Diagnostic delays in systemic vasculitides

Systemic vasculitides are among the less common disorders encountered in routine rheumatology practice. The low incidence and heterogeneous presentation at onset can potentially lead to delayed diagnosis. Not recognizing these in the early phase may prove detrimental, as some vasculitis may progress to a catastrophic course with major morbidity or mortality. The causes of diagnostic delay may vary among different types of vasculitis and may also be disease-, patient-, or physician-related. Disease-related factors include the myriad presentations with diverse and non-specific symptoms, mimicking other conditions like infections. In addition, some forms have prolonged prodromal phases before evident organ damage. Limited awareness among healthcare professionals, particularly outside rheumatology, and a lack of readily available diagnostic tools contribute to missed diagnoses. Delays in seeking care due to non-specific symptoms or lack of access to specialist care can worsen outcomes. The economic burden also increases with delayed diagnosis and damage accrual when the disease remains unrecognized or untreated for prolonged periods. Although the causes of vasculitis are numerous, including secondary causes, in this review, we focus on diagnostic delays in primary vasculitides and suggest potential steps to identify and treat these diseases early. These include educating both healthcare professionals and the public about the signs and symptoms of vasculitis; expanding the rheumatology workforce and facilitating timely referrals; implementing readily available and reliable tests for early detection; and streamlining care and diagnostic pathways. Such measures have the potential to improve the overall outcomes of the disease, with prolonged remission, minimal damage accrual, and improved quality of life.

RNAseq-based transcriptomics of treatment-naïve multi-inflammatory syndrome in children (MIS-C) demonstrates predominant activation of matrisome, innate and humoral immune pathways

MIS-C is a rare, highly inflammatory state resembling incomplete Kawasaki disease, temporarily associated with COVID-19. The pathogenesis is not completely known. RNAseq was carried out on whole blood of six treatment-naïve MIS-C patients. This was compared against RNAseq transcriptomics data of five healthy controls (HC), four Kawasaki Disease (KD) and seven systemic Juvenile Idiopathic Arthritis (sJIA). Using PCA, MIS-C clustered separately from HC, KD and sJIA. Amongst the top 50 significant genes in the three comparisons with HC, KD, and sJIA, common genes were: TMCC2, ITGA2B, DMTN, GFI1B, PF4, QSER1, GRAP2, TUBB1. DSEA revealed that maximum number of hits for overexpressed pathways was for NABA matrisome activation when MIS-C was compared against HC. Cytokine stimulated cellular activation pathways, specifically IL-10 were downregulated. MIS-C had more activated pathways of neutrophil degranulation and acquired immune activation but less of coagulation system or heat-shock system involvement as compared to KD. As compared to sJIA, humoral immune response and complements were activated. Matrisome activation was higher, with increased cell-cell interaction and ECM signalling. This analysis revealed novel insights into the pathogenesis of MIS-C, including the potential role of matrisomes, humoral immune system and down-regulated interleukin-10 pathways.

Juvenile xanthogranuloma of the lacrimal sac fossa

PURPOSE

Masses involving the medial canthus and lacrimal sac fossa include dacryocystoceles and, less commonly, mucoceles, hemangiomas, diverticula, and lacrimal sac neoplasms. To our knowledge, juvenile xanthogranuloma presenting as a lacrimal sac fossa mass has not been previously reported.

METHODS

We examined a 2-year-old boy who had epiphora in the left eye since birth and a mass in the left lacrimal sac fossa for 6 weeks. During surgery, left lacrimal probing disclosed obstruction at the level of the common canaliculus and lacrimal sac. Exploration and excision of the mass were performed.

RESULTS

Histopathologic evaluation disclosed a juvenile xanthogranuloma characterized by an inflammatory cell infiltrate with foamy histiocytes and scattered Touton-type multinucleated giant cells.

CONCLUSION

Juvenile xanthogranuloma should be included in the differential diagnosis of a medial canthal and lacrimal sac fossa mass.

Subjective and objective outcomes of strabismus surgery in children

BACKGROUND

The negative psychosocial impact of strabismus in adults has been well documented. Despite the increasingly recognized importance of outcomes research, parents' satisfaction with strabismus treatment in childhood and their assessment of its functional impact and "quality of life" impact have not been investigated.

METHODS

A survey instrument was designed to assess parents' perceptions of preoperative, surgical, and postoperative phases of the clinical experience, including the long-term impact of surgery on their children.

RESULTS

Overall satisfaction with the surgical result was rated "good" or "very good" in 85% of 77 children under age 6. The correlation between subjective satisfaction and objective alignment within 10 prism diopters (delta) of orthophoria was significant (P < .001). Parents of children under age 4 noted improved eye contact (61%) and appearance (94%). Parents of older children noted improved interactions with others (47%) and self-esteem (55%). Coordination was considered improved in 56% of the entire group. Subjective satisfaction and psychosocial benefits often occurred even in cases deemed objectively unsuccessful.

CONCLUSION

Surgical correction of strabismus in childhood is clearly perceived by parents to be both successful and important to them and their children.