Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

AB1166 MYOCARDITIS FOLLOWING mRNA COVID VACCINE COMPARED TO PAEDIATRIC MULTISYSTEM INFLAMMATORY SYNDROME MULTICENTER RETROSPECTIVE STUDY

Background

Since the development of COVID 19 vaccines, more than 300 million people have been immunized worldwide. Soon after vaccinations were initiated, reports on cases of myocarditis following the second vaccine dose have emerged.

Objectives

This study aims to report our experience with nine patients with post COVID-19 vaccine myocarditis, and to compare them to a cohort of patients who presented with paediatric inflammatory multisystem syndrome (PIMS / PIMS-TS) post COVID 19 infection.

Methods

We collected all reported cases of patients who developed myocarditis following COVID 19 vaccination (Pfizer mRNA BNT162b2), from all pediatric rheumatology centers in Israel, and compared them to the cohort of patients previously diagnosed with PIMS.

Results

Nine patients with myocarditis post-vaccination were identified and compared to 78 patients diagnosed with PIMS. All patients with post-vaccination myocarditis were males who developed symptoms following their second dose of the vaccine. Patients with myocarditis post-vaccination had a shorter duration of stay at the hospital (4.4±1.9 vs. 8.7±4.7 days), less myocardial dysfunction (11.1% vs. 61.5%), and all had excellent outcomes as compared to chronic changes among 9.2% of patients with PIMS.

Conclusion

The clinical course of vaccine-associated myocarditis appears favorable, with resolution of symptoms in all the patients in our cohort. The risk–benefit decision for vaccination remains highly favorable, given the potential morbidity of patients with COVID-19, especially those with PIMS.

Disclosure of Interests

None declared

POS1302 PATIENT AND PHYSICIAN REPORTED OUTCOMES OF JUVENILE SYSTEMIC SCLEROSIS PATIENTS SIGNIFICANTLY IMPROVE OVER 12 MONTHS OBSERVATION PERIOD IN THE JUVENILE SYSTEMIC SCLERODERMA INCEPTION COHORT. www.juvenile-scleroderma.com

Background

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1 000 000 children (1). The Juvenile Systemic Scleroderma Inception cohort (jSScC) is the largest cohort of jSSc patients in the world. The jSScC collects longitudinal data prospectively in jSSc, allowing the evaluation of the development of organ involvement and patients and physician reported outcomes in jSSc over time.

Objectives

To review the changes in the clinical characteristics and patient and physician reported outcomes over 12 months observation period from the time of inclusion into the cohort.

Methods

The jSScC cohort enrolls jSSc patients who developed the first non-Raynaud´s symptom before the age of 16 years and are under the age of 18 years at the time of inclusion (2, 3). We reviewed jSScC patient clinical data and patient and physician reported outcomes, who had 12 months follow up from the time of inclusion until 1st of December 2021.

Results

We could extract data of 113 patients. The female/male ratio was 3.5:1. Median age of onset of Raynaud´s was 10.1 years and the median age of onset of non-Raynaud´s was 10.8 years. Eighty-eight percent of the patients were treated with disease modifying anti-rheumatic drugs (DMARDs) at time of inclusion in the cohort (T0) and 93% after 12 months (T12). Median disease duration was 2.5 years at T0. Antibody profile stayed unchanged. Only 3 clinical parameters changed and improved significantly, the median modified Rodnan skin score improved from 13 to 8 (p=0.002), the number of patients with swollen joints decreased from 17% to 8% (p=0.043) and number of patients with joints with pain on motion decreased from 20% to 12% (p=0.048). All other organ involvement did not show any statistically significant change from T0 to T12.

All collected patient reported outcomes improved significantly from T0 to T12: the patient reported disease activity (VAS 0 – 100) from 40 to 20 (p=0.011), the patient reported disease damage (VAS 0 – 100) from 40 to 20 (p=0.001), patient reported ulceration activity (VAS 0 – 100) from 10 to 0 (p=0.02) and the CHAQ score from 0.3 to 0.1 (p=0.002). Two of the three physician reported outcomes improved significantly, the physician global disease activity (VAS 0 – 100) from 30 to 20 (p=0.011) and physician reported global disease damage (VAS 0 – 100) from 30 to 25 (p=0.028).

Conclusion

Skin and musculoskeletal clinical features improved over 12 months, with almost all patients on DMARDs, supporting likely response of these features to therapy. It was promising that internal organ involvement, like cardiac and lung, although potentially stable, did not significantly worsen or increase. The most striking observation in the positive direction is improvement across several patient and physician reported outcome measures over the 12 month time period in this large international cohort.

References

[1]Beukelman T, Xie F, Foeldvari I. Assessing the prevalence of juvenile systemic sclerosis in childhood using administrative claims data from the United States. Journal of Scleroderma and Related Disorders. 2018;3(2):189-90.

[2]Foeldvari I, Klotsche J, Kasapcopur O, Adrovic A, Terreri MT, Sakamoto AP, et al. Differences sustained between diffuse and limited forms of juvenile systemic sclerosis in expanded international cohort. www.juvenile-scleroderma.com. Arthritis Care Res (Hoboken). 2021.

[3]Foeldvari I, Klotsche J, Torok KS, Kasapcopur O, Adrovic A, Stanevica V, et al. CHARACTERISTICS OF THE FIRST 80 PATIENTS AT TIMEPOINT OF FIRST ASSESSMENT INCLUDED IN THE JUVENILE SYSTEMIC SCLEROSIS INCEPTION COHORT. WWW.JUVENILESCLERODERMA.COM. Journal of Scleroderma and Related Disorders. 2018;4(1-13).

Disclosure of Interests

None declared

POS0172 DIFFUSE JUVENILE SYSTEMIC SCLEROSIS PATIENTS SHOW DISTINCT ORGAN INVOLVEMENT AND HAVE MORE SEVERE DISEASE IN THE LARGEST jSSc COHORT OF THE WORLD. RESULTS FROM THE THE JUVENILE SCLERODERMA INCEPTION COHORT. www.juvenile-scleroderma.com

Background

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of 3 in 1 000 000 children (1). In adult patients there are significant differences between the clinical presentation of diffuse and limited subtypes (2). We reviewed clinical differences in presentation of subtypes in patients in the juvenile systemic scleroderma inception cohort up to 2021.

Objectives

To study the clinical presentation of jSSc patients with diffuse (djSSc) and limited (ljSSc) subtypes.

Methods

We reviewed the clinical baseline characteristics of the patients, who were recruited to the juvenile scleroderma inception cohort (jSScC) (3, 4) till 1st of December 2021. jSScC is a prospective cohort of jSSc patients, who developed the first non-Raynaud´s symptom before the age of 16 years and are under the age of 18 years at the time of inclusion.

Results

210 patients with jSSc were included in the cohort, 71% (n=162) had diffuse subtype. The median age at onset of Raynaud phenomenon was 10.4 years (7.3 – 12.9) and the median age at the first non-Raynaud symptom was 10.9 years (7.4 – 13.2). Median disease duration was 2.5 years (1 – 4.4) at the time of inclusion. The female/male ratio was significantly lower in the djSSc subtype (3.7:1 versus 5:1, p<0.001). Antibody profile was quite similar, with the exception of a significantly higher number of anticentromere positive patients in the ljSSc (12% versus 2%, p=0.013). Decreased FVC < 80% was found in approximately 30% and decreased DLCO < 80% was found in around 40% in both subtypes. Pulmonary hypertension assessed by ultrasound was identified in 5% in both groups. Patients with diffuse subtype had significantly higher modified Rodnan Skin Score (mRSS) (16 versus 4.5, p<0.001), sclerodactyly (84% versus 60%, p<0.001), history of digital ulceration (62% versus 31%, p<0.001), decreased Body Mass Index (BMI) < -2 z score (20% versus 4%, p=0.003) and decreased joint range of motion (64% versus 46%, p=0.019). Patients with ljSSc had significantly higher rate of cardiac involvement (13% versus 2%, p=0.001).

Regarding patient related outcomes djSSc patients had more severe disease, looking at patient reported global disease activity (VAS 0 – 100) (40 versus 25, p=0.039), patient reported global disease damage (VAS 0 – 100) (40 versus 25, p=0.021) and patient reported assessment of ulceration activity (10 versus 0, p=0.044). Regarding physician related outcomes the physician reported global disease activity (VAS 0 – 100) (32 versus 20, p<0.001) and physician reported global disease damage (VAS 0 – 100) (30 versus 15, p=0.014) was significantly higher in djSSc.

Conclusion

In this jSSc cohort, the largest in the world, djSSc patients have a significantly more severe disease than ljSSc patients. Interestingly, we found no differences regarding interstitial lung disease and pulmonary hypertension.

References

[1]Beukelman T, Xie F, Foeldvari I. Assessing the prevalence of juvenile systemic sclerosis in childhood using administrative claims data from the United States. Journal of Scleroderma and Related Disorders. 2018;3(2):189-90.

[2]Dougherty DH, Kwakkenbos L, Carrier ME, Salazar G, Assassi S, Baron M, et al. The Scleroderma Patient-Centered Intervention Network Cohort: baseline clinical features and comparison with other large scleroderma cohorts. Rheumatology (Oxford). 2018;57(9):1623-31.

[3]Foeldvari I, Klotsche J, Kasapcopur O, Adrovic A, Terreri MT, Sakamoto AP, et al. Differences sustained between diffuse and limited forms of juvenile systemic sclerosis in expanded international cohort. www.juvenile-scleroderma.com. Arthritis Care Res (Hoboken). 2021.

[4]Foeldvari I, Klotsche J, Torok KS, Kasapcopur O, Adrovic A, Stanevica V, et al. CHARACTERISTICS OF THE FIRST 80 PATIENTS AT TIMEPOINT OF FIRST ASSESSMENT INCLUDED IN THE JUVENILE SYSTEMIC SCLEROSIS INCEPTION COHORT. WWW.JUVENILESCLERODERMA.COM. Journal of Scleroderma and Related Disorders. 2018;4(1-13).

Disclosure of Interests

None declared

POS1299 JUVENILE SYSTEMIC SCLEROSIS TREATMENT PRACTICES IN AN INTERNATIONAL COHORT AND COMPARISON TO RECENT SHARE CONSENSUS GUIDELINES

Background

Juvenile systemic scleroderma (jSSc) is an orphan disease with a prevalence of 3 in 1,000,000 children. Currently no medications are licensed for the treatment of jSSc. Due to its rarity, only recently have the first management and treatment guidelines been published, the jSSc SHARE (Single Hub and Access point for paediatric Rheumatology in Europe) recommendations, reflecting consensus opinion upon pediatric rheumatologists (1).

Objectives

To better understand treatment practices internationally for jSSc, both at baseline and over 24 months observation period and to compare if real world therapies are congruent with the recent SHARE recommendations.

Methods

The juvenile systemic sclerosis inceptions cohort (jSScC) is a multinational cohort that prospectively collects clinical data, including medications at baseline and subsequent visits. The jSScC enrollment criteria include age of onset of the first non-Raynaud symptom younger than 16 years and age younger than 18 years at cohort entrance. The frequency of medications (general category and specific medication) was calculated across the cohort at timepoint 0 (enrollment), 12 months and 24 months.

Results

We extracted data from the jSScC of patients who were followed for 12 or 24 months. 109 patients were followed at time point 0 (T0) and 12 months (T12), and data was available for 77 of them up at 24 months (T24). The mean age of the patients was 13.2 years at the timepoint 0. 77% were female and 75% had diffuse subtype. Disease duration at baseline visit was 3.1 years. The medications the patients were on recorded by the physician were captured at T0, T12 and T24 listed in Table 1.

Table 1.MEDICATIONSTime point 0N=109T12 monthsN=109T24 months N=77Any Medication92% (100)97% (106)97% (75)Vascular medications Endothelial receptor antagonist16% (17)24% (26)21% (16) PDE-5-Blocker5% (5)8% (9)9% (7)ImmunomodulatorsCorticosteroids52% (57)44% (48)44% (21)All csDMARDs:81% (88)93% (101)92% (71) csDMARDs monotherapy61% (67)66% (72)60% (46) csDMARDs combination therapy17% (18)15% (16)14% (11) Methotrexate51% (56)50% (55)39% (30) Mycophenolate Mofetil26% (28)44% (48)47% (36) Hydroxychloriquine11% (12)15% (16)21% (16) Cyclophosphamide12% (13)2% (2)1% (1) Azathioprine2% (2)2% (2)3% (2)All bDMARDs:5% (5)14% (15)18% (14) bDMARDs monotherapy2%(2)2%(2)1% (1) bDMARDs combined with csDMARDs3% (3)12% (13)17% (13) Tocilizumab2% (2)10% (11)14% (11) Rituximab2% (2)4% (4)4% (3) Adalimumab1% (1)0% (0)0% (0)Autologous Stem cell transplantation0% (0)1% (1)0% (0)

csDMARDs: Conventional synthetic disease-modifying antirheumatic drugs

b DMARDs: Biological disease-modifying antirheumatic drugs

Conclusion

At baseline half of the patients were on corticosteroids. This is more frequent than typical adult SSc practice but coincides with jSSc SHARE treatment recommendations (#1). After 12 months observation in the cohort over 90% of patients received a DMARD therapy. Methotrexate and mycophenolate mofetil were the most commonly prescribed DMARDs, which also reflects the SHARE treatment recommendations (#2, #3). At 12 months the use of glucocorticoid decreased and the use of bDMARDs increased. In general, biological DMARDs are typically considered in severe or refractory (SHARE recommendation #7), reflecting the lower percentage compared to csDMARDs. Autologous stem cell transplantation was observed in one patient at 12 months, reflecting an option in jSSc with progressive and refractory disease (SHARE recommendation #8). Endothelial receptor antagonists, such as bosentan, were used over time in approximately 20% of the patients, reflecting SHARE recommendation #6 for pulmonary hypertension and/or digital tip ulcers. This is the first evaluation looking at clinical medication practice pattern in jSSc, and its comparison to recently published consensus guidelines.

References

[1]Foeldvari I, Culpo R, Sperotto F et al. Consensus-based recommendations for the management of juvenile systemic sclerosis. Rheumatology (Oxford). 2021;60(4):1651-8.

Disclosure of Interests

None declared

POS1239 RISK FACTORS FOR SEVERE DISEASE COURSE IN MULTISYSTEM INFLAMMATORY SYNDROME IN CHILDREN (MIS-C) – A MULTICENTER, RETROSPECTIVE STUDY

Background

Multisystem Inflammatory Syndrome in Children (MIS- C) associated with COVID-19, presents as a cytokine storm with features of Kawasaki disease. Many cases present with shock and require intensive care admission.

Objectives

We aimed to identify predictors for severe clinical course of MIS-C as defined by the need for ionotropic support during admission

Methods

A retrospective multinational cohort study was conducted. Patients with a diagnosis of MIS-C from 9 Israeli medical centers and one US medical center (Chicago, IL) were included. Demographic, clinical, laboratory and imaging variables during admission and hospitalization were retrieved. Univariate and multivariate regression models were used to assess odds ratio (OR) of ionotropic support need during hospitalization.

Results

Overall 100 MIS-C patients were included in the study. Sixty-five patients (65%) were hypotensive, 44% required ionotropic support, and 37% had finding of Left ventricular dysfunction. Univariate model showed that LVD was associated with the need for ionotropic support (OR 4.178 [95%CI 1.760-9.917], while conjunctivitis (OR 0.403 [95%CI 0.173-0.938]) and mucosal changes (OR 0.333 [95%CI 0.119-0.931]) were protective. Laboratory markers for severe disease course were low hemoglobin levels, leukocyte count, thrombocyte count, lymphocyte count, neutrophils count, albumin and potassium, as well as high troponin and BNP.

Conclusion

Patients with MIS-c that present with a Kawasaki-like phenotype are less likely to require ionotropic support, while other clinical and laboratory parameters were found as risk factors and should be monitored during MIS-C hospitalization.

References

[1]Chiotos K., Bassiri H., Behrens E.M. multisystem inflammatory syndrome in children during the coronavirus 2019 pandemic: a case series. J Pediatric Infect Dis Soc. 2020;9(3):393–398.

[2]Whittaker E, Bamford A, Kenny J, Kaforou M et al. Clinical Characteristics of 58 Children With a Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2. JAMA. 2020 Jul 21;324(3):259-269.

[3]Feldstein L.R, Rose E.B, Horwitz S.M, et al. multisystem inflammatory syndrome in U.S. children and adolescents. N Engl J Med. 2020 Jul 23;383(4):334-346.

[4]Pouletty M, Borocco C, Ouldali N, et al. Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multicentre cohort. Ann Rheum Dis. 2020 Aug;79(8):999-1006

[5]Abrams JY, Oster ME, Godfred-Cato SE, et al. Factors linked to severe outcomes in multisystem inflammatory syndrome in children (MIS-C) in the USA: a retrospective surveillance study. Lancet Child Adolesc Health. 2021 May;5(5):323-331.

Table 1.

and laboratory characteristics on admission of patients diagnosed with MIS-C

w/o Hemodynamic supportN=56 (56.0%)with Hemodynamic supportN=44 (44.0%)p-valueGastrointestinal symptoms46 (82.1%)41 (93.2%)0.103Mucosal changes18 (32.1%)6 (13.6%)0.031Rash34 (60.7%)20 (45.5%)0.129Conjunctivitis27 (48.2%)12 (27.3%)0.033Extremity changes4 (7.1%)6 (13.6%)0.280Lymphadenopathy11 (19.6%)11 (25.0%)0.521No. of days of fever at admission4 [3-5]5 [3-5]0.646Systolic BP99 [90-108]97 [85-102]0.263Diastolic BP60 [53-67]53 [45-59]0.006HR124 [114-143]126 [108-144]0.957hemoglobin admission (g/dL)11.65 [10.83-12.67]11.25 [10.22-12.58]0.220White cells admission (K/µL)9.02 [6.63-12.01]9.03 [5.75-16.99]0.742platelets admission (K/µL)174.0 [134.50-250.0]147.50 [121.25-146.25]0.126lymphocytes admission (K/µL)0.90 [0.64-1.70]0.70 [0.48-1.11]0.015ESR admission (mm/hr)43.00 [35.5-74.50]44.00 [28.50-66.00]0.575C-reactive protein admission (mg/dL)14.05 [10.32-22.28]19.50 [10.90-27.30]0.117Creatinine admission (mg/dL)0.55 [0.40-0.70]0.69 [0.50-0.81]0.008Figure 1.

- forest plot - clinical risk factors for need of hemodynamic support in MIS-C patients; Odds Ratio [95% CI] (univariate analysis)

Disclosure of Interests

None declared

AB1236 CLINICAL CHARACTERISTICS OF JUVENILE ONSET SYSTEMIC SCLEROSIS PATIENTS FROM THE JUVENILE SCLERODERMA INCEPTION COHORT COMPARED TO ADULT AGE JUVENILE-ONSET PATIENTS FROM EUSTAR. ARE THESE DIFFERENCES SUGGESTING RISK FOR MORTALITY?

Background

Juvenile systemic sclerosis (jSSc) is an orphan autoimmune disease with a prevalence of 3 in 1 000 000 children. Information on long-term development of organ involvement and clinical characteristics of jSSc patients in adulthood are lacking. It was believed that patients in adult cohorts may represent a survival biased population.

Objectives

To assess differences in clinical characteristics of jSSc-onset patients from the pediatric age group, with a mean disease duration of 3 years, compared to the adult age jSSc-onset group, with a mean disease duration of 18.5 years.

Methods

We extracted clinical data at time of inclusion into the cohorts from the Juvenile Scleroderma Inception Cohort (jSScC) and data from juvenile-onset adult SSc patients from the European Trials and Research Group (EUSTAR) cohort. We compared the clinical characteristics of the patients by descriptive statistics.

Results

We extracted data of 187 jSSc patients from the jSScC and 236 patients from EUSTAR. The mean age at time of assessment was 13.4 years old in the jSScC and 32.4 years old in EUSTAR. The mean disease duration since first non-Raynaud was 3.0 years in jSScC and 18.5 years in the EUSTAR (Table 1).

We found significant differences between the cohorts. There were more female patients in EUSTAR (87.7% versus 80.2%, p=0.04). More patients had diffuse subtype in jSScC (72.2% versus 40%, p<0.001). The modified Rodnan skin score (mRSS) was significantly higher in jSScC (14.2 versus 12.1, p=0.02). Active digital ulceration occurred more often in EUSTAR (26.6%, versus 17.8% p=0.01), but history of active ulceration was more frequent in jSScC (54.1% versus 43%, p<0.001). Mean DLCO was lower in jSScC (75.4 versus 86.3, p<0.001). Intestinal involvement was significantly more common in jSSc (33.2% versus 23.8%, p=0.04). Esophageal involvement was more common in EUSTAR (63.7% versus 33.7%, p<0.001). (Table 1).

Table 1.

Clinical characteristics of juvenile onset SSc patients at time point of the inclusion into the juvenile scleroderma inception (jSScC) cohort and in the adult EUSTAR- cohort

jSScCEUSTAR CohortP valueNumber of patients1872360.04Age in years, mean (SD)13.4 (3.6)32.4 (15.4)Female patients, n (%)150 (80.2%)207 (87.7%)jSSC Subtype, n (%)diffuse135 (72.2%)87 (38.1%)<0.001limited52 (27.8%)121 (53.3%)Age at Raynaud onset in years, mean (SD)10.0 (3.9)13.7 (9.1)Age at non-Raynaud onset in years, mean (SD)10.3 (3.9)11.7 (3.7)Duration since first Raynaud symptoms in years, mean (SD)3.4 (2.7)20.6 (15.9)Duration since first non-Raynaud symptoms in years, mean (SD)3.0 (2.7)18.5 (15.6)Raynaud´s, n (%)170 (90.9%)222 (94.9%)ANA positive, n (%)166 (91.7%)210 (92.9%)0.99Anti-Scl 70 positive, n (%)62 (34.4%)73 (33.3%)0.68Modified Rodnan Skin Score, mean (SD)5%Data missingModified Rodnan Skin Score, mean (SD)14.2 (11.7)12.1 (14.5)0.02Digital ulceration, n (%)At the time of inclusion33 (17.8)21 (26.6%)0.01In the past history100 (54.1%)34 (43%)<0.001Telangiectasia62 (37.4%)42 (53.2%)0.04FVC, mean (SD)84.1 (18.6)84 (22.4)0.96DLCO, mean (SD)75.4 (19.2)86.3 (19.9)<0.001Arterial hypertension, n (%)10 (5.4%)20 (8.5%)0.26Renal crisis, n (%)03 (1.3%)0.26Esophageal involvement, n (%)63 (33.7%)149 (63.7%)<0.001Intestinal involvement, n (%)62 (33.2%)56 (23.8%)0.04Articular involvement, n (%)34 (18.3%)27 (11.6%)0.06Muscular involvement, n (%)31 (19.3%)46 (19.8%)0.45

Conclusion

Patients with jSSc-onset who are currently adult age (defined as >18 years of age) are less frequently male and from the diffuse subset, have lower mRSS, less digital ulcers and intestinal involvement. This might represent a combination of both survival bias and/or be explained by the longer observation time with less active disease (i.e. natural progression decreased mRSS over time). Further long-term observational studies with jSSc patients are required to address this issue.

Disclosure of Interests

None declared

POS1306 EXTREME PERIODIC FEVER, APHTHOUS STOMATITIS, PHARYNGITIS AND CERVICAL ADENITIS (PFAPA) ARE A SUBSET OF PFAPA PATIENTS WITH FLARES THAT OCCUR MORE THAN TWICE A MONTH

Background

The febrile episodes of periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis (PFAPA) syndrome occur, by definition, every 2 to 8 weeks.

However, a subset of our patients appears to experience attacks at an even higher rate of more than twice a month, and was therefore named extreme PFAPA, or ePFAPA group.

Objectives

To characterize this group both demographically and clinically in order to compare them to the non-extreme PFAPA (nPFAPA) group.

Methods

We retrospectively reviewed the medical records of patients with PFAPA that were treated in the Schneider Children’s Medical Center of Israel from 3/2014 to 4/2021. Patients with concomitant familial Mediterranean fever were excluded. Thereafter the ePFAPA and nPFAPA groups were compared using Wilcoxon rank sum, Pearson’s chi-squared and Fisher’s exact tests.

Results

47 patients (12.9%) out a total of 365 PFAPA patients were included in the ePFAPA group. Compared to the nPFAPA group, ePFAPA patients had earlier disease onset (age 1.7 vs 2.96 years, P<0.001) and diagnosis (age 2.94 vs 5.02 years, P<0.001). Moreover, after initiation of an abortive treatment with corticosteroids, ePFAPA patients had higher increased flares frequency (72% vs 40%, P<0.001) and were treated with colchicine prophylaxis more often (67% vs 26%, P<0.001). Other clinical and demographic aspects were not significantly different between the two groups.

Conclusion

EPFAPA patients are a subset of patients who have earlier onset and diagnosis of PFAPA, and also increased flares frequently after abortive therapy with steroids. Current study is underway to describe the long-term outcome of this group.

References

[1]Periodic Fever, Aphthosis, Pharyngitis, and Adenitis Syndrome: Analysis of Patients From Two Geographic Areas

Batu E, Kara Eroğlu F, Tsoukas P, Hausmann J, Bilginer Y, Kenna M, Licameli G, Fuhlbrigge R, Özen S, Dedeoğlu F

Arthritis Care and Research (2016) 68(12)

[2]POS1326 FAMILIAL PERIODIC FEVER, APHTHOUS STOMATITIS, PHARYNGITIS AND ADENITIS (PFAPA) SYNDROME; IS IT A SEPARATE DISEASE?

Butbul Y

Annals of the Rheumatic Diseases (2021) 80(Suppl 1)

[3]PFAPA syndrome is not a sporadic disease

Cochard M, Clet J, Le L, Pillet P, Onrubia X, Guéron T, Faouzi M, Hofer M

Rheumatology (2010) 49(10)

[4]PFAPA syndrome in children: A meta-analysis on surgical versus medical treatment

Peridis S, Pilgrim G, Koudoumnakis E, Athanasopoulos I, Houlakis M, Parpounas K

International Journal of Pediatric Otorhinolaryngology

[5]The First International Conference on Periodic Fever, Aphthous Stomatitis, Pharyngitis, Adenitis Syndrome

Harel L, Hashkes P, Lapidus S, Edwards K, Padeh S, Gattorno M, Marshall G

Journal of Pediatrics (2018) 193

[6]Long-term follow-up of children with periodic fever, aphthous stomatitis, pharyngitis, and cervical adenitis syndrome

Wurster V, Carlucci J, Feder H, Edwards K

Journal of Pediatrics (2011) 159(6)

[7]Periodic fever, aphthous stomatitis, pharyngitis, and adenopathy syndrome: Clinical characteristics and outcome

Padeh S, Brezniak N, Zemer D, Pras E, Livneh A, Langevitz P, Migdal A, Pras M, Passwell J

Journal of Pediatrics (1999) 135(1)

[8]Risk factors for periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome: a case-control study

Kettunen S, Lantto U, Koivunen P, Tapiainen T, Uhari M, Renko M

European Journal of Pediatrics (2018) 177(8)

[9]A clinical review of 105 patients with PFAPA (a periodic fever syndrome)

Feder H, Salazar J

Acta Paediatrica, International Journal of Paediatrics

Disclosure of Interests

None declared

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

POS1294 EFFECT OF EMOTIONAL TRIGGERS ON THE FREQUENCY OF PFAPA ATTACKS - A MULTICENTER STUDY

Background:

The fact that mental state may serve as a trigger for attacks of periodic fever diseases is known in Familial Mediterranean fever (FMF). There is a lack of information regarding the role of emotional triggers for PFAPA attacks.

Objectives:

To examine whether emotional distress may trigger PFAPA attacks.

Methods:

Enrolled were patients with active PFAPA, from two Israeli medical centers. Researchers contacted their parents by phone in two occasions: a. within the two weeks of returning to school after the first COCID-19 lockdown; b. during the summer vacation (i.e., non-stressful period). Parents were asked regarding the occurrence of PFAPA attacks within the two weeks preceding the calls. The relative stress levels of the two periods were validated by an emotional distress scale questionnaire. Differences between occurrences of attacks during these two periods of time were recorded.

Results:

One-hundred and six pediatric patients enrolled in the study. Mean age was 7.37± 2.9. In the stressful period, 41 (38.7%) reported at least one attack during the preceding 2 weeks, compared to 24 (22.6%) in the non-stressful period (p = 0.017). Scores for the mean emotional distress questionnaire were higher in the stressful period compared to the non-stressful period (35.6± 8.1 vs. 32.1± 7.7, respectively, P = 0.047).

Conclusion:

This study shows that during a period of stress for children there were more PFAPA attacks compared to a relaxed period. These findings indicate that mental factors such as stress or excitement may be triggers for PFAPA attacks.

Table 1.

Attacks status during prior 2 weeks during stressful or non-stressful event

OutcomeFirst call(May 2020)Second call (August 2020)P-valuePediatric emotional distress score (PEDS), mean (±SD)35.6 (±8.1)32.1 (±7.7)0.047Any attacks during last 2 week, n (%)41 (39.8%)24 (24.2%)0.017Number of attacks0.04 One, n (%)27 (25.5%)19 (17.9%) Two, n (%)14 (13.2%)5 (4.7%)

References:

[1]Marshall GS, Edwards KM, Butler J, Lawton AR. Syndrome of periodic fever, pharyngitis, and aphthous stomatitis. J Pediatr. 1987;110(1):43-46. doi:10.1016/S0022-3476(87)80285-8

[2]Feder HM, Salazar JC. A clinical review of 105 patients with PFAPA (a periodic fever syndrome). Acta Paediatr Int J Paediatr. 2010;99(2):178-184. doi:10.1111/j.1651-2227.2009.01554.x

[3]Hall, J, Lindorff A. Children’s Transition to School: Relationships Between Preschool Attendance, Cortisol Patterns, and Effortful Control. The Educational and Developmental Psychologist. Educ Dev Psychol. 2017;34(1):1-18

[4]Stokes SJ, Saylor CF, Swenson CC, Daugherty TK. A comparison of children’s behaviors following three types of stressors. Child Psychiatry Hum Dev. 1995;26(2):113-123. doi:10.1007/BF02353235

[5]Førsvoll J, Kristoffersen EK, Øymar K. The immunology of the periodic fever, aphthous stomatitis, pharyngitis and cervical adenitis syndrome; what can the tonsils reveal. A literature review. Int J Pediatr Otorhinolaryngol. 2020;130. doi:10.1016/j.ijporl.2019.109795

[6]Gidron Y, Berkovitch M, Press J. Psychosocial correlates of incidence of attacks in children with Familial Mediterranean Fever. J Behav Med. 2003;26(2):95-104. doi:10.1023/A:1023038504481

[7]Makay B, Emiroğlu N, Ünsal E. Depression and anxiety in children and adolescents with familial Mediterranean fever. Clin Rheumatol. 2010;29(4):375-379. doi:10.1007/s10067-009-1330-9

[8]Kraszewska-Głomba B, Matkowska-Kocjan A, Szenborn L. The Pathogenesis of Periodic Fever, Aphthous Stomatitis, Pharyngitis, and Cervical Adenitis Syndrome: A Review of Current Research. Mediators Inflamm 2015;2015:563876. doi:10.1155/2015/563876

Disclosure of Interests:

None declared

POS0079 PATIENTS WITH JUVENILE SYSTEMIC SCLEROSIS HAVE A DISTINCT PATTERN OF ORGAN INVOLVEMENT.RESULTS FROM THE JUVENILE SYSTEMIC SCLEROSIS INCEPTION COHORT. WWW.JUVENILE-SCLERODERMA.COM

Background:

Juvenile systemic sclerosis (jSSc) is a rare disease with a prevalence of around 3 in 1,000,000 children. To better capture the clinical manifestations of jSSc the juvenile systemic sclerosis inception cohort (jSScC) has been prospectively enrolling patients with predetermined clinical variables over the past 12 years. One of the goals is to study the demographic, clinical features, and physician and patient reported outcome differences between those with juvenile limited cutaneous (lc) compared to diffuse cutaneous (dc) disease subtypes, to determine if characteristics are similar or different between dc and lc jSSc.

Objectives:

Evaluation of the baseline clinical characteristics of jSSc patients in the jSScC. Compare clinical phenotype between diffuse (dcjSSc) and limited cutaneous (lcjSSc) subtypes.

Methods:

Demographic, physical examination, organ system evaluation, autoantibody profile, treatment, and patient and physician reported outcome variables were evaluated from the jSSc Inception cohort and summary statistics applied using chi-square test and Mann Whitney U-test comparing lcjSSc and dcjSSc subtypes.

Results:

At the time of data extraction, 175 jSSc patients were enrolled in the cohort, 81% were Caucasian and 81% female. Diffuse cutaneous jSSc subtype predominated (73%). Mean disease duration was 3.1 year (±2.7). Mean age at Raynaud´s was 10 years (+3.8) and mean age of first non-Raynaud´s was 10.2 years (±3.8). Significant differences were found between dcjSSc versus lcjSSc, regarding several clinical characteristics. Patients with diffuse cutaneous subtype had significantly higher modified Rodnan skin score (p=0.001), presence of sclerodactyly (p=0.02), presence of Gottron’s papules (p=0.003), presence of telangiectasia (p=0.001), history of digital tip ulceration (p=0.01), and frequency of elevated CK value (p=0.04). Cardiac involvement was significantly higher in limited cutaneous jSSc subtype (p=0.02). Diffuse cutaneous jSSc patients had significantly worse scores for Physician Global Assessment of disease activity (38 vs 25; p=0.002) and disease damage (34 vs 19; p=0.008).

Table 1.

Comparison of demographic data and significant differences between dcjSSc and lcjSSc at time of inclusion

Whole CohortN=175Diffuse SubtypeN=128Limited SubtypeN=47P valueFemale to Male Ratio4.3:1 (142/33)4.1:1 (103/25)4.8:1 (39/8)0.829Cutaneous subtypeDiffuse subtype73% (128)1280Limited subtype27% (47)047Mean Disease duration (years)3.1 (± 2.7)3.3 (± 2.9)2.6 (± 2.2)0.135Mean age of onset of Raynaud´s (years)10.0 (± 3.8)17 non-Raynaud9.8 (± 3.6)10 non-Raynaud10.6 (± 4.3)7 non-Raynaud0.219Mean age of onset of non-Raynaud´s (years)10.2 (± 3.9)10.0 (± 3.7)10.9 (± 4.3)0.173Disease modifying drugs88% (154)89% (114)85% (40)0.446CutaneousMean modified Rodnan skin score14.3 (0-51)17.4 (0-51)6.1 (0-24)0.001Gottron Papules27% (46/171)33% (41/124)11% (5)0.003Sclerodactyly78% (126/162)82% (98/119)65% (28/43)0.020Laboratory valuesElevated CK25% (30/122)30% (26/88)12% (4/34)0.041VascularTelangiectasia36% (56/154)44% (49/111)16% (7/43)0.001History of ulceration53% (91/173)61% (77/127)30% (14/46)0.001CardiacCardiac Involvement6% (10)2% (3)15% (7)0.002Patient Related OutcomesPhysician global disease activity(0-100) min -max35(0-90) n=14138(0-90) n=10825(0-80) n=330.002Physician global disease damage(0-100) min -max31(0-85) n=14034(0-85) n=10819(0-60) n=320.008

Conclusion:

Results from this large international cohort of jSSc patients demonstrate significant differences between dcjSSc and lcjSSc patients. According to the general organ involvement and physician global scores, the dcjSSc patients had significantly more severe disease. These observations strengthen our previous findings of the unique organ pattern of pediatric patients.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests:

None declared.

POS1304 JUVENILE SYSTEMIC SCLEROSIS (JSSC) PATIENTS WITH OVERLAP CHARACTERISTICS DO NOT HAVE MILD DISEASE. RESULTS FROM THE JSSC INCEPTION COHORT. WWW.JUVENILESCLERODERMA.COM

Background:

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence of around 3 in 1, 000,000 children. It is known that in pediatric jSSc cohorts, there are a significant number of patients with overlap features, such as arthritis and myositis. However, the disease burden between those with and without overlap features in jSSc has not been defined.

Objectives:

Compare the clinical phenotype between children with and without overlap features in the juvenile systemic scleroderma inception cohort (jSScC).

Methods:

A cross-sectional study was performed using baseline visit data. Demographic, organ system evaluation, autoantibody profile, treatment, and patient and physician reported outcome variables were extracted from jSScC. Comparison between patients with and without overlap features was performed using chi-square test and Mann Whitney U-test.

Results:

At the time of data extraction, 175 jSSc patients were enrolled in the cohort, 81% were Caucasian and 81% female. Mean disease duration was 3.1 year (±2.7). Mean age at Raynaud´s onset was 10 years (±3.8) and mean age of first non-Raynaud´s was 10.2 years (±3.8). Overlap features occurred 17% (n=30) of the cohort, 12.5% in the diffuse cutaneous (dc) jSSc and in 30% in the limited cutaneous (lc) jSSc. Significant differences in clinical characteristics were found between those patients with compared to without overlap characteristics. Patients with overlap features presented more frequently with Gottron papules (p=0.007), swollen joints (p=0.019), muscle weakness (p=0.003), and lung involvement documented by decreased DLCO < 80% (p=0.06) and/or abnormal high resolution computed tomography (p=0.049). Anti-PM/Scl autoantibodies were also more common in this group (p=0.001). Significantly more patients without overlap features had Raynaud´s (p=0.006). Physician Global Assessment of disease activity was significantly higher in patients with overlap features (41 vs 34; p=0.041). (Table 1.)

Table 1.

Demographic and clinical characteristics of jSSc patients with and without overlap features.

Whole CohortN=175Patients without overlapN=145Patients with overlapN=30P valueFemale to Male Ratio 4.3:1(142/33)4:1(116/29)6.5:1(26/4)0.395Cutaneous subtypeDiffuse subtype (N)73% (128)11216Limited subtype (N)27% (47)3317Mean disease duration (years)3.1 (± 2.7)3.2 (± 2.8)3.1 (± 2.2)0.291Mean age of onset of Raynaud´s (years)10.0 (± 3.8)17 non-Raynaud10.0 (± 3.8)10 non-Raynaud10.0 (± 3.7)7 non-Raynaud0.931Mean age of onset of non-Raynaud´s (years)10.2 (± 3.8)10.2 (± 3.9)9.8 (± 3.7)Disease modifying drugs (N)88% (154) 89% (129)83% (25)0.388Raynaud´s phenomenon90% (158)93% (135)77% (23)0.006Anti-PMScl18% (12/68)9% (5/53)47% (7/15)0.001Gottron Papules (N)27% (46/171)23% (33/144)48% (13/27)0.007DLCO <80% (N)44% (39/88)39% (28/71)65% (11/17)0.06Abnormal findings in HRCT (N)44% (59/133)40% (43/107)62% (16/26)0.049Proportion of patients with swollen joints 18% (32) 14% (21) 37% (11)0.019Muscle Weakness (N) 21% (31/149)16% (20/123) 42% (11/26)0.003Physician global disease activity(0-100) min -max35 (0-90) n=14134 (0-90) n=11441 (0-80) n=270.041

Conclusion:

Results from this large international cohort of jSSc patients demonstrate significant differences between patients with and without overlap features. Patients with overlap have significantly more interstitial lung disease and more physician rated disease activity and should not be considered to have more “mild disease”.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests:

None declared

POS1295 PERFORMANCE OF 2019 EULAR/ACR CLASSIFICATION CRITERIA FOR SYSTEMIC LUPUS ERYTHEMATOSUS IN A PEDIATRIC POPULATION – A MULTICENTER STUDY

Background:

The “European League Against Rheumatism” and “American College of Rheumatology” 2019 (EULAR/ACR-19) criteria for the diagnosis of Systemic Lupus Erythematosus (SLE) were recently published, with the stated goal of maintaining the level of sensitivity and raising the level of specificity for classification of SLE in adults.

Objectives:

We aimed to examine the function of the new EULAR/ACR-19 criteria in a population of children and compare them to the SLICC-12 and ACR-97 criteria.

Methods:

In this multicenter study the charts of jSLE patients from three tertiary medical centers were reviewed and compared to patients with non-jSLE diagnosis. Pediatric rheumatologists, blinded to the original diagnosis, reviewed and diagnosed all cases. Pediatric patients’ clinical and laboratory data were retrospectively extracted and then examined with regard to how they met the new and old criteria.

Results:

Included were 225 patients (112 jSLE, 113 non-SLE). When applied to juvenile SLE classification, the sensitivity of the new EULAR/ACR-19 criteria was 0.96 (0.9-.0.99) and the specificity was 0.89 (0.82-0.94). These were comparable to the Systemic Lupus International Collaborating Clinics (SLICC) criteria. The sensitivity of the EULAR/ACR-19 criteria improves over time and was 0.83 twelve months following disease onset, reaching 0.96 after longer than 24 months.

Conclusion:

Among a cohort of jSLE patients, sensitivity of the new EULAR/ACR-19 criteria was found to be high and specificity may have improved slightly compared to the SLICC-12 criteria. We support the use of the new classification criteria for pediatric patients in future jSLE studies, but it should be noted that its specificity is lower than for adults.

ACR-97SLICC-12EULAR/ACR-19Sensitivity (95% CI)0.79 (0.70-0.86)0.96 (0.9-0.99)0.96 (0.9-.0.99)Specificity (95% CI)0.94 (0.88-0.97)0.85 (0.77-0.91)0.89 (0.82-0.94)Accuracy (95% CI)0.86 (0.81-0.9)0.9 (0.86-0.94)0.92 (0.88-.0.96)Positive Likelihood Ratio (95% CI)12.7(6.1-26.2)6.35(4.1-9.9)9.0 (5.3-15.4)Negative Likelihood Ratio (95% CI)0.23(0.16-0.33)0.05(0.02-0.12)0.05(0.02-0.12)Diagnostic odds ratio (95% CI)55.5(22.80-135.0)120.85(43.0-340.0)180.1(61.3-529.4)

References:

[1]Smith EMD, Lythgoe H, Midgley A, Beresford MW, Hedrich CM. Juvenile-onset systemic lupus erythematosus: Update on clinical presentation, pathophysiology and treatment options. Clin Immunol 2019 published on December 2019. doi: 10.1016/j.clim.2019.108274

[2]Massias JS, Smith EMD, Al-Abadi E, Armon K, Bailey K, Ciurtin C, et al. Clinical and laboratory characteristics in juvenile-onset systemic lupus erythematosus across age groups. Lupus 2020;29(5):474–81.

[3]Hochberg MC. Updating the American College of Rheumatology revised criteria for the classification of systemic lupus erythematosus. Arthritis Rheum. 1997 Sep;40(9):1725

[4]Petri M, Orbai AM, Alarcõn GS, Gordon C, Merrill JT, Fortin PR, et al. Derivation and validation of the systemic lupus international collaborating clinics classification criteria for systemic lupus erythematosus. Arthritis Rheum 2012 Aug;64(8):2677-86

[5]Hartman EAR, van Royen-Kerkhof A, Jacobs JWG, Welsing PMJ, Fritsch-Stork RDE. Performance of the 2012 Systemic Lupus International Collaborating Clinics classification criteria versus the 1997 American College of Rheumatology classification criteria in adult and juvenile systemic lupus erythematosus. A systematic review and meta-an. Autoimmun Rev. 2018;17(3):316–22.

[6]Aringer M, Costenbader K, Daikh D, Brinks R, Mosca M, Ramsey-Goldman R, et al. 2019 European League Against Rheumatism/American College of Rheumatology Classification Criteria for Systemic Lupus Erythematosus. Arthritis Rheumatol 2019;71(9):1400–12.

Disclosure of Interests:

None declared

THU0499 IS THERE A DIFFERENT PRESENTATION OF JUVENILE SYSTEMIC DIFFUSE AND LIMITED SUBSET? DATA FROM THE JUVENILE SCLERODERMA INCEPTION COHORT. WWW.JUVENILE-SCLEORDERMA.COM

Background:

Juvenile systemic scleroderma (jSSc) is an orphan disease with a prevalence of 3 per 1 000 000 children. There are limited data regarding the clinical presentation of jSSc. The Juvenile Systemic Scleroderma Inception Cohort (JSSIC) is the largest multinational registry that prospectively collects information about jSSc patients.

Objectives:

Evaluation of the jSSc patients at the time of inclusion in the JSSIC.

Methods:

Patients were included in the JSSIC if they fulfilled the adult ACR/EULAR classification criteria for systemic scleroderma, if they presented the first non-Raynaud symptom before 16 years of age and if they were younger than 18 years of age at time of inclusion. Patients’ characteristics at time of inclusion were evaluated.

Results:

Until 15thof December 2019 hundred fifty patients were included, 83% of them being Caucasian and 80% female. The majority had the diffuse subtype (72%) and 17% of all jSSc had overlap features. The mean age of first presentation of Raynaud´s phenomenon was 9.8 years in the diffuse subtype (djSSc) and 10.7 years in the limited subtype (ljSSc) (p=.197). The mean age at first non-Raynaud’s symptoms was 10.0 years in the djSSc and 11.2 years in the ljSSc (p=0.247). Mean disease duration at time of inclusion was 3.4 years in the djSSc and 2.4 years in the ljSSc group.

Significant differences were found between the groups regarding mean modified Rodnan skin score, 18.2 in the djSSc vs 6.2 in the ljSSc (p=0.02); presence of Gottron´s papulae (djSSc 30% vs ljSSc 13%, p=0.43);presence of teleangiectasia (djSSc 42% vs 18% ljSS, p=0.01); history of ulceration (djSSc 42% vs 18% ljSSc,p=0.008); 6 Minute walk test below the 10thpercentile (djSSc 85% vs ljSSc 54%, p=0.044), total pulmonary involvement (djSSc 49% vs ljSSc 31%, p=0.045), cardiac involvement (ljSSc 17% vs djSSc 3%, p=0.002). djSSc patients had significantly worse scores for Physician Global Assessment of disease activity compared to ljSSc patients (VAS 0-100) (40 vs 15) (p=0.001) and for Physician Global Assessment of disease damage (VAS 0-100) (36 vs 17) (p=0.001).

There were no statistically significant differences in the other presentations. Pulmonary hypertension occurred in approximately 6% in both groups. No systemic hypertension or renal crisis was reported. ANA positivity was 90% in both groups. Anti-Scl70 was positive in 35% in djSSc and 36% in the ljSSc group. Anticentromere positivity occurred in 3% in the djSSc and 7% in the ljSSc group.

Conclusion:

In this unique large cohort of jSSc patients there were significant differences between djSSc and ljSSc patients at time of inclusion into the cohort regarding skin, vascular, pulmonary and cardiac involvement. According to the physician global scores the djSSc patients had a significantly more severe disease. Interestingly the antibody profile was similar in both scleroderma phenotypes.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests: :

Ivan Foeldvari Consultant of: Novartis, Jens Klotsche: None declared, Ozgur Kasapcopur: None declared, Amra Adrovic: None declared, Kathryn Torok: None declared, Maria T. Terreri: None declared, Ana Paula Sakamoto: None declared, Valda Stanevicha: None declared, Flávio R. Sztajnbok: None declared, Jordi Anton Grant/research support from: grants from Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Grant/research support from: Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Consultant of: Novartis, Sobi, Pfizer, abbvie, Consultant of: Novartis, Sobi, Pfizer, abbvie, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Brian Feldman Consultant of: DSMB for Pfizer, OPTUM and AB2-Bio, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Maria Katsikas: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, edoardo marrani: None declared, Mikhail Kostik: None declared, Natalia Vasquez-Canizares: None declared, Simone Appenzeller: None declared, Mahesh Janarthanan: None declared, Monika Moll: None declared, Dana Nemcova: None declared, Anjali Patwardhan: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Sujata Sawhney: None declared, Dieneke Schonenberg: None declared, Cristina Battagliotti: None declared, Lillemor Berntson Consultant of: paid by Abbvie as a consultant, Speakers bureau: paid by Abbvie for giving speaches about JIA, Blanca Bica: None declared, Juergen Brunner Grant/research support from: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Abbvie, Roche, BMS, Speakers bureau: Pfizer, Novartis, Abbvie, Roche, BMS, Patricia Costa Reis: None declared, Despina Eleftheriou: None declared, Liora Harel: None declared, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Daniela Kaiser: None declared, Dragana Lazarevic: None declared, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche, Susan Nielsen: None declared, Farzana Nuruzzaman: None declared, Yosef Uziel: None declared, Nicola Helmus: None declared

FRI0454 UNDER DETECTION OF INTERSTITIAL LUNG DISEASE IN JUVENILE SYSTEMIC SCLEROSIS (JSSC) UTILIZING PULMONARY FUNCTION TESTS. RESULTS FROM THE JUVENILE SCLERODERMA INCEPTION COHORT

Background:

Juvenile systemic sclerosis (jSSc) is an orphan disease with a prevalence in around 3 in a million children. Pulmonary involvement in jSSc occurs in approximately 40 % in the inception cohort. Traditionally in jSSc, pulmonary function testing (PFT) with FVC and DLCO are used for screening and computed tomography (HRCT) was more reserved for those with abnormal PFTs. More recently, it has become apparent that PFTs might not be sensitive enough for detecting ILD in children.

Objectives:

Utilizing a prospective international juvenile systemic scleroderma cohort (JSScC) [2], to determine if pulmonary screening with FVC and DLCO is sufficient enough to assess the presence of interstitial lung disease in comparison to CT evaluation.

Methods:

The international juvenile systemic scleroderma cohort database was queried for available patients with recorded PFT parameters and HRCT performed to determine sensitivity of PFTs detecting disease process.

Results:

Of 129 patients in the jSScC, 67 patients had both CT imaging and an FVC reading from PFTs for direct comparison. DLCO readings were also captured but not in as many patients with tandem HRCT (n =55 DCLO and HRCT scan). Therefore, initial analyses focused on the sensitivity, specificity and accuracy of the FVC value from the PFTs to capture the diagnosis of interstitial lung disease as determined by HRCT.

Overall, 49% of the patients had ILD determined by HRCT, with 60% of patients having normal FVC (>80%) with positive HRCT findings, and 24% of patients having normal DLCO (> 80%) with positive HRCT findings. Fourteen percent (n = 3/21) of patients with both FVC and DLCO values within the normal range had a positive HRCT finding.

Conclusion:

The sensitivity of the FVC in the JSScC cohort in detecting ILD was only 39%. Relying on PFTs alone for screening for ILD in juvenile systemic sclerosis would have missed the detection of ILD in almost 2/3 of the sample cohort, supporting the use of HRCT for detection of ILD in children with SSc. In addition, the cut off utilized, of less than 80% of predicted FVC or DLCO could be too low for pediatric patients to exclude beginning ILD. This pilot data needs confirmation in a larger patient population.

Supported by the “Joachim Herz Stiftung”

Disclosure of Interests:

Ivan Foeldvari Consultant of: Novartis, Bernd Hinrichs: None declared, Kathryn Torok: None declared, Maria Jose Santos Speakers bureau: Novartis and Pfizer, Ozgur Kasapcopur: None declared, Amra Adrovic: None declared, Valda Stanevicha: None declared, Flávio R. Sztajnbok: None declared, Maria T. Terreri: None declared, Ana Paula Sakamoto: None declared, Ekaterina Alexeeva Grant/research support from: Roche, Pfizer, Centocor, Novartis, Speakers bureau: Roche, Novartis, Pfizer., Jordi Anton Grant/research support from: grants from Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Grant/research support from: Pfizer, abbvie, Novartis, Sobi. Gebro, Roche, Novimmune, Sanofi, Lilly, Amgen, Consultant of: Novartis, Sobi, Pfizer, abbvie, Consultant of: Novartis, Sobi, Pfizer, abbvie, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Speakers bureau: abbvie, Pfizer, Roche, Novartis, Sobi, Gebro, Maria Katsikas: None declared, Vanessa Smith Grant/research support from: The affiliated company received grants from Research Foundation - Flanders (FWO), Belgian Fund for Scientific Research in Rheumatic diseases (FWRO), Boehringer Ingelheim Pharma GmbH & Co and Janssen-Cilag NV, Consultant of: Boehringer-Ingelheim Pharma GmbH & Co, Speakers bureau: Actelion Pharmaceuticals Ltd, Boehringer-Ingelheim Pharma GmbH & Co and UCB Biopharma Sprl, Rolando Cimaz: None declared, Mikhail Kostik: None declared, Simone Appenzeller: None declared, Mahesh Janarthanan: None declared, Monika Moll: None declared, Dana Nemcova: None declared, Dieneke Schonenberg: None declared, Cristina Battagliotti: None declared, Lillemor Berntson Consultant of: paid by Abbvie as a consultant, Speakers bureau: paid by Abbvie for giving speaches about JIA, Blanca Bica: None declared, Juergen Brunner Grant/research support from: Pfizer, Novartis, Consultant of: Pfizer, Novartis, Abbvie, Roche, BMS, Speakers bureau: Pfizer, Novartis, Abbvie, Roche, BMS, Patricia Costa Reis: None declared, Despina Eleftheriou: None declared, Liora Harel: None declared, Gerd Horneff Grant/research support from: AbbVie, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Speakers bureau: AbbVie, Bayer, Chugai, Merck Sharp & Dohme, Novartis, Pfizer, Roche, Dragana Lazarevic: None declared, Kirsten Minden Consultant of: GlaxoSmithKline, Sanofi, Speakers bureau: Roche, Susan Nielsen: None declared, Farzana Nuruzzaman: None declared, Anjali Patwardhan: None declared, Yosef Uziel: None declared, Nicola Helmus: None declared

Iloprost treatment for refractory Raynaud's phenomenon in two infants

Raynaud's phenomenon (RP) is rare in young children. We describe two infants with severe RP, manifesting as fingertip necrosis, who were resistant to conventional vasodilators and were treated successfully with iloprost, a prostacyclin analogue. The application of iloprost is safe and should be considered in children with threatening ischemic digits.

Treatment of Achilles tendon calcinosis in juvenile dermatomyositis with external ilizarov fixator

Calcinosis is a devastating complication of juvenile dermatomyositis and a challenging therapeutic problem. We report the use of an external Ilizarov fixator for the treatment of Achilles tendon calcinosis causing severe disability in a young girl with juvenile dermatomyositis.

Outcome of a national Israeli cohort of pediatric systemic lupus erythematosus

The aim of this study was to describe the clinical manifestations and outcomes of a national cohort of childhood systemic lupus erythematosus (cSLE). All cases of cSLE registered in the Israeli national registry of children with rheumatic diseases between 1987-2003 were examined for disease activity and damage by the SLE disease activity index (SLEDAI) and SLE collaborating clinics/American College of Rheumatology (SLICC/ACR) damage index. Demographic, clinical, laboratory and treatment factors were analysed for their effect on the outcome. One-hundred and two patients were identified, 81% females, with a mean age at diagnosis of 13.3 +/- 2.6 years. The mean SLEDAI score was 17.2 +/- 9.0 (range 2-60). Fifty four patients were followed for at least five years. The mean SLEDAI decreased to 7.6 +/- 6.3 (0-29) and the mean SLICC/ACR damage index was 0.7 +/- 1.6 (0-8). Five patients developed chronic renal failure. No patients died. No factors were found to be significantly associated with the outcome except the initial SLEDAI score. The five-year outcome of our national cSLE cohort was good; with relatively low activity and minimal damage in most patients. The initial SLEDAI predicted the development of late damage.

Protracted febrile myalgia in children and young adults with familial Mediterranean fever: analysis of 15 patients and suggested criteria for working diagnosis

OBJECTIVES

To present an analysis of patients with protracted febrile myalgia (PFM), a rarely reported manifestation of familial Mediterranean fever (FMF), and propose clinical criteria for working diagnosis.

METHODS

A multicenter retrospective cohort study of children with PFM was performed. Clinical and laboratory data were obtained by medical record review.

RESULTS

The study group included 15 patients with PFM. PFM occurred as the presenting sign of FMF in 33%. FMF was diagnosed clinically in all and by genetic analysis in 93%. M694V allelic involvement was noted in 93% of the patients. PFM occurred at a mean age of 9 +/- 3.4 years and was characterized by severe generalized muscle pain in all patients and fever in 71%. Mean duration up to diagnosis was 15.5 +/- 6 days. Mean erythrocyte sedimentation rate was 104 +/- 26 mm/h; mean C-reactive protein was 15.4 +/- 6.3 mg%. Creatine kinase was normal. Treatment included corticosteroids (4 patients) and nonsteroidal anti-inflammatory drugs (NSAIDs) (9 patients) with a symptomatic relief achieved at a mean of 7.7 +/- 4.3 days and 5 +/- 3.8 days, respectively (p = 0.14) (mean severity score 3 and 2.2, respectively, p = 0.075). Symptomatic relief in 2 untreated patients was achieved at a mean of 45.5 days.

CONCLUSION

Based on our data, we propose criteria for working diagnosis including: severe disabling myalgia of at least 5 days in a young patient with FMF, associated with fever, elevated levels of inflammatory markers and presence of at least one M694V mutation.

Antiphospholipid syndrome and recurrent thrombosis in children

OBJECTIVE

Few studies have addressed antiphospholipid syndrome (APS) among children. Our aims were to analyze the clinical and laboratory manifestations in a pediatric APS cohort and to assess the influence of inherited thrombophilia factors on the outcome of children with APS.

METHODS

This was a multicenter study of children with APS who had no previous systemic autoimmune disease. We retrospectively reviewed their clinical and laboratory data, including hereditary thrombophilic deficits and outcomes.

RESULTS

The cohort comprised 28 patients (17 females, mean +/- SD age at onset 10.6 +/- 6.1 years). The most common initial manifestations of APS were venous thrombosis, stroke, and thrombocytopenia. Lupus anticoagulant was detected in 96% of those tested. After a mean +/- SD followup of 5.7 +/- 4.8 years, 16 children (57.1%) had central nervous system disease, 9 exhibited hematologic involvement, and 5 (all females) had systemic lupus erythematosus (SLE). None had renal, heart, or new skin disease. Seven of 24 patients exhibiting vascular thrombotic events had recurrences. Infants with perinatal stroke had monophasic disease, and other manifestations of APS did not develop later. Hereditary thrombophilia was more common in children who experienced a single episode of APS (8 [53.3%] of 15 patients) than in those who experienced recurrences (2 [28.6%] of 7 patients). However, only 2 patients in the latter group (28.6%) received anticoagulants after the first manifestation, compared with 12 (70.6%) of the 17 patients without recurrences.

CONCLUSION

APS in children has unique features. SLE may develop in a significant percentage of girls presenting with APS. Hereditary thrombophilia did not predict recurrent thrombosis, whereas the preventive impact of anticoagulant treatment following the first thrombotic event was noteworthy.

Bacterial susceptibility to oral antibiotics in community acquired urinary tract infection

BACKGROUND

The most common oral antibiotics used in the treatment of urinary tract infection (UTI) are sulphonamides and cephalosporins, but emerging resistance is not unusual.

AIMS

To assess the change in susceptibility of urinary pathogens to oral antibiotics during the past decade in children with community acquired UTI.

METHODS

The study sample included two groups of children with a first community acquired UTI: 142 children enrolled in 1991 and 124 enrolled in 1999. UTI was diagnosed by properly collected urine specimen (suprapubic aspiration, transurethral catheterisation, or midstream specimen in circumcised males) in symptomatic patients. Antimicrobial susceptibility of the isolates was compared between the two groups.

RESULTS

The pathogens recovered in the two groups were similar: in 1991--E coli 86%, Klebsiella 6%, others 8%; in 1999--E coli 82%, Klebsiella 13%, and others 5%. A slight but generalised decrease in bacterial susceptibility to common antibiotics in the two groups was shown: ampicillin 35% versus 30%; cephalexin 82% versus 63% (p < 0.001); nitrofurantoin 93% versus 92%. The only exception was co-trimoxazole, 60% versus 69%. Overall resistance to antibiotics in 1999 was as follows: ampicillin 70%, cephalexin 37%, co-trimoxazole 31%, amoxicillin-clavulanate 24%, nitrofurantoin 8%, cefuroxime-axetil 5%, nalidixic acid 3%.

CONCLUSIONS

This study shows a slight but generalised decrease in bacterial susceptibility to common oral antibiotics in the past decade in our population. Empirical initial treatment with co-trimoxazole or cephalexin is inadequate in approximately one third of UTI cases. A larger number of pathogens may be empirically treated with amoxicillin-clavulanate (24% resistance); 95% of organisms are susceptible to cefuroxime-axetil.

Familial infantile bilateral striatal necrosis: clinical features and response to biotin treatment

BACKGROUND

Infantile bilateral striatal necrosis (IBSN) encompasses several syndromes of bilateral symmetric, spongy degeneration of the caudate nucleus, putamen, and globus pallidus. The familial form of IBSN is rare, and inheritance is either autosomal recessive or maternal.

METHOD

The authors describe an Israeli Bedouin kindred in which 15 children born to consanguineous parents were affected with familial IBSN. They evaluated the clinical and radiologic evolution of the disease in 11 patients and the cerebral pathologic findings in one patient. Three of the children were treated with oral biotin 100 mg/day.

RESULTS

Inheritance was apparently autosomal recessive. The untreated children had a similar clinical picture including developmental arrest beginning at the age of 7 to 15 months, choreoathetosis, and dysphagia. Pendular nystagmus appeared at a late stage. MRI, performed at various stages of the disease, showed severe basal ganglia atrophy. Postmortem study in one patient showed severe atrophy of the lenticular nuclei with gliosis and loss of neurons. Biotin, 100 mg/day, administered to the proband over a period of 15 months, may have slowed progression. In two other children treatment was initiated earlier and appeared to arrest or improve disease.

CONCLUSIONS

Familial infantile bilateral striatal necrosis was inherited as an autosomal recessive trait. Clinical features included developmental arrest, dysphagia, and choreoathetosis. Imaging and pathology showed atrophy and degeneration of the basal ganglia. Oral biotin may have benefited three children.

Clinical dysentery in hospitalized children

BACKGROUND

Clinical dysentery is a severe presentation of an enteric infection. The aim of the study was to evaluate the impact of a serious bacterial etiology in clinical dysentery in hospitalized children and determine if children at high risk can be identified on the basis of clinical or laboratory parameters.

PATIENTS AND METHODS

A prospective study design was used. The study population included 60 children admitted to our department with clinical dysentery over a 16-month period. Fresh stool specimens were collected on days 1, 2 and 3. The clinical and laboratory data of the children were analyzed.

RESULTS

Clinical dysentery accounted for 1.7% of all pediatric hospitalizations during this period. Stool cultures were positive for Shigella spp. in 18 children (30%), and Salmonella spp. in 15 children (25%), Campylobacter jejuni was identified in one patient (2%). There were no significant differences in clinical characteristics or laboratory parameters between children with positive and negative stool cultures.

CONCLUSION

40% of the children hospitalized for clinical dysentery were eligible for antibiotic treatment. Early administration of empiric antibiotic treatment is justified in children hospitalized for clinical dysentery in Israel. Clinical or laboratory parameters were unable to differentiate those with clinical dysentery at risk of serous bacterial pathogens in stool.

Presence of the d8/17 B-cell marker in children with rheumatic fever in Israel

A genetic predisoposition to rheumatic fever (RF) has been suspected by several researchers. Ten years ago, using monoclonal antibodies, the B-cell alloantigen D8/17 was identified in 90-100% of patients with RF. The aim of the present study was to evaluate whether the marker is found in patients with RF in Israel, where the population is made up of diverse ethnic groups. The Schneider Children's Medical Center in Petah Tikva, Israel, was the setting for this study. The population included 22 children with RF and nine ethnically matched, disease-free individuals who served as controls. Each of the patients and controls were tested for the B-cell antigen with flow cytometry assay by using monoclonal antibodies. The main outcome measure was the difference in the presence of the D8/17 B-cell marker between the patients with RF and the controls. The mean percentage of B-cells expressing the marker was 11.5 +/- 2.9 in the patients and 4.24 +/- 2.7 in the controls (P < 0.001). There was no statistically significant difference in the frequency of the marker by ethnic origin. The present results support earlier studies suggesting that D8/17 is a disease-specific marker with a world-wide distribution which may potentially serve as an additional diagnostic tool in patients with suspected RF.

Radial osteomyelitis as a complication of venous cannulation

Venepuncture of the superficial veins in the forearm is considered a relatively safe procedure. We report two patients who presented with osteomyelitis of the proximal radius following venous cannulation of the median cubital vein, and one patient who developed osteomyelitis of the distal radius after cannulation of the cephalic vein. Osteomyelitis developing in proximity to a venepuncture site should raise the suspicion that a pathogen causing superficial thrombophlebitis has spread through the deep veins of the arm into the adjacent bone, thus causing osteomyelitis.

Long-Term outcome of neonatal Citrobacter koseri (diversus) meningitis treated with imipenem/meropenem and surgical drainage

Neonatal Citrobacter koseri (diversus) meningitis is often complicated by the formation of brain abscesses and has a poor neurological outcome with seizures, mental retardation and paresis as sequelae in 50% of the cases. As there is emerging resistance to ampicillin, gentamicin and third-generation cephalosporins, we attempted to treat this infection with carbapenems. Carbapenems in combination with cefotaxime and surgical drainage may play an important role in treating C. koseri meningitis.

A syndrome of transient encephalopathy associated with adenovirus infection

BACKGROUND AND OBJECTIVE

Adenovirus is a common pathogen in the pediatric population. Respiratory, gastrointestinal, or renal systems are often involved in adenovirus infections. Several neurologic syndromes have been attributed to adenovirus, such as adenovirus aseptic meningitis, myelitis, subacute focal encephalitis, and Reye-like syndrome. The purpose of this study was to describe the clinical features and encephalography findings in 7 infants treated in our center for a syndrome of transient encephalopathy associated with adenovirus infection.

STUDY PARTICIPANTS

Three females and 4 males ages 7 to 34 months seen in our department between July 1983 and February 1984 and September 1998 and May 1999 presented with fever of at least 7 days' duration and a gradual decline in the state of alertness. Score on the Glasgow Coma Scale ranged from 9 to 12. Findings on lumbar puncture were normal. In all 7 patients, the encephalogram showed moderate to severe background slowing compatible with encephalopathy. All patients were catarrheal and had mild hepatomegaly with slight elevation of liver enzymes. Some had bronchopneumonia, diarrhea, and conjunctivitis either isolated or in combination.

METHODS AND RESULTS

Adenovirus was isolated by immunfluorescence technique in all patients-from the sputum in 3 patients, nasopharynx in 5, conjunctiva in 4, and rectal swab in 5. In 5 patients, serotyping was performed by an antibody neutralization method. Adenovirus type 3 was ascertained from a nasal swab in 1 patient, sputum specimens in 3, throat swab in 3, and rectal cultures in 5. The clinical course was characterized by a progressive recovery of alertness. After several days, there was a complete reversal of neurologic findings.

CONCLUSION

We suggest that this syndrome of transient encephalopathy is a distinct entity and should be considered as another of the several neurologic syndromes known to be associated with adenovirus infection.

Treatment of calcinosis in juvenile dermatomyositis with probenecid: the role of phosphorus metabolism in the development of calcifications

OBJECTIVE

To report the efficacy of probenecid for calcinosis of juvenile dermatomyositis (JDM) and assess the changes in phosphorus metabolism during treatment.

METHODS

Biochemical studies of calcium and phosphorus metabolism were performed in a 9-year-old girl with JDM and extensive calcifications before and during probenecid treatment.

RESULTS

The calcifications resolved over 18 months of treatment. Probenecid was found to be effective in reducing calcifications by increasing renal phosphate clearance.

CONCLUSIONS

The tendency for calcifications in some patients with JDM might be related to an increase in renal phosphate reclamation, and therefore, probenecid treatment may be effective in these patients.

Effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home

Many clinicians advise their patients to increase the dose of inhaled corticosteroids during acute asthma exacerbations, without strong clinical evidence supporting this treatment. This study investigates the effectiveness of inhaled corticosteroids in controlling acute asthma exacerbations in children at home. The study population consisted of children with mild intermittent, mild and moderate persistent asthma aged 1 to 14 years who were treated in our outpatient clinic with inhaled budesonide for 1 year. After participating in an asthma education session, the parents were instructed to initiate treatment with inhaled budesonide at the first signs of asthma exacerbation, starting with 200 to 400 microg budesonide, in combination with beta-2 agonists 4 times a day and followed by a decrease in the dose in 4 to 8 days. Asthma status and peak expiratory flow rates were measured in the 3 monthly follow-up visits. Only children who complied with the treatment regimen and came for follow-up visits regularly were included in the final analysis. One hundred fifty children used our treatment protocol with inhaled budesonide to control their asthma attacks. Clinical improvement of asthma symptoms was achieved after a mean of 1.8 +/- 0.7 days from the beginning of treatment. The parents were able to control 94% of the 1,061 episodes of asthma exacerbation occurring during a cumulative follow-up period of 239 years. In the 3-month period before enrollment, 101 children (67%) had used oral corticosteroids to control their asthma attacks and 50 (33%) were hospitalized. During the entire follow-up period, only 11 children (7%) used oral corticosteroids, and none of the children were hospitalized. The present study demonstrates that children with asthma can control their exacerbations at home using inhaled corticosteroids (budesonide). Treatment, starting with relatively high doses followed by a rapid reduction in dose over 4-8 days, resulted in a decrease in the use of oral steroids and in hospitalization. To achieve good results, patient compliance is essential.

Improvement of atypical acute disseminated encephalomyelitis with steroids and intravenous immunoglobulins

Acute disseminated encephalomyelitis is a demyelinating syndrome that occurs infrequently in children. Various treatment modalities, such as plasmapheresis or steroids or intravenous immunoglobulins (IVIG), have been prescribed. The article describes the results of combined IVIG and high-dose steroids given for 3 days in the treatment of a patient with atypical encephalomyelitis. The results suggest that this approach may be more beneficial than the application of either drug alone.

Pro- and anti-inflammatory cytokines in children with febrile convulsions

The production of interleukin (IL)-1 beta, IL-6, tumor necrosis factor (TNF)-alpha, and IL-10 by peripheral blood mononuclear cells was examined in 13 children with and 11 children without any history of febrile convulsions. The results revealed an increase in all types of cytokine production by lipopolysaccharide-stimulated mononuclear cells from individuals of both groups. However, the secretion of IL-6 and IL-10 in response to lipopolysaccharide was higher in those with a previous history of convulsions. Because IL-1 beta production precedes that of IL-10, a cytokine known to suppress IL-1 beta generation, it is possible that its secretion was inhibited partially by the significantly higher amount of IL-10 found after 24 hours of incubation. If this were the case, these findings may explain the comparable levels of IL-1 beta produced by peripheral blood mononuclear cells from children of both groups. The higher level of IL-1 beta produced by mononuclear cells from children with history of convulsion after 5 hours of incubation with lipopolysaccharide supports this assumption.

Scintigraphic evaluation of calcinosis in juvenile dermatomyositis with Tc-99m MDP

Two children with juvenile dermatomyositis and extensive, debilitating soft tissue calcifications are described. Whole-body bone scans with Tc-99m MDP were performed in both cases before and during specific treatment for the calcinosis. Baseline studies showed marked tracer localization in the soft tissues and provided an objective baseline assessment of the extent of the soft tissue calcifications. Follow-up studies showed gradual clearance of the extraskeletal uptake and were useful in monitoring the therapeutic response. These cases show that skeletal scintigraphy can function as a useful auxiliary tool to evaluate calcinosis in children with juvenile dermatomyositis.

Reversible deafness caused by biotinidase deficiency

We present a child with complete biotinidase deficiency who developed bilateral sensorineural deafness without a response to a maximal stimulus of 90 dB in brainstem acoustic-evoked response. After treatment with 20 mg biotin daily, a repeated brainstem acoustic-evoked response demonstrated an improved hearing threshold of 65 dB, and the child began to talk. The case is a rare example of reversible hearing loss caused by to biotinidase deficiency and highlights the need for immediate replacement therapy once the diagnosis is established.

Successful treatment of rheumatic chorea with carbamazepine

Carbamazepine has been used successfully in the treatment of different movement disorders and was recently reported to be effective for nonhereditary chorea. In view of the significant side effects associated with the drugs currently used to treat chorea, we sought to further evaluate the efficacy of carbamazepine in children with rheumatic chorea. The study was prospective and included 10 children with chorea (eight females and two males; age range = 7-16 years) referred to our Pediatric Rheumatology Clinic between 1995 and 1999. Nine had rheumatic fever and one had antiphospholipid antibody syndrome that later evolved to systemic lupus erythematosus. All were treated with carbamazepine. Improvement was evident within 2-14 days of initiation of low doses of carbamazepine (4-10 mg/kg daily). The plasma drug levels were 2.8-8.2 microg/mL (therapeutic antiepileptic range = 8-12 microg/mL). The chorea disappeared within 2-12 weeks. The duration of treatment was 1-15 months. No side effects were observed. Recurrence was observed in three patients who received a second trial of carbamazepine with a good response. We suggest that carbamazepine may serve as a first-line treatment for rheumatic chorea.

Carbamazepine-induced Stevens-Johnson syndrome treated with IV steroids and IVIG

A 17-year-old female is presented who developed antiepileptic drug hypersensitivity syndrome after treatment with carbamazepine. The initial diagnoses were idiopathic thrombocytopenic purpura and toxic shock syndrome. The patient was treated with intravenous immunoglobulin and intravenous steroids. After a severe climax on days 2-4 she recovered completely and was discharged on the eighth day of hospitalization. Although we do not have direct proof, we believe that these treatment modalities, especially the IVIG, shortened and ameliorated the clinical course of the disease.

Raynaud's phenomenon as a manifestation of parvovirus B19 infection: case reports and review of parvovirus B19 rheumatic and vasculitic syndromes

Infection with human parvovirus B19 is manifested as erythema infectiosum, transient aplastic crisis, or hydrops fetalis. Rheumatic manifestations include arthropathy and various vasculitic syndromes. Isolated Raynaud's phenomenon due to parvovirus B19 has never been described. We report on 2 previously healthy sisters with new-onset Raynaud's phenomenon accompanied by severe generalized polyarthralgia. A full workup was negative, except serology for parvovirus B19, which was positive. All symptoms gradually subsided within 3-5 months, and no recurrence has been noted during the 3 years since onset. We review all the studies in the English-language literature on parvovirus B19-induced rheumatic and vasculitic syndromes. We hypothesize that the pathogenesis of Raynaud's phenomenon in our patients involved immune-mediated endothelial damage leading to platelet activation and vasoconstriction. We recommend that in cases of unexplained Raynaud's phenomenon, serology for parvovirus B19 be included in the evaluation.