Influenza vaccine uptake in juvenile idiopathic arthritis: a multi-centre cross-sectional study

While most countries provide safe and effective influenza vaccines for at-risk groups, influenza vaccine coverage among children with rheumatic diseases remains uncertain. This study investigated influenza vaccination rates in children with juvenile idiopathic arthritis (JIA) during the 2019-2020 season and assessed the knowledge and attitudes of caregivers of children with JIA regarding influenza vaccination. The secondary aims were to identify barriers to vaccination and explore strategies to improve vaccination rates. A multi-centre, cross-sectional anonymous survey was conducted in 7 countries during the 2019-2020 influenza season to assess the uptake history of influenza vaccination. Among 287 participants, only 87 (30%) children with JIA received the influenza vaccine during the 2019-2020 season. Children who were more likely to be vaccinated were those with systemic juvenile idiopathic arthritis (sJIA), a history of previous vaccination and those aware of the vaccination recommendations. Conversely, children who previously experienced adverse vaccine-related events reported the lowest uptake. The primary reason for non-vaccination was lack of awareness about the necessity of influenza vaccination.  Conclusion: Despite variations among countries, the uptake of influenza vaccines remains low in children with JIA. Improving awareness among families about the importance of influenza vaccination may increase vaccination rates in children with rheumatic diseases. What is Known: • Rheumatic children are at increased risk for influenza infection due to immunosuppressive therapy and immune dysregulation. • Influenza vaccine is formally recommended to children with rheumatic diseases. What is New: • This multicentre study showed that influenza vaccine uptake rates remain suboptimal among children with Juvenile Idiopathic Arthritis despite formal recommendations. • Factors like previous experience with vaccination and information provided by medical professionals via different ways play essential roles in increasing vaccination rates and can contribute to improved health outcomes for these vulnerable children.

Multisystem inflammatory syndrome in children (MIS-C): A nationwide collaborative study in the Greek population

Multisystem inflammatory syndrome in children (MIS-C) is a rare but severe hyperinflammatory condition that may occur following SARS-CoV-2 infection. This retrospective, descriptive study of children hospitalized with multisystem inflammatory syndrome in children (MIS-C) in 12 tertiary care centers from 3/11/2020 to 12/31/2021. Demographics, clinical and laboratory characteristics, treatment and outcomes are described. Among 145 patients (95 males, median age 8.2 years) included, 123 met the WHO criteria for MIS-C, while 112 (77%) had serological evidence of SARS-CoV-2 infection. Fever was present in 99%, gastrointestinal symptoms in 77%, mucocutaneous involvement in 68% and respiratory symptoms in 28%. Fifty-five patients (38%) developed myocarditis, 29 (20%) pericarditis and 19 (13%) coronary aneurysms. Among the above cases 11/55 (20%), 1/29 (3.4%) and 5/19 (26.3%), respectively, cardiac complications had not fully resolved at discharge. Underlying comorbidities were reported in 18%. Median CRP value was 155 mg/l, ferritin 535 ng/ml, PCT 1.6 ng/ml and WBC 14.2 × 109/mm3. Most patients had elevated troponin (41.3%) and/or NT-pro-BNP (49.6%). Intravenous immunoglobulin plus corticosteroids were used in 117/145 (80.6%), monotherapy with IVIG alone in 13/145 (8.9%) and with corticosteroids alone in 2/145 (1.3%). Anti-IL1 treatment was added in 15 patients (10.3%). Thirty-three patients (23%) were admitted to the PICU, 14% developed shock and 1 required ECMO. Mortality rate was 0.68%. The incidence of MIS-C was estimated at 0.69/1000 SARS-CoV-2 infections. Patients who presented with shock had higher levels of NT-pro-BNP compared to those who did not (p < 0.001). Acute kidney injury and/or myocarditis were associated with higher risk of developing shock.

CONCLUSION

MIS-C is a novel, infrequent but serious disease entity. Cardiac manifestations included myocarditis and pericarditis, which resolved in most patients before discharge. Timely initiation of immunomodulatory therapy was shown to be effective. NT-pro-BNP levels may provide a better prediction and monitoring of the disease course. Further research is required to elucidate the pathogenesis, risk factors and optimal management, and long-term outcomes of this clinical entity.

WHAT IS KNOWN

• MIS-C is an infrequent but serious disease entity. • Patients with MIS-C present with multi-organ dysfunction, primarily involving the gastrointestinal and cardiovascular systems.

WHAT IS NEW

• NT-pro-BNP levels may provide a better prediction and monitoring of the disease course. • Acute kidney injury and/or myocarditis were associated with higher risk of developing shock.

Antiphospholipid syndrome after streptococcal toxic shock syndrome later diagnosed as Behcet's disease

Streptococcal toxic shock syndrome is a severe complication of group A streptococci. The production of antiphospholipid antibodies has been associated with streptococcal infections and with autoimmune diseases. Furthermore, streptococcal infections could be a trigger of Behcet's disease. We report a case of a boy who presented antiphospholipid syndrome after streptococcal toxic shock syndrome later he was diagnosed with Behcet's disease.

EULAR/PRES recommendations for vaccination of paediatric patients with autoimmune inflammatory rheumatic diseases: update 2021

OBJECTIVES

Recent insights supporting the safety of live-attenuated vaccines and novel studies on the immunogenicity of vaccinations in the era of biological disease-modifying antirheumatic drugs in paediatric patients with autoimmune/inflammatory rheumatic diseases (pedAIIRD) necessitated updating the EULAR recommendations.

METHODS

Recommendations were developed using the EULAR standard operating procedures. Two international expert committees were formed to update the vaccination recommendations for both paediatric and adult patients with AIIRD. After a systematic literature review, separate recommendations were formulated for paediatric and adult patients. For pedAIIRD, six overarching principles and seven recommendations were formulated and provided with the level of evidence, strength of recommendation and Task Force level of agreement.

RESULTS

In general, the National Immunisation Programmes (NIP) should be followed and assessed yearly by the treating specialist. If possible, vaccinations should be administered prior to immunosuppressive drugs, but necessary treatment should never be postponed. Non-live vaccines can be safely given to immunosuppressed pedAIIRD patients. Mainly, seroprotection is preserved in patients receiving vaccinations on immunosuppression, except for high-dose glucocorticoids and B-cell depleting therapies. Live-attenuated vaccines should be avoided in immunosuppressed patients. However, it is safe to administer the measles-mumps-rubella booster and varicella zoster virus vaccine to immunosuppressed patients under specific conditions. In addition to the NIP, the non-live seasonal influenza vaccination should be strongly considered for immunosuppressed pedAIIRD patients.

CONCLUSIONS

These recommendations are intended for paediatricians, paediatric rheumatologists, national immunisation agencies, general practitioners, patients and national rheumatology societies to attain safe and effective vaccination and optimal infection prevention in immunocompromised pedAIIRD patients.

A Co-diagnosis of Crohn Disease and Autoimmune Diabetes in an Adolescent Patient

Inflammatory bowel disease (IBD) is a lifelong, immune-mediated disorder that often occurs in childhood and is becoming increasingly common worldwide. Diagnosis of IBD in children remains difficult due to the spectrum of symptoms, including gastrointestinal and extraintestinal manifestations. Type 1 diabetes mellitus (T1D) is one of the most common autoimmune diseases in children and adolescents. Classic manifestations of T1D in young people include polyuria, polydipsia, abdominal pain, weight loss, and ketoacidosis. However, children with autoimmunity of pancreatic β-cells may remain euglycemic and asymptomatic for many years. An accurate and prompt diagnosis of IBD and T1D is particularly important in children because they can negatively affect growth, psychosocial function and overall well-being. We present a case in which a previously healthy child was co-diagnosed with Crohn disease and T1D during a routine pediatric evaluation in the outpatient clinic of a peripheral secondary hospital.

Efficacy, Immunogenicity and Safety of Vaccination in Pediatric Patients With Autoimmune Inflammatory Rheumatic Diseases (pedAIIRD): A Systematic Literature Review for the 2021 Update of the EULAR/PRES Recommendations

Background

In 2011, the first European League Against Rheumatism (EULAR) vaccination recommendations for pediatric patients with autoimmune inflammatory rheumatic diseases (pedAIIRD) were published. The past decade numerous new studies were performed to assess the safety, efficacy and immunogenicity of vaccinations in pedAIIRD. A systematic literature review (SLR) was therefore performed to serve as the basis for the updated 2021 EULAR/PRES recommendations.

Methods

An SLR was performed according to the standard operating procedures for EULAR-endorsed recommendations. Primary outcomes were efficacy, immunogenicity and safety of vaccination in pedAIIRD. The search was performed in Medline, Embase and the Cochrane Library and included studies published from November 2010 until July 2020.

Results

The SLR yielded 57 studies which were included for critical appraisal and data extraction. Only 8 studies described the occurrence of vaccine-preventable infections after vaccination (efficacy), none of these studies were powered to assess efficacy. The majority of studies assessed (humoral) immune responses as surrogate endpoint for vaccine efficacy. Studies on non-live vaccines showed that these were safe and in general immunogenic. Biologic disease-modifying antirheumatic drugs (bDMARDs) in general did not significantly reduce seroprotection rates, except for B-cell depleting therapies which severely hampered humoral responses. Four new studies on human papilloma virus vaccination showed that this vaccine was safe and immunogenic in pedAIIRD. Regarding live-attenuated vaccinations, level 1 evidence of the measles mumps rubella (MMR) booster vaccination became available which showed the safety of this booster for patients treated with methotrexate. In addition, level 3 evidence became available that suggested that the MMR and varicella zoster virus (VZV) vaccination for patients on low dose glucocorticosteroids and bDMARDs might be safe as well.

Conclusions

The past decade, knowledge on the safety and immunogenicity of (live-attenuated) vaccines in pedAIIRD significantly increased. Data on efficacy (infection prevention) remains scarce. The results from this SLR are the basis for the updated EULAR/PRES vaccination recommendations in pedAIIRD.

Eyes wide open—an atypical presentation of Miller Fisher syndrome (MFS): case report

Background

Parinaud’s syndrome, also known as dorsal midbrain syndrome, is characterized by a combination of signs, including upgaze palsy, convergence–retraction nystagmus, eyelid retraction and pupillary dissociation. It is caused by pretectal or tegmental lesions of upper brainstem. Miller Fisher syndrome, characterized by the triad of ataxia, areflexia and ophthalmoplegia, has rarely been reported to present as Parinaud’s syndrome in adults. To our knowledge, this clinical manifestation has not been previously described in children.

Case presentation

A previously healthy 13-year-old girl presented with blurred vision and diplopia, 10 days after a viral infection. Initial examination revealed incomplete Parinaud’s syndrome, while rest of neurological examination was normal. Brain imaging (MRI, MRA) did not reveal any abnormal findings and CSF findings were also normal. During the first days after admission she gradually deteriorated, showing complete external ophthalmoplegia, unsteady gait, and absent deep tendon reflexes of lower limbs with normal muscle power. With the clinical suspicion of Miller Fisher syndrome IVIG was administered, leading to subsequent resolution of her symptoms. AntiGQ1b and antiGD1b antibodies came back positive confirming diagnosis. On 1 month follow-up, neurological examination revealed diplopia in left gaze, and a second dose of IVIG was administered with good response. She remains asymptomatic 1 year from disease onset.

Conclusions

Miller Fisher syndrome can rarely present as Parinaud’s syndrome in adults. Herein we described the first pediatric patient with similar clinical presentation. As the typical semiology of ataxia and areflexia may not be present initially, high index of suspicion is required to recognise and treat those patients promptly. Serological detection of anti-ganglioside antibodies, such as anti-GQ1b and anti-GD1b, may help confirm diagnosis.

Increased incidence of inflammatory bowel disease on etanercept in juvenile idiopathic arthritis regardless of concomitant methotrexate use

Objective

To describe risk factors for IBD development in a cohort of children with JIA.

Methods

JIA patients who developed IBD were identified from the international Pharmachild register. Characteristics were compared between IBD and non-IBD patients and predictors of IBD were determined using multivariable logistic regression analysis. Incidence rates of IBD events on different DMARDs were calculated, and differences between therapies were expressed as relative risks (RR).

Results

Out of 8942 patients, 48 (0.54% ) developed IBD. These were more often male (47.9% vs 32.0%) and HLA-B27 positive (38.2% vs 21.0%) and older at JIA onset (median 8.94 vs 5.33 years) than patients without IBD development. They also had more often a family history of autoimmune disease (42.6% vs 24.4%) and enthesitis-related arthritis (39.6% vs 10.8%). The strongest predictors of IBD on multivariable analysis were enthesitis-related arthritis [odds ratio (OR): 3.68, 95% CI: 1.41, 9.40] and a family history of autoimmune disease (OR: 2.27, 95% CI: 1.12, 4.54). Compared with methotrexate monotherapy, the incidence of IBD on etanercept monotherapy (RR: 7.69, 95% CI: 1.99, 29.74), etanercept with methotrexate (RR: 5.70, 95% CI: 1.42, 22.77) and infliximab (RR: 7.61, 95% CI: 1.27, 45.57) therapy was significantly higher. Incidence on adalimumab was not significantly different (RR: 1.45, 95% CI: 0.15, 13.89).

Conclusion

IBD in JIA was associated with enthesitis-related arthritis and a family history of autoimmune disease. An increased IBD incidence was observed for etanercept therapy regardless of concomitant methotrexate use.

Thrombotic Microangiopathy Associated with Macrophage Activation Syndrome: A Multinational Study of 23 Patients

OBJECTIVE

To describe the clinical characteristics, treatment, and outcomes of a multinational cohort of patients with macrophage activation syndrome (MAS) and thrombotic microangiopathy (TMA).

STUDY DESIGN

International pediatric rheumatologists were asked to collect retrospectively the data of patients with the co-occurrence of MAS and TMA. Clinical and laboratory features of patients with systemic juvenile idiopathic arthritis (sJIA)-associated MAS and TMA were compared with those of an historical cohort of patients with sJIA and MAS.

RESULTS

Twenty-three patients with MAS and TMA were enrolled: 17 had sJIA, 2 systemic lupus erythematosus, 1 juvenile dermatomyositis, 1 mixed connective tissue disease, and 2 undifferentiated connective tissue disease. Compared with the historical cohort of MAS, patients with sJIA with coexistent MAS and TMA had higher frequencies of renal failure and neurologic involvement, hemorrhage, jaundice, and respiratory symptoms, as well as more severe anemia and thrombocytopenia, higher levels of alanine aminotransferase, lactate dehydrogenase, bilirubin and D-dimer, and lower levels of albumin and fibrinogen. They also required admission to the intensive care unit more frequently. Among patients tested, complement abnormalities and reduced ADAMTS13 activity were observed in 64.3% and 44.4% of cases, respectively. All patients received glucocorticoids. Treatment for TMA included plasma-exchange, eculizumab, and rituximab.

CONCLUSIONS

The possible coexistence of MAS and TMA in rheumatic diseases may be underrecognized. This association should be considered in patients with MAS who develop disproportionate anemia, thrombocytopenia, and lactate dehydrogenase increase, or have multiorgan failure.

Persistent Tenosynovitis, Steroid Dependency and a Hyperpigmented Scaly Macular Rash in a Child With Juvenile Idiopathic Arthritis

Blau syndrome is a rare autoinflammatory disease, characterized by granulomatous symmetric arthritis, skin rash and uveitis. It is caused by mutations in the CARD15/NOD2 gene, which is a significant part of innate immunity. We describe the case of a patient with Blau syndrome, initially misdiagnosed as juvenile idiopathic arthritis. Genetic analysis showed R334Q mutation in the NOD2 gene that is known to be linked to Blau syndrome. Our patient was successfully treated with the IL-1β blocking agent canakinumab, with clinical and laboratory remission without any adverse effects. To our knowledge this is one of the rare cases of Blau syndrome successfully treated with canakinumab. After moving abroad, canakinumab was discontinued and she was treated with adalimumab instead. Change in her treatment resulted in a relapse of her disease. Prompt recognition of Blau syndrome and the optimal treatment, are vital for the prevention of severe sequelae such as vision loss and joint deformities. Canakinumab constitutes a promising therapeutic approach for Blau syndrome and requires further investigation.

Pediatric Synovitis, Acne, Pustulosis, Hyperostosis, Osteitis (SAPHO) Syndrome: Diagnostic Challenges and Treatment Approach

Synovitis, acne, pustulosis, hyperostosis, osteitis (SAPHO) syndrome is a rare disease; however, more and more case reports have been published that increase the awareness of this disorder, especially in children. Clinically it presents as a combination of chronic recurrent multifocal osteomyelitis symptoms and skin manifestations. SAPHO treatment remains a challenge. In most cases, non-steroidal anti-inflammatory drugs are initially used, although a combination with other drugs is preferred. In addition, antibiotics, corticosteroids, bisphosphonates, and disease-modifying anti-rheumatic drugs are usually administered with varied success. There are also promising results from novel biological therapy. This paper emphasizes some non-specific symptoms of the disease, in order to increase the suspicion of SAPHO in all pediatric clinical doctors. We present the case of a 13-year-old boy with severe acne, who was admitted to our hospital due to fever of unknown origin, accompanied by arthralgia of the right ankle and left knee. 

Opportunistic infections in immunosuppressed patients with juvenile idiopathic arthritis: analysis by the Pharmachild Safety Adjudication Committee

BACKGROUND

To derive a list of opportunistic infections (OI) through the analysis of the juvenile idiopathic arthritis (JIA) patients in the Pharmachild registry by an independent Safety Adjudication Committee (SAC).

METHODS

The SAC (3 pediatric rheumatologists and 2 pediatric infectious disease specialists) elaborated and approved by consensus a provisional list of OI for use in JIA. Through a 5 step-procedure, all the severe and serious infections, classified as per MedDRA dictionary and retrieved in the Pharmachild registry, were evaluated by the SAC by answering six questions and adjudicated with the agreement of 3/5 specialists. A final evidence-based list of OI resulted by matching the adjudicated infections with the provisional list of OI.

RESULTS

A total of 772 infectious events in 572 eligible patients, of which 335 serious/severe/very severe non-OI and 437 OI (any intensity/severity), according to the provisional list, were retrieved. Six hundred eighty-two of 772 (88.3%) were adjudicated as infections, of them 603/682 (88.4%) as common and 119/682 (17.4%) as OI by the SAC. Matching these 119 opportunistic events with the provisional list, 106 were confirmed by the SAC as OI, and among them infections by herpes viruses were the most frequent (68%), followed by tuberculosis (27.4%). The remaining events were divided in the groups of non-OI and possible/patient and/or pathogen-related OI.

CONCLUSIONS

We found a significant number of OI in JIA patients on immunosuppressive therapy. The proposed list of OI, created by consensus and validated in the Pharmachild cohort, could facilitate comparison among future pharmacovigilance studies.

TRIAL REGISTRATION

Clinicaltrials.gov NCT01399281; ENCePP seal: awarded on 25 November 2011.

A novel de novo KCNQ2 mutation in a child with treatmentresistant early-onset epileptic encephalopathy

Benetou C, Papailiou S, Maritsi D, Anagnostopoulou K, Kontos H, Vartzelis G. A novel de novo KCNQ2 mutation in a child with treatmentresistant early-onset epileptic encephalopathy. Turk J Pediatr 2019; 61: 279-281. Mutations in KCNQ2 gene, encoding for voltage-gated K+ channel subunit, may result in a wide spectrum of early-onset epileptic disorders. The phenotype of the disease varies from `benign familial neonatal seizures` to `severe epileptic encephalopathies`. In this report, we present a novel mutation [namely: c.683A > G (p.His228Arg)], as a presumable cause of severe infantile-onset neonatal seizures, in a 3-month old boy. The seizures have been poorly responsive to various pharmacological treatments, with phenytoin and carbamazepine presenting with the most favourable results so far. The study of our patient could help to further clarify the clinical manifestations of KCNQ2 mutations, revealing a previously unreported mutation.

Effect of Biologic Therapy on Clinical and Laboratory Features of Macrophage Activation Syndrome Associated With Systemic Juvenile Idiopathic Arthritis

OBJECTIVE

To assess performance of the 2016 macrophage activation syndrome (MAS) classification criteria for patients with systemic juvenile idiopathic arthritis (JIA) who develop MAS while treated with biologic medications.

METHODS

A systematic literature review was performed to identify patients with MAS while being treated with interleukin (IL)-1 and IL-6 blocking agents. Clinical and laboratory information was compared to a large previously compiled historical cohort.

RESULTS

Eighteen publications were identified, and after removing duplicates, 35 patients treated with canakinumab and 49 patients with tocilizumab were available for analysis; 5 anakinra-treated patients were excluded due to limited numbers. MAS classification criteria were less likely to classify tocilizumab-treated patients as having MAS compared to the historical cohort or canakinumab-treated patients (56.7%, 78.5%, and 84%, respectively; P < 0.01). Patients who developed MAS while treated with canakinumab trended towards lower ferritin at MAS onset than the historical cohort (4,050 versus 5,353 ng/ml; P = 0.18) but had no differences in other cardinal clinical or laboratory features. In comparison, patients who developed MAS while treated with tocilizumab were less likely febrile and had notably lower ferritin levels (1,152 versus 5,353 ng/ml; P < 0.001). Other features of MAS were more pronounced in patients treated with tocilizumab, including lower platelet counts, lower fibrinogen, and higher aspartate aminotransferase levels. Mortality rates for patients with MAS treated with tocilizumab or canakinumab were not significantly different from the historical cohort.

CONCLUSION

These findings show substantial alterations in MAS features that may limit utility of defined criteria for diagnosis of systemic JIA patients treated with biologic agents.

Development and Initial Validation of the Macrophage Activation Syndrome/Primary Hemophagocytic Lymphohistiocytosis Score, a Diagnostic Tool that Differentiates Primary Hemophagocytic Lymphohistiocytosis from Macrophage Activation Syndrome

OBJECTIVE

To develop and validate a diagnostic score that assists in discriminating primary hemophagocytic lymphohistiocytosis (pHLH) from macrophage activation syndrome (MAS) related to systemic juvenile idiopathic arthritis.

STUDY DESIGN

The clinical, laboratory, and histopathologic features of 362 patients with MAS and 258 patients with pHLH were collected in a multinational collaborative study. Eighty percent of the population was assessed to develop the score and the remaining 20% constituted the validation sample. Variables that entered the best fitted model of logistic regression were assigned a score, based on their statistical weight. The MAS/HLH (MH) score was made up with the individual scores of selected variables. The cutoff in the MH score that discriminated pHLH from MAS best was calculated by means of receiver operating characteristic curve analysis. Score performance was examined in both developmental and validation samples.

RESULTS

Six variables composed the MH score: age at onset, neutrophil count, fibrinogen, splenomegaly, platelet count, and hemoglobin. The MH score ranged from 0 to 123, and its median value was 97 (1st-3rd quartile 75-123) and 12 (1st-3rd quartile 11-34) in pHLH and MAS, respectively. The probability of a diagnosis of pHLH ranged from <1% for a score of <11 to >99% for a score of  ≥123. A cutoff value of ≥60 revealed the best performance in discriminating pHLH from MAS.

CONCLUSION

The MH score is a powerful tool that may aid practitioners to identify patients who are more likely to have pHLH and, thus, could be prioritized for functional and genetic testing.

Clinical features, treatment, and outcome of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis: a multinational, multicenter study of 362 patients

OBJECTIVE

To describe the clinical, laboratory, and histopathologic features, current treatment, and outcome of patients with macrophage activation syndrome (MAS) complicating systemic juvenile idiopathic arthritis (JIA).

METHODS

In this multinational, multicenter study, pediatric rheumatologists and hemato-oncologists entered patient data collected retrospectively into a web-based database.

RESULTS

A total of 362 patients, 22% of whom had MAS at the onset of systemic JIA, were included in the study by 95 investigators from 33 countries. The most frequent clinical manifestations were fever (96%), hepatomegaly (70%), and splenomegaly (58%). Central nervous system dysfunction and hemorrhages were recorded in 35% and 20% of the patients, respectively. Platelet count and liver transaminase, ferritin, lactate dehydrogenase, triglyceride, and d-dimer levels were the sole laboratory biomarkers showing a percentage change of >50% between the pre-MAS visit and MAS onset. Evidence of macrophage hemophagocytosis was found in 60% of the patients who underwent bone marrow aspiration. MAS occurred most frequently in the setting of active underlying disease, in the absence of a specific trigger. Nearly all patients were given corticosteroids, and 61% received cyclosporine. Biologic medications and etoposide were given to 15% and 12% of the patients, respectively. Approximately one-third of the patients required admission to the intensive care unit (ICU), and the mortality rate was 8%.

CONCLUSION

This study provides information on the clinical spectrum and current management of systemic JIA-associated MAS through the analysis of a very large patient sample. MAS remains a serious condition, as a sizeable proportion of patients required admission to the ICU or died.

Markedly decreased antibody titers against hepatitis B in previously immunised children presenting with juvenile idiopathic arthritis

OBJECTIVES

Hepatitis B is a vaccine preventable disease with intermediate endemicity in Greece. Patients with juvenile idiopathic arthritis (JIA) on immunomodulating therapy are prone to infection or reactivation of hepatitis B virus (HBV). The aim of this study is to define the immune status against HBV in children newly-diagnosed with JIA.

METHODS

Case-control prospective study including 89 JIA patients and 89 controls matched for age and gender. Eighty-nine JIA patients were included in the study (22 males), with a mean age of 6.8 years. Sera were tested for hepatitis B surface antigen, hepatitis B core antibody, and anti-HBs. Patients with anti-HBs titers ≥10 IU/L were considered immune. Data were analysed with SPSS 18.0 version.

RESULTS

In the JIA group 55% were HBV immune (anti-HBs level ≥10 IU/L) while in the control group 92% were immune against HBV (p<0.001). Antibody levels in the patient group were significantly lower compared to the control group. The mean concentration of anti-HBs levels in JIA patients was 18.3 IU/L versus 82.6 IU/L in the control group (p<0.001).

CONCLUSIONS

Antibody titers against HBV in fully vaccinated JIA patients due to start treatment are significantly lower compared to matched healthy children in this study. Diagnosis of JIA and older age were associated with the absence of protective antibodies. Although there is no evidence to support the introduction of a booster HBV dose in healthy children who mount low antibody response following immunisation, further studies are required to address this question in patients with JIA.

The Performance of Quantiferon TB Gold In-Tube as a Screening Tool in Paediatric Rheumatology prior to Initiation of Infliximab: A Single Centre's Experience

Background. Patients with autoimmune diseases and latent tuberculosis infection (LTBI) are at risk of developing catastrophic tuberculosis disease following infliximab treatment. Quantiferon-TB gold in-Tube (QTB) has proven a more accurate screening tool than tuberculin skin test (TST) in adult populations. Objectives. To assess the utility and validity of QTB in children, prior to treatment with infliximab. Methods. Retrospective cohort of patients started on infliximab following endorsement of QTB as a screening tool by the NICE guidelines in 2006. Results. Twenty three patients (12 females and 11 males) were included in the study. A chest radiograph (CXR) and QTB was performed prior to starting infliximab. Fourteen patients had a recorded negative TST result. One patient had a positive QTB while two had indeterminate results. Their CXRs were not suggestive of TB and TSTs were negative. The patients with indeterminate results were started on infliximab and had regular clinical assessment for TB disease. Repeat QTB was negative in one while remained indeterminate in the other. None of our 23 patients developed TB. Conclusion. QTB is a useful screen tool for LTBI. Indeterminate results warrant careful assessment and re-evaluation, but should not preclude from initiation of anti TNF treatment.

An unusual case of epidermolysis bullosa complicated by persistent oligoarticular juvenile idiopathic arthritis; lessons to be learned

Recessive Dystrophic Epidermolysis Bullosa (RDEB) is a rare and severe hereditary skin disease. Oligoarticular Juvenile Idiopathic Arthritis (JIA) although infrequent in the general paediatric population, is the most frequent type of autoimmune joint disease in children. While different in aetiology, both diseases are characterized by gradual deterioration in mobility and function. We report a female patient, diagnosed with RDEB at birth, who presented with inflammatory bowel disease (IBD) at the age of four years, and subsequently developed oligoarticular JIA at seven years of age, and discuss the diagnostic and treatment challenges of this unusual case. This report, besides presenting a unique case, also highlights the important issues that need to be taken into account when assessing and managing patients with such complex conditions.

Umbilical polyp in infants and children

AIM OF THE STUDY

The umbilical polyp is a rare congenital lesion resulting from the persistence of omphalomesenteric duct (OMD) enteric mucosa at the umbilicus. Exploration of the abdomen to exclude the presence of associated OMD remnants is controversial. The aim of this study was to evaluate the need for peritoneal cavity exploration in children with umbilical polyp.

METHODS

All umbilical lesions (n = 53) excised between 1995 and 2005 in a single institution were reviewed to identify patients with umbilical polyp (n = 13). This is characterised histologically by the presence of gastrointestinal mucosa. A follow-up study of patients with umbilical polyp was performed. Data are reported as median (range).

RESULTS AND CONCLUSIONS

All 13 patients underwent excision of an umbilical polyp at a median age of 15.1 months (3.1 - 80.5). All presented with a discharging polyp (associated with bleeding in 9) which did not respond to topical silver nitrate. Median diameter of the lesions was 0.5 cm (0.2 - 1). Histology revealed the presence of small bowel mucosa in 11 (associated with pancreatic tissue in 1 and gastric mucosa in 1) and large bowel mucosa in 2. All patients underwent inspection and probing of the base of the polyp after its excision. In 6 patients an associated OMD anomaly was suspected and exploration of the peritoneal cavity was performed (mini-laparotomy in 5 and laparoscopy in 1). No OMD anomaly was found. The 7 children who did not undergo exploration of the abdominal cavity remain asymptomatic after 5.8 years (0.9 - 13.7) follow-up. An umbilical polyp can be present in the absence of other OMD anomalies. Exploration of the peritoneal cavity in children with an umbilical polyp does not seem to be necessary.

Factors predicting failure of redo Nissen fundoplication in children

Recurrence of gastro-oesophageal reflux (GOR) following redo Nissen fundoplication represents a significant clinical problem. The aim of this study was to identify factors predicting failure of redo Nissen fundoplication. The notes of children who underwent redo Nissen fundoplication for recurrent GOR in a single institution between June 1994 and May 2005 were reviewed. Data are reported as median (range), or as numbers of cases. Multiple logistic regression analysis, using type of first fundoplication, neurological status, presence of gastrostomy, age-weight, retching-gas bloat after first fundoplication, associated anomalies, oesophageal atresia and length of follow-up as factors, was used to generate a model to identify factors predicting recurrent vomiting (failure) after redo. Eighty-one children underwent redo Nissen fundoplication 15.9 months (0.2-176) after the initial Nissen fundoplication. In 29, the first Nissen was laparoscopic. Age at redo Nissen fundoplication was 3.3 years (0.3-15.9) and weight 12.8 kg (5-60). Thirty-four children (42%) presented with recurrent vomiting (failure). Overall, the model successfully predicted vomiting (failure) after redo fundoplication (P = 0.009). Open surgery at first fundoplication (P = 0.011) and neurological impairment (P = 0.046) were both significant predictors of redo failure in the model, whereas presence of gastrostomy (P = 0.035) and older-heavier age-weight (P = 0.028) were associated with significantly better results. Retching-gas bloat, associated anomalies and oesophageal atresia were not significant predictors of failure. Redo Nissen fundoplication has a high failure rate. Risk factors are open fundoplication at first operation and neurological impairment. Redo fundoplication after primary laparoscopic Nissen has a lower risk of failure.

What's new in p53?

p53 is the main intrinsic factor inducing apoptosis by recognizing the external stimuli and activating the p53 responsive genes to an irreversible series of events. P53 activates the transcription of specific proapoptotic genes called p53 target genes. A growing number of p53 responsive genes have been identified and numerous studies have demonstrated that p53 proapoptotic factors such as Noxa, Puma and Perp play cell type specific roles in p53's mediated response to certain stimuli. Perp (p53 apoptosis effector related to PMP-22) is a direct proapoptotic target gene encoding a tetraspan protein. Perp is highly expressed in cells undergoing apoptosis compared to cells under G1 arrest and its overexpression is sufficient to cause cell death in fibroblasts. Noxa is another member of the preapoptotic p53 genes family. When expressed Noxa acts in a BH3 motif-dependent localization to mitochondria, causing structural changes, activation of caspase 9 and release of cytochrome c from mitochondria to cytosol. Puma (p53 mutant of apoptosis) is another critical mediator of p53-dependent apoptosis. P53 binds to Puma-promoter gene sites, leading to puma production. The mtCLIC, a member of intracellular chloride channels, is a cytoplasmic and mitochondrial protein positively regulated by p53. Caspase 10 is induced in p53-dependent manner leading to cellular apoptosis. Other newly announced factors are also involved in p53-regulated apoptosis such as brain-specific angiogenesis inhibitor-1 (BSAI1), MSOD and GPX genes. A global discussion on this topic is attempted in the present review article.