Childhood-Onset Lupus Nephritis in the Childhood Arthritis and Rheumatology Research Alliance Registry: Short-Term Kidney Status and Variation in Care

OBJECTIVE

The goal was to characterize short-term kidney status and describe variation in early care utilization in a multicenter cohort of patients with childhood-onset systemic lupus erythematosus (cSLE) and nephritis.

METHODS

We analyzed previously collected prospective data from North American patients with cSLE with kidney biopsy-proven nephritis enrolled in the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry from March 2017 through December 2019. We determined the proportion of patients with abnormal kidney status at the most recent registry visit and applied generalized linear mixed models to identify associated factors. We also calculated frequency of medication use, both during induction and ever recorded.

RESULTS

We identified 222 patients with kidney biopsy-proven nephritis, with 64% class III/IV nephritis on initial biopsy. At the most recent registry visit at median (interquartile range) of 17 (8-29) months from initial kidney biopsy, 58 of 106 patients (55%) with available data had abnormal kidney status. This finding was associated with male sex (odds ratio [OR] 3.88, 95% confidence interval [95% CI] 1.21-12.46) and age at cSLE diagnosis (OR 1.23, 95% CI 1.01-1.49). Patients with class IV nephritis were more likely than class III to receive cyclophosphamide and rituximab during induction. There was substantial variation in mycophenolate, cyclophosphamide, and rituximab ever use patterns across rheumatology centers.

CONCLUSION

In this cohort with predominately class III/IV nephritis, male sex and older age at cSLE diagnosis were associated with abnormal short-term kidney status. We also observed substantial variation in contemporary medication use for pediatric lupus nephritis between pediatric rheumatology centers. Additional studies are needed to better understand the impact of this variation on long-term kidney outcomes.

Inflammatory Arthritis in a 19-month-old with Von Hippel-Lindau Disease

Von Hippel-Lindau disease (VHL) is a rare autosomal dominant disease characterized by progressive development of cysts and tumors. Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disorder and the most common arthritis in children. Although the mechanism of pathogenesis is not fully understood, JIA is thought to be a polygenic, autoimmune-mediated disease. Inherited or acquired disorders resulting in immune dysregulation can lead to neoplastic and autoimmune disease, but very few cases of patients with VHL and concomitant autoimmune disease are reported in the literature. Herein, we describe, to the best of our knowledge, the first reported case of a child with VHL and inflammatory arthritis, and we discuss three possible pathophysiologic mechanisms that could link VHL and JIA. Understanding the shared pathophysiology and genetics of both diseases may help guide future direction of targeted therapies and lead to improved clinical outcomes.

Intraarticular steroids as DMARD-sparing agents for juvenile idiopathic arthritis flares: Analysis of the Childhood Arthritis and Rheumatology Research Alliance Registry

BACKGROUND

Children with juvenile idiopathic arthritis (JIA) who achieve a drug free remission often experience a flare of their disease requiring either intraarticular steroids (IAS) or systemic treatment with disease modifying anti-rheumatic drugs (DMARDs). IAS offer an opportunity to recapture disease control and avoid exposure to side effects from systemic immunosuppression. We examined a cohort of patients treated with IAS after drug free remission and report the probability of restarting systemic treatment within 12 months.

METHODS

We analyzed a cohort of patients from the Childhood Arthritis and Rheumatology Research Alliance (CARRA) Registry who received IAS for a flare after a period of drug free remission. Historical factors and clinical characteristics and of the patients including data obtained at the time of treatment were analyzed.

RESULTS

We identified 46 patients who met the inclusion criteria. Of those with follow up data available 49% had restarted systemic treatment 6 months after IAS injection and 70% had restarted systemic treatment at 12 months. The proportion of patients with prior use of a biologic DMARD was the only factor that differed between patients who restarted systemic treatment those who did not, both at 6 months (79% vs 35%, p < 0.01) and 12 months (81% vs 33%, p < 0.05).

CONCLUSION

While IAS are an option for all patients who flare after drug free remission, it may not prevent the need to restart systemic treatment. Prior use of a biologic DMARD may predict lack of success for IAS. Those who previously received methotrexate only, on the other hand, are excellent candidates for IAS.

Retropharyngeal involvement in multisystem inflammatory syndrome in children: Case report and review of literature

A diagnosis of multisystem inflammatory syndrome in children should be made in the appropriate context and after ruling out other infectious causes. At the same time, clinicians should be diligent as the initial presentation can be unusual and the clinical picture can evolve over time. We report a case that was initially diagnosed as a retropharyngeal infection that did not improve on appropriate antimicrobial coverage. However, as the clinical picture evolved, the patient was found to have multisystem inflammatory syndrome in children and appropriately responded to immunomodulatory treatment. Pediatric infectious diseases practice has been significantly affected by the COVID-19 virus and multisystem inflammatory syndrome in children; data are still emerging as the pandemic evolves. We report this case and conduct literature review to expand the body of evidence about the association between multisystem inflammatory syndrome in children and retropharyngeal involvement.

A case of ANCA-associated vasculitis in a 16-year-old female following SARS-COV-2 infection and a systematic review of the literature

BACKGROUND

Antineutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV) is a rare form of vasculitis in children. SARS-CoV-2, the virus that causes COVID-19 infection, seems to trigger autoimmunity and new-onset autoimmune disease in pediatric and adult patients. We present a case of new-onset AAV following COVID-19 infection in an adolescent patient, and we review the literature of AAV following COVID-19 infection.

CASE PRESENTATION

An adolescent female with a history of asthma was diagnosed with mild COVID-19 infection and subsequently developed persistent cough, wheezing, hearing loss, arthralgias, and rash. Her imaging and laboratory workup showed pulmonary nodules and cavitary lesions, elevated inflammatory markers, negative infectious testing, and positive ANCA. She was treated with glucocorticoids, rituximab, and mycophenolate mofetil. At six-month follow-up, she had improvement in her symptoms, pulmonary function tests, imaging findings, and laboratory markers.

CONCLUSIONS

We report the second case of new-onset anti-PR3, C-ANCA vasculitis and the fourth case of pediatric-onset AAV following COVID-19 infection. A systematic review of the literature found 6 cases of new-onset AAV in adults after COVID-19 infection. Pediatric and adult patients who develop AAV post COVID-19 infection have few, if any, comorbidities, and show marked radiographic and symptomatic improvement after treatment. There is increasing evidence for COVID-19-induced autoimmunity in children and our case highlights the importance of considering AAV in a child following a recent COVID-19 infection because timely treatment may improve clinical outcomes.

The evaluation of pancreas β-cell autoantibodies in non-diabetic COVID-19 patients

Objective

This study aims to evaluate potential pancreas endocrine damage due to SARS-CoV-2 by measuring β-cell autoantibodies in COVID-19 patients.

Subjects and methods

Between June and July 2020, 95 inpatients with a positive COVID-19 test result after polymerase-chain-reaction (PCR) and who met the inclusion criteria were enrolled in our study. Laboratory parameters that belong to glucose metabolism and β-cell autoantibodies, including anti-islet, anti-glutamic acid decarboxylase, and anti-insulin autoantibodies, were measured. β-cell autoantibodies levels of the patients were measured during COVID-19 diagnosis. Positive results were reevaluated in the 3rd month of control.

Results

In the initial evaluation, 4 (4.2%) patients were positive for anti-islet autoantibody. Only one (1.1%) patient was positive for anti-glutamic acid decarboxylase autoantibody. No patient had positive results for anti-insulin autoantibody. FPG, HbA1c, and C-peptide levels were similar in patients who were split into groups regarding the initial positive or negative status of anti-islet and anti-GAD autoantibodies (p>0.05). In the 3rd month after the initial measurements, anti-islet autoantibody positivity of 2 (50%) of 4 patients and anti-glutamic acid decarboxylase positivity of 1 (100%) patient were persistent. Finally, 3 (3.1%) patients in the whole group were positive for anti-islet autoantibody in the 3rd month of control. No difference was determined between the initial and the 3rd month of parameters of glucose metabolism.

Conclusion

Following an ongoing autoantibody positivity in the present study brings the mind that SARS-CoV-2 may be responsible for the diabetogenic effect. Clinicians should be aware of autoantibody-positive DM as a potential autoimmune complication in patients with SARS-CoV-2.

Multisystem Inflammatory Syndrome in an Adolescent Following SARS-CoV-2 Exposure Despite Three Doses of a COVID-19 Vaccine

The multisystem inflammatory syndrome in children (MIS-C) is a known complication of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in the pediatric population. Recent studies have demonstrated high efficacy of a two-dose vaccine series in preventing MIS-C among adolescents. To date, such studies have only included children exposed to SARS-CoV-2 prior to the emergence of the Omicron variant (B.1.1.529). We report a case of an adolescent who received three doses of a vaccine yet developed MIS-C following known exposure to SARS-CoV-2. Given the uncertainty in whether current vaccines offer as much protection against MIS-C due to the Omicron variant or any potential new variants as they have for older variants, pediatric providers should maintain a high index of suspicion for MIS-C regardless of vaccination status.

Social determinants of health influence disease activity and functional disability in Polyarticular Juvenile Idiopathic Arthritis

BACKGROUND

Social determinants of health (SDH) greatly influence outcomes during the first year of treatment in rheumatoid arthritis, a disease similar to polyarticular juvenile idiopathic arthritis (pJIA). We investigated the correlation of community poverty level and other SDH with the persistence of moderate to severe disease activity and functional disability over the first year of treatment in pJIA patients enrolled in the Childhood Arthritis and Rheumatology Research Alliance Registry.

METHODS

In this cohort study, unadjusted and adjusted generalized linear mixed effects models analyzed the effect of community poverty and other SDH on disease activity, using the clinical Juvenile Arthritis Disease Activity Score-10, and disability, using the Child Health Assessment Questionnaire, measured at baseline, 6, and 12 months.

RESULTS

One thousand six hundred eighty-four patients were identified. High community poverty (≥20% living below the federal poverty level) was associated with increased odds of functional disability (OR 1.82, 95% CI 1.28-2.60) but was not statistically significant after adjustment (aOR 1.23, 95% CI 0.81-1.86) and was not associated with increased disease activity. Non-white race/ethnicity was associated with higher disease activity (aOR 2.48, 95% CI: 1.41-4.36). Lower self-reported household income was associated with higher disease activity and persistent functional disability. Public insurance (aOR 1.56, 95% CI 1.06-2.29) and low family education (aOR 1.89, 95% CI 1.14-3.12) was associated with persistent functional disability.

CONCLUSION

High community poverty level was associated with persistent functional disability in unadjusted analysis but not with persistent moderate to high disease activity. Race/ethnicity and other SDH were associated with persistent disease activity and functional disability.

The effects of hydroxyurea on proinflammatory cytokine and tissue histopathology in an experimental sepsis model

OBJECTIVE

The diagnosis and treatment of sepsis are costly to healthcare services, and it is an important disease with high mortality rates. In the pathogenesis of sepsis, for which we still cannot provide a complete cure, there is increased cytokine release and organ damage. Hydroxyurea has been shown to reduce leukocyte counts, decrease inflammatory cytokines, and limit organ inflammation in ischemia-reperfusion models. This study aimed to evaluate leukocyte counts, interleukin-1 beta (IL-1β), IL-6, and tumor necrosis factor-alpha (TNF-α) cytokine values and organ inflammatory processes in hydroxyurea-treated rats with an experimental sepsis model.

MATERIALS AND METHODS

After ethical approval, rats were randomly divided into three groups, control (n= 7), sepsis (n= 7), and hydroxyurea (n= 7). Sepsis was created using the cecal ligation and puncture (CLP) method in rats other than in the control group. Rats in the hydroxyurea group received hydroxyurea (200 mg/kg) intragastrically, and the control and sepsis groups received sterile distilled water. IL-1β, IL-6, and TNF-α levels were measured at 0, 8, and 24 hours after CLP in all rats. Blood samples were collected at the time of sacrification 24 hours after CLP and analyzed for the complete blood count. Tissue specimens were taken for histopathologic examination.

RESULTS

Cytokine levels (IL-1β, IL-6, TNF-α), white blood cell counts, and tissue damage were increased after the sepsis model in rats. It was found that the cytokine levels at the 8th hour, white blood cell count, and brain tissue damage in the hydroxyurea group were decreased significantly compared with the sepsis group.

CONCLUSIONS

Early hydroxyurea treatment in rats with sepsis decreases proinflammatory cytokine (IL-1β, IL-6, and TNF-α) levels and thus reduces brain damage.

Cryptococcus albidus Fungemia in an Immunosuppressed Child: Case Report and Systematic Literature Review

Cryptococcus albidus, synonymous with Naganishia albida, rarely causes opportunistic infection in immunocompromised individuals. Its clinical features, particularly in children, are not well defined. Here, we report a case of C albidus fungemia in an immunosuppressed child; we also present results of a systematic review, for which we searched PubMed, Embase, and Web of Science using the keywords "cryptococcus" and "albidus." Our goal was to describe the spectrum of disease, diagnostic approaches, therapies, and outcomes. We identified 20 cases of invasive infection, only 2 of which involved children, and 7 cases of noninvasive infection. The reports originated in the Americas, Europe, and Asia. Of those with invasive infection, 16 (80%) patients had an underlying chronic disorder or had received immunosuppressive therapy, 8 (40%) had fungemia, and 6 (30%) had a central nervous system infection. The attributable case fatality rate was 40%. C albidus is an opportunistic yeast that can rarely cause life-threatening fungemia and central nervous system infection in individuals of any age, especially those who are immunocompromised.

SIADH in Systemic JIA Resolving After Treatment With an IL-6 Inhibitor

Interleukin-6 (IL-6) is implicated in the pathogenesis of both systemic juvenile idiopathic arthritis (SJIA) and syndrome of inappropriate secretion of antidiuretic hormone (SIADH), but the 2 have not been previously described as occurring together. We report a case of a 6-year-old girl with symptoms of arthralgia, daily fevers, evanescent rash, lymphadenopathy, and laboratory evaluation showing elevated inflammatory markers, consistent with SJIA. At presentation, the patient had hyponatremia with a sodium level of 128 mEq/L. She had low serum osmolality with elevated urine osmolality, consistent with SIADH. Hyponatremia improved temporarily during times of fluid restriction as expected in SIADH, but did not resolve until SJIA was treated successfully with tocilizumab, an IL-6 receptor antibody that inhibits IL-6 activity. The positive response to treatment with tocilizumab supports the role of IL-6 in the pathogenesis of both SJIA and SIADH. Patients with SJIA should be monitored for SIADH to avoid complications of untreated hyponatremia.

A Sweet Case of Mycoplasma

Sweet syndrome, also known as acute febrile neutrophilic dermatosis, is an uncommon inflammatory disorder marked by fever and swelling of the skin that can be very painful. It is especially rare in the pediatric population. Infection is a well-known trigger for Sweet syndrome, but this entity has, to our knowledge, never been described after Mycoplasma infection. Herein, we describe the first pediatric case of febrile neutrophilic dermatosis associated with Mycoplasma infection.

The effects of tramadol infiltration on wound healing in rats

PURPOSE

Infiltration of a local anesthetic to provide postoperative analgesia is a frequently used method. However the infiltrated agents may have negative effects on wound healing. This study aimed to investigate the effects of tramadol, a weak opioid with a local anesthetic effect, on wound healing.

METHODS

Wistar albino rats were used in the study. Tramadol and saline infiltration was randomly performed on the left and right backs of rats. Following a linear incision, the site was sutured. A follow-up was conducted after seven days, and the tissue samples from both locations were extracted for histopathological examinations (fibrotic index : no fibrosis 0, mild 1, moderate 2, severe 3) and hydroxyproline measurements.

RESULTS

The hydroxyproline level found in the tramadol group was 0.060 +/- 0.04 ng/mg.protein. In the control group the hydroxyproline level was 0.012 +/-0.01 ng/mg.protein (p = 0.01). The fibrotic index levels in the tramadol group were higher than the control group (p < 0.001).

CONCLUSION

It was concluded that tramadol infiltration in a surgical incision site has no adverse effect on wound healing.

The effects of supplementation with a mixture of arginine, glutamine, and beta-hydroxy beta-methylbutyrate on the healing of colon anastomoses

BACKGROUND

Several researchers have investigated how wound healing is effected by supplementation with each of the following amino acids : arginine (Arg), glutamine (Glu), and beta-hydroxy beta-methylbutyrate (HMB). This research investigates how a combination of these amino acids improves the wound healing associated with anastomoses.

METHODS

We tested the effects of a combination of Arg, Glu, and HMB on the healing of colon anastomoses in 50 male rats. We randomly divided the animals into two equal groups. In each animal, the cecum was transected from its midpoint to create an end-to end anastomosis. During the first postoperative week, Group 1 (G1) animals were fed standard chow, and Group 2 (G2) animals were fed standard chow plus a ready-to-use supplement that contained a mixture of Arg, Glu, and HMB. At the end of the week, all of the rats were sacrificed, and a cecum segment containing the anastomosis line was resected. Bursting pressure and tissue hydroxyproline were measured for all animals.

RESULTS

The mean values for hydroxyproline were 0.0013 ng/mg protein/ml (SD +/-0.00075) and 0.034 ng/mg protein/ ml (SD +/- 0.022) for G1 and G2, respectively (p <0.0001). The mean values for bursting pressure measurements were 122.8 mmHg (SD +/- 9.4) and 192.8 mmHg (SD+/- 31) for G1 and G2, respectively (p <0.0001). Statistically significant differences between the groups in terms of both bursting pressure levels and tissue hydroxyproline levels were observed.

CONCLUSION

In an animal model of colon surgery, supplementation with a combination of three amino acids seemingly benefits anastomosis healing.

Consensus treatment plans for induction therapy of newly diagnosed proliferative lupus nephritis in juvenile systemic lupus erythematosus

OBJECTIVE

To formulate consensus treatment plans (CTPs) for induction therapy of newly diagnosed proliferative lupus nephritis (LN) in juvenile systemic lupus erythematosus (SLE).

METHODS

A structured consensus formation process was employed by the members of the Childhood Arthritis and Rheumatology Research Alliance after considering the existing medical evidence and current treatment approaches.

RESULTS

After an initial Delphi survey (response rate = 70%), a 2-day consensus conference, and 2 followup Delphi surveys (response rates = 63-79%), consensus was achieved for a limited set of CTPs addressing the induction therapy of proliferative LN. These CTPs were developed for prototypical patients defined by eligibility characteristics, and included immunosuppressive therapy with either mycophenolic acid orally twice per day, or intravenous cyclophosphamide once per month at standardized dosages for 6 months. Additionally, the CTPs describe 3 options for standardized use of glucocorticoids, including a primarily oral, a mixed oral/intravenous, and a primarily intravenous regimen. There was consensus on measures of effectiveness and safety of the CTPs. The CTPs were well accepted by the pediatric rheumatology providers treating children with LN, and up to 300 children per year in North America are expected to be candidates for the treatment with the CTPs.

CONCLUSION

CTPs for induction therapy of proliferative LN in juvenile SLE based on the available scientific evidence and pediatric rheumatology group experience have been developed. Consistent use of the CTPs may improve the prognosis of proliferative LN, and support the conduct of comparative effectiveness studies aimed at optimizing therapeutic strategies for proliferative LN in juvenile SLE.

Consensus treatment plans for induction therapy of newly diagnosed proliferative lupus nephritis in juvenile systemic lupus erythematosus

OBJECTIVE

To formulate consensus treatment plans (CTPs) for induction therapy of newly diagnosed proliferative lupus nephritis (LN) in juvenile systemic lupus erythematosus (SLE).

METHODS

A structured consensus formation process was employed by the members of the Childhood Arthritis and Rheumatology Research Alliance after considering the existing medical evidence and current treatment approaches.

RESULTS

After an initial Delphi survey (response rate = 70%), a 2-day consensus conference, and 2 followup Delphi surveys (response rates = 63-79%), consensus was achieved for a limited set of CTPs addressing the induction therapy of proliferative LN. These CTPs were developed for prototypical patients defined by eligibility characteristics, and included immunosuppressive therapy with either mycophenolic acid orally twice per day, or intravenous cyclophosphamide once per month at standardized dosages for 6 months. Additionally, the CTPs describe 3 options for standardized use of glucocorticoids, including a primarily oral, a mixed oral/intravenous, and a primarily intravenous regimen. There was consensus on measures of effectiveness and safety of the CTPs. The CTPs were well accepted by the pediatric rheumatology providers treating children with LN, and up to 300 children per year in North America are expected to be candidates for the treatment with the CTPs.

CONCLUSION

CTPs for induction therapy of proliferative LN in juvenile SLE based on the available scientific evidence and pediatric rheumatology group experience have been developed. Consistent use of the CTPs may improve the prognosis of proliferative LN, and support the conduct of comparative effectiveness studies aimed at optimizing therapeutic strategies for proliferative LN in juvenile SLE.

Sexual maturation in Turkish boys

Ages of onset and attainment of various stages of secondary sexual characters were assessed from cross-sectional data on 1530 city schoolboys in Istanbul, Turkey. The subjects were grouped into four socio-economic classes. Ages of onset of pubic hair (11.80 years), axillary hair (13.15 years), facial hair (14.45 years) and laryngeal development (13.37 years) were relatively early in the highest socioeconomic class and agreed with recent values reported for European boys. In lower socioeconomic classes there was a relative delay of onset and attainment of the subsequent stages of secondary sexual characters. Acne was encountered in a significant proportion of the boys and increased in frequency with age. Socioeconomic level had no effect on its frequency. Gynaecomastia, unilateral in nearly half of the instances, was encountered in 7.0 per cent of the subjects. The frequency of gynaecomastia was lower in class 1 boys.

The complement component C3 plays a critical role in both Th1 and Th2 responses to antigen

BACKGROUND

Complement component C3 is synthesized by keratinocytes and is activated after skin injury. C3 is also synthesized by peritoneal macrophages, which are activated by the adjuvant alum.

OBJECTIVE

We sought to investigate the role of C3 in inciting allergic skin Inflammation and systemic immune responses after epicutaneous sensitization or intraperitoneal sensitization with antigen.

METHODS

C3-deficient (C3-/-) mice and wild-type (WT) control animals were subjected to epicutaneous sensitization with the antigen ovalbumin (OVA) on shaved and tape-stripped skin or intraperitoneal immunization with OVA in alum.

RESULTS

Skin Infiltration by eosinophils and expression of mRNA encoding the TH2 cytokines IL-4 and IL-5 in OVA-sensitized skin sites was impaired in C3-/- mice. Splenocytes from epicutaneously sensitized C3-/- mice secreted less IL-4, IL-5, IL-13, and IFN-gamma in response to OVA stimulation than splenocytes from WT control animals. The defect in cytokine secretion by splenocytes was also observed after intraperitoneal immunization of C3-/- mice. C3-/- mice had impaired IgG1, IgG2a, and IgE antibody responses after both epicutaneous and intraperitoneal immunization. The defect in cytokine secretion of C3-/- mice was not due to defective proliferation to antigen, was not observed after anti-CD3 stimulation, and was corrected by the addition of purified C3 protein.

CONCLUSION

These results suggest that C3 plays an important role in both the TH1 and TH2 response to antigen in vivo.

CLINICAL IMPLICATIONS

The complement pathway might be a potential target in the therapy of allergic diseases.

COX-2 inhibition enhances the TH2 immune response to epicutaneous sensitization

BACKGROUND

Mechanical injury to the skin by scratching is an important feature of atopic dermatitis (AD).

OBJECTIVE

To investigate the role of COX-2 in allergic skin inflammation elicited by epicutaneous (EC) sensitization via introduction of ovalbumin through shaved tape-stripped skin.

METHODS

COX-2 mRNA was measured by quantitative PCR, and COX-2 protein was measured by Western blotting. We investigated the effect of administration of the COX-2 selective inhibitor NS-398 during EC sensitization with ovalbumin in a mouse model of AD characterized by eosinophil skin infiltration, elevated total and antigen specific IgE, and a systemic TH2 response to antigen. We further examined the response of COX-2-deficient mice to EC immunization with ovalbumin.

RESULTS

Tape stripping caused a transient increase in skin COX-2 mRNA. In contrast, COX-2 mRNA was not increased after ovalbumin sensitization. Infiltration by eosinophils and expression of IL-4 mRNA in ovalbumin-sensitized skin sites, ovalbumin specific IgE and IgG1 antibody responses, and IL-4 secretion by splenocytes after ovalbumin stimulation were all significantly increased in EC mice that received NS-398. In contrast, ovalbumin specific IgG 2a antibody response and IFN-gamma secretion by splenocytes after ovalbumin stimulation were significantly decreased in these mice. COX-2-deficient mice also exhibited an enhanced systemic TH2 response to EC sensitization.

CONCLUSION

These results demonstrate that COX-2 limits the TH2 response to EC sensitization and suggest that COX inhibitors may worsen allergic skin inflammation in patients with AD.

The anaphylatoxin C3a downregulates the Th2 response to epicutaneously introduced antigen

Mechanical injury to the skin results in activation of the complement component C3 and release of the anaphylatoxin C3a. C3a binds to a seven-transmembrane G protein-coupled receptor, C3aR. We used C3aR(-/-) mice to examine the role of C3a in a mouse model of allergic inflammation induced by epicutaneous sensitization with OVA. C3aR(-/-) mice exhibited an exaggerated Th2 response to epicutaneous but not to intraperitoneal sensitization with OVA, as evidenced by significantly elevated levels of serum OVA-specific IgG1 and significantly increased secretion of the Th2 cytokines IL-4, IL-5, and IL-10 by antigen-stimulated splenocytes. Presentation of OVA peptide by C3aR(-/-) APCs caused significantly more IL-4 and IL-5 secretion by T cells from OVA-T cell receptor (OVA-TCR) transgenic mice compared with presentation by WT APCs. C3a inhibited the ability of splenocytes, but not of highly purified T cells, to secrete Th2 cytokines in response to TCR ligation. This inhibition was mediated by IL-12 secreted by APCs in response to C3a. These results suggest that C3a-C3aR interactions inhibit the ability of APCs to drive Th2 cell differentiation in response to epicutaneously introduced antigen and may have important implications for allergic skin diseases.

Epicutaneous sensitization with superantigen induces allergic skin inflammation

BACKGROUND

Atopic dermatitis (AD) is characterized by skin infiltration with eosinophils and lymphocytes and expression of Th2 cytokines in acute skin lesions. The skin of patients with AD is frequently colonized with enterotoxin-secreting strains of Staphylococcus aureus. Staphylococcal enterotoxins have been implicated in the exacerbations of the inflammatory skin lesions in patients with AD.

OBJECTIVE

We sought to determine whether epicutaneous (EC) sensitization of mice with staphylococcal enterotoxin B (SEB) results in allergic skin inflammation.

METHODS

BALB/c mice were EC-sensitized with SEB. Their skin was examined for allergic inflammation and cytokine expression, and their splenocytes were examined for cytokine secretion in response to SEB.

RESULTS

EC sensitization with SEB elicited a local, cutaneous, inflammatory response characterized by dermal infiltration with eosinophils and mononuclear cells and increased mRNA expression of the Th2 cytokine IL-4 but not of the Th1 cytokine IFN-gamma. EC-sensitized mice mounted a systemic Th2 response to SEB evidenced by elevated total and SEB-specific IgG1 and IgE. Although EC sensitization with SEB resulted in selective depletion of SEB-specific T-cell receptor Vbeta8+ cells from the spleen and sensitized skin, splenocytes from SEB-sensitized mice secreted relatively more IL-4 and less IFN-gamma than did saline-sensitized controls, consistent with Th2 skewing of the systemic immune response to the superantigen.

CONCLUSION

These results suggest that EC exposure to superantigens skews the immune response toward Th2 cells, leading to allergic skin inflammation and increased IgE synthesis that are characteristic of AD.

Aggressive management of juvenile dermatomyositis results in improved outcome and decreased incidence of calcinosis

BACKGROUND

Long-term consequences of juvenile dermatomyositis (JDM) include onset of calcinosis and subsequent functional impairment. Historic incidence of calcinosis has been reported between approximately 23% and 70%. Recent reports note improved outcome with high-dose steroids, yet the incidence of calcinosis has remained above 30%.

OBJECTIVE

We attempted to determine whether rapid, aggressive disease management can prevent calcinosis and improve functional outcome.

METHODS

Medical records of children with JDM managed at a pediatric medical center during a 10-year period were reviewed to determine (1) interval between onset of symptoms and diagnosis, (2) treatment modality, and (3) functional outcome and presence of calcinosis.

RESULTS

A total of 21 female and 14 male subjects diagnosed with JDM met inclusion criteria, with a mean age of diagnosis of 7.6 +/- 3.9 years. Mean time from onset of symptoms to treatment was 6.6 +/- 8.2 months. Pulse intravenous methylprednisone (30 mg/kg daily) or high-dose prednisone was used in 31 of 35 patients. Patients who failed to respond within 6 weeks were started on a regimen of methotrexate (23/35). At follow-up, 5 patients had mild calcinosis (14%). Onset of calcinosis was associated with a longer time to diagnosis and treatment (30.6 vs 6 months, P =.003), a longer duration of elevated muscle enzymes (34 vs 12.6 months, P =.03), and longer disease duration (42.8 vs 22.2 months, P =.05).

CONCLUSION

Stepwise, aggressive treatment directed at achieving rapid and complete control of muscle inflammation is highly successful in minimizing the long range sequelae of JDM, including calcinosis.

CCR3 is essential for skin eosinophilia and airway hyperresponsiveness in a murine model of allergic skin inflammation

The CC chemokine receptor 3 (CCR3) is expressed by eosinophils, mast cells, and Th2 cells. We used CCR3(-/-) mice to assess the role of CCR3 in a murine model of allergic skin inflammation induced by repeated epicutaneous sensitization with ovalbumin (OVA), and characterized by eosinophil skin infiltration, local expression of Th2 cytokines, and airway hyperresponsiveness (AHR) to inhaled antigen. Eosinophils and the eosinophil product major basic protein were absent from the skin of sham and OVA-sensitized CCR3(-/-) mice. Mast cell numbers and expression of IL-4 mRNA were normal in skin of CCR3(-/-) mice, suggesting that CCR3 is not important for infiltration of the skin by mast cells and Th2 cells. CCR3(-/-) mice produced normal levels of OVA-specific IgE, and their splenocytes secreted normal amounts of IL-4 and IL-5 following in vitro stimulation with OVA, indicating effective generation of systemic Th2 helper responses. Recruitment of eosinophils to lung parenchyma and bronchoalveolar lavage (BAL) fluid was severely impaired in CCR3(-/-) mice, which failed to develop AHR to methacholine following antigen inhalation. These results suggest that CCR3 plays an essential role in eosinophil recruitment to the skin and the lung and in the development of AHR.

Vasculitis in childhood

Inadequate understanding of the pathogenesis and etiology of vascular inflammation continues to hinder progress in the diagnosis and treatment of pediatric vasculitis. The greatest amount of work is being done in the most common vasculitides of childhood, including Kawasaki disease and Henoch-Schönlein purpura. Discussion of rarer types of vasculitis, on the other hand, such as antineutrophil cytoplasmic antibody-positive small vessel diseases, is largely restricted to case reports. Most aspects of the care of children with Wegener granulomatosis and microscopic polyangiitis are derived by extrapolating from data about adults. Virtually no data are available concerning ways in which these diseases may be different in children.