Aspectos clínicos y factores asociados a compromiso renal en pacientes pediátricos con púrpura de Schönlein Henoch / Clinical aspects and factors related with renal involvement in pediatrics patients with Schönlein Henoch purpura

INTRODUCCIÓN: La púrpura de Schönlein Henoch (PSH) es la vasculitis más frecuente de la infancia. Es generalmente autolimitada, con morbilidad renal a largo plazo. OBJETIVO: Determinar la frecuencia de las manifestaciones clínicas de la PSH y las variables asociadas al compromiso renal en pacientes con PSH del Servicio de Reumatología pediátrica de la Clínica Universitaria Reina Fabiola durante el periodo 2015-2020. MATERIALES Y METODOS: Estudio observacional, retrospectivo, transversal, analítico. Se incluyeron pacientes menores de 15 años con diagnóstico de PSH. Variables: edad, sexo, mes de diagnóstico, compromiso dermatológico, renal, gastrointestinal, articular y recurrencia y/o persistencia y otras manifestaciones. Análisis estadístico: test T de Student, test chi cuadrado y regresión logística multivariada. RESULTADOS: Se analizaron 107 pacientes, 61 (57%) de sexo femenino, con una media (desviación estándar, DE) de edad de 6,49 (3,48) años. El 100% presentó compromiso dérmico, 19 (18%) púrpura persistente o recurrente, 21 (19%) síntomas gastrointestinales, 38 (36%) compromiso articular y 21 (20%) manifestaciones renales. Se asoció con compromiso renal a pacientes con edad mayor a 7 años (p=0.0064), púrpura persistente o recurrente (p=0.0001), compromiso articular (p=0,0135) y dolor abdominal (p=0,0136). En el análisis multivariado, la púrpura persistente o recurrente se asoció con compromiso renal (OR=7,16; IC95%: 1,81-28,25); p=0.005). CONCLUSIONES: La púrpura persistente o recurrente fue considerada factor de riesgo para presentar compromiso renal y además se evidenció una asociación entre pacientes mayores a 7 años, compromiso articular y dolor abdominal con compromiso renal.

INTRODUCTION: Schönlein Henoch purpura (SHP) is the most frequent vasculitis in childhood. Its course is generally self-limited but can lead to long-term renal morbidity OBJECTIVE: To determine the frequency of the clinical manifestations of PSH. To determine the variables associated with renal involvement in patients with SHP, treated by the Pediatric Rheumatology Service of the Reina Fabiola University Clinic during the period 2015-2020. MATERIALS AND METHODS: Observational, retrospective, transversal, analytical study. Patients under 15 years of age with a diagnosis of HSP, were included. The variables were: age, sex, month of diagnosis, dermatological, renal, gastrointestinal, joint involvement, recurrence and/or prevalence and other manifestations. Statistical analysis: Student's t test, chi square test and multivariate logistic regression. RESULTS: 107 patients were analyzed, 57% were female (n = 61), with a mean age of 6.49 SD of 3.48 years. 100% presented dermal involvement, 19 (18%) persistent or recurrent purpura, 21 (19%) gastrointestinal symptoms, 38 (36%) joint involvement and 21 (20%) kidney manifestations. An association with kidney involvement was found in patients older than 7 years (p = 0.0064), persistent or recurrent purpura (p = 0.0001), joint involvement (p = 0.0135) and abdominal pain (p = 0.0136), but only persistent or recurrent purpura was the only risk factor associated with statistically significant renal involvement (OR = 71.17; 95% CI = 1.81 - 28.25; P = 0.005). CONCLUSION: Persistent or recurrent purpura was considered a risk factor for the fact of presenting kidney involvement and also an association was evidenced between patients older than 7 years, joint involvement and abdominal pain with kidney involvement.

Performance of current guidelines for diagnosis of macrophage activation syndrome complicating systemic juvenile idiopathic arthritis.

OBJECTIVE: To compare the capacity of the 2004 diagnostic guidelines for hemophagocytic lymphohistiocytosis (HLH-2004) with the capacity of the preliminary diagnostic guidelines for systemic juvenile idiopathic arthritis (JIA)-associated macrophage activation syndrome (MAS) to discriminate MAS complicating systemic JIA from 2 potentially confusable conditions, represented by active systemic JIA without MAS and systemic infection. METHODS: International pediatric rheumatologists and hemato-oncologists were asked to retrospectively collect clinical information from patients with systemic JIA-associated MAS and confusable conditions. The ability of the guidelines to differentiate MAS from the control diseases was evaluated by calculating the sensitivity and specificity of each set of guidelines and the kappa statistics for concordance with the physician's diagnosis. Owing to the fact that not all patients were assessed for hemophagocytosis on bone marrow aspirates and given the lack of data on natural killer cell activity and soluble CD25 levels, the HLH-2004 guidelines were adapted to enable the diagnosis of MAS when 3 of 5 of the remaining items (3/5-adapted) or 4 of 5 of the remaining items (4/5-adapted) were present. RESULTS: The study sample included 362 patients with systemic JIA and MAS, 404 patients with active systemic JIA without MAS, and 345 patients with systemic infection. The best capacity to differentiate MAS from systemic JIA without MAS was found when the preliminary MAS guidelines were applied. The 3/5-adapted HLH-2004 guidelines performed better than the 4/5-adapted guidelines in distinguishing MAS from active systemic JIA without MAS. The 3/5-adapted HLH-2004 guidelines and the preliminary MAS guidelines with the addition of ferritin levels ≥500 ng/ml discriminated best between MAS and systemic infections. CONCLUSION: The preliminary MAS guidelines showed the strongest ability to identify MAS in systemic JIA. The addition of hyperferritinemia enhanced their capacity to differentiate MAS from systemic infections. The HLH-2004 guidelines are likely not appropriate for identification of MAS in children with systemic JIA.

Phagocyte-specific S100 proteins and high-sensitivity C reactive protein as biomarkers for a risk-adapted treatment to maintain remission in juvenile idiopathic arthritis: a comparative study.

OBJECTIVES: Juvenile idiopathic arthritis (JIA) is a chronic inflammatory joint disease affecting children. Even if remission is successfully induced, about half of the patients experience a relapse after stopping anti-inflammatory therapy. The present study investigated whether patients with JIA at risk of relapse can be identified by biomarkers even if clinical signs of disease activity are absent. METHODS: Patients fulfilling the criteria of inactive disease on medication were included at the time when all medication was withdrawn. The phagocyte activation markers S100A12 and myeloid-related proteins 8/14 (MRP8/14) were compared as well as the acute phase reactant high-sensitivity C reactive protein (hsCRP) as predictive biomarkers for the risk of a flare within a time frame of 6 months. RESULTS: 35 of 188 enrolled patients experienced a flare within 6 months. Clinical or standard laboratory parameters could not differentiate between patients at risk of relapse and those not at risk. S100A12 and MRP8/14 levels were significantly higher in patients who subsequently developed flares than in patients with stable remission. The best single biomarker for the prediction of flare was S100A12 (HR 2.81). The predictive performance may be improved if a combination with hsCRP is used. CONCLUSIONS: Subclinical disease activity may result in unstable remission (ie, a status of clinical but not immunological remission). Biomarkers such as S100A12 and MRP8/14 inform about the activation status of innate immunity at the molecular level and thereby identify patients with unstable remission and an increased risk of relapse.

Performance of Birmingham Vasculitis Activity Score and disease extent index in childhood vasculitides.

OBJECTIVES: To evaluate the performance of the Birmingham Vasculitis Activity Score (BVAS) v3 and the Disease Extent Index (DEI) for the assessment of disease activity in 4 primary childhood (c-) systemic vasculitides. METHODS: Patients fulfilling the EULAR/PRINTO/PRES (Ankara) c-vasculitis classification criteria for Henoch-Schönlein purpura (HSP), childhood (c) polyarteritis nodosa (c-PAN), c-Wegener's granulomatosis (c-WG) and c-Takayasu arteritis (c-TA) with disease duration at the time of diagnosis ≤3 months were extracted from the PRINTO database. The performance of the BVAS and DEI were examined by assessing convergent validity, the pattern of disease involvement, and responsiveness. We also evaluated alternative unweighted scoring methods for both tools. RESULTS: The analysis set included 796 patients with 669 HSP, 80 c-PAN, 25 c-WG and 22 c-TA. The median age at diagnosis was 6.9 years (6.6-12) and median delay in making the diagnosis from the onset of signs/symptoms was 0.01 (0.003-0.027) years. A strong correlation was found between the BVAS and DEI (rs=0.78) while correlation with the physician global assessment was moderate (rs=0.48) with BVAS and poor with DEI (rs=0.25). Both the BVAS and DEI sub-scores and total scores were able to descrive the disease involvement in the 4 childhood vasculitides. Responsiveness was large (>1.5) for both tools. The performance characteristics of the BVAS and DEI with the unweighted methods were comparable. CONCLUSIONS: This study demonstrates that both the BVAS and DEI are valid tools for the assessment of the level of disease activity in a large cohort of childhood acute and chronic vasculitides.

Health-related quality of life of patients with juvenile dermatomyositis: results from the Pediatric Rheumatology International Trials Organisation multinational quality of life cohort study.

OBJECTIVE: To investigate the health-related quality of life (HRQOL) change over time, as measured by the Child Health Questionnaire (CHQ), and its determinants in patients with active juvenile dermatomyositis (DM). METHODS: We assessed patients with juvenile DM at both baseline and 6 months of followup, and healthy children age < or =18 years. Potential determinants of poor HRQOL included demographic data, physician's and parent's global assessments, muscle strength, functional ability as measured by the Childhood Health Assessment Questionnaire (C-HAQ), global disease activity assessments, and laboratory markers. RESULTS: A total of 272 children with juvenile DM and 2,288 healthy children were enrolled from 37 countries. The mean +/- SD CHQ physical and psychosocial summary scores were significantly lower in children with juvenile DM (33.7 +/- 11.7 versus 54.6 +/- 4.1) than in healthy children (45.1 +/- 9.0 versus 52 +/- 7.2), with physical well-being domains being the most impaired. HRQOL improved over time in responders to treatment and remained unchanged or worsened in nonresponders. Both physical and psychosocial summary scores decreased with increasing levels of disease activity, muscle strength, and parent's evaluation of the child's overall well-being. A C-HAQ score >1.6 (odds ratio [OR] 5.06, 95% confidence interval [95% CI] 2.03-12.59), child's overall well-being score >6.2 (OR 5.24, 95% CI 2.27-12.10), and to a lesser extent muscle strength and alanine aminotransferase level were the strongest determinants of poor physical well-being at baseline. Baseline disability and longer disease duration were the major determinants for poor physical well-being at followup. CONCLUSION: We found that patients with juvenile DM have a significant impairment in their HRQOL compared with healthy peers, particularly in the physical domain. Physical well-being was mostly affected by the level of functional impairment.

A randomized, placebo-controlled trial of infliximab plus methotrexate for the treatment of polyarticular-course juvenile rheumatoid arthritis.

OBJECTIVE: To evaluate the safety and efficacy of infliximab in the treatment of juvenile rheumatoid arthritis (JRA). METHODS: This was an international, multicenter, randomized, placebo-controlled, double-blind study. One hundred twenty-two children with persistent polyarticular JRA despite prior methotrexate (MTX) therapy were randomized to receive infliximab or placebo for 14 weeks, after which all children received infliximab through week 44. Patients received MTX plus infliximab 3 mg/kg through week 44, or MTX plus placebo for 14 weeks followed by MTX plus infliximab 6 mg/kg through week 44. RESULTS: Although a higher proportion of patients in the 3 mg/kg infliximab group than in the placebo group had achieved responses according to the American College of Rheumatology (ACR) Pediatric 30 (Pedi 30) criteria for improvement at week 14 (63.8% and 49.2%, respectively), the between-group difference in this primary efficacy end point was not statistically significant (P = 0.12). By week 16, after the crossover from placebo to infliximab 6 mg/kg when all patients were receiving infliximab, an ACR Pedi 30 response was achieved in 73.2% of all patients. By week 52, ACR Pedi 50 and ACR Pedi 70 responses had been reached in 69.6% and 51.8%, respectively, of patients. Infliximab was generally well tolerated, but the safety profile of infliximab 3 mg/kg appeared less favorable than that of infliximab 6 mg/kg, with more frequent occurrences of serious adverse events, infusion reactions, antibodies to infliximab, and newly induced antinuclear antibodies and antibodies to double-stranded DNA observed with the 3 mg/kg dose. CONCLUSION: While infliximab at 3 mg/kg and 6 mg/kg showed durable efficacy at 1 year, achievement of the primary efficacy end point at 3 months did not differ significantly between infliximab-treated and placebo-treated patients. Safety data indicated that the 6-mg/kg dose may provide a more favorable risk/benefit profile. These results warrant further investigation in children with JRA.

Calidad de vida en niños con artritis idiopática juvenil / Quality of life in children with juvenile idiopathic arthritis

El pronóstico de los pacientes con Artritis Idiopática Juvenil (AIJ) ha mejorado considerablemente en las últimas décadas probablemente debido al diagnóstico temprano, al reconocimiento de las formas leves, los avances en el conocimiento de las posibilidades terapéuticas de la enfermedad y sus complicaciones. A pesar de esto la AIJ está aún asociada con importante morbilidad y discapacidad funcional a largo plazo. La evaluación clínica de los niños con AIJ requiere no solamente las medidas de la actividad de la enfermedad sino también el entendimiento de los efectos de la enfermedad y la terapia prescripta sobre el bienestar físico y psicosocial. OBJETIVOS: 1. Investigar la Calidad de Vida Relacionada con la Salud (CVRS) y sus determinantes en pacientes con AIJ. 2. Evaluar la CVRS en los diferentes subtipos de AIJ. 3. Compara la CVRS entre los pacientes con AIJ y niños sanos de edades similares y provenientes de la misma área geográfica

Calidad de vida en niños con artritis idiopática juvenil / Quality of life in children with juvenile idiopathic arthritis

El pronóstico de los pacientes con Artritis Idiopática Juvenil (AIJ) ha mejorado considerablemente en las últimas décadas probablemente debido al diagnóstico temprano, al reconocimiento de las formas leves, los avances en el conocimiento de las posibilidades terapéuticas de la enfermedad y sus complicaciones. A pesar de esto la AIJ está aún asociada con importante morbilidad y discapacidad funcional a largo plazo. La evaluación clínica de los niños con AIJ requiere no solamente las medidas de la actividad de la enfermedad sino también el entendimiento de los efectos de la enfermedad y la terapia prescripta sobre el bienestar físico y psicosocial. OBJETIVOS: 1. Investigar la Calidad de Vida Relacionada con la Salud (CVRS) y sus determinantes en pacientes con AIJ. 2. Evaluar la CVRS en los diferentes subtipos de AIJ. 3. Compara la CVRS entre los pacientes con AIJ y niños sanos de edades similares y provenientes de la misma área geográfica

Granulomatosis de Wegener en la infancia / Wegener's granulomatosis in childhood

La Granulomatosis de Wegener (GW) es una enfermedad de etiología desconocida, poco frecuente en adultos, excepcional en la infancia, que se caracteriza por un cuadro clínico-patológico de vasculitis necrozante granulomatosa de vasos pequeños. Se presentaba el caso de una niña de 14 años de edad, quien evidencia la tríada clásica de sinutsitis, afectación pulmonar con hemosiderosis e infiltrados alveolares bilaterales difusos y glomerulonefritis. Además presentaba proptosis, queratoconjuntivitis, dacrioadenitis, retinitis miliar, otitis, cefalea, neuritis, artralgias, mialgias, tos, hemoptisis, fiebre y anemia. El cuadro, compatible con Granulomatosis de Wegener, fue tratado con Trimetoprima-Sufametoxazol (TMP-SMZ), prednisona y ciclofosfamida, con buena evolución hasta el momento de esta presentación

Granulomatosis de Wegener en la infancia / Wegeners granulomatosis in childhood

La Granulomatosis de Wegener (GW) es una enfermedad de etiología desconocida, poco frecuente en adultos, excepcional en la infancia, que se caracteriza por un cuadro clínico-patológico de vasculitis necrozante granulomatosa de vasos pequeños. Se presentaba el caso de una niña de 14 años de edad, quien evidencia la tríada clásica de sinutsitis, afectación pulmonar con hemosiderosis e infiltrados alveolares bilaterales difusos y glomerulonefritis. Además presentaba proptosis, queratoconjuntivitis, dacrioadenitis, retinitis miliar, otitis, cefalea, neuritis, artralgias, mialgias, tos, hemoptisis, fiebre y anemia. El cuadro, compatible con Granulomatosis de Wegener, fue tratado con Trimetoprima-Sufametoxazol (TMP-SMZ), prednisona y ciclofosfamida, con buena evolución hasta el momento de esta presentación (AU)