Tofacitinib, celiac disease and the elderly: mind the gut!

To the Editor, We read with great attention the interesting case report by Lenfant et al. narrating the successful use of tofacitinib in a patient with microscopic colitis and celiac disease (1), and we would point some insights about this peculiar situation. In fact, tofacitinib depicts potential side effects, including a higher risk of malignancies, and the FDA has even issued a warning about this drug’s hazard (2). Actually, a randomized open-label trial published in the New England Journal of Medicine in 2021 found that patients with rheumatoid arthritis who took tofacitinib had a higher risk of developing cancer than those who took a tumor necrosis factor (TNF) inhibitor (3). Recently, two recent randmoized controlled trials from the ORAL Surveillance Trial and published in the Annals of the Rheumatic Diseases in 2023 also contributed to shed the light on this potential risk : that patients with rheumatoid arthritis aged > 50 with cardiovascular risk who took tofacitinib had a higher risk of developing any type of cancer than those who took a TNF inhibitor (4), and secondary stratification found that they were more likely to develop cancer if they were over the age of 65 years (5). Adding insult to injury, the maligancies are also driven by the two peculiar forms of celiac disease : seronegative and refractory celiac disease (RCD), and this risk is also increased in CD diagnosed at adulthood : particularly, elder patients are prone to present a RCD, and giving immune checkpoint therapy might increase this risk (6). In conclusion, RCD ought to be definetly ruled out before starting JAK inhibitor therapy, especially in aged population with seronegative celiac disease and microscopic colitis, two well-known conditions associated with RCD.

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.

Morphea and Autoimmunity: HLA behind the scene?

We read with deep attention the case report recently published  about the peculiar association of morphea, celiac disease, dermatitis herpetiformis and dermatomyositis , and we would discuss the particular genetics that lay behind morphea and related autoimmune disorders, with a focus on HLA genes.

Under 5 Child Mortality in the Maghreb countries

INTRODUCTION

Mortality, particularly at younger ages, is a key measure of population health.

AIM

To describe under 5 children mortality trends and its related factors in the Great Maghreb countries over the last three decades 1994-2019.

METHODS

We conducted an observational descriptive study to clarify the situation in the Maghreb countries with regard to the under-five death rates and the various causes related to them during the last three decades (1990-2019). The data was collected from the Global Burden of Diseases, Injuries, and Risk Factors (GBD).

RESULTS

he overall trend for the five Maghreb countries was towards the decrease in the mortality rates for all age groups and for both sexes. Mauritania remains at the top of the list in term of the number of deaths followed directly by Morocco. The number of deaths of under-5 children is higher among boys in all Maghreb countries and the most affected age group is under 1 year old. Regarding the causes of under-5 mortality in Maghreb countries, the top-5 causes were similar; except in Mauritania where infectious diseases remain the leading under-5 mortality cause, like in other sub-Saharan countries.

CONCLUSION

Despite the big drop in under 5 child Mortality rates, a lot remains to be done in Maghreb countries to improve children health.

Breastfeeding for Primary Prevention of Stroke

A recent review by Zhang et al. published in the "Journal of the National Medical Association" focused on the major and emerging strategies for the prevention of stroke. We would highlight the evolving role of breastfeeding as an efficient intervention in primary prevention of such cardiovascular disease, including in black women.

Autism & Gluten: The Proof By Regression!

Investigators from different clinical and research centers from Paris, France studied the polymorphisms of the HLA class II loci in an autistic population. Through a case control design, they looked for the distribution of HLA class II alleles, genotypes and haplotypes in Autism Spectrum Disorders (ASD) patients meeting DSM-IV TR criteria versus healthy controls (HC).

Migraine, Celiac Disease and Intestinal Microbiota

Investigators from four European tertiary care hospitals (in Paris, France; Milan, Udine and Perugia, Italy) performed a case-control study of children and adolescents aged 6 to 17 years diagnosed with primary headaches in the emergency department by a pediatric neurologist using the validated ICHD-3 criteria.