Towards a standardized program of transitional care for adolescents with juvenile idiopathic arthritis for Turkey: a national survey study

BACKGROUND

Juvenile idiopathic arthritis (JIA) is a prevalent childhood chronic arthritis, often persisting into adulthood. Effective transitional care becomes crucial as these patients transition from pediatric to adult healthcare systems. Despite the concept of transitional care being recognized, its real-world implementation remains inadequately explored. This study aims to evaluate the thoughts and practices of healthcare providers regarding transitional care for JIA patients.

METHODS

A cross-sectional survey was conducted among pediatric and adult rheumatologists in Turkey. Based on the American Academy of Pediatrics' six core elements of transitional care, the survey included 86 questions. The respondents' demographic data, attitudes towards transitional care, and practical implementation were assessed.

RESULTS

The survey included 48 rheumatologists, with 43.7% having a transition clinic. The main barriers to establishing transition programs were the absence of adult rheumatologists, lack of time, and financial constraints. Only 23.8% had a multidisciplinary team for transition care. Participants agreed on the importance of coordination and cooperation between pediatric and adult healthcare services. The timing of the transition process varied, with no consensus on when to initiate or complete it. Participants advocated for validated questionnaires adapted to local conditions to assess transition readiness.

CONCLUSIONS

The study sheds light on the challenges and perspectives surrounding transitional care for JIA patients in Turkey. Despite recognized needs and intentions, practical implementation remains limited due to various barriers. Cultural factors and resource constraints affect the transition process. While acknowledging the existing shortcomings, the research serves as a ground for further efforts to improve transitional care and ensure better outcomes for JIA patients transitioning into adulthood.

Inflammatory comorbidities ın the largest pediatric Familial Mediterranean fever cohort: a multicenter retrospective study of Pediatric Rheumatology Academy (PeRA)-Research Group (RG)

AIM

The aim of this study was to investigate the frequency and type of FMF-associated inflammatory diseases in a large FMF pediatric patients and to compare them to those FMF patients without concomitant inflammatory diseases.

MATERIALS AND METHODS

Familial Mediterranean fever patients enrolled in the Pediatric Rheumatology Academy (PeRA)-Research Group (RG) were included. The patients were divided into two groups according to concomitant inflammatory disease as FMF patients who had a concomitant inflammatory disease (group 1) and FMF patients who did not have a concomitant inflammatory disease (group 1). The clinical findings and treatments were compared between the two groups.

RESULTS

The study group comprised 3475 patients with FMF. There were 294 patients (8.5%) in group 1 and 3181 patients (91.5%) in group 2. Juvenile idiopathic arthritis (n = 136) was the most common accompanying inflammatory disease. Arthritis, M694V homozygosity, and the need for biological therapy were more frequently observed in Group 1 (p < 0.05). Fever and abdominal pain were more frequently detected in Group 2 (p < 0.05). FMF patients with concomitant inflammatory diseas more frequently demonstrated colchicine resistance. There were no significant differences in the median attack frequency, chest pain, amyloidosis, erysipelas-like erythema, or family history of FMF between the two patient groups.

CONCLUSION

To the best of our knowledge, this is the largest pediatric cohort reviewed to date. FMF patients may have different clinical profiles and colchicine responses if they have with concomitant inflammatory diseases. Key points • FMF is associated with some inflammatory comorbidities diseases. • To the best of our knowledge, this is the largest cohort evlauated pediatric FMF associated inflammatory comorbidities diseases reviewed to date.

Evaluation of childhood malignancies presenting with musculoskeletal manifestations from two different divisions: a multicenter study

BACKGROUND

The aim of the study was to evaluate the approaches of pediatric rheumatologists and pediatric hematologists to patients with similar musculoskeletal (MSK) complaints and to highlight the differences that general pediatricians should consider when referring patients to these specialties.

METHODS

This is a cross-sectional study involving the patients who applied to pediatric rheumatology centers with MSK complaints and were diagnosed with malignancy, as well as patients who were followed up in pediatric hematology centers with a malignancy diagnosis, and had MSK complaints at the time of admission.

RESULTS

A total of 142 patients were enrolled in the study. Of these patients, 83 (58.4%) applied to pediatric rheumatology centers, and 59 (41.6%) applied to pediatric hematology centers. Acute lymphoblastic leukemia (ALL) was the most common diagnosis among the patients who applied to both centers, with 80 cases (56.3%). The median age of diagnosis was 87 (interquartile range, IQR: 48-140) months. The most common preliminary diagnosis in pediatric rheumatology centers was juvenile idiopathic arthritis (JIA), with 37 cases (44.5%). MSK involvement was mainly seen as arthralgia, and bone pain. While arthralgia (92.7%) was the most common complaint in rheumatology centers, bone pain (88.1%) was more common in hematology centers. The most frequently involved joints were the knee (62.9%), ankle (25.9%), hip (25%), and wrist (14%). The most common laboratory abnormalities were high lactate dehydrogenase (LDH), high C-reactive protein (CRP), anemia, and high erythrocyte sedimentation rate (ESR). Thrombocytopenia, neutropenia, and high LDH were statistically significantly more frequent in patients admitted to hematology centers than in patients admitted to rheumatology centers (p < 0.001, p=0.014, p=0.028, respectively). Patients who applied to rheumatology clinics were found to have statistically significantly higher CRP levels (p=0.032).

CONCLUSIONS

Malignancies may present with only MSK system complaints in childhood. Therefore, malignancies should be included in the differential diagnosis of patients presenting with MSK complaints.

PREDICT-crFMF score: A novel model for predicting colchicine resistance in children with familial Mediterranean fever

OBJECTIVES

To develop a novel scoring system to predict colchicine resistance in Familial Mediterranean fever (FMF) based on the initial features of the patients.

METHODS

The medical records of patients were analyzed prior to the initiation of colchicine. After generating a predictive score in the initial cohort, it was applied to an independent cohort for external validation of effectiveness and reliability.

RESULTS

Among 1418 patients with FMF, 56 (3.9%) were colchicine resistant (cr) and 1312 (96.1%) were colchicine responsive. Recurrent arthritis (4 points), protracted febrile myalgia (8 points), erysipelas-like erythema (2 points), exertional leg pain (2 points), and carrying M694V homozygous mutation (4 points) were determined as the parameters for predicting cr-FMF in the logistic regression model. The cut-off value of 9 was 87% sensitive and 82% specific to foresee the risk of cr-FMF in the receiver operating characteristic. Validation of the scoring system with an independent group (cr-FMF = 107, colchicine responsive = 1935) revealed that the cut-off value was 82% sensitive and 79% specific to identify the risk of cr-FMF.

CONCLUSIONS

By constructing this reliable and predictor tool, we enunciate that predicting cr-FMF at the initiation of the disease and interfering timely before the emergence of complications will be possible.

Is it possible to extend the dose interval of canakinumab treatment in children with familial Mediterranean fever? PeRA group experience

BACKGROUND

There is no clear data on the optimal duration of treatment with anti-interleukin-1 drugs in colchicine-resistant familial Mediterranean fever patients, as well as on the dose interval. This study aimed to assess patients whose canakinumab dose interval was adjusted according to a specific protocol, with the objective of evaluating the effectiveness of implementing this protocol for the patient care.

METHODS

The files of 45 patients whose canakinumab treatment interval was opened with a standard protocol previously determined by the Delphi method were retrospectively reviewed.

RESULTS

Canakinumab treatment was initiated once a month for all patients. In the sixth month of canakinumab treatment, a dose interval extension was introduced; however, 7 patients (15.5%) experienced an attack, and consequently, no further interval extension was administered to them. For 29 patients, the dose interval was successfully extended to once every three months, as they remained attack-free for a year after the first interval extension. Nine patients continued receiving the drug every 2 months, as they had not yet completed one year since the first extension. The study found no significant correlation between experiencing an attack during the dose interval extension protocol and the number, duration of attacks, or autoinflammatory diseases activity index score.

CONCLUSION

Extending treatment intervals with canakinumab in colchicine-resistant familial Mediterranean fever shows promise for favorable outcomes.

Remission rates and risk factors for relapse in pediatric morphea: a multicenter retrospective study of Pediatric Rheumatology Academy (PeRA)-Research Group (RG)

AIM

Morphea, also known as localized scleroderma, is an immune-mediated disease and the most common form of scleroderma in children. It is a localized sclerosing disease of the skin, but can also involve such adjacent tissues as the fascia, muscle, bone, and underlying tissues. This multicenter study aimed to evaluate Turkish pediatric morphea patients, regarding demographics, treatments, and response to treatment.

MATERIALS AND METHODS

The study was performed by the Pediatric Rheumatology Academy and included pediatric morphea patients from 6 Turkish pediatric rheumatology centers who were followed up for ≥6 months. Demographic, clinical, and laboratory findings and treatment modalities were analyzed. The patients were divided into 3 groups according to treatment response, as follows: group 1: topical treatment response, group 2: methotrexate response, and group 3: methotrexate resistance. Clinical findings were compared between the 3 groups.

RESULTS

The study included 76 patients, of which 53 (69.7%) were female. Mean age at diagnosis of morphea was 9.7 ± 4.3 years and mean duration of follow-up was 3.2 ± 2.9 years. Linear morphea was the most common form, accounting for 43.4% (n = 33) of the patients. Extracutaneous features were noted in 17 patients (22.4%) and anti-nuclear antibody positivity was noted in 32 (42.1%). In all, 14.4% of the patients received topical treatment only, whereas 86.6% received both topical and systemic treatment. The methotrexate response rate was 76.9% in the patients that received systemic immunosuppressive therapy. The overall relapse rate while under treatment was 19.7%.

CONCLUSION

In this study, most of the pediatric morphea patients responded well to methotrexate. Bilateral lesions were more common in the methotrexate-resistant group. Multiple involvement, and bilateral lesions, were more common in relapsed patients than in non-relapsed patients. Key points • Most of the pediatric morphea patients respond well to MTX. • Multiple involvement, and bilateral involvement, were more common in relapsed patients than in non-relapsed patients. • Presence of extracutaneous findings in patients increased relapse rate 5.7 times.

Do the features of juvenile psoriatic arthritis change according to age? A comprehensive evaluation of the PeRA Research Group Registry

OBJECTIVES

To describe the clinical features and treatment outcomes of children with juvenile psoriatic arthritis (JPsA) and to compare the distinct patterns of the disease between early-onset and late-onset age groups.

METHODS

Patients with JPsA followed regularly for at least 6 months between 2010-2020 in 7 pediatric rheumatology centers in Turkey were included in the study. The demographic features, clinical manifestations, treatment strategies, and outcomes of the patients were evaluated retrospectively.

RESULTS

Eighty-seven (46 male/41 female) patients were included in the study. The mean age at diagnosis was 11.9 ± 4.5. Fifty-seven (65.5%) patients had psoriasis at the time of diagnosis, arthritis preceded psoriasis in 10 (11.5%) patients. Thirty (34.5%) patients had dactylitis, 28 (32.2%) had nail pitting, 36 (41.4%) had involvement of the small joints, 20 (23%) had enthesitis. Sacroiliitis was detected in 11 (12.6%) patients by magnetic resonance imaging. Anti-nuclear antibodies (ANA) were positive in 35 (40.2%) patients. Twelve children (%13.8) were in the early-onset (<5 years) group. Uveitis and ANA positivity were more common in the early-onset group. Active joint counts and activity scores of our patients showed significant improvement at 6th month and at the last control compared with baseline.

CONCLUSION

About one-third of patients with JPsA do not have psoriasis at the time of diagnosis. In some patients, no skin lesion is seen during the course of the disease. Children with psoriatic arthritis seem to display two different phenotypes. Younger children have female predominance, ANA positivity, and uveitis, while older children have more axial involvement.

How common is remission in rheumatoid factor-positive juvenile idiopathic arthritis patients? The multicenter Pediatric Rheumatology Academy (PeRA) research group experience

OBJECTIVE

Rheumatoid factor (RF)-positive polyarthritis is the least common type of juvenile idiopathic arthritis (JIA). Functional disability in RF-positive polyarthritis patients is much more severe than in patients with other subtypes; but data on this subtype alone is limited. This study aimed to analyze clinical features, long-term follow-up, treatment response, and remission status in a large multicenter cohort of RF-positive polyarthritis patients.

METHODS

This retrospective study included RF-positive polyarthritis patients that were followed up for ≥ 6 months between 2017 and 2022 by the Pediatric Rheumatology Academy (PeRA)-Research Group (RG). Data on patient demographics, clinical and laboratory characteristics were obtained from medical charts. JIA treatments and duration of treatment were also recorded. The patients were divided into 2 groups based on methotrexate (MTX) response, as follows: group 1: MTX responsive, group 2: MTX unresponsive. Clinical and laboratory findings were compared between the 2 groups.

RESULTS

The study included 56 (45 female and 11 male) patients. The median age at onset of RF-positive polyarthritis was 13.2 years [(interquartile range) (IQR): 9.0-15.0 years] and the median duration of follow-up was 41.5 months (IQR: 19.5-75.7 months). Symmetrical arthritis affecting the metacarpophalangeal and proximal interphalangeal joints of the hands was commonly observed. Subcutaneous MTX was the preferred initial treatment; however, it was ineffective in 39 (69.6%) of the patients. Of 25 patients followed for 24 months, 56% still had active disease at 24 months.

CONCLUSION

During 2 years of treatment, 44% of RF-positive polyarthritis patients have inactive disease, and they should be considered as a distinct and important clinical entity requiring aggressive and early treatment.

Real-life data on efficacy and safety of original Adalimumab and biosimilar Adalimumab (ABP 501) in pediatric rheumatic diseases

BACKGROUND

We aimed to compare the efficacy and safety of the original product (OP) and biosimilar product (BP) of adalimumab in pediatric rheumatic diseases.

RESEARCH DESIGN AND METHODS

The study group consisted of patients who had received original or biosimilar adalimumab (ABP 501) therapy for at least 3 months. The patients were divided into uveitis and arthritis groups based on the indication of adalimumab treatment. Assessment of disease activity was performed by Juvenile Arthritis Disease Activity Score in patients with juvenile idiopathic arthritis, and by standardization of uveitis nomenclature criteria in patients with uveitis.

RESULTS

The study included 140 patients, of which 87 were treated with OP and 53 with BP. In the arthritis group, 26 (63.4%) and 20 (57.1%) patients reached inactive disease according to JADAS-27 in the original and biosimilar adalimumab groups, respectively. In the uveitis group the mean number of exacerbations throughout the treatment period was 0.84 ± 1.07 in the OP group, and 0.58 ± 0.79 in the BP group. There were 71 treatment-emergent adverse events in the OP group and 38 in the BP group.

CONCLUSION

There was no significant difference between the biosimilar and the original product in efficacy and safety.

Neuropsychiatric involvement in juvenile-onset systemic lupus erythematosus: A multicenter study

INTRODUCTION

Neuropsychiatric (NP) involvement is a restricted area in juvenile-onset systemic lupus erythematosus (jSLE).

AIM

To investigate the prevalence, demographic and clinical features, and outcomes of the neurological involvement in the Turkish jSLE population.

METHODS

This study was based upon 24 referral centers' SLE cohorts, multicenter and multidisciplinary network in Turkey. Patient data were collected by a case report form which was standardized for NP definitions according to American Collage of Rheumatology (ACR). Systemic Lupus International Collaborating Clinics/American College of Rheumatology Damage Index (SDI) neuropsychiatric part was used to determine NP damage. Variables were evaluated Ward's hierarchical clustering analyses, univariate, and multivariate logistic regression analyses.

RESULTS

A hundred forty-nine of 1107 jSLE patients had NP involvement (13.5%). The most common NPSLE findings were headache (50.3%), seizure (38.3%), and acute confusional state (33.6%). Five clusters were identified with all clinical and laboratory findings. The first two clusters involved neuropathies, demyelinating diseases, aseptic meningitis, and movement disorder. Cluster 3 involved headache, activity markers and other SLE involvements. Idiopathic intracranial hypertension, cerebrovascular disease, cognitive dysfunction, psychiatric disorders and SLE antibodies were in the fourth, and acute confusional state was in the fifth cluster. In multivariate analysis, APA positivity; OR: 2.820, (%95CI: 1.002-7.939), P: 0,050, plasmapheresis; OR: 13.804 (%95CI: 2.785-68.432), P: 0,001, SLEDAI scores; OR: 1.115 (%95CI: (1.049-1.186), P: 0,001 were associated with increased risk for neurologic sequelae.

CONCLUSION

We detected the prevalence of juvenile NPSLE manifestations in Turkey. We have identified five clusters that may shed light pathogenesis, treatment and prognosis of NP involvements. We also determined risk factors of neurological sequelae. Our study showed that new definitions NP involvements and sequelae for childhood period are needed.

The safety of canakinumab in systemic juvenile idiopathic arthritis and autoinflammatory diseases in pediatric patients: a multicenter study

OBJECTIVE

To evaluate the safety of canakinumab using real-world data in patients with systemic juvenile idiopathic arthritis (sJIA) and autoinflammatory diseases (AID).

RESEARCH DESIGN AND METHODS

This was a cross-sectional observational, multicenter study. Patients diagnosed with AID and sJIA treated with canakinumab were included in the study. The participating 13 centers retrospectively collected their patients' data.

RESULTS

A total of 335 patients were involved in the study. Among these patients, 280 were in the AID group and 55 were in the sJIA group. Canakinumab was administered at a median dose of 3 (2.5-4) mg/kg. The median total exposure time to canakinumab was 1.9 (0.8-3.2) years, corresponding to 759.5 patient-years. Seven hundred and seventy-nine total adverse events (AE) were identified. The total incidence of AE, and serious adverse events (SAE) throughout the study period was 1.02 per patient-years. The upper respiratory tract infection rate was 0.7 per patient-years, while the other infection rate was 0.13 per patient-years. While no death was observed in any patient, SAE were observed in 8 patients. Interstitial lung disease, anaphylaxis, or anaphylactoid reactions were not observed in any patient.

CONCLUSIONS

Real-life data from a large cohort of patients suggests that canakinumab is as safe as claimed in clinical trials.

Withdrawal of biologic therapy in juvenile idiopathic arthritis due to remission: predictors of flare and outcomes

OBJECTIVES

To investigate patients who flared after discontinuation of biological disease-modifying anti-rheumatic agents (bDMARDs) and identify risk factors associated with flare.

METHODS

A multicenter study evaluating systemic and non-systemic juvenile idiopathic arthritis (sJIA and non-sJIA) patients whose bDMARDs were ceased after remission.

RESULTS

A total of 101 patients whose bDMARDs were ceased after remission was evaluated. Children with sJIA had the lowest risk of flare and 11.1% of 36 sJIA patients experienced flare after a median of 9 (4-24) months of bDMARDs cessation with three of them flaring in the first year. High leukocyte counts in sJIA patients were associated with inactive disease at 1-year after the start of treatment (p = 0.004). In the non-sJIA group, 46.1% patients experienced flare after a median of 7 (1-32) months of biologic cessation, and of these, 25 flared in the first year. Antinuclear antibody positivity (p = 0.02), earlier disease onset (p = 0.03), long disease duration (p = 0.01), and follow-up (p = 0.02) and extended time from diagnosis to first biological onset (p = 0.03) were more common among patients with flare.

CONCLUSIONS

When considering discontinuation of bDMARDs, it should be kept in mind that the risk of exacerbation requiring re-initiation therapy is quite significant within the first year after discontinuation of therapy.

Does having MEFV gene sequence variants affect the clinical course and colchicine response in children with PFAPA syndrome?

The primary aim of this study was to document the treatment modalities used in periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome and look for the efficacy and safety of colchicine in the treatment of PFAPA patients. The secondary aim was to search for whether having MEFV (Mediterranean fever) gene sequence variants affect the clinical course and response to colchicine. The study was conducted in 2 pediatric rheumatology centers. The patients that have been diagnosed with PFAPA syndrome between December 2017 and December 2021 were evaluated retrospectively. The study included 157 patients with PFAPA syndrome (54.8% boys and 45.2% girls). The median follow-up duration was 18 (IQR: 12-30) months. One hundred and fifty-five patients (98.7%) had exudative pharyngitis, 120 patients (76.4%) had aphthous stomatitis, and 82 patients (52.2%) had cervical lymphadenitis during the attacks. Clinical features during attacks were not affected by the presence or absence of the MEFV gene sequence variants. Corticosteroid treatment during attacks was given to 152 patients (96.8%). The frequency of fever attacks did not change in 57 patients (37.5%), increased in 57 patients (37.5%), and decreased in 38 patients (25%) after corticosteroid use. Colchicine was given to 122 patients (77.7%) in the cohort. After colchicine treatment, complete/near-complete resolution of the attacks was observed in 57 patients (46.7%). Colchicine led to partial resolution of the attacks in 59 patients (48.4%). In only 6 patients (4.9%), no change was observed in the nature of the attacks with colchicine treatment. The median duration of the attacks was 4 (IQR: 4-5) days before colchicine treatment, and it was 2 (IQR: 1-2.5) days after colchicine treatment. Also, a significant decrease in the frequency of the attacks was observed before and after colchicine treatment [every 4 (IQR: 3-4) weeks versus every 10 (IQR: 8-24) weeks, respectively, (p < 0.001)]. The overall response to colchicine was not affected by MEFV sequence variants. It was seen that the frequency of fever attacks decreased dramatically in both groups, and children with MEFV variants had significantly less attacks than children without MEFV variants after colchicine treatment (every 11 weeks vs every 9.5 weeks, respectively, p: 0.02).

CONCLUSION

Colchicine seems to be an effective and safe treatment modality in PFAPA treatment. It led to a change in the nature of the attacks either in the frequency, duration, or severity of the attacks in 95.1% of the patients. This study has shown that having MEFV gene sequence variants did not affect the clinical course or response to colchicine. We recommend that colchicine should be considered in all PFAPA patients to see the response of the patient, irrespective of the MEFV gene mutations.

WHAT IS KNOWN

• Periodic fever, aphthous stomatitis, pharyngitis, and adenitis (PFAPA) syndrome is the most common periodic fever syndrome in the world. Familial Mediterranean fever (FMF) is the most common cause of periodic fever syndrome in Turkey. • Colchicine has become a new treatment option in PFAPA.

WHAT IS NEW

• Some PFAPA patients have Mediterranean fever (MEFV) gene variants, and it is speculated that PFAPA patients with MEFV gene mutations respond better to colchicine. • The aim of this study was to look for this hypothesis. We have seen that the clinical phenotype and colchicine response of PFAPA patients were not affected by MEFV gene sequence variants.

A rare complication of IgA vasculitis: renal and intestinal ischemia successfully treated with plasmapheresis

BACKGROUND

IgA vasculitis (IgAV) is a multisystemic small vessel vasculitis and is the most common vasculitis in childhood. The characteristic findings of IgAV are palpable purpuric rash, abdominal pain, arthralgia or arthritis, and hematuria. Ischemic complications are very rare in IgAV. Thrombotic complications can be observed after a COVID-19 infection. Also in the presence of familial Mediterranean fever, IgAV may have an atypical or more severe course.

CASE

We present a case of IgAV complicated with renal infarction and intestinal ischemia. There was no recent or distant history of COVID-19 in the patient or family members, but the patient`s COVID-19 antibody was positive. In addition, MEFV gene analysis of the patient showed homozygous M694V mutation. The patient did not respond to enoxaparin, pulse methylprednisolone, intravenous immunoglobulin (IVIG), iloprost, and cyclophosphamide treatments. She was successfully treated with six sessions of plasmapheresis.

CONCLUSIONS

Plasmapheresis seems to be an effective treatment option in IgAV-related ischemic findings that do not respond to intensive immunosuppressive therapy.

004 Systemic autoinflammatory diseases: a multicenter cohort study

Background

Systemic autoinflammatory diseases (SAIDs) are a group of hereditary diseases characterized by inflammatory attacks accompanied by clinical findings such as fever, skin rash, abdominal pain, and musculoskeletal symptoms and with high acute phase response.

Objectives

This study sought to define the characteristics, to report 24-month follow-up of children with SAIDs and to compare the performances of both the previously validated classification criteria Federici and new Eurofever/PRINTO classification criteria in a multicentre cohort under real-life conditions.

Method

The medical charts of 60 children diagnosed with SAIDs (CAPS, TRAPS and HIDS) who were followed up regularly every 1–3 months between 2010 and 2021 in 6 pediatric rheumatology centers in Turkey were retrospectively analyzed. Demographic data, clinical findings, laboratory results and treatments were recorded. All patients were analyzed by NGS panel containing 16 genes.

Results

A total of 60 patients with SAID were evaluated. Among them 30 (50%) were male and 30 (50%) were female. The median age at disease onset and diagnosis were 22 (0–193) months and 72 (2–213) months, respectively. The current age was median 10.3 (1.7–20.4) years. All patients were follow-up with a median 31 (6–97) months. Among 60 patients, 22 were diagnosed with CAPS, 8 with TRAPS and 30 with HIDS. The frequency of clinical symptoms was 95%, arthralgia 63.3%, gastrointestinal complaints 58.3%, urticarial rash 56.7%, myalgia 48.3%, lymphadenopathy 33.3%, respectively.

Urticarial rash (86.4%), cold induced rash (45.5%) and arthritis (50%) were significantly higher in CAPS patients compared with other two groups (p< 0.05). Lymphadenopathy (46.7%) was more common in HIDS patients (p = 0.03).

When we applied the diagnostic/classification criteria to our cohort, 71.7% met the Federici criteria, 53.3% fulfilled the Eurofever/PRINTO classification criteria. When performance of two diagnostic criteria (Federici and Eurofever/PRINTO criteria) was compared, the proportion of patients fulfilling the Eurofever/PRINTO criteria higher in TRAPS patients compared with other groups (p = 0.008).

Statistically significant decreases were found in AIDAI scores, CRP, ESR levels from the 1st month and in the leucocyte counts from the 6th month of the treatment in CAPS patients (p = <0.001, p = 0.035, p = 0.03 and p = 0.006, respectively). In addition, AIDAI scores were correlated with CRP values (p = 0.047).

In HIDS patients, there was a statistically significant decrease in AIDAI scores and ESR levels from the 1st month, CRP levels from the 3rd month, and leucocyte counts from the 12th month of treatment (p = <0.001, p = 0.003, p = <0.001 and p = 0.034, respectively). In addition, ESR values were correlated with CRP (p = 0.006). In TRAPS patients, on the other hand, there was a statistically significant decrease in AIDAI scores from the 1st month of treatment (p = 0.018).

At the last visit, 93.3% of the patients were receiving anti-IL-1, 5% anti-IL-6, and 1.7% were receiving colchicine. Ninety percent of the patients were in complete remission.

Conclusion

We showed that the diagnostic/classification criteria may not always be sufficient to make the diagnosis, and there is still low agreement between clinical diagnoses and molecular analyzes. Anti-IL-1 treatments have been found to be quite effective in the treatment from the early period.

POS1272 EVALUATION OF DIAGNOSIS, TREATMENT AND OUTCOME RESULTS OF MIS-C PATIENTS

Background

SARS-COV-2 infection, which has become a pandemic worldwide, has led to various results, from mild clinical findings to severe respiratory failure. Multisystem inflammatory syndrome (MIS-C) in children is a rare but severe condition characterized by fever, inflammation, and multi-organ failure, caused by an overreaction of the immune system after SARS-CoV-2 infection.

Objectives

This study aims to report the clinical and laboratory findings, diagnostic methods, treatment regimens, and short-term follow-up results of patients diagnosed with MIS-C.

Methods

This is a retrospective observational study from a tertiary pediatric rheumatology center including patients (aged 1 month to 21 years) diagnosed with MIS-C between April 2020-December 2021. Demographic, clinical, laboratory results, and follow-up data were collected through the electronic patient record system and analyzed.

Results

Of the 110 patients included in the study, 67.2% (n=74) were male. Fever was a common finding in all. Macrophage activation syndrome (MAS) was dominant in 28.2% (n=31), while Kawasaki-like disease was observed in 40% of the patients. Gastrointestinal symptoms were found in 64.5% of the cases, rash in 40%, conjunctivitis in 35.5%, lymphadenopathy in 30%, hypotension in 27.3%, cardiac decompensation in 16.4%, bradycardia in 8.2%, neurological findings in 4.5%, and/or coronary artery pathology in 3.6% respectively. Included in the study, 63.6% had lymphopenia, 48.2% had hypoalbuminemia, and 39.1% had hyponatremia. Thirty-eight patients (34.5%) were followed up in the intensive care unit; 19 of them had MAS. Concomitant chronic disease was present in 21.8% of the patients. The mean hospital stay was 12±7.8 days. Hypotension and MAS were the most common indications for admission to the intensive care unit. Intravenous immunoglobulin treatment was applied to 87.2% of the cases, the steroid was given to 70.9%, and anakinra treatment was given to 27.3%, respectively. In the outpatient follow-up, it was determined that the coronary abnormalities had regressed entirely. While 97.3% of the cases recovered without sequelae, three died. Three patients who died had the comorbid disease. While there was no significant difference in terms of Kawasaki-like disease and gender in those followed up in the intensive care unit (p=0.25, p=0.81), D-dimer was higher, and the mean age was greater (p=0.08, p=0.02). No statistical correlation was found between those with Kawasaki-like disease regarding age and gender (p=0.058 p=0.068).

Conclusion

Multisystem inflammatory syndrome in children may lead to severe cardiac findings and intensive care requirements at admission and hospital follow-up. The majority of MIS-C-related findings resolve completely until discharge or in short-term follow-up. Although the pathogenesis and treatment plan of the disease has been largely clarified, follow-up studies are needed in terms of long-term prognosis and relapse probabilities.

Disclosure of Interests

None declared

AB1264 CLINICAL, DEMOGRAPHIC CHARACTERISTICS AND TREATMENT RESPONSES OF PATIENTS WITH CRYOPYRIN-ASSOCIATED PERIODIC SYNDROME

Background

Cryopyrin-associated periodic syndrome (CAPS) is a rare autoinflammatory disease that inherited autosomal dominantly. The disease occurs as a result of mutations in the NLRP3 gene, which encodes cryopyrin (1). It has three clinical presentations called familial cold autoinflammatory syndrome (FCAS), Muckle-Wells syndrome (MWS) and neonatal-onset multisystem inflammatory disorder (NOMID) or chronic infantile neurologic, cutaneous and articular (CINCA) syndrome (2). FCAS is the mildest form of this spectrum, characterized by cold-induced fever, urticarial rash, joint complaints, conjunctivitis, and systemic inflammation.

Objectives

In our study, we aimed to evaluate the clinical and demographic characteristics and treatment responses of CAPS patients.

Methods

We retrospectively enrolled 44 pediatric patients who were diagnosed with CAPS admitted to Umraniye Training and Research Hospital, Pediatric Rheumatology Clinic, Istanbul, Turkey, June 2016 - December 2021. Medical records were analyzed for clinical presentation, disease associations, physical examination, and laboratory findings.

Results

A total of 44 patients (41 FCAS, 3 MWS) were included in the study. Of the patients, 19 were girls and 25 were boys. The median age of the patients was 10.5 (1.4-20.6) years. The median age of onset of attack was 3 years (1 month-14.6 year), age at diagnosis was 7.9 years (13 months-18 years), and the follow-up period was 2.2 years (4 months-5.2 years). There were a history of consanguinity in 9 (20.4%) patients. Twelve (27.2%) patients had the autoinflammatory disease in their families. The most common clinical findings were fever (100%), joint pain (86.4%), and abdominal pain (79.5%). Afterward, rash (56.8%), myalgia (45.5%), conjunctivitis (31.8%), arthritis (31.8%), diarrhea (31.8%), chest pain (27.3%), headache (25%), and vomiting (22.7%) were other findings accompanying the attacks. Thirty-nine (88.6%) patients had mutations in the NLRP3 gene. No mutation was detected in five (11.4%) patients. The most common Q705K mutation was detected in 28 (71.4%) patients. Forty-two (95.4%) patients were started on colchicine treatment. Biological therapy was started in 9 (21.4%) patients whose attacks continued despite colchicine. Anakinra and canakinumab, which are anti-interleukin 1 agents, were used as biologic therapy. FCAS patients had an adequate response to standard doses of canakinumab therapy, while MWS patients required significantly higher doses of canakinumab therapy.

Conclusion

Although familial Mediterranean fever and PFAPA are the most frequent periodic fever syndromes in our country, CAPS should be included in the differential diagnosis in patients with recurrent fever complaints and accompanying urticaria-like rash and conjunctivitis. In our clinical experience, some FCAS patients show significant clinical benefits with colchicine treatment. We think that it would be beneficial to try colchicine treatment before starting biologic therapy in FCAS patients.

References

[1]Kuemmerle-Deschner JB. CAPS--pathogenesis, presentation and treatment of an autoinflammatory disease. Semin Immunopathol. 2015;37(4):377-385. doi:10.1007/s00281-015-0491-7

Disclosure of Interests

None declared

Cluster Analysis of Pediatric Behçet's Disease: Data from The Pediatric Rheumatology Academy (PeRA)-Research Group (RG)

OBJECTIVES

Behçet's Disease (BD) is a systemic vasculitis affecting many organ systems with the involvement of all sized arteries and veins. Patients with BD may present with varying features. The study aims to determine the main characteristics of pediatric BD patients and also analyze the clustering phenotypes in a large multicentric cohort.

METHODS

Demographic data, clinical manifestations, laboratory features, treatment schedules, and disease outcomes were achieved from patients' charts retrospectively. A cluster analysis was performed according to phenotype.

RESULTS

A total of 225 (109 male/ 116 female) patients with BD were enrolled in the study. The median age of disease onset and diagnosis was 131 (36-151) and 156 (36-192) months, respectively. The median time between the onset of symptoms and diagnosis was 23.5 (0-45) months. According to cluster analysis; 132 (58.6%) patients belonged to the mucocutaneous-only cluster (C1) while 35 (15.6%) patients fitted to articular type (C2), 25 (11.1%) %) were in ocular cluster (C3), 26 (11.6%) were in vascular cluster (C4) and 7 (3.1%) belonged to the gastrointestinal cluster (C5). Ocular and vascular clusters were more common in boys (p<0.001), while girls usually presented with the mucocutaneous-only cluster. The clusters had comparable ages upon diagnosis. The disease activity at the diagnosis and the last control was higher in ocular, vascular, and gastrointestinal clusters.

CONCLUSIONS

We identified five different subtypes in juvenile BD patients. These subtypes express different phenotypes with different outcomes. Our analysis may help clinicians to identify the disease subtypes accurately and to arrange personalized treatment.

Is it all about age? Clinical characteristics of Kawasaki disease in the extremely young: PeRA research group experience

OBJECTIVES

: In the evaluation of children with Kawasaki disease (KD), the age of onset is important and complications may occur if the distinctive features are not assessed accordingly. The objective of the study is to define the clinical and laboratory presentations and treatment outcomes of KD in infants ≤6 months of age compared to those >6 months multicentrically.

METHODS

: This retrospective study reviewed the medical records of the patients diagnosed with KD and followed up between January 2009 and January 2019.

RESULTS

: A total of 204 KD patients were enrolled and grouped according to age as Group I (≤6 months, n=31) and Group II (>6 months, n=173). Except for cervical adenopathy (19.3% vs. 47.4%, p=0.03), the major clinical manifestations of KD were similar between groups I and II. However, the frequency of incomplete and atypical KD was higher in Group I (38.7% vs. 24.8%, p=0.04, 38.7% vs. 8.1% p<0.001, respectively). Clinical features such as vomiting/diarrhea (19.3% vs. 1.1% p<0.001), aseptic meningitis (19.3% vs. 2.3%, p=0.001) were more common in Group I. Percentage of neutrophils (45.5 vs. 36, p=0.004) and hemoglobin levels (8 vs. 10.5 gr/dL, p=0.02) were statistically lower and platelet count (737000 vs 400000/mm³, p=0.004) was statistically higher in group I. Coronary artery lesions (CALs) were more common in Group I (48% vs. 20 %, p<0.001). Harada and Kobayashi scores appear to be effective in predicting coronary artery lesions (CALs) and IVIG resistance in the entire cohort. There was no diagnostic delay in group I (5.5 vs 6.5 days, p=0.88).

CONCLUSIONS

: Since clinical presentations and laboratory features of KD may vary with age, and the frequency of atypical and incomplete presentations is high, awareness of KD in young children should be raised among pediatricians.

The Multifaceted Presentation of the Multisystem Inflammatory Syndrome in Children: Data from a Cluster Analysis

Background: The aim of this study was to evaluate the outcomes of patients with the multisystem inflammatory syndrome in children (MIS-C) according to phenotypes of disease and define the prognostic factors for the severe course. Methods: This cross-sectional study included 293 patients with MIS-C from seven pediatric rheumatology centers. A two-step cluster analysis was performed to define the spectrum of disease and their outcomes were compared between each group. Results: Four subgroups were identified as follows: cluster I, predominantly Kawasaki-like features (n = 100); cluster II, predominantly MAS-like features (n = 34); cluster III, predominantly LV dysfunction (n = 47); cluster IV, other presentations (n = 112). The duration of fever was longer in cluster II and the length of hospitalization was longer in both clusters II and III. Laboratory findings revealed lower lymphocyte and platelet counts and higher acute phase reactants (APRs) in cluster II, while patients in cluster IV showed less inflammation with lower APRs. The resolution of abnormal laboratory findings was longer in clusters II and III, while it was shortest in cluster IV. Seven patients died. Among them, four belonged to cluster II, while three were labeled as cluster III. Patients with severe course had higher levels of neutrophil–lymphocyte ratio, mean platelet volume, procalcitonin, ferritin, interleukin-6, fibrinogen, D-Dimer, BNP, and troponin-I, and lower levels of lymphocyte and platelet counts. Conclusion: As shown, MIS-C is not a single disease presenting with various clinical features and outcomes. Understanding the disease spectrum will provide individualized management.

Anakinra treatment in multisystemic inflammatory syndrome in children (MIS-C) associated with COVID-19

OBJECTIVE

The study aimed to report the efficacy and safety of anakinra treatment in patients with the refractory multisystemic inflammatory syndrome in children (MIS-C).

METHODS

This is a cross-sectional retrospective study consisting of pediatric patients diagnosed with MIS-C who were treated with anakinra.

RESULTS

Among the 378 patients diagnosed with MIS-C, 82 patients (21.6%) who were treated with anakinra were included in the study. The median age of patients was 115 (6-214) months. The median duration of hospitalization was 15 (6-42) days. Sixty patients (73.1%) were admitted to the pediatric intensive care unit. Patients were treated with a median dose of 2.7 mg/kg/day anakinra concomitant with IVIG and steroids. Intravenous anakinra was applied to 12 patients while 70 patients received it subcutaneously. Twenty-eight patients required high dose (4-10 mg/kg/day) anakinra. The median day of anakinra initiation was 2 (1-14) days and the median duration of anakinra use was 7 (1-41) days. No injection site reactions were observed while elevated transaminase levels were detected in 13 patients. Seventy-three patients (89.1%) were discharged without any sequela or morbidity. Seven patients (1.8%) died. Abnormal echocardiographic findings continued in two patients (2.4%) (coronary artery dilatation in one, low ejection fraction in one) at discharge and became normal on the 2^nd month.

CONCLUSION

Based on the results of the study, anakinra was associated with clinical improvements and was safe for most patients with refractory MIS-C.

Canakinumab in colchicine resistant familial Mediterranean fever and other pediatric rheumatic diseases

BACKGROUND AND OBJECTIVES

The aim of this observational retrospective cohort study was to demonstrate indications and response rates of the patients with pediatric rheumatic diseases that used canakinumab.

METHOD

The files of the patients that used canakinumab between December 2012 and July 2017 were reviewed. Canakinumab was used in 29 patients. Diagnosis of the patients were; colchicine resistant familial Mediterranean fever (crFMF) (19 cases), hyperimmunoglobulin D syndrome-mevalonate kinase deficiency (HIDS-MKD) (3 cases), cryopyrin-associated periodic syndrome (3 cases), systemic juvenile idiopathic arthritis (sJIA) (2 cases), idiopathic recurrent pericarditis (1 case) and pyoderma gangrenosum (1 case).

RESULTS

Canakinumab was used for 21.8 ± 15.8 months (6-54 months). crFMF patients had a female predominance; 16 girls and 3 boys. Mean age at the first symptoms of FMF was 2.8 ± 2.2 years. Mean number of attacks per year before colchicine was 18.7 ± 6.9 (10-36), after colchicine was 8.2 ± 2.7 (6-12) and after biologic agent the number dropped to 0.1 ± 0.3 (0-1). Canakinumab led to resolution of attacks in 3 HIDS-MKD cases. Two familial cold autoinflammatory syndrome patients were using canakinumab for 13 months with total remission. Chronic infantile neurological cutaneous articular syndrome patient did not show dramatic response to standard doses of IL-1 blockers and remission was achieved with high doses of canakinumab. Canakinumab led to the resolution of all systemic and articular manifestations in one sJIA case but the other sJIA case developed polyarticular joint involvement under canakinumab treatment. A severe pyoderma gangrenosum patient that failed dapson and anakinra, also failed canakinumab treatment that was used for 9 months. We have successfully treated a case of idiopathic recurrent pericarditis with canakinumab. Canakinumab was discontinued due to inefficacy only in two cases.

CONCLUSION

Overall efficacy of canakinumab was 93.1% in this study. No major adverse event was observed under canakinumab treatment. Canakinumab seems to be effective and safe in children with rheumatic diseases.

Comparison of Pediatric Familial Mediterranean Fever Patients Carrying Only E148Q Variant With the Ones Carrying Homozygous Pathogenic Mutations

OBJECTIVE

The aims of this study were to compare demographic data, clinical features, and severity scores of familial Mediterranean fever patients carrying E148Q variant with the patients having homozygous pathogenic MEFV mutations and to evaluate both of these groups for the performance of Tel-Hashomer, Livneh, and pediatric diagnostic criteria.

METHODS

The demographic and clinical data of patients with familial Mediterranean fever either heterozygous or homozygous for E148Q variant (group 1) and patients with homozygous mutations (M694V, M694I, M680I, V726A) (group 2) were collected retrospectively. All patients were evaluated for 3 diagnostic criteria.

RESULTS

E148Q variant was present in 128 patients (22.9%), 112 of whom had heterozygous and 16 of whom had homozygous E148Q mutation. Group 2 had 430 patients (77.1%), 372 of whom had homozygous M694V mutation, 50 of whom had homozygous M680I mutation, 5 of whom had homozygous V726A mutation, and 3 of whom had homozygous M694I mutation. Pleuritis, arthritis, recurrent fever, erysipelas-like erythema, and anemia were significantly more common in group 2 than group 1 (p < 0.05). Moderate and severe Pras scores were significantly higher in group 2 (p < 0.001). During attack-free periods, C-reactive protein, erythrocyte sedimentation rate, and serum amyloid A were found significantly higher in group 2 than in group 1 (p < 0.05). The percentage of children diagnosed according to Tel-Hashomer and pediatric criteria was significantly higher in group 2 than in group 1 (p < 0.05). Both groups show similar diagnostic utility by Livneh criteria.

CONCLUSIONS

Children with the E148Q variant met the 3 diagnostic criteria; they had a milder disease course both clinically and in laboratory means.

Neuroimaging of Children With Takayasu Arteritis

OBJECTIVE

Takayasu arteritis is a rare granulomatous chronic vasculitis that affects the aorta and its main branches. Neurologic manifestations can accompany the disease; however, there is no study on neuroimaging in children with Takayasu arteritis. Therefore, we aimed to evaluate cranial magnetic resonance imaging (MRI) in pediatric Takayasu arteritis patients.

MATERIALS AND METHODS

Demographic, clinical, and laboratory data were obtained retrospectively.

RESULTS

The study included 15 pediatric Takayasu arteritis patients. All patients presented with constitutional symptoms. Additionally, 6 patients suffered from headache, 2 had syncope, 1 had loss of consciousness, and 1 had convulsion. All patients underwent cranial and diffusion MRI a median 12 months after diagnosis. Cranial MRI findings were normal in 12 patients, whereas 3 patients had abnormal findings, as follows: stenosis in the M1 and M2 segments of the left middle cerebral artery (n = 1); diffuse thinning of the right internal carotid, middle cerebral, and right vertebral and basilar artery (n = 1); as a sequela, areas of focal gliosis in both the lateral ventricular and posterior periventricular regions (n = 1). Among these 3 patients, 1 had no neurologic complaints.

CONCLUSION

Abnormal MRI findings can be observed in pediatric Takayasu arteritis patients, even those that are asymptomatic; therefore, clinicians should carefully evaluate neurologic involvement in all pediatric Takayasu arteritis patients.

Sacroiliitis in children and adolescents with familial Mediterranean fever

BACKGROUND

Familial Mediterranean fever (FMF) is an autoinflammatory disease characterized by recurrent episodes of fever and serositis. Sacroiliitis can be observed in some FMF patients. This study aimed to compare the demographic, clinical, and laboratory findings, and treatment in children with FMF and sacroiliitis, and children with juvenile spondyloarthropathy (JSpA).

METHODS

In total, 1687 pediatric FMF patients that were followed-up between May 2010 and June 2020 were evaluated retrospectively. Among them, those with sacroiliitis (n = 63) were included in the study and compared to patients with JSpA (n = 102).

RESULTS

The study included 63 FMF patients with sacroiliitis (38 males [60.3%] and 25 females [39.7%]) with a mean age of 15.2 ± 4.1 years. Mean age at symptom onset was 7.2 ± 5.05 years and mean age at diagnosis was 9.74 ± 4.67 years. The most common mutation in the FMF patients was M694V/M694V (n = 22). Patients were diagnosed with sacroiliitis with a mean of 12 months (range: 6-36 months) after the diagnosis of FMF. Among the FMF patients, 28 (44.4%) had enthesitis, 23 (36.5%) had heel pain, and 11 (17.4%) had low back pain. The study also included 102 JSpA patients (90 males [88.2%] and 12 females [11.8%]). Mean age of patients with JSpA was 16.1 ± 2.8 years. As compared to 102 JSpA patients, patients with FMF and sacroiliitis had higher acute phase reactants, whereas HLA-B27 positivity rate was lower. In addition, axial involvement rate was higher in the JSpA patients.

CONCLUSION

Sacroiliitis is a common co-morbidity in FMF patients. The phenotypic features of these patients are different from patients with JSpA.

Real-Life Data From the Largest Pediatric Familial Mediterranean Fever Cohort

Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease manifesting phenotypic heterogeneity. It is a clinically diagnosed disease supported by MEditerranean FeVer (MEFV) gene mutation analysis. However, the phenotype-genotype correlation is not yet established clearly. We aimed to determine the clinical findings, phenotype-genotype correlation, and treatment outcomes within a large pediatric FMF cohort. The medical charts of children with FMF who were diagnosed and followed up at the eight pediatric rheumatology units were reviewed retrospectively. All patients in the cohort were analyzed for sequence variants in exon 2,3,5 and 10 of the MEFV gene. Patients without any mutations or with polymorphisms including R202Q were excluded. A total of 3,454 children were involved in the study. The mean ± standard deviation of current age, age at symptom onset, and age at diagnosis were 12.1 ± 5.2, 5.1 ± 3.8, and 7.3 ± 4.0 years, respectively. Of 3,454 patients, 88.2% had abdominal pain, 86.7% had fever, 27.7% had arthritis, 20.2% had chest pain, 23% had myalgia, and 13.1% had erysipelas-like erythema. The most common MEFV mutation patterns were homozygous (32.5%) and heterozygous (29.9%) mutations of exon 10. Homozygous M694V was present in 969 patients (28.1%). Allele frequencies of common mutations were M694V (55.3%), M680I (11.3%), V726A (7.6%), and E148Q (7.2%). Children carrying homozygous or compound heterozygous exon 10 mutations had an earlier age of disease onset (4.6 vs. 5.6 years, p = 0.000) and a higher number of attacks per year (11.1 vs. 9.6, p = 0.001). Although 8% of the patients had a family history of amyloidosis, 0.3% (n = 11) had the presence of amyloidosis. M694V homozygosity was detected in nine patients who developed amyloidosis. Colchicine resistance was present in 4.2% of our patients. In this largest pediatric cohort reviewed and presented to date, patients with exon 10 mutations, particularly the M694V homozygous mutation, have been demonstrated earlier disease onset, annual attack count, and more frequent colchicine-resistant cases. Although E148Q is considered as a polymorphism in some populations, it was identified as a disease-causing mutation in our cohort. Secondary amyloidosis is still happening in adults however, it is extremely rare among children, presumably due to increased awareness, tight control, and the availability of anti-IL1 agents in colchicine-resistant cases.

The Value of Serum Amyloid A Levels in Familial Mediterranean Fever to Identify Occult Inflammation During Asymptomatic Periods

OBJECTIVE

The aim of this observational study was to evaluate whether there was any correlation between the acute phase reactants in children with familial Mediterranean fever (FMF) during attack and attack-free periods.

METHODS

The study was conducted between June 2016 and January 2018. Clinical features and laboratory parameters of children with FMF during attack and attack-free periods were recorded longitudinally.

RESULTS

The cohort consisted of 168 children with FMF (84 boys, 84 girls). Median values of acute phase reactants during FMF attacks were 433.5 mg/L (34.0-1780.0 mg/L) for serum amyloid A (SAA), 56.7 mg/L (7.6-379.0 mg/L) for C-reactive protein (CRP), and 37.5 mm/h (5-100 mm/h) for erythrocyte sedimentation rate (ESR). Median values for the same tests in attack-free periods were 3.2 mg/L (0.1-25.0 mg/L), 1.7 mg/L (0.1-12.7 mg/L), and 8 mm/h (1-30 mm/h), respectively. Correlation analyses showed that SAA and CRP were highly correlated in FMF attack (r = 0.67, p < 0.01), but no correlation was found between SAA and ESR levels. C-reactive protein was elevated in 13.6%, ESR in 20.8%, and SAA in 28.5% of the patients during attack-free period. Age at onset, sex of the patients, and characteristics of attacks were found to be not associated with elevated SAA in attack-free period. On the other hand, having homozygous exon 10 mutation and having elevated CRP were found to be associated with high SAA in attack-free period.

CONCLUSIONS

C-reactive protein and SAA correlate well with FMF attacks. Therefore, checking for SAA during a FMF attack is not required. However, SAA seems to be the most sensitive method for demonstrating subclinical inflammation in attack-free period. Thus, checking SAA levels might be a valuable tool in selected FMF patients.

Protracted febrile myalgia syndrome as the first manifestation of familial Mediterranean fever in children: case-based review

Protracted febrile myalgia syndrome (PFMS) is one of the rare conditions characterized by long standing severe myalgia and fever in familial Mediterranean fever (FMF) patients. Laboratory studies show elevated values of inflammatory markers and normal creatinine phosphokinase (CPK) levels. Rarely, PFMS may be the first manifestation of FMF and this makes the diagnosis of FMF and PFMS challenging. The aim of this report was to describe case series of PFMS patients without previous diagnosis of FMF and discuss with other pediatric PFMS cases described in the literature. Six patients with PFMS as the first manifestation of FMF from two Pediatric Rheumatology clinics were presented. The male: female ratio was 1:1. The median (min-max) age at diagnosis was 7.05 (5.5-15.5) years. All patients had severe myalgia. No fever was detected in two patients. Only one patient had rash. Markedly elevated acute phase reactants were observed in all patients. CPK levels were normal in all patients. Also, we searched the PubMed/MEDLINE, Google Scholar, Web of Science and Scopus databases from inception to May 2020, using the keywords 'familial Mediterranean fever, protracted febrile myalgia, child' and 52 pediatric PFMS were found. In the literature, three patients did not have fever, and nineteen patients were not previously diagnosed with FMF as our patients. As a conclusion, PFMS may be the first manifestation of FMF. It should be suspected in cases with prolonged severe myalgia with or without fever, and high acute phase reactants.

The relevance of practical laboratory markers in predicting gastrointestinal and renal involvement in children with Henoch-Schönlein Purpura

OBJECTIVES

Henoch-Schönlein Purpura (HSP) is the most common self-limiting vasculitis of childhood. Both serious gastrointestinal and renal complications may be observed during the disease course. The aim of this study was to evaluate the role of hematological markers in predicting the likely complications of the disease.

METHODS

The demographic findings, clinical features, organ involvements and laboratory findings including white blood cell count (WBC), neutrophil, lymphocyte and platelet counts, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio (PLR), mean platelet volumes (MPV), MPV/platelet count ratio (MPR) were evaluated retrospectively from the charts of the patients with HSP and all these parameters were compared with the same parameters of healthy children.

RESULTS

A total of 376 patients with HSP and age- and sex-matched 233 healthy children were evaluated. Mean age at the diagnosis was 7.5 ± 3.5. All patients had palpable purpura, 46% had arthritis, 56.1% GIS involvement and 21.3% had renal involvement. While platelet counts, neutrophil counts, NLR, and PLR were higher, lymphocyte counts, MPV, and MPR were lower in patients with GIS involvement. NLR was the sole biomarker that was higher in patients with renal involvement.

CONCLUSIONS

This study had shown that platelet counts, neutrophil counts, NLR, and PLR were increasing and lymphocyte counts, MPV, and MPR were decreasing when the patients had GIS involvement. However, these parameters were not relevant in distinguishing severe and mild GIS involvement. When patients had renal involvement NLR was the unique elevated parameter.

Complete and sustained resolution of calcinosis universalis in a juvenile dermatomyositis case with mycophenolate mofetil

Çakan M, Karadağ ŞG, Aktay Ayaz N. Complete and sustained resolution of calcinosis universalis in a juvenile dermatomyositis case with mycophenolate mofetil. Turk J Pediatr 2019; 61: 771-775. Juvenile dermatomyositis (JDM) is a rare, multisystemic, idiopathic vasculopathy mainly affecting the muscles and the skin. Gastrointestinal system, lungs, joints and heart may also be involved. Characteristic skin findings are heliotrope rash and Gottron papules but extensive skin involvement as large necrotic lesions are rarely reported. Calcinosis is one of the major issues in the long term. Delay in diagnosis, inadequate therapy at the initial phase, prolonged persistent disease activity are considered as major risk factors for the development of calcinosis. Treatment of calcinosis is also a major issue because no single treatment modality has been found to reproducibly stop or reverse calcification. A 5-year-old girl was admitted to our clinic with typical signs and symptoms of JDM. She was initially treated with high-dose corticosteroids, methotrexate and intravenous immunoglobulin (IVIG). Soon after, she developed necrotic ulcerative skin lesions and cyclosporine was added to her treatment regimen. By this treatment all muscle and skin manifestations were controlled but on the first year of follow-up she developed superficial calcification plaques on the upper extremities and calcinosis universalis like calcifications on the lower extremities. Calcifications did not respond to bisphosphonate (pamidronate) and IVIG treatment but mycophenolate mofetil resulted in rapid and sustained resolution of all calcification plaques.

Atypical phenotype of an old disease or typical phenotype of a new disease: deficiency of adenosine deaminase 2

Çakan M, Aktay-Ayaz N, Karadağ ŞG, Tahir-Turanlı E, Stafstrom K, Bainter W, Geha RS, Chou J. Atypical phenotype of an old disease or typical phenotype of a new disease: deficiency of adenosine deaminase 2. Turk J Pediatr 2019; 61: 413-417. Deficiency of adenosine deaminase 2 (DADA2) is an autosomal recessive autoinflammatory disorder caused by mutations in CECR1 (cat eye syndrome chromosome region, canditate 1) gene, which encodes the enzyme adenosine deaminase 2 necessary for endothelial cell survival and function. The diversity of the clinical phenotypes associated with DADA2 include polyarteritis nodosa-like vasculitic features, early-onset stroke, mild to severe immunodeficiency and cytopenias. The diagnosis of the disease may be difficult due to complex clinical phenotype. Herein, we present a case of DADA2 presenting with vasculitis, amarousis fugax, gastrointestinal bleeding and silent lacunar infarct successfully treated with etanercept.

Differential diagnosis portfolio of a pediatric rheumatologist: eight cases, eight stories

There is no single diagnostic test for any rheumatic disease. The diagnosis of a rheumatic disease is made by the sum of the findings in history, physical examination, laboratory, and imaging tests. A differential diagnosis list in pediatric rheumatology is quite long and mainly includes malignant, infectious, and inherited metabolic disorders. We aim to present cases that were referred to a pediatric rheumatology outpatient clinic with provisional diagnosis of a rheumatic disease but finally diagnosed with a non-rheumatic disease in order to emphasize the importance of differential diagnoses. Eight cases were presented in this manuscript. Five cases were referred with the provisional diagnosis of juvenile idiopathic arthritis. Sarcoidosis, chronic non-bacterial osteomyelitis, and autoinflammatory disease were the provisional referral diagnoses in three patients. Definitive diagnoses of the patients were as follows: acute lymphoblastic leukemia (two cases), bilineage acute leukemia, Hodgkin lymphoma, brucellosis, mucolipidosis type III, anhidrotic ectodermal dysplasia, and Freiberg disease. In children presenting with rheumatic complaints malignant, infectious and inherited metabolic disorders should always be in the differential diagnosis list of a pediatric rheumatologist. Alternative diagnoses should always be considered even in patients with a rheumatic disease when the patient does not respond to treatment or follows an unusual clinical course. Key Points • Diagnosis of a rheumatic disease is made by exclusion of all other pathologies. • Malignant and infectious diseases may mimic the signs and symptoms of a rheumatic disease.

Clinical experiences in Turkish paediatric patients with chronic recurrent multifocal osteomyelitis

Sözeri B, Aktay Ayaz N, Yıldız Atıkan B, Karadağ ŞG, Çakan M, Argın M, Sezak M. Clinical experiences in Turkish paediatric patients with chronic recurrent multifocal osteomyelitis. Turk J Pediatr 2019; 61: 879-884. Chronic recurrent multifocal osteomyelitis (CRMO) is a clinical entity which occurs mainly in children and adolescents with recurrent episodes of pain occurring over several years. Cause and physiopathology of disease is still uncertain. We aim to assess clinical characteristics and treatment options, need and response to anti-inflammatory therapies in children diagnosed chronic recurrent multifocal osteomyelitis Demographic data and clinical features of seventeen children diagnosed with CRMO in 2 pediatric rheumatology centers in Turkey were reviewed retrospectively. The diagnosis was based on clinical findings, radiological images and histopathological and microbiological studies. A total of 17 patients were included in the study. The median age of diagnosis was 9.6±4.2 years. The mean follow-up time was 31.6 months (range 6-35 months). Most patients (n: 10) had a recurrent multifocal disease course ( > 6 months), 6 patients had a persistent course and a patient had only one episode of CRMO. MEFV gene mutations were detected in 4 patients whose clinical features reduced with colchicine therapy. All patients had received nonsteroidal anti-inflammatory drugs but only one had complete response. Thirteen children with NSAID failure subsequently received corticosteroids, sulfasalazine, methotrexate, Anti TNF α drugs, or a combination of these drugs. This study is the largest cohort of pediatric CRMO patients in our country. Clinical evolution and imaging investigations should be closely done to avoid delays in diagnosis. Ethnic differences create changes in the presentation of the disease and response to treatment.

Anterior Segment Analysis and Evaluation of Corneal Biomechanical Properties in Children with Joint Hypermobility

Objectives:

To compare anterior segment parameters and biomechanical analysis of the cornea in children with joint hypermobility (JH) and healthy children.

Materials and Methods:

Cross-sectional case-control study. Fifty eyes of 25 children with JH were compared with 74 eyes of 37 healthy age- and sex-matched controls in terms of refractive, anterior segment topographic, and corneal biomechanical measurements. Axial length (AL) was measured with a Nidek AL-Scan biometry device; corneal-compensated intraocular pressure (IOPcc), Goldmann-correlated IOP (IOPg), corneal hysteresis (CH), and corneal resistance factor (CRF) were measured with a Reichert ocular response analyzer (ORA). Central corneal thickness (CCT), anterior chamber depth (ACD), K1/K2 values, iris diameter, and anterior chamber volume (ACV) were measured with a Sirius topography device.

Results:

Mean age in the JH group was 10.56±4.03 years, while that of the control group was 11.27±2.59 years (p=0.23). Spherical equivalent was -0.22±1.02 diopter (D) in the JH group and -0.12±1.12 D in the control group (p=0.60); CCT was 23.01±0.82 µm in the JH group and 23.17±0.82 µm in the control group (p=0.33). There were no significant differences between the two groups in terms of age, sex, IOP, IOPcc, IOPg, CH, CRF, AL, K1, K2, iris diameter, ACD, and ACV.

Conclusion:

JH, which causes increased flexibility of the joints, was concluded not to cause a significant change in the corneal biomechanical markers of CRF and CH or in anterior segment topographic parameters.

Rheumatic diseases in Syrian refugee children: a retrospective multicentric study in Turkey

Since the Syrian civil war in 2011, an estimated number of 3.6 million Syrian refugees crossed into Turkey, and almost half of them were children. The distribution of rheumatic diseases in Syrian refugee children is not known. The aim of this study was to describe the profile of rheumatic diseases in Syrian refugee children living in Turkey. The demographic data, clinical and laboratory findings, medications, complications and outcome results of Syrian refugee children who had visited Pediatric Rheumatology Departments of University of Health Science Kanuni Sultan Süleyman Research and Training Hospital, Ümraniye Research and Training Hospital, Şanlıurfa Research and Training Hospital, and Cengiz Gökçek Maternity and Gynecology Hospital between April 1, 2011, and September 1, 2019, were evaluated retrospectively. A total of 151 patients were included in the study. Among them, 51 patients had juvenile idiopathic arthritis (JIA), 49 had familial Mediterranean fever (FMF), 43 had vasculitis, and 8 had connective tissue diseases. Homozygous M694V mutation was the most common mutation among FMF patients. Oligoarticular JIA (41.2%) was the most frequent type of JIA, and enthesitis-related arthritis (ERA) (27.5%) was the second one. The frequency of systemic JIA was 11.8%. One patient with SLE died due to complicated meningitis. This is the first study evaluating the distribution of rheumatic diseases in Syrian refugee children. Clinical follow-up of rheumatologic diseases is difficult in Syrian refugees due to language barriers, social and cultural differences. Health care systems should be well organized to provide appropriate care to asylum seekers.

Age of onset as an influencing factor for disease severity in children with familial Mediterranean fever

OBJECTIVES

To define the demographic, clinical and genetic features of familial Mediterranean fever (FMF) patients with early disease onset and to compare them with late-onset FMF patients.

METHODS

Patients were divided into two groups according to the age of disease onset: group 1 includes the patients who had their first attack ≤3 years of age; group 2 consisted of patients who had their first attack >3 years of age. Furthermore, we compared the proportion of patients fulfilling the three diagnostic criteria among two groups.

RESULTS

Of 1687 patients, 761 had first FMF attack at ≤3 years of age while 926 patients presented with their first manifestation of FMF at >3 years. Delay in diagnosis, fever and peritonitis were significantly higher in group 1. Frequency of arthritis, erysipelas-like erythema, non-nephrotic proteinuria, incomplete attacks, chronic arthritis, arthralgia and mean colchicine dose were significantly higher in group 2. Mean Pras score was higher and the presence of M694V mutation was more frequent in group 1. The percentage of children diagnosed according to Tel-Hashomer and pediatric criteria was significantly higher in group 1 than group 2. However, both groups meet Livneh criteria similarly.

CONCLUSION

Although patients with early disease onset seem to have more severe disease course, they are more likely to have a delay in diagnosis. To avoid the diagnostic delay, clinicians should be aware of the findings of FMF in early age.

Isotretinoin-induced sacroiliitis: Case series of four patients and a systematic review of the literature

Isotretinoin is the mainstay treatment in severe acne; however, its musculoskeletal adverse effects such as lower-back pain can be disabling. Herein, we present four cases of isotretinoin-induced sacroiliitis with variable severity. We also present a review of the literature of isotretinoin-induced sacroiliitis. All our cases were male and human leukocyte antigen (HLA)-B27 negative. Sacroiliitis was detected a median of 55 (10-120) days after isotretinoin initiation. Two patients were responsive to baseline sulfasalazine and indomethacin treatment, while the other two patients required more intensive treatments: adalimumab in one and methotrexate in the other. We also identified 15 articles describing 33 patients (17 of whom were female) with isotretinoin-induced sacroiliitis. Most of them were responsive to low-to-medium doses of systemic steroids or non-steroidal anti-inflammatory drugs (NSAIDs). Our patients illustrate that severity of isotretinoin-induced sacroiliitis varies from patient to patient.