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Hu YC, Yang YH, Chiang BL. Immunoglobulin A vasculitis: The clinical features and pathophysiology. Kaohsiung J Med Sci 2024; 40:612-620. [PMID: 38828518 DOI: 10.1002/kjm2.12852] [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: 05/03/2024] [Revised: 05/06/2024] [Accepted: 05/07/2024] [Indexed: 06/05/2024] Open
Abstract
Palpable purpura, gastrointestinal symptoms, joint involvement, and renal disease characterize immunoglobulin A vasculitis (IgAV). Renal involvement ranging from mild proteinuria to severe nephritic or nephrotic syndrome highlights the importance of monitoring kidney function in patients with IgAV. Recognizing these key features is crucial for early diagnosis and appropriate management to prevent long-term complications related to kidney disease. However, the pathogenesis of IgAV remains unclear. Disease mechanisms involve various factors, including the interplay of aberrantly glycosylated IgA, anti-endothelial cell antibodies, and neutrophils following infection triggers, which are the main pathogenic mechanisms of IgAV. Insights from cases of IgAV related to Coronavirus disease 2019 have offered additional understanding of the connection between infection and IgAV pathogenesis. This review provides a valuable resource for healthcare professionals and rheumatology researchers seeking a better understanding of the clinical features and pathophysiology of IgAV.
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Affiliation(s)
- Ya-Chiao Hu
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Yao-Hsu Yang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
| | - Bor-Luen Chiang
- Department of Pediatrics, National Taiwan University Hospital, Taipei, Taiwan
- Genome and Systems Biology Degree Program, College of Life Science, National Taiwan University, Taipei, Taiwan
- Medical Research, National Taiwan University Hospital, Taipei, Taiwan
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Sunar Yayla EN, Bakkaloğlu SA. Does age at disease onset affect the clinical presentation and outcome in children with immunoglobulin A vasculitis? Arch Rheumatol 2023; 38:633-641. [PMID: 38125056 PMCID: PMC10728748 DOI: 10.46497/archrheumatol.2023.9914] [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: 09/14/2022] [Accepted: 02/09/2023] [Indexed: 12/23/2023] Open
Abstract
Objectives The study aimed to determine whether there is a relationship between the age at diagnosis and the clinical, laboratory, and prognostic features in pediatric immunoglobulin A vasculitis (IgAV) patients. Patients and methods In this study, 539 pediatric IgAV patients (298 males, 241 females; mean age: 7.74±3.36 years; range, 1 to 17.8 years) were retrospectively evaluated between January 2005 and July 2020. The relationship between clinical findings and age at diagnosis was analyzed by univariate logistic regression analysis. Factors associated with renal involvement, steroid-dependent or refractory disease, and recurrence were examined. Results The median age of diagnosis was 7.1 (1-17.8) years in all patients. At the time of admission, purpura, abdominal pain, and arthritis were the most common clinical findings. At the time of diagnosis, there was a positive association between age and purpura and an inverse association with the presence of arthritis. There were associations between renal involvement and age at diagnosis (odds ratio=1.22, 95% confidence interval 1.13-1.31, p<0.001), follow-up time (p<0.001), no history of previous infection (p<0.001), and presence of gastrointestinal (GI) involvement (p=0.003). Significant relationships were found between the age at diagnosis, follow-up time, GI involvement, renal involvement, scrotal involvement, the C-reactive protein value at the time of diagnosis, and the presence of steroid-dependent disease. An association was found between recurrence and GI involvement. All refractory patients had renal involvement. Age at diagnosis (p<0.001) and follow-up time (p<0.001) was found to be associated with refractory disease. Conclusion Age at diagnosis and follow-up time may be associated with renal involvement and refractory and steroid-dependent disease in IgAV. In addition, there may be a relationship between steroid-dependent disease and renal, GI, and scrotal involvement and between GI involvement and recurrence.
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Affiliation(s)
- Emine Nur Sunar Yayla
- Department of Pediatrics, Division of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Türkiye
| | - Sevcan A. Bakkaloğlu
- Department of Pediatrics, Division of Pediatric Rheumatology, Gazi University Faculty of Medicine, Ankara, Türkiye
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Marro J, Williams C, Pain CE, Oni L. A case series on recurrent and persisting IgA vasculitis (Henoch Schonlein purpura) in children. Pediatr Rheumatol Online J 2023; 21:85. [PMID: 37580746 PMCID: PMC10424434 DOI: 10.1186/s12969-023-00872-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/02/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) is a small vessel vasculitis that is more common in childhood. Very limited evidence exists on patients who experience an atypical disease course. The aim of this study was to describe a cohort of children diagnosed with recurrent or persisting IgAV to identify any themes associated with their disease course and areas of unmet needs. METHODS A single centre retrospective study of children diagnosed with recurrent or persisting IgAV at Alder Hey Children's Hospital (Liverpool, UK). Clinical data, including features at presentation and during follow up, potential triggers, abnormal laboratory and histology results, treatment and outcome at last clinical review were retrospectively collected. Key themes were identified. RESULTS A total of 13 children met the inclusion criteria (recurrent disease, n = 4; persisting disease, n = 9). Median age at first presentation was 10.2 years [2.6-15.5], female:male ratio 1.2:1. Children in the atypical cohort were significantly older than a larger cohort of children who followed a non-complicated disease course (median age 5.5 years (range [0.6-16.7], p = 0.003)). All children re-presented with a purpuric rash (either recurring or persisting), accompanied by joint involvement in 92% of patients (12/13). Disease-modifying anti-rheumatic drugs (DMARDs) were used in 8/13 (62%) children. The median time from first presentation to diagnosis of atypical disease was 18.4 months [5.3-150.8] and the time from first presentation to treatment was 24.1 months [1.8-95.4]. Use of corticosteroids was significantly higher in children with renal involvement (p = 0.026). During follow up, 8/13 (62%) children were admitted at least once, whilst 10/13 (77%) had re-presented at least once to the emergency department. Five (38%) children were referred to psychology services and 7 (54%) children reported feelings of frustration. CONCLUSIONS This series describes some characteristics of a small cohort of children with atypical IgAV. It also identifies unmet needs in children with atypical IgAV, which includes delays in diagnosis and lengthy waits for treatment, lack of high-quality evidence regarding treatment choices and a high unrecognised disease burden. Further research is needed to study this subgroup of children as evidence is lacking.
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Affiliation(s)
- Julien Marro
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
| | - Chloe Williams
- Royal Liverpool and Broadgreeen University Hospital Trusts, Liverpool, UK
| | - Clare E Pain
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
- Department of Paediatric Rheumatology, Alder Hey Children's NHS Foundation Trust Hospital, Liverpool, UK
| | - Louise Oni
- Department of Women's and Children's Health, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Department of Paediatric Nephrology, University of Liverpool Alder Hey Children's NHS Foundation Trust Hospital, Institute in the Park Building, Eaton Road, Liverpool, L12 2AP, UK.
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Li Y, Zhang X, Liu H, Li G, Guan W, Zhang T, Zeng Q, Gong Y, Xu H, Sun L. Severe gastrointestinal involvement in pediatric IgA vasculitis: a retrospective single-center cohort study in China. Front Pediatr 2023; 11:1194214. [PMID: 37614903 PMCID: PMC10442948 DOI: 10.3389/fped.2023.1194214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Accepted: 07/20/2023] [Indexed: 08/25/2023] Open
Abstract
Objectives The study aimed to describe the characteristics of gastrointestinal (GI) involvement in a cohort of hospitalized children with IgA vasculitis (IgAV) in China. Method We reviewed the records of hospitalized IgAV patients from January 2014 to December 2020 at one tertiary medical center. The patients were divided into the severe GI group and the non-severe GI group according to the presence of massive GI bleeding and complications. The clinical manifestations, laboratory factors, and treatment were analyzed between the two groups. Results A total of 1,179 patients were hospitalized due to IgAV. GI involvement was noted in 50% (589) of the patients, of whom 288 (48.9%) had severe GI involvement. GI complications were observed in 34 patients with IgAV with GI involvement. Rare onset age (<3 years or within 13-17 years), purpura above the waist, vomiting, high neutrophil-to-lymphocyte ratio, and decreased serum albumin were factors associated with severe GI involvement. Frequencies of renal involvement and biopsy-proven nephritis were higher in the severe GI group. The most commonly used medications were corticosteroids (100.0%) in the severe GI group. The maximum corticosteroid dose was higher (2.9 vs. 2.0 mg/kg), and more second-line therapies were needed (30.9% vs. 16.94%) in the severe GI group. Conclusions Severe GI involvement in children is common in our center. Rare onset age, purpura above the waist, vomiting, high neutrophil-to-lymphocyte ratio, and decreased serum albumin are associated with severe GI involvement. Patients with severe GI involvement need higher doses of corticosteroids and second-line therapy.
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Affiliation(s)
- Yifan Li
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Xiaomei Zhang
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Haimei Liu
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Guomin Li
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Wanzhen Guan
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Tao Zhang
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Qiaoqian Zeng
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Yinv Gong
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Hong Xu
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
- Department of Nephrology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
| | - Li Sun
- Department of Rheumatology, Children’s Hospital of Fudan University, National Center for Children’s Health, Shanghai, China
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Coşkun S, Güngörer V, Ekici Tekin Z, Çelikel E, Kurt T, Tekgöz N, Sezer M, Karagöl C, Kaplan MM, Polat MC, Öner N, Acar BÇ. Preadolescent-versus adolescent-onset immunoglobulin A vasculitis: The impact of age on prognosis. Pediatr Int 2023; 65:e15426. [PMID: 36416667 DOI: 10.1111/ped.15426] [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: 09/30/2022] [Revised: 11/15/2022] [Accepted: 11/22/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to investigate the characteristics of patients with preadolescent- and adolescent-onset immunoglobulin A vasculitis (IgAV) and to determine whether age affects IgAV outcomes in adolescents. METHODS Demographic, clinical, and laboratory data of 333 patients diagnosed with IgAV at the Department of Pediatric Rheumatology, University of Health Sciences, Ankara City Hospital, were evaluated retrospectively. The patients were classified into two groups: preadolescents (<10 years) and adolescents (10-19 years). Subgroup analyses were also performed by grouping the adolescent patients into early, middle, and late adolescent groups. RESULTS Of the 333 patients, 219 (65.8%) and 114 (34.2%) were preadolescents and adolescents. Palpable purpura, renal, joint, and gastrointestinal (GI) tract involvement were detected in 333 (100%), 78 (23.4%), 79 (23.7%), and 124 (37.2%) patients, respectively; testicular involvement was observed in 25 (13.3%) of 187 male patients. The frequency of renal involvement was significantly higher in the adolescent group than in the preadolescent group at the time of diagnosis (p = 0.030). Notably, joint involvement was significantly higher in the adolescent group (p = 0.001). The need for aggressive therapy was significantly higher in the adolescent group than in the preadolescent group (p = 0.003). There was no significant difference in clinical data, demographic characteristics, and laboratory findings between the adolescent subgroups (p > 0.05). CONCLUSIONS Immunoglobulin A vasculitis can occur at any age but the disease prognosis appears to worsen with age. The present study reported that joint involvement, kidney involvement, and the need for more aggressive treatment were higher in the adolescent group than in the preadolescent group.
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Affiliation(s)
- Serkan Coşkun
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Vildan Güngörer
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Zahide Ekici Tekin
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Elif Çelikel
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Tuba Kurt
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Nilüfer Tekgöz
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Müge Sezer
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Cüneyt Karagöl
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Melike Mehveş Kaplan
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Merve Cansu Polat
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Nimet Öner
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
| | - Banu Çelikel Acar
- Division of Pediatric Rheumatology, Department of Pediatrics, Ankara City Hospital, University of Health Sciences, Ankara, Turkey
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Kelly BG, Stratton DB, Mansour I, Tanriover B, Culpepper KS, Curiel-Lewandrowski C. Navigating the initial diagnosis and management of adult IgA vasculitis: A review. JAAD Int 2022; 8:71-78. [PMID: 35721303 PMCID: PMC9204729 DOI: 10.1016/j.jdin.2022.05.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2022] [Indexed: 11/15/2022] Open
Abstract
Background IgA vasculitis in adults has not been thoroughly studied. This has left a practice gap related to the management and follow-up of a population that is at an increased risk of comorbidities and potentially poor outcomes. For this reason, it is important to synthesize evidence from the current literature because this can help direct the movement for more robust studies to clarify best practice recommendations. Objective We sought to create a narrative review for the practicing dermatologist when diagnosing and leading the care of IgA vasculitis in adult patients. Methods A broad literature search was performed with a focus on articles that were published after the introduction of the most updated European Alliance of Associations for Rheumatology/Pediatric Rheumatology International Trials Organization/Pediatric Rheumatology European Society criteria. Results The characteristics and management guidelines for IgA vasculitis in adults have been refined, although more rigorous studies are needed to develop best practice recommendations. Limitations Because of the lack of sufficient randomized controlled trials on IgA vasculitis in adults, this narrative review is composed of mostly observational, descriptive studies. Conclusion Adults with IgA vasculitis are at an increased risk of complicated disease course, necessitating formal diagnostic assessment and clear-cut follow-up recommendations to manage and prevent poor health outcomes related to various comorbidities.
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Affiliation(s)
- Brenna G. Kelly
- Division of Dermatology, University of Arizona, Tucson, Arizona
- Medical College of Wisconsin, Milwaukee, Wisconsin
| | | | - Iyad Mansour
- Division of Nephrology, University of Arizona, Tucson, Arizona
| | - Bekir Tanriover
- Division of Nephrology, University of Arizona, Tucson, Arizona
| | - Keliegh S. Culpepper
- Division of Dermatology, University of Arizona, Tucson, Arizona
- Dermpath Diagnostics, Tucson, Arizona
| | - Clara Curiel-Lewandrowski
- Division of Dermatology, University of Arizona, Tucson, Arizona
- Correspondence to: Clara Curiel-Lewandrowski, MD, Division of Dermatology, University of Arizona, 1501 N. Campbell Avenue, Tucson, AZ 85724.
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Kang Z, Xun M, Li Z, Yang Z. Association of the clinicopathological characteristics and proteinuria remission of pediatric IgAV with nephrotic-range proteinuria: A retrospective cohort study. Front Pediatr 2022; 10:959212. [PMID: 36340706 PMCID: PMC9634576 DOI: 10.3389/fped.2022.959212] [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: 07/12/2022] [Accepted: 09/29/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND IgA vasculitis (IgAV) combined with nephrotic-range proteinuria is uncommon, and nephrotic-range proteinuria is considered a risk factor for poor prognosis in children with IgAV. There are few clinical studies with large samples. METHODS Children with IgAV and nephrotic-range proteinuria who were hospitalized at the Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, from March 2008 to January 2020 were retrospectively studied; the patients were aged ≤18 years and were followed up for ≥12 months. We analyzed clinical characteristics, pathological changes, treatment responses, and their relationships in patients with IgAV combined with nephrotic-range proteinuria. RESULTS Two hundred seventy-seven children with an average age at onset of IgAV with nephritis (IgAVN) of 8.0 years (interquartile range (IQR), 6.0-10.0) were enrolled; 65.7% were aged 6-10 years. The male-to-female ratio was 1.35:1. All children had both nephrotic-range proteinuria and hematuria, 49 (17.7%) had hypoalbuminemia, and 9 (3.2%) had estimated glomerular filtration rate < 90 (mL/min/1.73 m2). All included children were followed up for at least 1 year. At 3, 6, and 12 months of follow-up, the remission rates of proteinuria in children with IgAV combined with nephrotic-range proteinuria were 27.8%, 62.1%, and 83.0%, respectively, and the remission rates of hematuria were 1.4%, 8.7%, and 35.7%, respectively. In addition, children with age at onset of IgAV with nephrotic-range proteinuria ≥10 years, who were female, who had proteinuria ≥100 mg/kg/24 h, and who had a pathological grade III or above had lower remission rates of hematuria and proteinuria (P < 0.05). Multivariate factor analysis was performed by logistic regression and showed age at onset of IgAVN ≥ 10 years and crescents to be risk factors for nonremission of proteinuria at 12 months of follow-up (P < 0.05). CONCLUSIONS Age at onset of IgAVN, sex, proteinuria level, pathological grade, and crescents significantly affect proteinuria remission in children with IgAV combined with nephrotic-range proteinuria.
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Affiliation(s)
- Zhijuan Kang
- Department of Pediatrics, Third Xiangya Hospital of Central South University, Changsha, China.,Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Mai Xun
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Zhihui Li
- Department of Nephrology, Rheumatology and Immunology, Hunan Children's Hospital, Changsha, China
| | - Zuocheng Yang
- Department of Pediatrics, Third Xiangya Hospital of Central South University, Changsha, China
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Dawood SA, Abodiah AM, Alqahtani SM, Shati AA, Alqahtani YA, Alshehri MA, Mahmood SE. Clinico-Epidemiological Profile and Outcome of Children with IgA Vasculitis in Aseer Region, Southwestern Saudi Arabia. Healthcare (Basel) 2021; 9:healthcare9121694. [PMID: 34946420 PMCID: PMC8701005 DOI: 10.3390/healthcare9121694] [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: 11/09/2021] [Revised: 12/02/2021] [Accepted: 12/04/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction: Immunoglobulin A (IgA) vasculitis is one of the most common forms of primary vasculitis in children; it typically has a benign course but can be aggressive and require intervention. Aim of the work: The aim of this retrospective study was to evaluate the epidemiological and clinical profile and treatment modalities used for children with IgA vasculitis in the southwestern region of Saudi Arabia. Material and Methods: We reviewed the medical records of 89 children admitted to Abha Maternity and Children Hospital in the southwestern region of Saudi Arabia from January 2016 to December 2020 with a confirmed diagnosis of IgA vasculitis according to the European League Against Rheumatism/Paediatric Rheumatology International Trials Organisation/Pediatric Rheumatology European Society criteria. Results: Eighty-nine children had a confirmed diagnosis of IgA vasculitis, with 50 boys (56.2%) and 39 girls (43.8%; male-to-female ratio of 1.28:1) and a mean age at diagnosis of 5.87 ± 2.81 years. The mean hospital stay duration was 5.66 ± 4.72 days. Infections preceded 29.2% of the cases, with upper respiratory tract infections comprising 24.7%. Approximately 31.5% of the cases were diagnosed in summer, followed by autumn in 28% of the cases. Rash was present in 100%, arthritis in 72.2%, gastrointestinal tract involvement in 60.7%, and renal involvement in 23.5% of cases. Thrombocytosis and leukocytosis were found in 35% and 46% of all cases, and 52.3% and 47.6.25% of cases with renal involvement, respectively (OR = 2.035, 95% CI: 0.75–5.52 and OR = 1.393, 95% CI: 0.522–1.716, respectively). Approximately 26% of cases experienced relapses. Treatment was conservative in 23.6%, oral prednisolone in 23.6%, and pulse steroid in 45% of cases. Abdominal pain with lower gastrointestinal tract bleeding was the primary indication for initiating pulse steroid treatment. Conclusions: There were similarities and differences in the epidemiology and frequency of clinical manifestations of patients with IgA vasculitis compared to previous studies. Children presenting with such epidemiological and clinical profile need to be closely monitored and long-term follow-up is recommended to improve the outcomes.
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Affiliation(s)
- Samy A. Dawood
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Abdoh M. Abodiah
- Pediatric Rheumatology Unit, Department of Pediatrics, Abha Maternity and Children Hospital, Abha 62562, Saudi Arabia;
| | - Saleh M. Alqahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Ayed A. Shati
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
- Correspondence:
| | - Youssef A. Alqahtani
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Mohammed A. Alshehri
- Department of Child Health, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia; (S.A.D.); (S.M.A.); (Y.A.A.); (M.A.A.)
| | - Syed E. Mahmood
- Department of Family and Community Medicine, College of Medicine, King Khalid University, Abha 62529, Saudi Arabia;
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