Clinical features, treatment and outcome of pediatric patients with severe cutaneous manifestations in IgA vasculitis: Multicenter international study

The extent of intestinal involvement is closely related to the severity of IgAV: a risk stratification study based on CT

OBJECTIVES

To analyze the differences in clinical manifestations between children and adults with intestinal involvement in IgAV and to identify the specific subtypes requiring particular attention.

METHODS

A systematic review of the HIS system was conducted on patient data from four centers at Tongji Hospital between January 2015 and October 2022. Patients with a diagnosis of IgAV with intestinal involvement were further analyzed. Clinical manifestations, laboratory data, and CT findings at the time of initial hospitalization were recorded. The differences in clinical manifestations between children and adults were analyzed. The extent of intestinal involvement, linked to disease severity, was quantitatively assessed by evaluating the number of affected intestinal segments on CT imaging. Laboratory markers that could reflect severe intestinal involvement were explored. Furthermore, patients were classified based on the sites of involved intestinal segments: L1 type (duodenum and/or jejunum), L2 type (ileum), L3 type (duodenum and/or jejunum and ileum), and L4 type (limited to the colorectum). A comparison of the first three types was performed.

RESULTS

A total of 148 patients were enrolled (67 children and 81 adults). The proportion of joint pain and renal involvement was higher in adults. D-dimer level was an independent risk factor for severe intestinal involvement (OR = 1.104, p = .016). In the first three types patients based on the sites of involved intestinal segments, it found that L3 type patients had a longer hospital stay.

CONCLUSION

With the exception of joint pain and renal involvement, there were no significant differences in clinical symptoms between children and adults. CT imaging provided objective insights into the extent of intestinal involvement, which correlated with disease severity. Patients with widespread small bowel involvement displayed a more severe disease state.

Immunoglobulin a vasculitis with central nervous system involvement: analysis of 10 cases

Immunoglobulin A vasculitis (IgAV) is a systemic inflammatory disease that affects small blood vessels. Central nervous system (CNS) involvement in IgAV is rare. This study analyzed the clinical characteristics of IgAV patients combined with CNS damage in children. Furthermore, the study made a comparison between the characteristics of IgAV patients with and without CNS damage, and initially explored the potential predictors for IgAV patients with CNS damage. A retrospective analysis was conducted on a cohort of 50 children diagnosed with IgAV and admitted to Beijing Children's Hospital from 2016 to 2019. The study encompassed a review of the clinical presentations, laboratory test results, imaging findings, therapeutic interventions, and prognoses of 10 children with IgAV who exhibited CNS involvement. These 10 cases were then compared with a group of 40 children with IgAV without CNS involvement. The prevalence of IgAV with CNS manifestations was 0.2%. The median age was 11.6 years, with a male-to-female ratio of 7:3. All CNS symptoms appeared after the purpuric rash. The mean period from IgAV onset to the development of neurological symptoms was 12.2 days (range: 1-27 days). Seizures were the most common neurological manifestation, with impaired consciousness and predominant convulsions. Other symptoms included headache, visual impairment, dysarthria, dyskinesia, and emotional irritation. The main abnormalities found on brain magnetic resonance imaging (MRI) were unilateral or bilateral abnormal focal signals, cortical and subcortical white matter edema, and thrombosis of the venous sinus. Glucocorticoid therapy and intravenous immunoglobulins were used to treat CNS damage caused by IgAV. All patients showed clinical improvement without recurrent neurological symptoms or sequelae. Statistically differences were identified in in terms of age, gastrointestinal damage, WBC count, NLR, ALB, C3 levels, and the CD4/CD8 ratio in IgAV patients with CNS damage when compared to those without CNS damage. Multivariable logistic regression analysis shows that age, NLR and C3 Levels are predictors of IgAV with CNS damage. CNS involvement in IgAV is a rare complication. Its clinical manifestations are diverse and vary in severity, and its diagnosis is exclusionary. Brain MRI is beneficial for diagnosis and follow-up. Steroid therapy is important for treating IgAV-associated CNS involvement. Age, NLR and C3 Levels are predictors of IgAV with CNS damage.

Characteristics of cutaneous manifestations in immunoglobulin a vasculitis and their relationships with system involvement and treatment needs

The aim of this study was to evaluate the cutaneous manifestations of immunoglobulin A vasculitis (IgAV) in terms of skin lesion type, distribution and persistence and to investigate the relationship between cutaneous manifestations and system involvement and treatment needs. This retrospective observational study was conducted with 489 IgAV patients who were followed-up for at least 6 months between 2013 and 2024. Demographic characteristics, detailed cutaneous manifestations, clinical findings and treatments were retrieved from electronic medical records. IgAV patients were divided into subgroups according to the presence or absence of vesicles/bullae, necrosis/ulcer, rash spreading above the buttocks and persistence. The groups were analyzed statistically for demographic findings, systemic involvement and treatments. Of 489 patients, 36 (7.4%) had vesicles/bullae and 22 (4.5%) had necrosis/ulcers. 345 (70.6%) patients had cutaneous manifestations limited to the lower extremities and buttocks, 144 (29.4%) had cutaneous manifestations spreading from the lower extremities to the trunk, upper extremities or face. 36 (7.4%) patients had persistent rash for more than 1 month. Patients with necrosis/ulcer had more genital tract involvement (p = 0.04). Patients with rash spreading above the buttocks had more gastrointestinal tract and genital tract involvement (p = 0.014, p = 0.003). Patients with persistent rash had more renal involvement (p = 0.05). Patients with vesicles/bullae, necrosis/ulcer, rash spreading above the buttocks and persistent rash required more steroid treatment (p = 0.003, p = 0.001, p < 0.001, p = 0.03).

CONCLUSIONS

The characteristics of cutaneous manifestations in IgAV patients may be helpful in predicting the course of the disease. The skin lesion type, distribution and persistence of cutaneous manifestations in IgAV are associated with system involvement. In addition, the need for intensive therapy increases in the presence of vesicles/bullae, necrosis/ulcer, rash spreading over the buttocks and persistent rash in IgAV.

WHAT IS KNOWN

• Palpable purpura localized to the lower extremities is the expected cutaneous manifestation of immunoglobulin A vasculitis.

WHAT IS NEW

• The type, distribution and duration of rash in IgAV have effects on the immunoglobulin A vasculitis disease course. • Genital tract involvement is more common in patients with necrosis/ulcers. • Gastrointestinal tract involvement and genital tract involvement are more common in patients with rash spreading above the buttocks. • Renal involvement is more common in patients with persistent rash.

IgA Vasculitis (Henoch-Schönlein Purpura): An Update on Treatment

Objective: IgA vasculitis (IgAV), previously named as Henoch-Schönlein purpura, is the most frequent systemic vasculitis in children. In adults, IgAV is less common although it is associated with more severe disease. In fact, the frequency of glomerulonephritis (referred to as IgAV nephritis) in adults is higher than in children and tends to present more severely, with around 10-30% of those affected eventually progressing to end-stage renal disease. In this review, we describe the pathophysiology, main clinical features, diagnosis of the disease, and latest clinical data regarding IgAV therapy. Methods: A narrative literature review, primarily based on articles published in PubMed, was conducted. In addition to discussing the main aspects of glucocorticoids and conventional disease-modifying drugs used in the management of IgAV, this review focuses on the latest information reported regarding biologics and potential future therapies. Results: Glucocorticoids are the first-line therapy for IgAV, especially in adults with severe manifestations. Colchicine, dapsone, and methotrexate can be useful for controlling minor manifestations. Several immunomodulatory agents, such as cyclosporine A, tacrolimus, and mycophenolate mofetil, have shown favorable results as glucocorticoid-sparing agents. Leflunomide has shown promising results but requires further study. The use of rituximab has demonstrated efficacy in reducing relapse frequency, lowering the cumulative glucocorticoid burden, and achieving long-term remission of the disease in children and adults with IgAV. Immunoglobulins and plasma exchange therapy can also be useful in difficult and life-threatening situations. Other potential therapies with encouraging results include TRF-budesonide, B-cell-directed therapy, B-cell-depleting agents, sodium-glucose cotransporter-2 inhibitors, endothelin receptor antagonists, and complement pathway inhibitors. Conclusions: Glucocorticoids are the first-line therapy for IgAV, especially in adults with severe manifestations. The role of various immunomodulatory therapies, such as calcineurin inhibitors and mycophenolate mofetil, remains promising, while rituximab reduces the long-term side effects of glucocorticoids and can help achieve disease remission. Other potential therapies with encouraging results require further research.

Clinical characteristics and risk factors of cardiac involvement in pediatric immunoglobulin A vasculitis: A 7-year retrospective study from a single tertiary medical center

Immunoglobulin A vasculitis(IgAV) is the most common form of systemic vasculitis affecting children. To date, cardiac involvement in pediatric IgAV has not been fully investigated and its prevalence may be underestimated. This study aims to reveal the clinical and laboratory characteristics of cardiac involvement in pediatric IgAV and further determine its risk factors. A total of 1451 children with IgAV were recruited between January 2016 and December 2022. According to the severity of cardiac involvement, the patients were divided into the myocarditis/suspected myocarditis group, cardiac abnormalities group, and non-cardiac involvement group. Demographic, clinical, and laboratory characteristics were retrospectively extracted from the individual data collected in the medical records. Among the 1451 pediatric IgAV patients, 179 (12.3%) were identified with cardiac involvement, including 154 (10.6%) with cardiac abnormalities and 25 (1.7%) with myocarditis/suspected myocarditis. Cardiac involvement in pediatric IgAV mainly manifested as elevated cardiac biomarker levels (n = 162), electrocardiogram abnormalities (n = 46), and echocardiogram/chest X-ray abnormalities (n = 15); however, cardiac-related symptoms were only observed in 15.1% of patients with cardiac involvement. Multivariate analysis demonstrated that interval from disease onset to diagnosis > 7 days (OR, 2.157; 95% CI, 1.523-3.057; p < 0.001), IgAV with multi-organ involvement (OR, 1.806; 95% CI, 1.242-2.627; p = 0.002), and elevated D-dimer levels (OR, 1.939; 95% CI, 1.259-2.985; p < 0.001) were independent risk factors for cardiac involvement in pediatric IgAV. The length of hospital stay was significantly longer in the myocarditis/suspected myocarditis group compared with the other two groups (p < 0.05).     Conclusion: This study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV. What is Known: • Immunoglobulin A vasculitis (IgAV) is the most common form of systemic vasculitis affecting children and adolescents, which exhibits diverse clinical manifestations. Cases of severe IgAV complicated by cardiac involvement have been anecdotally reported. What is New: • The present study suggests that cardiac involvements in pediatric IgAV is non-negligible, and cardiac involvement is associated with interval from disease onset to diagnosis > 7 days, IgAV with multi-organ involvement, and elevated D-dimer levels. Severe cardiac involvement may affect the prognosis of pediatric IgAV.

Regulatory T and B cells in pediatric Henoch-Schönlein purpura: friends or foes?

BACKGROUND AND OBJECTIVES

Henoch-Schönlein purpura (HSP) is the most common immunoglobulin A-mediated systemic vasculitis in childhood. We studied immune dysregulation in HSP by analyzing regulatory T (Treg), T helper 3 (Th3), and regulatory B cell (Breg) subpopulations that might intervene in immune activation, IgA production, and HSP clinical manifestations.

METHODS

This prospective study included 3 groups of children: 30 HSP on acute phase, 30 HSP on remission, and 40 healthy controls (HCs) matched on age. Treg, Breg, and Th3 were analyzed by flow cytometry. Serum immunoglobulin and cytokine levels were quantified by ELISA and Luminex.

RESULTS

Treg frequencies were higher in acute HSP than in remitting HSP and HCs (6.53% [4.24; 9.21] vs. 4.33% [3.6; 5.66], p = 0.002, and vs. 4.45% [3.01; 6.6], p = 0.003, respectively). Activated Th3 cells (FoxP3 + Th3 cells) tend to be more abundant in HSP than in HCs (78.43% [50.62; 80.84] vs. 43.30% [40.20; 49.32], p = 0.135). Serum IgA, IL-17, and latency-associated peptide (a marker of the anti-inflammatory cytokine TGF-beta production) were significantly and inflammatory cytokines TNF-alpha, IL-1-beta, and IL-6 were non-significantly higher in HSP than HCs. Bregs were identical between the groups, but, in patients with renal impairment, Breg percentage was lower compared to those without. Treg removal in PBMC culture resulted in an increase in IgA production in HSP proving a negative regulatory role of Tregs on IgA production.

CONCLUSIONS

In pediatric HSP, immune activation persists in spite of an increase in Th3 and Tregs. Th3 could be involved in IgA hyperproduction, inefficiently downregulated by Tregs. Lack of Bregs appears linked to renal impairment.