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Chakhunashvili DG, Chakhunashvili K, Kvirkvelia E. Visceral leishmaniasis misdiagnosed as an upper respiratory infection and iron-deficiency anemia in a 20-month-old male patient: a case report. J Med Case Rep 2024; 18:37. [PMID: 38291520 PMCID: PMC10829240 DOI: 10.1186/s13256-024-04356-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 01/03/2024] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Visceral Leishmaniasis should be suspected in every patient with a history of splenomegaly, fever, and pancytopenia. It is one of the most dangerous forms of infection and prompt recognition is the key to positive outcome. CASE PRESENTATION A 20-month-old Caucasian male patient was brought to our hospital as an outpatient with the complaint of persistent fever, which did not improve with empiric antibiotic treatment (> 96 hour after the initial dose). The antibiotic treatment had been prescribed by primary care physician at polyclinic, who also referred the patient to hematologist due to anemia, who prescribed iron supplement. Despite multiple subspecialist visits, bicytopenia was, unfortunately, left unidentified. Upon physical examination no specific signs were detected, however, spleen seemed slightly enlarged. Patient was admitted to the hospital for further work-up, management and evaluation. Abdominal ultrasound, complete blood count and c-reactive protein had been ordered. Hematologist and infectionist were involved, both advised to run serology for Epstein-Barr Virus and Visceral Leishmaniasis. The latter was positive; therefore, patient was transferred to the specialized clinic for specific management. CONCLUSION Both in endemic and non-endemic areas the awareness about VL should be increased among the medical professionals. We also recommend that our colleagues take the same approach when dealing with bicytopenia and fever, just as with pancytopenia and fever. The medical community should make sure that none of the cases of fever and pancytopenia are overlooked, especially if we have hepatomegaly and/or splenomegaly.
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Affiliation(s)
- Davit G Chakhunashvili
- Department of Pediatrics, Alte University, Tbilisi, Georgia
- Children's Clinic After I. Tsitsishvili, Tbilisi, Georgia
| | - Konstantine Chakhunashvili
- Department of Pediatrics, The University of Georgia, Tbilisi, Georgia.
- Children's Clinic After I. Tsitsishvili, Tbilisi, Georgia.
| | - Eka Kvirkvelia
- Department of Gynecology, Caucasus University, Tbilisi, Georgia
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Zhang Y, Ru J, Zhang J. Sequential Tocilizumab and Tofacitinib Treatment for Systemic Juvenile Idiopathic Arthritis: a Case Report. Rheumatol Ther 2023; 10:293-300. [PMID: 36443570 PMCID: PMC9931954 DOI: 10.1007/s40744-022-00496-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/15/2022] [Indexed: 12/02/2022] Open
Abstract
Systemic juvenile idiopathic arthritis (sJIA) is a complex and difficult to cure condition with high disability and mortality rates. Herein, we report the case of a patient with sJIA who was treated with sequential tocilizumab (TCZ) and tofacitinib treatment. The patient was a 4-year-old girl hospitalised with fever accompanied by multiple joint swelling and pain in June 2020. Laboratory tests revealed a white blood cell count of 15.3 × 109/L, platelet count of 676.8 × 109/L, haemoglobin of 91.8 g/L, serum ferritin level of 1103.8 U/L, erythrocyte sedimentation rate of 85.0 mm/h, C-reactive protein level of 146.0 g/L and interleukin (IL)-6 level of 288.0 pg/ml. Rheumatoid factor and autoantibodies test results were negative, and she was diagnosed with sJIA. The patient was started on a combination of ibuprofen, methotrexate and TCZ, and her fever decreased to the normal range without any recurrence. Painful joint swelling had resolved significantly at 3-month follow-up. Janus kinase (JAK) inhibitors inhibit the effects of several cytokines, particularly IL-6, and are economical and convenient. Therefore, we selected tofacitinib to replace TCZ in this case, while the other drugs remained unchanged. Arthritis symptoms disappeared gradually after 9-month follow-up. In May 2021, the patient was hospitalised owing to a slight recurrence of the upper respiratory tract infection. She was administered one intravenous infusion of TCZ along with a switch to oral tofacitinib, which quickly relieved the symptoms. In March 2022, the patient's condition was stable. The curative effect of sequential TCZ and tofacitinib treatment was remarkable. IL-6 inhibitors sequential to JAK inhibitors could be a new option in the treatment of systemic juvenile idiopathic joints.
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Affiliation(s)
- Ye Zhang
- Department of General Medicine, The Second Hospital of Shanxi Medical University (The Second Clinical Medical College of Shanxi Medical University, Shanxi Red Cross Hospital), No. 382, Wuyi Road, Taiyuan, 030001, Shanxi, China
| | - Jinli Ru
- Department of General Medicine, The Second Hospital of Shanxi Medical University (The Second Clinical Medical College of Shanxi Medical University, Shanxi Red Cross Hospital), No. 382, Wuyi Road, Taiyuan, 030001, Shanxi, China.
| | - Jinxiu Zhang
- Department of General Medicine, The Second Hospital of Shanxi Medical University (The Second Clinical Medical College of Shanxi Medical University, Shanxi Red Cross Hospital), No. 382, Wuyi Road, Taiyuan, 030001, Shanxi, China
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Molecular Biomarkers in Perthes Disease: A Review. Diagnostics (Basel) 2023; 13:diagnostics13030471. [PMID: 36766577 PMCID: PMC9914190 DOI: 10.3390/diagnostics13030471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2022] [Revised: 01/06/2023] [Accepted: 01/16/2023] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Perthes disease is a juvenile form of osteonecrosis of the femoral head that affects children under the age of 15. One hundred years after its discovery, some light has been shed on its etiology and the biological factors relevant to its etiology and disease severity. METHODS The aim of this study was to summarize the literature findings on the biological factors relevant to the pathogenesis of Perthes disease, their diagnostic and clinical significance, and their therapeutic potential. A special focus on candidate genes as susceptibility factors and factors relevant to clinical severity was made, where studies reporting clinical or preclinical results were considered as the inclusion criteria. PubMed databases were searched by two independent researchers. Sixty-eight articles were included in this review. Results on the factors relevant to vascular involvement and inflammatory molecules indicated as factors that contribute to impaired bone remodeling have been summarized. Moreover, several candidate genes relevant to an active phase of the disease have been suggested as possible biological therapeutic targets. CONCLUSIONS Delineation of molecular biomarkers that underlie the pathophysiological process of Perthes disease can allow for the provision of earlier and more accurate diagnoses of the disease and more precise follow-ups and treatment in the early phases of the disease.
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Berntson L, Palm J, Axling F, Zarelius P, Hellström PM, Webb DL. Haptoglobin in Juvenile Idiopathic Arthritis. Pediatr Rheumatol Online J 2022; 20:117. [PMID: 36517828 PMCID: PMC9753416 DOI: 10.1186/s12969-022-00777-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Accepted: 12/02/2022] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Haptoglobin (Hp), a liver derived acute phase inflammatory protein (APP), has scarcely been studied in juvenile idiopathic arthritis (JIA). Hp can occur in blood as two isoforms (Hp1 and Hp2) in precursor and mature forms. Routine clinical chemistry immunoturbidimetry does not discern these forms. It is unknown how different forms relate to disease activity in JIA. Our aims were to determine allele frequency and plasma concentrations of different Hp forms at higher versus lower JIA disease activity and compare to other APPs. METHODS Plasma from JIA (n = 77) and healthy (n = 42) children were analyzed for apparent Hp allelic frequency and densitometric concentrations of alpha forms by Western blot (WB). Polymerase chain reaction (PCR) (buffy coat) was performed in a subset to estimate conformity with genetics. At higher versus lower juvenile arthritis disease activity score (JADAS27) (which includes erythrocyte sedimentation rate (ESR)), total mature Hp concentration from WB was compared and correlated against immunoturbidimetry and total protein, albumin, serum amyloid A (SAA) and C-reactive protein (CRP). RESULTS At 300-fold dilution needed to study mature forms in Western blot, precursors were undetectable. Hp2 contributed most signal in most samples. Hp allele frequency was similar in JIA and controls. Both mature forms, taken separately or by sum, declined following treatment, but remained above concentrations of healthy controls, even in a remission subset that achieved JADAS27 < 1. Densitometry correlated with immunoturbidimetry. Hp concentrations correlated with JADAS27, albumin (negatively), CRP and SAA with immunoturbidimetric method correlating strongest to JADAS27 (Spearman R ~ 0.6, p < 0.0001). CONCLUSION Hp allele frequency in JIA is similar to the general population, indicating that children with JIA should have the same possibility as in healthy children to produce preHp2 (zonulin), thought to increase intestinal permeability. Circulating Hp concentrations largely parallel other APPs and ESR; none of these measures correlate very strongly to JADAS27 score but Hp can be measured from capillary sampling which is impossible with ESR.
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Affiliation(s)
- Lillemor Berntson
- Department of Women's and Children's Health, Uppsala University, Uppsala, 75185, Sweden.
| | - Jakob Palm
- grid.8993.b0000 0004 1936 9457Gastroenterology and Hepatology Unit, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Fredrik Axling
- grid.8993.b0000 0004 1936 9457Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Peter Zarelius
- grid.8993.b0000 0004 1936 9457Gastroenterology and Hepatology Unit, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Per M. Hellström
- grid.8993.b0000 0004 1936 9457Gastroenterology and Hepatology Unit, Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - Dominic-Luc Webb
- Gastroenterology and Hepatology Unit, Department of Medical Sciences, Uppsala University, Uppsala, Sweden.
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Sota J, Vitale A, Lopalco G, Pereira RMR, Giordano HF, Antonelli IP, Makowska J, Brzezińska O, Lewandowska-Polak A, Ruscitti P, Cipriani P, Cola ID, Govoni M, Ruffili F, Sfikakis PP, Laskari K, Ragab G, Hussein MA, Gentileschi S, Gaggiano C, La Torre F, Maier A, Emmi G, Marino A, Ciccia F, Sfriso P, Maggio MC, Bartoloni E, Lomater C, Hegazy MT, Tektonidou M, Dagostin MA, Opinc A, Sebastiani GD, Giacomelli R, Giudice ED, Olivieri AN, Tufan A, Kardas RK, Nuzzolese R, Cardinale F, Więsik-Szewczyk E, Veronica P, Tarsia M, Iannone F, Della Casa F, Fabiani C, Frediani B, Balistreri A, Rigante D, Cantarini L. Efficacy and safety of tocilizumab in adult-onset Still's disease: Real-life experience from the international AIDA registry. Semin Arthritis Rheum 2022; 57:152089. [PMID: 36063578 DOI: 10.1016/j.semarthrit.2022.152089] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 08/13/2022] [Accepted: 08/26/2022] [Indexed: 11/24/2022]
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Ailioaie LM, Ailioaie C, Litscher G. Biomarkers in Systemic Juvenile Idiopathic Arthritis, Macrophage Activation Syndrome and Their Importance in COVID Era. Int J Mol Sci 2022; 23:12757. [PMID: 36361547 PMCID: PMC9655921 DOI: 10.3390/ijms232112757] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 10/18/2022] [Accepted: 10/19/2022] [Indexed: 08/30/2023] Open
Abstract
Systemic juvenile idiopathic arthritis (sJIA) and its complication, macrophage activation syndrome (sJIA-MAS), are rare but sometimes very serious or even critical diseases of childhood that can occasionally be characterized by nonspecific clinical signs and symptoms at onset-such as non-remitting high fever, headache, rash, or arthralgia-and are biologically accompanied by an increase in acute-phase reactants. For a correct positive diagnosis, it is necessary to rule out bacterial or viral infections, neoplasia, and other immune-mediated inflammatory diseases. Delays in diagnosis will result in late initiation of targeted therapy. A set of biomarkers is useful to distinguish sJIA or sJIA-MAS from similar clinical entities, especially when arthritis is absent. Biomarkers should be accessible to many patients, with convenient production and acquisition prices for pediatric medical laboratories, as well as being easy to determine, having high sensitivity and specificity, and correlating with pathophysiological disease pathways. The aim of this review was to identify the newest and most powerful biomarkers and their synergistic interaction for easy and accurate recognition of sJIA and sJIA-MAS, so as to immediately guide clinicians in correct diagnosis and in predicting disease outcomes, the response to treatment, and the risk of relapses. Biomarkers constitute an exciting field of research, especially due to the heterogeneous nature of cytokine storm syndromes (CSSs) in the COVID era. They must be selected with utmost care-a fact supported by the increasingly improved genetic and pathophysiological comprehension of sJIA, but also of CSS-so that new classification systems may soon be developed to define homogeneous groups of patients, although each with a distinct disease.
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Affiliation(s)
- Laura Marinela Ailioaie
- Department of Medical Physics, Alexandru Ioan Cuza University, 11 Carol I Boulevard, 700506 Iasi, Romania
| | - Constantin Ailioaie
- Department of Medical Physics, Alexandru Ioan Cuza University, 11 Carol I Boulevard, 700506 Iasi, Romania
| | - Gerhard Litscher
- Research Unit of Biomedical Engineering in Anesthesia and Intensive Care Medicine, Research Unit for Complementary and Integrative Laser Medicine, Traditional Chinese Medicine (TCM) Research Center Graz, Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Auenbruggerplatz 39, 8036 Graz, Austria
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Wu J, Sun L, Tang X, Zheng Q, Guo L, Xu L, Li Y, Lu M. Effective Therapy of Tocilizumab on Systemic Juvenile Idiopathic Arthritis Associated Refractory Macrophage Activation Syndrome. Mod Rheumatol 2021; 32:1114-1121. [PMID: 34971386 DOI: 10.1093/mr/roab119] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 10/23/2021] [Accepted: 11/19/2021] [Indexed: 11/12/2022]
Abstract
OBJECTIVES To evaluate the safety and efficacy of tocilizumab (TCZ) on refractory macrophage activation syndrome (rMAS) associated with systemic juvenile idiopathic arthritis (sJIA-rMAS). METHODS We retrospectively reviewed the charts of 14 patients diagnosed with sJIA-rMAS, who were treated with TCZ after failing conventional therapies at three hospital centers from Jan 2016 to Dec 2020. Demographic, clinical, and laboratory characteristics were recorded at the onset of MAS, before TCZ (pre-TCZ) and 14 days after TCZ (post-TCZ). RESULTS The clinical manifestation of sJIA-rMAS included fever (100%), skin rashes (35.7%), lymphadenomegaly (42.9%), hepatomegaly (57.1%), splenomegaly (7.1%), gastrointestinal symptoms (28.6%), arthritis (14.3%), myalgia (28.6%) and polyserositis (14.3%). After TCZ treatment, fever (100%, 14/14), gastrointestinal symptoms (100%, 4/4) and myalgia (100%, 4/4) were significantly improved after one week (p< 0.05). Skin rashes, lymphadenomegaly and arthritis also improved in many patients but these parameters did not reach statistical significance. In post-TCZ group, decreases in levels of c-reactive protein, erythrocyte sedimentation rate and serum ferritin of sJIA-rMAS were observed compared with pre-TCZ (p< 0.05). Although not statistically significant, post-TCZ group showed normalization of white blood cell, platelet count, alanine aminotransferase, aspartate aminotransferase, lactic dehydrogenase and triglyceride levels compared with pre-TCZ. No disease relapse or fatality was recorded during the follow-up (25 months, range 3-60 months). CONCLUSIONS TCZ is safe and effective for the treatment of sJIA-rMAS after failure of conventional therapies.
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Affiliation(s)
- Jianqiang Wu
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Li Sun
- Department of Rheumatology, Children's Hospital of Fudan University, National Children's Medical Center, Shanghai, China
| | - Xuemei Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Qi Zheng
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Li Guo
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Li Xu
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yandie Li
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
| | - Meiping Lu
- Department of Rheumatology Immunology and Allergy, The Children's Hospital, Zhejiang University School of Medicine, National Clinical Research Center for Child Health, Hangzhou, China
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Diaz F, Bustos B R, Yagnam F, Karsies TJ, Vásquez-Hoyos P, Jaramillo-Bustamante JC, Gonzalez-Dambrauskas S, Drago M, Cruces P. Comparison of Interleukin-6 Plasma Concentration in Multisystem Inflammatory Syndrome in Children Associated With SARS-CoV-2 and Pediatric Sepsis. Front Pediatr 2021; 9:756083. [PMID: 34869111 PMCID: PMC8634719 DOI: 10.3389/fped.2021.756083] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Accepted: 10/05/2021] [Indexed: 11/13/2022] Open
Abstract
Importance: Multisystem Inflammatory Syndrome in Children (MIS-C) associated with SARS-CoV-2 infection is thought to be driven by a post-viral dysregulated immune response, where interleukin 6 (IL-6) might have a central role. In this setting, IL-6 inhibitors are prescribed as immunomodulation in cases refractory to standard therapy. Objective: To compare plasma IL-6 concentration between critically ill children with MIS-C and sepsis. Design: A retrospective cohort study from previously collected data. Setting: Individual patient data were gathered from three different international datasets. Participants: Critically ill children between 1 month-old and 18 years old, with an IL-6 level measured within 48 h of admission to intensive care. Septic patients were diagnosed according to Surviving Sepsis Campaign definition and MIS-C cases by CDC criteria. We excluded children with immunodeficiency or immunosuppressive therapy. Exposure: None. Main Outcome(s) and Measure(s): The primary outcome was IL-6 plasma concentration in MIS-C and sepsis group at admission to the intensive care unit. We described demographics, inflammatory biomarkers, and clinical outcomes for both groups. A subgroup analysis for shock in each group was done. Results: We analyzed 66 patients with MIS-C and 44 patients with sepsis. MIS-C cases were older [96 (48, 144) vs. 20 (5, 132) months old, p < 0.01], but no differences in sex (41 vs. 43% female, p = 0.8) compared to septic group. Mechanical ventilation use was 48.5 vs. 93% (p < 0.001), vasoactive drug use 79 vs. 66% (p = 0.13), and mortality 4.6 vs. 34.1% (p < 0.01) in MIS-C group compared to sepsis. IL-6 was 156 (36, 579) ng/dl in MIS-C and 1,432 (122, 6,886) ng/dl in sepsis (p < 0.01), while no significant differences were observed in procalcitonin (PCT) and c-reactive protein (CRP). 52/66 (78.8%) patients had shock in MIS-C group, and 29/44 (65.9%) had septic shock in sepsis group. Septic shock had a significantly higher plasma IL-6 concentration than the three other sub-groups. Differences in IL-6, CRP, and PCT were not statistically different between MIS-C with and without shock. Conclusions and Relevance: IL-6 plasma concentration was elevated in critically ill MIS-C patients but at levels much lower than those of sepsis. Furthermore, IL-6 levels don't discriminate between MIS-C cases with and without shock. These results lead us to question the role of IL-6 in the pathobiology of MIS-C, its diagnosis, clinical outcomes, and, more importantly, the off-label use of IL-6 inhibitors for these cases.
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Affiliation(s)
- Franco Diaz
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile
- Escuela de Medicina, Universidad Finis Terrae, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
| | - Raúl Bustos B
- Unidad de Paciente Crítico Pediátrico, Hospital Guillermo Grant Benavente, Concepción, Chile
- UCI Pediátrica, Clínica Sanatorio Alemán, Concepción, Chile
| | - Felipe Yagnam
- Unidad de Paciente Crítico Pediátrico, Hospital Exequiel González Cortés, Santiago, Chile
| | - Todd J. Karsies
- Pediatric Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, United States
| | - Pablo Vásquez-Hoyos
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Sociedad de Cirugía de Bogotá Hospital de San José, FUCS, Bogotá, Colombia
- Universidad Nacional de Colombia, Bogotá, Colombia
| | - Juan-Camilo Jaramillo-Bustamante
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Pediatric Intensive Care Unit, Hospital General de Medellín, Medellin, Colombia
- Department of Pediatrics, University of Antioquia, Medellín, Colombia
| | - Sebastián Gonzalez-Dambrauskas
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Cuidados Intensivos Pediátricos Especializados (CIPe), Casa de Galicia, Montevideo, Uruguay
- Facultad de Medicina, Unidad de Cuidados Intensivos de Niños del Centro Hospitalario Pereira Rossell (UCIN-CHPR), Universidad de la República, Montevideo, Uruguay
| | - Michelle Drago
- Unidad de Paciente Crítico Pediátrico, Hospital Exequiel González Cortés, Santiago, Chile
| | - Pablo Cruces
- Unidad de Paciente Crítico Pediátrico, Hospital El Carmen de Maipú, Santiago, Chile
- Red Colaborativa Pediátrica de Latinoamérica (LARed Network), Montevideo, Uruguay
- Centro de Investigación de Medicina Veterinaria, Escuela de Medicina Veterinaria, Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
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Abstract
Juvenile idiopathic arthritis is a group of heterogeneous chronic inflammatory arthropathies occurring in childhood without a known cause. This article discusses the key clinical features of juvenile idiopathic arthritis and treatment updates for oligoarthritis, polyarthritis, enthesitis-related arthritis, psoriatic arthritis, and systemic arthritis. Paradigm changes in management include the earlier use of biologic agents and the introduction of biosimilars and targeted synthetic disease modifying agents like tofacitinib. This review summarizes recent developments while considering potential areas for improvement and study.
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Affiliation(s)
- Karen Onel
- Division of Pediatric Rheumatology, Hospital for Special Surgery, Weill Cornell Medicine, 535 E 70th St 5th Floor, New York, NY 10021, USA
| | - Dax G Rumsey
- Department of Pediatrics, Division of Rheumatology, University of Alberta, 3-502 ECHA, 11405 87 Ave NW, Edmonton, AB T6G 1C9
| | - Susan Shenoi
- Division of Pediatric Rheumatology, Seattle Children's Hospital, University of Washington, MA.7.110, Sand Point Way NE, Seattle, WA 98105, USA.
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10
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Abstract
PURPOSE OF REVIEW Biologics and novel targeted therapeutics have transformed the management of pediatric rheumatic diseases over the past two decades; however, questions about short-term and long-term safety remain. Safety data gathered from recent clinical trials, long-term extensions of prior trials, registries, and other real-world evidence are summarized here for biologics and novel therapeutics commonly prescribed for pediatric rheumatic diseases. RECENT FINDINGS With nearly 20 years of therapeutic experience, tumor necrosis inhibitors (TNFi) are generally well tolerated, although infections, malignancy, and development of new autoimmunity remain a concern. Risk of infections may be higher in IL-1 and IL-6 inhibitors, and lower in abatacept, compared with TNFi. Safety data for B-cell-targeted therapeutics and janus kinase inhibitors are emerging, but remain limited, especially in children. SUMMARY Biologic and novel targeted therapeutics offer a promising future for children with pediatric rheumatic disease. However, long-term safety data in children remain limited for several agents. With any therapeutic option, both short-term and long-term safety concerns must be weighed against individual clinical needs when choosing the optimal treatment for each child.
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Affiliation(s)
- Rachel L. Randell
- Department of Pediatrics, Division of Rheumatology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Mara L. Becker
- Department of Pediatrics, Division of Rheumatology, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Clinical Research Institute, Durham, North Carolina, USA
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Lun Y, Borjini N, Miura NN, Ohno N, Singer NG, Lin F. CDCP1 on Dendritic Cells Contributes to the Development of a Model of Kawasaki Disease. THE JOURNAL OF IMMUNOLOGY 2021; 206:2819-2827. [PMID: 34099547 DOI: 10.4049/jimmunol.2001406] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 04/09/2021] [Indexed: 11/19/2022]
Abstract
The etiology and pathology of Kawasaki disease (KD) remain elusive. Cub domain-containing protein 1 (CDCP1), a cell-surface protein that confers poor prognosis of patients with certain solid tumors, was recently identified as one of the most significantly upregulated genes in SARS-CoV-2-infected children who developed systemic vasculitis, a hallmark of KD. However, a potential role of CDCP1 in KD has not previously been explored. In this study, we found that CDCP1 knockout (KO) mice exhibited attenuated coronary and aortic vasculitis and decreased serum Candida albicans water-soluble fraction (CAWS)-specific IgM/IgG2a and IL-6 concentrations compared with wild-type mice in an established model of KD induced by CAWS administration. CDCP1 expression was not detectable in cardiomyocytes, cardio fibroblasts, or coronary endothelium, but constitutive expression of CDCP1 was observed on dendritic cells (DCs) and was upregulated by CAWS stimulation. CAWS-induced IL-6 production was significantly reduced in CDCP1 KO DCs, in association with impaired Syk-MAPK signaling pathway activation. These novel findings suggest that CDCP1 might regulate KD development by modulating IL-6 production from DCs via the Syk-MAPK signaling pathway.
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Affiliation(s)
- Yu Lun
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA.,Department of Vascular Surgery, The First Hospital, China Medical University, Shenyang, China
| | - Nozha Borjini
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Noriko N Miura
- Laboratory for Immunopharmacology of Microbial Products, School of Pharmacy, Tokyo University of Pharmacy and Life Science, Hachioji, Tokyo, Japan; and
| | - Naohito Ohno
- Laboratory for Immunopharmacology of Microbial Products, School of Pharmacy, Tokyo University of Pharmacy and Life Science, Hachioji, Tokyo, Japan; and
| | - Nora G Singer
- Division of Rheumatology, MetroHealth Medical Center, Cleveland, OH
| | - Feng Lin
- Department of Inflammation and Immunity, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio, USA;
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12
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Lainka E, Baehr M, Raszka B, Haas JP, Hügle B, Fischer N, Foell D, Hinze C, Weissbarth-Riedel E, Kallinich T, Horneff G, Windschall D, Lilienthal E, Niehues T, Neudorf U, Berendes R, Küster RM, Oommen PT, Rietschel C, Lutz T, Weller-Heinemann F, Tenbrock K, Heubner GL, Klotsche J, Wittkowski H. Experiences with IL-1 blockade in systemic juvenile idiopathic arthritis - data from the German AID-registry. Pediatr Rheumatol Online J 2021; 19:38. [PMID: 33752669 PMCID: PMC7986520 DOI: 10.1186/s12969-021-00510-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 02/24/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Systemic juvenile idiopathic arthritis (sJIA) is a complex disease with dysregulation of the innate immune system driven by cytokines. A major role is ascribed to interleukin-1β (IL-1β), supporting the autoinflammatory character of the disease and offering an effective blocking mechanism for treatment. Here we present clinical practice data from the German AID-registry for patients treated with IL-1 inhibition (IL-1i). METHODS In 2009 a clinical and research consortium (AID-Net) was established, including an online AID-registry. Patients with documented sJIA diagnosis were identified. Data for this retrospective IL-1i study were recorded by 17 centers. Response to treatment was evaluated according to Wallace criteria and additionally by an own classifying clinical response system. RESULTS In 6 years, 202 patients with confirmed sJIA were recorded in the AID-registry. Out of these, 111 children received therapy with Anakinra (ANA) (n = 84, 39 f) and/or Canakinumab (CANA) (n = 27, 15 f) at a median age of 8.7 y (range 0.6-19.1). During the first 12 months 75/111 (ANA 55, CANA 20) patients were evaluated according to Wallace criteria (achievement of inactive disease 28/55 and 17/20, remission over 6 months under medication 13/55 and 7/20 cases). Over the whole period of time, clinical response was preserved in the majority of patients (ANA 54/80, CANA 20/27). Arthritis mostly persisted in polyarticular (PA) courses. During treatment with IL-1i concomitant medication could be tapered in about 15%. IL-1i was discontinued in 59/111 patients. 45 (15) adverse events (AE)s in ANA (CANA) treated patients (19.7 (26.6) AE/100 ANA (CANA) exposure years, 95%CI: 14.4-26.4 (14.9-43.9)) were reported. CONCLUSION In a large cohort of sJIA patients from Germany, we can confirm an overall favorable clinical response to both available IL-1 blocking agents. IL-1i was well tolerated with acceptable safety and effectiveness in a real-life clinical setting.
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Affiliation(s)
- Elke Lainka
- Department of Pediatric Rheumatology, University Children's Hospital Essen, Essen, Germany.
| | - Melanie Baehr
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Essen, Germany
| | - Bernadette Raszka
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Essen, Germany
| | - Johannes-Peter Haas
- grid.500039.fGerman Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Boris Hügle
- grid.500039.fGerman Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Nadine Fischer
- grid.500039.fGerman Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Dirk Foell
- grid.5949.10000 0001 2172 9288Department of Pediatric Rheumatology and Immunology, University of Muenster, Muenster, Germany
| | - Claas Hinze
- grid.5949.10000 0001 2172 9288Department of Pediatric Rheumatology and Immunology, University of Muenster, Muenster, Germany
| | - Elisabeth Weissbarth-Riedel
- grid.13648.380000 0001 2180 3484Pediatric Rheumatology, University Children’s Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Tilmann Kallinich
- grid.6363.00000 0001 2218 4662Department of Pediatric Pneumology, Immunology and Intensive Medicine and Center for Chronically Sick Children, Charité University Medicine Berlin and German Rheumatism Research Centre Berlin, Berlin, Germany
| | - Gerd Horneff
- grid.6190.e0000 0000 8580 3777Department of Pediatrics, Asklepios Clinic, Centre for Pediatric Rheumatology, St. Augustin and Medical Faculty, University of Cologne, Cologne, Germany
| | - Daniel Windschall
- grid.416438.cDepartment of Pediatric Rheumatology, St. Josef Hospital, Sendenhorst, Germany
| | - Eggert Lilienthal
- grid.5570.70000 0004 0490 981XDepartment of Pediatrics, Ruhr-University Bochum, Bochum, Germany
| | - Tim Niehues
- HELIOS Children’s Hospital, Pediatric Immunology and Rheumatology, Krefeld, Germany
| | - Ulrich Neudorf
- Department of Pediatric Rheumatology, University Children’s Hospital Essen, Essen, Germany
| | - Rainer Berendes
- Department of Pediatric Rheumatology, St. Marien’s Children’s Hospital Landshut, Landshut, Germany
| | | | - Prasad Thomas Oommen
- grid.411327.20000 0001 2176 9917Department of Pediatric Oncology, Hematology and Clinical Immunology, Center for Child and Adolescent Health, Medical Faculty, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Christoph Rietschel
- Department of Pediatrics, Clementine Children’s Hospital Frankfurt, Frankfurt, Germany
| | - Thomas Lutz
- grid.5253.10000 0001 0328 4908Center for Pediatric and Adolescent Medicine/Pediatric Rheumatology, University Hospital Heidelberg, Heidelberg, Germany
| | | | - Klaus Tenbrock
- grid.1957.a0000 0001 0728 696XDepartment of Pediatric Pneumology, Allergology and Immunology, RWTH Aachen, Aachen, Germany
| | | | - Jens Klotsche
- grid.418217.90000 0000 9323 8675German Rheumatism Research Centre Berlin, Berlin, Germany
| | - Helmut Wittkowski
- grid.5949.10000 0001 2172 9288Department of Pediatric Rheumatology and Immunology, University of Muenster, Muenster, Germany
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13
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Choida V, Hall-Craggs M, Jebson BR, Fisher C, Leandro M, Wedderburn LR, Ciurtin C. Biomarkers of Response to Biologic Therapy in Juvenile Idiopathic Arthritis. Front Pharmacol 2021; 11:635823. [PMID: 33603671 PMCID: PMC7884612 DOI: 10.3389/fphar.2020.635823] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 12/31/2020] [Indexed: 01/22/2023] Open
Abstract
Background: Juvenile idiopathic arthritis (JIA) is the most common chronic inflammatory arthritis of childhood, characterized by various clinical phenotypes associated with variable prognosis. Significant progress has been achieved with the use of biologic treatments, which specifically block pro-inflammatory molecules involved in the disease pathogenesis. The most commonly used biologics in JIA are monoclonal antibodies and recombinant proteins targeting interleukins 1 (IL-1) and 6 (IL-6), and tumor necrosis factor α (TNF-α). Several biomarkers have been investigated in JIA. Aims: To assess the level of evidence available regarding the role of biomarkers in JIA related to guiding clinical and therapeutic decisions, providing disease prognostic information, facilitating disease activity monitoring and assessing biologic treatment response in JIA, as well as propose new strategies for biologic therapy-related biomarker use in JIA. Methods: We searched PubMed for relevant literature using predefined key words corresponding to several categories of biomarkers to assess their role in predicting and assessing biologic treatment response and clinical remission in JIA. Results: We reviewed serological, cellular, genetic, transcriptomic and imaging biomarkers, to identify candidates that are both well-established and widely used, as well as newly investigated in JIA on biologic therapy. We evaluated their role in management of JIA as well as identified the unmet needs for new biomarker discovery and better clinical applications. Conclusion: Although there are no ideal biomarkers in JIA, we identified serological biomarkers with potential clinical utility. We propose strategies of combining biomarkers of response to biologics in JIA, as well as routine implementation of clinically acceptable imaging biomarkers for improved disease assessment performance.
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Affiliation(s)
- Varvara Choida
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
| | | | - Bethany R. Jebson
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- University College London Great Ormond Street Institute for Child Health, London, United Kingdom
| | - Corinne Fisher
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
| | - Maria Leandro
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
| | - Lucy R. Wedderburn
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- University College London Great Ormond Street Institute for Child Health, London, United Kingdom
- NIHR Biomedical Research Centre at Great Ormond Street Hospital, London, United Kingdom
| | - Coziana Ciurtin
- Centre for Adolescent Rheumatology Versus Arthritis at UCL UCLH and GOSH, Division of Medicine, University College London, London, United Kingdom
- Department of Adolescent Rheumatology, University College London Hospital, London, United Kingdom
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14
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Yan X, Tang W, Zhang Z, Zhang Y, Luo C, Tang X. Tocilizumab in Systemic Juvenile Idiopathic Arthritis: Response Differs by Disease Duration at Medication Initiation and by Phenotype of Disease. Front Pediatr 2021; 9:735846. [PMID: 34820342 PMCID: PMC8606744 DOI: 10.3389/fped.2021.735846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 10/01/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: We performed a single-center retrospective study to determine the different efficacy of tocilizumab (TCZ) in the early and late stages and in three phenotypic subgroups (monocyclic, polycyclic, and persistent) of systemic juvenile idiopathic arthritis (sJIA). Methods: Clinical and serological parameters of 77 sJIA patients treated by TCZ were collected from November 1, 2013 to May 1, 2019. Patients were grouped based on the duration group A < 6 months (n = 41) and group B > 6 months (n = 36) and divided into three phenotypes: monocyclic (n = 12), polycyclic (n = 14), and persistent (n = 51) course. Results: At baseline, group A had pronounced ESR, fever less active arthritis than group B (p < 0.05). After 12 weeks of therapy, TCZ alleviated fever, ESR, CRP, and systemic-onset juvenile arthritis disease activity score-27 (sJADAS27) in both group A and group B (p>0.05), while the efficacy of TCZ in relieving active arthritis in group A was better than that in group B (p<0.05). After 1 year of TCZ therapy, it showed that patients with monocyclic phenotype had the highest clinical response rate (91.7%, odds ratio = 0, 95% CI: 24-24, p = 0.00), followed by the polycyclic (28.6%, odds ratio = 2.1, 95% CI: 10.5-18.8, p = 0.00) and the persistent course (9.8%, odds ratio = 1.2, 95% CI: 9.5-13.8, p = 0.00). Conclusion: TCZ can quickly relieve fever and inflammation, especially when patients have less active arthritis with shorter disease duration. The long-term efficacy of TCZ is related to the phenotypes, among which the monocyclic is the best, and the persistent is the worst.
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Affiliation(s)
- Xin Yan
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Wenjing Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Zhiyong Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Zhang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Chong Luo
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Xuemei Tang
- Department of Rheumatology and Immunology, Children's Hospital of Chongqing Medical University, Chongqing, China.,Chongqing Key Laboratory of Child Infection and Immunity, Children's Hospital of Chongqing Medical University, Chongqing, China.,Ministry of Education Key Laboratory of Child Development and Disorders, National Clinical Research Center for Child Health and Disorders, China Development and Critical Disorders, Children's Hospital of Chongqing Medical University, Chongqing, China
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15
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Kedor C, Listing J, Zernicke J, Weiß A, Behrens F, Blank N, Henes JC, Kekow J, Rubbert-Roth A, Schulze-Koops H, Seipelt E, Specker C, Feist E. Canakinumab for Treatment of Adult-Onset Still's Disease to Achieve Reduction of Arthritic Manifestation (CONSIDER): phase II, randomised, double-blind, placebo-controlled, multicentre, investigator-initiated trial. Ann Rheum Dis 2020; 79:1090-1097. [PMID: 32404342 PMCID: PMC7392486 DOI: 10.1136/annrheumdis-2020-217155] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 04/22/2020] [Accepted: 04/22/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Inhibition of interleukin (IL)-1 represents a promising treatment option in adult-onset Still's disease (AOSD). OBJECTIVE To investigate the efficacy and safety of canakinumab in patients with AOSD and active joint involvement by means of a multicentre, double-blind, randomised, placebo-controlled trial. METHODS Patients with AOSD and active joint involvement (tender and swollen joint counts of ≥4 each) were treated with canakinumab (4 mg/kg, maximum 300 mg subcutaneous every 4 weeks) or placebo. The primary endpoint was the proportion of patients with a clinically relevant reduction in disease activity at week 12 as determined by the change in disease activity score (ΔDAS28>1.2). RESULTS At enrolment, patients had high active disease with a mean DAS28(ESR) of 5.4 in the canakinumab and 5.3 in the placebo group, respectively. In the intention-to-treat analysis, 12 patients (67%) in the canakinumab group and 7 patients (41%) in the placebo group fulfilled the primary outcome criterion (p=0.18). In the per-protocol analysis, significantly higher American College of Rheumatology (ACR) 30% (61% vs 20%, p=0.033), ACR 50% (50% vs 6.7%, p=0.009) and ACR 70% (28% vs 0%, p=0.049) response rates were observed in the canakinumab group compared with the placebo group. Two patients in the canakinumab group experienced a serious adverse event. CONCLUSION Although the study was terminated prematurely and the primary endpoint was not achieved, treatment with canakinumab led to an improvement of several outcome measures in AOSD. The overall safety findings were consistent with the known profile of canakinumab. Thus, our data support indication for IL-1 inhibition with canakinumab in AOSD.
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Affiliation(s)
- Claudia Kedor
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Joachim Listing
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Jan Zernicke
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Anja Weiß
- Epidemiology Unit, German Rheumatism Research Centre, Berlin, Germany
| | - Frank Behrens
- CIRI/Rheumatology and Fraunhofer TMP, Goethe-University, Frankfurt, Germany
| | - Norbert Blank
- Internal Medicine 5, University of Heidelberg, Heidelberg, Germany
| | - Joerg Christoph Henes
- Centre for Interdisciplinary Clinical Immunology, Rheumatology and Auto-inflammatory Diseases and Department of Internal Medicine II (Oncology, Haematology, Immunology, Rheumatology, Pulmology), University Hospital Tuebingen, Tuebingen, Germany
| | - Joern Kekow
- Clinic of Rheumatology and Orthopaedics, Otto-von-Guericke University Magdeburg, Vogelsang-Gommern, Germany
| | - Andrea Rubbert-Roth
- Division of Rheumatology, Cantonal Hospital St Gallen, St Gallen, Switzerland
| | | | - Eva Seipelt
- Abteilung Rheumatologie und Klinische Immunologie, Immanuel Krankenhaus Berlin, Standort Berlin-Buch, Berlin, Germany
| | - Christof Specker
- Klinik für Rheumatologie und Klinische Immunologie, KEM Kliniken Essen-Mitte, Essen, Germany
| | - Eugen Feist
- Department of Rheumatology and Clinical Immunology, Charité Universitätsmedizin Berlin, Berlin, Germany
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16
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Predicting disease severity and remission in juvenile idiopathic arthritis: are we getting closer? Curr Opin Rheumatol 2020; 31:436-449. [PMID: 31085941 DOI: 10.1097/bor.0000000000000620] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE OF REVIEW To summarize current research on the prediction of severe disease or remission in children with juvenile arthritis, and define further steps needed towards developing prediction tools with sufficient accuracy for clinical use. RECENT FINDINGS High disease activity, poor patient-reported outcomes, ankle or wrist involvement, and a longer time from onset to the start of treatment herald a severe disease course and a low chance of remission. Other studies confirmed that age less than 7 years and positive ANA are the strongest predictors of uveitis development. Preliminary evidence suggests ultrasound findings may predict flare in patients with clinically inactive disease, and several new biomarkers show promise. A few prediction tools that combine predictors to estimate the chance of remission or a severe disease course in the medium-term to long-term have shown good accuracy when internally validated in the population in which they were developed. SUMMARY Promising candidate tools for predicting disease severity and long-term remission in juvenile arthritis are now available. These tools need external validation in other populations, and ideally formal trials to assess whether their use in practice improves patient outcomes. We are definitively getting closer, but we are not there yet.
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17
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Severe sepsis caused by serious gastrointestinal infection in sJIA patients treated with IL-6 receptor antagonist: a case report. BMC Pediatr 2020; 20:126. [PMID: 32188441 PMCID: PMC7079483 DOI: 10.1186/s12887-020-02032-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2019] [Accepted: 03/12/2020] [Indexed: 01/30/2023] Open
Abstract
Background Interleukin (IL)-6 plays an essential role in the pathogenesis of systemic juvenile idiopathic arthritis (sJIA). Tocilizumab (TCZ), a kind of biological agent against both membrane and soluble IL-6 receptor, is the only biological agent approved for the treatment of sJIA in China. Infections are the most common adverse events during TCZ therapy, and most of infections are mild or moderate. Severe sepsis originated from gastrointestinal infection is rarely reported. Case presentation In this article, we reported two 13-year-old sJIA patients who suffered from life-threatening infections after TCZ administration. Within one day, both of them presented rapidly progressive conditions that included fever, abdominal pain, dizziness, diarrhea and vomiting, and laboratory tests showed multi-organ dysfunctions. They were diagnosed with severe sepsis and septic shock that were supposed to be caused by the pathogens from the gastrointestinal tract, and they were eventually rescued by timely treatment. In addition, we also reviewed the literature about serious gastrointestinal infections and sepsis in sJIA patients receiving TCZ therapy. Conclusions In summary, for sJIA patients with TCZ therapy, invading pathogens from the gastrointestinal tract can cause an intensely systemic infection that may even be fatal. Therefore, it is essential to pay attention to the gastrointestinal management of sJIA patients as well as remind them of their intestinal hygiene.
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18
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Hinze C, Fuehner S, Kessel C, Wittkowski H, Lainka E, Baehr M, Hügle B, Haas J, Ganser G, Weißbarth‐Riedel E, Jansson A, Foell D. Impact of
IL1RN
Variants on Response to Interleukin‐1 Blocking Therapy in Systemic Juvenile Idiopathic Arthritis. Arthritis Rheumatol 2020; 72:499-505. [DOI: 10.1002/art.41130] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Accepted: 10/03/2019] [Indexed: 12/29/2022]
Affiliation(s)
| | | | | | | | | | | | - Boris Hügle
- German Center for Pediatric and Adolescent Rheumatology Garmisch‐Partenkirchen Germany
| | - Johannes‐Peter Haas
- German Center for Pediatric and Adolescent Rheumatology Garmisch‐Partenkirchen Germany
| | - Gerd Ganser
- St. Josef‐Stift Sendenhorst Sendenhorst Germany
| | | | | | - Dirk Foell
- University Hospital Munster Munster Germany
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Abstract
The autoinflammatory diseases comprise a broad spectrum of disorders characterized by unchecked activation of the innate immune system. Whereas aberrations in adaptive immunity have long been identified in 'autoimmune' disorders, the concept of 'autoinflammation' emerged relatively recently, first describing a group of clinical disorders characterized by spontaneous episodes of systemic inflammation without manifestations typical of autoimmune disorders. Improved knowledge of innate immune mechanisms, coupled with remarkable progress in genomics and an expanding number of clinical cases, has since led to an increasing number of disorders classified as autoinflammatory or containing an autoinflammatory component. Biologic therapies targeting specific components of the innate immune system have provided immense clinical benefit, and have further elucidated the role of innate immunity in autoinflammatory disorders. This article reviews the basic mechanisms of autoinflammation, followed by an update on the pathophysiology and treatment of the monogenic and multifactorial autoinflammatory diseases, and the common dermatologic conditions in which autoinflammation plays a major role.
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20
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Barut K, Adrovic A, Sahin S, Tarcin G, Tahaoglu G, Koker O, Yildiz M, Kasapcopur O. Prognosis, complications and treatment response in systemic juvenile idiopathic arthritis patients: A single-center experience. Int J Rheum Dis 2019; 22:1661-1669. [PMID: 31273940 DOI: 10.1111/1756-185x.13649] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Revised: 05/15/2019] [Accepted: 06/13/2019] [Indexed: 02/06/2023]
Abstract
AIM Systemic juvenile idiopathic arthritis (sJIA) is a distinctive subtype of JIA characterized by systemic features and poor outcome. We aimed to investigate demographic and clinical features, long-term treatment response and disease complications in a large sJIA cohort. METHODS Patients diagnosed with sJIA followed up at a pediatric rheumatology outpatient department from January 2003 to December 2017 were included. Demographic and clinical features, long-term treatment response and disease complications were retrospectively collected. RESULTS A total of 168 sJIA patients (51.8% female, 48.2% male) were included: 31.5% with monocyclic, 13.7% polycyclic and 54.8% with persistent clinical course. Corticosteroids were initially used in all patients. Methotrexate was used in 75% and cyclosporine A was used in 17.3% patients. Biological drugs were used in 42.8% patients; etanercept in 29.7%, anakinra in 16%, canakinumab in 16%, tocilizumab in 10% patients. Remission off medication was achieved in 82 (48.8%). Macrophage activation syndrome (MAS) was present in 11.9%, growth retardation in 11.3% patients. Eight percent (4/50) of patients had low bone mineral density. Three patients (1.78%) died due to MAS secondary multiorgan insufficiency and infection. CONCLUSION The disease is characterized with diverse clinical presentation and possibly severe complications. MAS complicated with multiorgan insufficiency is the major mortality factor. Corticosteroids represent the mainstay of the initial treatment. In patients resistant to classic treatment, biological drugs should be timely introduced.
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Affiliation(s)
- Kenan Barut
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Amra Adrovic
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Sezgin Sahin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gurkan Tarcin
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Gulberk Tahaoglu
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Oya Koker
- Department of Pediatric Rheumatology, Istanbul Faculty of Medicine, Istanbul University, Istanbul, Turkey
| | - Mehmet Yildiz
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Ozgur Kasapcopur
- Department of Pediatric Rheumatology, Cerrahpasa Medical School, Istanbul University-Cerrahpasa, Istanbul, Turkey
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Abstract
Juvenile idiopathic arthritis (JIA) is a chronic childhood arthritis. Its pathogenesis is very complicated, with the involvement of not only immune cells but various types of parenchymal cells, and is affected by both genetic and environmental predispositions. The clinical spectrum from inflammation to related conditions is largely mediated by cytokines including interleukin (IL)-6. Fluctuations in IL-6 and its related molecules can modulate the pathogenesis and the clinical presentation positively or negatively. The recent clinical impact of IL-6 blockade on JIA has begun a therapeutic paradigm shift. This review describes the characteristics of JIA, mainly focused on IL-6 with the current therapeutic perspective.
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Affiliation(s)
- Shinji Akioka
- a Department of Pediatrics , Kyoto Prefectural University of Medicine , Kyoto , Japan
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22
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Jung JH, Kim JH, Song GG, Choi SJ. Association between interleukin-10 polymorphisms and juvenile idiopathic arthritis: a meta-analysis. Minerva Pediatr (Torino) 2018; 74:81-89. [PMID: 30511559 DOI: 10.23736/s2724-5276.18.05369-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The aim of this review is to investigate IL-10 polymorphisms (-1082 G/A, -819 C/T, and -592 C/A) and their association with susceptibility to JIA. EVIDENCE ACQUISITION A meta-analysis was conducted after database search for relevant articles (MEDLINE and EMBASE). EVIDENCE SYNTHESIS A total of seven studies involving 1495 patients and 1670 controls were considered in the meta-analysis. There was no association between the IL-10 -1082 G/A, -819 C/T, and -592 C/A polymorphisms and JIA in allele contrast and any of the genetic models (allele contrast: odds ratio [OR] 0.90, 95% confidence interval [CI] 0.79-1.02, P=0.09; OR=0.97, 95% CI 0.83-1.13, P=0.68; OR=0.92, 95% CI 0.81-1.06, P=0.24, respectively). In subgroup analysis, none of the subtypes of JIA including systemic, rheumatoid factor (RF)-positive polyarticular, RF-negative polyarticular, and oligoarticular was not significantly associated with IL-10 polymorphism. Meta-analysis of the IL-10 haplotype revealed no association between GCC, ACC, and ATA haplotypes and JIA. CONCLUSIONS This meta-analysis showed that IL-10 polymorphisms were not associated with risk of JIA.
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Affiliation(s)
- Jae Hyun Jung
- Korea University College of Medicine, Seoul, South Korea.,Division of Rheumatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Jae-Hoon Kim
- Korea University College of Medicine, Seoul, South Korea.,Division of Rheumatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Gwan Gyu Song
- Korea University College of Medicine, Seoul, South Korea.,Division of Rheumatology, Department of Internal Medicine, Korea University Guro Hospital, Seoul, South Korea
| | - Sung Jae Choi
- Korea University College of Medicine, Seoul, South Korea - .,Division of Rheumatology, Department of Internal Medicine, Korea University Ansan Hospital, Ansan, South Korea
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Feng M, Kang M, He F, Xiao Z, Liu Z, Yao H, Wu J. Plasma interleukin-37 is increased and inhibits the production of inflammatory cytokines in peripheral blood mononuclear cells in systemic juvenile idiopathic arthritis patients. J Transl Med 2018; 16:277. [PMID: 30305171 PMCID: PMC6180625 DOI: 10.1186/s12967-018-1655-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 10/04/2018] [Indexed: 12/22/2022] Open
Abstract
Background Interleukin (IL)-37 has emerged as a novel anti-inflammatory cytokine that play an immunosuppressive role in regulating inflammatory response. This study aimed to measure IL-37 levels in the plasma and peripheral blood mononuclear cells (PBMCs) of patients with systemic juvenile idiopathic arthritis (sJIA), and to establish the correlation between IL-37 levels and disease activity, laboratory parameters and inflammatory cytokines. Methods The mRNA levels of IL-37 in PBMCs and plasma IL-37 concentrations in 46 sJIA patients and 30 age- and sex-matched healthy controls were measured by real-time polymerase chain reaction (RT-PCR) and enzyme-linked immunosorbent assay (ELISA), respectively. The correlations between plasma IL-37 levels and disease activity, laboratory parameters and inflammatory cytokines in sJIA were analyzed by Spearman correlation test. PBMCs from the sJIA patients were stimulated with recombinant human IL-37 (rhIL-37) protein, expressions of IL-1β, IL-6, TNF-α and IL-17 were detected by RT-PCR and ELISA. Results Plasma levels of IL-37 and relative IL-37 mRNA expression were significantly elevated in sJIA patients, especially in active sJIA patients, when compared with the healthy controls (P < 0.001). Furthermore, patients with active disease showed higher IL-37 mRNAs and plasma protein levels than those with inactive disease as well as healthy controls. Plasma IL-37 levels were correlated with disease activity and inflammatory cytokines (IL-6, TNF-α, IL-17 and GM-CSF) in sJIA patients. The productions of inflammatory cytokines such as IL-6, TNF-α, IL-17 in PBMCs from sJIA patients were obviously decreased after recombinant IL-37 stimulation, whereas the production of IL-1β was not changed. Conclusions Our results demonstrate that levels of IL-37 were higher in sJIA patients, which were correlated with disease activity and sJIA related inflammatory cytokines. In addition, rhIL-37 down-regulates the expressions of inflammatory cytokines form PBMCs in sJIA patients, suggesting that IL-37 may have the potential role as a natural inhibitor for the pathogenesis and therapy of sJIA. Electronic supplementary material The online version of this article (10.1186/s12967-018-1655-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Miao Feng
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Min Kang
- Department of Immunology and Rheumatology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Feng He
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Zonghui Xiao
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Zhewei Liu
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China
| | - Hailan Yao
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China.
| | - Jianxin Wu
- Department of Biochemistry and Immunology, Capital Institute of Pediatrics, No. 2 Yabao Road, Chao Yang District, Beijing, 100020, China.
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