Successful treatment of severe juvenile microscopic polyangiitis with rituximab

Comparing Rituximab and Cyclophosphamide in Induction Therapy for Childhood-Onset Anti-Neutrophil Cytoplasmic Antibody-Associated Vasculitis: An ARChiVe Registry Cohort Study

OBJECTIVE

Granulomatosis with polyangiitis (GPA) and microscopic polyangiitis (MPA) are chronic life-threatening vasculitides requiring substantial immunotherapy. Adult trials identified rituximab (RTX) as an alternative to cyclophosphamide (CYC) for remission induction of GPA and MPA. Disease rarity has limited feasibility of similar trials with pediatric patients. We aim to evaluate the relative efficacy and toxicity of CYC and RTX for patients with childhood GPA and MPA through registry-based comparative evaluation.

METHODS

From A Registry of Childhood Vasculitis, we identified patients with GPA and MPA who received induction with RTX or CYC. Pediatric Vasculitis Activity Score (PVAS) and Pediatric Vasculitis Damage Index (pVDI) score evaluated disease activity and damage. Descriptive statistics summarized patient characteristics. RTX and CYC comparisons used logistic regression for primary outcomes of postinduction remission (PVAS = 0) or low disease activity (PVAS ≤ 2). Hospital admission for adverse events and pVDI scores were compared using logistic regression and ordinal regression, respectively.

RESULTS

Among 104 patients, 43% received RTX, 46% CYC, 11% both. Treatment groups did not significantly differ for diagnosis PVAS and onset age. There was no difference in remission among the groups (63% overall; odds ratio [OR] 1.07, 95% confidence interval [CI] 0.45-2.52). Hospitalizations occurred in 22% of patients receiving RTX versus 10% patients receiving CYC (OR 2.27, 95% CI 0.73-7.05). The median 12-month pVDI score was 1 in both groups (OR 0.98, 95% CI 0.43-2.22).

CONCLUSION

This is the first study comparing CYC and RTX for induction in pediatric GPA and MPA. No significant differences were shown in rates of remission, severe adverse events, or organ damage. Limitations included lack of standardized treatment regimens, retrospectivity, and lack of longitudinal adverse drug-related event data.

Microscopic polyangiitis presenting with persistent cough and hemoptysis in pediatrics: A case report and review of the literature

Background

Microscopic polyangiitis (MPA) is a necrotizing vasculitis that involves small- and medium-sized vessels and is associated with the presence of antineutrophil cytoplasmic antibodies with a perinuclear staining pattern (p-ANCA). The kidney and lungs are the organs primarily affected. MPA is rare in children and is easily misdiagnosed. Below is a complete case history of the course of the disease.

Case presentation

An 11-year-old girl with a 1-month history of cough and hemoptysis showed no improvement after imipenem-cilastatin treatment. p-ANCA and microscopic hematuria and proteinuria were positive, and a chest CT revealed an area of shadow in the bilateral lower lobe of the lungs. Renal biopsies showed crescentic glomerulonephritis, and MPA was diagnosed based on these criteria. The patient exhibited dramatic clinical and imaging improvements after immunosuppressive treatment.

Conclusion

The organs most commonly involved in MPA in children are the lungs, kidneys, skin, nervous system organs, and organs of the gastrointestinal tract. Careful examination should be carried out in these patients while biopsies of the kidney or any other organs remain the gold standard for diagnostic purposes. Pulmonary involvement may be the initial symptom of the disease and should not be confused with pneumonia. A urinalysis should be performed in patients with hemoptysis. Antibiotics should be used with caution.

Is B-cell depletion first choice in antineutrophil cytoplasmic antibody-associated vasculitis?

PURPOSE OF REVIEW

To discuss in detail the efficacy and safety of rituximab (RTX) for induction and maintenance of remission in patients with antineutrophil cytoplasmic autoantibody (ANCA)-associated vasculitis (AAV) who are either treatment naive, relapsing or refractory to standard of care.

RECENT FINDINGS

In treatment naive AAV patients, RTX without maintenance treatment is as effective as cyclophosphamide (CYC) followed by azathioprine (AZA) for maintenance for up to 18 months. RTX is superior to CYC for induction of remission in patients with relapsing AAV. Nevertheless, long-term follow-up shows relapsing disease in up to 50% of patients with proteinase 3-ANCA, irrespective of the induction regimen. RTX is useful in patients with refractory AAV, but percentages of patients achieving complete remission differ between series. RTX seems more effective than AZA for maintaining remission, but detailed results from prospective studies are being awaited. Adverse events do not differ between RTX and classical induction regimens, but infections related to hypogammaglobulinemia and neutropenia could be items of concern with repeated administration of RTX.

SUMMARY

RTX is an alternative for CYC for induction of remission in generalized AAV and could be first choice for relapsing patients and patients refractory to CYC. RTX is promising for maintenance of remission, but long-term safety should be awaited.

Quantitative MRI analysis in children with multiple sclerosis: a multicenter feasibility pilot study

BACKGROUND

Pediatric multiple sclerosis (MS) is a rare disorder with significant consequences. Quantitative MRI measurements may provide significant insights, however multicenter collaborative studies are needed given the small numbers of subjects. The goal of this study is to demonstrate feasibility and evaluate lesion volume (LV) characteristics in a multicenter cohort of children with MS.

METHODS

A common MRI-scanning guideline was implemented at six member sites of the U.S. Network of Pediatric MS Centers of Excellence. We included in this study the first ten scans performed at each site on patients meeting the following inclusion criteria: pediatric RRMS within 3 years of disease onset, examination within 1 month of MRI and no steroids 1 month prior to MRI. We quantified T2 number, T2-LV and individual lesion size in a total of 53 MRIs passing quality control procedures and assessed gadolinium-enhancing lesion number and LV in 55 scans. We studied MRI measures according to demographic features including age, race, ethnicity and disability scores, controlling for disease duration and treatment duration using negative binomial regression and linear regression.

RESULTS

The mean number of T2 lesions was 24.30 ± 19.68 (range:1-113) and mean gadolinium-enhancing lesion count was 1.85 ± 5.84, (range:0-32). Individual lesion size ranged from 14.31 to 55750.60 mm3. Non-white subjects had higher T2-LV (unadjusted pT2-LV = 0.028; adjusted pT2-LV = 0.044), and maximal individual T2-LV (unadjusted pMax = 0.007; adjusted pMax = 0.011) than white patients. We also found a trend toward larger mean lesion size in males than females (p = 0.07).

CONCLUSION

Assessment of MRI lesion LV characteristics is feasible in a multicenter cohort of children with MS.

ANCA-associated vasculitides-lessons from the adult literature

Anti-neutrophil cytoplasmic antigen antibody (ANCA)-associated disease is a rare manifestation of primary systemic vasculitis in paediatric patients but one that carries significant morbidity, potential long-term disability and early mortality. It therefore requires a high index of suspicion, targeted investigation, prompt treatment and long-term follow-up with specialist input at every stage. The well-recognised diversity and overlap in clinical, laboratory and histopathological features of the ANCA-associated systemic vasculitides continue to hamper accurate diagnosis, confounding epidemiological data and necessitating a blanket approach to treatment, which is largely extrapolated from studies in adult patients and carries significant side-effects. Herein we summarise current knowledge of the epidemiology, pathogenesis, principal manifestations, investigation and evidence-based management, extrapolated from adult studies, of these disorders. We also discuss recent efforts towards classification of the childhood vasculitides that emphasise the value of histological diagnosis. Progress in our understanding of the pathophysiology underlying ANCA-associated disease should lead to targeted, safer and more effective therapies for these conditions. Nonetheless, many questions remain outstanding, and academic paediatricians face real challenges in identifying and collating the few cases they encounter into study cohorts. Meeting this challenge will require international collaboration, not only among paediatricians but also with the specialists taking over care of these patients as they reach adulthood.

Update in paediatric vasculitis

Vasculitis refers to a heterogeneous group of disorders that are characterised by inflammatory destruction of blood vessels. Although simple to define, almost nothing about vasculitis is simple. From classification to diagnosis, and from pathogenesis to management, large gaps remain in our understanding. Despite extensive and ongoing research, the fundamental mechanisms underlying the initiation and continuation of systemic vasculitis remain poorly understood. Thus, vasculitis continues to provide tremendous challenges to both clinicians and investigators and remains a rich source of issues for discussion. This review concentrates on recent changes proposed for the classification of paediatric vasculitis and advances in the concepts of aetiopathogenesis. Availability of improved classification criteria for children should prompt planning for multicentre-controlled studies for the treatment of these rare but important diseases.