Ocular involvement in pediatric Behçet's disease: is it different than in adults? (a short case series and mini review)

BACKGROUND

Pediatric Behçet's disease (PBD) is rarer than BD and can be a challenging diagnosis as clinical picture may be incomplete. As in adult patients, sight-threatening ocular manifestations may lead to diagnosis. In this study, we aimed to report a series of cases of PBD with ocular manifestations and provide a review of the literature.

METHODS

Retrospective case series of PBD patients with ocular manifestations. Demographic, ophthalmological and systemic data at presentation and during follow-up were collected and analyzed.

RESULTS

Four patients, aged 13.0 ± 2.9 years (9-16) were included. Posterior uveitis with retinal vasculitis, papillitis and macular edema was present in all patients, with associated anterior uveitis in 2 cases. Other features included occlusive vasculitis (2/4) and necrotizing retinitis (2/4). All patients were improved by systemic treatments except one patient with severe bilateral optic neuropathy. Ocular manifestations were the presenting symptoms in 3/4 cases.

CONCLUSION

Ocular manifestations and systemic associations of PBD are comparable to those encountered in adult patients. The lack of complains in pediatric patients may lead to a longer diagnosis delay, especially in unilateral uveitis. Aggressive and long-term treatment is mandatory to prevent vision loss and recurrences.

Multisystem inflammatory syndrome in children during the COVID-19 waves: data from the Juvenile Inflammatory Rheumatism cohort

Introduction

Multisystem inflammatory syndrome in children (MIS-C) is a new condition that first appeared in children and adolescents during the COVID-19 pandemic. We aimed to describe the diagnostic course, clinical and biological manifestations, and treatment of MIS-C during the first three COVID-19 waves.

Methods

We extracted patient data from the Juvenile Inflammatory Rheumatism (JIR) cohort. We analyzed data for patients meeting the World Health Organization diagnostic criteria for MIS-C from the start of the COVID-19 pandemic from March 2020 to June 30, 2021. We then compared data for patients in wave one to those in waves two and three.

Results

We identified 136 patients with MIS-C. The median age decreased but not significantly during the waves, from 9.9 years to 7.3 years (p = 0.105). Boys represented 52.2% (n = 71) of patients, and 46% (n = 41) of patients originated from sub-Saharan Africa (p < 0.001). Patients presented less diarrhea (p = 0.004), respiratory distress (p < 0.001), and myocarditis (p < 0.001) with progressive waves. Biological inflammation also decreased, namely, C-reactive protein level (p < 0.001), neutrophil count (p = 0.004), and albumin level (p < 0.001). Patients received more corticosteroids (p < 0.001) and required less ventilation support (p < 0.01) and less inotrope treatment (p < 0.001) in the later waves. The duration of hospitalization gradually decreased (p < 0.001), as did critical care unit admissions (p = 0.002).

Conclusion

Over the three COVID-19 waves, with a change in the management of MIS-C, children in the JIR cohort in France showed a less severe disease course, in particular, a greater use of corticosteroids. This observation may reflect the impact of both improved management and different SARS-CoV-2 variant.

Contribution of Ultrasound in Current Practice for Managing Juvenile Idiopathic Arthritis

The interest and application of musculoskeletal ultrasound (MSUS) in juvenile idiopathic arthritis (JIA) are increasing. Numerous studies have shown that MSUS is more sensitive than clinical examination for detecting subclinical synovitis. MSUS is a well-accepted tool, easily accessible and non-irradiating. Therefore, it is a useful technique throughout JIA management. In the diagnostic work-up, MSUS allows for better characterizing the inflammatory involvement. It helps to define the disease extension, improving the classification of patients into JIA subtypes. Moreover, it is an essential tool for guiding intra-articular and peritendinous procedures. Finally, during the follow-up, in detecting subclinical disease activity, MSUS can be helpful in therapeutic decision-making. Because of several peculiarities related to the growing skeleton, the MSUS standards defined for adults do not apply to children. During the last decade, many teams have made large efforts to define normal and pathological US features in children in different age groups, which should be considered during the US examination. This review describes the specificities of MSUS in children, its applications in clinical practice, and its integration into the new JIA treat-to-target therapeutic approach.

OP0220 CRITERIA ASSOCIATED WITH TREATMENT DECISIONS IN JUVENILE IDIOPATHIC ARTHRITIS WITH A FOCUS ON ULTRASONOGRAPHY: RESULTS FROM THE JIRECHO COHORT

Background

Treatment of children with juvenile idiopathic arthritis (JIA) is a major challenge in paediatric rheumatology. The presence of synovitis, which is difficult to detect in children, is associated with structural damage. Musculoskeletal ultrasonography (MSUS) can be used in JIA patients to reveal subclinical synovitis.

Objectives

Our aim was to determine if the use of MSUS is associated with therapeutic modifications in JIA. Secondary outcomes were to identify other factors associated with therapeutic modifications.

Methods

We conducted an observational study based on the JIRECHO multicentre cohort which was developed to provide a systematic MSUS follow-up for JIA patients. Follow-up occurred every six months and included clinical and US examinations. We included children who underwent MSUS of the elbows, wrists, second metacarpophalangeal joints, knees and ankles. Synovitis in US was defined by the presence of joint effusion and/or synovial hypertrophy in B-mode (≥ grade 1) associated or not with Doppler signals (≥ grade 1). US was performed by expert sonographers with good experience in the field of JIA who previously participated in the study of the reliability of the OMERACT paediatric US synovitis definitions and scoring system in JIA (1). Clinical and biological data, disease activity score and information on therapeutics were collected.

Results

We included 112 patients with 185 visits in total. Three groups of patients were defined according to their therapeutic status: increased(22%), decreased(14%) or stable(64%) treatment. First, we compared patients with treatment escalation with the other patients. Patients with “increased treatment” had more synovitis in B-mode US than the other patients (80% vs. 65%, p=0.06). There was no difference for the presence of synovitis in Power Doppler (PD) US (30% vs 23%, p=0.4). Patient’s and physician’s visual analogue scale (VAS) scores were significantly higher in patients with therapeutic escalation [3.3 vs 1.7, p<0.01 and 3.6 vs 1.6, p<0.0001] as well as disease activity score and inflammatory biological markers. Then, we compared patients with therapeutic de-escalation with the other patients. There was no difference in the presence of synovitis in US when compared with patients with stable treatment (62% vs. 69%, p=0.5) but there was less synovitis in B-mode ≥ grade 2 (8% vs. 24%, p=0.05).

We performed ROC curves analysis that showed that the sensitivity and specificity of the US in B-mode was similar to the physician’s VAS, disease score activity or inflammatory biological markers (Figure 1).

Figure 1.

ROC curves for clinical and biological items and US in B-mode in patients with « therapeutic escalation »

Conclusion

In our study, MSUS of ten joints was not statistically associated with treatment escalation or de-escalation in B-mode and PD in patients with JIA.

References

[1]Rossi-Semerano, L. et al. Application of the OMERACT synovitis ultrasound scoring system in juvenile idiopathic arthritis: a multicenter reliability exercise. Rheumatol. Oxf. Engl. (2020) doi:10.1093/rheumatology/keaa804.

Disclosure of Interests

None declared

Juvenile Idiopathic Arthritis and COVID-19 Pandemic: Good Compliance With Treatment, Reluctance to Return to School

Objective: The SARS-CoV-2 pandemic has induced an exceptional sanitary crisis, potentially having an impact on treatment continuation, for juvenile idiopathic arthritis (JIA) patients receiving immunosuppressive therapies. After national lockdowns, many patients were also concerned about their safety at school. We evaluated the impact of the pandemic on the optimal continuation of treatment and on the return to school in JIA patients.

Methods: JIA patients under 18 years of age, usually treated with disease-modifying anti-rheumatic drugs (DMARDs) were prospectively included during their outpatient visit and completed a standardized questionnaire. The primary outcome was DMARD treatment modification in relation to the context of the pandemic but we also evaluated the pandemic's impact on the schooling.

Results: One hundred and seventy three patients from 8 different expert centers were included between May and August 2020. Their mean age was 11.6 years (± 4.1 years), and most of them 31.2% (54/173) had a rheumatoid factor-negative polyarticular JIA. Fifty percent (86/172) were treated with methotrexate, and 72.5% (124/171) were treated with bDMARDs. DMARD treatment modification in relation to the pandemic was observed in 4.0% (7/173) of participants. 49.1% (81/165) of the patients did not return to school due to a personal/parental decision in 69.9% (55/81) of cases. Two patients were diagnosed positive for SARS-CoV-2 infection.

Conclusion: This study suggests that JIA patients treated with DMARDs continued their treatment during the pandemic and were rarely affected by symptomatic COVID-19. In contrast, parents' reluctance was a major obstacle for returning to school. Therefore, more solidified school reopening strategies should be developed.

SARS-CoV-2-associated Henoch-Schönlein purpura in a 13-year-old girl

In the context of the current coronavirus disease 2019 (COVID-19) pandemic, cutaneous lesions are being described. Here, we report on a 13-year-old girl with SARS-CoV-2-associated Henoch–Schönlein purpura and Epstein–Barr virus (EBV) infection. She presented without any respiratory symptoms, only a purpuric skin rash, abdominal pain, low-grade fever, and pharyngitis. Virology tests by polymerase chain reaction (PCR) were positive for SARS-CoV-2 and EBV. The potential association of Henoch–Schönlein purpura and SARS-CoV-2 should be kept in mind in order to reduce the spread of the virus, particularly in children with few respiratory symptoms.

POS1314 JUVENILE IDIOPATHIC ARTHRITIS IN THE CONTEXT OF THE CORONAVIRUS DISEASE 19 PANDEMIC: IMPACT ON THE DECREASE IN TREATMENT AND THE RETURN TO SCHOOL

Background:

The SARS-CoV-2 pandemic has induced an exceptional sanitary crisis, potentially having an impact on treatment continuation, for juvenile idiopathic arthritis (JIA) patients receiving immunosuppressive therapies. In France, after the first lockdown from March to May 2020, many parents and children were then also concerned about whether reopening plans for school could ensure the safety of students, despite data concerning children with COVID-19 seem reassuring, and very few of them develop severe forms of the disease (1, 2, 3).

Objectives:

Our objectives were to evaluate the impact of the COVID-19 pandemic on the therapeutic management of JIA, the frequency of returning to school after the first lockdown period and the prevalence of SARS-CoV-2 infection at the time of the survey.

Methods:

JIA patients under 18 years of age, usually treated with disease-modifying anti-rheumatic drugs (DMARDs) were prospectively included during their outpatient visit and completed a standardized questionnaire. Data regarding the general characteristics of the participants, medical history, SARS-CoV-2 infection, characteristics of JIA subtypes and treatment modifications were collected.

Results:

A total of 173 patients from 8 different expert centers were included between May and August 2020. Their mean age was 11.6 years (± 4.1 years), and most of them 31.2% (54/173) had a rheumatoid factor-negative polyarticular JIA. Fifty percent (86/172) were treated with methotrexate, and 72.5% (124/171) were treated with bDMARDs. DMARD treatment modification in relation to the pandemic was observed in 4.0% (7/173) of participants, our results reflect good adherence of the patient/parents to their immunosuppressive treatments. 49.1% (81/165) of the patients did not return to school due to a personal/parental decision in 69.9% (55/81) of cases, due to anxiety of the patient/parents regarding COVID-19. Two patients were diagnosed positive for SARS-CoV-2 infection.

Conclusion:

This study suggests that JIA patients treated with DMARDs continued their treatment during the pandemic. In contrast, parents’ reluctance was a major obstacle for returning to school. Therefore, more solidified school reopening strategies should be developed.

References:

[1]Filocamo G, et al. “Absence of severe complications from SARS-CoV-2 infection in children with rheumatic diseases treated with biologic drugs.” J Rheumatol. 25 avr 2020;

[2]Tagarro A, et al. “Screening and Severity of Coronavirus Disease 2019 (COVID-19) in Children in Madrid, Spain.” JAMA Pediatr. 8 avr 2020;

[3]Lu X, et al. « SARS-CoV-2 Infection in Children”. N Engl J Med. 23 avr 2020;382(17):1663-5.

Acknowledgements:

We would like to thank all the participants involved in this clinical research and six medical students who helped completing the forms: Margaux Blondel, Alice Bonnod, Marie Desval, Béatrice Dordain, Gabrielle Fagnet, and Madouc De Saint Martin Pernot.

Disclosure of Interests:

None declared

Paediatric multisystem inflammatory syndrome temporally associated with SARS-CoV-2 mimicking Kawasaki disease (Kawa-COVID-19): a multicentre cohort

BACKGROUND

Current data suggest that COVID-19 is less frequent in children, with a milder course. However, over the past weeks, an increase in the number of children presenting to hospitals in the greater Paris region with a phenotype resembling Kawasaki disease (KD) has led to an alert by the French national health authorities.

METHODS

Multicentre compilation of patients with KD in Paris region since April 2020, associated with the detection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) ('Kawa-COVID-19'). A historical cohort of 'classical' KD served as a comparator.

RESULTS

Sixteen patients were included (sex ratio=1, median age 10 years IQR (4·7 to 12.5)). SARS-CoV-2 was detected in 12 cases (69%), while a further three cases had documented recent contact with a quantitative PCR-positive individual (19%). Cardiac involvement included myocarditis in 44% (n=7). Factors prognostic for the development of severe disease (ie, requiring intensive care, n=7) were age over 5 years and ferritinaemia >1400 µg/L. Only five patients (31%) were successfully treated with a single intravenous immunoglobulin (IVIg) infusion, while 10 patients (62%) required a second line of treatment. The Kawa-COVID-19 cohort differed from a comparator group of 'classical' KD by older age at onset 10 vs 2 years (p<0.0001), lower platelet count (188 vs 383 G/L (p<0.0001)), a higher rate of myocarditis 7/16 vs 3/220 (p=0.0001) and resistance to first IVIg treatment 10/16 vs 45/220 (p=0.004).

CONCLUSION

Kawa-COVID-19 likely represents a new systemic inflammatory syndrome temporally associated with SARS-CoV-2 infection in children. Further prospective international studies are necessary to confirm these findings and better understand the pathophysiology of Kawa-COVID-19. Trial registration number NCT02377245.

Inflammatory Bowel Disease in Children With Systemic Juvenile Idiopathic Arthritis

OBJECTIVE

The incidence of inflammatory bowel disease (IBD) in juvenile idiopathic arthritis (JIA) is higher than in the general pediatric population. However, reports of IBD in the systemic JIA (sJIA) subtype are limited. We sought to characterize sJIA patients diagnosed with IBD and to identify potential contributing risk factors.

METHODS

Using an internationally distributed survey, we identified 16 patients with sJIA who were subsequently diagnosed with IBD (sJIA-IBD cohort). Five hundred twenty-two sJIA patients without IBD were identified from the CARRA Legacy Registry and served as the sJIA-only cohort for comparison. Differences in demographic, clinical characteristics, and therapy were assessed using chi-square test, Fisher exact test, t-test, and univariate and multivariate logistic regression, as appropriate.

RESULTS

Of the patients with sJIA-IBD, 75% had a persistent sJIA course and 25% had a history of macrophage activation syndrome. sJIA-IBD subjects were older at sJIA diagnosis, more often non-White, had a higher rate of IBD family history, and were more frequently treated with etanercept or canakinumab compared to sJIA-only subjects. Sixty-nine percent of sJIA-IBD patients successfully discontinued sJIA medications following IBD diagnosis, and sJIA symptoms resolved in 9 of 12 patients treated with tumor necrosis factor-α (TNF-α) inhibitors.

CONCLUSION

IBD in the setting of sJIA is a rare occurrence. The favorable response of sJIA symptoms to therapeutic TNF-α inhibition suggests that the sJIA-IBD cohort may represent a mechanistically distinct sJIA subgroup. Our study highlights the importance of maintaining a high level of suspicion for IBD when gastrointestinal involvement occurs in patients with sJIA and the likely broad benefit of TNF-α inhibition in those cases.

The French paediatric cohort of Castleman disease: a retrospective report of 23 patients

BACKGROUND

Castleman disease (CD) is a rare non-malignant lymphoproliferation of undetermined origin. Two major disease phenotypes can be distinguished: unicentric CD (UCD) and multicentric CD (MCD). Diagnosis confirmation is based on histopathological findings in a lymph node. We attempted to survey all cases of paediatric CD identified to date in France to set up a national registry aiming to improve CD early recognition, treatment and follow-up, within the context of a new national reference center (http://www.castleman.fr).

METHODS

In 2016, we e-mailed a questionnaire to members of the French paediatric immunohaematology society, the paediatric rheumatology society and the Reference Centre for Castleman Disease to retrospectively collect cases of paediatric CD (first symptoms before age 18 years). Anatomopathological confirmation was mandatory.

RESULTS

We identified 23 patients (12 girls) with a diagnosis of UCD (n = 17) and MCD (n = 6) between 1994 and 2018. The mean age at first symptoms was 11.47 ± 4.23 years for UCD and 8.3 ± 3.4 years for MCD. The mean diagnosis delay was 8.16 ± 10.32 months for UCD and 5.16 ± 5.81 years for MCD. In UCD, the initial symptoms were isolated lymph nodes (n = 10) or lymph node associated with other symptoms (n = 7); fever was present in 3 patients. Five patients with MCD presented fever. No patients had HIV or human herpesvirus 8 infection. Autoinflammatory gene mutations were investigated in five patients. One patient with MCD carried a K695R heterozygous mutation in MEFV, another patient with MCD and Duchenne myopathy carried two variants in TNFRSF1A and one patient with UCD and fever episodes carried two heterozygous mutations, in IL10RA and IL36RN, respectively. Treatment of UCD was mainly surgical resection, steroids, and radiotherapy. Treatment of MCD included tocilizumab, rituximab, anakinra, steroids, chemotherapy, and splenectomy. Overall survival after a mean of 6.1 ± 6.4 years of follow-up, was 100% for both forms.

CONCLUSION

Paediatric CD still seems underdiagnosed, with a significant diagnosis delay, especially for MCD, but new international criteria will help in the future. Unlike adult CD, which is strongly associated with HIV and human herpesvirus 8 infection, paediatric CD could be favored by primary activation of innate immunity and may affect life expectancy less.