Kawasaki disease in Kenya and review of the African literature

BACKGROUND

Kawasaki disease has been described across the globe, although publications from Africa are limited. To our knowledge, there are no publications on Kawasaki disease from Kenya, which triggered this report.

METHODS

A retrospective cross-sectional study was undertaken to identify in-patients with a discharge diagnosis of Kawasaki disease, over 2 different 5-year periods, at two pediatric hospitals in Nairobi, Kenya. We reviewed the medical records of all patients and report their clinical findings, diagnostic workup and treatment. In addition, we undertook a detailed review of the literature.

RESULTS

Twenty-three patients with Kawasaki disease were identified, of those 12 (52.2%) had incomplete disease. The mean age was 2.3 years (SD+/-2.2) (range 0.3-10.3) with a male to female ratio of 1:1. The mean duration of fever at diagnosis was 8.3 days (SD+/-4.7) (range 2-20). Oral changes were the most common clinical feature and conjunctivitis the least common. Thrombocytosis at diagnosis was seen in 52% (12/23). Twenty-one patients (91.3%) were treated with intravenous immunoglobulin and all except 1 received aspirin. Baseline echocardiograms were performed in 95.7% (22/23) and found to be abnormal in 3 (13.6%). Follow-up data was limited. Our literature review identified 79 publications with documented cases of Kawasaki disease in children from 22 countries across the African continent with a total of 1115 patients including those from this report. Only 153 reported cases, or 13.7%, are from sub-Saharan Africa.

CONCLUSIONS

This is the first publication on Kawasaki disease from Kenya and one of the largest reports from sub-Saharan Africa. It is the first to have a complete review of the number of published cases from the African continent. Challenges in the diagnosis and management of Kawasaki disease in many African countries include disease awareness, infectious confounders, access and cost of intravenous immunoglobulin, access to pediatric echocardiography and follow-up. Increasing awareness and health care resources are important for improving outcomes of Kawasaki disease in Africa.

Genetic changes from type I interferons and JAK inhibitors: clues to drivers of juvenile dermatomyositis

OBJECTIVE

To better understand the pathogenesis of juvenile dermatomyositis (JDM), we examined the effect of the cytokines type I interferons (IFN I) and JAK inhibitor drugs (JAKi) on gene expression in bioengineered pediatric skeletal muscle.

METHODS

Myoblasts from 3 healthy pediatric donors were used to create three-dimensional skeletal muscle units termed myobundles. Myobundles were treated with IFN I, either IFNα or IFNβ. A subset of IFNβ-exposed myobundles was treated with JAKi tofacitinib or baricitinib. RNA sequencing analysis was performed on all myobundles.

RESULTS

Seventy-six myobundles were analyzed. Principal component analysis showed donor-specific clusters of gene expression across IFNα and IFNβ-exposed myobundles in a dose-dependent manner. Both cytokines upregulated interferon response and proinflammatory genes; however, IFNβ led to more significant upregulation. Key downregulated pathways involved oxidative phosphorylation, fatty acid metabolism and myogenesis genes. Addition of tofacitinib or baricitinib moderated the gene expression induced by IFNβ, with partial reversal of upregulated inflammatory and downregulated myogenesis pathways. Baricitinib altered genetic profiles more than tofacitinib.

CONCLUSION

IFNβ leads to more pro-inflammatory gene upregulation than IFNα, correlating to greater decrease in contractile protein gene expression and reduced contractile force. JAK inhibitors, baricitinib more so than tofacitinib, partially reverse IFN I-induced genetic changes. Increased IFN I exposure in healthy bioengineered skeletal muscle leads to IFN-inducible gene expression, inflammatory pathway enrichment, and myogenesis gene downregulation, consistent with what is observed in JDM.

Majority of new patient referrals to a large pediatric rheumatology center result in non-rheumatic diagnosis

OBJECTIVE

Pediatric rheumatology faces a looming supply-demand crisis. While strategies have been proposed to address the supply shortfall, investigation into the increased demand for pediatric rheumatic care has been limited. Herein, we analyze new patient visits to a large tertiary care pediatric rheumatology center to identify emerging trends in referrals and areas for potential intervention to meet this increased demand.

METHODS

All patients referred to and seen by the University of Alabama at Birmingham Pediatric Rheumatology Division between January 2019 and December 2021 for a new patient evaluation were identified. Patient data was retrospectively abstracted, de-identified, and analyzed to develop trends in referrals and frequency of rheumatic disease, non-rheumatic disease, and specific diagnoses.

RESULTS

During the study period, 2638 patients were referred to and seen in by the pediatric rheumatology division. Six hundred and ten patients (23.1%) were diagnosed with rheumatic disease. The most common rheumatic disease was juvenile idiopathic arthritis (JIA) at 45.6%, followed by primary Raynaud phenomenon (7.4%), recurrent fever syndromes (6.9%), vasculitides (6.7%), and inflammatory eye disease (6.2%). Of the 2028 patients (76.9%) diagnosed with a non-rheumatic condition, benign musculoskeletal pain was the most common (61.8%), followed by a combination of somatic conditions (11.6%), and non-inflammatory rash (7.7%).

CONCLUSION

In this analysis of new patient referrals to a large pediatric rheumatology center, the majority of patients were diagnosed with a non-rheumatic condition. As a worsening supply-demand gap threatens the field of pediatric rheumatology, increased emphasis should be placed on reducing non-rheumatic disease referrals.

Results from the CAPRI Registry

OBJECTIVE

To identify differences between baseline Canadian JIA practices and the 2019 American College of Rheumatology guidelines for juvenile idiopathic arthritis (JIA Guidelines).

METHODS

Canadian pediatric rheumatologists were surveyed for their opinion on reasonable a priori target adherence rates for JIA Guideline recommendations. Then, prospectively collected data for 266 newly diagnosed children from 2017 to 2019 were analyzed to calculate observed adherence rates. Kaplan Meier survival curves were used to estimate the cumulative incidence of starting synthetic or biologic DMARDs for different patient groups.

RESULTS

Twenty-five of 61 (41%) eligible physicians answered the survey. Most survey respondents (64%) felt that adherence targets should vary depending on the strength of recommendation and quality of evidence, from a mean of 84% for strong recommendations with high quality evidence, to 29% for conditional recommendations with very low-quality evidence. Data showed 13/19 (68%) recommendations would have met proposed targets and 10/19 (53%) had ≥80% observed adherence. Exceptions were the use of subcutaneous over oral methotrexate (MTX) (53%) and infrequent treatment escalation from NSAIDs to biologic DMARDs in patients with sacroiliitis (31%) or enthesitis (0%). By 12 weeks, 95% of patients with polyarthritis received synthetic DMARD, 38% of patients with systemic JIA received biologic DMARD, and 22% of patients with sacroiliitis received biologic DMARD.

CONCLUSION

Canadian pediatric rheumatology practices were in line with many 2019 JIA Guidelines recommendations before their publication, except for frequent use of oral methotrexate and infrequent direct escalation from NSAIDs to biologic DMARDs in sacroiliitis and enthesitis.

Chasing Fevers: An Interactive Exercise for Pediatrics Residents on Triaging and Assessing Inpatients With Fever

INTRODUCTION

Pediatrics residents are frequently tasked with triaging fevers in pediatric inpatients. The variety of clinical scenarios in the inpatient setting-patients with a multitude of diseases and a spectrum of risk for invasive infection-makes this task challenging. To enhance our residents' training on this topic, we developed an activity providing explicit instruction on how to approach these patient scenarios.

METHODS

The 45-minute activity began with an interactive discussion on approaching pediatric inpatient fevers, followed by a case-based exercise where small groups were assigned one of six clinical scenarios involving inpatients with fever. Learners discovered new information about their patient by drawing paper slips out of a container. Each slip could take their patient's story in a different direction. Small groups discussed decision-making options for their assigned case at each step. Among the potential events were rapid response calls-acute issues requiring immediate assessment-in which learners competed for limited seats to determine who would respond to the call. The activity concluded with a discussion about treatment of inpatient fevers.

RESULTS

Respondents to the postevent evaluation rated the activity as highly engaging, effective in helping them achieve its learning objectives, highly relevant to their career, and effective in simulating real-life clinical decision-making situations.

DISCUSSION

This instructional technique offers a unique, engaging, case-based approach to teaching about inpatient fever management in which instructors facilitate and support learners' articulation of clinical reasoning. Future directions include using this technique for other common clinical problems and with other learner groups.

Immunopathogenesis of Juvenile Systemic Sclerosis

Juvenile-onset systemic sclerosis (jSSc) is a rare and severe autoimmune disease with associated life-threatening organ inflammation and evidence of fibrosis. The organ manifestations of jSSc resemble adult SSc, but with better outcomes and survival. The etiology of jSSc appears to reflect adult-onset SSc, with similar inflammatory mediators and autoantibodies, but with a significant population of children with uncharacterized anti-nuclear antibodies. The genetics of patients with jSSc differ from women with SSc, resembling instead the genes of adult males with SSc, with additional HLA genes uniquely associated with childhood-onset disease. Current treatments are aimed at inhibiting the inflammatory aspect of disease, but important mechanisms of fibrosis regulated by dermal white adipose tissue dendritic cells may provide an avenue for targeting and potentially reversing the fibrotic stage.

Pediatric Rheumatology Curriculum for the Pediatrics Resident: A Case-Based Approach to Learning

INTRODUCTION

Pediatric rheumatologic disease occurs more frequently than several other chronic pediatric diseases but is often underrecognized. It is estimated that in the US, one in 250 children has some form of juvenile arthritis and 300,000 children have a form of rheumatologic disease. However, there are only approximately 400 practicing pediatric rheumatologists nationwide.

METHODS

Kern's six-step method was used to develop a pediatric rheumatology curriculum based on respondents' perceived lack of training and comfort with four key areas: workup, musculoskeletal exam, laboratory interpretation, and referral to rheumatology. These cases were developed for second-year pediatric and second- and third-year internal medicine-pediatric residents rotating with the service. The curriculum was composed of four 30-minute case discussions as well as an observed musculoskeletal exam session.

RESULTS

In 2017, weekly case study sessions reached 34 trainees. Survey results from these trainees are representative of our overall results and reveal that learners felt the content of the cases helped increase comfort with compiling pertinent history and information of symptoms consistent with autoimmune disease, recognizing physical exam findings of autoimmune disease, ordering and interpreting laboratory studies in children with concerns for autoimmune disease, and referring to pediatric rheumatology.

DISCUSSION

This case-based curriculum exposed residents to presentations of the more common autoimmune diseases encountered in the pediatric population. The curriculum helps fill a gap in pediatric training through increased exposure to this subset of chronic diseases and expands physical examination skills not typically taught in general pediatrics.

Kawasaki disease: abnormal initial echocardiogram is associated with resistance to IV Ig and development of coronary artery lesions

BACKGROUND

Kawasaki disease (KD) is an acute febrile systemic vasculitis that affects small and medium blood vessels. Intensified treatments for the most severely affected patients have been proposed recently, and the early identification of KD patients at high risk for coronary artery aneurysms (CAA) is crucial. However, the risk scoring systems developed in Japan have not been validated in European populations, and little data is available concerning the link between initial echocardiogram findings other than high z-scores and cardiac prognosis.

METHODS

In order to investigate whether the presence of any abnormalities, other than high z-scores in first echocardiogram, are associated with resistance to IV immunoglobulins and/or subsequent development of CAA, we retrospectively analyzed data from children diagnosed with KD between 2006 and 2016 at a tertiary Hospital in Paris, France.

RESULTS

A total of 157 children were included. The initial echocardiogram was performed after a median of 7 days of fever and was abnormal in 48 cases (31%). The initial presence of any echocardiographic abnormality (coronary artery dilatation, CAA, pericardial effusion, perivascular brightness of the coronary arteries, left-ventricular dysfunction and mitral insufficiency) was strongly associated with resistance to intravenous immunoglobulin (p = 0.005) and development of coronary artery lesions within the first 6 weeks of disease (p = 0.01). All patients (n = 7) with persistent coronary abnormalities at 1 year already had an abnormal initial echocardiogram. Severity scoring systems from Japan had low sensitivity (0-33%) and low specificity (71-82%) for predicting immunoglobulin resistance or cardiac involvement.

CONCLUSIONS

In European populations with mixed ethnic backgrounds, the presence of any abnormalities at the initial echocardiogram may contribute to early identification of patients with severe disease.