Deficiencia de IgA y comorbilidades autoinmunes en la artritis idiopática juvenil / IgA deficiency and autoimmune comorbidities in juvenile idiopathic arthritis

Objetivos: 1) Describir la prevalencia de deficiencia de IgA (DIgA), uveítis, enfermedad celiaca (EC) y alteraciones tiroideas en una cohorte multicéntrica de pacientes diagnosticados de artritis idiopática juvenil (AIJ), y 2) evaluar si los pacientes con AIJ y DIgA presentan otras enfermedades autoinmunes con más frecuencia que los pacientes con niveles normales de IgA. Métodos: Estudio retrospectivo de una cohorte de pacientes con AIJ en seguimiento en unidades de Reumatología pediátrica en 2 hospitales de Madrid (España). Resultados: Se incluyó a 193 pacientes, de los cuales 123 eran mujeres (64%). La edad media al inicio fue 5,6 años (RIC 2,5-9,7) y la mediana de seguimiento 5,1 años (RIC 2,2-8,1). Las 3 categorías ILAR más frecuentes fueron oligoarticular (53%), poliarticular con factor reumatoide negativo (20%) y artritis relacionada con entesitis (10%). Los niveles séricos de IgA estaban disponibles en 172/193 (89%); 25/172 (15%) tenían DIgA, selectiva (< 7mg/dl, n=8) o parcial (7-69mg/dl, n=17). Todos los pacientes tuvieron revisiones oftalmológicas periódicas. Tuvieron uveítis anterior 18 pacientes (9%), 15/18 crónica y 3/18 aguda. Los niveles séricos de antitransglutaminasa IgA (o IgG en pacientes con DIgA) fueron obtenidos en 135/193 (70%); 4 pacientes (3%) fueron diagnosticados de EC por biopsia (n=3) o por criterios clínicos, serológicos o genéticos (n=1); 2 de ellos tenían DIgA (p=0,12; OR=6,4; IC del 95%, 0,9-47,6). Solo 1/153 (0,7%) tuvo hipertirotropinemia con anticuerpos antitiroideos positivos y requirió tratamiento. Conclusión: Los pacientes con AIJ presentan comorbilidades autoinmunes con frecuencia. La DIgA no parece aumentar su prevalencia, con la posible excepción de la EC. (AU)

Objectives: (1) To describe the prevalence of IgA deficiency (IgAD), uveitis, coeliac disease (CD) and thyroid disorders in a multicentre cohort of patients with juvenile idiopathic arthritis (JIA), and (2) to assess whether patients with JIA and IgAD have additional autoimmune disorders more frequently than patients with JIA and normal serum levels of IgA. Methods: Retrospective chart review of a cohort of patients with JIA managed in the paediatric rheumatology units of 2hospitals in Madrid, Spain. Results: This study included 193 patients, 123 (64%) female. The median age at disease onset was 5.6 years (IQR 2.5–9.7) and the median duration of followup was 5.1 years (IQR 2.2–8.1). The 3most common categories of JIA based on the ILAR classification were oligoarticular (53%), poliartritis RF-negative (20%) and enthesitis-related arthritis (10%). Serum IgA levels were available in 172/193 (89%); 25/172 (15%) had selective (<7mg/dl, n=8) or partial (7-69mg/dl, n=17) IgAD. All patients underwent periodic ophthalmic examinations. Eighteen children (9%) had anterior uveitis, which was chronic in 15 and acute in 3. Serum levels of anti-transglutaminase IgA, or IgG in IgAD were obtained in 135/193 (70%). Four children (3%) were diagnosed with CD either by intestinal biopsy (n=3) or by the combination of characteristic clinical, serological and genetic features (n=1); 2of them had IgAD (OR=6.4; 95% CI, 0.9–47.6; p=.12). Only 1 of these 153 patients (0.7%) had hyperthyrotropinaemia with positive anti-thyroid antibodies and required replacement therapy. Conclusion: Patients with JIA frequently present autoimmune comorbidities. IgAD does not seem to increase their prevalence, with the possible exception of CD. (AU)

IgA deficiency and autoimmune comorbidities in Juvenile Idiopathic Arthritis.

OBJECTIVES: (1) To describe the prevalence of IgA deficiency (IgAD), uveitis, coeliac disease (CD) and thyroid disorders in a multicentric cohort of patients diagnosed with JIA and, (2) to evaluate whether patients with JIA and IgAD present other autoimmune diseases more frequently than patients with normal serum levels of IgA. METHODS: Retrospective chart review of a cohort of patients diagnosed with JIA followed at the paediatric rheumatology units of two hospitals in Madrid, Spain. RESULTS: A total of 193 patients were included. Of them, 123 were females (64%). Median age at disease onset was 5.6 years (IQR 2.5-9.7) and the median time of follow-up was 5.1 years (IQR 2.2-8.1). The three most common ILAR categories were oligoarticular (53%), polyarticular RF negative (20%) and enthesitis related arthritis (10%). Serum IgA levels were available in 172/193 (89%); 25/172 (15%) had selective (<7mg/dl, n=8) or partial (7-69mg/dl, n=17) IgAD. All the patients had periodic eye exams. Eighteen children (9%) had anterior uveitis, 15/18 chronic and 3/18 acute. Serum anti transglutaminase IgA, or IgG in IgAD were obtained in 135/193 (70%). Four children (3%) were diagnosed with CD either by intestinal biopsy (n=3) or by the combination of characteristic clinical, serological and genetic features (n=1); two of them had IgAD (p=0.12; OR=6.4; 95% CI 0.9-47.6). Only 1/153 (0.7%) patient had hyperthyrotropinemia with positive anti-thyroid antibodies and required replacement therapy. CONCLUSION: Patients with JIA frequently present autoimmune comorbidities. IgAD does not seem to increase their prevalence, with the possible exception of CD.

T-replete HLA-matched grafts vs T-depleted HLA-mismatched grafts in inborn errors of immunity.

Hematopoietic cell transplantation (HCT) has become standard-of-care for an increasing number of inborn errors of immunity (IEI). This report is the first to compare transplant outcomes according to T-cell-replete (ie, T-replete) HLA-matched grafts using alemtuzumab (n = 117) and T-cell-depleted (ie, T-depleted) HLA-mismatched grafts using T-cell receptor-αß (TCRαß)/CD19 depletion (n = 47) in children with IEI who underwent first HCT between 2014 and 2019. All patients received treosulfan-based conditioning except patients with DNA repair disorders. For T-replete grafts, the stem cell source was marrow in 25 (21%) patients, peripheral blood stem cell (PBSC) in 85 (73%), and cord blood in 7 (6%). TCRαß/CD19 depletion was performed on PBSCs from 45 haploidentical parental donors and 2 mismatched unrelated donors. The 3-year overall survival (OS) and event-free survival for the entire cohort were 85% (77%-90%) and 79% (69%-86%), respectively. Analysis according to age at transplant revealed a comparable 3-year OS between T-replete grafts (88%; 76%-94%) and T-depleted grafts (87%; 64%-96%) in younger patients (aged <5 years at HCT). For older patients (aged >5 years), the OS was significantly lower in T-depleted grafts (55%; 23%-78%) compared with T-replete grafts (87%; 68%-95%) (P = .03). Grade III to IV acute graft-versus-host disease was observed in 8% of T-replete marrow, 7% of T-replete PBSC, 14% of T-replete cord blood, and 2% of T-depleted PBSC (P = .73). Higher incidence of viremia (P < .001) and delayed CD3 reconstitution (P = .003) were observed after T-depleted graft HCT. These data indicate that mismatched donor transplant after TCRαß/CD19 depletion represents an excellent alternative for younger children with IEI in need of an allograft.

HSCT in two brothers with CGD arising from mutations in CYBC1 corrects the defect in neutrophil function.

Homozygous mutations in cytochrome b-245 chaperone 1 (CYBC1) have been recently described as causing recurrent infections and inflammatory disease in an Icelandic cohort and a patient from Saudi Arabia, by destabilising the dimerisation of gp91phox with p22phox, manifesting as phenotypic chronic granulomatous disease (CGD). Haematopoietic stem cell transplantation is the treatment of choice in CGD, though experience of transplantation in this subtype of CGD is limited to a brief description in one patient. We provide clinical and transplant data for two Icelandic brothers with CGD due to homozygous p.Tyr2Ter mutations in CYBC1, demonstrating maintained cure of the immune defect 11 years post-transplant in one brother, and death in the peri-transplant period for the other.

Outcome of Non-hematological Autoimmunity After Hematopoietic Cell Transplantation in Children with Primary Immunodeficiency.

PURPOSE: Knowledge of post-hematopoietic cell transplantation (HCT) non-hematological autoimmune disease (AD) is far from satisfactory. METHOD: This multicenter retrospective study focuses on incidence, risk factors, and outcomes of post-HCT AD in 596 children with primary immunodeficiency (PID) who were transplanted from 2009 to 2018. RESULTS: The indications of HCT were severe combined immunodeficiency (SCID, n = 158, 27%) and non-SCID PID (n = 438, 73%). The median age at HCT was 2.3 years (range, 0.04 to 18.3 years). The 5-year overall survival for the entire cohort was 79% (95% cumulative incidence (CIN), 74-83%). The median follow-up of surviving patients was 4.3 years (0.08 to 14.7 years). The CIN of post-HCT AD was 3% (2-5%) at 1 year post-HCT, 7% (5-11%) at 5 years post-HCT, and 11% (7-17%) at 8 years post-HCT. The median onset of post-HCT AD was 2.2 years (0.12 to 9.6 years). Autoimmune thyroid disorder (n = 19, 62%) was the most common post-HCT AD, followed by neuromuscular disorders (n = 7, 22%) and rheumatological manifestations (n = 5, 16%). All patients but one required treatment for post-HCT AD. After multivariate analysis, age at transplant (p = 0.01) and T cell-depleted graft (p < 0.001) were significant predictors of post-HCT AD. None of the T cell-depleted graft recipients developed post-HCT AD. Patients with a lower CD3+ count at 6 months post-HCT had a significant higher incidence of post-HCT AD compared to disease controls. Graft-versus-host disease, viral infection, and donor chimerism had no association with post-HCT AD. CONCLUSION: Post-HCT AD occurred in 11% at 8 years post-HCT and its occurrence was associated with older age at HCT and unmanipulated graft.

Two Cases of SARS-CoV-2 Infection in Pediatric Oncohematologic Patients in Spain.

Since December 2019, severe acute respiratory syndrome coronavirus 2 infection has spread worldwide. We all are concerned about immunocompromised children, especially hematologic and oncologic pediatric patients. We want to share our experience with 2 pediatric cancer patients with severe acute respiratory syndrome coronavirus 2 infection. Both presented mild disease and good outcome. No respiratory symptoms were identified, but both developed diarrhea, one probably secondary to lopinavir/ritonavir. Pediatric cancer patients may have milder disease than adults, but larger studies are needed to make conclusions.

Neutropenia febril posquimioterapia. Estancia hospitalaria y experiencia en nuestro medio / Post chemoterapy febrile neutropenia. Length of stay and experience in our population

INTRODUCCIÓN: Las infecciones son una causa importante de morbimortalidad en los pacientes con cáncer (mortalidad estimada en 3%). La neutropenia febril conlleva con frecuencia el ingreso hospitalario de los pacientes oncológicos, incrementando el riesgo de infección nosocomial así como los costes sanitarios por ingresos. MÉTODOS: Estudio observacional ambispectivo (01/07/2015 - 31/12/2018) de los episodios de neutropenia febril posquimioterapia en población pediátrica. Se recogieron edad, sexo, percentil de peso (OMS), estancia hospitalaria (días), temperature (oC), aislamiento de germen, foco infeccioso, profilaxis o no antibiótica y antifúngica, cifras de hemoglobina (g/dl), plaquetas (/mm3), neutrófilos (/mm3), linfocitos (/mm3), monocitos (/mm3), proteína C reactiva (PCR) (mg/L) y procalcitonina (PCT) (ng/ml) al ingreso y días con neutropenia < 500/mm3. El análisis estadístico se realizó con el programa SPSSv.23. RESULTADOS: De 69 pacientes, se registraron 101 episodios. La estancia media fue de 7,43 días (mediana 6 días). Se aisló germen en un 44,6% de los episodios, no identificándose foco infeccioso en un 36% de los mismos. Se halló correlación inversa entre hemoglobina, plaquetas y linfocitos al ingreso con la estancia hospitalaria (-0,356 (p 0,001); -0,216 (p 0,042) y -0,216 (p 0,042) respectivamente). La estancia media fue mayor si al ingreso presentaron PCR > 90 mg/L (10,94 vs. 6,66 días p 0,017), si PCT > 1 ng/ml (16,50 vs. 6,77 días p 0,0002), si ≤ 100 neutrófilos (8,27 vs. 5,04 días p 0,039) y si hubo aislamiento microbiológico (9,54 vs. 5,78 días p 0,006). CONCLUSIÓN: La relación entre hemoglobina, plaquetas y linfocitos al ingreso con la estancia media es inversamente proporcional. Además, aquellos pacientes con ≤ 100 neutrófilos al ingreso, PCR > 90 mg/L y PCT > 1 ng/ml presentaron mayor estancia media. Estos factores podrían ser importantes en el manejo de la neutropenia febril en el paciente con cáncer infantil

INTRODUCTION: Infections are significant cause of morbidity and mortality in cancer patients (mortality is estimated at around 3%). Febrile neutropenia often leads to the hospitalisation of cancer patients, increasing the risk of nosocomial infection, as well as health costs due to the hospital admission. METHODS: An ambispective (01 July 2015 - 12 July 2018) observational study was conducted on all episodes of chemotherapy-induced febrile neutropenia in a paediatric population. A record was made of age, gender, weight percentile (WHO), length of hospital stay (days), temperature (oC), microbial isolation, infectious source, antibiotic or antifungal prophylaxis, haemoglobin (g/dl), platelets (/mm3), neutrophils (/mm3), lymphocytes (/mm3), monocytes (/mm3), CRP (mg/L) and procalcitonin (PCT) (ng/ml) on admission, and days with neutropenia < 500/mm3. Statistical analysis was performed using the SPSSv.23 program. RESULTS: The study included 69 patients, and 101 episodes were recorded. The mean stay was 7.43 days (median 6 days). Microbial isolation was found in 44.6% of the episodes, with no infectious source identified in 36% of them. An inverse correlation was found between haemoglobin, platelets, and lymphocytes on admission and the hospital stay (-0.356: P = .001, -0.216: P = .042, and -0.216: P = .042, respectively). The mean stay was greater if there was a CRP > 90 mg/L (10.94 vs. 6.66 days, P=.017), if PCT > 1 ng/ml (16.50 vs. 6.77 days, P = .0002), if ≤ 100 neutrophils (8.27 vs. 5.04 days P=.039) on admission, and if there was microbe isolation (9.54 vs. 5.78 days P = .006). CONCLUSION: The relationship between haemoglobin, platelets, and lymphocytes on admission and the mean stay is inversely proportional. In addition, those patients with ≤ 100 neutrophils, CRP > 90 mg/L, and PCT>1ng/ml on admission had a longer hospital stay

[Post chemoterapy febrile neutropenia. Length of stay and experience in our population]. / Neutropenia febril posquimioterapia. Estancia hospitalaria y experiencia en nuestro medio.

INTRODUCTION: Infections are significant cause of morbidity and mortality in cancer patients (mortality is estimated at around 3%). Febrile neutropenia often leads to the hospitalisation of cancer patients, increasing the risk of nosocomial infection, as well as health costs due to the hospital admission. METHODS: An ambispective (01 July 2015 - 12 July 2018) observational study was conducted on all episodes of chemotherapy-induced febrile neutropenia in a paediatric population. A record was made of age, gender, weight percentile (WHO), length of hospital stay (days), temperature (oC), microbial isolation, infectious source, antibiotic or antifungal prophylaxis, haemoglobin (g/dl), platelets (/mm3), neutrophils (/mm3), lymphocytes (/mm3), monocytes (/mm3), CRP (mg/L) and procalcitonin (PCT) (ng/ml) on admission, and days with neutropenia<500/mm3. Statistical analysis was performed using the SPSSv.23 program. RESULTS: The study included 69 patients, and 101 episodes were recorded. The mean stay was 7.43 days (median 6 days). Microbial isolation was found in 44.6% of the episodes, with no infectious source identified in 36% of them. An inverse correlation was found between haemoglobin, platelets, and lymphocytes on admission and the hospital stay (-0.356: P=.001, -0.216: P=.042, and -0.216: P=.042, respectively). The mean stay was greater if there was a CRP>90mg/L (10.94 vs. 6.66 days, P=.017), if PCT>1ng/ml (16.50 vs. 6.77 days, P=.0002), if ≤ 100 neutrophils (8.27 vs. 5.04 days P=.039) on admission, and if there was microbe isolation (9.54 vs. 5.78 days P=.006). CONCLUSION: The relationship between haemoglobin, platelets, and lymphocytes on admission and the mean stay is inversely proportional. In addition, those patients with ≤100 neutrophils, CRP>90mg/L, and PCT>1ng/ml on admission had a longer hospital stay.

Community-onset extended-spectrum ß-lactamase producing Escherichia coli in urinary tract infections in children from 2015 to 2016: Prevalence, risk factors, and resistances.

Over the past 10 years, the resistances among microbes are increasing gradually in Europe and greater resistances are seen in southern countries. We studied the prevalence of community-onset ESBL-producing Escherichia coli urinary tract infections in children.As secondary objectives, we analyzed associated risk factors and the resistance patterns in ESBL-producing E coli isolates.Retrospective observational study in a tertiary care hospital about children ≤14 years old with community-onset E coli urinary tract infection. The variables studied were age, sex, ESBL-producing, antibiotic therapy 7 to 30 days before the infection, hospitalization 7 to 30 days before the infection, nefrourologic pathology, and vesicoureteral reflux.Between January 1st, 2015 and December 31st, 2016, 229 isolates of E coli were obtained, of whom 21 (9.2%) where ESBL-producing E coli. Median age in non-ESBL-producing was 18 months versus 7 months in ESBL-producing group. Fourteen (66%) of the ESBL-producing group were men (P = .001), 5 (23.8%) were hospitalized 30 days before the infection (P = .001), 12 (57.1%) had nefrourological pathology (P = .003), 6 (28.5%) had vesicoureteral reflux (P = .032). Previous antibiotic therapy was not statistically significant. Multiple regression analyses between sex and 30 days previous hospitalization were r = 3.51 (P = .0001). Multidrug resistant isolates among ESBL-producing E coli was 12 (57%).The retrospective study allowed assessing the problem of ESBL-producing isolates in the outpatient settings. Some risk factors from past studies were confirmed and a combined risk is suggested. The resistant spectrum should be taken into account when choosing antibiotic regimens.