Kawarabi: Administrative Structuring of a Multicenter Research Collaborative to Study Kawasaki Disease in the Arab Countries

Kawasaki disease (KD), the leading cause of acquired heart disease in children in developed countries, merits conducting detailed studies in Arab countries. We introduce Kawarabi, as a multicenter research collaborative effort dedicated to improving diagnosis, care, and outcome of children and adults with KD in the Arab world. During the COVID-19 pandemic, there emerged a new multisystem inflammatory syndrome in children; a disease similar to KD. This highlighted the challenges that Arab physicians face in diagnosing and managing children with KD and KD-like illnesses. Kawarabi brings together experts in North America and Arab nations to study this family of diseases in a not-for-profit, voluntary scientific collaborative setting. Bylaws addressing the vision, objectives, structure, and governance of Kawarabi were established, and vetted by the 45 organizing members in 2021. An initial scientific publication showed evidence of a decreased level of awareness of the disease in the general population, as well as the lack of access to resources available for physicians caring for children with KD in Arab countries. Kawarabi has since held several educational webinars and an inaugural yearly meeting. The groundwork for future initiatives targeted at increasing awareness and understanding of the management and the long-term outcomes of children with KD in the region was established. Data on KD in the Arab world are lacking. Kawarabi is a multicenter research collaborative organization that has the unique resources, diversified ethnic makeup, and energy, to accomplish significant advances in our understanding and management of KD and its variants.

Efficacy of Anakinra Treatment in two Moroccan Patients With Mevalonate Kinase Deficiency

Mevalonate kinase deficiency (MKD) is a rare hereditary autoinflammatory disease, with a widely variable clinical spectrum. It is characterized by febrile recurrent episodes and systemic inflammation. Data on therapeutic options for MKD are still limited and remain unknown in our country. We report Moroccan cases with MKD referred in our unit and treated with Anakinra, an interleukin-1 receptor antagonist. Through this study, we evaluate the efficacy of this bioagent, in our 2 MKD patients, in whom Anakinra has shown a complete clinical remission, with a remaining mild inflammation for one case, and normalization of growth with rare episodes of cervical adenopathies for the second case. Our experience provides an additional argument supporting the efficacy of Anakinra treatment, demonstrated previously but still lacks of objective data.

Disease evolution in systemic juvenile idiopathic arthritis: an international, observational cohort study through JIRcohort

BACKGROUND

Systemic juvenile idiopathic arthritis (systemic JIA) is a severe disease with both systemic and joint inflammation. This study aims to identify predictors of disease evolution within the systemic JIA population enrolled in the Juvenile Inflammatory Rheumatism cohort (JIRcohort).

METHODS

Observational patient cohort study with 201 recruited children from 4 countries (3 European, 1 North Africa) from 2005 until 2019, using retrospectively (2005-2015) and prospectively (2015-2019) routine care collected data.

RESULTS

Sixty-five patients with complete follow-up data for 24 months after first diagnosis were classified as monophasic (n = 23), polyphasic (n = 6) or persistent group (n = 36) corresponding to their evolution (unique flare, recurrent flares, or persistent disease activity respectively). The patients of the persistent group were more likely to have an earlier disease onset, before the age of 6 (OR 2.57, 95%-CI 0.70-9.46), persistence of arthritis at 12-months post-diagnosis (OR 4.45, 95%-CI 0.58-34.20) and higher use of synthetic DMARD (sDMARD, OR 5.28, 95%-CI 1.39-20.01). Other variables like global assessment by physician and by patient and C Reactive Protein levels at 12-months post-diagnosis were assessed but without any predictive value after adjusting for confounding factors.

CONCLUSIONS

Our results suggest that the earlier disease onset, the persistence of arthritis throughout the first year of disease evolution and the need of sDMARD might predict a persistent disease course.

Factors associated with poor prognosis of hip arthritis in juvenile idiopathic arthritis: Data from the JIR cohort

OBJECTIVES

Hip involvement remains a predictor of severe juvenile idiopathic arthritis (JIA) course and carries a high risk of disability. This study aims to determine the factors of poor prognosis of hip involvement in patients with JIA and to assess the treatment response.

METHODS

This is a multicenter observational cohort study. Patients were selected from the JIR Cohort database. Hip involvement was defined as clinically suspected and confirmed by an imaging tool. Follow-up data were collected during 5 years.

RESULTS

Among the 2223 patients with JIA, 341(15%) patients had hip arthritis. Male gender, enthesitis-related arthritis, and North African origin were factors associated with hip arthritis. Hip inflammation was associated with disease activity parameters during the first year, particularly Physician Global Assessment, joint count, and inflammatory marks. Structural hip progression was associated with early onset of the disease, a longer time to diagnosis, geographic origin, and JIA subtypes. Anti-TNF therapy was found to be the only treatment able to effectively reduce structural damage progression.

CONCLUSION

The early onset diagnostic delay, origin, and systemic subtype of JIA predict a poor prognosis of hip arthritis in children with JIA. The use of anti-TNF was associated with a better structural prognosis.

Access to Care and Therapy for Kawasaki Disease in the Arab Countries: A Kawasaki Disease Arab Initiative (Kawarabi) Multicenter Survey

Kawasaki Disease (KD) is still the most common acquired heart disease in children below the age of five years; it has been well described in the developed world; however, data from the Arab world are limited to case reports or single-center case series. In an effort of optimizing KD research in the Arab world, a group of physicians and researchers established the KD Arab Initiative (Kawarabi) in 2021, and published the first survey, which showed disparities in the availability of intravenous immunoglobulin (IVIG); this had prompted Kawarabi to assess the access to care and therapy of KD patients in Arab countries. A 32 structured questions survey was conducted in thirteen Arab countries and addressed KD patients' access to healthcare in urban and rural settings. The survey results showed that access to care was uniform across large, mid-size cities and rural areas in 7/13 (54%) countries, while in 6/13 (46%) countries, it was in favor of large and mid-size cities over rural areas. The quality of medical services received by children with KD in large cities was rated as excellent in 6/13 or good in 7/13 countries compared to fair in 4/13 or poor in 4/13 countries in rural areas. Availability of IVIG was limited (23%) in mid-size cities and almost impossible (23%) in rural areas. The KD patients in mid-size cities and rural areas have limited access to standard healthcare in the Arab world. This survey laid the foundation for future Kawarabi endeavors to improve the care of children with KD.

Spectrum of auto-inflammatory diseases in Morocco: a monocentric experience

Objective

Auto-inflammatory diseases (AIDs) result from mutations in genes of the innate immune system leading to periodic multisystemic inflammation. We aimed to describe the clinical, biological and molecular features (when available) and outcomes of Moroccan patients with AIDs.

Methods

Patient data were collected retrospectively and analysed over a 13-year period.

Results

Among 30 patients, 60% had FMF, 16% mevalonate kinase deficiency (MKD) and 24% other AIDs. The mean age at first consultation was 6.9 years, and the mean diagnostic delay was 3 years. Consanguinity was reported in 16 cases. IgA vasculitis was associated with 33% of FMF patients, in whom the main clinical features were fever (88.8%), abdominal pain (100%), arthralgias (88.8%) and arthritis (50%), and the most frequent mutation was M694V (66%). All FMF patients were treated with colchicine. Most MKD patients were confirmed by elevated urinary mevalonic acid levels, and four of five MKD patients received targeted therapy. Chronic recurrent osteomyelitis patients were confirmed by radiological and histological analysis. Two cases of Marshall syndrome were diagnosed according to validated criteria. A case of familial pustular psoriasis was diagnosed based on histological analysis and a patient with Muckle-Wells syndrome by clinical features. The outcome was favourable in 76%, partial in 13%, and three deaths were reported.

Conclusion

FMF and MKD are the most reported diseases. AIDs are probably underestimated because they are unknown to clinicians. The aim of this work is to raise awareness among paediatricians about AIDs and create a network for best practice.

70 Comparative study between PIMS and Kawasaki disease

Background

Kawasaki disease (kDa) is a multisystemic vasculitis affecting medium and small vessels with a predilection for the coronary arteries. It appears to be very similar to the pediatric multisystemic inflammatory syndrome (PIMS), which is a post-infectious inflammatory condition occurring after SARS-COV2 infection. Although these two entities have clinical and biological similarities, marked differences are identified. The aim of this study is to compare the two conditions in order to highlight the specific criteria of each of these related entities and to describe their demographic, clinical, biological and therapeutic characteristics in our context.

Method

Single center prospective observational study from January 2021 to March 2022 was conducted, comparing children admitted for PIMS on the basis of persistent fever, inflammatory syndrome, and positive COVID-19 IgG serology to patients hospitalized for kDa according to American Heart Association criteria.

Results

42 cases were recruited, among them 24 PIMS and 18 kDa, with a male predominance. The average age was 5 years for PIMS and 2 years and 7 months for kDa. All had a persistant fever with an average duration of 8 days as reason for consultation. Conjunctivitis was found in 88% of kDa vs 75% of PIMS and cheilitis in 94% of kDa vs 75% of PIMS. Skin rash, extremity involvement, cervical adenopathy were reported in both pathologies with respective percentages of 62.5%, 17.4% and 25% for PIMS vs 61.1%, 33.3% and 33.3% for kDa. Abdominal pain was reported in 54.2% of PIMS patients vs 5.6% of kDa. All patients had an inflammatory syndrome. The mean sedimentation rate was 67 mm at the first h in PIMS and 99 mm at the first h in kDa. The mean CRP was 147 mg/l in PIMS vs 132 mg/l in kDa. Lymphopenia was predominant in PIMS with 33% vs 11% in kDa. Cardiac enzymes were higher in PIMS with 29% of myocarditis and 15% of coronary dilatation vs 16.7% of coronary involvement in kDa. All PIMS patients received immunoglobulin infusion IV-IG, corticosteroid therapy, and an antiplatelet agent, whereas patients with kDa received IV-IG and acetyl salicylic acid in anti-inflammatory doses. Apyrexia was obtained at day 1 of treatment in the majority of patients, whereas 5.6% of kDa had persistent aneurysm.

Conclusion

PIMS cases predominated over kDa cases during this pandemic period. The distinction between the two entities could be difficult given the clinico-biological similarities. Abdominal pain was significantly more frequent in PIMS patients, whereas lymphopenia and myocarditis were not. The prognosis was better in PIMS.

58 Comparison of the 2015 pediatric diagnostic criteria for Behcet’s disease with the 2014 and 1990 International Study Group Diagnostic Criteria

Background

Behçet's disease is a multisystem vasculitis whose pathogenesis remains unclear. Although usually described in young adults, it may begin in childhood. The diagnosis is clinical, based on international criteria. The limitations of early diagnosis are related to the progressive onset of symptoms and the variety of differential diagnoses at this age in the absence of a pathognomonic diagnostic test.

Objectives

To report the epidemiological features of our series and to compare the 2015 pediatric criteria with the 2014 and 1990 international criteria.

Materials and Methods

This is a monocentric, retrospective study of 31 children over an 11-year period from January 2011 to December 2021. All patients suspected with Behcet's disease by a pediatric rheumatologist were included in the study, the 2014 international criteria “ISG 2014” being the gold standard classification criteria used in our center.

Results

31 cases of Behcet's were collected. The mean age was 10 years (5.5–16) ± 2.87 years. A female predominance is noted with a sex ratio F/M of 1.21. A quarter of the patients were from a consanguineous marriage and 38.7% had a family history of Behcet disease. Mucocutaneous manifestations were represented by recurrent oral aphthosis 87.1%, genital aphthosis 29%, pseudofolliculitis 48.4%, erythema nodosum 6.5% and acne lesions 3.2%. The pathergy test was positive in 1 case. Ocular involvement was reported in 29% and joint involvement in 45.2%. Thromboembolic complication was seen in 9.6% and neurobehcet in one patient. The HLA B51 antigen was present in 45.2% of cases. In our series 38.7% respond the pediatric criteria, while 61.3% met the 2014 international criteria and 35.5% met the 1990 international criteria. The 2015 pediatric criteria have respectively a sensitivity and specificity of 63.2% and 100% (p = 0.002) compared with the 2014 international criteria taken as gold standard, as well as the 1990 international criteria with a respective sensitivity and specificity of 52.6% and 91.7% (p = 0.034).

Conclusion

Our study highlights a female predominance, a high rate of consanguinity and familial Behcet. The sensitivity and specificity of the 1990 pediatric and international criteria appear to be better than those of 2014, with a more significant trend for the 2015 pediatric criteria (p = 0.002).

Dilated cardiomyopathy: An unusual and severe condition in juvenile systemic lupus erythematosus

Background

Systemic juvenile lupus erythematosus can affect any organ including the heart. While pericarditis and endocarditis are the most common cardiac complications, dilated cardiomyopathy remains rare. We report the full recovery of dilated cardiomyopathy in a girl with juvenile lupus.

Case presentation

A 7-year-old girl presented with persistent fever, weight loss, alopecia, positive anti-lupus antibodies, and decreased complement. Examination found dyspnea, tachycardia, and hypotension. Chest X-ray revealed an enlarged cardiac silhouette, and echocardiography showed a left ventricular ejection fraction of 35%. After excluding other causes, systemic lupus erythematosus related dilated cardiomyopathy was selected. Heart failure treatment, Prednisone, and hydroxychloroquine were prescribed. On day three, she developed macrophage activation syndrome which responded to methylprednisolone boluses. Clinical and biological improvement was observed after 4 weeks, normalization of echocardiography after 4 months.

Conclusion

A review of the literature confirmed the rare and severe nature of dilated cardiomyopathy in juvenile lupus emphasizing the importance of performing echocardiography at the slightest cardiac sign.

Biotherapy in juvenile idiopathic arthritis Moroccan patients: a single center experience

In this study, we aimed to evaluate the clinicobiological findings and the biotherapy treatment response of Moroccan patients with juvenile idiopathic arthritis (JIA), and compare our results with those of populations of the same or different ethnicity. This retrospective cross-sectional study included patients aged 1-14 years, diagnosed between 2003 and 2018 with JIA according to the International League of Associations for Rheumatology (ILAR) 2004 revised criteria, who received biologics and who followed up during the year 2018 in the day hospital of our single-center tertiary pediatric rheumatology unit. Among 59 patients, 53% had systemic JIA, 29% seronegative polyarticular JIA, 8% arthritis-related enthesitis, 5% seropositive polyarticular JIA, 3% oligoarthritis and 2% psoriatic arthritis. Tocilizumab was the most prescribed biologic (34 patients), followed by Etanercept (25 patients), Adalimumab (6 patients), Anakinra (3 patients) and biosimilar Infliximab (3 patients). Eleven patients switched biologics. Erythrocyte sedimentation rate, number of active joints and the Juvenile Arthritis Disease Activity Score 27 (JADAS 27) decreased significantly at month three for 56 patients. These results were maintained at the last visit for 31 patients, while there was a slight worsening in 15 of them and no assessment in 13 patients due to lack of data. At the end of the evaluation, 39% of the patients were exclusively on biotherapy, while 61% were still on other disease-modifying antirheumatic drugs (DMARDs). Twenty-eight patients developed lymphopenia, 4 patients had elevated transaminases, 4 patients developed moderate infection, and 2 patients developed macrophage activation syndrome. To the best of our knowledge, this is the first Moroccan study on biotherapy in JIA. Our study population was characterized by a male predominance, a high frequency of the systemic form and a low percentage of positive antinuclear antibodies. We have shown that in the era of biologics, only 67.4% patients are nearly disease-free at the end of the study with a real risk of side effects. Although effective, biotherapy must be closely monitored because of potentially severe side effects, especially with Tocilizumab use.

Epidemiology and demographics of juvenile idiopathic arthritis in Africa and Middle East

Juvenile Idiopathic Arthritis (JIA) is a group of chronic heterogenous disorders that manifests as joint inflammation in patients aged <16 years. Globally, approximately 3 million children and young adults are suffering from JIA with prevalence rates consistently higher in girls. The region of Africa and Middle East constitute a diverse group of ethnicities, socioeconomic conditions, and climates which influence the prevalence of JIA. There are only a few studies published on epidemiology of JIA in the region. There is an evident paucity of adequate and latest data from the region. This review summarizes the available data on the prevalence of JIA and its subtypes in Africa and Middle East and discusses unmet needs for patients in this region. A total of 8 journal publications were identified concerning epidemiology and 42 articles describing JIA subtypes from Africa and Middle East were included. The prevalence of JIA in Africa and Middle East was observed to be towards the lower range of the global estimate. We observed that the most prevalent subtype in the region was oligoarticular arthritis. The incidence of uveitis and anti-nuclear antibody (ANA) positivity were found to be lower as compared to the incidence from other regions. There is a huge unmet medical need in the region for reliable epidemiological data, disease awareness, having regional and local treatment guidelines and timely diagnosis. Paucity of the pediatric rheumatologists and economic disparities also contribute to the challenges regarding the management of JIA.

P049 Comparison between the ACR 1997, SLICC 2012 and EULAR/ACR 2019 classification criteria in juvenile systemic lupus erythematosus

Background

Juvenile systemic lupus erythematosus is a multisystem inflammatory autoimmune disease affecting patients under 16 years old. Diagnosis may be difficult because of the large clinical heterogeneity. Classification criteria are important to ensure a clear definition and consistent inclusion of patients in clinical trials. The objective of the work: is to Compare the performance of the classification criteria of the American College of Rheumatology (ACR 1997), those of the Systemic Lupus International Collaborating Clinics (SLICC 2012) and the new classification criteria together with the European League Against Rheumatism “EULAR” and the American College of Rheumatology “ACR” (EULAR/ACR 2019).

Methods

This is a cross-sectional retrospective study carried out in a tertiary care service over a period of one year, from January 1, 2020 to December 31, 2020. The patients were subjected to the different classification criteria ACR 1997, SLICC 2012 and EULAR/ACR 2019. All our patients were matched in age and sex with control cases followed for inflammatory disease (12 control cases).

Results

Six patients were diagnosed with juvenile systemic lupus erythematosus (JSL) over the period of our study. A clear predominance of women was noted with a sex ratio of 5 girls/1 boy. The mean age at the time of diagnosis was 9 years (extremes: 3 –12 years). The diagnosis was made after an average delay of 5 months (extremes: 1–12 months). All of our patients met the three classification criteria. Sensitivity to all criteria was noted at diagnosis and during the first months of follow-up with higher sensitivity for SLICC criteria. Regarding the control cases, 3 patients met the ACR 1997 criteria.

Conclusion

In this population of Juvenile systemic lupus erythematosus, the SLICC criteria gave the best results in terms of sensitivity and precision at the time of diagnosis and during the first months of follow-up, while the ACR 1997 criteria were less specific.

P060 Childhood uveitis: epidemiological, clinical and etiological profile, about 52 cases

Background

Childhood uveitis is a rare, often serious condition, and accounts for 2% to13% of all uveitis. It is characterized by an asymptomatic onset delaying the diagnosis and exposing a high risk of complications. The etiological profile of childhood uveitis seems to be different from that of adults. The objective of our work is to analyze the epidemiological, clinical, etiological, therapeutic and disease course characteristics of pediatric uveitis.

Method

This retrospective study, carried out in a tertiary care center, involved a number of 87 eyes in 52 children under the age of 16, collected over a period extending between January 2015 and September 2019 with a minimum follow-up of 6 months.

Results

The patients mean age was 8.15 years with a sex ratio of 1.47 and a mean consultation delay of 6.7 months. Uveitis was bilateral in 67.3% of cases. Pan-uveitis predominated, followed by intermediate, anterior and posterior uveitis in 50%, 21%, 17% and 12% of cases, respectively. Uveitis was idiopathic in 67.3% of cases. Inflammatory uveitis was the most frequent aetiology with 5 cases of Behçet's disease, 2 cases of juvenile idiopathic arthritis (JIA) and 2 cases of TINU syndrome. Ophthalmologic complications were dominated by iridocrystalline synechiae in 13.5%, retinal detachment in 10.4%, cataract in 5.4% and macular oedema in 2.7%. Corticosteroid therapy was administered to all children, combined with immunosuppressive therapy in 48% of cases (azathioprine, methotrexate). The use of anti-TNF alpha was justified in 11 patients. The disease course was marked by complete remission in 11 children and partial remission in 15 patients, 26 children presented relapses of their uveitis with satisfactory final visual acuity in 73% of cases.

Conclusion

Our results show the predominance of panuveitis, probably due to diagnostic delay. Idiopathic uveitis, as described in the literature, and inflammatory causes of Behçet's disease are at the top of the list of etiologies. Pediatric uveitis is a particular entity, which requires regular monitoring by a team of experts in order to avoid eye complications and amblyopia in the youngest.

P092 Infantile osteopetrosis: a case report Traduction en Anglais

Background

Infantile osteopetrosis is a rare genetic disorder characterized by increased bone density due to defective osteoclastic resorption.

Case report

We report the case of a 6 years old girl, born of a consanguineous marriage, hospitalized in our department for bone deformations and visual disturbances. On clinical examination, there was conjunctival pallor, thoracic deformity, genu-valgum and dentigenesis disorder as well as nystagmus and severe loss of visual acuity. The complete blood count showed regenerative normochromic normocytic anaemia as well as thrombocytopenia. Assessment for infectious disorders was negative. The skeletal X-ray revealed diffuse osteocondensation of the skeleton. The CT scan of the rock bones of cranial bases revealed bilateral segmental stenosis of the facial canal with densification of the ossicular chain and thickening of the stapes. Cranio-orbital MRI revealed bilateral optic duct stenosis with atrophy of the optic nerves and chiasma. The diagnosis of osteopetrosis was retained according to this set of clinical and radiological arguments. Unfortunately, the genetic study could not be performed. Histocompatible bone marrow transplant may be curative but was not available for our patient. Genetic counseling was offered for the family as well as dental and orthopedic care.

Conclusion

Infantile osteopetrosis is a rare but serious pathology that can have severe functional repercussion and even be life-threatening, requiring early diagnosis and management.

O007. Register of hereditary auto-inflammatory diseases in a pediatric rheumatology unit

Background

Autoinflammatory diseases (AID) are a group of genetic syndromes resulting from an excessive activation of the innate immune system, caused by mutations in genes regulating the inflammatory pathways and can involve several organs. The aim of this study is to evaluate the clinical, paraclinical, epidemiogical and genetic data of Moroccan patients with confirmed AID, in order to allow a first experience of AID registry in our unit.

Material

We have retrospectively analyzed 30 cases of patients in our unit over a period of 13 years (between 2006 and 2019), according to inclusion criterias (recurrent fever &gt; 3 episodes and a CRP &gt; 40mg/L) and having excluded immune deficiency, autoimmune disease, neoplasia and infectious diseases.

Results

The mean age of our patients at 1st consultation was 6.9 years (with extremes ranging from 8 months to 14 years). Consanguinity was reported in 16 cases, and unknown in one case of an adopted child. The patients were classified as follows: 66% of cases with Familial Mediterranean Fever (FMF) including 1 case with a characteristic phenotype of Marshall/Periodic Fever Aphtous Pharyngitis Adenitis (PFAPA) syndrome, 16% of cases with Mevalonate Kinase Deficiency (MKD), 10% of cases with Chronic Recurrent Multifocal Osteomyelitis (CRMO), 1 patient with Familial Pustular Psoriasis (FPP) and another symptomatic patient with Muckle Wells syndrome. An association with Henoch Schonlein purpura was reported in 30% of cases and with periarteritis nodosa in 1 case in FMF patients. The mean diagnostic delay was 3 years (with extremes ranging from 1 month to 12 years). The main clinical features found in our patients included fever (83%), abdominal pain (90%), arthralgia (83%), arthritis (46%), adenopathies (40%), aphtous (30%) and other specific signs. Genetic analysis revealed that M694V was the most frequent mutation (60%), followed by A744S (15%), E148Q (10%), K695R (10%) and P369S/ R408Q (5%) in all FMF patients, and V337I found in 1 patient with MKD while the 4 others were confirmed basing on a high rate of urinary mevalonic acid. CRMO patients were confirmed by radiological and histological analysis. The case of FPP was confirmed histologically by skin biopsy and the patients with Muckle Wells and PFAPA syndroms were diagnosed basing on characteristic clinical features. Therapeutically, all FMF patients were treated with colchicine in addition of corticosteroids in 1 case of PFAPA syndrome. Patients with MKD received targeted therapy (Anakinra, Etanercept) and Ibuprofen in 1 case. CRMO patients were treated with targeted therapy and NSAIDs. The case of FPP was treated with Methotrexate combined with Etanercept and the patient with Muckel Wells Syndrome received corticosteroid therapy combined with Azathioprine and then Anakinra. The clinical and biological evolution was considered favorable in 76% of cases, partial in 13% of cases and 3 death cases were reported.

Conclusion

AIDs remain rare genetic syndromes whose lack of knowledge explains the late diagnostic delay. Therefore, it is necessary for any pediatrician to know how to evoke an AID in front of recurrent fever with free intervals, clinical features and inflammatory syndrome, in order to choose the optimal treatment as well as to make the genetic counseling.

Abbreviations

AID: Auto-Inflammatory Disease

CAPS: Cryopyrin Associated Periodic Syndromes

CARD14: Caspase Recruitment Domain Family Member 14

CIAS1: Cold-Induced Autoinflammatory Syndrome 1

CRMO: Chronic Recurrent Multifocal Osteomyelitis

CRP: C-Reactive Protein

CT scan: Computerized Tomography scan

DNA: DeoxyriboNucleic Acid

ESR: Erythrocyte Sedimentation Rate

FMF: Familial Mediterranean Fever

FPP: Familial Pustular Psoriasis

IL-1β: Interleukine-1beta

IL-17A: Interleukine 17A

MEFV: Mediterranean fever gene

MKD: Mevalonate Kinase Deficiency

MVK: Mevalonate Kinase

MW: Muckle Wells

NALP3: NAcht Leucine-rich repeat Protein 3

NLRP3: NOD-like receptor family, pyrin domain containing 3

NSAID: Non-Steroidal Anti Inflammatory Drugs

PFAPA: Periodic Fever Aphtous Pharyngitis Adenitis

PRINTO: Pediatric Rheumatology INternational Trials Organization

SAA: Serum Amyloid A

TRAPS: TNF Receptor Associated Periodic Syndroms

TNF: Tumor Necrosis Factor

Dilated cardiomyopathy: A rare and late complication of the hemolytic-uremic syndrome

Hemolytic uremic syndrome (HUS) is a non-exceptional, progressive complication of acute gastroenteritis in children, especially secondary to Escherichia coli infection. It is responsible for significant morbidity and significant mortality (10% of deaths) because of acute renal failure which often complicates it. Dilated cardiomyopathy is a rare but critical extra renal manifestation of the HUS. This article highlights the importance of considering the diagnosis of associated cardiomyopathy in the acute phase of HUS and the following months. A five-year-old boy presented with HUS with acute renal failure requiring peritoneal dialysis for 24 days. No cardiac signs appeared during the acute phase of the disease. After dialysis and normalization of blood pressure, fluid, and electrolyte disturbance, severe dilated cardiomyopathy with cardiac failure appeared three months later without definite etiology. A review of the literature confirmed the rare and severe nature of cardiac lesions occurring in HUS. Dilated cardiomyopathy is a rare but important extra renal manifestation of the HUS and is best demonstrated by echocardiography. A cardiac manifestation should also be screened for in the acute phase of HUS and several months later. <Learning objective: The main message to draw from this case is that despite the rarity of cardiac complications, routine echocardiographic screening of children with hemolytic uremic syndrome should be performed both in the acute phase and during subsequent follow-up even in the absence of clinical signs because of severe prognosis of this complication, and it is therefore the investigation of choice.>.

Consensus classification criteria for paediatric Behçet's disease from a prospective observational cohort: PEDBD

BACKGROUND

We aimed to describe the main features of Behçet's disease (BD) in children in the largest prospective cohort to date and to propose a classification.

METHODS

An international expert consensus group was formed to define a data set of minimal symptoms for the inclusion of patients. Patients were entered prospectively during 66 months. Experts classified patients on a consensus basis. The concordance of two international classifications was analysed in confirmed patients with BD. Comparisons of subgroups of patients helped define consensus criteria. BD-associated clinical manifestations were also investigated in three control diseases extracted from an independent data set (Eurofever).

FINDINGS

In total, 42 centres from 12 countries included 230 patients; data for 219 (M/F ratio=1) could be analysed. The experts classified 156 patients (71.2%) as having confirmed BD. Males more often than females showed cutaneous, ocular and vascular symptoms and females more often genital aphthosis. Age at disease onset and skin and vascular involvement were lower for European than non-European children. Oral aphthosis was the presenting sign for 81% (179/219) of patients. The mean delay to the second symptom was 2.9±2.2 years. International classifications were not concordant with the expert classification. Our paediatric classification contains six categories, a minimum of three signs (each in a distinct category) defining paediatric BD. Three clinical signs discriminated our cohort from the Eurofever cohorts.

INTERPRETATION

We present a comprehensive description of a large cohort of patients from both European and non-European countries and propose the first classification of paediatric BD for future therapeutic trials.

[Contribution of recent physiopathogenic progresses to the diagnosis of recurrent fevers]

Recurrent fevers are characterized by fever lasting for a few days or few weeks and followed by a fever-free interval and state of well-being. It is first necessary to eliminate infections, which are the most common causes of fever. Several recurrent fevers belong to inflammatory diseases of unclear physiopathogeny. Recent advances are now available permitting to immunogenetically identify some of them. It also opens a better understanding and consequently the possibility of specific therapeutic approach.