Juvenile systemic lupus erythematosus in Turkey: demographic, clinical and laboratory features with disease activity and outcome

Objectives This paper aims to assess in a retrospective fashion the clinical and laboratory features, severity and outcome of juvenile systemic lupus erythematosus (jSLE) from a referral center in Turkey. Methods We have included all jSLE patients ( n = 92) diagnosed according to the revised American College of Rheumatology 1997 criteria between January 2004 and January 2017. Results The most prevalent clinical feature in our cohort was mucocutaneous manifestations (97.8%), followed by constitutional (81.5%), hematological (59.8%) and musculoskeletal manifestations (56.5%). Renal involvement was observed in 38% ( n = 35) of the patients, whereas biopsy-proven lupus nephritis was detected in 29.3% ( n = 27) of the cohort. Neurologic involvement was seen in 15 (16.3%) individuals. Among the patients positive for anticardiolipin IgM and/or IgG ( n = 11, 12%), only three developed antiphospholipid antibody syndrome. The mean SLEDAI-2K scores at disease onset (10.5 ± 4.8) showed a substantial decrease at last visit (4.3 ± 4.6). One-quarter of the patients (26.1%, n = 24) had damage according to the PedSDI criteria with a mean score of 0.45 ± 1.0 (range 0-7). When the PedSDI damage items were evaluated individually, growth failure was the most frequent damage criterion ( n = 6), followed by seizure ( n = 5). Two patients died during the designated study period of end-stage renal disease. The five-year and 10-year survival rate of our cohort was 100% and 94.4%, respectively. Conclusions Given the lower frequency of nephritis and central nervous system disease and lower basal disease activity and damage scores, we could conclude that children with jSLE in Turkey have a more favorable course compared to Asian and African American children, as expected from Caucasian ethnicity.

Dissection of the abdominal aorta in a child with Takayasu's arteritis

Takayasu's arteritis is a chronic inflammatory disease that primarily involves the aorta and its main branches. Varying degrees of narrowing, occlusion, or dilatation develop in the involved vessel segments. However, dissection of the aorta is quite rare in this disease, and it may develop particularly after angioplasty. We report a very rare case of Takayasu's arteritis with dissection of the abdominal aorta just distal to the origin of the inferior mesenteric artery in a 9-year-old girl. She was treated conservatively with close follow-up. At the end of 1 year's follow-up, the dissection of the aorta did not show progression, and new lesions were not identified. To our knowledge, this patient is the youngest child presented with arterial dissection as the initial manifestation of the disease.

Hepatitis B vaccination in children with juvenile idiopathic arthritis

OBJECTIVES

To evaluate the responsiveness of children with juvenile idiopathic arthritis (JIA) to hepatitis B vaccination and to determine the most useful vaccination schedule.

METHODS

39 children with JIA were enrolled in the study; all were in remission and negative to serological testing for hepatitis B surface antigen (HbsAg). The control group consisted of 41 healthy children. There were two different vaccination schedules: group I was vaccinated at 0, 1, and 3 months; group II was vaccinated at 0, 1, and 6 months. Positive responsiveness to the vaccine was defined as an anti-hepatitis B antibody titre above 10 mIU/ml.

RESULTS

All the children except one with systemic JIA developed an antibody response. None of the JIA patients experienced a flare up or clinical deterioration related to the vaccination. The antibody levels in children with JIA were significantly lower than in the healthy controls. Comparison of the antibody levels between the two vaccination schedules showed no statistical difference in the controls; in the JIA subjects the group II schedule resulted in a trend to a greater response than the group I schedule (p<0.07). Vaccine responsiveness was not influenced by either methotrexate or prednisolone treatment.

CONCLUSIONS

Children with JIA had an adequate response to hepatitis B vaccination and the response was not affected by immunosuppressive treatment. A vaccination schedule at 0, 1, and 6 months seems to be preferable to 0, 1, and 3 months.

Growth and IGF-1 levels of children with familial Mediterranean fever on colchicine treatment

OBJECTIVE

To evaluate growth process and insulin like growth factor-1 (IGF-1) levels in children with familial Mediterranean fever (FMF).

METHODS

This prospective study group consisted of 51 children with FMF under colchicine therapy (20 boys, 31 girls) and 42 healthy children (22 boys, 20 girls). All children were prepubertal. Bone ages and IGF-1 levels were determined in all cases. Height velocity (HV), height standard deviation score (SDS), target height and target height SDS were calculated.

RESULTS

There was no statistical difference in age, HSDS, target height SDS and bone ages between healthy and diseased subjects. HV of children with FMF did not differ significantly from the control group. There was no statistical difference in age, HSDS, target height SDS and bone ages between healthy and FMF subjects. HV of children with FMF did not differ significantly from the control group. There was no significant correlation between disease duration, number of attacks, erythrocyte sedimentation rate and HV, HSDS and IGF-1 levels of FMF patients. There was positive correlation between cumulative colchicine dose and HV (r = 0.29).

CONCLUSION

Growth and IGF-1 levels of children with FMF do not differ from their healthy peers. However, there was positive correlation between HV and cumulative colchicine dose. This study suggests that colchicine not only has no adverse influence on growth, but more by suppressing disease activity and inflammation it has an enhancing role.

Hypercalciuria and hematuria in juvenile rheumatoid arthritis

OBJECTIVE

To investigate the frequency of hypercalciuria and the relationship between hypercalciuria and hematuria in patients with juvenile rheumatoid arthritis (JRA).

METHODS

Twenty-eight children with JRA were studied, as well as 10 patients with acute arthritis unrelated to JRA and 14 healthy children as control groups. Cases with urinary calcium excretion (UCE) >4 mg/kg/day were considered hypercalciuric. Urinalysis was performed for detecting hematuria in all cases.

RESULTS

UCE was 4.19 +/- 2.9 mg/kg/day in patients with JRA, 1.94 +/- 1.57 mg/kg/day in children with acute arthritis, and 2.0 +/- 1.45 mg/kg/day in healthy children. UCE was significantly higher in JRA compared with the other study groups. Of the 28 patients with JRA, 13 (46.4%) had hypercalciuria and 6 (21.4%) had hematuria. UCE was significantly higher in hematuric patients with JRA than in those with no hematuria (p<0.05). UCE in patients with JRA without hematuria was also higher than the UCE values detected in the disease and healthy control groups (p<0.05).

CONCLUSION

Hypercalciuria is a frequent finding in patients with JRA [13/28 (46.4%)] and should be considered during the investigation of hematuria in patients with JRA.

Erythromelalgia associated with hypertension and leukocytoclastic vasculitis in a child

Erythromelalgia is an acrocyanotic rheumatic disease presenting with erythema, and pain and a burning sensation in the hands and feet; it is rarely encountered during childhood. Hot or warm conditions may precipitate pain and erythema in the extremities and the symptoms may regress upon the application of cold water. The disease is usually secondary to other systemic diseases in adults. On the other hand, it is idiopathic in children. This article describes a case of erythromelalgia presenting with leukocytoclastic vasculitis and hypertension in a 7-year-old child who responded to therapy with prednisolone and phenoxybenzamine.

Superior vena cava syndrome as a result of thrombosis in a child with nephrotic syndrome

A three-year-old nephrotic girl is presented with vena cava superior syndrome. Angiography showed obliteration of the distal ends of both axillary veins and echocardiographic examination revealed a mobile mass in the right atrium. A thrombus originating from the vena cava superior with a stalk extending to the right atrium was surgically removed. To our knowledge, vena cava superior thrombosis in nephrotic syndrome has not been reported previously.

Tubular markers in children with insulin-dependent diabetes mellitus

The aim of the present study was to investigate the prevalence of tubular dysfunction and to assess the clinical significance of low-molecular-weight proteinuria and enzymuria in children with insulin-dependent diabetes mellitus (IDDM). N.acetyl-beta-D-glucosaminidase (NAG) and beta-microglobulin (beta 2 M) excretion was determined in 52 children with insulin-dependent diabetes mellitus and 28 controls. Patients were grouped according to the duration of diabetes: group 1 (n = 7): less than one year; group 2 (n = 27): one to five years; groups 3 (n = 18): greater than five years. Both parameters were significantly increased in groups 2 and 3 compared to controls. Urinary beta 2 M levels correlated significantly with albuminuria and HbA1C, while urinary NAG levels correlated only with HbA1C. Two to four samples were obtained from 35 of 52 diabetic patients in the study group at one-month intervals. Of these, 23 patients had elevated NAG levels, and 22 patients increased beta 2 M excretion. However, only six patients displayed persistent enzymuria, and nine low-molecular-weight proteinuria. The mean (SD) of coefficients of variation of each patient was 50.45 (+/-28.24) for NAG and 68.25 (+/-42.57) for beta 2 M excretion. We concluded that early tubular dysfunction and/or damage occurs in IDDM but is not established in the majority of children.

Vasculitis in familial Mediterranean fever

OBJECTIVE

To evaluate the frequency of vasculitis, mainly in the forms of Henoch-Schönlein purpura and polyarteritis nodosa (PAN), and to investigate the presence of occult blood in the first stool specimens after an abdominal attack in Turkish patients with familial Mediterranean fever (FMF).

METHODS

Review of the charts of 207 patients with FMF seen between 1983 and 1993 with respect to clinical vasculitis. A prospective study designed to test the presence of occult blood in the first stool specimens obtained after abdominal attack and at least one week later in 36 patients with FMF compared with healthy and diseased controls.

RESULTS

There were 15 patients with Henoch-Schönlein purpura (7%), 2 with definite and one with probable PAN (1%), one of whom developed perirenal hematoma. The diagnosis of FMF was made after the onset of Henoch-Schönlein purpura in 9 and subsequent to the development of PAN in one patient. Occult blood was positive in the first stool specimens obtained after an attack in 17 of the 36 patients with FMF (47%), a finding not reported previously.

CONCLUSION

Vasculitis seems to be an important but not a widely recognized feature of FMF.

The New York Angler Cohort Study: exposure characterization and reproductive and developmental health

The New York State Angler Study will evaluate the association between past and current consumption of contaminated fish from Lake Ontario and both short- and long-term health effects in a population-based cohort. It will measure fish consumption and reproductive and developmental health among 10,518 male anglers and 6,651 of their wives or partners, as well as among 913 female anglers. To characterize exposure among subgroups of the cohort, further analytical methods were developed and implemented to measure specific polychlorinated biphenyls (PCB) congeners, methylmercury, and other substances in biological samples. Exposure assessment has been completed for a stratified random sample of 321 anglers. In addition, analyses for 79 congeners of PCBs are complete for 177 anglers. A special study of duck and turtle consumers currently is underway. Telephone interviews have been completed with 2,454 of the 2,999 women who planned a pregnancy between 1991 and 1994. The entire cohort of male anglers, partners of male anglers, and female anglers has been submitted for matching with the New York State live birth and fetal death registries to obtain lifetime reproductive histories. A medical record abstraction study will assess perinatal and developmental outcomes among the 3,442 births that occurred between 1986 and 1991. Finally, a study of breast milk from currently lactating women is underway, and 215 breast milk samples have been collected from the planned pregnancy subcohort. Progress on each of the study components is discussed herein.

Urinary N-acetyl-beta-D-glucosaminidase and beta 2-microglobulin excretion in primary nephrotic children

Enzymuria and low molecular weight proteinuria reflect tubular damage and dysfunction, respectively. We examined urinary N-acetyl-beta-D-glucosaminidase (U-NAG) and beta 2-microglobulin (U-beta 2M) excretion in 17 steroid-resistant and 39 steroid-sensitive children with nephrotic syndrome whose glomerular filtration rates were within the normal range. Fourteen healthy children were taken as controls. U-NAG and U-beta 2M levels did not show a difference between the steroid-resistant and steroid-sensitive groups but were significantly higher in the nephrotic groups compared to the controls (p < 0.0001 and p < 0.01, respectively). In the steroid-sensitive group, U-NAG levels were significantly higher in patients in the relapse phase than in those in remission (p < 0.0001). This finding was also valid for U-beta 2M excretion, but reached significance only for patients in remission who did not receive steroids (p < 0.01). There was a positive correlation between proteinuria and U-NAG and U-beta 2M excretion in all patients (rs = 0.69, p < 0.001 and rs = 0.39, p < 0.001, respectively). In conclusion, massive glomerular proteinuria may cause a marked U-NAG excretion and a moderate urinary U-beta 2M elevation independent of primary renal disease.

Haemoperfusion in Amanita phalloides poisoning

Amanita phalloides is responsible for about 90 per cent of all fatal cases of mushroom intoxication. The amatoxins, the main toxic component of these fungi, are responsible for gastro-intestinal symptoms as well as hepatic and renal failure. Three brothers with Amanita phalloides poisoning were admitted with gastro-intestinal symptoms beginning 12 h after ingestion. Jaundice, hepatomegaly and neurological symptoms were not present, but liver enzymes were moderately increased. Alfa-amanitin was detected in sera of all patients. All patients underwent charcoal hemoperfusion and two of them had additional hemodialysis along with conservative therapy. Liver enzymes that showed a marked increase on the second day of therapy decreased to normal levels on the 28th day. All of our patients survived. This life saving role of early haemoperfusion in Amanita phalloides poisoning is emphasized.

Congenital defects and electric bed heating in New York State: a register-based case-control study

Exposure to 60-cycle electromagnetic fields has been hypothesized to be a cause of childhood cancer and congenital defects. Because electric bed heaters are a major source of variation in electromagnetic field exposure in the population, the authors conducted a case-control study in 1988-1989 to examine the relations between congenital defects and the use of electric blankets and heated waterbeds. Cases were identified by the New York State Congenital Malformations Registry as babies with cleft palate (n = 121), cleft lip with or without cleft palate (n = 197), born in 1983-1984, and anencephalus and spina bifida (n = 224), born in 1983-1986, all to upstate New York residents. Controls were selected at random from birth registrations individually matched to cases by maternal race, age, home county, month of last menses, and child's sex. Information on periconceptional electric blanket and heated waterbed use as well as known and suspected risk factors for defects was obtained from questionnaires mailed to the mothers. Matched odds ratio estimates and 95% confidence intervals (CIs) for electric blanket use relative to nonuse were 0.8 (95% CI 0.3-2.1) for cleft palate, 0.7 (95% CI 0.3-1.3) for cleft lip, and 0.9 (95% CI 0.5-1.6) for neural tube defects. The respective odds ratios for heated waterbed use were nearly identical to these. Adjustment for potential confounding factors (maternal education, vitamin use, smoking) and stratification by season of conception and bed heat control setting had no meaningful effect on odds ratios. These results suggest that 60-cycle fields do not cause neural tube and oral cleft defects.

Pulmonary hypertension due to chronic upper airway obstruction: a clinical review and report of four cases

Partial airway obstruction due to the enlargement of the tonsils and adenoids is a well recognized clinical entity, but cardiorespiratory changes due to chronic obstruction have infrequently been reported. Four children with severe nasopharyngeal obstruction due to tonsil and adenoid hypertrophy, who developed pulmonary hypertension and cardiac failure, were studied. Relief of upper airway obstruction by adenotonsillectomy resulted in a regression of the presenting signs and symptoms.