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Alaboud S, Al Hawsawi W, Alqahtani N, Aldosari M, Alhawsawi WK, Al Hawsawi K. Juvenile Dermatomyositis Presenting As Generalized Poikiloderma: A Case Report. Cureus 2023; 15:e50573. [PMID: 38222200 PMCID: PMC10788081 DOI: 10.7759/cureus.50573] [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] [Accepted: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
Juvenile dermatomyositis (JDM) is a chronic autoimmune inflammatory disorder and is considered the most common form of idiopathic inflammatory myopathies. JDM primarily affects the skin and the skeletal muscles. Characteristic signs and symptoms include Gottron papules, heliotrope rash, calcinosis cutis, and symmetrical proximal muscle weakness. However, JDM presenting with generalized scaly poikeloderma is an unfamiliar presentation. Herein we report a 14-month-old female toddler presented with generalized progressive asymptomatic scaly mottled violaceous patches (poikilodermatous) that started when she was seven months old. Her lab results were unremarkable. She was diagnosed with poikilodermatous skin rash with a differential diagnosis of Amyopathic dermatomyositis, poikilodermatous genodermatosis, and patch-stage mycosis fungoides. She was prescribed moisturizer creams only. A year later, during a follow-up, she presented with a full picture of JDM, with a history of scaly poikilodermatous skin patches that became more widespread, frequent choking during oral intake, and not being able to stand and sit unsupported. Laboratory workup was significant for low WBC and hemoglobin counts, along with elevated CPK, LDH, ferritin, CRP, and ESR levels. MRI revealed the right anterior thigh and vastus lateralis subcutaneous edema. Therefore, the child was diagnosed and treated as a case of JDM.
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Affiliation(s)
- Sarah Alaboud
- College of Medicine, Umm Al-Qura University, Makkah, SAU
| | - Wafi Al Hawsawi
- Collage of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
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Rosina S, Rebollo-Giménez AI, Consolaro A, Ravelli A. Treat-to-Target in Pediatric Rheumatic Diseases. Curr Rheumatol Rep 2023; 25:226-235. [PMID: 37584859 DOI: 10.1007/s11926-023-01112-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/29/2023] [Indexed: 08/17/2023]
Abstract
PURPOSE OF REVIEW To summarize the current evidence on the adoption of the treat-to-target (T2T) strategy in pediatric rheumatic diseases (PRD). RECENT FINDINGS The recent advances in the management of PRD have markedly increased the ability to achieve disease remission. Complete disease quiescence is regarded as the ideal therapeutic goal because its attainment leads to lesser long-term damage and physical disability, and to optimization of quality of life. Studies in adult rheumatic diseases have shown that patient outcomes are improved if complete suppression of the inflammatory process is aimed for by frequent adjustments of therapy according to quantitative indices. This approach, which underlies the T2T concept, has been applied in strategic trials in rheumatoid arthritis (RA). Furthermore, recommendations for the T2T have been issued for RA and other adult rheumatic diseases. There is currently a growing interest for the introduction of T2T in PRD, and recommendations for treating juvenile idiopathic arthritis (JIA) to target were promulgated. A similar initiative has been undertaken for childhood-onset systemic lupus erythematosus. Preliminary therapeutic studies have explored the T2T design in JIA. The T2T strategy is a modern therapeutic approach that holds the promise of improving the outcomes in patients with PRD.
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Affiliation(s)
- Silvia Rosina
- UOC Reumatologia E Malattie Autoinfiammatorie, IRCCS Istituto Giannina Gaslini, Genoa, Italy.
| | | | - Alessandro Consolaro
- UOC Reumatologia E Malattie Autoinfiammatorie, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Dipartimento Di Neuroscienze, Scienze Materno-Infantili, Università Degli Studi Di Genova, RiabilitazioneGenoa, Oftalmologia, Geneticae , Italy
| | - Angelo Ravelli
- Dipartimento Di Neuroscienze, Scienze Materno-Infantili, Università Degli Studi Di Genova, RiabilitazioneGenoa, Oftalmologia, Geneticae , Italy
- Direzione Scientifica, IRCCS Istituto Giannina Gaslini, Genoa, Italy
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Sherman MA, Kim H, Banschbach K, Brown A, Gewanter HL, Lang B, Perron M, Robinson AB, Spitznagle J, Stingl C, Syverson G, Tory HO, Spencer CH, Tarvin SE. Treatment escalation patterns to start biologics in refractory moderate juvenile dermatomyositis among members of the Childhood Arthritis and Rheumatology Research Alliance. Pediatr Rheumatol Online J 2023; 21:3. [PMID: 36609397 PMCID: PMC9825021 DOI: 10.1186/s12969-022-00785-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 12/26/2022] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Despite new and better treatments for juvenile dermatomyositis (JDM), not all patients with moderate severity disease respond adequately to first-line therapy. Those with refractory disease remain at higher risk for disease and glucocorticoid-related complications. Biologic disease-modifying antirheumatic drugs (DMARDs) have become part of the arsenal of treatments for JDM. However, prospective comparative studies of commonly used biologics are lacking. METHODS The Childhood Arthritis and Rheumatology Research Alliance (CARRA) JDM biologics workgroup met in 2019 and produced a survey assessing current treatment escalation practices for JDM, including preferences regarding use of biologic treatments. The cases and questions were developed using a consensus framework, requiring 80% agreement for consensus. The survey was completed online in 2020 by CARRA members interested in JDM. Survey results were analyzed among all respondents and according to years of experience. Chi-square or Fisher's exact test was used to compare the distribution of responses to each survey question. RESULTS One hundred twenty-one CARRA members responded to the survey (denominators vary for each question). Of the respondents, 88% were pediatric rheumatologists, 85% practiced in the United States, and 43% had over 10 years of experience. For a patient with moderately severe JDM refractory to methotrexate, glucocorticoids, and IVIG, approximately 80% of respondents indicated that they would initiate a biologic after failing 1-2 non-biologic DMARDs. Trials of methotrexate and mycophenolate were considered necessary by 96% and 60% of respondents, respectively, before initiating a biologic. By weighed average, rituximab was the preferred biologic over abatacept, tocilizumab, and infliximab. Over 50% of respondents would start a biologic by 4 months from diagnosis for patients with refractory moderately severe JDM. There were no notable differences in treatment practices between respondents by years of experience. CONCLUSION Most respondents favored starting a biologic earlier in disease course after trialing up to two conventional DMARDs, specifically including methotrexate. There was a clear preference for rituximab. However, there remains a dearth of prospective data comparing biologics in refractory JDM. These findings underscore the need for biologic consensus treatment plans (CTPs) for refractory JDM, which will ultimately facilitate comparative effectiveness studies and inform treatment practices.
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Affiliation(s)
- Matthew A. Sherman
- grid.94365.3d0000 0001 2297 5165Muscle Disease Unit, Laboratory of Muscle Stem Cells and Gene Regulation, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, 9000 Rockville Pike 50 South Drive Building 50, Room 1142, 20892 Bethesda, MD USA ,grid.239560.b0000 0004 0482 1586Division of Rheumatology, Children’s National Hospital, Washington, DC USA
| | - Hanna Kim
- grid.420086.80000 0001 2237 2479Juvenile Myositis Pathogenesis and Therapeutics Unit, National Institute of Arthritis Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD USA
| | - Katelyn Banschbach
- grid.240741.40000 0000 9026 4165Division of Rheumatology, Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, WA USA
| | - Amanda Brown
- grid.241054.60000 0004 4687 1637University of Arkansas for Medical Sciences and Arkansas Children’s Hospital, Little Rock, AR USA
| | - Harry L. Gewanter
- grid.414220.1Children’s Hospital of Richmond at VCU, Richmond, VA USA
| | - Bianca Lang
- grid.55602.340000 0004 1936 8200IWK Health, Dalhousie University, Halifax, NS Canada
| | - Megan Perron
- grid.413957.d0000 0001 0690 7621Department of Pediatric Rheumatology, Children’s Hospital Colorado, Aurora, CO USA
| | - Angela Byun Robinson
- grid.239578.20000 0001 0675 4725Pediatric Rheumatology, Cleveland Clinic Children’s Hospital, Cleveland, OH USA
| | - Jacob Spitznagle
- grid.240741.40000 0000 9026 4165Division of Rheumatology, Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, WA USA
| | - Cory Stingl
- grid.416230.20000 0004 0406 3236Department of Pediatrics, Spectrum Health, Grand Rapids, MI USA
| | - Grant Syverson
- grid.490404.d0000 0004 0425 6409Sanford Health, Fargo, ND USA
| | - Heather O. Tory
- grid.63054.340000 0001 0860 4915Connecticut Children’s Medical Center, Hartford, CT, USA and University of Connecticut School of Medicine, Farmington, Farmington, CT USA
| | - Charles H. Spencer
- grid.410721.10000 0004 1937 0407University of Mississippi Medical Center, Batson Children’s Hospital, Jackson, MS USA
| | - Stacey E. Tarvin
- grid.257413.60000 0001 2287 3919Division of Rheumatology, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN USA
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Criteria Associated with Treatment Decisions in Juvenile Idiopathic Arthritis with a Focus on Ultrasonography: Results from the JIRECHO Cohort. Rheumatol Ther 2022; 10:225-238. [PMID: 36427176 PMCID: PMC9702887 DOI: 10.1007/s40744-022-00512-2] [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: 09/26/2022] [Accepted: 11/07/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND The treatment of children with juvenile idiopathic arthritis (JIA) to prevent disability is a major challenge in paediatric rheumatology. The presence of synovitis, which is difficult to detect in children, is associated with structural damage. Musculoskeletal ultrasonography (MSUS) can be used in patients with JIA to reveal subclinical synovitis. OBJECTIVE The primary aim was to determine whether the use of MSUS was associated with therapeutic modification in patients with JIA. The secondary aim was to identify other factors associated with therapeutic decisions. METHODS We conducted an observational study based on the JIRECHO multi-centre cohort, which was developed to provide a systematic MSUS follow-up for patients with JIA. Follow-up occurred every 6 months and included clinical and MSUS examinations. We included children who underwent MSUS of the elbows, wrists, second metacarpophalangeal joints, knees and ankles, which was performed by expert sonographers. Clinical and biological data, disease activity scores and information on therapeutics were collected. RESULTS A total of 185 visits concerning 112 patients were recorded. Three groups were defined according to the therapeutic decision: escalation (22%, n = 40), de-escalation (14%, n = 26) or stable (64%, n = 119). In the "therapeutic escalation" group: the presence of ultrasonographic synovitis in B-mode and the presence of grade 2 or 3 synovitis in B-mode were not significantly more frequent than in the "stable therapeutic or de-escalation" group (80% versus 65%, p = 0.06; 33% versus 19%, p = 0.06), and the patient's and physician's visual analogue scale (VAS) scores, the clinical JADAS and the C-reactive protein level were significantly higher, but only physician's VAS score remained in the model of logistic regression. In the "therapeutic de-escalation" group: there was no difference in the presence of US synovitis compared with the "stable therapeutic or escalation" group (62% versus 69%, p = 0.48). CONCLUSION Even though US synovitis tended to be more frequent in patients with therapeutic escalation, the study did not show that the presence of synovitis in MSUS was statistically associated with therapeutic modifications in patients with JIA. Treatment remained stable despite the presence of US synovitis.
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Cancarini P, Nozawa T, Whitney K, Bell-Peter A, Marcuz JA, Taddio A, Guo J, Dover S, Feldman BM. The clinical features of juvenile dermatomyositis: A single-centre inception cohort. Semin Arthritis Rheum 2022; 57:152104. [PMID: 36183479 DOI: 10.1016/j.semarthrit.2022.152104] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 08/30/2022] [Accepted: 09/21/2022] [Indexed: 12/01/2022]
Abstract
INTRODUCTION Juvenile Dermatomyositis (JDM), a severe and rare autoimmune disease, is the most common idiopathic inflammatory myopathy in children. We describe the clinical features of a large single-centre cohort. METHODS We studied an inception cohort (0-18 years old) referred for diagnosis to the JDM clinic at The Hospital for Sick Children (SickKids), between January 1989 and September 2017. Probable or definite diagnosis of JDM was done according to the 2017 ACR/EULAR Criteria. We excluded children who had treatment started at another hospital. The data were collected retrospectively from clinical charts and the SickKids JDM database. RESULTS 172/230 (74.8%) patients were included. They were most often female (female:male = 1.8:1); the age at diagnosis was 8.5±4.3 years. There was a positive family history for autoimmune disease in 52%, mainly rheumatoid arthritis. No patient died. The most common signs at inception were muscle weakness (85.5%), nailfold capillary abnormalities (83.4%), Gottron papules (78.5%), heliotrope rash (66.3%), abnormal gait (55.8%), and malar/facial rash (54.7%). The prevalence of Gottron papules, heliotrope rash, facial/malar rash, nailfold capillary abnormalities, Raynaud phenomenon, dysphonia/dysphagia (a frequent cause of hospitalization), mouth ulcers, calcinosis, eye problems, joint involvement, acanthosis nigricans and lipodystrophy increased during follow-up. Muscle enzymes, namely CK, ALT, AST, were often normal or only slightly raised despite active muscle disease; conversely LD was often high. Anti-Nuclear Autoantibodies were positive in 49.7% of patients at diagnosis. The course of the disease was: 29.1% monocyclic, 5.3% polycyclic, 33.1% chronic. The course of 56 patients (32.5%) was not classifiable due to length of follow-up. Corticosteroids were used as treatment in almost all our patients and 30% required intravenous therapy due to the severity of the presentation; methotrexate was added in 64%, more often in recent years. Unresponsive patients were treated mostly with intravenous immunoglobulins (IVIG). CONCLUSIONS The information obtained from this relatively large number of patients adds to the growing knowledge base of this rare disease. TRIAL REGISTRATION SickKids Research Ethics Board approved the study.
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Affiliation(s)
- Paola Cancarini
- Operative Unit of Pediatrics, ASST del Garda, Desenzano del Garda (BS), Italy
| | - Tomo Nozawa
- Department of Pediatrics, Graduate School of Medicine, Yokohama City University, Yokohama, Kanagawa, Japan; Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Kristi Whitney
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Canada
| | - Audrey Bell-Peter
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada
| | - Jo-Anne Marcuz
- Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; Department of Rehabilitation, The Hospital for Sick Children, Toronto, Canada
| | - Andrea Taddio
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo" and University of Trieste, Trieste, Italy
| | - Jessica Guo
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada
| | - Saunya Dover
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada
| | - Brian M Feldman
- Child Health Evaluative Sciences, Hospital for Sick Children Research Institute, Toronto, Canada; Division of Rheumatology, Department of Pediatrics, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, Faculty of Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management & Evaluation, The Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
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An Unusual Cause of Necrotising Fasciitis in a Young Male with Juvenile Dermatomyositis. Case Rep Rheumatol 2022; 2022:8758263. [PMID: 35982709 PMCID: PMC9381251 DOI: 10.1155/2022/8758263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 03/28/2022] [Accepted: 07/22/2022] [Indexed: 11/17/2022] Open
Abstract
Juvenile dermatomyositis (JDM) is a rare condition worldwide, affecting children younger than 16 years. It is characterized by weakness in the proximal skeletal muscles and a pathognomonic skin rash. Patients with JDM develop complications that are usually a consequence of vasculopathy affecting multiple organ systems. Occult gastrointestinal (GI) perforation is an uncommon complication and is associated with an increased risk of mortality due to a delay in diagnosis. We report on a 14-year-old male with JDM with an aggressive course over two years and severe clinical manifestations. The patient developed necrotizing fasciitis, an unusual rapidly progressing lethal infection of the fascia resulting from bowel contents seeping from multiple intestinal perforations. This case, less commonly seen in males, highlights the occurrence of multiple phenomena—JDM complicated by skin and gastrointestinal vasculopathy with resultant development of multiple GI perforations and consequently life-threatening necrotizing fasciitis of the leg. Physicians need a high index of suspecting GI perforation in JDM patients as the delayed recognition of this complication can result in significant morbidity and/or mortality since the typical symptoms of perforation may be absent.
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Mondal S, Barman P, Vignesh P. Cardiovascular Abnormalities in Juvenile Dermatomyositis: A Scoping Review for the Clinical Rheumatologists. Front Med (Lausanne) 2022; 9:827539. [PMID: 35814777 PMCID: PMC9263083 DOI: 10.3389/fmed.2022.827539] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 05/09/2022] [Indexed: 11/17/2022] Open
Abstract
Juvenile dermatomyositis (JDM) is a common form of inflammatory myositis in children. Vasculopathy and endothelial dysfunction play significant roles in the pathogenesis of JDM. Cardiac involvement in JDM is often underestimated, and it may be a potential indicator of poor prognosis. Cardiac dysfunction in JDM can occur both in the acute and chronic stages of the disease. Amongst the acute complications, acute congestive heart failure (CHF), myocarditis, arrhythmia, and complete heart block are common. However, these remain unrecognized due to a lack of overt clinical manifestations. Increased rates of cardiovascular abnormalities have been noted with anti-SRP and anti-Jo 1 auto-antibody positivity. Long-term follow-up studies in JDM have shown an increased prevalence of hypertension, atherosclerosis, coronary artery disease, and metabolic syndrome in adolescence and adulthood. Monitoring of body-mass index, blood pressure, and laboratory evaluation of fasting glucose and lipid profile may help in identifying metabolic syndrome in children with JDM. Steroid-sparing agents, daily exercise, and a healthy diet may reduce such long-term cardiac morbidities. Current use of multimodality imaging such as stress-echocardiography, contrast-enhanced echocardiography, cardiac magnetic resonance imaging, and positron emission tomography has increased the diagnostic yield of subclinical heart disease during acute and chronic stages of JDM. This review elaborates on different aspects of cardiac dysfunction in JDM. It also emphasizes the importance of cardiac screening in long-term follow-up of children with JDM.
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Ginter DC, Ramien ML, Brundler MA, Swaney LC, Miettunen PM, Luca NJ. A rare case of suspected lupus erythematous panniculitis as the presenting skin feature of juvenile dermatomyositis: A case report. SAGE Open Med Case Rep 2022; 10:2050313X221086317. [PMID: 35355853 PMCID: PMC8958673 DOI: 10.1177/2050313x221086317] [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] [Indexed: 11/25/2022] Open
Abstract
Juvenile dermatomyositis is a rare autoimmune myopathy of childhood, associated with systemic vasculopathy, primarily affecting the capillaries. Panniculitis is seen histologically in about 10% of patients with dermatomyositis; however, its clinical presentation is rare, with only 30 cases presented in the literature to date. The histopathology overlaps with other inflammatory disease states, and is almost identical to the panniculitis seen in lupus erythematous panniculitis. In the cases with both panniculitis and dermatomyositis, skin and muscle inflammation is usually the first clinical manifestation. We present a case of a 16-year-old female with panniculitis as the initial presenting feature of juvenile dermatomyositis in the context of a prior diagnosis of indeterminate colitis.
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Affiliation(s)
- Dylan C Ginter
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Michele L Ramien
- Division of Community Pediatrics, Department of Pediatrics, and Division of Dermatology, Department of Medicine, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Marie-Anne Brundler
- Department of Pathology and Laboratory Medicine and Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Laura C Swaney
- Division of General Pediatrics, Department of Pediatrics, Faculty of Medicine, The University of British Columbia, Vancouver, BC, Canada
| | - Paivi Mh Miettunen
- Section of Pediatric Rheumatology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
| | - Nadia Jc Luca
- Section of Pediatric Rheumatology, Department of Pediatrics, Alberta Children's Hospital, University of Calgary, Calgary, AB, Canada
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Quddusi FI, Youssef MJ, Davis DMR. Dermatologic Manifestations of Systemic Diseases in Childhood. Pediatr Rev 2021; 42:655-671. [PMID: 34850179 DOI: 10.1542/pir.2020-000679] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
| | - Molly J Youssef
- Department of Pediatric and Adolescent Medicine.,Department of Dermatology, Mayo Clinic, Rochester, MN
| | - Dawn Marie R Davis
- Department of Pediatric and Adolescent Medicine.,Department of Dermatology, Mayo Clinic, Rochester, MN
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Orandi AB, Fotis L, Lai J, Morris H, White AJ, French AR, Baszis KW. Favorable outcomes with reduced steroid use in juvenile dermatomyositis. Pediatr Rheumatol Online J 2021; 19:127. [PMID: 34404425 PMCID: PMC8369654 DOI: 10.1186/s12969-021-00615-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/14/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND High-intensity glucocorticoid regimens are commonly used to induce and maintain remission in Juvenile Dermatomyositis but are associated with several adverse side-effects. Evidence-based treatment guidelines from North American and European pediatric rheumatology research societies both advocate induction with intravenous pulse steroids followed by high dose oral steroids (2 mg/kg/day), which are then tapered. This study reports the time to disease control with reduced glucocorticoid dosing. METHODS We retrospectively reviewed the records at a single tertiary-care children's hospital of patients diagnosed with Juvenile Dermatomyositis between 2000 and 2014 who had a minimum of 2 years of follow-up. The primary outcome measure was time to control of muscle and skin disease. Additional outcome measures included glucocorticoid dosing, effect of treatment on height, frequency of calcinosis, and complications from treatment. RESULTS Of the 69 patients followed during the study period, 31 fulfilled inclusion criteria. Median length of follow-up was 4.58 years, (IQR 3-7.5). Myositis control was achieved in a median of 7.1 months (IQR 0.9-63.4). Cutaneous disease control was achieved in a median of 16.7 months (IQR 4.3-89.5). The median starting dose of glucocorticoids was 0.85 mg/kg/day, (IQR 0.5-1.74). The median duration of steroid treatment was 9.1 months, (IQR 4.7-17.4), while the median duration of any pharmacotherapy was 29.2 months (IQR 10.4 to 121.3). Sustained disease control off medications was achieved in 21/31 (68%) patients by the end of review. Persistent calcinosis was identified in only one patient (3%). CONCLUSION Current accepted treatment paradigms for Juvenile Dermatomyositis include oral glucocorticoids beginning at 2 mg/kg/day and reduced over a prolonged time period. However, our results suggest that treatment using reduced doses and duration with early use of steroid-sparing agents is comparably effective in achieving favorable outcomes in Juvenile Dermatomyositis.
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Affiliation(s)
- Amir B. Orandi
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA ,grid.66875.3a0000 0004 0459 167XPresent Address: Department of Pediatric and Adolescent Medicine, Division of Pediatric Rheumatology, Mayo Clinic, Rochester, MN USA
| | - Lampros Fotis
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA ,grid.5216.00000 0001 2155 0800Present Address: Department of Pediatrics, Division of Pediatric Rheumatology, National and Kapodistrian University of Athens, Athens, Greece
| | - Jamie Lai
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA ,grid.39382.330000 0001 2160 926XPresent Address: Department of Pediatrics, Division of Pediatric Rheumatology, Baylor College of Medicine, Houston, TX USA
| | - Hallie Morris
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA ,grid.253615.60000 0004 1936 9510Present Address: Division of Neonatology, George Washington University School of Medicine and Health Science, Washington, D.C, USA
| | - Andrew J. White
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
| | - Anthony R. French
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
| | - Kevin W. Baszis
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
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Ryu HK, Jeong HS, Chung YW. Juvenile Dermatomyositis Presenting with Erythematous Swelling of the Upper Eyelid. JOURNAL OF THE KOREAN OPHTHALMOLOGICAL SOCIETY 2021. [DOI: 10.3341/jkos.2021.62.5.719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Kishi T, Warren-Hicks W, Bayat N, Targoff IN, Huber AM, Ward MM, Rider LG. Corticosteroid discontinuation, complete clinical response and remission in juvenile dermatomyositis. Rheumatology (Oxford) 2021; 60:2134-2145. [PMID: 33067611 DOI: 10.1093/rheumatology/keaa371] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/31/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE A North American registry of JDM patients was examined for frequency of and factors associated with corticosteroid discontinuation, complete clinical response and remission. METHODS We evaluated probability of achieving final corticosteroid discontinuation, complete clinical response and remission in 307 JDM patients by Weibull time-to-event modelling; conditional probability of complete clinical response and remission using Bayesian network modelling; and significant predictors with multivariable Markov chain Monte-Carlo Weibull extension models. RESULTS The probability of corticosteroid discontinuation was 56%, complete clinical response 38% and remission 30% by 60 months after initial treatment in 105 patients. The probability of remission was conditional on corticosteroid discontinuation and complete clinical response. Photosensitivity, contractures and a longer time to complete clinical response were predictive of the time to final corticosteroid discontinuation. Anti-MJ (NXP2) autoantibodies and a Northwest residential geoclimatic zone were predictive of shorter time to complete clinical response, while dysphonia, contractures, an increase in medications within 24 months and a longer time to corticosteroid discontinuation were associated with longer time to complete clinical response. Anti-p155/140 (TIF1) autoantibodies, an increase in medications within 12-24 months, or longer times to corticosteroid discontinuation and complete clinical response were associated with longer time to remission. CONCLUSION JDM patients achieve favourable outcomes, including corticosteroid discontinuation, complete clinical response and remission, although timelines for these may be several years based on time-dependent analyses. These outcomes are inter-related and strong predictors of each other. Selected clinical features and myositis autoantibodies are additionally associated with these outcomes.
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Affiliation(s)
- Takayuki Kishi
- Environmental Autoimmunity Group, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD
| | | | - Nastaran Bayat
- Environmental Autoimmunity Group, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD
| | - Ira N Targoff
- VA Medical Center, University of Oklahoma Health Sciences Center.,Oklahoma Medical Research Foundation, Oklahoma City, OK, USA
| | - Adam M Huber
- IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Lisa G Rider
- Environmental Autoimmunity Group, National Institute of Environmental Health Sciences, National Institutes of Health, Bethesda, MD
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13
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Doudouliaki T, Papadopoulou C, Deakin CT. Use of Rescue Therapy with IVIG or Cyclophosphamide in Juvenile Myositis. Curr Rheumatol Rep 2021; 23:24. [PMID: 33686540 DOI: 10.1007/s11926-021-00990-3] [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] [Accepted: 01/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review aims to present the literature available to date on the use of intravenous immunoglobulin and cyclophosphamide for juvenile patients with inflammatory myopathies, to evaluate the strength of the evidence so far for both these medications, and to reach conclusions about their efficacy. RECENT FINDINGS Juvenile idiopathic inflammatory myopathies, mainly represented by juvenile dermatomyositis (JDM), are rare diseases but quite debilitating for the patients. JDM is an autoimmune condition with predominantly muscle and skin involvement but also systemic features affecting the cardiovascular, respiratory, and gastrointestinal systems. The mainstay therapy is based on corticosteroids and methotrexate, but often other therapeutic alternatives are sought for patients with severe or refractory disease. The rarity of these conditions makes research for new medications even more challenging. Innovative trial designs or statistical methods can be used to emulate a randomized study and investigate drug effectiveness. Despite the lack of Level I evidence on the use and efficacy of intravenous immunoglobulin and cyclophosphamide, their use is advocated by a substantial number of case reports and case series as well as analyses using marginal structural models.
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Affiliation(s)
- Theonymfi Doudouliaki
- Department of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - Charalampia Papadopoulou
- Department of Rheumatology, Great Ormond Street Hospital NHS Foundation Trust, London, UK
- Infection, Immunity and Inflammation Research and Teaching Department, UCL, Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK
| | - Claire T Deakin
- Infection, Immunity and Inflammation Research and Teaching Department, UCL, Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, UK.
- Centre for Adolescent Rheumatology Versus Arthritis at UCL, UCLH and GOSH, London, UK.
- NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, UK.
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14
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Pachman LM, Nolan BE, DeRanieri D, Khojah AM. Juvenile Dermatomyositis: New Clues to Diagnosis and Therapy. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2021; 7:39-62. [PMID: 34354904 PMCID: PMC8336914 DOI: 10.1007/s40674-020-00168-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/17/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE OF REVIEW To identify clues to disease activity and discuss therapy options. RECENT FINDINGS The diagnostic evaluation includes documenting symmetrical proximal muscle damage by exam and MRI, as well as elevated muscle enzymes-aldolase, creatine phosphokinase, LDH, and SGOT-which often normalize with a longer duration of untreated disease. Ultrasound identifies persistent, occult muscle inflammation. The myositis-specific antibodies (MSA) and myositis-associated antibodies (MAA) are associated with specific disease course variations. Anti-NXP-2 is found in younger children and is associated with calcinosis; anti-TIF-1γ+ juvenile dermatomyositis has a longer disease course. The diagnostic rash-involving the eyelids, hands, knees, face, and upper chest-is the most persistent symptom and is associated with microvascular compromise, reflected by loss of nailfold (periungual) end row capillaries. This loss is associated with decreased bioavailability of oral prednisone; the bioavailability of other orally administered medications should also be considered. At diagnosis, at least 3 days of intravenous methyl prednisolone may help control the HLA-restricted and type 1/2 interferon-driven inflammatory process. The requirement for avoidance of ultraviolet light exposure mandates vitamin D supplementation. SUMMARY This often chronic illness targets the cardiovascular system; mortality has decreased from 30 to 1-2% with corticosteroids. New serological biomarkers indicate occult inflammation: ↑CXCL-10 predicts a longer disease course. Some biologic therapies appear promising.
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Affiliation(s)
- Lauren M. Pachman
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Cure JM Center of Excellence in Juvenile Myositis Research and Care, The Stanley Manne Research Center for Children, Chicago, IL, USA
| | - Brian E. Nolan
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Deidre DeRanieri
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Amer M. Khojah
- Northwestern Feinberg School of Medicine, Divisions of Pediatric Rheumatology, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
- Division of Allergy/Immunology, Chicago, IL, USA, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
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15
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Abstract
Children with rheumatic disease have rare pulmonary manifestations that may cause significant morbidity and mortality. These children are often clinically asymptomatic until disease has significantly progressed, so they should be screened for pulmonary involvement. There has been recent recognition of a high mortality-related lung disease in systemic-onset juvenile idiopathic arthritis; risk factors include onset of juvenile idiopathic arthritis less than 2 years of age, history of macrophage activation syndrome, presence of trisomy 21, and history of anaphylactic reaction to biologic therapy. Early recognition and treatment of lung disease in children with rheumatic diseases may improve outcomes.
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16
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Liu K, Tomlinson G, Reed AM, Huber AM, Saarela O, Bout-Tabaku SM, Curran M, Dvergsten JA, Eberhard BA, Jung LK, Kim S, Ringold S, Rouster-Steven KA, Tesher M, Wahezi DM, Feldman BM. Pilot Study of the Juvenile Dermatomyositis Consensus Treatment Plans: A CARRA Registry Study. J Rheumatol 2020; 48:114-122. [PMID: 32238513 DOI: 10.3899/jrheum.190494] [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] [Accepted: 02/10/2020] [Indexed: 01/26/2023]
Abstract
OBJECTIVES To determine the feasibility of comparing the Childhood Arthritis and Rheumatology ResearchAlliance (CARRA) consensus treatment plans (CTP) in treating moderate new-onset juvenile dermatomyositis (JDM) using the CARRA registry, and to establish appropriate analytic methods to control for confounding by indication and missing data. METHODS A pilot cohort of 39 patients with JDM from the CARRA registry was studied. Patients were assigned by the treating physician, considering patient/family preferences, to 1 of 3 CTP: methotrexate (MTX) and prednisone (MP); intravenous (IV) methylprednisolone, MTX, and prednisone (MMP); or IV methylprednisolone, MTX, prednisone, and IV immunoglobulin (MMPI). The primary outcome was the proportion of patients achieving moderate improvement at 6 months under each CTP. Statistical methods including multiple imputation and inverse probability of treatment weighting were used to handle missing data and confounding by indication. RESULTS Patients received MP (n = 13), MMP (n = 18) and MMPI (n = 8). Patients in all CTP had significant improvement in disease activity. Of the 36 patients who remained in our pilot study at 6 months, 16 (44%) of them successfully achieved moderate improvement at 6 months (6/13, 46% for MP; 7/15, 47% for MMP; 3/8, 38% for MMPI). After correcting for confounding, there were no statistically significant pairwise differences between the CTP (P = 0.328-0.88). CONCLUSION We gained valuable experience and insight from our pilot study that can be used to guide the design and analysis of comparative effectiveness studies using the CARRA registry CTP approach. Our analytical methods can be adopted for future comparative effectiveness studies and applied to other rare disease observational studies.
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Affiliation(s)
- Kuan Liu
- K. Liu, MMath, B.M. Feldman, MD, MSc, FRCPC, The Hospital for Sick Children, Toronto, and Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - George Tomlinson
- G. Tomlinson, PhD, Department of Medicine, University Health Network, Toronto, Ontario, Canada.,G. Tomlinson, PhD, Department of Medicine, University Health Network, Toronto, Ontario, Canada
| | - Ann M Reed
- A.M. Reed, MD, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Adam M Huber
- A.M. Huber, MD, MSc, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Olli Saarela
- O. Saarela, PhD, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Sharon M Bout-Tabaku
- S.M. Bout-Tabaku, MD, MSCE, Department of Pediatric Medicine, Sidra Medicine, Doha, Weill Cornell Medicine - Qatar, Doha, Qatar
| | - Megan Curran
- M.L. Curran, MD, Department of Pediatrics, University of Colorado, Denver, Colorado, USA
| | - Jeffrey A Dvergsten
- J.A. Dvergsten, MD, Department of Pediatrics, Duke University Medical Center, Durham, and Department of Pediatrics, Duke Children's Hospital, Durham, North Carolina, USA
| | - Barbara A Eberhard
- B.A. Eberhard, MBBS, MS, Division of Pediatric Rheumatology, Steven and Alexandra Cohen Children's Medical Center of New York, Lake Success, New York, and Department of Pediatrics, Hofstra Northwell School of Medicine, Hempstead, New York, USA
| | - Lawrence K Jung
- L.K. Jung, MD, Division of Rheumatology, Children's National Health System, Washington, D.C., USA
| | - Susan Kim
- S. Kim, MD, MMSc, Department of Pediatrics, University of California San Francisco, San Francisco, California, USA
| | - Sarah Ringold
- S. Ringold, MD, Seattle Children's Hospital and Research Institute, Seattle, Washington, USA
| | - Kelly A Rouster-Steven
- K.A. Rouster-Steven, MD, Department of Pediatrics, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Melissa Tesher
- M. Tesher, MD, Comer Children's Hospital, University of Chicago Medical Center, Chicago, Illinois, USA
| | - Dawn M Wahezi
- D.M. Wahezi, MD, Msc, Division of Pediatric Rheumatology, the Children's Hospital at Montefiore, Bronx, New York, USA
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17
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Wu JQ, Lu MP, Reed AM. Juvenile dermatomyositis: advances in clinical presentation, myositis-specific antibodies and treatment. World J Pediatr 2020; 16:31-43. [PMID: 31556011 DOI: 10.1007/s12519-019-00313-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is a chronic autoimmune disease characteristic by inflammation of small vessels within the skin, muscle and vital organs. But the clinical features and treatment of JDM have not been fully clarified. DATA SOURCES Databases underwent through PubMed for articles about the clinical features, myositis-specific antibodies of JDM and its treatment, and we selected publications written in English which were relevant to the topic of this review. RESULTS Clinical features and myositis-specific antibodies may predict the severity and prognosis of disease. Although the mortality rate has been lower with traditional treatments, such as corticosteroid, intravenous immunoglobulin, and disease-modifying anti-rheumatic drugs such as methotrexate, their usages are variable. Novel biological therapies seem to be effective for refractory JDM patients, but more clinical trials are necessary. CONCLUSIONS JDM is a sever disease of childhood. We need to better understand recent advances of JDM in the context of clinical features including skin manifestations, muscle weakness and organ damage, myositis-specific antibodies and their associated outcomes and the treatment of disease.
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Affiliation(s)
- Jian-Qiang Wu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Ann M Reed
- Department of Pediatrics, Division of Pediatric Rheumatology, Duke University School of Medicine, Durham, 27710, USA.
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18
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Liu K, Saarela O, Feldman BM, Pullenayegum E. Estimation of causal effects with repeatedly measured outcomes in a Bayesian framework. Stat Methods Med Res 2020; 29:2507-2519. [PMID: 31994451 DOI: 10.1177/0962280219900362] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Constructing causal inference methods to handle longitudinal data in observational studies is of high interest. In an observational setting, treatment assignment at each clinical visit follows a decision strategy where the treating clinician selects treatment based on current and past clinical measurements as well as treatment histories. These time-dependent structures, coupled with inherent correlations between and within each visit, add on to the data complexity. Despite recent interest in Bayesian causal methods, only a limited literature has explored approaches to handle longitudinal data and no method handles repeatedly measured outcomes. In this paper, we extended two Bayesian approaches: Bayesian estimation of marginal structural models and two-stage Bayesian propensity score analysis to handle a repeatedly measured outcome. Our proposed methods permit causal estimation of treatment effects at each visit. Time-dependent inverse probability of treatment weights are obtained from the Markov chain Monte Carlo samples of the posterior treatment assignment model for each follow-up visit. We use a simulation study to validate and compare the proposed methods and illustrate our approaches through a study of intravenous immunoglobulin therapy in treating newly diagnosed juvenile dermatomyositis.
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Affiliation(s)
- Kuan Liu
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
| | - Olli Saarela
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Brian M Feldman
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Division of Rheumatology, The Hospital for Sick Children, Toronto, Canada
| | - Eleanor Pullenayegum
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada.,Child Health Evaluative Sciences, The Hospital for Sick Children, Toronto, Canada
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19
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Giancane G, Lavarello C, Pistorio A, Oliveira SK, Zulian F, Cuttica R, Fischbach M, Magnusson B, Pastore S, Marini R, Martino S, Pagnier A, Soler C, Staņēvicha V, Ten Cate R, Uziel Y, Vojinovic J, Fueri E, Ravelli A, Martini A, Ruperto N. The PRINTO evidence-based proposal for glucocorticoids tapering/discontinuation in new onset juvenile dermatomyositis patients. Pediatr Rheumatol Online J 2019; 17:24. [PMID: 31118099 PMCID: PMC6530070 DOI: 10.1186/s12969-019-0326-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Accepted: 05/02/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prednisone (PDN) in juvenile dermatomyositis (JDM), alone or in association with other immunosuppressive drugs, namely methotrexate (MTX) and cyclosporine (CSA), represents the first-line treatment option for new onset JDM patients. No clear evidence based guidelines are actually available to standardize the tapering and discontinuation of glucocorticoids (GC) in JDM. Aim of our study was to provide an evidence-based proposal for GC tapering/discontinuation in new onset juvenile dermatomyositis (JDM), and to identify predictors of clinical remission and GC discontinuation. METHODS New onset JDM children were randomized to receive either PDN alone or in combination with methotrexate (MTX) or cyclosporine (CSA). In order to derive steroid tapering indications, PRINTO/ACR/EULAR JDM core set measures (CSM) and their median absolute and relative percent changes over time were compared in 3 groups. Group 1 included those in clinical remission who discontinued PDN, with no major therapeutic changes (MTC) (reference group) and was compared with those who did not achieve clinical remission, without or with MTC (Group 2 and 3, respectively). A logistic regression model identified predictors of clinical remission with PDN discontinuation. RESULTS Based on the median change in the CSM of 30/139 children in Group 1, after 3 pulses of methyl-prednisolone, GC could be tapered from 2 to 1 mg/kg/day in the first two months from onset if any of the CSM decreased by 50-94%, and from 1 to 0.2 mg/kg/day in the following 4 months if any CSM further decreased by 8-68%, followed by discontinuation in the ensuing 18 months. The achievement of PRINTO JDM 50-70-90 response after 2 months of treatment (ORs range 4.5-6.9), an age at onset > 9 years (OR 4.6) and the combination therapy PDN + MTX (OR 3.6) increase the probability of achieving clinical remission (p < 0.05). CONCLUSIONS This is the first evidence-based proposal for glucocorticoid tapering/discontinuation based on the change in JDM CSM of disease activity. TRIAL REGISTRATION Trial full title: Five-Year Single-Blind, Phase III Effectiveness Randomized Actively Controlled Clinical Trial in New Onset Juvenile Dermatomyositis: Prednisone versus Prednisone plus Cyclosporine A versus Prednisone plus Methotrexate. EUDRACT registration number: 2005-003956-37 . CLINICAL TRIAL gov is NCT00323960 . Registered on 17 August 2005.
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Affiliation(s)
- Gabriella Giancane
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica – Reumatologia, PRINTO, Genoa, Italy
| | - Claudio Lavarello
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica – Reumatologia, PRINTO, Genoa, Italy
| | - Angela Pistorio
- IRCCS Istituto Giannina Gaslini, Servizio di Epidemiologia e Biostatistica, Genoa, Italy
| | - Sheila K. Oliveira
- 0000 0001 2294 473Xgrid.8536.8Instituto de Puericultura e Pediatria Martagão Gesteira (IPPMG), Universidade Federal do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Francesco Zulian
- 0000 0004 1757 3470grid.5608.bDepartment of Woman and Child Health, University of Padua, Padua, Italy
| | - Ruben Cuttica
- Hospital General de Niños Pedro de Elizalde, Unidad de Reumatología, Buenos Aires, Argentina
| | - Michel Fischbach
- 0000 0004 0593 6932grid.412201.4Hôpital Universitaire Hautepierre, Pédiatrie I, Strasbourg, France
| | - Bo Magnusson
- 0000 0000 9241 5705grid.24381.3cPediatric Rheumatology Unit, Karolinska University Hospital, Stockholm, Sweden
| | - Serena Pastore
- 0000 0004 1760 7415grid.418712.9IRCCS Burlo Garofolo, Institute for Maternal and Child Health, Trieste, Italy
| | - Roberto Marini
- 0000 0001 0723 2494grid.411087.bDepartamento de Pediatria, Faculdade de Ciências Médicas, Universidade Estadual de Campinas, Campinas, Brazil
| | - Silvana Martino
- 0000 0001 2336 6580grid.7605.4Clinica Pediatrica, Università degli Studi di Torino, Torino, Italy
| | - Anne Pagnier
- 0000 0001 0792 4829grid.410529.bMédecine Infantile, Centre Hospitalier Universitaire Grenoble-Alpes (CHU de Grenoble), Grenoble, France
| | - Christine Soler
- grid.413770.6Service de Pédiatrie, Hôpital de l’Archet, Nice, France
| | - Valda Staņēvicha
- Department of Pediatrics, Bērnu Klīniskā Universitātes Slimnīca, Riga, Latvia
| | - Rebecca Ten Cate
- 0000000089452978grid.10419.3dAfdelingkindergeneeskunde, Academisch Ziekenhuis Leiden, Leiden, Netherlands
| | - Yosef Uziel
- 0000 0004 1937 0546grid.12136.37Meir Medical Centre, Pediatric Rheumatology Unit, Department of Pediatrics, Kfar Saba and Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Jelena Vojinovic
- 0000 0001 0942 1176grid.11374.30Department of Pediatric Immunology and Rheumatology, Faculty of Medicine, University of Nis, Nis, Serbia ,0000 0004 0517 2741grid.418653.dClinic of Pediatrics, Department of Pediatric Rheumatology, Clinical Center Nis, Nis, Serbia
| | - Elena Fueri
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica – Reumatologia, PRINTO, Genoa, Italy
| | - Angelo Ravelli
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica – Reumatologia, Genoa, Italy ,0000 0001 2151 3065grid.5606.5Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Alberto Martini
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica – Reumatologia, Genoa, Italy ,0000 0001 2151 3065grid.5606.5Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genoa, Italy
| | - Nicolino Ruperto
- IRCCS Istituto Giannina Gaslini, Clinica Pediatrica - Reumatologia, PRINTO, Genoa, Italy.
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20
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Reed AM, Crowson CS, Dvergsten JA. A Path to Prediction of Outcomes in Juvenile Idiopathic Inflammatory Myopathy. Front Immunol 2019; 10:638. [PMID: 31001260 PMCID: PMC6454149 DOI: 10.3389/fimmu.2019.00638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2018] [Accepted: 03/08/2019] [Indexed: 12/20/2022] Open
Abstract
Humans have an innate desire to observe and subsequently dissect an event into component pieces in an effort to better characterize the event. We then examine these pieces individually and in combinations using this information to determine the outcome of future similar events and the likelihood of their recurrence. Practically, this attempt to foretell an occurrence and predict its outcomes is evident in multiple disciplines ranging from meteorology to sociologic studies. In this manuscript we share the historical and present-day tools to predict course and outcome in juvenile idiopathic inflammatory myopathy including clinical features, testing, and biomarkers. Further we discuss considerations for building more complex predictive models of outcome especially in diseases such as juvenile idiopathic inflammatory myopathy where patients numbers are low. Many of the barriers to developing risk prediction models for juvenile idiopathic inflammatory myopathy outcomes have improved with many remaining challenges being addressed.
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Affiliation(s)
- Ann Marie Reed
- School of Medicine, Duke University, Durham, NC, United States.,Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, NC, United States
| | | | - Jeffrey Arthur Dvergsten
- Division of Pediatric Rheumatology, Department of Pediatrics, Duke University, Durham, NC, United States
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21
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Kishi T, Bayat N, Ward MM, Huber AM, Wu L, Mamyrova G, Targoff IN, Warren-Hicks WJ, Miller FW, Rider LG. Medications received by patients with juvenile dermatomyositis. Semin Arthritis Rheum 2018; 48:513-522. [PMID: 29773230 PMCID: PMC6162169 DOI: 10.1016/j.semarthrit.2018.03.016] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Revised: 02/12/2018] [Accepted: 03/26/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE Few controlled studies are available to guide treatment decisions in juvenile dermatomyositis (JDM). This study evaluated therapies received, changes of treatment over time, and factors associated with medication choices in JDM. METHODS We performed a retrospective analysis of the number and type of therapies and duration of treatment for 320 patients with JDM enrolled in a North American registry. Kaplan-Meier and logistic regression analysis were used to assess the association of demographic and clinical features and autoantibodies with medication usage. RESULTS High-dose oral prednisone was the primary therapy given to 99% of patients. 1997 was determined to be a threshold year for increasing usage of medications other than prednisone. The median time to half the initial oral prednisone dose was shorter in patients diagnosed after vs. before 1997 (10 vs. 19 months, P < 0.01). Patients received intravenous methylprednisolone (IVMP), methotrexate, intravenous immunoglobulin, antimalarial drugs, and combination therapy more frequently when diagnosed after 1997. IVMP was frequently received by patients with severe illness onset, anti-p155/140 (anti-TIF1) and anti-MJ (anti-NXP2) autoantibodies. Treatment with methotrexate was associated with older age at diagnosis and anti-MJ autoantibodies, while antimalarial therapy was associated with anti-p155/140 autoantibodies and mild onset severity. CONCLUSION Oral prednisone has been the mainstay of therapy in JDM, and prednisone was reduced faster in patients diagnosed after 1997 when there was also an increase in other medications. Specific medications received by patients with JDM correlated with year and age at diagnosis, myositis autoantibodies, onset severity, and illness features.
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Affiliation(s)
- Takayuki Kishi
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Building 10, Rm 4-2352, MSC 1301, 10 Center Drive, Bethesda, MD 20892-1301
| | - Nastaran Bayat
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Building 10, Rm 4-2352, MSC 1301, 10 Center Drive, Bethesda, MD 20892-1301
| | - Michael M Ward
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD
| | - Adam M Huber
- Division of Rheumatology, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada
| | - Lan Wu
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Building 10, Rm 4-2352, MSC 1301, 10 Center Drive, Bethesda, MD 20892-1301
| | - Gulnara Mamyrova
- Division of Rheumatology, Department of Medicine, George Washington University School of Medicine, Washington, DC
| | - Ira N Targoff
- VA Medical Center, University of Oklahoma Health Sciences Center, and Oklahoma Medical Research Foundation, Oklahoma City, OK
| | | | - Frederick W Miller
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Building 10, Rm 4-2352, MSC 1301, 10 Center Drive, Bethesda, MD 20892-1301
| | - Lisa G Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Building 10, Rm 4-2352, MSC 1301, 10 Center Drive, Bethesda, MD 20892-1301.
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22
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Abstract
INTRODUCTION Juvenile dermatomyositis (JDM) is a rare, chronic autoimmune illness with primary features of symmetric, proximal muscle weakness and involvement of the skin with a number of identifiable rashes. Evidence to support treatment decisions is limited, given the paucity of clinical trials. Consensus based methods, informed by available data, play an important role in treatment recommendations. Areas covered: This review focuses on evidence and consensus opinion regarding therapeutic options in JDM and identifies gaps where future research is needed. Expert commentary: The combination of trial evidence (as limited as it is) and consensus opinion support standard initial management for children with JDM to consist of high-dose corticosteroids, either intravenous or oral, and methotrexate. Several other agents have preliminary support, either through clinical trials or case series for their use in patients who either fail to respond adequately, have severe disease or have contraindications to standard initial therapy. One of the important goals of management in JDM will be to reduce the corticosteroid exposure experienced by patients. To meet this goal, progress in a number of key areas is needed: increased international collaboration, advances in study design and increased translational research.
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Affiliation(s)
- Adam M Huber
- a Division of Pediatric Rheumatology , Dalhousie University , Halifax , Nova Scotia , Canada
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Hinze CH, Oommen PT, Dressler F, Urban A, Weller-Heinemann F, Speth F, Lainka E, Brunner J, Fesq H, Foell D, Müller-Felber W, Neudorf U, Rietschel C, Schwarz T, Schara U, Haas JP. Development of practice and consensus-based strategies including a treat-to-target approach for the management of moderate and severe juvenile dermatomyositis in Germany and Austria. Pediatr Rheumatol Online J 2018; 16:40. [PMID: 29940960 PMCID: PMC6019723 DOI: 10.1186/s12969-018-0257-6] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/13/2018] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is the most common inflammatory myopathy in childhood and a major cause of morbidity among children with pediatric rheumatic diseases. The management of JDM is very heterogeneous. The JDM working group of the Society for Pediatric Rheumatology (GKJR) aims to define consensus- and practice-based strategies in order to harmonize diagnosis, treatment and monitoring of JDM. METHODS The JDM working group was established in 2015 consisting of 23 pediatric rheumatologists, pediatric neurologists and dermatologists with expertise in the management of JDM. Current practice patterns of management in JDM had previously been identified via an online survey among pediatric rheumatologists and neurologists. Using a consensus process consisting of online surveys and a face-to-face consensus conference statements were defined regarding the diagnosis, treatment and monitoring of JDM. During the conference consensus was achieved via nominal group technique. Voting took place using an electronic audience response system, and at least 80% consensus was required for individual statements. RESULTS Overall 10 individual statements were developed, finally reaching a consensus of 92 to 100% regarding (1) establishing a diagnosis, (2) case definitions for the application of the strategies (moderate and severe JDM), (3) initial diagnostic testing, (4) monitoring and documentation, (5) treatment targets within the context of a treat-to-target strategy, (6) supportive therapies, (7) explicit definition of a treat-to-target strategy, (8) various glucocorticoid regimens, including intermittent intravenous methylprednisolone pulse and high-dose oral glucocorticoid therapies with tapering, (9) initial glucocorticoid-sparing therapy and (10) management of refractory disease. CONCLUSION Using a consensus process among JDM experts, statements regarding the management of JDM were defined. These statements and the strategies aid in the management of patients with moderate and severe JDM.
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Affiliation(s)
- Claas H. Hinze
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building D3, 48149 Münster, Germany
| | - Prasad T. Oommen
- 0000 0000 8922 7789grid.14778.3dDepartment of Pediatric Oncology, Hematology and Clinical Immunology, University Hospital Düsseldorf, Düsseldorf, Germany
| | - Frank Dressler
- 0000 0000 9529 9877grid.10423.34Department of Pediatric Pulmonology, Allergy and Neonatology, Hanover Medical School, Hanover, Germany
| | - Andreas Urban
- Department of Pediatrics, St. Mary’s Hospital, Amberg, Germany
| | | | - Fabian Speth
- 0000000121858338grid.10493.3fDivision of Pediatric Rheumatology, University Medicine, Rostock, Germany ,grid.410712.1Division of Immunology, Bone Marrow Transplantation and Rheumatology, University Hospital Ulm, Ulm, Germany
| | - Elke Lainka
- 0000 0001 0262 7331grid.410718.bDepartment of Pediatrics, University Hospital Essen, Essen, Germany
| | - Jürgen Brunner
- 0000 0000 8853 2677grid.5361.1Department of Pediatrics, Medical University Innsbruck, Innsbruck, Austria
| | - Heike Fesq
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen Department of Dermatology, Oberammergau Center for Rheumatic Diseases, Oberammergau, Germany
| | - Dirk Foell
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building D3, 48149 Münster, Germany
| | - Wolfgang Müller-Felber
- 0000 0004 0477 2585grid.411095.8Department of Pediatric Neurology, University Hospital Munich, Munich, Germany
| | - Ulrich Neudorf
- 0000 0001 0262 7331grid.410718.bDepartment of Pediatrics, University Hospital Essen, Essen, Germany
| | - Christoph Rietschel
- Department of Pediatrics, Clementine Children’s Hospital, Frankfurt, Germany
| | - Tobias Schwarz
- grid.416438.cDepartment of Pediatric Rheumatology, St. Josef Hospital, Sendenhorst, Germany
| | - Ulrike Schara
- 0000 0001 0262 7331grid.410718.bDepartment of Pediatric Neurology, University Hospital Essen, Essen, Germany
| | - Johannes-Peter Haas
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen Department of Dermatology, Oberammergau Center for Rheumatic Diseases, Oberammergau, Germany
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Hinze CH, Speth F, Oommen PT, Haas JP. Current management of juvenile dermatomyositis in Germany and Austria: an online survey of pediatric rheumatologists and pediatric neurologists. Pediatr Rheumatol Online J 2018; 16:38. [PMID: 29925381 PMCID: PMC6011340 DOI: 10.1186/s12969-018-0256-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 06/12/2018] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Juvenile Dermatomyositis (JDM) is a rare pediatric autoimmune disease with broad variations of the individual course. Data on the optimal management are mostly lacking. Currently treatment decisions are often based on experts' opinions. In order to develop consensus-based treatment strategies for JDM in Germany a survey was pursued to analyze the current clinical practice. METHODS An online survey addressing all members of the Society for Pediatric Rheumatology (GKJR) in Germany and Austria and pediatric neurologists with expertise in JDM was performed in February/March of 2016. The questionnaire consisted of 5 case scenarios including diagnostic criteria, treatment of moderate, severe and refractory JDM, using either multiple choice or a 5-point Likert scale. Basic descriptive statistics were used to analyze the findings. RESULTS The survey was completed by 60 pediatric rheumatologists and 7 pediatric neurologists experienced in the management of JDM. Typical findings allowing a diagnosis were considered to be: typical skin changes, proximal muscle weakness, MRI findings, elevated muscle enzymes, nailfold capillary changes, presence of calcinosis and muscle biopsy. Regarding induction treatment of moderate/severe JDM: 59%/74% opted for intermittent intravenous methylprednisolone (IVMP) pulse therapy, and 21%/40% for conventional high-dose oral glucocorticoids. Methotrexate (MTX) was the preferred disease-modifying conventional anti-rheumatic drug (cDMARD) for moderate and severe JDM. Regarding the management of refractory moderate or severe JDM, intravenous immune globulins, mycophenolate mofetil and rituximab were preferred treatment options. CONCLUSION There is consensus about the diagnosis of JDM strongly supported by classic clinical and MRI findings. There is great variety in the treatment of JDM in Germany regarding both induction and maintenance therapy. The development of consensus-based treatment strategies for JDM based on harmonization of current clinical practice is essential in order to allow comparative effectiveness research in the future.
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Affiliation(s)
- Claas H. Hinze
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Albert-Schweitzer-Campus 1, Building D3, 48149 Münster, Germany
| | - Fabian Speth
- 0000000121858338grid.10493.3fDivision of Pediatric Rheumatology, University Medicine, Rostock, Germany ,Division of Immunology, Bone Marrow Transplantation and Rheumatology, Ulm, Germany
| | - Prasad T. Oommen
- 0000 0001 2176 9917grid.411327.2Center of Child and Adolescent Health, Department of Pediatric Oncology, Hematology and Clinical Immunology, Heinrich-Heine University Duesseldorf, Münster, Germany
| | - Johannes-Peter Haas
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
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25
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Pachman LM, Khojah AM. Advances in Juvenile Dermatomyositis: Myositis Specific Antibodies Aid in Understanding Disease Heterogeneity. J Pediatr 2018; 195:16-27. [PMID: 29576174 PMCID: PMC5881602 DOI: 10.1016/j.jpeds.2017.12.053] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 11/27/2017] [Accepted: 12/18/2017] [Indexed: 12/15/2022]
Affiliation(s)
- Lauren M Pachman
- Department of Pediatrics , Northwestern University Feinberg School of Medicine, Chicago, IL; Stanley Manne Children's Research Institute, Cure JM Center of Excellence in Juvenile Myositis (JM) Research, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Amer M Khojah
- Department of Pediatrics, Division of Pediatric Rheumatology, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
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Ringold S, Nigrovic PA, Feldman BM, Tomlinson GA, von Scheven E, Wallace CA, Huber AM, Schanberg LE, Li SC, Weiss PF, Fuhlbrigge RC, Morgan EM, Kimura Y. The Childhood Arthritis and Rheumatology Research Alliance Consensus Treatment Plans. Arthritis Rheumatol 2018; 70:669-678. [DOI: 10.1002/art.40395] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 11/29/2017] [Indexed: 01/17/2023]
Affiliation(s)
| | - Peter A. Nigrovic
- Brigham and Women's Hospital and Boston Children's Hospital; Boston Massachusetts
| | | | | | | | - Carol A. Wallace
- University of Washington School of Medicine and Seattle Children's Hospital; Seattle Washington
| | - Adam M. Huber
- IWK Health Centre; Dalhousie University; Halifax Nova Scotia Canada
| | | | - Suzanne C. Li
- Hackensack University Medical Center; Hackensack New Jersey
| | - Pamela F. Weiss
- Children's Hospital of Philadelphia; Philadelphia Pennsylvania
| | | | - Esi M. Morgan
- Cincinnati Children's Hospital Medical Center; Cincinnati Ohio
| | - Yukiko Kimura
- Hackensack University Medical Center; Hackensack New Jersey
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Abstract
Juvenile dermatomyositis (JDM) is a rare autoimmune disease mainly characterized by muscle and skin involvement. Vasculopathy is considered central to the pathogenesis of the disease. The exact nature of vasculopathy is not yet understood but it is a complex process with both an inflammatory and a non-inflammatory, occlusive component. Impaired function of JDM vasculature includes immune complex deposition, altered expression of cell adhesion molecules predominantly inducing Th17 cell infiltration, and endothelial cell dysfunction. Development of vasculopathy is associated with the severe extra-muscular manifestations of JDM, such as gastrointestinal and cardiac manifestations, interstitial lung disease, ulcerative skin disease or development of calcinosis, and portends a poor prognosis. Correlation of histopathological findings, autoantibodies, and extensive diagnostic workup represent key elements to the early detection of vasculopathic features and early aggressive treatment. Monitoring of vasculopathy remains challenging due to the lack of non-invasive biomarkers. Current treatment approaches provide variable benefit, but better understanding of the essential pathogenic mechanisms should help lead to improved outcomes. Whilst acknowledging that evidence is limited, this review aims to describe the vasculopathy of JDM in the context of pathophysiology, clinical features, and treatment of disease.
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Affiliation(s)
- Charalampia Papadopoulou
- Infection, Inflammation, and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Liza J McCann
- Department of Pediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
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28
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Abstract
The idiopathic inflammatory myopathies of childhood consist of a heterogeneous group of autoimmune diseases characterised by proximal muscle weakness and pathognomonic skin rashes. The overall prognosis of juvenile myositis has improved significantly over recent years, but the long-term outcome differs substantially from patient to patient, suggestive of distinct clinical phenotypes with variable responses to treatment. High doses of corticosteroids remain the cornerstone of therapy along with other immunosuppressant therapies depending on disease severity and response. The advent of biological drugs has revolutionised the management of various paediatric rheumatologic diseases, including inflammatory myopathies. There are few data from randomised controlled trials to guide management decisions; thus, several algorithms for the treatment of juvenile myositis have been developed using international expert opinion. The general treatment goals now include elimination of active disease and normalisation of physical function, so as to preserve normal growth and development, and to prevent long-term damage and deformities. This review summarises the newer and possible future therapies of juvenile inflammatory myopathies, including evidence supporting their efficacy and safety.
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29
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Orandi AB, Baszis KW, Dharnidharka VR, Huber AM, Hoeltzel MF. Assessment, classification and treatment of calcinosis as a complication of juvenile dermatomyositis: a survey of pediatric rheumatologists by the childhood arthritis and rheumatology research alliance (CARRA). Pediatr Rheumatol Online J 2017; 15:71. [PMID: 28934971 PMCID: PMC5609060 DOI: 10.1186/s12969-017-0199-4] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 09/18/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND There is no standardized approach to the management of JDM-associated calcinosis and its phenotypes. Current knowledge of treatment outcomes is confined to small series and case reports. We describe physician perspectives toward diagnostic approach, classification and treatment directly targeting calcinosis, independent of overall JDM therapy. METHODS An electronic survey of 22 questions was organized into sections regarding individual practices of assessment, classification and treatment of calcinosis, including perceived successes of therapies. Invitations to complete the survey voluntarily and anonymously were sent to CARRA physician members and the Pediatric Rheumatology Bulletin Board, an electronic list-serv. Results were analyzed by descriptive statistics and chi-square analyses. RESULTS Of 139 survey responses, 118 were included in analysis. Of these, 70% were based in the USA and 88 (75%) were CARRA members. Only 17% of responders have seen more than 20 cases of calcinosis, and only 28% perform screening imaging studies on new JDM diagnoses. Increasing systemic immunosuppression is first-line therapy for 67% of respondents. Targeted therapy against calcinosis is most often instituted for symptomatic patients. IVIG and bisphosphonates are most frequently used and considered most successful, but many other agents are used. Experienced physicians are more likely to use bisphosphonates, calcium channel blockers and topical sodium thiosulfate (p< 0.002 or lower). CONCLUSIONS Coexisting JDM disease activity influences whether calcinosis is considered active disease or targeted directly. Experience treating JDM-related calcinosis is low, as are rates of formal screening for calcinosis. Experienced physicians are more likely to use non-immunosuppressive treatments.
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Affiliation(s)
- A. B. Orandi
- 0000 0001 2355 7002grid.4367.6Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Bo 8116, St. Louis, Missouri 63110 USA
| | - K. W. Baszis
- 0000 0001 2355 7002grid.4367.6Department of Pediatrics, Division of Rheumatology, Washington University School of Medicine, 660 S. Euclid Ave, Campus Bo 8116, St. Louis, Missouri 63110 USA
| | - V. R. Dharnidharka
- 0000 0001 2355 7002grid.4367.6Department of Pediatrics, Division of Nephrology, Washington University School of Medicine, St. Louis, Missouri USA
| | - A. M. Huber
- Department of Pediatrics, Division of Rheumatology, IWK Health Centre and Dalhousie University, Halifax, Nova Scotia Canada
| | - M. F. Hoeltzel
- 0000000086837370grid.214458.eDepartment of Pediatrics, Division of Rheumatology, University of Michigan Medical School, Ann Arbor, Michigan USA
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30
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Juvenile dermatomyositis: Latest advances. Best Pract Res Clin Rheumatol 2017; 31:535-557. [DOI: 10.1016/j.berh.2017.12.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2017] [Accepted: 11/10/2017] [Indexed: 12/20/2022]
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31
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Spencer CH, Rouster-Stevens K, Gewanter H, Syverson G, Modica R, Schmidt K, Emery H, Wallace C, Grevich S, Nanda K, Zhao YD, Shenoi S, Tarvin S, Hong S, Lindsley C, Weiss JE, Passo M, Ede K, Brown A, Ardalan K, Bernal W, Stoll ML, Lang B, Carrasco R, Agaiar C, Feller L, Bukulmez H, Vehe R, Kim H, Schmeling H, Gerstbacher D, Hoeltzel M, Eberhard B, Sundel R, Kim S, Huber AM, Patwardhan A. Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America. Pediatr Rheumatol Online J 2017; 15:50. [PMID: 28610606 PMCID: PMC5470177 DOI: 10.1186/s12969-017-0174-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 05/17/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA). METHODS The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting. RESULTS One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups. CONCLUSIONS Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.
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Affiliation(s)
- CH Spencer
- 0000 0004 0392 3476grid.240344.5Nationwide Children’s Hospital and Ohio State University, Columbus, OH USA
| | - K Rouster-Stevens
- 0000 0001 0941 6502grid.189967.8Emory University School of Medicine, Atlanta, GA USA
| | - H Gewanter
- Pediatric and Adolescent Health Partners, Richmond, VA USA
| | - G Syverson
- 0000 0001 2167 3675grid.14003.36University of Wisconsin-Madison, Madison, WI USA
| | - R Modica
- 0000 0004 1936 8091grid.15276.37University of Florida, Gainesville, FL USA
| | - K Schmidt
- 0000 0001 2113 1622grid.266623.5University of Louisville, Louisville, KY USA
| | - H Emery
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - C Wallace
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - S Grevich
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - K Nanda
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - YD Zhao
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - S Shenoi
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - S Tarvin
- Riley Hospital for Children, Indiana University Medical Center, Indianapolis, IN India
| | - S Hong
- grid.412984.2University of Iowa Health Care, Iowa City, IA USA
| | - C Lindsley
- 0000 0001 2177 6375grid.412016.0University of Kansas Medical Center, Kansas City, KS USA
| | - JE Weiss
- 0000 0004 0407 6328grid.239835.6Sanzari Children’s Hospital, Hackensack University Medical Center, Hackensack, NJ USA
| | - M Passo
- 0000 0000 9075 106Xgrid.254567.7University of South Carolina, Charleston, SC USA
| | - K Ede
- 0000 0001 0381 0779grid.417276.1Phoenix Children’s Hospital, Phoenix, AZ USA
| | - A Brown
- 0000 0001 2200 2638grid.416975.8Texas Children’s Hospital, Houston, TX USA
| | - K Ardalan
- 0000 0004 0388 2248grid.413808.6Lurie Children’s Hospital, Chicago, IL USA
| | - W Bernal
- 0000 0001 2297 6811grid.266102.1University of California, San Francisco, San Francisco, CA USA
| | - ML Stoll
- 0000000106344187grid.265892.2University of Alabama at Birmingham, Birmingham, AL USA
| | - B Lang
- 0000 0004 1936 8200grid.55602.34WK Health Center and Dalhousie University, Halifax, NS Canada
| | - R Carrasco
- Dell Children’s Hospital, Austin, TX USA
| | - C Agaiar
- Children’s Hospital of The Kings Daughter, Norfolk, VA USA
| | - L Feller
- Inland Rheumatology, Waterville, ME USA
| | - H Bukulmez
- 0000 0001 0035 4528grid.411931.fMetro Health Medical Center and Case Western Reserve University, Cleveland, OH USA
| | - R Vehe
- 0000000419368657grid.17635.36University of Minnesota, Minneapolis, MN USA
| | - H Kim
- 0000 0001 2237 2479grid.420086.8National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD USA
| | - H Schmeling
- 0000 0004 1936 7697grid.22072.35Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - D Gerstbacher
- 0000000419368956grid.168010.eLucille Packard Children’s Hospital, Stanford University, Stanford, CA USA
| | - M Hoeltzel
- 0000000086837370grid.214458.eMott Children’s Hospital, University of Michigan, Ann Arbor, MI USA
| | - B Eberhard
- grid.415338.8Cohen Children’s Medical Center of New York, New york, USA
| | - R Sundel
- 0000 0004 0378 8438grid.2515.3Boston Children’s Hospital and Harvard Medical School, Boston, MA USA
| | - S Kim
- 0000 0001 2297 6811grid.266102.1University of California, San Francisco, San Francisco, CA USA
| | - AM Huber
- 0000 0004 1936 8200grid.55602.34WK Health Center and Dalhousie University, Halifax, NS Canada
| | - A Patwardhan
- 0000 0001 2162 3504grid.134936.aSchool of Medicine, University of Missouri, Columbia, MO USA
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Kim S, Kahn P, Robinson AB, Lang B, Shulman A, Oberle EJ, Schikler K, Curran ML, Barillas-Arias L, Spencer CH, Rider LG, Huber AM. Childhood Arthritis and Rheumatology Research Alliance consensus clinical treatment plans for juvenile dermatomyositis with skin predominant disease. Pediatr Rheumatol Online J 2017; 15:1. [PMID: 28077146 PMCID: PMC5225591 DOI: 10.1186/s12969-016-0134-0] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 12/29/2016] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is the most common form of the idiopathic inflammatory myopathies in children. A subset of children have the rash of JDM without significant weakness, and the optimal treatments for these children are unknown. The goal of this study was to describe the development of consensus clinical treatment plans (CTPs) for children with JDM who have active skin rashes, without significant muscle involvement, referred to as skin predominant JDM in this manuscript. METHODS The Children's Arthritis and Rheumatology Research Alliance (CARRA) is a North American consortium of pediatric rheumatology health care providers. CARRA members collaborated to determine consensus on typical treatments for JDM patients with skin findings without significant weakness, to develop CTPs for this subgroup of patients. We used a combination of Delphi surveys and nominal group consensus meetings to develop these CTPs. RESULTS Consensus was reached on patient characteristics and outcome assessment, and CTPs were developed and finalized for patients with skin predominant JDM. Treatment option A included hydroxychloroquine alone, Treatment option B included hydroxychloroquine and methotrexate, and Treatment option C included hydroxychloroquine, methotrexate and corticosteroids. CONCLUSIONS Three CTPs were developed for use in children with skin predominant JDM, which reflect typical treatment approaches. These are not considered to be specific recommendations or standard of care. Using the CARRA network and prospective data collection, we will be able to apply statistical methods in the future to allow comparisons of JDM patients following these consensus treatment plans.
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Affiliation(s)
- Susan Kim
- Division of Pediatric Rheumatology, Benioff Children's Hospital, University of California at San Francisco, 550 16th St, San Francisco, CA, USA.
| | - Philip Kahn
- Division of Pediatric Rheumatology, New York University Langone Medical Center, 550 First Avenue, New York, NY USA
| | - Angela B. Robinson
- Pediatric Rheumatology, Rainbow Babies and Children’s Hospital, 11100 Euclid Ave MS6008B, Cleveland, OH USA
| | - Bianca Lang
- Department of Pediatrics, IWK Health Centre and Dalhousie University, 5980 University Ave, Halifax, NS Canada
| | - Andrew Shulman
- Pediatric Rheumatology, Children’s Hospital of Orange County, 1201 W La Veta Ave, Irvine, CA USA
| | - Edward. J. Oberle
- Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH USA
| | - Kenneth Schikler
- Divisions of Adolescent Medicine and Pediatric Rheumatology, Department of Pediatrics, University of Louisville School of Medicine, 571 South Floyd St, Louisville, KY USA
| | - Megan Lea Curran
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois; Division of Rheumatology, Ann and Robert H. Lurie Children’s Hospital of Chicago, 225 E Chicago Ave, Chicago, IL USA
| | - Lilliana Barillas-Arias
- Department of Pediatrics, Rheumatology, Albany Medical Center, 43 New Scotland Ave, Albany, NY USA
| | - Charles H. Spencer
- Department of Pediatrics, The Research Institute at Nationwide Children’s Hospital, 700 Children’s Dr, Columbus, OH USA
| | - Lisa G. Rider
- Environmental Autoimmunity Group, Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, 10 Center Drive, Bethesda, MD USA
| | - Adam M. Huber
- Department of Pediatrics, IWK Health Centre and Dalhousie University, 5980 University Ave, Halifax, NS Canada
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Huber AM, Kim S, Reed AM, Carrasco R, Feldman BM, Hong SD, Kahn P, Rahimi H, Robinson AB, Vehe RK, Weiss JE, Spencer C. Childhood Arthritis and Rheumatology Research Alliance Consensus Clinical Treatment Plans for Juvenile Dermatomyositis with Persistent Skin Rash. J Rheumatol 2016; 44:110-116. [PMID: 27803135 DOI: 10.3899/jrheum.160688] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/14/2016] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Juvenile dermatomyositis (JDM) is the most common form of idiopathic inflammatory myopathy in children. While outcomes are generally thought to be good, persistence of skin rash is a common problem. The goal of this study was to describe the development of clinical treatment plans (CTP) for children with JDM characterized by persistent skin rash despite complete resolution of muscle involvement. METHODS The Childhood Arthritis and Rheumatology Research Alliance, a North American consortium of pediatric rheumatologists and other healthcare providers, used a combination of Delphi surveys and nominal group consensus meetings to develop CTP that reflected consensus on typical treatments for patients with JDM with persistent skin rash. RESULTS Consensus was reached on patient characteristics and outcome assessment. Patients should have previously received corticosteroids and methotrexate (MTX). Three consensus treatment plans were developed. Plan A added intravenous immunoglobulin (IVIG) if it was not already being used. Plan B added mycophenolate mofetil, while Plan C added cyclosporine. Continuation of previous treatments, including corticosteroids, MTX, and IVIG, was permitted in plans B and C. CONCLUSION Three consensus CTP were developed for use in children with JDM and persistent skin rash despite complete resolution of muscle disease. These CTP reflect typical treatment approaches and are not to be considered treatment recommendations or standard of care. Using prospective data collection and statistical methods to account for nonrandom treatment assignment, it is expected that these CTP will be used to allow treatment comparisons, and ultimately determine the best treatment for these patients.
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Affiliation(s)
- Adam M Huber
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA. .,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University.
| | - Susan Kim
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Ann M Reed
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Ruy Carrasco
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Brian M Feldman
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Sandy D Hong
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Philip Kahn
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Homaira Rahimi
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Angela Byun Robinson
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Richard K Vehe
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Jennifer E Weiss
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
| | - Charles Spencer
- From the IWK Health Centre; Dalhousie University, Halifax, Nova Scotia; Hospital for Sick Children, Toronto; University of Toronto, Toronto, Ontario, Canada; Boston Children's Hospital, Boston; Harvard University, Cambridge, Massachusetts; Duke University School of Medicine, Durham, North Carolina; Seattle Children's Hospital; University of Washington, Seattle, Washington; Dell Children's Medical Center of Central Texas, Austin; University of Texas at Austin, Austin, Texas; University of Iowa Children's Hospital and University of Iowa, Iowa City, Iowa; New York Langone Medical Center; New York University, New York; University of Rochester Medical Center; University of Rochester, Rochester, New York; Rainbow Babies and Children's Hospital, Cleveland; Case Western Reserve University, Cleveland; Nationwide Children's Hospital, Columbus; Ohio State University, Columbus, Ohio; University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, Minnesota; Hackensack University Medical Center, Hackensack; University of Medicine and Dentistry of New Jersey, Newark, New Jersey, USA.,A.M. Huber, MSc, MD, IWK Health Centre, and Dalhousie University; S. Kim, MD, MMSc, Boston Children's Hospital, and Harvard University; A.M. Reed, MD, Duke University School of Medicine; R. Carrasco, MD, Dell Children's Medical Center of Central Texas, and University of Texas at Austin; B.M. Feldman, MD, MSc, Hospital for Sick Children, and University of Toronto; S.D. Hong, MD, University of Iowa Children's Hospital, and University of Iowa; P. Kahn, MD, New York Langone Medical Center, and New York University; H. Rahimi, MD, MTR, University of Rochester Medical Center, University of Rochester; A.B. Robinson, MD, Rainbow Babies and Children's Hospital, and Case Western Reserve University; R.K. Vehe, MD, University of Minnesota Masonic Children's Hospital, and University of Minnesota; J.E. Weiss, MD, Hackensack University Medical Center, and University of Medicine and Dentistry of New Jersey; C. Spencer, MD, Nationwide Children's Hospital, and Ohio State University
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[Juvenile dermatomyositis: Early onset and unusual presentation]. Arch Pediatr 2016; 23:1071-1075. [PMID: 27622296 DOI: 10.1016/j.arcped.2016.07.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Revised: 04/04/2016] [Accepted: 07/04/2016] [Indexed: 11/20/2022]
Abstract
Juvenile dermatomyositis (JDM) is a rare disease, with a mean age of onset of 7 years. We report a case of JDM in a 13-month-old infant. OBSERVATION A 13-month-old infant presented with an edema of the upper lip, 4 days after receiving amoxicillin-clavulanate. The patient was treated with betamethasone and an antihistamine. Progression was marked by the appearance of a white edema of the periorbital area and the upper lip, with purpuric lesions, aphthoid ulcerations, and a drooping head. Very high muscle enzymes, a myogenic electromyogram, and hypertrophic cardiomyopathy were found and diagnosis of JDM was retained. The patient was treated with a high dose of corticosteroids and methotrexate. Before the installation of dysphagia, dysphonia, and axial hypotonia, the bolus of cyclophosphamide was administered, with clear improvement. Corticosteroids and methotrexate were then kept over the long term. DISCUSSION AND CONCLUSION The originality of this observation of JDM resides in the very young age of onset of the disease, its unusual cutaneous signs including labial edema extending to the regions around the eyes, its severe muscle manifestations causing axial hypotonia, and finally, in its association with hypertrophic cardiomyopathy. Early initiation of treatment (12 days after the onset of symptoms) greatly improved the prognosis of this form of JDM, which is very severe and refractory to first-line therapy.
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Timpane S, Brandling-Bennett H, Kristjansson AK. Autoimmune collagen vascular diseases: Kids are not just little people. Clin Dermatol 2016; 34:678-689. [PMID: 27968927 DOI: 10.1016/j.clindermatol.2016.07.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Morphea, dermatomyositis (DM), and discoid lupus erythematosus (DLE) are autoimmune collagen vascular diseases that can present at any age. In all three of these diseases, the tenants of diagnosis and treatment are largely the same in both children and adults, with a few notable differences. Children with morphea are more likely to present with the linear subtype and have a higher incidence of extracutaneous manifestations. Children often need early aggressive systemic treatment to try to prevent long-term sequelae of morphea. In DM, adult disease has a clear association with malignancy that is not seen in children. Adults have a higher rate of pulmonary involvement and increased mortality, whereas calcinosis is more common in juvenile DM. DLE in adults is generally considered to have a low rate of progression from discoid lesions alone to systemic lupus erythematosus (SLE). DLE is less common in children, but several studies have suggested a higher rate of progression from DLE to SLE in children compared with adults.
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Affiliation(s)
- Sean Timpane
- Resident, Department of Pediatrics, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Heather Brandling-Bennett
- Assistant Professor, Department of Pediatrics, Division of Dermatology, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, WA
| | - Arni K Kristjansson
- Assistant Professor of Dermatology, University of Connecticut School of Medicine, Farmington, CT
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de Inocencio J, Enríquez-Merayo E, Casado R, González-Granado LI. Subcutaneous Immunoglobulin in Refractory Juvenile Dermatomyositis. Pediatrics 2016; 137:peds.2015-3537. [PMID: 26966131 DOI: 10.1542/peds.2015-3537] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/23/2015] [Indexed: 11/24/2022] Open
Abstract
Juvenile dermatomyositis (JDM) is the most common form of juvenile idiopathic inflammatory myopathy. We report a child with steroid-dependent JDM refractory to hydroxychloroquine and subcutaneous methotrexate who experienced systemic reactions to intravenous immunoglobulin and was successfully treated with subcutaneous immunoglobulin. This form of therapy has been shown to be safe, has a very low rate of adverse effects, does not require hospital admission, reduces the number of missed school days, and decreases the costs associated with treatment.
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Affiliation(s)
| | | | | | - Luis Ignacio González-Granado
- Section of Pediatric Immunodeficiency Diseases, Department of Pediatrics, University Hospital 12 de Octubre, Universidad Complutense de Madrid and Instituto de Investigación Hospital 12 Octubre, Madrid, Spain
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Abstract
PURPOSE OF REVIEW This article highlights efforts in pediatric rheumatology related to optimizing the care provided to patients with pediatric rheumatic diseases and describes various approaches to improve health outcomes. RECENT FINDINGS Recent studies report low rates of remission, frequent occurrence of comorbidities, disease damage, and decreased health-related quality of life in pediatric rheumatic diseases. The Pediatric Rheumatology Care and Outcomes Improvement Network is a quality improvement learning network that has demonstrated improvement in the process of care measures through use of a centralized patient registry, and interventions, including previsit planning, population management, shared decision making, and patient/parent engagement. A pediatric rheumatology patient-powered research network was established to enable patient and caregiver participation in setting research priorities and to facilitate data sharing to answer research questions. Quality measure development and benchmarking are proceeding in multiple pediatric rheumatic diseases. SUMMARY The review summarizes the current efforts to improve care delivery and outcomes in pediatric rheumatic diseases through a learning health system approach that harnesses knowledge from the clinical encounter to serve quality improvement, research, and discovery. Incorporating standard approaches to medication treatment plans may reduce variation in care, including using the patient voice to design research studies to bring focus on more patient relevant outcomes. VIDEO ABSTRACT http://links.lww.com/COR/A28.
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Affiliation(s)
| | | | - Esi M. Morgan
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
- University of Cincinnati College of Medicine, Cincinnati, OH
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Barsell A, Librizzi J. A 5-Year-Old Girl with Fatigue, Diffuse Edema, and Weakness. Pediatr Ann 2015; 44:471-6. [PMID: 26587813 DOI: 10.3928/00904481-20151112-04] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Pagnini I, Vitale A, Selmi C, Cimaz R, Cantarini L. Idiopathic Inflammatory Myopathies: an Update on Classification and Treatment with Special Focus on Juvenile Forms. Clin Rev Allergy Immunol 2015; 52:34-44. [DOI: 10.1007/s12016-015-8512-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Rainsford KD, Parke AL, Clifford-Rashotte M, Kean WF. Therapy and pharmacological properties of hydroxychloroquine and chloroquine in treatment of systemic lupus erythematosus, rheumatoid arthritis and related diseases. Inflammopharmacology 2015; 23:231-69. [PMID: 26246395 DOI: 10.1007/s10787-015-0239-y] [Citation(s) in RCA: 349] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2015] [Accepted: 06/23/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVES This review examines the pharmacokinetics, modes of action and therapeutic properties of the anti-malarial drugs, hydroxychloroquine (HCQ) and chloroquine (CQ), in the treatment of systemic lupus erythematosus (SLE), rheumatoid arthritis (RA) and related conditions, as well as osteoarthritis (OA). KEY FINDINGS Both HCQ and CQ have historically been employed successfully for the treatment of SLE and RA for over 70 years. HCQ has been used extensively for SLE where it has a good reputation for controlling the dermatological complications in SLE. It has also been reported to effectively control the symptoms of Sjøgren's syndrome, as well as preventing thrombosis in phospholipid antibody (aPL) syndrome. In RA and SLE, HCQ is preferred because of the lower incidence of gastrointestinal adverse reactions compared with CQ and it might have a lower risk of ocular adverse reactions. There is increasing evidence that HCQ may reduce atherosclerosis and risks of cardiovascular disease in rheumatic patients. Both HCQ and CQ have been shown to improve glycaemia and reduce the risks of type II diabetes mellitus. Although both HCQ and CQ are effective in low-moderate RA, HCQ is now preferred as part of combination therapy for more severe disease. The advantages of combination therapy are that the doses of the individual drugs may be lowered so reducing adverse reactions. Both HCQ and CQ are diastereoisomers, have basic properties and are given as the sulphate and phosphate salts. While being relatively well absorbed orally and with good bioavailability, they have long and variable plasma terminal elimination half-lives (approximately 40-60 days). This reflects their high volume of distribution, V D (HCQ 44,000L; CQ 65,000L) which extends into aqueous compartments, long mean residence time (HCQ 1300 h; CQ 900 h) and with about half the drugs (metabolites) undergoing renal clearance. The strong binding to melanin reflects the ocular injury and dermatological properties of these drugs. The consensus is that the occurrence of ocular adverse reactions can be minimised by close attention to the dose (which should be set on a body weight basis) with regular (e.g. quarterly) retinal examination. Although HCQ and CQ can pass through the placenta, the use of these drugs during pregnancy does not appear to risk harm to the baby and might be beneficial to the mother with SLE and her child by controlling the SLE disease activity, which is known to be an important factor affecting pregnancy outcome. The modes of action of HCQ and CQ in these arthritides represent somewhat of an enigma. Undoubtedly, these drugs have multiple actions related, in part, their ability to accumulate in lysosomes and autophagosomes of phagocytic cells as well as affecting MHC Class II expression and antigen presentation; actions of the production of pro-inflammatory cytokines [e.g. interleukin-1 (IL-1) tumour necrosis factor-α (TNFα)]; control of toll-like receptor-9 activation; and leucocyte generation of reactive oxygen species (ROS); i.e. antioxidant activity. The actions of these drugs on T and B cells are less clear but may depend on these leucocyte-mediated actions. Anti-malarials also protect against cytokine-mediated cartilage resorption. This and other actions may underlie the potential benefits in treating OA. The exact relationships of these various actions, mostly determined in vitro, have not been specifically defined in vivo or ex vivo in relation to clinical efficacy. OUTCOMES HCQ and CQ have a good reputation for being effective and relatively safe treatments in SLE, mild-moderate RA and Sjøgren's syndrome. There is need for (a) more information on their mode of action in relation to the control of these diseases, (b) scope for developing formulations that have improved pharmacokinetic and therapeutic properties and safety, and (c) further exploring their use in drug combinations not only with other disease modifying agents but also with biologics.
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Affiliation(s)
- K D Rainsford
- Biomedical Research Centre, Sheffield Hallam University, Howard Street, Sheffield, S1 1WB, UK
| | - Ann L Parke
- Department of Rheumatology, St Francis Hospital and Medical Center, Hartford, CT, 06105, USA
| | | | - W F Kean
- Department of Medicine (Rheumatology), McMaster University Faculty of Health Sciences, Hamilton, ON, L8S 4K9, Canada.
- Department of Medicine (Rheumatology), McMaster University Faculty of Health Sciences, Suite #708, 1 Young Street, Hamilton, ON, L8N 1T8, Canada.
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McCann LJ, Kirkham JJ, Wedderburn LR, Pilkington C, Huber AM, Ravelli A, Appelbe D, Williamson PR, Beresford MW. Development of an internationally agreed minimal dataset for juvenile dermatomyositis (JDM) for clinical and research use. Trials 2015; 16:268. [PMID: 26063230 PMCID: PMC4472260 DOI: 10.1186/s13063-015-0784-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2015] [Accepted: 05/29/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is a rare autoimmune inflammatory disorder associated with significant morbidity and mortality. International collaboration is necessary to better understand the pathogenesis of the disease, response to treatment and long-term outcome. To aid international collaboration, it is essential to have a core set of data that all researchers and clinicians collect in a standardised way for clinical purposes and for research. This should include demographic details, diagnostic data and measures of disease activity, investigations and treatment. Variables in existing clinical registries have been compared to produce a provisional data set for JDM. We now aim to develop this into a consensus-approved minimum core dataset, tested in a wider setting, with the objective of achieving international agreement. METHODS/DESIGN A two-stage bespoke Delphi-process will engage the opinion of a large number of key stakeholders through Email distribution via established international paediatric rheumatology and myositis organisations. This, together with a formalised patient/parent participation process will help inform a consensus meeting of international experts that will utilise a nominal group technique (NGT). The resulting proposed minimal dataset will be tested for feasibility within existing database infrastructures. The developed minimal dataset will be sent to all internationally representative collaborators for final comment. The participants of the expert consensus group will be asked to draw together these comments, ratify and 'sign off' the final minimal dataset. DISCUSSION An internationally agreed minimal dataset has the potential to significantly enhance collaboration, allow effective communication between groups, provide a minimal standard of care and enable analysis of the largest possible number of JDM patients to provide a greater understanding of this disease. The final approved minimum core dataset could be rapidly incorporated into national and international collaborative efforts, including existing prospective databases, and be available for use in randomised controlled trials and for treatment/protocol comparisons in cohort studies.
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Affiliation(s)
- Liza J McCann
- Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK.
| | - Jamie J Kirkham
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Lucy R Wedderburn
- Infection, Immunology, and Rheumatology Section UCL Institute of Child Health, University College London, London, UK.
- Great Ormond Street Hospital NHS Foundation Trust, London, UK.
- Centre for Adolescent Rheumatology at University College London, University College London Hospital, London, UK.
| | - Clarissa Pilkington
- Great Ormond Street Hospital NHS Foundation Trust, London, UK.
- Centre for Adolescent Rheumatology at University College London, University College London Hospital, London, UK.
| | - Adam M Huber
- IWK Health Centre and Dalhousie University, 5850 University Avenue, Halifax, NS, B3K 6R8, Canada.
| | - Angelo Ravelli
- Università degli Studi di Genova and Istituto Giannina Gaslini, Via G. Gaslini 5, 16147, Genoa, Italy.
| | - Duncan Appelbe
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Paula R Williamson
- MRC North West Hub for Trials Methodology Research, Department of Biostatistics, University of Liverpool, Liverpool, UK.
| | - Michael W Beresford
- Alder Hey Children's NHS Foundation Trust, Eaton Road, Liverpool, UK.
- Department of Women's and Children's Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK.
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Management of inflammatory muscle disease. Rheumatology (Oxford) 2015. [DOI: 10.1016/b978-0-323-09138-1.00150-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Clinical course and outcomes of Iranian children with juvenile dermatomyositis and polymyositis. Clin Rheumatol 2014; 33:1113-8. [PMID: 24878926 DOI: 10.1007/s10067-014-2675-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 05/09/2014] [Accepted: 05/12/2014] [Indexed: 12/23/2022]
Abstract
This study evaluated the clinical features, course, and outcomes of Iranian children with juvenile dermatomyositis (JDM), juvenile polymyositis (JPM), and other uncommon connective tissue disorders. A chart review of 85 Iranian children with JDM and JPM was performed during a 10-year period from 2003 to 2013. The patients' clinical signs and symptoms, laboratory data, and other factors affecting clinical outcomes were recorded using questionnaires. Statistical analysis was performed using SPSS software version 20. In all, 40 boys and 45 girls were included in the study (F/M, 1.1:1). Disease frequency was significantly higher in boys aged <5 years (F/M, 0.4:1) and girls aged >5 years (F/M, 1.6:1). The combined mean age at diagnosis was 7.5 years. Muscle weakness, particularly in the proximal muscles of lower extremities (96 %); fatigue (83 %); and heliotrope rash (71 %) were the most frequently recorded symptoms. Elevated lactate dehydrogenase level was the most common enzyme disturbance (98 %). Monocyclic course was seen in 60 % of patients. The mean treatment duration was 3 years. The incidence rate of complications such as calcinosis, lipodystrophy, and growth disturbances was 20, 9, and 30 %, respectively. The occurrence of these complications in patients with monocyclic disease was significantly lower. Vital organ involvement led to the death of four patients. The incidence of calcinosis was significantly lower in patients having a shorter interval between disease onset and treatment. Two important complications, failure to thrive and lipodystrophy, were significantly higher in patients having antinuclear antibodies. The incidence of the above three complications was higher in patients with polycyclic or continuous chronic disease. Respiratory failure was the most common cause of patient mortality.
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Robinson AB, Hoeltzel MF, Wahezi DM, Becker ML, Kessler EA, Schmeling H, Carrasco R, Huber AM, Feldman BM, Reed AM. Clinical characteristics of children with juvenile dermatomyositis: the Childhood Arthritis and Rheumatology Research Alliance Registry. Arthritis Care Res (Hoboken) 2014; 66:404-10. [PMID: 23983017 DOI: 10.1002/acr.22142] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2012] [Accepted: 08/13/2013] [Indexed: 01/16/2023]
Abstract
OBJECTIVE To investigate aspects of juvenile dermatomyositis (DM), including disease characteristics and treatment, through a national multicenter registry. METHODS Subjects meeting the modified Bohan and Peter criteria for definite juvenile DM were analyzed from the cross-sectional Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry between 2010 and 2012 from 55 US pediatric rheumatology centers. Demographics, disease characteristics, diagnostic assessments, and medication exposure data were collected at enrollment. RESULTS A total of 384 subjects met the criteria for analysis. At enrollment, the median Childhood Myositis Assessment Scale score was 51 (interquartile range [IQR] 46-52), the median Childhood Health Assessment Questionnaire score was 0 (IQR 0-0.5), and the median physician and subject global assessment scores were 1 (IQR 0-2) and 1 (IQR 0-3), respectively, out of a maximum of 10. Of the diagnostic assessments, magnetic resonance imaging was more likely than electromyography or muscle biopsy to show abnormalities. A total of 329 subjects had ≥2 diagnostic studies performed, and >34% of these subjects reported ≥1 negative study. Ninety-five percent had been treated with corticosteroids and 92% with methotrexate, suggesting that these medications were almost universally prescribed for juvenile DM in the US. CONCLUSION In 2 years, the ongoing CARRA Registry has collected clinical data on 384 children with juvenile DM and has the potential to become one of the largest juvenile DM cohorts in the world. More research is needed about prognostic factors in juvenile DM, and differences in therapy based on manifestations of disease need to be explored by practitioners. This registry provides the infrastructure needed to advance clinical and translational research and represents a major step toward improving outcomes of children with juvenile DM.
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Rider LG, Katz JD, Jones OY. Developments in the classification and treatment of the juvenile idiopathic inflammatory myopathies. Rheum Dis Clin North Am 2013; 39:877-904. [PMID: 24182859 PMCID: PMC3817412 DOI: 10.1016/j.rdc.2013.06.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This review updates recent trends in the classification of the juvenile idiopathic inflammatory myopathies (JIIM) and the emerging standard of treatment of the most common form of JIIM, juvenile dermatomyositis. The JIIM are rare, heterogeneous autoimmune diseases that share chronic muscle inflammation and weakness. A growing spectrum of clinicopathologic groups and serologic phenotypes defined by the presence of myositis autoantibodies are now recognized, each with differing demographics, clinical manifestations, laboratory findings, and prognoses. Although daily oral corticosteroids remain the backbone of treatment, disease-modifying anti-rheumatic drugs are almost always used adjunctively and biologic therapies may benefit patients with recalcitrant disease.
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Affiliation(s)
- Lisa G Rider
- Environmental Autoimmunity Group, Program of Clinical Research, National Institute of Environmental Health Sciences, National Institutes of Health, CRC 4-2352, MSC 1301, 10 Center Drive, Bethesda, MD 20892-1301, USA; Myositis Center, Division of Rheumatology, Department of Medicine, George Washington University, G-400, 2150 Pennsylvania Avenue Northwest, Washington, DC 20037, USA.
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Kumar S, Pile K, Danda D. Juvenile dermatomyositis management: moving but in need of a push. Int J Rheum Dis 2013; 16:497-8. [PMID: 24164834 DOI: 10.1111/1756-185x.12216] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Affiliation(s)
- Sathish Kumar
- Christian Medical College & Hospital, Vellore, India
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Femia A, Vleugels RA. Pediatric Autoimmune Connective Tissue Diseases: An Update on Disease Characteristics, Associations, and Management. CURRENT DERMATOLOGY REPORTS 2013. [DOI: 10.1007/s13671-013-0058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Hasija R, Pistorio A, Ravelli A, Demirkaya E, Khubchandani R, Guseinova D, Malattia C, Canhao H, Harel L, Foell D, Wouters C, De Cunto C, Huemer C, Kimura Y, Mangge H, Minetti C, Nordal EB, Philippet P, Garozzo R, Martini A, Ruperto N. Therapeutic approaches in the treatment of juvenile dermatomyositis in patients with recent-onset disease and in those experiencing disease flare: an international multicenter PRINTO study. ACTA ACUST UNITED AC 2013; 63:3142-52. [PMID: 21647864 DOI: 10.1002/art.30475] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate response to therapy over a 24-month period in a large prospective international cohort of patients with juvenile dermatomyositis (DM). METHODS The study included 145 patients with recent-onset juvenile DM and 130 juvenile DM patients experiencing disease flare, all of whom were <18 years old. Disease activity parameters and therapeutic approaches in 4 geographic areas were analyzed at baseline and at 6, 12, and 24 months. Response was assessed according to the Pediatric Rheumatology International Trials Organization (PRINTO) juvenile DM response criteria, and data were reported "as observed" and in the intent-to-treat (ITT) population. RESULTS Patients with recent-onset juvenile DM at baseline had higher baseline disease activity and greater improvement over 24 months when compared to juvenile DM patients experiencing disease flare at baseline. Methotrexate (MTX) or high-dose corticosteroids were administered more frequently to patients with recent-onset juvenile DM, compared to juvenile DM patients experiencing disease flare, who were more likely to receive cyclosporine. Compared to patients from Western and Eastern Europe, a higher proportion of patients from South and Central America and North America received pulse steroids, and the average steroid dosage was higher in the North American and South and Central American patients. The use of MTX was similar in all 4 regions, while cyclosporin A was more frequently used in Western Europe. In the "as observed" analysis, 57.9% of the patients with recent-onset juvenile DM and 36.4% of the patients experiencing disease flare (P<0.001) reached at least a 70% response by PRINTO criteria at 6 months; these proportions had increased at month 24 to 78.4% and 51.2%, respectively (P<0.001). Corresponding results of the ITT analysis were much lower, with only one-third of the patients able to maintain the initial assigned therapy over 24 months. CONCLUSION Patients with recent-onset juvenile DM are more likely to achieve significant clinical improvement over 24 months, when compared to patients experiencing flares of juvenile DM. Internationally, various therapeutic approaches are used to treat this disease.
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Martin N, Krol P, Smith S, Beard L, Pilkington CA, Davidson J, Wedderburn LR. Comparison of children with onset of juvenile dermatomyositis symptoms before or after their fifth birthday in a UK and Ireland juvenile dermatomyositis cohort study. Arthritis Care Res (Hoboken) 2013; 64:1665-72. [PMID: 22674907 PMCID: PMC3533762 DOI: 10.1002/acr.21753] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Objective To compare 2 groups of children with juvenile dermatomyositis (DM), those with onset of symptoms before their fifth birthday versus those whose disease begins either on or after their fifth birthday, and to assess whether age at onset is associated with differences in disease presentation, treatments received, or outcomes 2 years after diagnosis. Methods Data were analyzed on children recruited to a UK juvenile DM cohort study with a diagnosis of probable or definite juvenile DM and less than 12 months between diagnosis and recruitment. Results Fifty-five (35%) of 157 children had onset of symptoms before their fifth birthday. At diagnosis, cutaneous ulceration was found in 32.7% of the younger group versus 11.8% of the older group (P = 0.003). Facial or body swelling was reported more often in the younger group, whereas headaches, alopecia, and Raynaud's phenomenon were all more frequently reported in the older group. At followup 2 years later, there were no important differences in outcomes between the groups. More than 90% of patients in both groups received both methotrexate and steroids. Twenty-three percent of both groups remained on steroids 2 years after diagnosis. Conclusion Our study showed that children with juvenile DM with disease onset at age <5 years are more likely to present with ulcerative skin disease and edema. There were no clinically significant differences in outcomes between the 2 groups.
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Affiliation(s)
- N Martin
- Great Ormond Street Hospital, London, UK.
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