Diagnosis and Management of Opsoclonus-Myoclonus-Ataxia Syndrome in Children: An International Perspective

BACKGROUND AND OBJECTIVES

Opsoclonus-myoclonus-ataxia syndrome (OMAS) is a rare disorder of the nervous system that classically presents with a combination of characteristic eye movement disorder and myoclonus, in addition to ataxia, irritability, and sleep disturbance. There is good evidence that OMAS is an immune-mediated condition that may be paraneoplastic in the context of neuroblastoma. This syndrome may be associated with long-term cognitive impairment, yet it remains unclear how this is influenced by disease course and treatment. Treatment is largely predicated on immune suppression, but there is limited evidence to indicate an optimal regimen.

METHODS

Following an international multiprofessional workshop in 2004, a body of clinicians and scientists comprising the International OMS Study group continued to meet biennially in a joint professionals and family workshop focusing on pediatric OMAS. Seventeen years after publication of the first report, a writing group was convened to provide a clinical update on the definitions and clinical presentation of OMAS, biomarkers and the role of investigations in a child presenting with OMAS, treatment and management strategies including identification and support of long-term sequelae.

RESULTS

The clinical criteria for diagnosis were reviewed, with a proposed approach to laboratory and radiologic investigation of a child presenting with possible OMAS. The evidence for an upfront vs escalating treatment regimen was reviewed, and a treatment algorithm proposed to recognize both these approaches. Importantly, recommendations on monitoring of immunotherapy response and longer-term follow-up based on an expert consensus are provided.

DISCUSSION

OMAS is a rare neurologic condition that can be associated with poor cognitive outcomes. This report proposes an approach to investigation and treatment of children presenting with OMAS, based on expert international opinion recognizing the limited data available.

Changes in ventilation distribution in children with neuromuscular disease using the insufflator/exsufflator technique: an observational study

Patients with neuromuscular disease often suffer from weak and ineffective cough resulting in mucus retention and increased risk for chest infections. Different airway clearance techniques have been proposed, one of them being the insufflator/exsufflator technique. So far, the immediate physiological effects of the insufflator/exsufflator technique on ventilation distribution and lung volumes are not known. We aimed to describe the immediate effects of the insufflator/exsufflator technique on different lung volumes, forced flows and ventilation distribution. Eight subjects (age 5.8–15.2 years) performed lung function tests including spirometry, multiple breath washout and electrical impedance tomography before and after a regular a chest physiotherapy session with an insufflator/exsufflator device. Forced lung volumes and flows as well as parameters of ventilation distribution derived from multiple breath washout and electrical impedance tomography were compared to assess the short-term effect of the therapy. In this small group of stable paediatric subjects with neuromuscular disease we could not demonstrate any short-term effects of insufflation/exsufflation manoeuvres on lung volumes, expiratory flows and ventilation distribution. With the currently used protocol of the insufflation/exsufflation manoeuvre, we cannot demonstrate any immediate changes in lung function.

Heterozygous frameshift variants in HNRNPA2B1 cause early-onset oculopharyngeal muscular dystrophy

Missense variants in RNA-binding proteins (RBPs) underlie a spectrum of disease phenotypes, including amyotrophic lateral sclerosis, frontotemporal dementia, and inclusion body myopathy. Here, we present ten independent families with a severe, progressive muscular dystrophy, reminiscent of oculopharyngeal muscular dystrophy (OPMD) but of much earlier onset, caused by heterozygous frameshift variants in the RBP hnRNPA2/B1. All disease-causing frameshift mutations abolish the native stop codon and extend the reading frame, creating novel transcripts that escape nonsense-mediated decay and are translated to produce hnRNPA2/B1 protein with the same neomorphic C-terminal sequence. In contrast to previously reported disease-causing missense variants in HNRNPA2B1, these frameshift variants do not increase the propensity of hnRNPA2 protein to fibrillize. Rather, the frameshift variants have reduced affinity for the nuclear import receptor karyopherin β2, resulting in cytoplasmic accumulation of hnRNPA2 protein in cells and in animal models that recapitulate the human pathology. Thus, we expand the phenotypes associated with HNRNPA2B1 to include an early-onset form of OPMD caused by frameshift variants that alter its nucleocytoplasmic transport dynamics.

Missense variants in RNA-binding proteins underlie many diseases. Here the authors report an oculopharyngeal muscular dystrophy caused by heterozygous frameshift mutations in HNRNPA2B1 that alter its nucleocytoplasmic transport dynamics and result in cytoplasmic accumulation of hnRNPA2 protein.

[Update on collaborative autopsy-based research in German pathology, neuropathology, and forensic medicine]

BACKGROUND

Autopsies are a valuable tool for understanding disease, including COVID-19.

MATERIALS AND METHODS

The German Registry of COVID-19 Autopsies (DeRegCOVID), established in April 2020, serves as the electronic backbone of the National Autopsy Network (NATON), launched in early 2022 following DEFEAT PANDEMIcs.

RESULTS

The NATON consortium's interconnected, collaborative autopsy research is enabled by an unprecedented collaboration of 138 individuals at more than 35 German university and non-university autopsy centers through which pathology, neuropathology, and forensic medicine autopsy data including data on biomaterials are collected in DeRegCOVID and tissue-based research and methods development are conducted. More than 145 publications have now emerged from participating autopsy centers, highlighting various basic science and clinical aspects of COVID-19, such as thromboembolic events, organ tropism, SARS-CoV‑2 detection methods, and infectivity of SARS-CoV-2 at autopsy.

CONCLUSIONS

Participating centers have demonstrated the high value of autopsy and autopsy-derived data and biomaterials to modern medicine. The planned long-term continuation and further development of the registry and network, as well as the open and participatory design, will allow the involvement of all interested partners.

Enhanced superconductivity and ferroelectric quantum criticality in plastically deformed strontium titanate

The properties of quantum materials are commonly tuned using experimental variables such as pressure, magnetic field and doping. Here we explore a different approach using irreversible, plastic deformation of single crystals. We show that compressive plastic deformation induces low-dimensional superconductivity well above the superconducting transition temperature (T_c) of undeformed SrTiO₃, with evidence of possible superconducting correlations at temperatures two orders of magnitude above the bulk T_c. The enhanced superconductivity is correlated with the appearance of self-organized dislocation structures, as revealed by diffuse neutron and X-ray scattering. We also observe deformation-induced signatures of quantum-critical ferroelectric fluctuations and inhomogeneous ferroelectric order using Raman scattering. Our results suggest that strain surrounding the self-organized dislocation structures induces local ferroelectricity and quantum-critical dynamics that strongly influence T_c, consistent with a theory of superconductivity enhanced by soft polar fluctuations. Our results demonstrate the potential of plastic deformation and dislocation engineering for the manipulation of electronic properties of quantum materials.

Subcutaneous injection of an immunologically tolerated protein up to 5 days before skin injuries improves wound healing

Oral tolerance blocks the development of specific immune responses to proteins ingested by the oral route. One of the first registries of oral tolerance showed that guinea pigs fed corn became refractory to hypersensitivity to corn proteins. Mice fed with chow containing corn are tolerant to zein, and parenteral injection of zein plus adjuvant blocks immunization to unrelated proteins injected concomitantly and reduces unspecific inflammation. Extensive and prolonged inflammatory infiltrate in the wound bed is one of the causes of pathological wound healing. Previous research shows that intraperitoneal injection of zein concomitant with skin injuries reduces the inflammatory infiltrate in the wound bed and improves wound healing. Herein, we tested if one subcutaneous injection of zein before skin injury improves wound healing. We also investigated how long the effects triggered by zein could improve skin wound healing. Mice fed zein received two excisional wounds on the interscapular skin under anesthesia. Zein plus Al(OH)₃ was injected at the tail base at 10 min, or 3, 5, or 7 days before skin injuries. Wound healing was analyzed at days 7 and 40 after injury. Our results showed that a zein injection up to 5 days before skin injury reduced the inflammatory infiltrate, increased the number of T-cells in the wound bed, and improved the pattern of collagen deposition in the neodermis. These findings could promote the development of new strategies for the treatment and prevention of pathological healing using proteins normally found in the common diet.

Disposable, Lightweight Shield Decreases Operator Eye and Brain Radiation Dose When Attached to Safety Eyewear During Fluoroscopically-Guided-Interventions

OBJECTIVE

Long-term radiation exposure from fluoroscopically-guided-interventions (FGIs) can cause cataracts and brain tumors in the operator. We have previously demonstrated that leaded eyewear does not decrease operator eye dose unless lead shielding is added to the lateral and inferior portions. Therefore, we developed a disposable, lightweight, lead-equivalent shield that can be attached to the operator's eyewear, conforming around the face and adhering to the surgical mask. This study evaluates the efficacy of our new prototype in lowering operator brain and eye dose when added to both leaded and non-leaded eyewear.

METHODS

The attenuating efficacy of leaded eyewear alone, leaded eyewear + prototype and non-leaded eyewear + prototype were compared to no eyewear protection in both a simulated setting and clinical practice. In the simulation, optically stimulated, luminescent nanoDot detectors (Landauer, Glenwood, II) were placed inside the ocular, temporal lobe, and midbrain spaces of a head phantom (ATOM model-701: CIRS, Norfolk, VA). The phantom was positioned to represent a primary operator performing right femoral access. Fluorography was performed on a plastic scatter phantom at 80kVp for an exposure of 3 Gy RAK. In the clinical setting, nanoDots were placed below the operator's eye both inside and outside the prototype during FGIs. Median and interquartile ranges were calculated for the dose at each nanoDot location for both the phantom and clinical study, with average dose reduction also reported.

RESULTS

Wearing standard leaded eyewear alone did not decrease operator ocular or brain dose. In the phantom experiment, the leaded glasses + prototype reduced dose to the lens, temporal lobe and midbrain by 83% (p<0.001), 78% (p<0.001), and 75% (p<0.001), respectively. The non-leaded glasses + prototype also reduced dose to the lens, temporal lobe and midbrain by 85% (p<0.001), 81% (p<0.001), and 71% (p<0.001). In the clinical setting, 15 FGIs were included, with median RAK of 98.4 mGy. Our prototype led to an average operator eye dose reduction of 89% (p<0.001).

CONCLUSIONS

Attaching our prototype to both leaded and non-leaded glasses significantly decreased eye and brain radiation dose to the operator. This face shield attachment provides meaningful radiation protection and should be considered as either a replacement or adjunct to routine eyewear.

Use of a 2 Dimensional Vessel Navigator Roadmap Decreases Patient Radiation Dose Compared to Standard 3D Mapping for Fenestrated Endovascular Aneurysm Repair

OBJECTIVE

For fenestrated endovascular aneurysm repair (FEVAR), the implementation of the VesselNavigator (Philips Healthcare, Best, The Netherlands) to provide a 3-dimensional vessel roadmap has been shown to reduce patient radiation exposure. Unfortunately, FEVAR radiation doses remain substantial despite utilization of this technology. Traditionally, registration of the live fluoroscopy with the pre-operative CTA is performed via the acquisition of a low-dose cone-beam CT scan. However, this registration can also be accomplished with the acquisition of 2D X-rays using the c-arm in 2 different projection angles. We hypothesized that the 2D image acquisition for vessel roadmap development would result in a significant reduction in patient radiation dose in comparison to the 3D CT registration without compromising image quality or increasing procedural length.

METHODS

This single-center, retrospective study included FEVARs performed from January 2015 to May 2019. For patient data, the cumulative reference air kerma (RAK) was presented as geometric mean and standard deviation. A general linear model with log-normal distribution was used to test the difference in patient RAK between 2D X-ray and 3D CT VesselNavigator registration after adjusting for BMI and the number of vessel fenestrations (1 to 2 vs. 3 to 4). Fluoroscopy time was recorded and used as a surrogate for case complexity. All analyses were done in SAS 9.4 (SAS Institute, Inc., Cary, North Carolina).

RESULTS

One hundred and sixty four FEVARs were performed on a Philips Allura Xper FD 20 fluoroscopy system equipped with clarity technology. The VesselNavigator registration was completed using 3D CT mapping in 99 cases and 2D X-rays in 65 procedures. On average, utilization of 2D mapping versus 3D mapping for the VesselNavigator resulted in a 20.4% reduction in patient RAK after controlling for BMI and number of vessel fenestrations, P = 0.0135. There was no significant difference in fluoroscopy time between the 2 study groups (P= 0.81) suggesting that image quality was not compromised by the use of 2D mapping leading to the need for additional fluoroscopy.

CONCLUSION

Acquisition of 2D films rather than a 3D CT scan for VesselNavigator registration allows for a significant reduction in patient radiation dose during FEVAR without increasing the case complexity or compromising image quality.

[Newborn screening program for spinal muscular atrophy]

BACKGROUND

The introduction of a comprehensive newborn screening program for spinal muscular atrophy (SMA), specifically for 5q-SMA, is planned for the end of 2021 in Germany. Several targeted treatment options have become available for all patients with SMA.

MATERIAL AND METHODS

Newborn screening for 5q-SMA is based on the detection of a homozygous deletion of exon 7 in the SMN1 gene by molecular genetic analysis from the dried blood card. In all cases a second blood sample must be drawn as a part of confirmation diagnostics including the determination of the SMN2 copy numbers.

RESULTS

Insights from pilot projects performed in parts of Germany are presented. Advantages and disadvantages of the screening project are discussed.

CONCLUSION

Consultation and treatment should be carried out in a department of neuropediatrics with experience in the treatment of children with 5q-SMA, which is able to provide all current treatment options for the child, so that, when necessary, the treatment can be started within the first month of life.

Health-related quality of life in patients with recurrent pericarditis: results from RHAPSODY, a phase 3 study of rilonacept

Background

Recurrent pericarditis (RP) patients report that painful, debilitating flares negatively impact their health-related quality of life (HRQoL). RHAPSODY, the Phase 3 trial of rilonacept (IL-1α/IL-1β cytokine trap), included a daily pain diary and patient-reported outcome SF-36v2 to measure HRQoL throughout the trial.

Purpose

The purpose of this research is to evaluate the effect of rilonacept on HRQoL in relation to changes in pain for RP patients who have a recurrence.

Methods

RHAPSODY enrolled 86 patients with acute symptomatic RP to receive weekly rilonacept for a 12-week run-in (RI) period and randomized 61 patients (1:1) to receive placebo (n=31) or continue rilonacept (n=30) for the event-driven randomized-withdrawal (RW) period. Patients on placebo who experienced a qualifying recurrence during RW (return of pericarditis pain and increase in C-reactive protein) were rescued with bailout rilonacept. Patients reported daily pericarditis pain electronically, using a 0–10 numeric rating scale (NRS), and completed the SF-36v2 at study visits prior to clinician interaction. Scores from RI Baseline (BL), RI Week 12 (RW BL), Recurrence visit, and RW up to Week 24 (or end of study; EOS) were evaluated for patients who experienced recurrence in RW. Analyses exclude one patient randomized to placebo who had a recurrence after Week 24 of the RW period.

Results

Analyses focused on the 22 of 30 patients (73%) in the placebo group who experienced a recurrence before Week 24 of RW (median time from RW BL to recurrence: 8.6 weeks). During RI, daily pain scores decreased while on rilonacept (Cohen's effect size [ES] d=−2.0), and SF-36v2 scores improved, with scores at RI BL (Fig. 1 red line) below the general population average of 50 and near or above average at RI Week 12 (Fig. 1 blue line); ES were all large (d&gt;0.8), ranging from 0.917 (Mental Component Summary) to 2.021 (Bodily Pain). At recurrence, pain scores increased (d=6.5; Fig. 2) and SF-36v2 scores were below the population average (Fig. 1 orange line), with largest reductions between RI Week 12 (RW BL) and recurrence for Bodily Pain (−13.4) and Physical Component Summary (−10.6). Following rilonacept bailout, average pain decreased (d=−2.1; Fig. 2), and by RW Week 24/EOS, SF-36v2 scores returned to similar levels as at the end of the RI period (Fig. 1 green line).

Conclusion

Impaired RI BL SF-36v2 scores indicate negative impact of RP on HRQOL in RP patients. While receiving rilonacept, HRQoL scores improved to near or above population averages, in conjunction with patient-reported pain. After discontinuing rilonacept during RW, HRQoL scores worsened at recurrence and improved upon receipt of bail-out rilonacept, similar to pain. These results provide support for the broader benefit of rilonacept treatment beyond pain, when administered on top of conventional therapies and as mono-therapy, providing evidence of its potential to improve HRQoL in this patient population.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Kiniksa Pharmaceuticals, Ltd.

Left atrial strain evaluation and prognostic value in constrictive pericarditis patients undergoing pericardiectomy

Background

Left Atrial (LA) phasic volumes analyses is flawed with geometrical assumption requiring high endocardial border definition. LA strain analysis is an emergent technique that overcome some of these technical limitations. Prior studies of LA mechanics in pericardiectomy patients found improvement in LA strain at follow-up and manifested as symptomatic improvement, however their relationships with survival have not been investigated.

Purpose

We assessed LA strain before and after pericardiectomy and its association with all- cause mortality.

Methods

Consecutive patients with constrictive pericarditis who underwent pericardiectomy from 2000–2017 were retrospectively analyzed, analyzing pre-operative and post-operative (at 12 months) echocardiography. Exclusion criteria included atrial fibrillation, previous left sided valve surgery, concomitant valvular surgery at the index pericardiectomy, more than mild left sided valvulopathy and poor echocardiographic windows. Strain analyses was performed with Vector velocity imaging independent software. Univariate and multivariable analyses were utilized to identify factors associated with reduced survival.

Results

Amongst 190 patients included in the analyses, mean age was 58.5±12.7 years and 37 (19.5%) were female. The etiology of constriction was deemed idiopathic in 61.6% of the cases, median time interval surgery-postoperative echo was 67 days (IQR 6, 312 days). During median follow up of 3.3 years (IQR 0.73, 5.9 years) there were 37 deaths. After surgery, there was a significant decrease in LA reservoir, conduit and regional wall strains. (Table 1). Multivariable analysis demonstrated that postoperative 4C AL strain reservoir was independently associated with all-cause mortality (Table 2).

Conclusions

In pericardiectomy patients, postoperative 4C LA strain reservoir is independently associated with all-cause mortality. Perhaps, compensatory changes of septal and antero-posterior walls during constriction explain why after surgery these walls become less dynamic, negatively impacting the overall function. Overall, LA quantification and strains may become a useful clinical tool for risk stratification in pericardiectomy patients

Funding Acknowledgement

Type of funding sources: None. Table 1. Left atrial variables.Table 2. All-cause mortality predictors

RESONANCE Registry: rationale and design of the retrospective and prospective longitudinal, observational registry in pediatric and adult patients with recurrent pericarditis

Background

Annually in the United States (US), an estimated 80–90,000 patients are diagnosed with acute pericarditis and 15–30% experience recurrent pericarditis (RP), resulting in increased morbidity and reduced health-related quality of life (HRQoL). Treatment options include non-steroidal anti-inflammatory drugs (NSAIDs) and colchicine. Corticosteroids (CS) are often added to the treatment plan in RP despite CS-associated adverse events and inherent potentiation of recurrence with long-term treatment. A recent Phase 3 clinical trial RHAPSODY (NCT03737110) demonstrated efficacy and safety of rilonacept, an interleukin-1 α and β cytokine trap, in patients with RP. RHAPSODY data helped support FDA approval of the first therapy for RP. With the emergence of this targeted therapy, there is increased interest to learn more about this disease with the goal to better inform treatment and management decisions and improve long-term outcomes.

Purpose

RESONANCE Registry aims to evaluate the natural history of RP by collecting retrospective and prospective, longitudinal physician- and patient-reported outcomes data in real-world clinical practice across the US.

Methods

RP patients with active disease (recurrence within 3 years) will have both retrospective and prospective data collected (Figure 1) for as long as their RP is managed up to 5 years. For patients with inactive disease (no recurrence within 3 years), data collection will be retrospective (Figure 2). Up to 500 patients in the US are planned for enrollment at pediatric and adult medical centers, with the potential for expansion to European sites. Additionally, patients will be recruited through a novel, internet-based technology platform and screened for eligibility at a “decentralized” trial site. The registry will include variables obtained from health records, including baseline characteristics and medical history, as well as patient reported outcome (PRO) measures collected every 3 months. The RESONANCE protocol is designed to include a broad population of pediatric and adult patients, regardless of etiology or treatment course, including patients treated with rilonacept. Data will be analyzed to understand disease heterogeneity, variability in treatment and management, and impact on HRQoL. The protocol and Case Report Forms (CRFs) were developed in collaboration with physicians, patients, and patient advocates.

Conclusions

Registries utilize real-world data to fill knowledge gaps in the management of less common diseases such as RP. The RESONANCE Registry is the first RP registry designed to collect data across a broad range of patients regardless of treatment. The registry will also serve as a connection point for physicians to further educate and empower patients with information about their disease. In addition, PRO data may enable greater insights into the understanding of the burden of RP from the patient's perspective.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Kiniksa Pharmaceuticals

Anti-interleukin 1 agents for the treatment of recurrent pericarditis

Background

Corticosteroid-dependent and colchicine-resistant recurrent pericarditis (RP) is a challenging management problem, in which conventional anti-inflammatory therapy (nonsteroidal anti-inflammatory drugs, colchicine, corticosteroids) is unable to control the disease. Recent data suggest a potential role for anti-interleukin-1 (IL-1) agents for this condition.

Purpose

This study was designed to assess the safety and efficacy of anti-IL-1 agents in this setting.

Methods

We performed a systematic review and meta-analysis of randomised controlled trials and observational studies assessing pericarditis recurrences and drug-related adverse events in patients receiving anti-IL-1 drugs for pericarditis.

Results

The meta-analysis assessed 7 studies including 397 pooled patients with RP. The median age was 42 years, 60% were women and the aetiology was idiopathic in 87%. After a median follow-up of 14 months (IQR,12–39), patients receiving anti-IL-1 agents (anakinra or rilonacept) had a significantly reduction in pericarditis recurrences (incidence rate ratio 0.06, 95% CI 0.03 to 0.14, see figure), compared with placebo and/or standard medical therapy. Anti-IL-1 agents were associated with increased risk of adverse events compared with placebo (risk ratio (RR) 5.38, 95% CI 2.08 to 13.92): injection-site reactions occurred in 15/41 (36.6%) vs. none (RR 14.98, 95% CI 2.09 to 107.09), infections occurred in 13/51 (25.5%) vs. 3/41 (7.3%; RR 3.65, 95% CI 1.23 to 10.85). Anti-IL-1 agents were not associated with increased risk of severe adverse events.

Conclusions

In patients with RP, anti-IL-1 agents (anakinra and rilonacept) are efficacious for prevention of recurrences, without severe adverse events.

Funding Acknowledgement

Type of funding sources: None.

POS1202 EXPERIENCE WITH COVID-19 IN GERMAN PAEDIATRIC RHEUMATOLOGY CENTRES

Background:

COVID-19 is a major challenge worldwide. Although the risk for a severe disease course is low among children with COVID-19, symptoms may be exacerbated by underlying disease and/or immunosuppressive medication. We analysed clinical data from COVID-19 cases in among pediatric patients with juvenile idiopathic arthritis (JIA) in Germany reported to the BIKER registry.

Objectives:

This is an analysis of clinical data for 56 COVID-19 cases reported to the German BIKER registry from 29 German pediatric rheumatology centers and clinics from February 2020 to January 2021.

Methods:

The major task of the German BIKER (Biologics in Paediatric Rheumatology) Registry is surveillance of biologics used in pediatric rheumatology patients. Following the start of the COVID-19 pandemic in Germany, a survey was established to proactively interview all participating centers regarding the occurrence, presentation and outcome of SARS-CoV-2-infected children with rheumatic diseases. Initially, the interviews were conducted in weekly intervals, later bi-weekly.

A standardized Adverse Event of Special Interest form was developed requesting biographic data, pre-treatment, current medication, data on clinical presentation, course, treatment and outcome of COVID-19 pediatric rheumatology patients.

Results:

In all, 56 patients with JIA and SARS-CoV-2 infection were reported (Table 1). Of these patients, 71% were 12 or more years old.

Table 1.

Patient characteristics. COVID-19 positive patients.

JIA patients, n=56n (%)Age 0-5 years / 6-11years / 12-18years3 (5.4) / 13 (23.2) / 40 (71.4)JIA category•Systemic JIA5 (8.9)•Oligoarthritis JIA9 (16)•Polyarticular JIA32 (57)•Enthesitis-related JIA2 (3.6)•Psoriatic JIA1 (1.8)•Unknown7 (12.5)Uveitis (concomitant)4 (7.1)Treatment•DMARD / MTX23/ 22 (41/39)•Biologics29 (52)•TNF inhibitors20 (36)•Tocilizumab5 (8.9)•Abatacept1 (1.8)•Anakinra1 (1.8)•Ustekinumab1 (1.8)•JAK inhibitors1 (1.8)•Steroids5 (8.9)Asymptomatic13 (23.2)Hospitalized/ICU/Ventilation/Death1/1/1/1 (1.8)

At the time of infection, 41% of the patients received conventional DMARDs and 52% received biologics (Table 1). Forty-four patients (79%) received either a conventional DMARD or a biologic. Most patients had a polyarticular course of their JIA (57%).

In 49 of the 56 cases (88%) COVID-19 was detected directly by PCR (n=46), by antigen test only (n=1) or an undisclosed method (n= 2). Six patients had detectable SARS-CoV2 antibodies and reported to have had typical symptoms. One patient tested negative but developed typical symptoms at approximately the same time a positive SARS-CoV-2 test was returned for a family member.

Symptoms were reported in 43 of the 56 patients (77%): fever n=15, rhinitis n=14, cough n=12, headache n=10, loss of sense of taste and/or smell n=9, pharyngitis n=8, fatigue n=5, musculoskeletal pain n=5, GI symptoms n=2 (abdominal pain n=1, diarrhoea n=1), dizziness n=3, encephalitis/seizure/respiratory failure/death n=1. Thirteen patients (23%) were asymptomatic.

A 3½ -year-old female patient initially diagnosed with systemic JIA developed intracranial oedema and respiratory failure. Her SARS-CoV2 PCR test was positive and pulmonary imaging displayed typical changes in lung texture. Before her SARS-CoV-2 infection, the patient was treated with methotrexate and low-dose steroids. Unfortunately, she died three days following hospital admission. Genetic testing revealed an inborn immunodeficiency. Except for this one patient, all other cases were treated as outpatients and no deaths were reported.

Conclusion:

Apart from one patient with an inborn immunodeficiency who died from her COVID-19 infection, no case of hospitalization or severe COVID-19 was reported in our cohort of JIA patients. At the time of COVID-19 diagnosis, nearly 80% of patients in our cohort had been treated with conventional DMARD and/or biologics. This seemed not to have a negative effect on severity or outcome of SARS-CoV2 infection.

Acknowledgements:

Thanks also for contributing Reports for this analysis to: Normi Brück, Frank Dressler, Ivan Foeldvari, Tilman Geikowski, Hermann Girschick, Johannes-Peter Haas, Tilmann Kallinich, Bernd-Ulrich Keck, Eggert Lilienthal, Anna-Hedrich Müller, Ulrich Neudorf, Nils Onken, Peggy Rühmer.

Disclosure of Interests:

None declared.

POS1301 DRUG SURVIVAL OF BIOLOGICS WITH RESPECT TO COMBINATION WITH METHOTREXATE IN TREATMENT OF POLYARTICULAR JIA

Background:

In polyarticular juvenile idiopathic arthritis (pJIA) biologic therapies are often combined with methotrexate (MTX). This combination was shown to increase efficacy in adult rheumatoid arthritis patients. MTX may also have a protective effect on the formation of anti-drug antibodies and thus may prolong drug survival. In pJIA, there are few and sometimes controversial data available.

Objectives:

To compare the effect of combination treatment with MTX on discontinuation due to inefficacy and on drug survival discontinuation of biologics approved for first line treatment of pJIA.

Methods:

Patients from the German BIKER registry with their first treatment course with Adalimumab, Etanercept, Golimumab or Tocilizumab were selected. Rates of ineffectiveness-related withdrawal were analysed and compared using χ2-test, Wald-test and Kaplan-Meier analysis of patients receiving biologic monotherapy or concomitant methotrexate. Cases were censored if MTX was discontinued before the biologic.

Results:

2173 pJIA patients were identified who for the first time received a biologic. Etanercept (ETA) was by far the most frequently used biologic for first line biologic treatment in pJIA (77%) followed by Adalimumab (ADA, 16%). Patients on Golimumab (GOL) received most frequently a combination with MTX (86.5%), while patients on Tocilizumab (TOC) had the lowest rate of combination treatment (53%).

ETA/ADA/GOL/TOC was given as monotherapy in 500(30%)/89(26%)/5(13.5%)/46(47%) and combined with MTX in 1179 (70%)/259(74%)/32(86.5%)/51(53%) cases. More patients with rheumatoid-factor negative (54 vs 50%; p=0.04) and rheumatoid-factor positive pJIA (13 vs 10%, p=0.04) received combination with MTX, while more patients in the monotherapy cohort had extended oligoarthritis (40 vs 32%, p<0.001). Patients with MTX had a shorter disease duration (4 vs 5.5years, p<0.001) and received concomitant steroid more often (34 vs 24%), p<0.001). There was no statistical difference regarding disease activity parameters (active joint count, patient assessment and physician assessment of disease activity, ESR, CRP, CHAQ-DI, JADAS10). Discontinuation due to ineffectiveness was reported for ETA/ADA/GOL/TOC in 20%/18%/14%/28% of patients, respectively in 3.7/4.9/6/10.5 patients/100 treatment years. Thus discontinuation due to inefficacy was reported less frequently with ETA compared to ADA (p=0.046) and TOC (p<0.001) and with ADA compared to TOC (p<0.001).

Patients on ETA and ADA had a slightly, but not statistically significant lower rate of withdrawal for ineffectiveness if on methotrexate (Figure 1). There was no difference regarding baseline disease activity parameters in patients with ETA/ADA monotherapy compared with combination with MTX, apart from patients with ETA+MTX receiving more often systemic steroids at baseline (36vs 24%,p<0-001). For both GOL and TOC treatment, no baseline differences in disease activity between cohorts with monotherapy and MTX combination could be shown. The combination with MTX led to significantly lower rates of discontinuation due to inefficacy (p<0.05) with GOL and TOC (Figure 1).

Conclusion:

Patients with pJIA mostly were treated with a combination of the biologic and MTX rather than with biologic monotherapy. Treatment was discontinued due to lack of efficacy in 14% to 28%. No statistically significant effect of combination treatment with MTX versus monotherapy could be observed regarding the rate of treatment failures in patients treated with ETA or ADA. However, combination treatment with MTX significantly prolonged the survival of GOL and TOC in patients with polyarticular JIA. The results are limited by low patient numbers in the GOL cohort and possible bias by JIA category.

Figure 1.

Kaplan Meier plot of drug survival in patients with monotherapy or with combination with MTX of the indicated biologic

Disclosure of Interests:

Gerd Horneff Speakers bureau: MSD, Grant/research support from: Pfizer, Roche, Chugai, MSD, Daniel Windschall: None declared, Kirsten Minden Speakers bureau: Pfizer, Abbvie, Grant/research support from: Pfizer, Toni Hospach: None declared, Frank Dressler: None declared, Frank Weller-Heinemann: None declared, Boris Huegle: None declared, Ivan Foeldvari Speakers bureau: Pfizer, Ariane Klein: None declared

POS0075 SAFETY AND EFFICACY OF GOLIMUMAB FOR THE TREATMENT OF POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS - AN UPDATE FROM THE BIKER REGISTRY

Background:

Golimumab (GOL) is approved for treatment of polyarticular juvenile idiopathic arthritis (pJIA) in patients 2 years and older. Data on long-term safety of GOL in this indication are limited.

Objectives:

To assess long-term safety and efficacy of GOL in pJIA patients.

Methods:

In this ongoing non-interventional observational study, clinical characteristics, disease activity and safety parameters were analysed using the German Biologics in Paediatric Rheumatology (BiKeR) registry. 81 pJIA-patients treated with GOL were body weight-matched with 162 patients receiving alt. tumor necrosis factor inhibitors (TNFi) and 81 biologic–naïve patients under methotrexate (MTX)-therapy.

Results:

Baseline parameters of GOL patients differed from the alternative TNFi and MTX cohorts. In patients starting with GOL treatment, disease duration was longer, corticosteroid use was less and disease activity, measured by the mean number of active joints and the JADAS10, was lower (Table 1).

The long-term clinical efficacy of GOL in pJIA is highlighted by a decrease of the mean JADAS 10 from 11.6 (baseline) to 5.2 after 24 months. After 2 years, a JADAS 10 minimal disease activity was reached by 44.4 % of patients, whereas 22.2 % of patients were in remission and the JIA ACR 30/50/70/90 response rates were 77.8/72.2/66.7/55.6% respectively.

AE, SAE and infectious AE rates between the three cohorts were comparable (Table 1). In the GOL cohort, 4 SAE (1 uveitis, 1 arthritis flare, 1 fibromyalgia syndrome and 1 abscess) were reported, while in the alt. TNFi group 7 SAEs and in the MTX cohort 1 SAE were noted (Table 1). One serious infectious event (1 abscess) was documented in the GOL cohort, 2 alt. TNFi patients had influenza and no serious infectious events were seen in the MTX control group.

Table 1.

Baseline parameters and adverse events

GOLn=81alt. TNFin=162MTXn=81p-value ∞GOL vs alt. TNFip-value∞ GOL vs MTXGender female °67 (83)127 (78)64 (79)0.50.7Disease duration (yrs)7.1±4.34.3±3.71.2±2.1<0.0001<0.0001RF neg. Polyarthritis °40 (49)79 (49)50 (62)1.00.15RF pos. Polyarthritis °8 (10)22 (14)16 (20)0.50.1Extended Oligoarthritis °30 (37)54 (33)13 (16)0.60.004Psoriatic arthritis °3 (4)7 (4)2 (3)1.0/1.01.0Pretreatment bDMARD °68 (84.0)35 (21.6)0<0.0001<0.0001Concomitant systemic steroids, n (%)13 (16)38 (24)39 (48)0.2<0.0001Active joint count #4.6±4.84.9±5.79.6±6.50.4<0.0001CHAQ DI #0.4±0.50.5±0.50.6±0.60.10.02JADAS10 #11.6±6.212.1±6.116.8±5.30.6<0.0001AE *91 (107.4; 88-132)213 (88.7; 78-101)113 (119.8; 100-144)0.10.4SAE *4 (4.7; 2-13)7 (2.9; 1-6)1 (1.1; 0.1-8)0.40.2Serious infections *1 (1.2; 0.2-8.4)2 (0.8; 0.2-3.3)00.7n.a.Autoimmune process (%)2 (2.4)3 (1.9)1 (1.2)1.01.0Patients with uveitis new manifestation after study entry *1 (1.2; 0.2-8)2 (0.8; 0.5-3)00.7n.a.Patients with uveitis flare events with preexisting uveitis at baseline*6 (7.1; 3-16)00n.a.n.a.

Rheumatoid factor (RF), biologic disease modifying antirheumatic drug (bDMARD), childhood health assessment questionnaire disability index (CHAQ Di), juvenile arthritis disease activity index (JADAS), adverse event (AE), patient year (PY), ° n (%), # mean (SD), * n (rate/100PY; 95%CI), Golimumab (GOL), alternative tumor necrosis factor inhibitor (alt. TNFi), methotrexate (MTX), ∞ by t-test or χ2-test as appropriate.

Few autoimmune processes occurred: 2 incident events in the GOL cohort (1 uveitis, 1 psoriasis), 3 cases in the alt. TNFi group (2 uveitis, 1 psoriasis,) and 1 event in MTX-patients (celiac disease) (Table 1). Out of the 20 GOL patients with preexisting uveitis at baseline, 6 had flare events; there were no reported uveitis flares of the 17 patients in the alt. TNFi group and no patients with preexisting uveitis in the MTX-group. No malignancies or deaths were reported.

Conclusion:

Our interim results show an acceptable safety profile of GOL therapy, comparable to treatment with alt. TNFi or MTX. No new safety signals occurred. The efficacy outcome data confirm long-term benefits of GOL treatment in pJIA patients.

Acknowledgements:

We greatly appreciate the kind support of Z. Huang, S. Calhoun.

Disclosure of Interests:

Angela Zimmer: None declared, Ariane Klein: None declared, Kirsten Minden: None declared, Toni Hospach: None declared, Frank Weller-Heinemann: None declared, Jasmin Kuemmerle-Deschner: None declared, Maria Fasshauer: None declared, Nadja Hofmann: None declared, Hans Koessel: None declared, Ivan Foeldvari: None declared, Sonja Mrusek: None declared, Daniel Windschall: None declared, Nils Onken: None declared, Markus Hufnagel: None declared, Dirk Foell: None declared, Normi Brueck: None declared, Prassad Thomas Oommen: None declared, Frank Dressler: None declared, Astrid Helling-Bakki: None declared, Gerd Horneff Speakers bureau: MSD.

OP0165 RISK FOR UVEITIS EVENTS AFTER WITHDRAWAL OF DISEASE MODIFYING ANTIRHEUMATIC DRUGS IN THE TREATMENT OF PATIENTS WITH EXTENDED OLIGOARTHRITIS OR RHEUMATOID FACTOR NEGATIVE POLYARTHRITIS

Background:

Juvenile idiopathic arthritis (JIA) associated uveitis is an extra-articular manifestation of the JIA disease that may cause vision-threatening complications and an uncontrolled uveitis may even lead to blindness. Uveitis occurs in up to 20% of patients with JIA, depending on the JIA category. The majority of patients develop uveitis within the first two years after JIA symptom onset, but uveitis can continue into adulthood.

Objectives:

The main objective of this study was to analyze the risk for uveitis events after discontinuing disease-modifying antirheumatic drugs (DMARD) in patients with extended oligoarthritis and rheumatoid factor (RF)-negative polyarthritis.

Methods:

Data of the two ongoing multicenter biologic registers: German Biologics in Pediatric Rheumatology (BiKeR) and the Juvenile arthritis Methotrexate/Biologics long-term Observation (JuMBO) were used to analyze the adverse-event (AE) and events of special interest (ESI) reports about uveitis events during treatment and after discontinuation of DMARDs. Biker started recruitment of children and adolescent patients with JIA exposed to biological (b) or conventional (cs) DMARD’s in 2001. The patients were further followed in JuMBO after reaching the age of 18 or transitioning to an adult rheumatologist. Disease characteristics, treatment data, AE’s and ESI’s were reported by the pediatric or adults rheumatologist, respectively.

Results:

A total of 2,041 patients with RF-negative polyarthritis (n=1,280) or extended oligoarthritis (n=761) were included into the analyses. The mean follow-up of this study was 7.6 years (SD 5.3). About half of the patients were enrolled in BiKeR with start of etanercept (1,137, 55.7%), followed by 635 (31.1%) patients with start of methotrexate (MTX) monotherapy or adalimumab (ADA, n=198, 9.7%). A history of uveitis was reported for 238 (11.7%) patients at enrolment in BiKeR. More patients with a history of uveitis treated with ADA were included in BiKeR initiating ADA (n=98 of 238, 41.2%). Patients with uveitis had a lower age at JIA onset in comparison to patients without uveitis (mean 3.6 (SD 3.0) versus 7.0 (SD 4.5) years). A total of 142 recurrent (84% of 169) uveitis events were reported in 93 patients and for 27 patients (1.3% of 2,041) was an incident uveitis reported during follow-up. More than one uveitis event was reported for 32 patients with a maximum number of 4 uveitis flares in 3 patients. Nineteen uveitis flares (11.2% of 169) were reported for patients after the age of 18. The longer the time since DMARD discontinuation the fewer uveitis events occurred. Uveitis events were significantly more often reported in the first 24 months after MTX discontinuation (<6 months: OR=3.19, 95%CI: 1.70 to 5.96; 6 to <12 months: OR=2.06, 95%CI: 1.01 to 4.66; 12 to <24 months: OR=2.20, 95%CI: 1.14 to 4.25) and in the first three months after biological DMARD discontinuation (OR=5.4, 95%CI: 1.56 to 18.33). Patients with a MTX dose of ≤ 10 mg/m2 at last MTX intake had a higher likelihood for uveitis events (OR=1.40, 95%CI: 1.02 to 1.92).

Conclusion:

This is the first study that analyzed the risk of uveitis after DMARD withdrawal. Uveitis relapses are common. Patients who discontinued DMARD therapy were at high risk for uveitis within the first 3 to 24 months after discontinuation. Rheumatologists and ophthalmologists should be aware about this risk which should lead to a regular uveitis screening after DMARD withdrawal.

Disclosure of Interests:

Jens Klotsche: None declared, Ariane Klein: None declared, Martina Niewerth: None declared, Tilmann Kallinich: None declared, Daniel Windschall: None declared, Johannes-Peter Haas: None declared, Frank Weller-Heinemann Speakers bureau: Pfizer, Abbvie, SOBI, Roche, Novartis, Toni Hospach: None declared, Frank Dressler: None declared, Kirsten Minden: None declared, Gerd Horneff: None declared

OP0163 COMPARATIVE ANALYSIS OF ETANERCEPT BIOSIMILAR AND ORIGINATOR USE IN CLINICAL PRACTICE: DATA FROM THE GERMAN BIKER-REGISTRY

Background:

In 2017, 2 Etanercept biosimilars became approved. Comparative studies performed in adult patients with rheumatoid arthritis, ankylosing spondylitis or psoriasis by extrapolation led to approval for juvenile idiopathic arthritis (JIA).

Objectives:

So far there is limited experience with Etanercept biosimilars in JIA: The large national data base of the BIKER-registry was used to describe experience with Etanercept biosimilars in clinical practice.

Methods:

In this retrospective analysis patients exposed to ETA were identified in the German BIKER-registry and grouped into cohorts according to initiation of treatment after 2017, use of the originator and of biosimilars. The course of JADAS10, Physician global assessment VAS 0–100-mm, Parent/patient global assessment VAS 0–100-cm, Active joint count 0-71, truncated at 10, ESR and CHAQ-DI was analyzed. Descriptive statistics was used for demographic, clinical data, drug exposure, adverse events (AEs) and events of special interest (ESI).

Results:

Until 31.10.2020, 2917 JIA patients were reported to have received Etanercept. Since January 1 2017, in 39 centres treatment with Etanercept was started in 439 patients (377 (85.9%) started with the originator and 62 (14.1%) started a Biosimilar). Biosimilars were prescribed n 17 centres (44%). In 12 centres (31%), Etanercept biosimilars were used first line in 62 patients. In 17 centres (44%), 63 patients switched for the originator to a biosimilar. 3 patients reswitched from the biosimilar to the originator. 4 patient switched from a biosimilar to the originator). 22 centres (56%) had not prescribed a biosimilars so far.

In not a single centre, initiation of a biosimilar was more frequent than of the originator.

The patients’ characteristics and disease activity parameters were widely comparanble. Patients receiving biosimilar first line were slightly older at disease onset and had a longer disease duration. Patients receiving biosimilar first line had more often rheumatoid factor (RF) negative polyarthritis while extended oligoarthritis was more frequent in the originator cohort. In the switching cohort, more patients had extended oligoarthritis and fewer had RF negative polyarthritis and ERA JIA.

No difference in disease activity parameters was noted, neither at baseline, during the course of treatment nor at last observation upon treatment. A decrease of the JADAS10 indicates improvement in both groups (Figure 1). At the time of switching, 68% had JADAS minimal disease activity (MDA) and 43% were in JASDAS remission. At month 6 and 12 these numbers increased to 74%/65% and 62%/50%.

In total, 66 adverse events (AE) were reported in 45 patients upon biosimilar treatment.

33 patients had 1, 5 patients 2, 5 patients had 3 and 2 reported 4 events. Adverse event of special interest were hypersensitivity n=1, injection site reaction n=1, new onset of psoriasis n=1, celiac disease n=1, Crohn‘s diesease n=1, elevated transaminases n=2, depression n=1 and disease deterioration (arthritis flare) in n=21. In 20 patients, the etanercept biosimilar was discontinued.

Conclusion:

This analysis is the first attempt to present a large data sample on JIA patients exposed to Etanercept biosimilars. Biosimilar were used in a minority of patients and by a minority of centers although no difference in efficacy or safety was noted from our analysis. Until today, the use of the originator is by far exceeding the use of biosimilars. The prescription of a biosimilar either first line or by switching from the originator is limited to a part of centres. Differences in efficacy between first line biosimilar users and originator users could not be observed. Also, after switching, no loss of efficacy was observed.

Disclosure of Interests:

Gerd Horneff Speakers bureau: Pfizer, Daniel Windschall: None declared, Toni Hospach: None declared, Sonja Mrusek: None declared, Michael Rühlmann: None declared, Ariane Klein: None declared

POS1303 EXPERIENCE WITH ADALIMUMAB BIOSIMILAR USE IN CLINICAL PRACTICE: DATA FROM THE GERMAN BIKER-REGISTRY

Background:

In 2017, Adalimumab Biosimilars became approved. Comparative studies to the originator have been performed in adult patients with rheumatoid arthritis, ankylosing spondylitis and psoriasis and extrapolation led to approval for juvenile idiopathic arthritis (JIA).

Objectives:

So far there is limited experience with biosimilars in JIA: The large national data base of the BIKER-registry was used to describe experience with Adalimumab biosimilars in clinical practice

Methods:

This retrospective analysis used data of the German BIKER-registry. The data basis war screened for patients exposed to Adalimumab. Subcohorts with initiation of treatment after 2017, use of the originator and of biosimilars were built. The course of JADAS10, Physician global assessment VAS 0–100-mm, Parent/patient global assessment VAS 0–100-cm, Active joint count 0-71, truncated at 10, ESR and CHAQ-DI was analyzed. Descriptive statistics was used for demographic, clinical data, drug exposure, adverse events (AEs) and events of special interest (ESI).

Results:

Until 31.10.2020, 1173 JIA patients were reported to have received Adalimumab. 352 treatments have been started after January 1, 2017. A biosimilar was used first line in 44 patients. Further 55 patients switched for the originator to a biosimilar. 2 patient switched from a biosimilar to the originator. 3 patients switched to a second biosimilar while 5 patients who switched from the originator to a biosimilar reswitched back to the originator.

After 2017, 33 pediatric rheumatology centres reported initiation of Adalimumab treatment. 17 have used a biosimilar. 15 centres have swichted at least 1 patient from the originator to a biosimilar and 14 have used first line a biosimilar in at least 1 patient. In a single centre, initiation of a biosimilar was used more frequently (8 versus 7).

The patients’ characteristics and disease activity parameters were brightly comparable. The JIA category rheumatoid factor (RF) negative polyarthritis was less frequent in the biosimilar first cohort while RF positive polyarthritis and psoriatic arthritis was more frequent. In patients with idiopathic uveitis the originator was used more often. In the switching cohort, more patients had RF negative polyarthritis, persistent oligoarthritis but less had psoriatic arthritis and no had RF positive polyarthritis.

No difference in disease activity parameters between patients receiving the originator or biosimilars were noted, neither at baseline, during the course of treatment nor at last observation upon treatment (Figure 1). At the time of switching, 46 (92%) had JADAS minimal disease activity (MDA) and 30 (69%) were in JASDAS remission. At last observation, those numbers were comparable with 42 (86%) with JADAS MDA and 28 (57%) with JADAS remission.

In total, 45 adverse events (AE) were reported in 45 patients upon biosimilar treatment. 26 patients had 1, 12 patients had 2 and 6 patients reported 3 and 1 reported 4 events. Adverse event of special interest were Infection associated leukopenia (n=1), COVID 19 infection (n=1), Uveitis flare (n=8), other disease deterioration (arthritis flare) (n=20), injection site reaction n=2. A single serious AE was reported. A 16 year old female adolescent was admitted for unexpected CK elevation. In 10 patients, Adalimumab was discontinued, in 2 it was temporarily paused.

Conclusion:

This article is the first attempt to present a large sample of data on JIA patients exposed to Adalimumab biosimilars. Since approval of Adalimumab-Biosimilars, limited experience from clinical practice is available. Biosimilars are used in a minority of patients and by a minority of centers although no difference in efficacy or safety was noted from our analysis.

Disclosure of Interests:

Gerd Horneff Speakers bureau: Novartis, MSD, Sobi, Grant/research support from: MSD, Roche, Frank Dressler: None declared, Michael Rühlmann: None declared, Tilmann Geikowski: None declared, Sonja Mrusek: None declared, Ariane Klein: None declared

POS1199 CLINICAL MANIFESTATIONS OF SARS-CoV2 INFECTIONS IN CHILDREN AND ADOLESCENTS WITH RHEUMATIC AND MUSCULUSKELETAL DISEASES – SURVEY DATA FROM GERMANY

Background:

Although children and adolescents are less likely to develop COVID-19 and generally show milder disease courses, it is unclear what impact the SARS-CoV2 infection has on children and adolescents with rheumatic and musculoskeletal disease (RMD). Due to their underlying disease as well as therapeutic immunosuppression these patients may be at higher risk of being more severely affected by SARS-CoV2. Furthermore, SARS-CoV2 infection might trigger a flare of the underlying disease.

Objectives:

To evaluate clinical characteristics and disease course of COVID-19 in children and adolescents with RMD and to analyze possible effects of SARS-CoV2 infection on the underlying disease under different therapeutic regimens.

Methods:

Data from juvenile patients with RMD recorded via the SARS-CoV2 questionnaire within the National Pediatric Rheumatology Database and the registry for hospitalized children and adolescents with COVID-19 of the German Society for Pediatric Infectious Diseases were analyzed. In addition to age, sex and diagnosis, information was collected about the date and method of a positive SARS-CoV2 testing, reason for testing, on clinical manifestations, disease course, treatment and outcome of COVID-19, on drug therapy at the time of virus detection, on disease activity (NRS 0 – 10, 0 = best) of the underlying disease at the last visit before and after the SARS-CoV2 infection.

Results:

From April 17th 2020 until January 25th 2021, data of 67 patients with RMD and confirmed SARS-CoV2 infection were collected. Mean age was 13.5 ± 3.9 years with equal sex distribution. The majority of patients were diagnosed with juvenile idiopathic arthritis (JIA, 64%), 12 (18%) patients had an autoinflammatory disease (FMF, CAPS, PFAPA, TRAPS) and 5 (7%) a connective tissue disease. Fifty-two patients (78%) were treated with a disease modifying antirheumatic drug (DMARD), 39% with a biological DMARD and 9% systemic glucocorticoids at the time of SARS-CoV-2 infection. Nineteen patients (28%) were tested for SARS-CoV-2 because of typical symptoms, the majority (67%) because of contact to an infected person. PCR was used most often (in 60 %).

52 patients (78%) developed symptoms of COVID-19, 15 patients remained asymptomatic. The most common symptom of COVID-19 was rhinitis (42%) and fever (38%), followed by fatigue (34%), taste/smell disorder (33%), sore throat (27%) and cough (23%).

Disease severity was graded as mild in 44 of 52 (85%) symptomatic patients, only two patients were hospitalized, one of whom required intensive care and died of cardiorespiratory failure 3 days after symptom onset. In 22 of 26 (85%) SARS-CoV2-positive patients, no relevant increase in disease activity (difference in NRS ≤ 1 before/after infection) of the underlying disease was observed 31 days after symptom onset (median, IQR 17-52 days). One patient, who had paused tocilizumab for 2 doses, experienced a flare of his seronegative polyarthritis 2 months after asymptomatic SARS-CoV-2 infection.

Conclusion:

In our cohort, the clinical picture of COVID-19 in children and adolescents with RMD was similar to that of healthy peers. The majority of patients showed mild disease course with good outcome under various medications, however, one patient with a severe course of COVID-19 died. In addition, SARS-CoV2 infection does not appear to have a relevant impact on the underlying disease activity, whereas discontinuation of therapy might pose a risk of flare.

Disclosure of Interests:

None declared.