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Handa A, Bedoya MA, Iwasaka-Neder J, Johnston PR, Lo MS, Bixby SD. Measuring synovial thickness on knee MRI in pediatric patients with arthritis: is contrast necessary? Pediatr Radiol 2024:10.1007/s00247-024-05929-1. [PMID: 38641735 DOI: 10.1007/s00247-024-05929-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024]
Abstract
BACKGROUND The use of contrast-enhanced imaging has long been standard for magnetic resonance imaging (MRI) assessments of synovitis in juvenile idiopathic arthritis (JIA). However, advancements in MRI technology have allowed for reliable identification of synovium without contrast. OBJECTIVE To assess the equivalence of unenhanced MRI with contrast-enhanced MRI in evaluating synovial thickness. MATERIALS AND METHODS This is an institutional review board approved, retrospective study performed in a tertiary children's hospital. Pediatric JIA patients under 21 years old were included who underwent knee MRI scans (1.5 T or 3 T) without and with contrast between January 2012 and January 2022. Two radiologists independently measured synovial thickness at 6 knee sites on contrast-enhanced and unenhanced sequences. Numerical measurements and ordinal scores based on juvenile idiopathic arthritis magnetic resonance imaging scoring (JAMRIS) system were recorded, and tests of equivalence were conducted, as well as between-reader and within-reader reliability by concordance correlation coefficient (CCC). All tests were considered significant at the 5% level. RESULTS A total of 38 studies from 35 patients (25 females, median age 14 years; interquartile range 7 to 15.7) were included. Equivalence was demonstrated at each of the 6 sites for both continuous measurements (P-values < 0.05) and ordinal scores (P-values < 0.05) based on the average over readers. Within-reader reliability was moderate to high (CCC 0.50-0.89), except for the cruciate ligaments site. Averaged over the 6 sites, reliability between readers was low for unenhanced (CCC 0.47, with 95% CI: [0.41, 0.53]) and moderate for contrast-enhanced (CCC 0.64, with 95% CI: [0.59, 0.69]) sequences. CONCLUSION Unenhanced knee MRI is equivalent to contrast-enhanced MRI in assessment of synovial thickness using conventional MRI sequences. Contrast material helped improve inter-reader reliability.
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Affiliation(s)
- Atsuhiko Handa
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA.
| | - M Alejandra Bedoya
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Jade Iwasaka-Neder
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Patrick R Johnston
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Mindy S Lo
- Department of Immunology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
| | - Sarah D Bixby
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, 02115, USA
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Brodeur KE, Liu M, Ibanez D, de Groot MJ, Chen L, Du Y, Seyal E, Laza-Briviesca R, Baker A, Chang JC, Chang MH, Day-Lewis M, Dedeoglu F, Dionne A, de Ferranti SD, Friedman KG, Halyabar O, Lo MS, Meidan E, Sundel RP, Henderson LA, Nigrovic PA, Newburger JW, Son MB, Lee PY. Elevation of IL-17 Cytokines Distinguishes Kawasaki Disease From Other Pediatric Inflammatory Disorders. Arthritis Rheumatol 2024; 76:285-292. [PMID: 37610270 PMCID: PMC10842426 DOI: 10.1002/art.42680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 07/26/2023] [Accepted: 08/17/2023] [Indexed: 08/24/2023]
Abstract
OBJECTIVE Kawasaki disease (KD) is a systemic vasculitis of young children that can lead to development of coronary artery aneurysms. We aimed to identify diagnostic markers to distinguish KD from other pediatric inflammatory diseases. METHODS We used the proximity extension assay to profile proinflammatory mediators in plasma samples from healthy pediatric controls (n = 30), febrile controls (n = 26), and patients with KD (n = 23), multisystem inflammatory syndrome in children (MIS-C; n = 25), macrophage activation syndrome (n = 13), systemic and nonsystemic juvenile idiopathic arthritis (n = 14 and n = 10, respectively), and juvenile dermatomyositis (n = 9). We validated the key findings using serum samples from additional patients with KD (n = 37) and febrile controls (n = 28). RESULTS High-fidelity proteomic profiling revealed distinct patterns of cytokine and chemokine expression across pediatric inflammatory diseases. Although KD and MIS-C exhibited many similarities, KD differed from MIS-C and other febrile diseases in that most patients exhibited elevation in one or more members of the interleukin-17 (IL-17) cytokine family, IL-17A, IL-17C, and IL-17F. IL-17A was particularly sensitive and specific, discriminating KD from febrile controls with an area under the receiver operator characteristic curve of 0.95 (95% confidence interval 0.89-1.00) in the derivation set and 0.91 (0.85-0.98) in the validation set. Elevation of all three IL-17-family cytokines was observed in over 50% of KD patients, including 19 of 20 with coronary artery aneurysms, but was rare in all other comparator groups. CONCLUSION Elevation of IL-17 family cytokines is a hallmark of KD and may help distinguish KD from its clinical mimics.
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Affiliation(s)
| | - Meng Liu
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Guangzhou, China
| | - Daniel Ibanez
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Mareike J. de Groot
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Division of Rheumatology, Department of Medicine V (Hematology, Oncology and Rheumatology), Heidelberg University Hospital, Heidelberg, Germany
| | - Liang Chen
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Yan Du
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Eman Seyal
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Annette Baker
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Joyce C. Chang
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Megan Day-Lewis
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Kevin G. Friedman
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Olha Halyabar
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Esra Meidan
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Robert P. Sundel
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | | | - Peter A. Nigrovic
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jane W. Newburger
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, USA
| | - Mary Beth Son
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
| | - Pui Y. Lee
- Division of Immunology, Boston Children’s Hospital, Boston, MA, USA
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3
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Huang Z, Brodeur KE, Chen L, Du, Wobma H, Hsu EE, Liu M, Chang JC, Chang MH, Chou J, Day-Lewis M, Dedeoglu F, Halyabar O, Lederer JA, Li T, Lo MS, Lu M, Meidan E, Newburger JW, Randolph AG, Son MB, Sundel RP, Taylor ML, Wu H, Zhou Q, Canna SW, Wei K, Henderson LA, Nigrovic PA, Lee PY. Type I interferon signature and cycling lymphocytes in macrophage activation syndrome. J Clin Invest 2023; 133:e165616. [PMID: 37751296 PMCID: PMC10645381 DOI: 10.1172/jci165616] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 09/19/2023] [Indexed: 09/27/2023] Open
Abstract
BACKGROUNDMacrophage activation syndrome (MAS) is a life-threatening complication of Still's disease (SD) characterized by overt immune cell activation and cytokine storm. We aimed to further understand the immunologic landscape of SD and MAS.METHODWe profiled PBMCs from people in a healthy control group and patients with SD with or without MAS using bulk RNA-Seq and single-cell RNA-Seq (scRNA-Seq). We validated and expanded the findings by mass cytometry, flow cytometry, and in vitro studies.RESULTSBulk RNA-Seq of PBMCs from patients with SD-associated MAS revealed strong expression of genes associated with type I interferon (IFN-I) signaling and cell proliferation, in addition to the expected IFN-γ signal, compared with people in the healthy control group and patients with SD without MAS. scRNA-Seq analysis of more than 65,000 total PBMCs confirmed IFN-I and IFN-γ signatures and localized the cell proliferation signature to cycling CD38+HLA-DR+ cells within CD4+ T cell, CD8+ T cell, and NK cell populations. CD38+HLA-DR+ lymphocytes exhibited prominent IFN-γ production, glycolysis, and mTOR signaling. Cell-cell interaction modeling suggested a network linking CD38+HLA-DR+ lymphocytes with monocytes through IFN-γ signaling. Notably, the expansion of CD38+HLA-DR+ lymphocytes in MAS was greater than in other systemic inflammatory conditions in children. In vitro stimulation of PBMCs demonstrated that IFN-I and IL-15 - both elevated in MAS patients - synergistically augmented the generation of CD38+HLA-DR+ lymphocytes, while Janus kinase inhibition mitigated this response.CONCLUSIONMAS associated with SD is characterized by overproduction of IFN-I, which may act in synergy with IL-15 to generate CD38+HLA-DR+ cycling lymphocytes that produce IFN-γ.
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Affiliation(s)
- Zhengping Huang
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Southern Medical University, Guangzhou, China
| | - Kailey E. Brodeur
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Liang Chen
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Du
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Holly Wobma
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Evan E. Hsu
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Meng Liu
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Southern Medical University, Guangzhou, China
| | - Joyce C. Chang
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret H. Chang
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Janet Chou
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Megan Day-Lewis
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olha Halyabar
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - James A. Lederer
- Center for Data Sciences, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Tianwang Li
- Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, Southern Medical University, Guangzhou, China
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Meiping Lu
- Department of Rheumatology, Immunology and Allergy, Zhejiang University School of Medicine, Hangzhou, China
| | - Esra Meidan
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Beth Son
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert P. Sundel
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria L. Taylor
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Huaxiang Wu
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Qing Zhou
- The MOE Key Laboratory of Biosystems Homeostasis and Protection, Life Sciences Institute, Zhejiang University, Hangzhou, China
| | - Scott W. Canna
- Division of Rheumatology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Kevin Wei
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter A. Nigrovic
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pui Y. Lee
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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Du Y, Brodeur KE, Hsu E, Chen L, Chen Q, Liu M, Cheng Q, Rosen S, Michniacki TF, Chou J, Lo MS, Platt CD, Lee PY. In cis "benign" SOCS1 variants linked to enhanced interferon signaling and autoimmunity. J Autoimmun 2023; 140:103119. [PMID: 37797401 PMCID: PMC10987394 DOI: 10.1016/j.jaut.2023.103119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
We aimed to characterize the genetic basis of disease in a family with multiple autoimmune manifestations, including systemic lupus erythematosus (SLE), immune thrombocytopenia, and autoimmune thyroiditis. Whole exome sequencing (WES) was conducted to identify candidate variants, which were analyzed by flow cytometry, immunoblotting, immunoprecipitation, and luciferase reporter assay in transfected 293T cells. Gene expression in peripheral blood mononuclear cells (PBMC) was profiled by bulk RNA sequencing and plasma cytokines were measured by proximity extension assay. In two siblings with early-onset SLE and immune thrombocytopenia, WES identified two maternally inherited in cis variants (p. Pro50Leu and p.Ala76Gly) in Suppressor of cytokine signaling 1 (SOCS1), flanking the kinase inhibitory domain that interacts with Janus kinases (JAK). Both variants were predicted to be benign by most in silico algorithms and neither alone affected the ability of SOCS1 to inhibit JAK-STAT1 signaling by functional studies. When both variants were expressed in cis, the mutant SOCS1 protein displayed decreased binding to JAK1 and reduced capacity to inhibit type I interferon (IFN-I) signaling by ∼20-30% compared to the wildtype protein. PBMC from the probands and their mother showed increased expression of interferon-inducible genes compared to healthy controls, supporting defective regulation of IFN-I signaling. Cells from all three subjects displayed heightened sensitivity to IFN-I stimulation, while response to IFN-γ, IL-4, and IL-6 was comparable to healthy controls. Our work illustrates the critical fine-tuning of IFN-I signaling by SOCS1 to prevent autoimmunity. We show that a combination of genetic variants that are individually benign may have deleterious consequences.
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Affiliation(s)
- Yan Du
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Kailey E Brodeur
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Evan Hsu
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Liang Chen
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Qian Chen
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Meng Liu
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA; Department of Rheumatology and Immunology, Guangdong Second Provincial General Hospital, The Second School of Clinical Medicine, Southern Medical University, Guangzhou, China
| | - Qi Cheng
- Department of Rheumatology, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Seymour Rosen
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Thomas F Michniacki
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Michigan, Ann Arbor, MI, USA
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Craig D Platt
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA.
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5
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Wobma H, Arvila SR, Taylor ML, Lam KP, Ohashi M, Gebhart C, Powers H, Case S, Chandler MT, Chang MH, Cohen E, Day-Lewis M, Fishman MP, Halyabar O, Hausmann JS, Hazen MM, Lee PY, Lo MS, Meidan E, Roberts JE, Son MBF, Sundel RP, Dedeoğlu F, Nigrovic PA, Casey A, Chang J, Henderson LA. Incidence and Risk Factors for Eosinophilia and Lung Disease in Biologic-Exposed Children With Systemic Juvenile Idiopathic Arthritis. Arthritis Care Res (Hoboken) 2023; 75:2063-2072. [PMID: 37038961 PMCID: PMC10524230 DOI: 10.1002/acr.25129] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Revised: 03/15/2023] [Accepted: 04/04/2023] [Indexed: 04/12/2023]
Abstract
OBJECTIVE Although interleukin-1 (IL-1)/IL-6 inhibitors are effective therapies for systemic juvenile idiopathic arthritis (JIA), some patients develop eosinophilia and lung disease during treatment. This study was undertaken to retrospectively evaluate incidence and risk factors for eosinophilia and describe lung disease outcomes in IL-1/IL-6 inhibitor-exposed patients with systemic JIA. METHODS Among JIA patients at our institution exposed to interleukin-1 (IL-1)/IL-6 inhibitors (1995-2022), we compared incidence rate of eosinophilia in systemic JIA compared to other JIA, stratified by medication class (IL-1/IL-6 inhibitors, other cytokine inhibitors, methotrexate). We used Cox models to identify predictors of eosinophilia during IL-1/IL-6 inhibitor use and summarized treatment changes and outcomes after eosinophilia, including lung disease. HLA typing was performed on a clinical or research basis. RESULTS There were 264 new medication exposures in 75 patients with systemic JIA and 41 patients with other JIA. A total of 49% of patients with systemic JIA with HLA typing (n = 45) were positive for HLA-DRB1*15 alleles. Eosinophilia was common during IL-1/IL-6 inhibitor use and did not differ by systemic JIA compared to other JIA (0.08 and 0.07 per person-year, respectively; P = 0.30). Among systemic JIA patients, pretreatment macrophage activation syndrome (MAS) was associated with a higher rate of subsequent eosinophilia on biologic therapy (unadjusted hazard ratio 3.2 [95% confidence interval 1.2-8.3]). A total of 4 of 5 patients who switched therapy within 10 weeks of eosinophilia experienced disease flare compared to none of the patients who continued the original therapy. A total of 8 of 25 patients with pulmonary evaluations had lung disease, and all had severe manifestations of systemic JIA (MAS, intensive care unit stay). One death was attributed to systemic JIA-lung disease. CONCLUSION Eosinophilia is common in JIA patients using IL-1/IL-6 inhibitors. Severe disease may be associated with eosinophilia and lung disease in systemic JIA.
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Affiliation(s)
- Holly Wobma
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Sage R. Arvila
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Maria L. Taylor
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Ki Pui Lam
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | | | | | - Helene Powers
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Siobhan Case
- Division of Immunology, Boston Children’s Hospital, Boston, MA
- Division of Rheumatology, Inflammation, and Immunity, Brigham & Women’s Hospital, Boston, MA
| | - Mia T. Chandler
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | | | - Ezra Cohen
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Megan Day-Lewis
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Martha P. Fishman
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA
| | - Olha Halyabar
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | | | | | - Pui Y. Lee
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Esra Meidan
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | | | | | | | - Fatma Dedeoğlu
- Division of Immunology, Boston Children’s Hospital, Boston, MA
| | - Peter A. Nigrovic
- Division of Immunology, Boston Children’s Hospital, Boston, MA
- Division of Rheumatology, Inflammation, and Immunity, Brigham & Women’s Hospital, Boston, MA
| | - Alicia Casey
- Division of Pulmonary Medicine, Boston Children’s Hospital, Boston, MA
| | - Joyce Chang
- Division of Immunology, Boston Children’s Hospital, Boston, MA
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6
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Wobma H, Bachrach R, Farrell J, Chang MH, Day‐Lewis M, Dedeoglu F, Fishman MP, Halyabar O, Harris C, Ibanez D, Kim L, Klouda T, Krone K, Lee PY, Lo MS, McBrearty K, Meidan E, Prockop SE, Samad A, Son MBF, Nigrovic PA, Casey A, Chang JC, Henderson LA. Development of a Screening Algorithm for Lung Disease in Systemic Juvenile Idiopathic Arthritis. ACR Open Rheumatol 2023; 5:556-562. [PMID: 37688362 PMCID: PMC10570670 DOI: 10.1002/acr2.11600] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/12/2023] [Accepted: 07/19/2023] [Indexed: 09/10/2023] Open
Abstract
OBJECTIVE Lung disease (LD) is an increasingly recognized complication of systemic juvenile idiopathic arthritis (sJIA). As there are no currently available guidelines for pulmonary screening in sJIA, we sought to develop such an algorithm at our institution. METHODS A multidisciplinary workgroup was convened, including members representing rheumatology, pulmonary, stem cell transplantation, and patient families. The workgroup leaders drafted an initial algorithm based on published literature and experience at our center. A modified Delphi approach was used to achieve agreement through three rounds of anonymous, asynchronous voting and a consensus meeting. Statements approved by the workgroup were rated as appropriate with moderate or high levels of consensus. These statements were organized into the final approved screening algorithm for LD in sJIA. RESULTS The workgroup ultimately rated 20 statements as appropriate with a moderate or high level of consensus. The approved algorithm recommends pulmonary screening for newly diagnosed patients with sJIA with clinical features that the workgroup agreed may confer increased risk for LD. These "red flag features" include baseline characteristics (young age of sJIA onset, human leukocyte antigen type, trisomy 21), high disease activity (macrophage activation syndrome [MAS], sJIA-related ICU admission, elevated MAS biomarkers), respiratory symptoms or abnormal pulmonary examination findings, and features of drug hypersensitivity-like reactions (eosinophilia, atypical rash, anaphylaxis). The workgroup achieved consensus on the recommended pulmonary work-up and monitoring guidelines. CONCLUSION We developed a pulmonary screening algorithm for sJIA-LD through a multidisciplinary consensus-building process, which will be revised as our understanding of sJIA-LD continues to evolve.
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Affiliation(s)
- Holly Wobma
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Ronny Bachrach
- Division of Immunology, Boston Children's HospitalBostonMassachusetts
| | - Joseph Farrell
- Division of Immunology, Boston Children's HospitalBostonMassachusetts
| | - Margaret H. Chang
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Megan Day‐Lewis
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Fatma Dedeoglu
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Martha P. Fishman
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Olha Halyabar
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Claudia Harris
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Daniel Ibanez
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Liyoung Kim
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Timothy Klouda
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Katie Krone
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Pui Y. Lee
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Mindy S. Lo
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Kyle McBrearty
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Esra Meidan
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Susan E. Prockop
- Dana‐Farber/Boston Children's Cancer and Blood Disorders Center, Harvard Medical SchoolBostonMassachusetts
| | - Aaida Samad
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Mary Beth F. Son
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Peter A. Nigrovic
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Alicia Casey
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Joyce C. Chang
- Boston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
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7
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Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, Johnson SR, Imundo LF, Winthrop KL, Arasaratnam RJ, Baden LR, Berard R, Bridges SL, Cheah JTL, Curtis JR, Ferguson PJ, Hakkarinen I, Onel KB, Schultz G, Sivaraman V, Smith BJ, Sparks JA, Vogel TP, Williams EA, Calabrese C, Cunha JS, Fontanarosa J, Gillispie-Taylor MC, Gkrouzman E, Iyer P, Lakin KS, Legge A, Lo MS, Lockwood MM, Sadun RE, Singh N, Sullivan N, Tam H, Turgunbaev M, Turner AS, Reston J. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2023; 75:333-348. [PMID: 36597810 DOI: 10.1002/art.42386.10.1002/art.42386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 05/20/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). METHODS This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation. RESULTS This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence. CONCLUSION Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.
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Affiliation(s)
- Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Lisa F Imundo
- Columbia University Irving Medical Center, New York, New York
| | | | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | - Lindsey R Baden
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roberta Berard
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Karen B Onel
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Vidya Sivaraman
- The Ohio State University and Nationwide Children's Hospital, Columbus
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joanne S Cunha
- Brown University, Brown Physicians Inc., and Providence Veterans Affairs Medical Center, East Providence, Rhode Island
| | | | | | | | - Priyanka Iyer
- University of California Irvine Medical Center, Orange
| | - Kimberly S Lakin
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Alexandra Legge
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Herman Tam
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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8
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Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, Johnson SR, Imundo LF, Winthrop KL, Arasaratnam RJ, Baden LR, Berard R, Bridges SL, Cheah JTL, Curtis JR, Ferguson PJ, Hakkarinen I, Onel KB, Schultz G, Sivaraman V, Smith BJ, Sparks JA, Vogel TP, Williams EA, Calabrese C, Cunha JS, Fontanarosa J, Gillispie-Taylor MC, Gkrouzman E, Iyer P, Lakin KS, Legge A, Lo MS, Lockwood MM, Sadun RE, Singh N, Sullivan N, Tam H, Turgunbaev M, Turner AS, Reston J. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Rheumatol 2023; 75:333-348. [PMID: 36597810 DOI: 10.1002/art.42386] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). METHODS This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation. RESULTS This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence. CONCLUSION Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.
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Affiliation(s)
- Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Lisa F Imundo
- Columbia University Irving Medical Center, New York, New York
| | | | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | - Lindsey R Baden
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roberta Berard
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Karen B Onel
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Vidya Sivaraman
- The Ohio State University and Nationwide Children's Hospital, Columbus
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joanne S Cunha
- Brown University, Brown Physicians Inc., and Providence Veterans Affairs Medical Center, East Providence, Rhode Island
| | | | | | | | - Priyanka Iyer
- University of California Irvine Medical Center, Orange
| | - Kimberly S Lakin
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Alexandra Legge
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Herman Tam
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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9
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Bass AR, Chakravarty E, Akl EA, Bingham CO, Calabrese L, Cappelli LC, Johnson SR, Imundo LF, Winthrop KL, Arasaratnam RJ, Baden LR, Berard R, Bridges SL, Cheah JTL, Curtis JR, Ferguson PJ, Hakkarinen I, Onel KB, Schultz G, Sivaraman V, Smith BJ, Sparks JA, Vogel TP, Williams EA, Calabrese C, Cunha JS, Fontanarosa J, Gillispie-Taylor MC, Gkrouzman E, Iyer P, Lakin KS, Legge A, Lo MS, Lockwood MM, Sadun RE, Singh N, Sullivan N, Tam H, Turgunbaev M, Turner AS, Reston J. 2022 American College of Rheumatology Guideline for Vaccinations in Patients With Rheumatic and Musculoskeletal Diseases. Arthritis Care Res (Hoboken) 2023; 75:449-464. [PMID: 36597813 DOI: 10.1002/acr.25045] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To provide evidence-based recommendations on the use of vaccinations in children and adults with rheumatic and musculoskeletal diseases (RMDs). METHODS This guideline follows American College of Rheumatology (ACR) policy guiding management of conflicts of interest and disclosures and the ACR guideline development process, which includes the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. It also adheres to the Appraisal of Guidelines for Research and Evaluation (AGREE) criteria. A core leadership team consisting of adult and pediatric rheumatologists and a guideline methodologist drafted clinical population, intervention, comparator, outcomes (PICO) questions. A review team performed a systematic literature review for the PICO questions, graded the quality of evidence, and produced an evidence report. An expert Voting Panel reviewed the evidence and formulated recommendations. The panel included adult and pediatric rheumatology providers, infectious diseases specialists, and patient representatives. Consensus required ≥70% agreement on both the direction and strength of each recommendation. RESULTS This guideline includes expanded indications for some vaccines in patients with RMDs, as well as guidance on whether to hold immunosuppressive medications or delay vaccination to maximize vaccine immunogenicity and efficacy. Safe approaches to the use of live attenuated vaccines in patients taking immunosuppressive medications are also addressed. Most recommendations are conditional and had low quality of supporting evidence. CONCLUSION Application of these recommendations should consider patients' individual risk for vaccine-preventable illness and for disease flares, particularly if immunosuppressive medications are held for vaccination. Shared decision-making with patients is encouraged in clinical settings.
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Affiliation(s)
- Anne R Bass
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Elie A Akl
- American University of Beirut, Beirut, Lebanon
| | | | | | | | - Sindhu R Johnson
- Toronto Western Hospital, Mount Sinai Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Lisa F Imundo
- Columbia University Irving Medical Center, New York, New York
| | | | - Reuben J Arasaratnam
- VA North Texas Health Care System and University of Texas Southwestern Medical Center, Dallas
| | - Lindsey R Baden
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Roberta Berard
- Children's Hospital, London Health Sciences Centre, London, Ontario, Canada
| | - S Louis Bridges
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | | | | | | | - Karen B Onel
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | | | - Vidya Sivaraman
- The Ohio State University and Nationwide Children's Hospital, Columbus
| | | | - Jeffrey A Sparks
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | | | | | - Joanne S Cunha
- Brown University, Brown Physicians Inc., and Providence Veterans Affairs Medical Center, East Providence, Rhode Island
| | | | | | | | - Priyanka Iyer
- University of California Irvine Medical Center, Orange
| | - Kimberly S Lakin
- Hospital for Special Surgery and Weill Cornell Medicine, New York, New York
| | - Alexandra Legge
- Dalhousie University and QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Herman Tam
- British Columbia Children's Hospital, Vancouver, British Columbia, Canada
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
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10
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Julé AM, Lam KP, Taylor M, Hoyt KJ, Wei K, Gutierrez-Arcelus M, Case SM, Chandler M, Chang MH, Cohen EM, Dedeoglu F, Halyabar O, Hausmann J, Hazen MM, Janssen E, Lo J, Lo MS, Meidan E, Roberts JE, Wobma H, Son MBF, Sundel RP, Lee PY, Sage PT, Chatila TA, Nigrovic PA, Rao DA, Henderson LA. Disordered T cell-B cell interactions in autoantibody-positive inflammatory arthritis. Front Immunol 2023; 13:1068399. [PMID: 36685593 PMCID: PMC9849554 DOI: 10.3389/fimmu.2022.1068399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 12/12/2022] [Indexed: 01/06/2023] Open
Abstract
T peripheral helper (Tph) cells, identified in the synovium of adults with seropositive rheumatoid arthritis, drive B cell maturation and antibody production in non-lymphoid tissues. We sought to determine if similarly dysregulated T cell-B cell interactions underlie another form of inflammatory arthritis, juvenile oligoarthritis (oligo JIA). Clonally expanded Tph cells able to promote B cell antibody production preferentially accumulated in the synovial fluid (SF) of oligo JIA patients with antinuclear antibodies (ANA) compared to autoantibody-negative patients. Single-cell transcriptomics enabled further definition of the Tph gene signature in inflamed tissues and showed that Tph cells from ANA-positive patients upregulated genes associated with B cell help to a greater extent than patients without autoantibodies. T cells that co-expressed regulatory T and B cell-help factors were identified. The phenotype of these Tph-like Treg cells suggests an ability to restrain T cell-B cell interactions in tissues. Our findings support the central role of disordered T cell-help to B cells in autoantibody-positive arthritides.
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Affiliation(s)
- Amélie M. Julé
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ki Pui Lam
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Maria Taylor
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kacie J. Hoyt
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Kevin Wei
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Maria Gutierrez-Arcelus
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Broad Institute of Massachusetts Institute of Technology (MIT) and Harvard, Cambridge, MA, United States
| | - Siobhan M. Case
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Mia Chandler
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Margaret H. Chang
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Ezra M. Cohen
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Division of Rheumatology, Boston Medical Center, Boston University School of Medicine, Boston, MA, United States
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Olha Halyabar
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jonathan Hausmann
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Melissa M. Hazen
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Erin Janssen
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jeffrey Lo
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Esra Meidan
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Jordan E. Roberts
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Holly Wobma
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Robert P. Sundel
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Pui Y. Lee
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter T. Sage
- Transplantation Research Center, Renal Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Talal A. Chatila
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Peter A. Nigrovic
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Deepak A. Rao
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
| | - Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, MA, United States
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11
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Taylor ML, Hoyt KJ, Han J, Benson L, Case S, Chandler MT, Chang MH, Platt C, Cohen EM, Day-Lewis M, Dedeoglu F, Gorman M, Hausmann JS, Janssen E, Lee PY, Lo J, Priebe GP, Lo MS, Meidan E, Nigrovic PA, Roberts JE, Son MBF, Sundel RP, Alfieri M, Yeun JC, Shobiye DM, Degar B, Chang JC, Halyabar O, Hazen MM, Henderson LA. An Evidence-Based Guideline Improves Outcomes for Patients With Hemophagocytic Lymphohistiocytosis and Macrophage Activation Syndrome. J Rheumatol 2022; 49:1042-1051. [PMID: 35840156 PMCID: PMC9588491 DOI: 10.3899/jrheum.211219] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/22/2022] [Indexed: 06/15/2023]
Abstract
OBJECTIVE To compare clinical outcomes in children with hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) who were managed before and after implementation of an evidence-based guideline (EBG). METHODS A management algorithm for MAS-HLH was developed at our institution based on literature review, expert opinion, and consensus building across multiple pediatric subspecialties. An electronic medical record search retrospectively identified hospitalized patients with MAS-HLH in the pre-EBG (October 15, 2015, to December 4, 2017) and post-EBG (January 1, 2018, to January 21, 2020) time periods. Predetermined outcome metrics were evaluated in the 2 cohorts. RESULTS After the EBG launch, 57 children were identified by house staff as potential patients with MAS-HLH, and rheumatology was consulted for management. Ultimately, 17 patients were diagnosed with MAS-HLH by the treating team. Of these, 59% met HLH 2004 criteria, and 94% met 2016 classification criteria for MAS complicating systemic juvenile idiopathic arthritis. There was a statistically significant reduction in mortality from 50% before implementation of the EBG to 6% in the post-EBG cohort (P = 0.02). There was a significant improvement in time to 50% reduction in C-reactive protein level in the post-EBG vs pre-EBG cohorts (log-rank P < 0.01). There were trends toward faster time to MAS-HLH diagnosis, faster initiation of immunosuppressive therapy, shorter length of hospital stay, and more rapid normalization of MAS-HLH-related biomarkers in the patients post-EBG. CONCLUSION While the observed improvements may be partially attributed to advances in treatment of MAS-HLH that have accumulated over time, this analysis also suggests that a multidisciplinary treatment pathway for MAS-HLH contributed meaningfully to favorable patient outcomes.
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Affiliation(s)
- Maria L Taylor
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Kacie J Hoyt
- K.J. Hoyt, MSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, and Virginia Tech Carilion School of Medicine, Roanoke, Virginia
| | - Joseph Han
- J. Han, BS, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Leslie Benson
- L. Benson, MD, M. Gorman, MD, Division of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Siobhan Case
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mia T Chandler
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Margaret H Chang
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Craig Platt
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Ezra M Cohen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Megan Day-Lewis
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Fatma Dedeoglu
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Mark Gorman
- L. Benson, MD, M. Gorman, MD, Division of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | - Jonathan S Hausmann
- J.S. Hausmann, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Erin Janssen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Pui Y Lee
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Jeffrey Lo
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Gregory P Priebe
- G.P. Priebe, MD, Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Mindy S Lo
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Esra Meidan
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Peter A Nigrovic
- S. Case, MD, M.H. Chang, MD, PhD, P.A. Nigrovic, MD, Division of Immunology, Boston Children's Hospital, and Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jordan E Roberts
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Mary Beth F Son
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Robert P Sundel
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Maria Alfieri
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Jenny Chan Yeun
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Damilola M Shobiye
- M. Alfieri, MPH, J. Chan Yeun, MSPH, D.M. Shobiye, MPH, Department of Pediatric Quality Program, Boston Children's Hospital, Boston, Massachusetts
| | - Barbara Degar
- B. Degar, MD, Department of Pediatric Oncology, Dana-Farber Cancer Institute, Boston, Massachusetts, USA
| | - Joyce C Chang
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Olha Halyabar
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Melissa M Hazen
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts
| | - Lauren A Henderson
- M.L. Taylor, BS, M.T. Chandler, MD, C. Platt, MD, PhD, E.M. Cohen, MD, M. Day-Lewis, RN, MSN, CPNP, F. Dedeoglu, MD, E. Janssen, MD, PhD, P.Y. Lee, MD, PhD, J. Lo, MD, M.S. Lo, MD, PhD, E. Meidan, MD, J.E. Roberts, MD, M.B.F. Son, MD, R.P. Sundel, MD, J.C. Chang, MD, MSCE, O. Halyabar, MD, M.M. Hazen, MD, L.A. Henderson, MD, MMSc, Division of Immunology, Boston Children's Hospital, Boston, Massachusetts;
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12
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Wobma H, Perkins R, Bartnikas L, Dedeoğlu F, Chou J, Vleugels RA, Lo MS, Janssen E, Henderson LA, Whangbo J, Vargas SO, Fishman M, Krone KA, Casey A. Genetic diagnosis of immune dysregulation can lead to targeted therapy for interstitial lung disease: A case series and single center approach. Pediatr Pulmonol 2022; 57:1577-1587. [PMID: 35426264 PMCID: PMC9627679 DOI: 10.1002/ppul.25924] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 03/23/2022] [Accepted: 04/04/2022] [Indexed: 11/08/2022]
Abstract
In recent years, a growing number of monogenic disorders have been described that are characterized by immune dysregulation. A subset of these "primary immune regulatory disorders" can cause severe interstitial lung disease, often recognized in late childhood or adolescence. Patients presenting to pulmonary clinic may have long and complex medical histories, but lack a unifying genetic diagnosis. It is crucial for pulmonologists to recognize features suggestive of multisystem immune dysregulation and to initiate genetic workup, since targeted therapies based on underlying genetics may halt or even reverse pulmonary disease progression. Through such an approach, our center has been able to diagnose and treat a cohort of patients with interstitial lung disease from gene defects that affect immune regulation. Here we present representative cases related to pathogenic variants in three distinct pathways and summarize disease manifestations and treatment approaches. We conclude with a discussion of our perspective on the outstanding challenges for diagnosing and managing these complex life-threatening and chronic disorders.
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Affiliation(s)
- Holly Wobma
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ryan Perkins
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lisa Bartnikas
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Fatma Dedeoğlu
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Janet Chou
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Ruth Ann Vleugels
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Dermatology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Erin Janssen
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jennifer Whangbo
- Dana-Farber/Boston Children's Cancer and Blood Disorders Center, Boston, Massachusetts, USA
| | - Sara O Vargas
- Department of Pathology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Martha Fishman
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Katie A Krone
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Alicia Casey
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
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13
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Yildirim-Toruner C, Pooni R, Goh YI, Becker-Haimes E, Dearing JW, Fernandez ME, Morgan EM, Parry G, Burnham JM, Ardoin SP, Barbar-Smiley F, Chang JC, Chiraseveenuprapund P, Del Gaizo V, Eakin G, Johnson LC, Kimura Y, Knight AM, Kohlheim M, Lawson EF, Lo MS, Pan N, Ring A, Ronis T, Sadun RE, Smitherman EA, Taxter AJ, Taylor J, Vehe RK, Vora SS, Weiss JE, von Scheven E. Translating research into practice-implementation recommendations for pediatric rheumatology; Proceedings of the childhood arthritis and rheumatology research alliance 2020 implementation science retreat. Pediatr Rheumatol Online J 2022; 20:10. [PMID: 35130904 PMCID: PMC8822721 DOI: 10.1186/s12969-022-00665-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/10/2022] [Indexed: 11/17/2022] Open
Abstract
The translation of research findings into clinical practice is challenging, especially fields like in pediatric rheumatology, where the evidence base is limited, there are few clinical trials, and the conditions are rare and heterogeneous. Implementation science methodologies have been shown to reduce the research- to- practice gap in other clinical settings may have similar utility in pediatric rheumatology. This paper describes the key discussion points from the inaugural Childhood Arthritis and Rheumatology Research Alliance Implementation Science retreat held in February 2020. The aim of this report is to synthesize those findings into an Implementation Science Roadmap for pediatric rheumatology research. This roadmap is based on three foundational principles: fostering curiosity and ensuring discovery, integration of research and quality improvement, and patient-centeredness. We include six key steps anchored in the principles of implementation science. Applying this roadmap will enable researchers to evaluate the full range of research activities, from the initial clinical design and evidence acquisition to the application of those findings in pediatric rheumatology clinics and direct patient care.
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Affiliation(s)
| | - Rajdeep Pooni
- grid.414123.10000 0004 0450 875XStanford University School of Medicine, Lucile Packard Children’s Hospital, Stanford Children’s Health, Palo Alto, CA USA
| | - Y. Ingrid Goh
- grid.42327.300000 0004 0473 9646The Hospital for Sick Children, Toronto, Ontario Canada
| | - Emily Becker-Haimes
- grid.25879.310000 0004 1936 8972University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA USA
| | - James W. Dearing
- grid.17088.360000 0001 2150 1785Michigan State University, Michigan, MI USA
| | - Maria E. Fernandez
- grid.267308.80000 0000 9206 2401University of Texas Health Science Center at Houston, Houston, TX USA
| | - Esi M. Morgan
- grid.34477.330000000122986657University of Washington, Seattle, WA USA
| | - Gareth Parry
- grid.418700.a0000 0004 0614 6393Boston Children’s Hospital, (formerly at Institute for Healthcare Improvement (IHI)), Boston, MA USA
| | - Jon M. Burnham
- grid.239552.a0000 0001 0680 8770Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Stacy P. Ardoin
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA
| | - Fatima Barbar-Smiley
- grid.240344.50000 0004 0392 3476Nationwide Children’s Hospital, Columbus, OH USA
| | - Joyce C. Chang
- grid.239552.a0000 0001 0680 8770Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | | | - Vincent Del Gaizo
- grid.499903.eCARRA, Partnerships and Patient Engagement, Milwaukee, WI USA
| | - Guy Eakin
- grid.422901.c0000 0004 0371 5124Arthritis Foundation, Atlanta, GA USA
| | - Lisa C. Johnson
- grid.414049.c0000 0004 7648 6828The Dartmouth Institute for health policy and Clinical Practice, Lebanon, NH USA
| | - Yukiko Kimura
- grid.429392.70000 0004 6010 5947The Joseph M. Sanzari Children’s Hospital, Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Andrea M. Knight
- grid.42327.300000 0004 0473 9646The Hospital for Sick Children, Toronto, Ontario Canada
| | - Melanie Kohlheim
- grid.499903.eCARRA, Partnerships and Patient Engagement, Milwaukee, WI USA
| | - Erica F. Lawson
- grid.266102.10000 0001 2297 6811University of California, San Francisco, San Francisco, CA USA
| | - Mindy S. Lo
- grid.418700.a0000 0004 0614 6393Boston Children’s Hospital, (formerly at Institute for Healthcare Improvement (IHI)), Boston, MA USA
| | - Nancy Pan
- grid.5386.8000000041936877XHospital for Special Surgery, Weill Medical College of Cornell University, New York, NY, USA
| | - Andrea Ring
- grid.422901.c0000 0004 0371 5124Arthritis Foundation, Atlanta, GA USA
| | - Tova Ronis
- grid.239560.b0000 0004 0482 1586Children’s National Hospital, George Washington University, Washington, DC USA
| | | | - Emily A. Smitherman
- grid.265892.20000000106344187University of Alabama/ Children’s of Alabama, Birmingham, AL USA
| | - Alysha J. Taxter
- grid.241167.70000 0001 2185 3318Wake Forest University, Winston-Salem, NC USA
| | - Janalee Taylor
- grid.239573.90000 0000 9025 8099Cincinnati Children’s Hospital, OH Cincinatti, USA
| | - Richard K. Vehe
- grid.17635.360000000419368657University of Minnesota, Minnesota, MN USA
| | - Sheetal S. Vora
- grid.17635.360000000419368657University of Minnesota, Minnesota, MN USA ,grid.415907.e0000 0004 0411 7193Atrium Health Levine Children’s Hospital, Charlotte, NC USA
| | - Jennifer E. Weiss
- grid.429392.70000 0004 6010 5947The Joseph M. Sanzari Children’s Hospital, Hackensack Meridian School of Medicine, Hackensack, NJ, USA
| | - Emily von Scheven
- grid.266102.10000 0001 2297 6811University of California, San Francisco, San Francisco, CA USA
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14
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Affiliation(s)
- Jordan E. Roberts
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Peter A. Nigrovic
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mindy S. Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Margaret H. Chang
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, MA
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15
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Abstract
Childhood noninfectious uveitis leads to sight-threatening complications. Idiopathic chronic anterior uveitis and juvenile idiopathic arthritis-associated uveitis are most common. Inflammation arises from an immune response against antigens within the eye. Ophthalmic work-up evaluates anatomic involvement, disease activity, ocular complications, and disease course. Local and/or systemic glucocorticoids are initial treatment, but not as long-term sole therapy to avoid glucocorticoids-induced toxicity or persistent ocular inflammation. Children with recurrent, refractory, or severe disease require systemic immunosuppression with methotrexate and/or anti-tumor necrosis factor monoclonal antibody medications (adalimumab, infliximab). Goals of early detection and treatment are to optimize vision in childhood uveitis.
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Affiliation(s)
- Margaret H Chang
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Jessica G Shantha
- Department of Ophthalmology, Emory University, Emory Eye Center, 1365 Clifton Road, Clinic Building B, Atlanta, GA 30326, USA
| | - Jacob J Fondriest
- Department of Internal Medicine, Summa Health System, Internal Medicine Center, 55 Arch Street, Suite 1B, Akron, OH 44304, USA; Rush Eye Center, 1725 West Harrison Street, Suite 945, Chicago, IL 60612, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Fegan 6, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Sheila T Angeles-Han
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, 3333 Burnett Avenue, Cincinnati, OH 45229, USA; Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Division of Ophthalmology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Ophthalmology, University of Cincinnati, Cincinnati, OH, USA.
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16
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Julé AM, Hoyt KJ, Wei K, Gutierrez-Arcelus M, Taylor ML, Ng J, Lederer JA, Case SM, Chang MH, Cohen EM, Dedeoglu F, Hazen MM, Hausmann JS, Halyabar O, Janssen E, Lo J, Lo MS, Meidan E, Roberts JE, Son MBF, Sundel RP, Lee PY, Chatila T, Nigrovic PA, Henderson LA. Th1 polarization defines the synovial fluid T cell compartment in oligoarticular juvenile idiopathic arthritis. JCI Insight 2021; 6:e149185. [PMID: 34403374 PMCID: PMC8492302 DOI: 10.1172/jci.insight.149185] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
Oligoarticular juvenile idiopathic arthritis (oligo JIA) is the most common form of chronic inflammatory arthritis in children, yet the cause of this disease remains unknown. To understand immune responses in oligo JIA, we immunophenotyped synovial fluid T cells with flow cytometry, bulk RNA-Seq, single-cell RNA-Seq (scRNA-Seq), DNA methylation studies, and Treg suppression assays. In synovial fluid, CD4+, CD8+, and γδ T cells expressed Th1-related markers, whereas Th17 cells were not enriched. Th1 skewing was prominent in CD4+ T cells, including Tregs, and was associated with severe disease. Transcriptomic studies confirmed a Th1 signature in CD4+ T cells from synovial fluid. The regulatory gene expression signature was preserved in Tregs, even those exhibiting Th1 polarization. These Th1-like Tregs maintained Treg-specific methylation patterns and suppressive function, supporting the stability of this Treg population in the joint. Although synovial fluid CD4+ T cells displayed an overall Th1 phenotype, scRNA-Seq uncovered heterogeneous effector and regulatory subpopulations, including IFN-induced Tregs, peripheral helper T cells, and cytotoxic CD4+ T cells. In conclusion, oligo JIA is characterized by Th1 polarization that encompasses Tregs but does not compromise their regulatory identity. Targeting Th1-driven inflammation and augmenting Treg function may represent important therapeutic approaches in oligo JIA.
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Affiliation(s)
- Amélie M. Julé
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kacie J. Hoyt
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kevin Wei
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria Gutierrez-Arcelus
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Broad Institute of MIT and Harvard, Cambridge, Massachusetts, USA
| | - Maria L. Taylor
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Julie Ng
- Division of Pulmonary and Critical Care Medicine, and
| | - James A. Lederer
- Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Siobhan M. Case
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret H. Chang
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ezra M. Cohen
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa M. Hazen
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan S. Hausmann
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Olha Halyabar
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erin Janssen
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Lo
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Esra Meidan
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jordan E. Roberts
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Beth F. Son
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert P. Sundel
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pui Y. Lee
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Talal Chatila
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter A. Nigrovic
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
- Division of Rheumatology, Inflammation, and Immunity, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
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17
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Basiaga ML, Stern SM, Mehta JJ, Edens C, Randell RL, Pomorska A, Irga-Jaworska N, Ibarra MF, Bracaglia C, Nicolai R, Susic G, Boneparth A, Srinivasalu H, Dizon B, Kamdar AA, Goldberg B, Knupp-Oliveira S, Antón J, Mosquera JM, Appenzeller S, O'Neil KM, Protopapas SA, Saad-Magalhães C, Akikusa JD, Thatayatikom A, Cha S, Nieto-González JC, Lo MS, Treemarcki EB, Yokogawa N, Lieberman SM. Childhood Sjögren syndrome: features of an international cohort and application of the 2016 ACR/EULAR classification criteria. Rheumatology (Oxford) 2021; 60:3144-3155. [PMID: 33280020 DOI: 10.1093/rheumatology/keaa757] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2020] [Revised: 10/02/2020] [Indexed: 12/13/2022] Open
Abstract
OBJECTIVE Sjögren syndrome in children is a poorly understood autoimmune disease. We aimed to describe the clinical and diagnostic features of children diagnosed with Sjögren syndrome and explore how the 2016 ACR/EULAR classification criteria apply to this population. METHODS An international workgroup retrospectively collected cases of Sjögren syndrome diagnosed under 18 years of age from 23 centres across eight nations. We analysed patterns of symptoms, diagnostic workup, and applied the 2016 ACR/EULAR classification criteria. RESULTS We identified 300 children with Sjögren syndrome. The majority of patients n = 232 (77%) did not meet 2016 ACR/EULAR classification criteria, but n = 110 (37%) did not have sufficient testing done to even possibly achieve the score necessary to meet criteria. Even among those children with all criteria items tested, only 36% met criteria. The most common non-sicca symptoms were arthralgia [n = 161 (54%)] and parotitis [n = 140 (47%)] with parotitis inversely correlating with age. CONCLUSION Sjögren syndrome in children can present at any age. Recurrent or persistent parotitis and arthralgias are common symptoms that should prompt clinicians to consider the possibility of Sjögren syndrome. The majority of children diagnosed with Sjögren syndromes did not meet 2016 ACR/EULAR classification criteria. Comprehensive diagnostic testing from the 2016 ACR/EULAR criteria are not universally performed. This may lead to under-recognition and emphasizes a need for further research including creation of paediatric-specific classification criteria.
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Affiliation(s)
- Matthew L Basiaga
- Division of Pediatric Rheumatology, Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN, USA
| | - Sara M Stern
- Division of Rheumatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Jay J Mehta
- Division of Rheumatology, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Cuoghi Edens
- Department of Internal Medicine and Pediatrics, The University of Chicago Medical Center, Chicago, IL, USA
| | - Rachel L Randell
- Department of Pediatrics, Duke University School of Medicine, Durham, NC, USA
| | - Anna Pomorska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Ninela Irga-Jaworska
- Department of Pediatrics, Hematology and Oncology, Medical University of Gdansk, Gdansk, Poland
| | - Maria F Ibarra
- Children's Mercy Hospital, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Claudia Bracaglia
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Rebecca Nicolai
- Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
| | - Gordana Susic
- Department of Pediatric Rheumatology, Institute of Rheumatology, Belgrade, Serbia
| | - Alexis Boneparth
- Department of Pediatrics, Columbia University Medical Center, New York, NY, USA
| | - Hemalatha Srinivasalu
- Division of Rheumatology, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Brian Dizon
- Division of Rheumatology, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.,National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases, Bethesda, MD, USA
| | - Ankur A Kamdar
- Department of Pediatrics, University of Texas McGovern Medical School at Houston, Houston, TX, USA
| | - Baruch Goldberg
- Division of Pediatric Rheumatology, Children's Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA, USA
| | - Sheila Knupp-Oliveira
- Instituto de Puericultura e Pediatria Martagão Gesteira, Universidade Federal do Rio de Janeiro, Brazil
| | - Jordi Antón
- Pediatric Rheumatology, Hospital Sant Joan de Déu, Esplugues (Barcelona), Spain.,Universitat de Barcelona, Barcelona, Spain
| | - Juan M Mosquera
- Pediatric Rheumatology, Hospital Sant Joan de Déu, Esplugues (Barcelona), Spain
| | - Simone Appenzeller
- Rheumatology Unit, Department of Medicine, School of Medical Science, University of Campinas, São Paulo, Brazil
| | - Kathleen M O'Neil
- Division of Rheumatology, Department of Pediatrics, University of Indiana School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Stella A Protopapas
- Division of Rheumatology, Department of Pediatrics, University of Indiana School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Claudia Saad-Magalhães
- Pediatric Rheumatology Unit, São Paulo State University (UNESP), Botucatu, São Paulo, Brazil
| | - Jonathan D Akikusa
- Rheumatology Service, Royal Children's Hospital, Melbourne and Murdoch Children's Research Institute, Melbourne, Australia
| | - Akaluck Thatayatikom
- Division of Pediatric Allergy, Immunology, & Rheumatology, Department of Pediatrics, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Seunghee Cha
- Division of Oral Medicine, Department of Oral & Maxillofacial Diagnostic Sciences, College of Dentistry, University of Florida, Gainesville, FL, USA
| | | | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Department of Pediatrics, Harvard Medical School, Boston, MA, USA
| | - Erin Brennan Treemarcki
- Division of Rheumatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT, USA
| | - Naoto Yokogawa
- Department of Rheumatic Diseases, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Scott M Lieberman
- Division of Rheumatology, Allergy, and Immunology, Stead Family Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA, USA
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18
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Wahezi DM, Lo MS, Rubinstein TB, Ringold S, Ardoin SP, Downes KJ, Jones KB, Laxer RM, Pellet Madan R, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID-19 Pandemic: Version 2. Arthritis Rheumatol 2021; 73:e46-e59. [PMID: 34114365 DOI: 10.1002/art.41772] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 04/08/2021] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To provide clinical guidance to rheumatology providers who treat children with pediatric rheumatic disease (PRD) in the context of the coronavirus disease 2019 (COVID-19) pandemic. METHODS The task force, consisting of 7 pediatric rheumatologists, 2 pediatric infectious disease physicians, 1 adult rheumatologist, and 1 pediatric nurse practitioner, was convened on May 21, 2020. Clinical questions and subsequent guidance statements were drafted based on a review of the queries posed by the patients as well as the families and healthcare providers of children with PRD. An evidence report was generated and disseminated to task force members to assist with 3 rounds of asynchronous, anonymous voting by email using a modified Delphi approach. Voting was completed using a 9-point numeric scoring system with predefined levels of agreement (categorized as disagreement, uncertainty, or agreement, with median scores of 1-3, 4-6, and 7-9, respectively) and consensus (categorized as low, moderate, or high). To be approved as a guidance statement, median vote ratings were required to fall into the highest tertile for agreement, with either moderate or high levels of consensus. RESULTS To date, 39 guidance statements have been approved by the task force. Those with similar recommendations were combined to form a total of 33 final guidance statements, all of which received median vote ratings within the highest tertile of agreement and were associated with either moderate consensus (n = 5) or high consensus (n = 28). CONCLUSION These guidance statements have been generated based on review of the available literature, indicating that children with PRD do not appear to be at increased risk for susceptibility to SARS-CoV-2 infection. This guidance is presented as a "living document," recognizing that the literature on COVID-19 is rapidly evolving, with future updates anticipated.
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Affiliation(s)
- Dawn M Wahezi
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, New York, New York, United States
| | - Mindy S Lo
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts, United States
| | - Tamar B Rubinstein
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, New York, New York, United States
| | - Sarah Ringold
- Seattle Children's Hospital, Seattle, Washington, United States
| | - Stacy P Ardoin
- Nationwide Children's Hospital and Ohio State University, Columbus, Ohio, United States
| | - Kevin J Downes
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
| | - Karla B Jones
- Nationwide Children's Hospital and Ohio State University, Columbus, Ohio, United States
| | - Ronald M Laxer
- University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rebecca Pellet Madan
- New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, New York, United States
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia, United States
| | - David R Karp
- University of Texas Southwestern Medical Center, Dallas
| | - Jay J Mehta
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, United States
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19
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Lo J, Gauvreau K, Baker AL, de Ferranti SD, Friedman KG, Lo MS, Dedeoglu F, Sundel RP, Newburger JW, Son MBF. Multiple Emergency Department Visits for a Diagnosis of Kawasaki Disease: An Examination of Risk Factors and Outcomes. J Pediatr 2021; 232:127-132.e3. [PMID: 33453202 DOI: 10.1016/j.jpeds.2021.01.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/31/2020] [Accepted: 01/07/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To determine predictors of >1 emergency department (ED) visit for a Kawasaki disease diagnosis in a quaternary care pediatric hospital and compare outcomes between patients with 1 vs >1 visit for Kawasaki disease diagnosis. STUDY DESIGN Medical records of patients evaluated for Kawasaki disease between January 2006 and August 2018 at Boston Children's Hospital were abstracted for demographic and clinical data. Predictors of >1 visit were explored using logistic regression and classification and regression tree analysis. RESULTS Of 530 patients diagnosed with Kawasaki disease, 117 (22%) required multiple ED visits for Kawasaki disease diagnosis. Multivariable regression and classification and regression tree analysis identified ≤2 Kawasaki disease criteria (OR 33.9; 95% CI 18.1-63.6), <3 days of fever at the first visit (OR 3.47; 95% CI 1.77-6.84), and non-White race (OR 2.15; 95% CI 1.18-3.95) as predictors of >1 visit. There were no significant differences in duration of hospitalization, day of illness at initial Kawasaki disease treatment, intravenous immunoglobulin resistance, need for adjunctive therapies, or coronary artery outcomes between patients diagnosed with Kawasaki disease at initial visit vs subsequent visits. CONCLUSIONS Incomplete Kawasaki disease criteria, fewer days of fever, and non-White race were significant predictors of multiple ED visits for Kawasaki disease diagnosis in this single institution study. Our findings underscore the importance of maintaining a high index of suspicion for Kawasaki disease in patients with <4 Kawasaki disease criteria. Further research is needed to determine causes for increased healthcare use in non-White patients to receive a Kawasaki disease diagnosis.
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Affiliation(s)
- Jeffrey Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Robert P Sundel
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mary Beth F Son
- Division of Immunology, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA.
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20
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Lee PY, Day-Lewis M, Henderson LA, Friedman KG, Lo J, Roberts JE, Lo MS, Platt CD, Chou J, Hoyt KJ, Baker AL, Banzon TM, Chang MH, Cohen E, de Ferranti SD, Dionne A, Habiballah S, Halyabar O, Hausmann JS, Hazen MM, Janssen E, Meidan E, Nelson RW, Nguyen AA, Sundel RP, Dedeoglu F, Nigrovic PA, Newburger JW, Son MBF. Distinct clinical and immunological features of SARS-CoV-2-induced multisystem inflammatory syndrome in children. J Clin Invest 2020; 130:5942-5950. [PMID: 32701511 DOI: 10.1172/jci141113] [Citation(s) in RCA: 251] [Impact Index Per Article: 62.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2020] [Accepted: 07/22/2020] [Indexed: 01/08/2023] Open
Abstract
BACKGROUNDPediatric SARS-CoV-2 infection can be complicated by a dangerous hyperinflammatory condition termed multisystem inflammatory syndrome in children (MIS-C). The clinical and immunologic spectrum of MIS-C and its relationship to other inflammatory conditions of childhood have not been studied in detail.METHODSWe retrospectively studied confirmed cases of MIS-C at our institution from March to June 2020. The clinical characteristics, laboratory studies, and treatment response were collected. Data were compared with historic cohorts of Kawasaki disease (KD) and macrophage activation syndrome (MAS).RESULTSTwenty-eight patients fulfilled the case definition of MIS-C. Median age at presentation was 9 years (range: 1 month to 17 years); 50% of patients had preexisting conditions. All patients had laboratory confirmation of SARS-CoV-2 infection. Seventeen patients (61%) required intensive care, including 7 patients (25%) who required inotrope support. Seven patients (25%) met criteria for complete or incomplete KD, and coronary abnormalities were found in 6 cases. Lymphopenia, thrombocytopenia, and elevation in inflammatory markers, D-dimer, B-type natriuretic peptide, IL-6, and IL-10 levels were common but not ubiquitous. Cytopenias distinguished MIS-C from KD and the degree of hyperferritinemia and pattern of cytokine production differed between MIS-C and MAS. Immunomodulatory therapy given to patients with MIS-C included intravenous immune globulin (IVIG) (71%), corticosteroids (61%), and anakinra (18%). Clinical and laboratory improvement were observed in all cases, including 6 cases that did not require immunomodulatory therapy. No mortality was recorded in this cohort.CONCLUSIONMIS-C encompasses a broad phenotypic spectrum with clinical and laboratory features distinct from KD and MAS.FUNDINGThis work was supported by the National Institutes of Health, National Institute of Arthritis and Musculoskeletal and Skin Diseases; the National Institute of Allergy and Infectious Diseases; Rheumatology Research Foundation Investigator Awards and Medical Education Award; Boston Children's Hospital Faculty Career Development Awards; the McCance Family Foundation; and the Samara Jan Turkel Center.
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Affiliation(s)
| | | | | | - Kevin G Friedman
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | | | | | | | | | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Ezra Cohen
- Division of Immunology and.,Division of Pediatric Rheumatology, Department of Pediatrics, Boston Medical Center, Boston, Massachusetts, USA
| | - Sarah D de Ferranti
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Audrey Dionne
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Jonathan S Hausmann
- Division of Immunology and.,Division of Rheumatology and Clinical Immunology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | | | | | | | | | | - Peter A Nigrovic
- Division of Immunology and.,Division of Rheumatology, Inflammation, and Immunity, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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21
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Wahezi DM, Lo MS, Rubinstein TB, Ringold S, Ardoin SP, Downes KJ, Jones KB, Laxer RM, Pellet Madan R, Mudano AS, Turner AS, Karp DR, Mehta JJ. American College of Rheumatology Guidance for the Management of Pediatric Rheumatic Disease During the COVID-19 Pandemic: Version 1. Arthritis Rheumatol 2020; 72:1809-1819. [PMID: 32705780 PMCID: PMC7404941 DOI: 10.1002/art.41455] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 07/21/2020] [Indexed: 12/16/2022]
Abstract
Objective To provide clinical guidance to rheumatology providers who treat children with pediatric rheumatic disease (PRD) in the context of the coronavirus disease 2019 (COVID‐19) pandemic. Methods The task force, consisting of 7 pediatric rheumatologists, 2 pediatric infectious disease physicians, 1 adult rheumatologist, and 1 pediatric nurse practitioner, was convened on May 21, 2020. Clinical questions and subsequent guidance statements were drafted based on a review of the queries posed by the patients as well as the families and healthcare providers of children with PRD. An evidence report was generated and disseminated to task force members to assist with 3 rounds of asynchronous, anonymous voting by email using a modified Delphi approach. Voting was completed using a 9‐point numeric scoring system with predefined levels of agreement (categorized as disagreement, uncertainty, or agreement, with median scores of 1–3, 4–6, and 7–9, respectively) and consensus (categorized as low, moderate, or high). To be approved as a guidance statement, median vote ratings were required to fall into the highest tertile for agreement, with either moderate or high levels of consensus. Results The task force drafted 33 guidance statements, which were voted upon during the second and third rounds of voting. Of these 33 statements, all received median vote ratings within the highest tertile of agreement and were associated with either moderate consensus (n = 6) or high consensus (n = 27). Statements with similar recommendations were combined, resulting in 27 final guidance statements. Conclusion These guidance statements have been generated based on review of the available literature, indicating that children with PRD do not appear to be at increased risk for susceptibility to SARS–CoV‐2 infection. This guidance is presented as a “living document,” recognizing that the literature on COVID‐19 is rapidly evolving, with future updates anticipated.
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Affiliation(s)
- Dawn M Wahezi
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, New York, New York
| | - Mindy S Lo
- Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Tamar B Rubinstein
- Children's Hospital at Montefiore and Albert Einstein College of Medicine, New York, New York
| | | | - Stacy P Ardoin
- Nationwide Children's Hospital and Ohio State University, Columbus, Ohio
| | - Kevin J Downes
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Karla B Jones
- Nationwide Children's Hospital and Ohio State University, Columbus, Ohio
| | - Ronald M Laxer
- University of Toronto and The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Rebecca Pellet Madan
- New York University Grossman School of Medicine and Hassenfeld Children's Hospital, New York, New York
| | | | - Amy S Turner
- American College of Rheumatology, Atlanta, Georgia
| | - David R Karp
- University of Texas Southwestern Medical Center, Dallas
| | - Jay J Mehta
- Children's Hospital of Philadelphia and University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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22
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Henderson LA, Hoyt KJ, Lee PY, Rao DA, Jonsson AH, Nguyen JP, Rutherford K, Julé AM, Charbonnier LM, Case S, Chang MH, Cohen EM, Dedeoglu F, Fuhlbrigge RC, Halyabar O, Hazen MM, Janssen E, Kim S, Lo J, Lo MS, Meidan E, Son MBF, Sundel RP, Stoll ML, Nusbaum C, Lederer JA, Chatila TA, Nigrovic PA. Th17 reprogramming of T cells in systemic juvenile idiopathic arthritis. JCI Insight 2020; 5:132508. [PMID: 32213704 DOI: 10.1172/jci.insight.132508] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 02/26/2020] [Indexed: 12/21/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (sJIA) begins with fever, rash, and high-grade systemic inflammation but commonly progresses to a persistent afebrile arthritis. The basis for this transition is unknown. To evaluate a role for lymphocyte polarization, we characterized T cells from patients with acute and chronic sJIA using flow cytometry, mass cytometry, and RNA sequencing. Acute and chronic sJIA each featured an expanded population of activated Tregs uncommon in healthy controls or in children with nonsystemic JIA. In acute sJIA, Tregs expressed IL-17A and a gene expression signature reflecting Th17 polarization. In chronic sJIA, the Th17 transcriptional signature was identified in T effector cells (Teffs), although expression of IL-17A at the protein level remained rare. Th17 polarization was abrogated in patients responding to IL-1 blockade. These findings identify evolving Th17 polarization in sJIA that begins in Tregs and progresses to Teffs, likely reflecting the impact of the cytokine milieu and consistent with a biphasic model of disease pathogenesis. The results support T cells as a potential treatment target in sJIA.
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Affiliation(s)
- Lauren A Henderson
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kacie J Hoyt
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pui Y Lee
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, and
| | - Deepak A Rao
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, and
| | - A Helena Jonsson
- Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, and
| | - Jennifer P Nguyen
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kayleigh Rutherford
- Harvard Bioinformatics Core, Harvard School of Public Health, Boston, Massachusetts, USA
| | - Amélie M Julé
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Louis-Marie Charbonnier
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Siobhan Case
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret H Chang
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, and
| | - Ezra M Cohen
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fatma Dedeoglu
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert C Fuhlbrigge
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Department of Rheumatology, Children's Hospital Colorado, Aurora, Colorado, USA
| | - Olha Halyabar
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Melissa M Hazen
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Erin Janssen
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Susan Kim
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jeffrey Lo
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mindy S Lo
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Esra Meidan
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mary Beth F Son
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert P Sundel
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Matthew L Stoll
- Division of Pediatric Rheumatology, Department of Pediatrics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chad Nusbaum
- Broad Technology Labs, Broad Institute, Massachusetts Institute of Technology and Harvard University, Cambridge, Massachusetts, USA
| | - James A Lederer
- Department of Surgery, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Talal A Chatila
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter A Nigrovic
- Division of Immunology, Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Division of Rheumatology, Inflammation, and Immunity, Department of Medicine, and
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23
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Abstract
Kawasaki disease (KD) is a common vasculitis of childhood, typically affecting children under the age of five. Despite many aspects of its presentation that bear resemblence to acute infection, no causative infectious agent has been identified despite years of intense scrutiny. Unlike most infections, however, there are significant differences in racial predilection that suggest a strong genetic influence. The inflammatory response in KD specifically targets the coronary arteries, also unusual for an infectious condition. In this review, we discuss recent hypotheses on KD pathogenesis as well as new insights into the innate immune response and mechanisms behind vascular damage. The pathogenesis is complex, however, and remains inadequately understood.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115, United States of America; Department of Pediatrics, Harvard Medical School, Boston, MA 02115, United States of America.
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24
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Lee PY, Schulert GS, Canna SW, Huang Y, Sundel J, Li Y, Hoyt KJ, Blaustein RB, Wactor A, Do T, Halyabar O, Chang MH, Dedeoglu F, Case SM, Meidan E, Lo MS, Sundel RP, Richardson ET, Newburger JW, Hershfield MS, Son MB, Henderson LA, Nigrovic PA. Adenosine deaminase 2 as a biomarker of macrophage activation syndrome in systemic juvenile idiopathic arthritis. Ann Rheum Dis 2019; 79:225-231. [PMID: 31707357 DOI: 10.1136/annrheumdis-2019-216030] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 10/14/2019] [Accepted: 10/18/2019] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Macrophage activation syndrome (MAS) is a life-threatening complication of systemic juvenile idiopathic arthritis (sJIA) characterised by a vicious cycle of immune amplification that can culminate in overwhelming inflammation and multiorgan failure. The clinical features of MAS overlap with those of active sJIA, complicating early diagnosis and treatment. We evaluated adenosine deaminase 2 (ADA2), a protein of unknown function released principally by monocytes and macrophages, as a novel biomarker of MAS. METHODS We established age-based normal ranges of peripheral blood ADA2 activity in 324 healthy children and adults. We compared these ranges with 173 children with inflammatory and immune-mediated diseases, including systemic and non-systemic JIA, Kawasaki disease, paediatric systemic lupus erythematosus and juvenile dermatomyositis. RESULTS ADA2 elevation beyond the upper limit of normal in children was largely restricted to sJIA with concomitant MAS, a finding confirmed in a validation cohort of sJIA patients with inactive disease, active sJIA without MAS or sJIA with MAS. ADA2 activity strongly correlated with MAS biomarkers including ferritin, interleukin (IL)-18 and the interferon (IFN)-γ-inducible chemokine CXCL9 but displayed minimal association with the inflammatory markers C reactive protein and erythrocyte sedimentation rate. Correspondingly, ADA2 paralleled disease activity based on serial measurements in patients with recurrent MAS episodes. IL-18 and IFN-γ elicited ADA2 production by peripheral blood mononuclear cells, and ADA2 was abundant in MAS haemophagocytes. CONCLUSIONS These findings collectively identify the utility of plasma ADA2 activity as a biomarker of MAS and lend further support to a pivotal role of macrophage activation in this condition.
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Affiliation(s)
- Pui Y Lee
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA .,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
| | - Grant S Schulert
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, United States
| | - Scott W Canna
- RK Mellon Institute for Pediatric Research, Pittsburg, PA, United States
| | - Yuelong Huang
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
| | - Jacob Sundel
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
| | - Ying Li
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
| | - Kacie J Hoyt
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Rachel B Blaustein
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
| | - Alexandra Wactor
- Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
| | - Thuy Do
- Division of Rheumatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Olha Halyabar
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Margaret H Chang
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Siobhan M Case
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Esra Meidan
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert P Sundel
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward T Richardson
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, United States
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA, United States
| | - Michael S Hershfield
- Department of Medicine and Biochemistry, Duke University School of Medicine, Durham, NC, United States
| | - Mary Beth Son
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lauren A Henderson
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter A Nigrovic
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA .,Division of Rheumatology, Immunology and Allergy, Brigham and Women's Hospital, Boston, MA, United States
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Angeles-Han ST, Lo MS, Henderson LA, Lerman MA, Abramson L, Cooper AM, Parsa MF, Zemel LS, Ronis T, Beukelman T, Cox E, Sen HN, Holland GN, Brunner HI, Lasky A, Rabinovich CE. Childhood Arthritis and Rheumatology Research Alliance Consensus Treatment Plans for Juvenile Idiopathic Arthritis-Associated and Idiopathic Chronic Anterior Uveitis. Arthritis Care Res (Hoboken) 2019; 71:482-491. [PMID: 29806733 PMCID: PMC6261704 DOI: 10.1002/acr.23610] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 05/22/2018] [Indexed: 01/27/2023]
Abstract
OBJECTIVE Systemic immunosuppressive treatment of pediatric chronic anterior uveitis (CAU), both juvenile idiopathic arthritis-associated and idiopathic anterior uveitis, varies, making it difficult to identify best treatments. The Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed consensus treatment plans (CTPs) for CAU for the purpose of reducing practice variability and allowing future comparison of treatments using comparative effectiveness analysis techniques. METHODS A core group of pediatric rheumatologists, ophthalmologists with uveitis expertise, and a lay advisor comprised the CARRA uveitis workgroup that performed a literature review on pharmacologic treatments, held teleconferences, and developed a case-based survey administered to the CARRA membership to delineate treatment practices. We held 3 face-to-face consensus meetings using nominal group technique to develop CTPs. RESULTS The survey identified areas of treatment practice variability. We developed 2 CTPs for the treatment of CAU, case definitions, and monitoring parameters. The first CTP is directed at children who are naive to steroid-sparing medication, and the second at children initiating biologic therapy, with options for methotrexate, adalimumab, and infliximab. We defined a core data set and outcome measures, with data collection at 3 and 6 months after therapy initiation. The CARRA membership voted to accept the CTPs with a >95% approval (n = 233). CONCLUSION Using consensus methodology, 2 standardized CTPs were developed for systemic immunosuppressive treatment of CAU. These CTPs are not meant as treatment guidelines, but are designed for further pragmatic research within the CARRA research network. Use of these CTPs in a prospective comparison effectiveness study should improve outcomes by identifying best practice options.
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Affiliation(s)
- Sheila T. Angeles-Han
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, Boston, MA
| | | | - Leslie Abramson
- Vermont Children’s Hospital at University of Vermont Medical Center, Burlington, VT
| | | | | | | | - Tova Ronis
- Children’s National Health System, Washington, DC
| | | | | | - H. Nida Sen
- National Eye Institute, National Institutes of Health, Bethesda, Maryland
| | - Gary N. Holland
- UCLA Stein Eye Institute and David Geffen School of Medicine at University of California Los Angeles, Los Angeles, CA
| | - Hermine I. Brunner
- Division of Rheumatology, Cincinnati Children’s Hospital Medical Center and Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Andrew Lasky
- Randall Children’s Hospital at Legacy Emmanuel, Portland, OR
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Halyabar O, Chang MH, Schoettler ML, Schwartz MA, Baris EH, Benson LA, Biggs CM, Gorman M, Lehmann L, Lo MS, Nigrovic PA, Platt CD, Priebe GP, Rowe J, Sundel RP, Surana NK, Weinacht KG, Mann A, Yuen JC, Meleedy-Rey P, Starmer A, Banerjee T, Dedeoglu F, Degar BA, Hazen MM, Henderson LA. Calm in the midst of cytokine storm: a collaborative approach to the diagnosis and treatment of hemophagocytic lymphohistiocytosis and macrophage activation syndrome. Pediatr Rheumatol Online J 2019; 17:7. [PMID: 30764840 PMCID: PMC6376762 DOI: 10.1186/s12969-019-0309-6] [Citation(s) in RCA: 61] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2018] [Accepted: 02/04/2019] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hemophagocytic lymphohistiocytosis (HLH) and macrophage activation syndrome (MAS) were historically thought to be distinct entities, often managed in isolation. In fact, these conditions are closely related. A collaborative approach, which incorporates expertise from subspecialties that previously treated HLH/MAS independently, is needed. We leveraged quality improvement (QI) techniques in the form of an Evidence-Based Guideline (EBG) to build consensus across disciplines on the diagnosis and treatment of HLH/MAS. METHODS A multidisciplinary work group was convened that met monthly to develop the HLH/MAS EBG. Literature review and expert opinion were used to develop a management strategy for HLH/MAS. The EBG was implemented, and quality metrics were selected to monitor outcomes. RESULTS An HLH/MAS clinical team was formed with representatives from subspecialties involved in the care of patients with HLH/MAS. Broad entry criteria for the HLH/MAS EBG were established and included fever and ferritin ≥500 ng/mL. The rheumatology team was identified as the "gate-keeper," charged with overseeing the diagnostic evaluation recommended in the EBG. First-line medications were recommended based on the acuity of illness and risk of concurrent infection. Quality metrics to be tracked prospectively based on time to initiation of treatment and clinical response were selected. CONCLUSION HLH/MAS are increasingly considered to be a spectrum of related conditions, and joint management across subspecialties could improve patient outcomes. Our experience in creating a multidisciplinary approach to HLH/MAS management can serve as a model for care at other institutions.
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Affiliation(s)
- Olha Halyabar
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Margaret H. Chang
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8294grid.62560.37Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Boston, MA USA
| | - Michelle L. Schoettler
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Marc A. Schwartz
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Ezgi H. Baris
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0001 0668 8422grid.16477.33Department of Pediatrics, Marmara University Pendik Research and Training Hospital, Istanbul, Turkey
| | - Leslie A. Benson
- 0000 0004 0378 8438grid.2515.3Department of Neurology, Boston Children’s Hospital, Boston, MA USA
| | - Catherine M. Biggs
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2288 9830grid.17091.3eDepartment of Pediatrics, British Columbia Children’s Hospital, University of British Columbia, Vancouver, BC Canada
| | - Mark Gorman
- 0000 0004 0378 8438grid.2515.3Department of Neurology, Boston Children’s Hospital, Boston, MA USA
| | - Leslie Lehmann
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Mindy S. Lo
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Peter A. Nigrovic
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8294grid.62560.37Division of Rheumatology, Immunology, and Allergy, Brigham and Women’s Hospital, Boston, MA USA
| | - Craig D. Platt
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Gregory P. Priebe
- 0000 0004 0378 8438grid.2515.3Division of Critical Care Medicine, Boston Children’s Hospital, Boston, MA USA
| | - Jared Rowe
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Robert P. Sundel
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Neeraj K. Surana
- 0000 0004 0378 8438grid.2515.3Division of Infectious Diseases, Boston Children’s Hospital, Boston, MA USA ,0000 0004 1936 7961grid.26009.3dDepartment of Pediatrics, Duke University, Durham, NC USA
| | - Katja G. Weinacht
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA ,0000 0004 0450 875Xgrid.414123.1Division of Stem Cell Transplantation and Regenerative Medicine, Lucile Packard Children’s Hospital Stanford, Stanford, CA USA
| | - Alison Mann
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Jenny Chan Yuen
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Patricia Meleedy-Rey
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Amy Starmer
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Taruna Banerjee
- 0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Fatma Dedeoglu
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
| | - Barbara A. Degar
- 0000 0004 0378 8438grid.2515.3Division of Hematology-Oncology, Boston Children’s Hospital, Boston, MA USA ,0000 0001 2106 9910grid.65499.37Department of Pediatric Oncology, Dana Farber Cancer Institute, Boston, MA USA
| | - Melissa M. Hazen
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA ,0000 0004 0378 8438grid.2515.3Department of Pediatrics, Boston Children’s Hospital, Boston, MA USA
| | - Lauren A. Henderson
- 0000 0004 0378 8438grid.2515.3Division of Immunolgy, Boston Children’s Hospital, Boston, MA USA
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Abstract
The pathophysiology of systemic lupus erythematosus (SLE) has been intensely studied but remains incompletely defined. Currently, multiple mechanisms are known to contribute to the development of SLE. These include inadequate clearance of apoptotic debris, aberrant presentation of self nucleic antigens, loss of tolerance, and inappropriate activation of T and B cells. Genetic, hormonal, and environmental influences are also known to play a role. The study of lupus in children, in whom there is presumed to be greater genetic influence, has led to new understandings that are applicable to SLE pathophysiology as a whole. In particular, characterization of inherited disorders associated with excessive type I interferon production has elucidated specific mechanisms by which interferon is induced in SLE. In this review, we discuss several monogenic forms of lupus presenting in childhood and also review recent insights gained from cytokine and autoantibody profiling of pediatric SLE.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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Abstract
INTRODUCTION The objective of the study was to assess correlates of adolescent and parent perceptions of their involvement in medical decision-making (MDM). METHOD Study participants included 28 pairs of pediatric patients with chronic rheumatologic illnesses and their parents presenting to an outpatient rheumatology clinic. Participants completed measures assessing perceptions of MDM involvement, health consciousness, and decisional conflict. RESULTS Adolescent health consciousness correlated positively with parent health consciousness and adolescent-valuing involvement. There was a significant positive correlation between adolescents-valuing involvement in medical decisions and perception of actual involvement. Adolescents who perceived themselves as more involved in their care reported less decisional conflict. Parents who wanted to participate in MDM reported greater actual involvement. DISCUSSION Adolescents who value participation in MDM reported higher levels of actual participation, suggesting their preferences may be considered by providers. Greater engagement in MDM was related to lower decisional conflict for adolescents, suggesting that including adolescents in the MDM process does not necessarily result in confusion or distress. (PsycINFO Database Record
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Affiliation(s)
- Jennie G David
- Department of Psychological and Brain Sciences, Boston University
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital
| | - David A Langer
- Department of Psychological and Brain Sciences, Boston University
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Lo MS, Towne M, VanNoy GE, Brownstein CA, Lane AA, Chatila TA, Agrawal PB. Monogenic Hashimoto thyroiditis associated with a variant in the thyroglobulin (TG) gene. J Autoimmun 2018; 86:116-119. [DOI: 10.1016/j.jaut.2017.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 09/08/2017] [Accepted: 09/11/2017] [Indexed: 11/29/2022]
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Abstract
Intravenous immunoglobulin (IVIg) is a purified plasma product that is used for many immune-deficient conditions and autoimmune conditions. Use of IVIg for treatment for Kawasaki disease (KD) is critical for control of inflammation. The American Heart Association (AHA) recommends a single infusion of 2 g/kg preferably given during the first 10 days of illness. In this review, we have discussed the possible mechanisms of action of IVIg in KD and its clinical usage in this condition.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Pediatrics, Harvard Medical School, Boston, MA.,Division of Cardiology, Boston Children's Hospital, Boston, MA
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Abstract
PURPOSE OF REVIEW Systemic lupus erythematosus (SLE) is a multisystem autoimmune disease known for its clinical heterogeneity. Over time, new insights into the complex genetic origin of SLE have started to explain some of this clinical variability. These findings, reviewed here, have also yielded important understanding in the immune mechanisms behind SLE pathogenesis. RECENT FINDINGS Several new monogenic disorders with lupus-like phenotype have been described. These can be organized into physiologic pathways that parallel mechanisms of disease in SLE. Examples include genes important for DNA damage repair (e.g., TREX1), nucleic acid sensing and type I interferon overproduction (e.g., STING, TREX1), apoptosis (FASLG), tolerance (PRKCD), and clearance of self-antigen (DNASE1L3). Further study of monogenic lupus may lead to better genotype/phenotype correlations in SLE. Eventually, the ability to understand individual patients according to their genetic profile may allow the development of more targeted and personalized approaches to therapy.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Boston Children's Hospital, 300 Longwood Ave, Boston, MA, USA.
- Department of Pediatrics, Harvard Medical School, Boston, MA, USA.
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Henderson LA, Volpi S, Frugoni F, Janssen E, Kim S, Sundel RP, Dedeoglu F, Lo MS, Hazen MM, Beth Son M, Mathieu R, Zurakowski D, Yu N, Lebedeva T, Fuhlbrigge RC, Walter JE, Nee Lee Y, Nigrovic PA, Notarangelo LD. Next-Generation Sequencing Reveals Restriction and Clonotypic Expansion of Treg Cells in Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2017; 68:1758-68. [PMID: 26815131 DOI: 10.1002/art.39606] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 01/19/2016] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Treg cell-mediated suppression of Teff cells is impaired in juvenile idiopathic arthritis (JIA); however, the basis for this dysfunction is incompletely understood. Animal models of autoimmunity and immunodeficiency demonstrate that a diverse Treg cell repertoire is essential to maintain Treg cell function. The present study was undertaken to investigate the Treg and Teff cell repertoires in JIA. METHODS Treg cells (CD4+CD25+CD127(low) ) and Teff cells (CD4+CD25-) were isolated from peripheral blood and synovial fluid obtained from JIA patients, healthy controls, and children with Lyme arthritis. Treg cell function was measured in suppressive assays. The T cell receptor β chain (TRB) was amplified by multiplex polymerase chain reaction and next-generation sequencing was performed, with amplicons sequenced using an Illumina HiSeq platform. Data were analyzed using ImmunoSEQ, International ImMunoGeneTics system, and the Immunoglobulin Analysis Tools. RESULTS Compared to findings in controls, the JIA peripheral blood Treg cell repertoire was restricted, and clonotypic expansions were found in both blood and synovial fluid Treg cells. Skewed usage and pairing of TRB variable and joining genes, including overuse of gene segments that have been associated with other autoimmune conditions, was observed. JIA patients shared a substantial portion of synovial fluid Treg cell clonotypes that were private to JIA and not identified in Lyme arthritis. CONCLUSION We identified restriction and clonotypic expansions in the JIA Treg cell repertoire with sharing of Treg cell clonotypes across patients. These findings suggest that abnormalities in the Treg cell repertoire, possibly engendered by shared antigenic triggers, may contribute to disease pathogenesis in JIA.
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Affiliation(s)
| | | | | | - Erin Janssen
- Boston Children's Hospital, Boston, Massachusetts
| | - Susan Kim
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Mindy S Lo
- Boston Children's Hospital, Boston, Massachusetts
| | | | | | | | | | - Neng Yu
- American Red Cross Blood Services-East Division, New England HLA Services, Dedham, Massachusetts
| | - Tatiana Lebedeva
- American Red Cross Blood Services-East Division, New England HLA Services, Dedham, Massachusetts
| | - Robert C Fuhlbrigge
- Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Jolan E Walter
- Boston Children's Hospital and Massachusetts General Hospital for Children, Boston, Massachusetts
| | - Yu Nee Lee
- Boston Children's Hospital, Boston, Massachusetts
| | - Peter A Nigrovic
- Boston Children's Hospital and Brigham and Women's Hospital, Boston, Massachusetts
| | - Luigi D Notarangelo
- Boston Children's Hospital, Harvard Medical School, and Harvard Stem Cell Institute, Boston, Massachusetts
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33
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Abstract
The aetiology of systemic lupus erythematosus (SLE) is multifactorial, and includes contributions from the environment, stochastic factors, and genetic susceptibility. Great gains have been made in understanding SLE through the use of genetic variant identification, mouse models, gene expression studies, and epigenetic analyses. Collectively, these studies support the concept that defective clearance of immune complexes and biological waste (such as apoptotic cells), neutrophil extracellular traps, nucleic acid sensing, lymphocyte signalling, and interferon production pathways are all central to loss of tolerance and tissue damage. Increased understanding of the pathogenesis of SLE is driving a renewed interest in targeted therapy, and researchers are now on the verge of developing targeted immunotherapy directed at treating either specific organ system involvement or specific subsets of patients with SLE. Accordingly, this Review places these insights within the context of our current understanding of the pathogenesis of SLE and highlights pathways that are ripe for therapeutic targeting.
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Affiliation(s)
- George C Tsokos
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Harvard Medical School, 110 Francis Street, Boston, Massachusetts 02215, USA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, Massachusetts 02115, USA
| | - Patricia Costa Reis
- Department of Pediatrics, Lisbon Medical School, Lisbon University, Santa Maria Hospital, Avenida Professor Egas Moniz, 1649-035 Lisbon, Portugal
| | - Kathleen E Sullivan
- Division of Allergy and Immunology, The Children's Hospital of Philadelphia, The University of Pennsylvania Perelman School of Medicine, 3615 Civic Center Boulevard, Philadelphia, Pennsylvania 19104, USA
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34
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Son MBF, Gauvreau K, Kim S, Tang A, Dedeoglu F, Fulton DR, Lo MS, Baker AL, Sundel RP, Newburger JW. Predicting Coronary Artery Aneurysms in Kawasaki Disease at a North American Center: An Assessment of Baseline z Scores. J Am Heart Assoc 2017; 6:JAHA.116.005378. [PMID: 28566299 PMCID: PMC5669166 DOI: 10.1161/jaha.116.005378] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Accurate risk prediction of coronary artery aneurysms (CAAs) in North American children with Kawasaki disease remains a clinical challenge. We sought to determine the predictive utility of baseline coronary dimensions adjusted for body surface area (z scores) for future CAAs in Kawasaki disease and explored the extent to which addition of established Japanese risk scores to baseline coronary artery z scores improved discrimination for CAA development. Methods and Results We explored the relationships of CAA with baseline z scores; with Kobayashi, Sano, Egami, and Harada risk scores; and with the combination of baseline z scores and risk scores. We defined CAA as a maximum z score (zMax) ≥2.5 of the left anterior descending or right coronary artery at 4 to 8 weeks of illness. Of 261 patients, 77 patients (29%) had a baseline zMax ≥2.0. CAAs occurred in 15 patients (6%). CAAs were strongly associated with baseline zMax ≥2.0 versus <2.0 (12 [16%] versus 3 [2%], respectively, P<0.001). Baseline zMax ≥2.0 had a C statistic of 0.77, good sensitivity (80%), and excellent negative predictive value (98%). None of the risk scores alone had adequate discrimination. When high‐risk status per the Japanese risk scores was added to models containing baseline zMax ≥2.0, none were significantly better than baseline zMax ≥2.0 alone. Conclusions In a North American center, baseline zMax ≥2.0 in children with Kawasaki disease demonstrated high predictive utility for later development of CAA. Future studies should validate the utility of our findings.
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Affiliation(s)
- Mary Beth F Son
- Division of Immunology, Boston Children's Hospital, Boston, MA .,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kimberlee Gauvreau
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Susan Kim
- University of California San Francisco School of Medicine, San Francisco, CA
| | - Alexander Tang
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Fatma Dedeoglu
- Division of Immunology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - David R Fulton
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Annette L Baker
- Department of Cardiology, Boston Children's Hospital, Boston, MA
| | - Robert P Sundel
- Division of Immunology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Jane W Newburger
- Department of Cardiology, Boston Children's Hospital, Boston, MA.,Department of Pediatrics, Harvard Medical School, Boston, MA
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35
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Henderson LA, Zurakowski D, Angeles-Han ST, Lasky A, Rabinovich CE, Lo MS. Medication use in juvenile uveitis patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry. Pediatr Rheumatol Online J 2016; 14:9. [PMID: 26879972 PMCID: PMC4755024 DOI: 10.1186/s12969-016-0069-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 02/04/2016] [Indexed: 12/03/2022] Open
Abstract
BACKGROUND There is not yet a commonly accepted, standardized approach in the treatment of juvenile idiopathic uveitis when initial steroid therapy is insufficient. We sought to assess current practice patterns within a large cohort of children with juvenile uveitis. METHODS This is a cross-sectional cohort study of patients with uveitis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRAnet) registry. Clinical information including, demographic information, presenting features, disease complications, and medications were collected. Chi-square and Fisher's exact tests were used to assess for associations between medications and clinical characteristics. RESULTS Ninety-two children with idiopathic and 656 with juvenile idiopathic arthritis (JIA)-associated uveitis were identified. Indication (arthritis or uveitis) for medication use was not available for JIA patients; therefore, detailed analysis was limited to children with idiopathic uveitis. In this group, 94 % had received systemic steroids. Methotrexate (MTX) was used in 76 % of patients, with oral and subcutaneous forms given at similar rates. In multivariable analysis, non-Caucasians were more likely to be treated initially with subcutaneous MTX (P = 0.003). Of the 53 % of patients treated with a biologic DMARD, all received a tumor necrosis factor (TNF) inhibitor. TNF inhibitor use was associated with a higher frequency of cataracts (52 % vs 21 %; P = 0.001) and antinuclear antibody positivity (49 % vs 29 %; P = 0.04), although overall complication rates were not higher in these patients. CONCLUSION Among idiopathic uveitis patients enrolled in the CARRAnet registry, MTX was the most commonly used DMARD, with subcutaneous and oral forms equally favored. Patients who received a TNF inhibitor were more likely to be ANA positive and have cataracts.
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Affiliation(s)
- Lauren A. Henderson
- Division of Immunology, Boston Children’s Hospital, Boston, MA and Department of Pediatrics, Harvard Medical School, 1 Blackfan Circle, Karp Building, 10th Floor, Boston, MA 02115 USA
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA.
| | - Sheila T. Angeles-Han
- Department of Pediatrics and Ophthalmology, Emory University School of Medicine, Atlanta, GA USA
| | - Andrew Lasky
- Department of Pediatric Rheumatology, Randall Children's Hospital at Legacy Emanuel, Portland, OR, USA.
| | - C. Egla Rabinovich
- Division of Rheumatology, Department of Pediatrics, Duke Children’s, Durham, NC USA
| | - Mindy S. Lo
- Division of Immunology, Boston Children’s Hospital, Boston, MA and Department of Pediatrics, Harvard Medical School, 1 Blackfan Circle, Karp Building, 10th Floor, Boston, MA 02115 USA
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Walter JE, Lo MS, Kis-Toth K, Tirosh I, Frugoni F, Lee YN, Csomos K, Chen K, Pillai S, Dunham J, Tsokos GC, Luning Prak ET, Notarangelo LD. Impaired receptor editing and heterozygous RAG2 mutation in a patient with systemic lupus erythematosus and erosive arthritis. J Allergy Clin Immunol 2014; 135:272-3. [PMID: 25312763 DOI: 10.1016/j.jaci.2014.07.063] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2014] [Revised: 07/23/2014] [Accepted: 07/25/2014] [Indexed: 01/11/2023]
Affiliation(s)
- Jolan E Walter
- Division of Immunology, Boston Children's Hospital, Boston, Mass; Division of Pediatric Allergy/Immunology, Massachusetts General Hospital for Children, Boston, Mass.
| | - Mindy S Lo
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Katalin Kis-Toth
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Irit Tirosh
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | | | - Yu Nee Lee
- Division of Immunology, Boston Children's Hospital, Boston, Mass
| | - Krisztian Csomos
- Division of Pediatric Allergy/Immunology, Massachusetts General Hospital for Children, Boston, Mass
| | - Karin Chen
- Division of Allergy, Immunology & Rheumatology, Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah
| | - Shiv Pillai
- Cancer Center, Massachusetts General Hospital, Boston, Mass
| | - Jonathan Dunham
- Division of Rheumatology, University of Pennsylvania, Philadelphia, Pa
| | - George C Tsokos
- Division of Rheumatology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Eline T Luning Prak
- Department of Pathology and Laboratory Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Luigi D Notarangelo
- Division of Immunology, Boston Children's Hospital, Boston, Mass; The Manton Center For Orphan Disease Research, Boston Children's Hospital, Boston, Mass; Harvard Stem Cell Institute, Boston, Mass
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Henderson LA, Zurakowski D, Angeles-Han S, Lasky A, Rabinovich CE, Lo MS. A70: Medication Use in the Treatment of Juvenile Idiopathic Uveitis Patients Enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry. Arthritis Rheumatol 2014. [DOI: 10.1002/art.38486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Henderson LA, Volpi S, Frugoni F, Kim S, Janssen E, Sundel RP, Dedeoglu F, Lo MS, Hazen MM, Mathieu R, Fuhlbrigge RC, Lee YN, Nigrovic PA, Notarangelo LD. A119: Deep Sequencing Analysis of the T Regulatory and T Effector Repertoire in Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2014. [DOI: 10.1002/art.38540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | | | | | - Susan Kim
- Boston Children's Hospital; Boston MA
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Abstract
OBJECTIVE Disparities in outcomes among adults with systemic lupus erythematosus (SLE) have been documented. We investigated associations between sociodemographic factors and volume of annual inpatient hospital admissions with hospitalization characteristics and poor outcomes among patients with childhood-onset SLE. METHODS By using the Pediatric Health Information System, we analyzed admissions for patients aged 3 to <18 years at index admission with ≥ 1 International Classification of Diseases, Ninth Revision code for SLE from January 2006 to September 2011. Summary statistics and univariable analyses were used to examine demographic characteristics of hospital admissions, readmissions, and lengths of stay. We used multivariable logistic regression analyses, controlling for patient gender, age, race, ethnicity, insurance type, hospital volume, US census region, and severity of illness, to examine risk factors for poor outcomes. RESULTS A total of 10,724 admissions occurred among 2775 patients over the study period. Hispanic patients had longer lengths of stay, more readmissions, and higher in-hospital mortality. In multivariable analysis, African American race was significantly associated with ICU admission. African American race and Hispanic ethnicity were associated with end-stage renal disease and death. Volume of patients with SLE per hospital and hospital location were not significantly associated with outcomes. CONCLUSIONS In this cohort of hospitalized children with SLE, race and ethnicity were associated with outcomes. Further studies are needed to elucidate the relationship between sociodemographic factors and poor outcomes in patients with childhood-onset SLE.
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Affiliation(s)
- Mary Beth F. Son
- Division of Immunology and,Departments of Pediatrics and,Address correspondence to Mary Beth F. Son, MD, Division of Immunology, Boston Children’s Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail:
| | - Victor M. Johnson
- Department of Anesthesiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Aimee O. Hersh
- Department of Pediatrics, University of Utah, Salt Lake City, Utah; and
| | - Mindy S. Lo
- Division of Immunology and,Departments of Pediatrics and
| | - Karen H. Costenbader
- Medicine, Harvard Medical School, Boston, Massachusetts;,Department of Rheumatology, Brigham & Women’s Hospital, Boston, Massachusetts
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Lo MS, Zurakowski D, Son MBF, Sundel RP. Hypergammaglobulinemia in the pediatric population as a marker for underlying autoimmune disease: a retrospective cohort study. Pediatr Rheumatol Online J 2013; 11:42. [PMID: 24180594 PMCID: PMC3831248 DOI: 10.1186/1546-0096-11-42] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Accepted: 10/26/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The significance of hypergammaglobulinemia as a marker of immune activation is unknown, as a differential diagnosis for hypergammaglobulinemia in children has not been adequately established. The goal of this study was to identify conditions associated with hypergammaglobulinemia in children, with the hypothesis that elevated immunoglobulin levels may precede or predict the development of autoimmune conditions. METHODS We reviewed the medical records for all children with IgG level ≥2000 mg/dL treated at a tertiary care children's hospital from January 1, 2000 through December 31, 2009. We compared clinical and laboratory features of these patients, and developed an algorithm to predict the likelihood of underlying autoimmunity based on these characteristics. RESULTS After excluding children who had received IVIG, a total of 442 patients with hypergammaglobulinemia were identified. Of these, nearly half had autoimmune conditions, most frequently systemic lupus erythematosus and lupus-related disorders. Autoimmune gastrointestinal disorders such as inflammatory bowel disease were also common. Infectious diseases were the next largest category of diseases, followed with much less frequency by malignant, drug-related, and other conditions. In comparison with non-autoimmune conditions, patients with autoimmune disease had higher IgG levels, lower white blood cell counts, lower hemoglobin values, and lower C-reactive protein (CRP) levels. Multivariable logistic regression confirmed that CRP (P = 0.002), white blood cell count (P < 0.001), hemoglobin (P = 0.015), and female gender (P < 0.001) are independent risk factors for autoimmune disease in patients with high IgG levels. CONCLUSIONS In a cohort of pediatric patients at a tertiary care children's hospital, hypergammaglobulinemia was most commonly associated with autoimmune diseases. In female patients with hypergammaglobulinemia, the presence of leukopenia, anemia, and normal CRP was 95% predictive of underlying autoimmune disease.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Department of Medicine, Boston Children's Hospital and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Fegan 6, Boston, MA 02115, USA.
| | - David Zurakowski
- Departments of Anesthesia and Surgery, Boston Children’s Hospital and Harvard Medical School, 300 Longwood Avenue, Boston, MA 02115, USA
| | - Mary Beth F Son
- Division of Immunology, Department of Medicine, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Fegan 6, Boston, MA 02115, USA
| | - Robert P Sundel
- Division of Immunology, Department of Medicine, Boston Children’s Hospital and Department of Pediatrics, Harvard Medical School, 300 Longwood Avenue, Fegan 6, Boston, MA 02115, USA
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Lo MS, Lee GM, Gunawardane N, Burchett SK, Lachenauer CS, Lehmann LE. The impact of RSV, adenovirus, influenza, and parainfluenza infection in pediatric patients receiving stem cell transplant, solid organ transplant, or cancer chemotherapy. Pediatr Transplant 2013; 17:133-43. [PMID: 23228170 DOI: 10.1111/petr.12022] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/01/2012] [Indexed: 11/29/2022]
Abstract
RVIs are a significant cause of morbidity and mortality in immunocompromised children. We analyzed the characteristics and outcomes of infection by four respiratory viruses (RSV, adenovirus, influenza, and parainfluenza) treated at a pediatric tertiary care hospital in a retrospective cohort of patients who had received cancer chemotherapy, hematopoietic stem cell, or SOT. A total of 208 infections were studied among 166 unique patients over a time period of 1993-2006 for transplant recipients, and 2000-2005 for patients with cancer. RSV was the most common respiratory virus identified. There were 17 (10% of all patients) deaths overall, of which 12 were at least partly attributed to the presence of a RVI. In multivariate models, LRT symptoms in the absence of upper respiratory symptoms on presentation (OR 10.2 [2.3, 45.7], p = 0.002) and adenoviral infection (OR 3.7 [1.1, 12.6], p = 0.034) were significantly associated with poor outcome, defined as death or disability related to RVI. All of the deaths occurred in patients who had received either solid organ or HSCT. There were no infections resulting in death or disability in the cancer chemotherapy group.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Department of Medicine, Boston Children's Hospital, Boston, MA, USA
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Abstract
Treatment for systemic lupus erythematosus (SLE) has traditionally been restricted to broad-based immunosuppression, with glucocorticoids being central to care. Recent insights into lupus pathogenesis promise new, selective therapies with more favorable side effect profiles. The best example of this is belimumab, which targets the B cell cytokine BLyS and has now received Food and Drug Administration (FDA) approval for its use in SLE. Strategies targeting other cytokines, such as interleukin 6 (IL-6) and interferon (IFN)-α, are also on the horizon. Blockade of costimulatory interactions between immune cells offers another opportunity for therapeutic intervention, as do small molecule inhibitors that interfere with cell signaling pathways. We review here the current strategies for SLE treatment, with particular focus on therapies now in active pharmaceutical development. We will also discuss new understandings in lupus pathogenesis that may lead to future advances in therapy.
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Affiliation(s)
- Mindy S Lo
- Division of Immunology, Children's Hospital Boston, Boston, Massachusetts, USA
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Abstract
Abnormal expression of key signaling molecules and defective functions of T lymphocytes play a significant role in the pathogenesis of systemic lupus erythematosus (SLE). T cell receptor (TCR/CD3)-mediated stimulation of SLE T cells show increased protein tyrosine phosphorylation of cellular proteins with faster kinetics, heightened calcium flux response, and decreased IL-2 production. The molecular mechanisms of T cell signaling abnormalities in SLE T cells are complex. Current research has been directed towards investigating various factors that contribute to abnormal tyrosine phosphorylation, intracellular calcium response, and cytokine production. Central to this dysfunction is the aberrant expression and function of the TCR/CD3ζ chain. Latest developments suggest multiple explanations are involved, including altered receptor structure, supramolecular assembly, modulation of membrane clustering, aberrant cellular distribution, and pre-compartmentalization with lipid-rafts. The methods and protocols described here pertaining to T cell signaling abnormalities in SLE T cells are optimized in many ways and are derived by the combined task and continuous efforts of many researchers in the lab over a long period of time. These simplified protocols can be readily applied to study T cell signaling abnormalities in SLE to identify the genetic, molecular, and biochemical factors contributing to aberrant immune cell function and unravel the pathophysiology of SLE.
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Affiliation(s)
- Vaishali R Moulton
- Division of Rheumatology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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Stutius LM, Pessach I, Lee J, Lo MS, Levy S, Schram P, Schizer M, Wong J, Phipatanakul W, Umetsu DT. Sublingual desensitization for buprenorphine hypersensitivity. J Allergy Clin Immunol 2010; 125:938-9. [PMID: 20226512 DOI: 10.1016/j.jaci.2009.12.982] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2009] [Revised: 11/24/2009] [Accepted: 12/11/2009] [Indexed: 10/19/2022]
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Holtzman MJ, Kim EY, Lo MS, Tyner JW, Shornick LP, Sumino KC, Zhang Y. Defining and adjusting divergent host responses to viral infection. Immunol Res 2006; 32:123-41. [PMID: 16106064 DOI: 10.1385/ir:32:1-3:123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Our laboratory focuses on the signal-transduction basis for mucosal immunity, inflammation, and remodeling, especially in relation to respiratory viral infection. Our approach aims to answer two major questions: (1) What are the mechanisms that control common viral infections? and (2) How can these transient infections cause long-term diseases, such as asthma? Our studies show that antiviral defense depends critically on a specialized network of mucosal epithelial cells and macrophages. When this network is compromised, the host is highly susceptible to infection, but when it is engineered to be broadly hyperresponsive to interferon, the host is markedly resistant to otherwise lethal viral infections. Similar but less effective hyperresponsiveness appears in asthma, suggesting that evolving attempts to improve antiviral defense may instead cause inflammatory disease. Indeed, in susceptible genetic backgrounds, respiratory viruses can also cause a hit-and-run phenomenon that is manifest by the development of a permanent asthmatic phenotype long after the infection has been cleared. This complex phenotype can be segregated into individual traits using pharmacologic, immunologic, and genetic strategies to achieve more precise definition of just how viruses can reprogram host behavior. Evidence of reprogramming is manifest by persistent abnormalities in epithelial cell survival and macrophage activation that when corrected can prevent the development of disease phenotypes. Our results led us to pursue the hypothesis that specific components of the innate immune system may manifest an aberrant antiviral response as a basis for chronic inflammatory diseases and that adjusting this response can improve short- and long-term outcomes after viral infection.
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Affiliation(s)
- Michael J Holtzman
- Pulmonary and Critical Care Medicine, Department of Medicine, Washington University School of Medicine, St. Louis, MO 63110, USA.
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Holtzman MJ, Tyner JW, Kim EY, Lo MS, Patel AC, Shornick LP, Agapov E, Zhang Y. Acute and chronic airway responses to viral infection: implications for asthma and chronic obstructive pulmonary disease. Ann Am Thorac Soc 2006; 2:132-40. [PMID: 16113481 PMCID: PMC2713316 DOI: 10.1513/pats.200502-015aw] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Despite the high clinical impact of established and emerging respiratory viruses, some critical aspects of the host response to these pathogens still need to be defined. In that context, we aimed at two major issues: first, what are the innate immune mechanisms that control common respiratory viral infections; and second, whether these mechanisms also cause long-term airway disease. Using a mouse model of viral bronchiolitis, we found that antiviral defense depends at least in part on a network of mucosal epithelial cells and macrophages specially programmed for immune-response gene expression. When this network is compromised, the host is highly susceptible to infection, but network components can be engineered to provide increased resistance to infection. Similar alterations appear in asthma and chronic bronchitis/chronic obstructive pulmonary disease, suggesting that evolving attempts to improve antiviral defense may also lead to inflammatory airway disease. Indeed, in genetically susceptible mice, respiratory paramyxoviruses cause a "hit and run" phenomenon that is manifested by the development of a permanent airway disease phenotype long after the infection has cleared. The phenotype can be segregated into individual traits to achieve more precise definition of just how viruses reprogram host behavior. Identifying specific components of the mucosal immune system that manifest an aberrant antiviral response may thereby allow for adjusting this response to improve acute and chronic outcomes after viral infection.
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Affiliation(s)
- Michael J Holtzman
- Washington University School of Medicine, Campus Box 8052, 660 South Euclid Avenue, St. Louis, MO 63110, USA.
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Zhang Y, Takami K, Lo MS, Huang G, Yu Q, Roswit WT, Holtzman MJ. Modification of the Stat1 SH2 Domain Broadly Improves Interferon Efficacy in Proportion to p300/CREB-binding Protein Coactivator Recruitment. J Biol Chem 2005; 280:34306-15. [PMID: 16107341 DOI: 10.1074/jbc.m503263200] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
A normal level of interferon (IFN) responsiveness via the Stat1 transcription factor is critical to the host, since decreased Stat1 signaling causes immune compromise and increased signaling is associated with inflammatory and neoplastic disease. Here we report how this balance may be influenced by novel alterations in the efficiency of Stat1 signaling. To enable disulfide-dependent and spontaneous formation of active Stat1 homodimer (as was done previously for Stat3), we engineered Stat1-CC with double-cysteine substitutions in the Src homology 2 (SH2)-homodimerization domain (at Ala-656 and Asn-658). In this case, however, mutant and wild-type Stat1 exhibited no difference inspontaneousdimerization. Moreover, Stat1-CC still required ligand-dependent Tyr-701 phosphorylation for function and exhibited hyperresponsiveness to IFN-beta (that depends on Stat1/Stat2 heterodimerization) as well as IFN-gamma (that depends on Stat1/Stat1 homodimerization). Hyperresponsivenss of Stat1-CC was accompanied by increased capacities for Tyr-701 phosphorylation and DNA binding, but these features were also found in a similarly substituted serine mutant (Stat1-SS) that showed no hyperresponsiveness to IFN-gamma. This finding raised the possibility that SH2 domain mutations also influence downstream transcriptional efficiency. Indeed, each of these mutations also enhanced recruitment of the normally rate-limiting p300/CREB-binding Protein (CBP) coactivator to the transcriptional complex in proportion to the level of IFN-driven transactivation and gene expression. Additional modifications indicated that the mutant residues in the SH2 domain appeared to cooperate with Ser-727 in the C-terminal domain to regulate p300/CBP interaction with Stat1. The profile of IFN responsiveness translated into the same progressive increase in the level of viral clearance from Stat1- to Stat1-SS- to Stat1-CC-expressing cells. Thus, SH2 domain determinants may be modified to direct better Stat1 phosphorylation, DNA binding, and coactivator recruitment to fully improve IFN efficacy.
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Affiliation(s)
- Yong Zhang
- Department of Medicine, Washington University School of Medicine, St. Louis, Missouri 63110, USA
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Lo MS, Brazas RM, Holtzman MJ. Respiratory syncytial virus nonstructural proteins NS1 and NS2 mediate inhibition of Stat2 expression and alpha/beta interferon responsiveness. J Virol 2005; 79:9315-9. [PMID: 15994826 PMCID: PMC1168759 DOI: 10.1128/jvi.79.14.9315-9319.2005] [Citation(s) in RCA: 217] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Respiratory syncytial virus (RSV) subverts the antiviral interferon (IFN) response, but the mechanism for this evasion was unclear. Here we show that RSV preferentially inhibits IFN-alpha/beta signaling by expression of viral NS1 and NS2. Thus, RSV infection or expression of recombinant NS1 and NS2 in epithelial host cells causes a marked decrease in Stat2 levels and the consequent downstream IFN-alpha/beta response. Similarly, NS1/NS2-deficient RSV no longer decreases Stat2 levels or IFN responsiveness. RSV infection decreased human but not mouse Stat2 levels, so this mechanism of IFN antagonism may contribute to viral host range, as well as immune subversion.
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Affiliation(s)
- Mindy S Lo
- Department of Medicine, Washington University School of Medicine, Campus Box 8052, 660 South Euclid Avenue, St. Louis, MO 63110, USA
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