individual centres.
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Affiliation(s)
- Polly Livermore
- Rheumatology Department, University College London Great Ormond Street Institute of Child Health.,Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust.,NIHR Biomedical Research Centre at Great Ormond Street Hospital.,Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London
| | - Faith Gibson
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability (ORCHID), Great Ormond Street Hospital for Children NHS Foundation Trust.,School of Health Sciences, University of Surrey, Guildford
| | - Kathleen Mulligan
- Centre of Health Services Research, University of London.,East London NHS Foundation Trust, London
| | - Lucy R Wedderburn
- Rheumatology Department, University College London Great Ormond Street Institute of Child Health.,NIHR Biomedical Research Centre at Great Ormond Street Hospital.,Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London
| | - Liza J McCann
- Rheumatology Department, Alder Hey Children's NHS Foundation Trust, Liverpool
| | - Suzanne Gray
- Psychological Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Kim H, Huber AM, Kim S. Updates on Juvenile Dermatomyositis from the Last Decade: Classification to Outcomes. Rheum Dis Clin North Am 2021; 47:669-690. [PMID: 34635298 DOI: 10.1016/j.rdc.2021.07.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Juvenile dermatomyositis (JDM) is a heterogeneous disease with new classification criteria and updates in myositis-specific autoantibody and myositis-associated antibody groups. There are many validated assessment tools for assessing disease activity in JDM. Future studies will optimize these tools and improve feasibility in clinical and research contexts. Genetic and environmental risk factors, mechanisms of muscle pathology, role of interferon, vascular markers, and changes in immune cells provide insights to JDM pathogenesis. Outcomes have improved, but chronic disease, damage, and mortality highlight the need for better outcome predictors and treatments. Increased collaboration of stakeholders may help overcome research barriers and improve JDM treatment.
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Affiliation(s)
- Hanna Kim
- Juvenile Myositis Pathogenesis and Therapeutics Unit, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health, 10 Center Drive, Building 10, 12N-240, Bethesda, MD 20892, USA.
| | - Adam M Huber
- IWK Health Centre and Dalhousie University, Division of Pediatric Rheumatology, 5850 University Avenue, Halifax, Nova Scotia B3K 6R8, Canada
| | - Susan Kim
- University of California, San Francisco, 550 16th Street, San Francisco, CA 94158, USA
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Nitiyarom R, Charuvanij S, Likasitwattanakul S, Thanoophunchai C, Wisuthsarewong W. Juvenile dermatomyositis in Thai children: Retrospective review of 30 cases from a tertiary care center. Indian J Dermatol Venereol Leprol 2021; 88:162-170. [PMID: 34491668 DOI: 10.25259/ijdvl_297_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2020] [Accepted: 03/01/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Juvenile dermatomyositis is a rare condition, but it is the most common idiopathic inflammatory myopathy in pediatric patients. AIM To study the clinical manifestations, investigations, treatment, clinical course, and outcomes of juvenile dermatomyositis in Thai children. METHOD This retrospective study included juvenile dermatomyositis patients treated at Siriraj Hospital, a 2,300-bed national tertiary referral center in Bangkok, Thailand, from 1994 to 2019. RESULTS Thirty patients (22 females and 8 males) were included with a female to male ratio of 2.7:1. Median age at diagnosis was 5.1 years (range, 2.6-14.8 years). Median duration of illness before diagnosis was 6.5 months (range, 0.3-84.0 months). Acute and subacute onset occurred in the majority of patients. Presenting symptoms included muscle weakness in 27/30 (90%), skin rash in 26/30 (86.7%), muscle pain in 17/26 (65.4%), and arthralgia in 4/18 (22.2%) of patients. Dermatologic examination revealed Gottron's rash, heliotrope rash, and periungual telangiectasia in 25/30 (83.3%), 21/30 (70.0%), and 15/24 (62.5%) of patients, respectively. Interestingly, scalp dermatitis was found in 8/21 (38.1%) of patients. The most commonly used treatment regimen in this series was a combination of prednisolone and methotrexate. During the median follow-up of 3.1 years (range, 0.0-18.5 years), only one-third of patients were seen to have monocyclic disease. Extraskeletal osteosarcoma at a previous lesion of calcinosis cutis was observed in one patient at 12 years after juvenile dermatomyositis onset. LIMITATIONS This was a retrospective single-center study, and our results may not be generalizable to other healthcare settings. Prospective multicenter studies are needed to confirm the findings of this study. CONCLUSION juvenile dermatomyositis usually poses a diagnostic and therapeutic challenge, which can be compounded by the ethnic variations in the clinical presentation, as observed in this study. Asian patients tend to present with acute or subacute onset of disease, and arthralgia and/or arthritis are less common than in Caucasian patients. Scalp dermatitis is not uncommon in pediatric juvenile dermatomyositis patients. An association between juvenile dermatomyositis and malignancy, though rare, can occur.
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Affiliation(s)
- Rattanavalai Nitiyarom
- Division of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sirirat Charuvanij
- Division of Rheumatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Surachai Likasitwattanakul
- Division of Neurology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiwat Thanoophunchai
- Division of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Wanee Wisuthsarewong
- Division of Dermatology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Chevalier G, Fakih O, Lhose A, Ballot-Schmit C, Prati C, Puzenat E, Aubin F. Long-term outcome in patients with juvenile dermatomyositis: A case series. Arch Pediatr 2021; 28:475-479. [PMID: 34034928 DOI: 10.1016/j.arcped.2021.04.006] [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: 11/10/2020] [Revised: 03/29/2021] [Accepted: 04/16/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Follow-up of juvenile dermatomyositis (JDM) patients has demonstrated the impact of the disease on several organs in the long term. OBJECTIVE As there is little information on the long-term outcome of JDM, we aimed to assess long-term outcomes in a series of JDM patients. METHODS After selection of JDM patients, a consultation with a dermatologist and a rheumatologist was held for each patient. Cutaneous, muscle, and disease damage was assessed using different validated scores including the abbreviated Cutaneous Assessment Tool (aCAT), 8-muscle Manual Muscle Testing (MMT8), Childhood Myositis Assessment Scale (CMAS), Myositis Damage Index (MDI), Childhood Health Assessment Questionnaire (CHAQ), and Health Assessment Questionnaire (HAQ). Long-term disease outcomes were recorded including growth and pubertal development, educational and vocational achievement, and development of comorbidities. RESULTS Seven patients were included in the study. After a mean follow-up of 14.9±8.8 years, the mean aCAT score was 0.57±1.4 and only one patient had a positive aCAT activity score. The mean aCAT damage score was 1.4±1.3 and five (71%) patients had a score of ≥1. Five (71.4%) patients had normal muscle strength with an MMT8 score of >72, and none had severe muscle weakness (MMT8 ≤32, and CMAS<35). The mean total extent of damage according to the MDI was ≥1 in five (71%) patients and mainly involved the skin. Two (29%) patients had mild disability according to the CHAQ/HAQ disability index. In terms of quality of life, no patient had a score of<40 (1 SD below the mean for healthy controls). CONCLUSIONS Based on validated cutaneous and musculoskeletal scores, our study demonstrated the good functional outcomes of JDM at long-term follow-up.
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Affiliation(s)
- G Chevalier
- Service de Dermatologie, Inserm 1098 RIGHT, Université de Franche Comté, Centre Hospitalier Universitaire, 3, boulevard Fleming, 25030 Besançon, France
| | - O Fakih
- Service de Rhumatologie, Inserm 1098 RIGHT, Université de Franche Comté, Centre Hospitalier Universitaire, Besançon, France
| | - A Lhose
- Service de Rhumatologie, Centre Hospitalier, Belfort, France
| | - C Ballot-Schmit
- Service de Rhumatologie, Centre Hospitalier, Belfort, France
| | - C Prati
- Service de Rhumatologie, Inserm 1098 RIGHT, Université de Franche Comté, Centre Hospitalier Universitaire, Besançon, France
| | - E Puzenat
- Service de Dermatologie, Inserm 1098 RIGHT, Université de Franche Comté, Centre Hospitalier Universitaire, 3, boulevard Fleming, 25030 Besançon, France
| | - F Aubin
- Service de Dermatologie, Inserm 1098 RIGHT, Université de Franche Comté, Centre Hospitalier Universitaire, 3, boulevard Fleming, 25030 Besançon, France.
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Leung AKC, Lam JM, Alobaida S, Leong KF, Wong AHC. Juvenile Dermatomyositis: Advances in Pathogenesis, Assessment, and Management. Curr Pediatr Rev 2021; 17:273-287. [PMID: 33902423 DOI: 10.2174/1573396317666210426105045] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 02/15/2021] [Accepted: 02/18/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Juvenile dermatomyositis is the most common inflammatory myopathy in the pediatric age group and a major cause of mortality and morbidity in individuals with childhood rheumatic diseases. Mounting evidence suggests that early diagnosis and timely aggressive treatment are associated with better outcomes. OBJECTIVE The purpose of this article is to provide readers with an update on the evaluation, diagnosis, and the treatment of juvenile dermatomyositis. METHODS A PubMed search was performed in Clinical Queries using the key term "juvenile dermatomyositis" in the search engine. The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature. The information retrieved from the above search was used in the compilation of the present article. RESULTS Juvenile dermatomyositis is a chronic autoimmune inflammatory condition characterized by systemic capillary vasculopathy that primarily affects the skin and muscles with possible involvement of other organs. In 2017, the European League Against Rheumatism (EULAR) and the American College of Rheumatology (ACR) developed diagnostic criteria for juvenile idiopathic inflammatory myopathies and juvenile dermatomyositis. In the absence of muscle biopsies which are infrequently performed in children, scores (in brackets) are assigned to four variables related to muscle weakness, three variables related to skin manifestations, one variable related to other clinical manifestations, and two variables related to laboratory measurements to discriminate idiopathic inflammatory myopathies from non-idiopathic inflammatory myopathies as follows: objective symmetric weakness, usually progressive, of the proximal upper extremities (0.7); objective symmetric weakness, usually progressive, of the proximal lower extremities (0.8); neck flexors relatively weaker than neck extensors (1.9); leg proximal muscles relatively weaker than distal muscles (0.9); heliotrope rash (3.1); Gottron papules (2.1); Gottron sign (3.3); dysphagia or esophageal dysmotility (0.7); the presence of anti-Jo-1 autoantibody (3.9); and elevated serum levels of muscle enzymes (1.3). In the absence of muscle biopsy, a definite diagnosis of idiopathic inflammatory myopathy can be made if the total score is ≥7.5. Patients whose age at onset of symptoms is less than 18 years and who meet the above criteria for idiopathic inflammatory myopathy and have a heliotrope rash, Gottron papules or Gottron sign are deemed to have juvenile dermatomyositis. The mainstay of therapy at the time of diagnosis is a high-dose corticosteroid (oral or intravenous) in combination with methotrexate. CONCLUSION For mild to moderate active muscle disease, early aggressive treatment with high-dose oral prednisone alone or in combination with methotrexate is the cornerstone of management. Pulse intravenous methylprednisolone is often preferred to oral prednisone in more severely affected patients, patients who respond poorly to oral prednisone, and those with gastrointestinal vasculopathy. Other steroid-sparing immunosuppressive agents such as cyclosporine and cyclophosphamide are reserved for patients with contraindications or intolerance to methotrexate and for refractory cases, as the use of these agents is associated with more adverse events. Various biological agents have been used in the treatment of juvenile dermatomyositis. Data on their efficacy are limited, and their use in the treatment of juvenile dermatomyositis is considered investigational.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, The University of Calgary, Alberta Children's Hospital, Calgary, Alberta,Canada
| | - Joseph M Lam
- Department of Pediatrics and Department of Dermatology and Skin Sciences, The University of British Columbia, Vancouver, British Columbia,Canada
| | - Saud Alobaida
- Department of Dermatology, King Faisal Specialist Hospital & Research Centre, Riyadh,Saudi Arabia
| | - Kin F Leong
- Pediatric Institute, Kuala Lumpur General Hospital, Kuala Lumpur,Malaysia
| | - Alex H C Wong
- Department of Family Medicine, The University of Calgary, Calgary, Alberta,Canada
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Monitoring disease activity and damage in adult and juvenile idiopathic inflammatory myopathy. Curr Opin Rheumatol 2020; 32:553-561. [PMID: 32890032 DOI: 10.1097/bor.0000000000000749] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
PURPOSE OF REVIEW We have reviewed the literature to identify significant advances related to disease activity and damage in the idiopathic inflammatory myopathies (IIMs) from January 2019 to July 2020. RECENT FINDINGS New observations in the field from 2019 to 2020 have resulted in a better understanding of the clinical association and pathogenic origins of IIM. The use of patient-reported outcome measures and perspectives, identifying biomarkers and making better use of autoantibody testing are summarized. Basic sciences have led to an improved understanding of the role of NETosis in calcinosis, and of interferon type 1, in IIM. Preliminary insights are offered into Covid-19 in the setting of IIM, and the use of potential tools for monitoring disease remotely, which may assume larger importance for optimal disease management during a global pandemic. The wider exploration of newer imaging modalities and the use of nailfold capillaroscopy is a further step in better management of the condition. SUMMARY The summarized research in IIM is a step forward in being able to further define, and to distinguish disease activity from damage, in order to potentially aid future clinical diagnosis and management in this challenging disease.
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