ANKYLOSING SPONDYLITIS IN CHILDREN AND ADOLESCENTS

The Disease of the Italian Poet Giacomo Leopardi (1798-1837): A Case of Juvenile Ankylosing Spondylitis in the 19th Century?

Some authors sustained that the pessimistic thought of the Italian writer and philosopher Giacomo Leopardi (1798-1837) may be attributed to his unhappy life, characterized by several health problems. His philosophical theories appear as the result of depressive and melancholic state, related to his precarious health conditions, so limiting their intrinsic values. Several authors formulated various hypotheses on the diseases that Leopardi suffered from and postulated different theories on the cause of his early death. This article assumed that Leopardi may have been affected by juvenile ankylosing spondylitis, conditioning spinal deformities, relapsing-remitting uveitis, urinary tract and bowel tract problems, and acute arthritis. Chest deformity, as a complication of juvenile ankylosing spondylitis, may have caused progressive cardiorespiratory failure, worsened by recurrent bronchial and pulmonary complications, until his death caused by acute right ventricular heart failure. The acknowledgment of a physical cause of Leopardi's disease contributes to reevaluate his "cosmic pessimism" as an original expression of his thought, so leading a general revaluation of the figure of one of the most important European thinkers of the 19th century.

Spondyloarthritis in a pediatric population: risk factors for sacroiliitis

OBJECTIVE

Pediatric rheumatologists may have an opportunity to diagnose sacroiliitis in its early stages, prior to the development of irreversible radiographic changes. Early diagnosis frequently requires magnetic resonance imaging (MRI), the use of which is limited by expense and requirement for sedation. We set out to identify features of juvenile spondyloarthritis (SpA) associated with the highest risk of sacroiliitis, to identify patients who may be candidates for routine MRI-based screening.

METHODS

We reviewed the charts of 143 children seen at Texas Scottish Rite Hospital for Children diagnosed with SpA based on the International League of Associations for Rheumatology criteria for enthesitis-related arthritis or the Amor criteria for SpA. We performed logistic regression analysis to identify risk factors for sacroiliitis.

RESULTS

A group of 143 children were diagnosed with SpA. Consistent with the diagnosis of SpA, 16% had psoriasis, 43% had enthesitis, 9.8% had acute anterior uveitis, and 70% were HLA-B27+. Fifty-three children had sacroiliitis, of which 11 cases were identified by imaging studies in the absence of suggestive symptoms or physical examination findings. Logistic regression analysis revealed that hip arthritis was a positive predictor of sacroiliitis, while dactylitis was a negative predictor.

CONCLUSION

Children with SpA are at risk for sacroiliitis, which may be present in the absence of suggestive symptoms or physical examination findings. The major risk factor for sacroiliitis is hip arthritis, while dactylitis may be protective. Routine screening by MRI should be considered in patients at high risk of developing sacroiliitis.

The history of pediatric rheumatology

The care and study of children with rheumatic diseases began slowly in the 19th century, with the most attention centered on rheumatic fever. Other rheumatic diseases of children received little attention until the 1940s. Rheumatic diseases taken together remain a significant cause of chronic illness in children throughout the world. A number of other conditions that masquerade as rheumatic diseases in children also demand recognition and management. Although ultimate causes and cures of childhood rheumatic diseases remain elusive, advances in therapy have improved the outlook for affected children, and advances in biomedical research are adding to our basic understanding of the disease process involved. Pediatric rheumatology has become a well-organized, although underpopulated, specialty that enhances recognition and care of affected children and contributes to basic research knowledge in infectious disease, immunology, and genetics. This review focuses most prominently on the early history of pediatric rheumatology and its development as a specialty. The recent burgeoning of new biomedical science and new means of treatment will be better told in the historical perspective of years to come.

The juvenile-onset spondyloarthritides

The juvenile-onset spondyloarthritides comprise a group of HLA-B27-associated disorders, which are mainly characterized by enthesitis and arthritis affecting the lower extremities, and in a variable proportion of cases, the sacroiliac and spinal joints. Additional features include a variety of extra-articular manifestations, and in some cases, bacterial infections as triggers. Except for the prevalence of some clinical features at onset and severity throughout the course of the disease, juvenile-onset SpA resemble their adult counterpart in most clinical aspects, strength of HLA-B27 association, and the role of arthritogenic bacteria in their pathogenesis. Not surprisingly, several aspects, from nomenclature to classification, and diagnostic criteria reflect to some extent those developed in the adult onset populations.

Joint disease in children of Asiatic origin

Joint disorders in Asian children are varied due to the diversity of the Asian population and show some ethnic trends. The ethnic diversity, socio-economic and geographic factors in Asia have limited the availability of data from some of the ethnic groups, many of whom live in remote and relatively underdeveloped areas, are not subjected to epidemiological surveillance and have little awareness of these diseases and their consequences. Geographic and socio-economic factors also play a significant role in some of the joint diseases peculiar to Asian children. In general, the current available data suggests that there are no large differences in the epidemiology and clinical features between the Western and Asian children. This article reviews the available literature on joint diseases in Asian children.

Juvenile-onset spondyloarthropathies

This article discusses the clinical spectrum and characteristics of juvenile-onset spondyloarthropathies and includes a review of the demographic, clinical, radiographic (and other imaging techniques), and laboratory data of conditions, syndromes, and diseases making up this group. The pathogenic role of several factors in the context of adult-onset patients, but also in regards to studies already performed in juvenile-onset patients, is discussed.

The early clinical recognition of juvenile-onset ankylosing spondylitis and its differentiation from juvenile rheumatoid arthritis

OBJECTIVE

To determine which early clinical data differentiate juvenile-onset ankylosing spondylitis (AS) from juvenile rheumatoid arthritis (JRA).

METHODS

Medical records of 35 patients with juvenile-onset AS and 75 with JRA (excluding type II pauciarticular JRA), all of whom had disease onset at age < or = 16 years, disease duration of < or = 2 1/2 years at the initial visit to the rheumatology clinic, and followup of > or = 10 years, were analyzed retrospectively with regard to features of disease found 6 months, 12 months, and 10 years after onset.

RESULTS

At 6 months, various features appeared more frequently in the juvenile-onset AS group than in the JRA group, i.e., pauciarthritis (54.3% versus 30.7%; P = 0.03, odds ratio [OR] = 2.7), enthesopathy (82.9% versus 0%; P < 0.0001, OR = 321.4), tarsal disease (71.4% versus 1.3%; P < 0.0001, OR = 185.0), and lumbar/sacroiliac symptoms (11.4% versus 0%; P = 0.02, OR = 11.9). At 12 months, the features found more frequently among juvenile-onset AS patients than JRA patients were enthesopathy (88.6% versus 4.0%; P < 0.0001, OR = 186.0), tarsal disease (85.7% versus 10.7%; P < 0.0001, OR = 50.3), and knee disease (100.0% versus 82.7%; P = 0.04, OR = 8.0). Involvement of the upper extremities (especially the hands) was found in significantly fewer juvenile-onset AS patients compared with the JRA group. Definite involvement of the spine and sacroiliitis in juvenile-onset AS occurred after a mean +/- SD of 7.3 +/- 2.0 years.

CONCLUSION

Regardless of axial disease, enthesopathy and tarsal disease in children who have arthritis of the lower, but not of the upper extremities differentiate juvenile-onset AS from JRA within 1 year of symptoms. The discriminative value of these parameters approaches that of axial disease (the gold standard) throughout the followup period.

Ankylosing spondylitis of juvenile onset: comparison with adult onset disease

Although less frequently, ankylosing spondylitis (AS) may also occur during childhood. The present report describes the clinical features in 24 patients with AS of juvenile onset and its comparison with those found in 71 patients with adult onset AS. A slightly increased prevalence of female patients was found in the juvenile onset group. Peripheral joint involvement as a mono- or oligoarticular arthritis was significantly more frequent in juvenile onset patients, not only as a mode of onset but also during the course of the disease. 5.4 years after onset all these patients had developed axial involvement. Extra-articular manifestations occurred with similar frequency in juvenile and adult onset patients. One juvenile patient had associated multiple sclerosis; one juvenile and one adult onset patient developed amyloidosis. Impairment of functional capacity was more severe in the juvenile onset group; hip joint involvement was closely related to a poorer prognosis.

HLA-B27-associated spondyloarthritis and enthesopathy in childhood: clinical, pathologic, and radiographic observations in 58 patients

HLA-B27 typing of all arthritic children helped to identify and focus attention on a subset whose disease was pathogenetically related to and demonstrated clinical features of ankylosing spondylitis and Reiter syndrome, but only rarely fulfilled current diagnostic criteria for those disorders (spondyloarthritis). In contrast to other forms of childhood arthritis, enthesopathy (inflammation at the sites of attachment of ligaments and tendons to bone) was a prominent feature in 75%; a family history of similar arthritis was obtained from 60%; boys were more frequently affected (2:1); urethritis, acute iritis, conjunctivitis, or keratoderma blennorrhagicum occurred at some time in 42%; and the initial attack followed an unexplained febrile illness, known dysentery or urethritis, or severe musculoskeletal trauma in 41%. The arthritis was generally pauciarticular, asymmetric, and primarily in the feet and large joints of the lower extremities. Distinctive radiographic features included periostitis, severe osteopenia, calcaneal erosions, and heel spurs; three of 58 had rapid destruction of a single joint. Only ten patients (all boys) were found to have radiographic sacroiliitis after an average of five years of disease, and only three had the Reiter triad. The lifetime risk of sacroiliitis and spinal ankylosis can only be determined by long-term follow-up of such prospectively identified groups of spondyloarthritic children.

Ankylosing spondylitis

Ankylosing spondylitis occurs chiefly in young men and affects principally the sacroiliac, apophyseal, and costovertebral joints. Physical findings may be minimal, and special tests may be necessary to find objective evidence of the disease. HLA-B27 histocompatibility antigen is present in 90% to 95% of patients. The feature of highest diagnostic significance is the roentgenographic finding of syndesmophytes. The natural course of the disease is characterized by spontaneous remissions and exacerbations and by possible arrest at any stage. In general, the prognosis is good for maintenance of functional ability despite the development of severe back deformities. In management, emphasis must be given to maintaining normal posture and body habitus and to encouraging the patient to cope with individual needs and problems. If basic measures, including salicylate therapy, do not control the disease, additional drug therapy must be initiated. Surgical intervention is a last resort.

Radiological manifestations of ankylosing spondylitis according to age at onset

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Grading of films for sacro-iliitis in population studies

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