67 Double impact: hypophosphatemic rickets and vitamin D intoxication

Background

Vitamin D prevents deficiency rickets, but its prescription must be weighed carefully!

Objective

We report a rare case of iatrogenic toxic hypervitaminosis D in a child with vitamin D resistant rickets…!

Methods

We admitted a two-year-old girl, presenting signs of rickets resistant to the usual then therapeutic doses of vitamin D3. Vitamin D2 in oral suspension is then ordered in addition, for a few weeks until the onset of hearing loss motivating her hospitalization in pediatrics.

Results

Biological and radiological explorations revealed renal failure with threatening arterial hypertension, as well as diffuse and severe arteriosclerosis on Doppler signal.

Eviction (stopping vitamin D in all its forms), symptomatic and conservative management by (converting-enzyme inhibitors) and hydration allowed a progressive blood pressure normalisation, arteriosclerosis disappearance (undetected by Doppler signal and by angio-scan) along with a gradual normalising of the kidney function; all this over a period of 2 years

The girl actually had hypophosphatemic rickets, and oral phosphorus (syrup) was also prescribed

Conclusion

Vitamin D is potentially toxic with sometimes severe renal risks (lithiasis, nephrocalcinosis), and hypercalcemia might be severe, especially if renal function is impaired.

Blindly treating any rickets with vitamin D can be adventurous and might expose the child to serious morbidity.

40 Arthralgia and celiac disease

Background

In a large cohort of 2125 children followed in rheumatology, 2% had celiac disease (CD) (about 3 times the rate in the general population). Inversely, CD was reported in up to 2–3% of children with juvenile idiopathic arthritis

Objectives

Reporting joint damage such as arthrlagia in a celiac pediatric cohort

Material and method

We collected 58 celiac children and reported those with arthralgia and studied their clinical aspects

Results

Arthralgia was reported in 10/58 children (i.e. 17.24%) of the entire cohort studied (n = 58), including 09 children with positive HLA DQ2/DQ8 typing, potentially with an autoimmune background. The arthralgia was not accompanied by arthritis, and had an apyretic, labile and transient character. Only one case of episodic spinal pain was reported in the history

Conclusion

More than a sixth of the pediatric celiac cohort presents with arthralgia. These joint pains can be caused by vitamin D deficiency, osteoporosis, associated juvenile idiopathic arthritis (JIA), in particular HIV-positive. They can also be isolated and respond to the gluten-free diet.

74 Hereditary angioedema revealed by compartment syndrome

Background

Hereditary angioedema (HAE) can present with a wide spectrum of clinical symptoms, including articular features like the compartment syndrome.

Objective

We present the peculiar case of a young female patient suffering from this rare complement system disorder and presenting as a « wrist oedema ».

Methods

A 14-year-old girl was admitted in the emergency room during a night shift. She presented with acute compartment (wrist) syndrome due to edematous compression of the median nerve, associated with a typical personal history of HAE. It resolved within 6 h with IV steroids and hyperhydration.

The quantitative and qualitative C1 INH esterase returning negative, the diagnosis of HAE type III was made.

The patient was treated with long-term treatment based on Danazol, (the most frequently prescribed attenuated androgen to treat HAE).

Results

HAE is due to the deficiency or dysfunction of the C1 inhibitor protein (quantitative or qualitative deficiency). A new nomenclature has replaced the initial use of denominations HAE type 1, 2 or 3; to speak rather of HAE with a deficient C1 inhibitor (type 1), with a dysfunctional C1 inhibitor (type 2) or with a normal C1 inhibitor (type 3)

Type 3 HAE is rare and difficult to treat. It may respond to anti-estrogenic drugs such as progestins and especially to androgens; specific (very expensive) molecules do exist and act directly on the bradykinin pathways

Conclusion

A compartment syndrome may reveal extremely rare conditions such as hereditary angioedema.

Early recognition and management are the guarantee of a preserved functional prognosis.

64 Conical teeth? Think outside the box!

Background

2. Case reports

3. Discussion

4. Conclusion

73 Joint pains revealing a dysautonomic syndrome

Background

Primary dysautonomia is a disorder of the autonomic nervous system with nonspecific manifestations, mainly affecting blood pressure and heart rate.

Objective

We report the diagnostic odyssey in an 11-year-old girl starting with arthralgia and leading to the final diagnosis of a rare dysautonomia.

Methods

A 13-year-old girl, with no pathologic history, was admitted to pediatrics for diffuse arthralgia without clinical inflammatory signs.

Biological exploration unmasked a morning proteinuria without hypoalbuminemia and with a normal electrophoretic profile, microcytic anaemia and orthostatic hypotension authenticated during his hospitalization.

Exhaustive explorations were undertaken (including autoimmune panel, ophthalomological examination, full metabolic screen and even renal biopsy), without any conclusive result.

Results

The development—after one year of follow up—of arterial hypertension, associated with orthostatic hypotension and proteinuria, points toward the extremely rare defect in baroreceptors.

The management, in collaboration with the cardiology department, enhanced the patient’s quality of life with a reduction in hypertensive peaks. An appropriate lifestyle also amended the intensity of orthostatic hypotension.

The close multidisciplinary follow-up over >48 months is reassuring.

Conclusion

The peculiar baroreceptor defect in a context of dysautonomia should be kept in mind in the (long) list of differential diagnosis of arthralgias, as joint pain can be triggered by dysautonomia. Management is mainly symptomatic.

Inborn Errors of Immunity in Algerian Children and Adults: A Single-Center Experience Over a Period of 13 Years (2008–2021)

Background

Inborn errors of immunity (IEI) predispose patients to various infectious and non-infectious complications. Thanks to the development and expanding use of flow cytometry and increased awareness, the diagnostic rate of IEI has markedly increased in Algeria the last decade.

Aim

This study aimed to describe a large cohort of Algerian patients with probable IEI and to determine their clinical characteristics and outcomes.

Methods

We collected and analyzed retrospectively the demographic data, clinical manifestations, immunologic, genetic data, and outcome of Algerian IEI patients - diagnosed in the department of medical immunology of Beni Messous university hospital center, Algiers, from 2008 to 2021.

Results

Eight hundred and seven patients with IEI (482 males and 325 females) were enrolled, 9.7% of whom were adults. Consanguinity was reported in 50.3% of the cases and a positive family history in 32.34%. The medium age at disease onset was 8 months and at diagnosis was 36 months. The median delay in diagnosis was 16 months. Combined immunodeficiencies were the most frequent (33.8%), followed by antibody deficiencies (24.5%) and well-defined syndromes with immunodeficiency (24%). Among 287 patients tested for genetic disorders, 129 patients carried pathogenic mutations; 102 having biallelic variants mostly in a homozygous state (autosomal recessive disorders). The highest mortality rate was observed in patients with combined immunodeficiency (70.1%), especially in patients with severe combined immunodeficiency (SCID), Omenn syndrome, or Major Histocompatibility Complex (MHC) class II deficiency.

Conclusion

The spectrum of IEI in Algeria is similar to that seen in most countries of the Middle East and North Africa (MENA) region, notably regarding the frequency of autosomal recessive and/or combined immunodeficiencies.

P026 Efficacy and safety of Etanercept for the treatment of Juvenile Idiopathic Arthritis

Background

Etanercept (ETN) is the first anti-TNF to have obtained FDA approval in 1999 for juvenile idiopathic arthritis (JIA) refractory to methotrexate. Currently, the indications of ETN cover the polyarticular JIA, the extended oligoarticular, and enthesitis-related arthritis. To assess the efficacy of Etanercept, as well as its tolerance in JIA.

Material and methods

We carried out a retrospective study of children with JIA according to the criteria of the ILAR classification and treated with Etanercept at the pediatric center of the CHU de Sétif since 2015.

Nineteen children were included and considered to 3 months, 6 months, 1 year, 2 years, 3 years, 4 years, 5 years on the criteria epidemiology, the efficiency criteria (joint Scores, uveitis, ESR, CHAQ), and the occurrence possible side effects.

We defined the improvement of 30% (ACR 30), 50% (ACR 50), 70% (ACR 70), 90% (ACR 90), and 100% (ACR 100) as the improvement of minus 3 criteria out of 6 of 30%, 50%, 70%, 90%, 100%; patients must not have a worsening of > 30% of any of the 6 criteria.

Results

The epidemiological features were the following: 12 girls and 7 boys, 10 present polyarticular form, 6 present oligoarticular form, 2 cases with psoriatic arthritis, and a single case of enthesitis-related arthritis. ACR 30 is obtained in 75%, 84%, 88% of cases at 3 months, 6 months, and 1 year, respectively. The strongest responses were obtained in polyarticular, oligoarticular, and enthesitis-related arthritis. Complete remission was maintained in the majority of patients for varied durations depending on the follow-up. Furthermore, no clinical or biological adverse effects were noted.

Conclusion

The Etanercept has been dramatically effective in children with juvenile idiopathic arthritis, especially in the polyarticular subtype, oligoarticular, and enthesitis-related arthritis. Its overall tolerance is very good.

P052 Juvenile dermatomyositis, a multi-faceted disease

Background

Dermatomyositis is a rare disease. In children, the incidence is 2–3 per million habitants. It is a serious disease whose mortality is < 5% but whose complications and long-term prognosis remain pejorative for some children. The objective is to report the epidemiological, clinical, therapeutic options and the course of a retrospective series carried out at the CHU pediatric center of Sétif (Algeria) comprising 8 cases of juvenile dermatomyositis.

Methods

The mean age of onset is 7.7 years (0–15.5 years), The sex ratio was 0.1; The diagnosis delay averaged at 4, 4 months. At disease onset, 100% had rash, 84% a eyelids telangiectasias, 40% Gottron nodules, 90% muscular weakness, 40% arthritis, 13% fever, and 25% dysphagia. The muscular enzymes were increased in 8 cases. The DNA antibodies were present in one patient with myositis overlap, NXP was positive in one child. The electromyogram is myogenic in all patients. Seven patients underwent a histopathological exam, showing interstitial and parenchymal myositis. Treatment regimens were variable depending on the severity of the disease onset. All children were treated with steroids as the first line. Methotrexate was prescribed in 5 cases (62.5%). The immunoglobulin was indicated in 2 cases. The failure to thrive was observed in 2 (25%), and one child died following aspiration pneumonia.

Results

The dermatomyositis diagnosis is based on the Bohan and Peter criteria. The clinical characteristics of our series are in line with the literature data with a predominance of cutaneous and muscular involvement. However, some specificities are individualized: a case of overlapping myositis with lupus, a case of extensive calcinosis. The treatment was based on corticosteroids and methotrexate.

Conclusion

Dermatomyositis juvenile is a rare disease with a pejorative prognosis requiring a multidisciplinary management.

P048 Juvenile systemic lupus erythematosus, what specificities?

Background

Juvenile systemic lupus erythematosus (J-SLE) is a chronic autoimmune disease characterized by multi-visceral involvement with an unpredictable prognosis. The diagnosis is usually made in young women between the ages of 20 and 40, however, it can set in at any age and will be classified as juvenile (LESj) when it begins before the age of 16.We report the epidemiological, clinical, therapeutic and evolutionary characteristics of a retrospective series carried out at the level of the pediatric center—CHU de Sétif comprising 13 girls and one boy.

Methods

The mean age of onset is 12 years and 3 months, the mean time to diagnosis is 7 months. The clinical picture is made of e reached articulaire skin and e fever in 86% respectively 57% and 57% of cases, followed by kidney disease in 57% of cases. Cardiac involvement pulmon area ophtalmologiqu e is referred to in low percentages. The blood reached logic of étectée on blood counts in 85% of patient e s i and the syndrome nflammatoire was almost constant. A positive titer of antinuclear antibodies and anti- AD Nn is objectified, as well as a reduction in the level of complement. The anti-GP 2 and anti- cardio lopine antibodies are positive in 57% of cases. Has the present hue kidney in 42% of cases. A single case of overlap syndrome with dermatomyositis has been reported. As for the neurological form, only one adolescent presented it. With a single case of familial lupus and a single case of Rhupus.

Results

The diagnosis is based on the American College of Rheumatology (ACR) 1982 classification revised in 1997 and the new SLICC “Systemic Lupus International Collaborating Clinics” criteria.

The clinical characteristics of our series are consistent with the overall data in the literature with a predominance of cutaneous and joint involvement. with however some specific characteristics which are individualized by a more advanced age of onset, of 13 years on average in our study vs 10 years and 12 years, the rarity of the familial forms (1 case), a lower percentage of renal damage (42% vs 63% and 80%). The therapeutic management was based on corticosteroids and Hydroxychloroquine in most cases, the use of immunosuppressants was reserved for x severe.

Conclusion

Lupus is an autoimmune disease with protean clinical manifestations, the prognosis of which is dominated by renal, neurological and thrombotic damage. Corticosteroid treatments and immunosuppressants markedly improved the vital prognosis.