Successful treatment of invasive gastric mucormycosis in a child with systemic lupus erythematosus

We describe a child with systemic lupus erythematosus and invasive gastric mucormycosis, who was successfully treated with aggressive antifungal therapy and a unique interventional radiology procedure. Lupus (2010) 19, 646—649.

Juvenile rheumatoid arthritis and the spondyloarthropathies

Juvenile rheumatoid arthritis (JRA) and the spondyloarthropathies affect approximately one in a thousand children under the age of 17 years and are more common than diabetes, cystic fibrosis, and many other chronic conditions. The author explores differential diagnoses for musculoskeletal pain, classifies types of JRA and the spondyloarthropathies, and describes how such conditions may be effectively managed with drug and physical rehabilitation therapy. The article also discusses behavioral, school, and vocational issues.

Considerations in child and adolescent athletes

Excessive efforts to groom competitive and elite athletes from a very young age may expose children to significant external pressure to perform inappropriate training regimes, sometimes at the expense of their health and psychological well-being. It is essential for the physician to recognize the special physiologic, anatomic, and psychological issues of the child and adolescent athlete and to balance the benefits of appropriate participation in sports and exercise with the risks of physical and psychological injury.

Migrating monopredominant arthritis in children of Assyrian ancestry

We describe an unusual form of arthritis affecting 3 Assyrian children to inspire a search for further cases to determine how unique it may be. After different patterns of onset, 3 of 4 children with arthritis from the Assyrian community in northern California had an unusual course of recurrent arthritis, predominantly in one joint at a time. There was rapid cartilage and bone destruction in involved joints. The 3 children are HLA-DR4. The 4th patient had a more typical childhood polyarticular course. Two of the first 3 patients had fever with attacks. None had rheumatoid factor, antinuclear antibody, or the HLA-B27 antigen. This unusual, severe, monopredominant but migrating arthritis appears to be particularly associated with Assyrian descent.

Vogt-Koyanagi-Harada syndrome in a 4-year old child

PURPOSE

We studied a case of severe bilateral Vogt-Koyanagi-Harada syndrome in a 4-year-old boy.

METHODS

We evaluated the patient's clinical course.

RESULTS

The patient had severe bilateral, nongranulomatous uveitis and mild uveitic glaucoma. Initial examination and laboratory evaluation failed to provide a diagnosis. The patient subsequently developed areas of vitiligo, alopecia, and poliosis, suggesting the diagnosis of Vogt-Koyanagi-Harada syndrome. This diagnosis was confirmed by the eventual development of bilateral neurosensory retinal detachments. Vision was lost despite aggressive therapy with corticosteroids and chlorambucil.

CONCLUSION

Although uncommon, Vogt-Koyanagi-Harada may affect young children, and may be severe.

Rehabilitation of the child with a rheumatic disease

This article discusses the principles of rehabilitation of the most common childhood rheumatic diseases, especially juvenile rheumatoid arthritis, dermatomyositis, and scleroderma. Any rehabilitation program must be undertaken in conjunction with understanding of disease processes, appropriate medical management, and patient and family education. Investing effort into avoiding contractures, weakness, osteoporosis, and disability is considerably less time-consuming, painful, and costly than trying to reverse established problems.

Treatment of juvenile rheumatoid arthritis

New information on the treatment of juvenile rheumatoid arthritis emphasizes more aggressive control of arthritis, particularly the use of methotrexate, both in low- and higher-dose regimens. Information concerning drug toxicity, including that of the nonsteroidal anti-inflammatory drugs, second-line agents, and methotrexate, suggests that these drugs are well tolerated in children. A new corticosteroid, deflazacort, minimizes bone demineralization and growth retardation. Adjunctive measures, including erythropoietin, pain management techniques, conditioning programs, and nutrition, have demonstrated advantages in some children with juvenile rheumatoid arthritis.

Physical modalities of therapy in pediatric rheumatic diseases

The approach to rehabilitation management of childhood rheumatic disease differs in many ways from that of adult disease. Among the special considerations are the effects of chronic musculoskeletal inflammation in a growing and developing individual and the tendency of children to tighten their joints into positions of comfort, with fewer problems resulting from ligamentous laxity and instability. A comprehensive management approach includes much more than simply using medications--the tendency for the disease to exert deforming forces on the limbs must be constantly fought by a vigorous program of rehabilitation; education and psychologic support must be provided to the patient and family; potential problems must be discussed with the school; financial and vocational issues must be addressed.

Intermittent intravenous cyclophosphamide therapy for lupus nephritis

We carried out a preliminary study to determine whether intermittent intravenous cyclophosphamide therapy could be safely and effectively used in the treatment of childhood lupus nephritis. Sixteen children (4 to 18 years of age) with lupus nephritis were treated with cyclophosphamide monthly for 6 months and then every 3 months. Eight children were treated because of corticosteroid-unresponsive active lupus nephritis, with a fall in their creatinine clearance to less than 100 ml/min/1.75 m2, and eight children were treated because of corticosteroid-dependent nephrotic syndrome or active lupus nephritis with unacceptable corticosteroid-induced side effects. Cyclophosphamide treatment was associated with significant improvement at 1 year in mean levels of hemoglobin (11.3 +/- 0.5 to 13.1 +/- 0.3 gm/dl), C3 (52 +/- 5.9 to 108 +/- 13.7 mg/dl), and C4 (7.6 +/- 0.9 to 15.9 +/- 2.2 mg/dl) (all p less than 0.005), despite a significant reduction in mean prednisone dosage (31 +/- 5 to 14 +/- 2 mg/day; p less than 0.005). There was a decrease in 24-hour urine protein excretion from 3121 +/- 913 to 1016 +/- 364 mg/24 hours (p less than 0.05). For children whose initial creatinine clearance was less than 100 ml/min/1.75 m2, creatinine clearance also improved significantly (57.5 +/- 11 to 121 +/- 24.5 ml/min/1.75 m2; p less than 0.05). The long-term safety of intravenous cyclophosphamide therapy and its long-term efficacy in comparison with prednisone alone remain to be established. In the interim, intravenous cyclophosphamide therapy should be reserved for children with severe, unacceptable corticosteroid side effects or with corticosteroid-resistant and potentially life-threatening disease.

Cellular immunity in patients with systemic juvenile rheumatoid arthritis

We studied the cellular immune responses in 10 patients with systemic form of juvenile rheumatoid arthritis. The numbers of peripheral T lymphocytes and their helper/inducer and cytotoxic/suppressor subpopulation were within normal levels. Activated T lymphocytes (DR+) were slightly increased but not at statistically significant levels. In contrast to the T cells, B lymphocytes were increased; both the percentage of B cells (B1+) and the number of cells spontaneously secreting IgG, IgA, and IgM were increased. Stimulation of peripheral mononuclear cells in vitro with pokeweed mitogen induced poor plaque-forming cell responses, which were partially improved upon removal of monocytes. The presence of concanavalin A in the cultures led to complete suppression. We conclude that patients with systemic JRA are characterized primarily by B-cell rather than T-cell abnormalities.

Aspirin and fenoprofen (Nalfon) in the treatment of juvenile rheumatoid arthritis results of the double blind-trial. A segment II study

We compared efficacy and safety of aspirin (ASA) and fenoprofen in the treatment of JRA. Ninety-nine children with JRA were given ASA or fenoprofen in a 12-wk, multicentered, double-blind, parallel study. Initial fenoprofen dosage was 900 mg/m2/d increased to 1800 mg/m2/d (3200 mg/d-max). Initial ASA dosage was 1500 mg/m2/d increased to 3000 mg/m2/d (5450 mg/d-max). Adverse reactions forced removal of 14% of ASA treated patients from the trial, whereas no fenoprofen patient was removed for this reason. Forty of 50 ASA patients, and 47 of 49 fenoprofen patients completed at least 10 wk of therapy and analysis showed that the 2 drugs were nearly identical in efficacy, but toxicity was considerably less among fenoprofen treated patients.