Diagnosis and investigation of suspected haemophagocytic lymphohistiocytosis in adults: 2023 Hyperinflammation and HLH Across Speciality Collaboration (HiHASC) consensus guideline

Haemophagocytic lymphohistiocytosis (HLH) is a hyperinflammatory syndrome characterised by persistently activated cytotoxic lymphocytes and macrophages, which, if untreated, leads to multiorgan dysfunction and death. HLH should be considered in any acutely unwell patient not responding to treatment as expected, with prompt assessment to look for what we term the three Fs-fever, falling blood counts, and raised ferritin. Worldwide, awareness of HLH and access to expert management remain inequitable. Terminology is not standardised, classification criteria are validated in specific patient groups only, and some guidelines rely on specialised and somewhat inaccessible tests. The consensus guideline described in this Health Policy was produced by a self-nominated working group from the UK network Hyperinflammation and HLH Across Speciality Collaboration (HiHASC), a multidisciplinary group of clinicians experienced in managing people with HLH. Combining literature review and experience gained from looking after patients with HLH, it provides a practical, structured approach for all health-care teams managing adult (>16 years) patients with possible HLH. The focus is on early recognition and diagnosis of HLH and parallel identification of the underlying cause. To ensure wide applicability, the use of inexpensive, readily available tests is prioritised, but the role of specialist investigations and their interpretation is also addressed.

P72 Research experience across the paediatric rheumatology multi-disciplinary team

Introduction/Background

Embedding research into clinical practice has many benefits, with research-active healthcare settings reporting better clinical outcomes and improved staff recruitment and retention. This is recognised by the NHS who aim to ‘build the capacity and capability of our current and future workforce to embrace and actively engage with research’. In spite of this, clinical academic capacity across the NHS remains challenging; the number of consultants working in clinical academia has declined in recent years and there is concern about lack of academic progression for non-medical professions. Reported barriers include clinical pressures and lack of dedicated time, individual skill and confidence.

Description/Method

Our aim was to gather information about research exposure across the Paediatric Rheumatology multidisciplinary team (MDT), including paediatric trainees (rheumatology grid, rheumatology spin and level 2 trainees), clinical nurse specialists (CNS), advanced nurse practitioners (ANPs) and Allied Health Professionals (AHPs).

We initially sought to identify if trainees were receiving adequate research opportunities during their training. A pilot questionnaire was distributed, and results collated and presented at the Spring Clinical Studies Group (CSG) annual meeting. Feedback was received from both questionnaire respondents and the CSG. Following this, we modified and broadened the scope of the questionnaire to include the Paediatric Rheumatology MDT, with the aim of comparing experiences across the MDT. This was developed using an online survey platform with the link distributed via email and messaging groups for trainees, AHPs and CNSs.

The aims of the modified questionnaire were to;

1. Understand the current research experience across the paediatric rheumatology MDT and identify barriers and ways to support participation in research.

2. Identify if individuals wanted more exposure to research and what specific research skills they would like to develop.

Discussion/Results

There were 34 respondents: 14 (41%) paediatric trainees (7 grid, 2 spin, 2 post-CCT fellows, 3 level-2 trainees), 14 (41%) CNS, 4 (12%) AHPs and 2(6%) ANPs.

Across the MDT, 19 respondents (56%) agreed they had adequate opportunity to be involved in research, of which 7 (21%) strongly agreed. In terms of research exposure, 22 (65%) have undertaken postgraduate degrees, 5 (15%) PhD, 9 (26%) MSc, 5 (15%) diploma and 6 (18%) postgraduate certificate. Eight-respondents (24%) had taken time out to develop research skills.

Research experience: 

18 respondents (53%) have been on the delegation-log for clinical trials. 20 (59%) have contributed to data collection for National Registries. 23 (68%) have given a poster/oral presentation at national/international conferences and 15 (44%) have published in peer-reviewed journals - the majority trainees (n = 11,73%).

Research training: 

51% report adequate training in critical appraisal, 48% in literature review and 40% in consent; fewer reported adequate training in designing research projects (21%), ethics applications (21%) and statistical analysis (23%).

Further training would be desirable in:

• designing research projects (68%);

• discussing research with patients (65%);

• statistical analysis (49%);

• critical appraisal (40%);

• literature search (37%).

Future research involvement: 

94% would like more opportunities to be involved in research. In the future, 63% would like allocated research time, 6% to be mainly academic (1 CNS, 1 trainee) and 12% to be full-time clinical (1 spin, 1 level-2 trainee, 2 CNS).

Barriers to research: 

Free text answers were used to gather information and common themes identified included lack of:

• time/heavy clinical commitment (60%);

• supervision/support from seniors (9%);

• local resources (9%);

• research funding (9%);

• awareness of projects (12%);

• research skills (9%).

Encourage participation in research: 

Common suggestions included:

• protected research time during training/career (35%);

• further research training (21%);

• earlier awareness of projects/trials (18%);

• Increased support from more experienced colleagues (15%);

• improved collaboration/networking (12%).

Key learning points/Conclusion

This survey provides an interesting insight into the research experience throughout the Paediatric Rheumatology MDT.

It is encouraging that within the Rheumatology MDT 56% of respondents reported that they have had adequate opportunities to be involved in research and the majority have presented or published their research. However, 94% have reported they would like more opportunities to be involved in research. Lack of time was reported as the most common barrier to research involvement; this finding is consistent with the British Society for Rheumatology’s 2019 ‘Paediatric State of Play’ report. Additionally, significant numbers report they would like further training in research skills. Academic writing for publication was noted as a particular area of concern for nurses and AHPs.

We advocate for further research opportunities throughout the MDT. For Rheumatology trainees, it was suggested that research skills be incorporated into the curriculum, with dedicated time allocated to gain experience and contribute to research. All members of the MDT may benefit from research skills training courses, although this would need to be carefully considered, given lack of time and resources were common barriers reported by respondents. Several professionals reported lack of support or supervision from seniors and suggested the benefit of mentoring networks.

A weakness of this study is the relatively low number of respondents; the survey remains open and we intend to collect further data to maximise representation across the MDT. Additionally, there is potential bias, with individuals with a research interest possibly more likely to contribute, meaning research experience may be over-represented by this sample of the MDT. Also, representation from AHPs was limited compared to paediatric trainees and CNS.

Further work is needed to understand research experience across the MDT, however this initial survey is a valuable first step in encouraging discussion of MDT participation in research.

P40 Dry eyes and a dry mouth: is it Sjögren’s syndrome?

Introduction/Background

Sjögren's syndrome (SS) is a rare, multi-system, autoimmune disease characterised by immune-mediated inflammation and damage to salivary and lacrimal glands causing ‘sicca symptoms’ (dry eyes and mouth). There is a female predominance, and the median age of disease onset is 10 years, although the diagnosis is often delayed. Sicca symptoms are unusual in children presenting to primary or secondary care, and their presence may lead to referral to Paediatric Rheumatology with concerns about SS. Here we report two cases of children with dry eyes and mouth but without other features typical of SS.

Description/Method

Case 1: A 16-month-old boy was referred to Paediatric Rheumatology with a history of dry eyes from infancy and a dry mouth. Previous Ophthalmology assessment showed blocked tear ducts. At age 14 months, dental review showed an unusually dry mouth. He was otherwise well with no history of rashes, joint pain or swelling. Examination was normal apart from mild eczema and particularly no obvious salivary gland enlargement. Initial blood tests showed a mild microcytic anaemia and raised erythrocyte sedimentation rate (ESR) at 24. Anti-nuclear antibodies (ANA), rheumatoid factor (RF) and antibodies against expressed nuclear antigens (ENA) were all negative. Salivary gland ultrasound was challenging but was reported as showing heterogenous parenchyma with numerous small hypoechoic/anechoic areas, suggestive of SS. Biopsy of this area did not show salivary gland tissue. A subsequent MRI showed absent parotid, submandibular and lacrimal glands.

Case 2: A 12-year-old boy was referred to Paediatric Rheumatology after previously presenting to General Paediatrics at the age of 8 years with a history of a dry mouth, dry eyes and thick nasal secretions. He suffered with angular cheilitis, mouth ulcers, phimosis and recurrent balanitis. Due to a history of dysphagia, he had previously been referred to Paediatric Gastroenterology who had diagnosed eosinophilic oesophagitis based on endoscopy findings and histology. On Rheumatology assessment, there was no history of rashes or joint symptoms, and examination revealed normal joints and no enlargement of his parotid glands. Other than a microcytic anaemia, blood tests were normal including ESR, negative ANA, RF and ENA. Ultrasound showed absent parotid and submandibular glands bilaterally.

Discussion/Results

Both these boys presented with a history of dry eyes and a dry mouth but without other features of an inflammatory or autoimmune disease, and with negative autoantibodies. In Case 1, the salivary gland ultrasound was unexpectedly reported as showing some features of SS. Further investigation was felt to be necessary in light of his age, sex and unusual presentation, and was essential in making his diagnosis. On the basis of the MRI scan, he was diagnosed with congenital absence of salivary and lacrimal glands. This condition has been associated with variants in the fibroblast-growth factor 10 (FGF10) gene, and he was referred to Clinical Genetics for further evaluation. Analysis showed a novel variant, but it was unclear if this was pathogenic. Further genetic testing of his parents is awaited.

In Case 2, the ultrasound findings rapidly led to the diagnosis of congenital absence of salivary and lacrimal glands. He is awaiting an MRI scan to confirm the ultrasound findings. It is interesting that he presented with thick secretions, as opposed to absent secretions, and this may potentially explain his swallowing difficulties. Other conditions that lead to thick secretions such as cystic fibrosis and ciliary dyskinesia were considered but thought to be unlikely in light of his lack of respiratory symptoms.

These cases illustrate some of the challenges in the diagnostic process for rare diseases. The very early age of onset in Case 1 argued against SS and for a congenital disease, however the ultrasound imaging findings prompted further investigation. In Case 2, although the symptom onset was at an older age, the ultrasound findings of absent salivary glands pointed to the diagnosis of congenital absence of these glands.

Key learning points/Conclusion

There are no validated diagnostic criteria for childhood SS. The American College of Rheumatology (ACR) and European League Against Rheumatism (EULAR) published classification criteria for SS in 2016 which include the following features: histopathologic evidence of focal lymphocytic sialadenitis on minor salivary gland biopsy; positive anti-SS-A/Ro antibodies; evidence of glandular dysfunction with decreased tear or saliva production. Referrals to Paediatric Rheumatology of a child with dry eyes and a dry mouth are relatively rare, but the priority is to diagnose or exclude SS.

An important differential diagnosis of SS is congenital absence of salivary and lacrimal glands. Features pointing to this diagnosis include a young age at symptom onset, absence of parotid gland swelling, absence of systemic symptoms and signs of autoimmune disease, and negative autoantibodies. Imaging with ultrasound or MRI confirms the diagnosis.

Some cases of congenital absence of salivary and lacrimal glands have been found to be associated with pathogenic variants in the FGF10 gene. In this situation, the disease is known as aplasia of the lacrimal and salivary glands (ALSG; OMIM #180920). It is inherited in an autosomal dominant pattern with variable expressivity. If ALSG is suspected, referral to Clinical Genetics is recommended for testing and family counselling.

Management of patients with congenital absence of salivary and lacrimal glands is supportive and includes lubricating eye drops and attention to dental hygiene, with follow-up by an optician/ophthalmologist and dentist. Early recognition of the condition by Paediatric Rheumatologists can help to avoid excessive investigation and unnecessary immunosuppression.

P171 Reasons for stopping biologic and non-biologic disease-modifying treatments in children and young people managed by a tertiary paediatric rheumatology centre

Background/Aims

The Paediatric Rheumatology Department at Newcastle upon Tyne Hospitals looks after children and young people (CYP) across the North East and Cumbria region. The centre treats around 220 patients (250 active prescriptions) using homecare services to deliver injectable medicines. These prescriptions are for five medicines: methotrexate, adalimumab, anakinra, tocilizumab and etanercept. This project aimed to analyse the reasons treatments were stopped and identify potentially-modifiable factors to optimise treatment.

Methods

Patients were identified from the departmental database. Cases were included if they stopped one of the 5 subcutaneous treatments during the period 1st July 2020 to 30th June 2021. Demographic details, the underlying diagnoses and reasons for stopping treatment were extracted from electronic patient records.

Results

During the 12-month period analysed, 109 prescriptions were stopped. This represented 104 unique patients (56% female). The commonest indications for treatment were juvenile idiopathic arthritis in 80% (87/109), idiopathic uveitis in 11% (12/109) and autoinflammatory diseases in 5.5% (6/109). The following treatments were stopped: methotrexate in 47 patients, adalimumab in 43, etanercept in 7, tocilizumab in 6 and anakinra in 6. The reasons for stopping prescriptions are shown in Table 1.

After excluding 17 cases whose prescriptions were taken over by another unit, 92 prescriptions were stopped for clinical reasons. Of these, 28% were stopped due to side effects. All 19 patients who suffered nausea or vomiting, and all 5 patients with abnormal liver function tests, were receiving methotrexate. The 2 patients who stopped treatment due to neutropenia were both receiving tocilizumab. Almost 23% (21/92) of prescriptions were stopped due to inefficacy. All cases were switched to another biologic drug.

Conclusion

A substantial proportion of subcutaneous disease-modifying treatments were stopped due to inefficacy or side effects. Stopping and switching treatments represents a period of uncertainty for CYP and their families, with potential impact on disease control and quality of life. Management could be improved by a stratified medicine approach, using biomarkers to predict patients at highest risk of side effects or most likely to respond to a particular treatment. This is a key aim of current research.

Disclosure

K. Hartley: None. E.S. Sen: None.

A validation study of the identification of haemophagocytic lymphohistiocytosis in England using population-based health data

We assessed the validity of coded healthcare data to identify cases of haemophagocytic lymphohistiocytosis (HLH). Hospital Episode Statistics (HES) identified 127 cases within five hospital Trusts 2013-2018 using ICD-10 codes D76.1, D76.2 and D76.3. Hospital records were reviewed to validate diagnoses. Out of 74 patients, 73 were coded D76.1 or D76.2 (positive predictive value 89·0% [95% Confidence Interval {CI} 80·2-94·9%]) with confirmed/probable HLH. For cases considered not HLH, 44/53 were coded D76.3 (negative predictive value 97·8% [95% CI 88·2-99·9%]). D76.1 or D76.2 had 68% sensitivity in detecting HLH compared to an established active case-finding HLH register in Sheffield. Office for National Statistics (ONS) mortality data (2003-2018) identified 698 patients coded D76.1, D76.2 and D76.3 on death certificates. Five hundred and forty-one were coded D76.1 or D76.2 of whom 524 (96·9%) had HLH in the free-text cause of death. Of 157 coded D76.3, 66 (42·0%) had HLH in free text. D76.1 and D76.2 codes reliably identify HLH cases, and provide a lower bound on incidence. Non-concordance between D76.3 and HLH excludes D76.3 as an ascertainment source from HES. Our results suggest electronic healthcare data in England can enable population-wide registration and analysis of HLH for future research.

Advancing the treatment of juvenile idiopathic arthritis

Treatment for juvenile idiopathic arthritis has undergone substantial changes in recent decades. These changes are partly due to the availability of new treatments, mainly biological agents, as well as developments in treatment strategies, including a focus on concepts such as treat-to-target. In addition, the creation of large paediatric research networks has improved patient access to, and design of, clinical trials for rare paediatric diseases. Although these advances have resulted in improvements in care for most patients with juvenile idiopathic arthritis, certain subgroups of patients continue to have a poor prognosis. Further research aims to identify patients in these subgroups early, to personalise their care, improve functional outcomes, and minimise long-term damage and harm. Optimising the duration of therapy for those individuals who require systemic immunosuppression is also of importance. Incorporation of novel biomarkers in combination with validated clinical measures in an effort to predict outcomes and target therapy accordingly is an exciting development.

Macrophage Activation Syndrome in Children: Diagnosis and Management

Macrophage activation syndrome is a severe yet under-recognized complication encountered in pediatric rheumatology. It manifests as secondary hemophagocytic lymphohistiocytosis leading to a hyper-inflammatory state resulting from an underlying cytokine storm. If unchecked, it may lead to multiorgan failure and mortality. Early diagnosis and timely initiation of specific therapy is pivotal for a successful outcome. This review outlines the key clinical and laboratory features and management of macrophage activation syndrome.

Response to First Course of Intensified Immunosuppression in Genetically Stratified Steroid Resistant Nephrotic Syndrome

BACKGROUND AND OBJECTIVES

Intensified immunosuppression in steroid-resistant nephrotic syndrome is broadly applied, with disparate outcomes. This review of patients from the United Kingdom National Study of Nephrotic Syndrome cohort aimed to improve disease stratification by determining, in comprehensively genetically screened patients with steroid-resistant nephrotic syndrome, if there is an association between response to initial intensified immunosuppression and disease progression and/or post-transplant recurrence.

DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS

Pediatric patients with steroid-resistant nephrotic syndrome were recruited via the UK National Registry of Rare Kidney Diseases. All patients were whole-genome sequenced, whole-exome sequenced, or steroid-resistant nephrotic syndrome gene-panel sequenced. Complete response or partial response within 6 months of starting intensified immunosuppression was ascertained using laboratory data. Response to intensified immunosuppression and outcomes were analyzed according to genetic testing results, pattern of steroid resistance, and first biopsy findings.

RESULTS

Of 271 patients, 178 (92 males, median onset age 4.7 years) received intensified immunosuppression with response available. A total of 4% of patients with monogenic disease showed complete response, compared with 25% of genetic-testing-negative patients (P=0.02). None of the former recurred post-transplantation. In genetic-testing-negative patients, 97% with complete response to first intensified immunosuppression did not progress, whereas 44% of nonresponders developed kidney failure with 73% recurrence post-transplant. Secondary steroid resistance had a higher complete response rate than primary/presumed resistance (43% versus 23%; P=0.001). The highest complete response rate in secondary steroid resistance was to rituximab (64%). Biopsy results showed no correlation with intensified immunosuppression response or outcome.

CONCLUSIONS

Patients with monogenic steroid-resistant nephrotic syndrome had a poor therapeutic response and no post-transplant recurrence. In genetic-testing-negative patients, there was an association between response to first intensified immunosuppression and long-term outcome. Patients with complete response rarely progressed to kidney failure, whereas nonresponders had poor kidney survival and a high post-transplant recurrence rate. Patients with secondary steroid resistance were more likely to respond, particularly to rituximab.

P23 Establishment of a cross-specialty collaboration and national registry to enable research and improve management of haemophagocytic lymphohistiocytosis/macrophage activation syndrome

Poster presentation Tuesday 8 October

Background

Haemophagocytic lymphohistiocytosis (HLH)/macrophage activation syndrome (MAS) is a hyperinflammatory syndrome which can complicate sepsis, malignancy or autoimmune/autoinflammatory disease, potentially leading to critical illness and death at all ages. A previous service evaluation of children with ferritin > 10,000 μg/L, which is highly specific for HLH/MAS, reported mortality of 33% and in 44% there was no documented evidence that HLH had been considered by clinicians. The condition may present to generalists, specialists and intensivists and prompt recognition and treatment can be life-saving. A consensus for the management of HLH in older children and adults has not been defined. The aim of this ongoing project is to identify current practice and improve the evidence-base for diagnosis and treatment of HLH.

Methods

A national cross-specialty group was established in June 2018 including paediatric and adult specialists in rheumatology, haematology, oncology, immunology, infectious diseases, virology, nephrology and intensive care. Clinicians, scientists, pharmacists and data management experts have been incorporated. The group, which numbers over 50 professionals, has met on three occasions to set clinical and research priorities and is supported by Histiocytosis UK, a charity representing patients with HLH.

Results

The group agreed these priorities: To complete a retrospective service evaluation of adult patients with ferritin > 10,000 μg/L identified over a 3-year period using a standardised proforma established in the previous paediatric cohort [provisionally, this has identified over 200 adults with a mortality rate of 39%]To provide education to clinicians across the UK to improve recognition of HLH [in progress]To develop guidance for investigation of suspected HLH [in progress]To link local multi-specialty teams experienced in managing HLH to create a national network [in progress]To conduct a retrospective, observational study of the use and outcomes of anakinra treatment in HLHTo establish a national registry for HLH as part of the UK Histiocytosis Registry (UKHR) using the REDCap online portal for data collection.

Patients with definite and probable HLH, including those with MAS secondary to rheumatological conditions, will be eligible for recruitment.

Baseline demographic and clinical data, investigations which contribute to the HLH 2004 criteria and H score, and underlying diagnoses will constitute a minimal dataset. Treatments, and responses, and long-term follow-up data will be recorded. In addition to data collection, with the appropriate consents, biological samples will be available for genetic and histopathological analysis and cellular samples for in vitro studies.

Conclusion

HLH/MAS is an under-recognised condition with high mortality. A national cross-specialty, all-age collaboration has established priorities to improve clinical care and advance research. Development of a registry, with collection of biological samples, will facilitate investigation of disease pathogenesis and help to stratify patients with a view to future clinical trials.

Conflicts of Interest

The authors declare no conflicts of interest.

Juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis (JIA) is the commonest rheumatic disease in children and JIA-associated uveitis its most frequent extra-articular manifestation. The uveitis is potentially sight-threatening and thus carries a considerable risk of morbidity with associated reduction in quality of life. The commonest form of uveitis seen in association with JIA is chronic anterior uveitis, which is almost always asymptomatic in the initial stages. Therefore, screening for JIA-associated uveitis in at-risk patients is essential. The aim of early detection and treatment is to minimise intraocular inflammation and to avoid complications that lead to visual loss, which can result from both disease activity and medications. The sight-threatening complications of JIA-associated uveitis include cataracts, glaucoma, band keratopathy, and macular oedema. There is increasing evidence for the early introduction of systemic immunosuppressive therapies to reduce topical and systemic use of glucocorticoids. A recently published randomised controlled trial of adalimumab in JIA-associated uveitis now provides convincing evidence for the use of this biologic in patients who fail to respond adequately to methotrexate. Tocilizumab and abatacept are being investigated as alternatives in children inadequately treated with anti-tumour necrosis factor drugs.

Clinical genetic testing using a custom-designed steroid-resistant nephrotic syndrome gene panel: analysis and recommendations

BACKGROUND

There are many single-gene causes of steroid-resistant nephrotic syndrome (SRNS) and the list continues to grow rapidly. Prompt comprehensive diagnostic testing is key to realising the clinical benefits of a genetic diagnosis. This report describes a bespoke-designed, targeted next-generation sequencing (NGS) diagnostic gene panel assay to detect variants in 37 genes including the ability to identify copy number variants (CNVs).

METHODS

This study reports results of 302 patients referred for SRNS diagnostic gene panel analysis. Phenotype and clinical impact data were collected using a standard proforma. Candidate variants detected by NGS were confirmed by Sanger sequencing/Multiplex Ligation-dependent Probe Amplification with subsequent family segregation analysis where possible.

RESULTS

Clinical presentation was nephrotic syndrome in 267 patients and suspected Alport syndrome (AS) in 35. NGS panel testing determined a likely genetic cause of disease in 44/220 (20.0%) paediatric and 10/47 (21.3%) adult nephrotic cases, and 17/35 (48.6%) of haematuria/AS patients. Of 71 patients with genetic disease, 32 had novel pathogenic variants without a previous disease association including two with deletions of one or more exons of NPHS1 or NPHS2.

CONCLUSION

Gene panel testing provides a genetic diagnosis in a significant number of patients presenting with SRNS or suspected AS. It should be undertaken at an early stage of the care pathway and include the ability to detect CNVs as an emerging mechanism for genes associated with this condition. Use of clinical genetic testing after diagnosis of SRNS has the potential to stratify patients and assist decision-making regarding management.

Cross sectional, qualitative thematic analysis of patient perspectives of disease impact in juvenile idiopathic arthritis-associated uveitis

BACKGROUND

Chronic health conditions in children can have a significant impact on their quality of life. The aim of this study was to explore the subjective experience of children and young people being treated for chronic, non-infectious uveitis associated with a systemic disease such as juvenile idiopathic arthritis.

METHODS

A semi-structured interview was conducted with 10 children and young people aged between 6 and 18 years of age and their parents.

RESULTS

Preliminary thematic analysis indicated that both the treatment and complications of the disorder have a significant impact on the quality of life and emotional well-being of patients, not only in terms of the discomfort experienced but also in perceptions of social isolation, anxiety and sense of injustice.

CONCLUSION

This study shows that themes including "impact on school", "social factors" and "emotional reactions" are important domains influencing health-related quality of life (HRQoL) in children with chronic uveitis. Inclusion of questions relating to these domains should be considered in future uveitis-specific tools examining HRQoL in these patients.

Diagnosing haemophagocytic syndrome

Haemophagocytic syndrome, or haemophagocytic lymphohistiocytosis (HLH), is a hyperinflammatory disorder characterised by uncontrolled activation of the immune system. It can result from mutations in multiple genes involved in cytotoxicity or occur secondary to a range of infections, malignancies or autoimmune rheumatic diseases. In the latter case, it is also known as macrophage activation syndrome (MAS). Characteristic features are persistent fever, hepatosplenomegaly, petechial/purpuric rash, progressive cytopenias, coagulopathy, transaminitis, raised C reactive protein, falling erythrocyte sedimentation rate, hypertriglyceridaemia, hypofibrinogenaemia and extreme hyperferritinaemia often associated with multi-organ impairment. Distinguishing HLH from systemic sepsis can present a major challenge. Criteria for diagnosis and classification of HLH and MAS are available and a serum ferritin >10 000 µg/L is strongly supportive of HLH. Without early recognition and appropriate treatment, HLH is almost universally fatal. However, with prompt referral and advancements in treatment over the past two decades, outcomes have greatly improved.

Genomic and clinical profiling of a national nephrotic syndrome cohort advocates a precision medicine approach to disease management

Steroid Resistant Nephrotic Syndrome (SRNS) in children and young adults has differing etiologies with monogenic disease accounting for 2.9-30% in selected series. Using whole exome sequencing we sought to stratify a national population of children with SRNS into monogenic and non-monogenic forms, and further define those groups by detailed phenotypic analysis. Pediatric patients with SRNS were identified via a national United Kingdom Renal Registry. Whole exome sequencing was performed on 187 patients, of which 12% have a positive family history with a focus on the 53 genes currently known to be associated with nephrotic syndrome. Genetic findings were correlated with individual case disease characteristics. Disease causing variants were detected in 26.2% of patients. Most often this occurred in the three most common SRNS-associated genes: NPHS1, NPHS2, and WT1 but also in 14 other genes. The genotype did not always correlate with expected phenotype since mutations in OCRL, COL4A3, and DGKE associated with specific syndromes were detected in patients with isolated renal disease. Analysis by primary/presumed compared with secondary steroid resistance found 30.8% monogenic disease in primary compared with none in secondary SRNS permitting further mechanistic stratification. Genetic SRNS progressed faster to end stage renal failure, with no documented disease recurrence post-transplantation within this cohort. Primary steroid resistance in which no gene mutation was identified had a 47.8% risk of recurrence. In this unbiased pediatric population, whole exome sequencing allowed screening of all current candidate genes. Thus, deep phenotyping combined with whole exome sequencing is an effective tool for early identification of SRNS etiology, yielding an evidence-based algorithm for clinical management.

Juvenile idiopathic arthritis-associated uveitis

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease of childhood, with JIA-associated uveitis its most common extra-articular manifestation. JIA-associated uveitis is a potentially sight-threatening condition and thus carries a considerable risk of morbidity. The aetiology of the condition is autoimmune in nature with the predominant involvement of CD4(+) T cells. However, the underlying pathogenic mechanisms remain unclear, particularly regarding interplay between genetic and environmental factors. JIA-associated uveitis comes in several forms, but the most common presentation is of the chronic anterior uveitis type. This condition is usually asymptomatic and thus screening for JIA-associated uveitis in at-risk patients is paramount. Early detection and treatment aims to stop inflammation and prevent the development of complications leading to visual loss, which can occur due to both active disease and burden of disease treatment. Visually disabling complications of JIA-associated uveitis include cataracts, glaucoma, band keratopathy and macular oedema. There is a growing body of evidence for the early introduction of systemic immunosuppressive therapies in order to reduce topical and systemic glucocorticoid use. This includes more traditional treatments, such as methotrexate, as well as newer biological therapies. This review highlights the epidemiology of JIA-associated uveitis, the underlying pathogenesis and how affected patients may present. The current guidelines and criteria for screening, diagnosis and monitoring are discussed along with approaches to management.

The child with joint pain in primary care

Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of 'rheumatological/autoimmune disease screen' in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.

Republished: new age of biological therapies in paediatric rheumatology

Many paediatric rheumatic diseases result from the abnormal activation or control of the immune system. Biologic drugs, which are synthesised within a biological system, have been designed to target specific molecules involved in cytokine signalling or cell-cell interactions. The past 15 years have seen a revolution in the range of effective treatments for rheumatic diseases, particularly juvenile idiopathic arthritis (JIA). As a result, the target of inactive disease and minimal long-term disease-associated damage is increasingly becoming achievable. In this article we review evidence from recent trials of the use of biologic drugs in the treatment of systemic JIA, juvenile dermatomyositis and juvenile systemic lupus erythematosus. We also highlight novel agents currently undergoing investigation which may broaden our therapeutic armamentarium over the coming decade. Key to these developments are well-designed multicentre controlled clinical trials and long-term safety monitoring as part of international drug registries.

How to use antistreptolysin O titre

Group A streptococcus (GAS) is the cause of a wide range of acute suppurative and, following a latent period, non-suppurative diseases such as rheumatic fever and poststreptococcal glomerulonephritis. Diagnosis of the latter group requires evidence of preceding GAS infection. The bacteria produce a range of extracellular antigens, including streptolysin O, which induce an antibody response in the host. A rise in antistreptolysin O titre (ASOT) is indicative of preceding GAS infection. In clinical practice, often only a single ASOT measurement is available and its timing in relation to a possible GAS infection is unknown. Interpretation of the result in this context is liable to misdiagnosis. In order to optimise diagnosis of preceding GAS infection, at least two sequential ASOT measurements, together with simultaneous assay for anti-DNase B, a second antistreptococcal antibody, is recommended.

Assessment of musculoskeletal abnormalities in children with mucopolysaccharidoses using pGALS

BACKGROUND

Children with mucopolysaccharidoses (MPS) often have musculoskeletal (MSK) abnormalities. Paediatric Gait, Arms, Legs, and Spine (pGALS), is a simple MSK assessment validated in school-age children to detect abnormal joints. We aimed to identify MSK abnormalities in children with MPS performing pGALS.

METHODS

Videos of children with a spectrum of MPS performing pGALS were analysed. A piloted proforma to record abnormalities for each pGALS manoeuvre observed in the videos (scored as normal/abnormal/not assessable) was used by three observers blinded to MPS subtype. Videos were scored independently and rescored for intra- and inter-observer consistency. Data were pooled and analysed.

RESULTS

Eighteen videos of children [12 boys, 6 girls, median age 11 years (4-19)] with MPS (13 type I [5 Hurler, 8 attenuated type I]; 4 type II; 1 mannosidosis) were assessed. The most common abnormalities detected using pGALS were restrictions of the shoulder, elbow, wrist, jaw (>75% cases), and fingers (2/3 cases). Mean intra-observer Κ 0.74 (range 0.65-0.88) and inter-observer Κ 0.62 (range 0.51-0.77). Hip manoeuvres were not clearly demonstrated in the videos.

CONCLUSIONS

In this observational study, pGALS identifies MSK abnormalities in children with MPS. Restricted joint movement (especially upper limb) was a consistent finding. Future work includes pGALS assessment of the hip and testing pGALS in further children with attenuated MPS type I. The use of pGALS and awareness of patterns of joint involvement may be a useful adjunct to facilitate earlier recognition of these rare conditions and ultimately access to specialist care.

New age of biological therapies in paediatric rheumatology

Many paediatric rheumatic diseases result from the abnormal activation or control of the immune system. Biologic drugs, which are synthesised within a biological system, have been designed to target specific molecules involved in cytokine signalling or cell-cell interactions. The past 15 years have seen a revolution in the range of effective treatments for rheumatic diseases, particularly juvenile idiopathic arthritis (JIA). As a result, the target of inactive disease and minimal long-term disease-associated damage is increasingly becoming achievable. In this article we review evidence from recent trials of the use of biologic drugs in the treatment of systemic JIA, juvenile dermatomyositis and juvenile systemic lupus erythematosus. We also highlight novel agents currently undergoing investigation which may broaden our therapeutic armamentarium over the coming decade. Key to these developments are well-designed multicentre controlled clinical trials and long-term safety monitoring as part of international drug registries.

The safety and efficacy of noncorticosteroid triple immunosuppressive therapy in the treatment of refractory chronic noninfectious uveitis in childhood

OBJECTIVE

To assess the safety and efficacy of noncorticosteroid triple immunosuppressive therapy in the treatment of refractory chronic noninfectious childhood uveitis.

METHODS

Subjects were retrospectively selected from a database. Patients were included if they were diagnosed with chronic, noninfectious uveitis at 16 years of age or under and treated with triple immunosuppressive therapy for at least 6 months (following failure of a combination of 2 immunosuppressants). Patient demographics, diagnoses, duration of uveitis, drug dosages, active joint inflammation, and ophthalmologic data were recorded. Efficacy outcomes for triple therapy were recorded at 6 months.

RESULTS

Thirteen patients with bilateral uveitis were included. Using Standardized Uveitis Nomenclature (SUN) criteria, at 6 months only 11 eyes (42%) had a 2-step improvement in anterior chamber cell inflammation (n = 26). In addition, 2 patients required additional oral corticosteroid treatment. There were 4 significant infectious adverse events during a total of 21.9 patient-years (PY) on triple therapy (0.18 events per PY).

CONCLUSION

In this group of children with refractory uveitis, addition of a third immunosuppressive agent did not confer substantial benefit in redressing ocular inflammation and was associated with significant infections in a minority of patients.

Too cold for comfort: a neonate with severe hypothermia

Severe neonatal hypothermia is an infrequent presentation to the Emergency Department. This case report describes the successful resuscitation and rapid rewarming of a newborn baby who presented to the Emergency Department with a core temperature of 14.8°C. This is the lowest temperature documented in the literature to date from which an infant has been successfully resuscitated.

Treatment of primary angiitis of the central nervous system in childhood with mycophenolate mofetil

OBJECTIVE

To assess the use of mycophenolate mofetil (MMF) in the treatment of refractory primary angiitis of the CNS in childhood (cPACNS).

METHODS

A retrospective chart review was performed in patients with cPACNS who were treated with MMF following failure of a combination of corticosteroids and another immunosuppressant.

RESULTS

Three patients from two centres were included in this study. The age of onset of disease was 5, 6 and 9 years. All the patients improved when treated with MMF, such that the dose of corticosteroids could be weaned or stopped.

CONCLUSIONS

MMF should be considered for maintenance treatment in the management of patients with cPACNS refractory to the combination of corticosteroids and first-line immunosuppressive agents.

[Human leukocyte antigens A and B in Turkish patients with sarcoidosis]

OBJECTIVE

Associations between human leukocyte antigens (HLA) and sarcoidosis have been reported in several studies. We aimed to investigate these associations in Turkish patients.

PATIENTS AND METHOD

We performed HLA-A, HLA-B, HLA-C, and HLA-D typing in 83 patients with sarcoidosis and in 250 healthy controls using a microlymphocytotoxicity method to investigate genetic susceptibility to the disease.

RESULTS

Because of significant violation of Hardy-Weinberg equilibrium at HLA-C and HLA-DQB1 loci, only results obtained at other HLA loci were used. Although HLA-A9, HLA-B5, and HLA-B8 allele frequencies were significantly higher in the patient group compared to the controls (odds ratio [OR]= 21.8, P= .015; OR= 9.34, P= .049; OR= 2.26, P= .031, respectively), none of the differences remained significant after applying the Bonferroni correction. HLA-A24, HLA-A26, and HLA-B62 alleles were significantly less frequent in the patient group compared to the controls (OR= 0.48, P= .018; OR= 0.19, P= .003; OR= 0.11, P= .044, respectively). However, the differences also failed to remain significant after Bonferroni correction.

CONCLUSIONS

These results suggest that both HLA may play significant roles (either increasing or reducing risk) in the pathogenesis of sarcoidosis and in its distinct clinical forms and laboratory findings.