- Meeting abstracts
- Open Access
Proceedings of the 25th European Paediatric Rheumatology Congress (PReS 2018)
© The Author(s). 2018
- Published: 22 August 2018
O01 PREDICTING WHICH CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS WILL NOT ATTAIN EARLY REMISSION WITH CONVENTIONAL TREATMENT: RESULTS FROM A CANADIAN INCEPTION COHORT
Jaime Guzman Ramirez1, Andrew Henrey2, Thomas Loughin2, Roberta Berard3, Natalie J. Shiff4, Roman Jurencak5, Adam M. Huber6, Kiem Oen7, Kerstin Gerhold7, Brian M. Feldman8, Rosie Scuccimarri9, Kristin Houghton10, Gaelle Chedeville9, Kimberley Morishita10, Bianca Lang6, Paul Dancey11, Alan M. Rosenberg12, Julie Barsalou13, Alessandra Bruns14, Karen Watanabe Duffy5, Susanne Benseler15, Ciaran Duffy5, Lori B. Tucker10 and ReACCh-Out Investigators
1Pediatrics, University of British Columbia, Vancouver; 2Statistics, Simon Fraser University, Burnaby; 3Pediatrics, Western University, London, Canada; 4Pediatrics, University of Florida, Gainesville, USA; 5Pediatrics, University of Ottawa, Ottawa; 6Pediatrics, Dalhousie University, Halifax; 7Pediatrics, University of Manitoba, Winnipeg; 8Pediatrics, University of Toronto, Toronto; 9Pediatrics, McGill University, Montreal; 10Pediatrics, UBC and BC Children's Hospital, Vancouver; 11Pediatrics, Memorial University, St. John's; 12Pediatrics, University of Saskatchewan, Saskatoon; 13Pediatrics, Universite de Montreal, Montreal; 14Pediatrics, Universite de Sherbrooke, Sherbrooke; 15Pediatrics, University of Calgary, Calgary, Canada
Correspondence: Jaime Guzman Ramirez
Introduction: Accurate estimates of the likelihood of attaining early remission with conventional treatment escalation may help target aggressive treatment to children with juvenile idiopathic arthritis (JIA) who have a low chance of remission.
Objectives: To develop a clinical prediction tool to estimate the chance of early clinical remission with conventional treatment for each child at the time of JIA diagnosis.
Methods: Prediction models were developed using data from 1074 subjects in the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) cohort diagnosed 2005-2010. Treatment was compatible with the 2011 recommendations of the American College of Rheumatology. The predicted outcome was clinical inactive disease for 6 or more months starting within one year of the diagnosis in patients who did not receive early biologic agents or triple DMARD therapy. Models were developed in 200 random splits of 75% of the cohort, and tested on the remaining 25% of subjects, calculating expected and observed frequencies of remission and c-index values.
Results: A Cox-logistic model combining 18 clinical variables at a median of 2 days after diagnosis had a c-index of 0.69 (95%CI: 0.67-0.71) and performed better than JIA category alone (0.59, 0.56-0.63). Table 1 lists the top 8 variables included in the final model. Using the model, an online calculator (https://andrew-j-henrey.shinyapps.io/JIA_Remission_Calc/) produces estimates of the chance of remission for each child with JIA at diagnosis. Children in the lowest decile of probability of remission according to the model had a 20% chance of remission and 21% of them remitted; children in the highest decile had a 69% chance of remission and 73% remitted. Compared to 5% of subjects identified by JIA category alone, the model identified 14% of the cohort as having a low chance of remission (<0.25 probability of remission), of whom 77% failed to attain remission within one year of diagnosis.
Conclusion: Although the model did not meet our a priori performance threshold (c-index>0.70), it identified three times more subjects with low chance of remission than JIA category alone, and it may serve as a benchmark for judging the value added by future biomarkers.
Disclosure of Interest
The top 8 variables in the final prediction model (full model uses 18 variables)
Adjusted Hazard Ratio for time to remission on medications (95% CI)
Physician global (0-10)
Weeks from onset to diagnosis
Subtalar joint involved
Symmetric joints involved
Pain intensity (0-10)
No. enthesitis sites
O02 TREG SPECIFIC CONSTITUTIVE NRF2 ACTIVATION INDUCES AUTOIMMUNITY
Klaus Tenbrock1, Patricia Klemm1, Kim Ohl1
1Pediatrics, RWTH AACHEN UNIVERSITY, Aachen, Germany
Correspondence: Klaus Tenbrock
Introduction: Immune cells are constantly confronted with intracellular and extracellular radical oxygen species (ROS) under steady-state and even more under inflammatory and pathogenic conditions. To investigate the effects of oxidative stress and ROS molecules in regulatory T cells (Tregs), we deciphered the role of Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) in this context. Tregs were already found to be more resistant to ROS than effector T cells and activated Treg cells show higher expression of genes, which belong to the Nrf2-mediated oxidative stress response compared to activated effector T cells.
Objectives: To analyze the specific role of Nrf2 in Tregs.
Methods: To define the role of Nrf2 in Tregs, we generated mice with a knock out of Keap in all hematopoietic cells (VAVCRE-Keapfl/fl) with a Treg specific knockout of Keap 1, which is the constitutive binding partner of Nrf2 (Foxp3CRE-Keap1fl/fl) and characterized the mice using flow cytometry, T cell suppression assays and metabolomics.
Results: While mice bearing a constitutive activation of Nrf2 activation in all immune cells (VavcreKeapfl/fl) accumulate high percentages of Foxp3-positive Tregs in the spleen, lymph nodes and thymus, their suppressive capacity seems to be defective. Interestingly, a Treg specific activation of Nrf2 (Foxp3creKeapfl/fl) results in an auto-inflammatory phenotype with immune cell infiltrates in the lungs, enhanced effector T cell activation and high percentages of IFN-γ producing effector T cells. Moreover, the constitutive Nrf2 activation in Tregs increases their in-vitro proliferation, glucose uptake and mTOR activity, while the differentiation and Foxp3 expression in Tregs declines
Conclusion: We demonstrate for the first time that constitutive Nrf2 activation specific to Tregs affects Treg lineage stability and metabolism and might thereby induce an auto-inflammatory phenotype.
Our results therefore may have implications for diseases associated with oxidative stress and dysregulated Treg responses.
Disclosure of Interest
O03 EXTENDED PHENOTYPIC IMMUNOME CHARACTERISATION (EPIC): A WEB-BASED IMMUNE REFERENCE ATLAS
Joo Guan Yeo1,2, Pan Lu1, Thaschawee Arkachaisri1,2, Su Li Poh1, Fauziah Ally1, Jingyao Leong1, Kee Thai Yeo1,2, Loshinidevi D/O Thana Bathi1, Angela Yun June Tan2, Liyun Lai1, Elene Seck Choon Lee2, Salvatore Albani1,2
1Translational Immunology Institute, SingHealth Duke-NUS Academic Medical Centre; 2KK Women’s and Children’s Hospital, Singapore, Singapore
Correspondence: Joo Guan Yeo
Introduction: An atlas of the developing immune system is key to understanding its normal maturation and identifying disease-associated cell subsets. The availability of high dimensional mass cytometry, in comparison to traditional oligo-dimensional approach such as fluorescence-based flow cytometry, provides an opportunity for the creation of this reference. However to date, the power available from these big data has not been fully harnessed due to the absence of clinically relevant and standardised datasets. This results in issues of fragmentation by focusing on individual cell subsets and lack the ability to transverse the whole developmental gradient from neonatal to adult age. There is a critical unmet need for standardised datasets depicting at single cell level and with high dimensionality the entire human immune system. These limitations hamper translational and clinical research.
Objectives: To address this need, we aim to construct a mass cytometry based immune atlas from healthy peripheral blood mononuclear cells (PBMC) samples ranging from cord blood to adult age and make this dataset available to the research community via an interactive web portal to enable its mining and comparison with diseased dataset.
Methods: The mass cytometry data from 113 healthy individuals (cord blood, newborn to adult) using 63 immune markers encompassing the major immune lineages were obtained. Quality control was performed before dimensional reduction and clustering to identify the cell subsets using our in-house analysis and visualisation pipeline. Their frequencies across the ages were presented as 3-D frequency histograms to create the immune landscape. This database and the analytic pipeline were incorporated into a web-based portal allowing users to interact and upload their own data for comparison.
Results: Here, we described EPIC with examples of its potential by exploring the evolution of some representative immune subsets over the full gradient of ages. Three developmental trajectories made up the healthy immune landscape with the most distinct being an increase or decrease in the cell populations with age. The last trajectory constituted an increase in population size in early childhood followed by a region of levelling. There was a distinct segregation of the naive T cell subset enriched in the cord blood/newborn period with the memory T cell subset enriched in adulthood. The naive IL8+ and TNFα+ CD4+ T cells were prominent peaks in the landscape and were found in higher frequency in the cord blood/newborn period. In contrast, the memory IFNɣ+ and TNFα+ CD4+ T cells were enriched in adulthood.
For specific cell subsets, transition developmental milestones were observed in the TNFα+ CD4+ T cells where the size of its memory subset would exceed its naive subset at 8 year old. There was a significant reduction and increase with age in the frequency of the naive and memory TNFα+ CD4+ T cells with a Spearman’s correlation coefficient, rho, of -0.4662 and 0.4164 respectively (p<0.0001). A similar intersection was present for the naive and memory regulatory T cell (CD4+, CD25+, Foxp3+, CD152+) subsets at 14 year old with a rho of -0.537 and 0.5034 respectively (p<0.0001).
Conclusion: A holistic description of the developing immunome was obtained with key developmental milestones in the T cell compartment identified. This atlas has the translational potential of helping us define the stage of immune maturity and identify the pathological cell subset in both paediatric and adult immune mediated diseases by the direct comparison with this reference atlas using the web-based portal that will be made freely available.
Disclosure of Interest
O04 VALIDATION OF THE RECENTLY DEVELOPED EVIDENCE-BASED EUROFEVER CLASSIFICATION CRITERIA FOR HEREDITARY RECURRENT FEVERS (HRF) AND PFAPA
Silvia Federici1,2, Federica Vanoni3,4, Francesca Bovis5, Nicola Ruperto1, Michael Hofer6, Marco Gattorno1 and on behalf of the Expert Committee for the Classification Criteria in periodic fever
1Division of Rheumatology, Istituto Giannina Gaslini, Genova; 2Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy; 3Pediatric Rheumatology Unit CHUV, University of Lausanne, Lausanne; 4Departement of Pediatric of Southern Switzerland, Bellinzona, Switzerland; 5Biostatistic Unit, Department of Health Sciences, University of Genoa, genoa, Italy; 6Pediatric Rheumatology Unit, CHUV, Lausanne, Switzerland
Correspondence: Silvia Federici
Introduction: Provisional Eurofever evidence-based classification criteria for the 4 inherited recurrent fever (FMF, CAPS, TRAPS, MKD) have been published and other diagnostic criteria are available in the literature for FMF, CAPS and PFAPA. Despite a significant increase of accuracy of the recent Eurofever classification criteria in respect to the previous ones, none of them combine the clinical criteria with the results of molecular analysis. This is a major limitation considering the fact that the genetic analysis might be considered per se pathognomonic, and therefore diagnostic, at least in the presence of a confirmatory genotype. Recently new evidence-based classification criteria for hereditary recurrent fevers (HRF) and PFAPA have been identified during a Consensus Conference held in Genoa in March 2017. For each of the monogenic recurrent fever new classification criteria based on genetic and clinical variables were developed. For PFAPA novel classification criteria based on positive and negative clinical variables were also approved by experts (Gattorno et al. PRES 2017, submitted).
Objectives: To evaluate the performance of the final set of classification criteria, in discriminating patients with the different HRF and PFAPA in a separate set of real patients coming from the Eurofever Registry and to compare their accuracy with respect to existing criteria.
Methods: We selected those patients with recurrent HPF coming from the Eurofever Registry excluding patients belonging to the original dataset of 360 patients used for the development of the criteria themselves. Patients with inherited periodic fever (TRAPS, FMF, MKD and CAPS), PFAPA and undefined periodic fevers were considered and classified according to the indication of each center, without any process of validation by expert. Sensitivity, specificity, accuracy, negative and positive predictive values and AUC-ROC of the new criteria were calculated.
Results: A total of 1018 new patients coming from the Eurofever Registry were included. The performance of the criteria coming from the Consensus conference in comparison with the criteria of the literature is listed in Table 1. Overall, their performance was superior (accuracy ranging from 0.81 to 0.98) to the already published literature’s criteria (accuracy 0.56-0.94) with a very high specificity and a variable sensitivity. Most of the patients not classified with the new criteria were negative for genetic analysis or carriers of low-penetrance mutations with an inconsistent clinical phenotype.
Conclusion: The validation of the new Eurofever classification criteria in a large group of unselected patients coming from the registry confirms their high specificity and overall better performance in comparison to other criteria available in the literature. It is recommended to use them as classification rather that diagnostic criteria, for clinical trials and pathogenic studies.
Disclosure of Interest
See text for description
New CAPS criteria (clinical + genetics)
Kuemmerle CAPS criteria
New FMF criteria (clinical + genetics)
Pediatric FMF criteria
New MKD criteria (clinical + genetics)
New TRAPS criteria (clinical + genetics)
New PFAPA clinical criteria
Modified Marshall criteria
O05 PERFORMANCE OF THE AUTOINFLAMMATORY DISEASE ACTIVITY INDEX (AIDAI) IN PATIENTS WITH COLCHICINE-RESISTANT FMF, HIDS/MKD AND TRAPS: RESULTS FROM A PIVOTAL, PHASE 3 TRIAL OF CANAKINUMAB
Isabelle Kone-Paut1, Maryam Piram1, S Benseler2, J. B Kuemmerle-Deschner3, A. F Jansson4, I Rosner5, A Tomassini6, S Murias7, O Karadag8, J Levy9, S Smeets10, F De Benedetti11
1APHP, CHU de Bicêtre, Univ Paris Sud, Le Kremlin Bicêtre, France; 2Alberta Children's Hospital, Calgary, Canada; 3University Hospital Tuebingen, Tuebingen; 4Ludwig Maximilian University, Munich, Germany; 5Bnai-Zion Medical Center, Rheumatology, Haifa, Israel; 6Department of Internal Medicine, Università Cattolica Sacro Cuore, Rome, Italy; 7Hospital La Paz, Madrid, Spain; 8Hacettepe University Faculty of Medicine, Ankara, Turkey; 9BIOP, Reinach, Switzerland; 10Novartis Pharma B.V., Arnhem, Netherlands; 11IRCCS Ospedale Bambino Gesú, Rome, Italy
Correspondence: Isabelle Kone-Paut
Introduction: AIDAI is a novel and unique, validated patient (pt)-reported assessment tool to evaluate disease activity in familial Mediterranean fever (FMF), hyper-IgD syndrome/mevalonate kinase deficiency (HIDS/MKD) and TNF receptor-associated periodic syndrome (TRAPS).1
Objectives: To perform an external validation of AIDAI, we calculated scores over 40 weeks (wks) of canakinumab (CAN) treatment in pts enrolled into the CLUSTER trial and assessed correlation between AIDAI and disease/response characteristics.
Methods: CLUSTER consisted of one cohort per disease (crFMF, HIDS/MKD and TRAPS).2 AIDAI was calculated as the sum of 12 items (Yes=1; No=0)1 for 30 consecutive days. AIDAI score was calculated if the first score was recorded before ≥29 days. Missing items beyond last evaluable measurement were imputed by last observation carried forward (LOCF). Inactive disease (ID) was defined as AIDAI score <9. Correlation analysis of AIDAI with Sheehan disability score (SDS), child health questionnaire–psychological/physical (CHQ–PsCS/PCS), physician global assessment (PGA), short form 12–physical/mental component summaries (SF12–PCS/MCS), C-reactive protein (CRP) and serum amyloid A (SAA) were performed. Significance was set at p<0.05.
Results: Overall, 167 (crFMF: N=59; HIDS/MKD: N=66; TRAPS: N=42) pts were randomized to CAN 150 mg or placebo every 4 wks. Median AIDAI scores in all 3 cohorts decreased from baseline (BL) to Wk 16 (crFMF: 22.5 to 5.0; HIDS/MKD: 41.5 to 12.0; TRAPS: 89.0 to 13.0) and through Wk 40 (crFMF: 1.0; HIDS/MKD: 5.0; TRAPS: 20.5). In all 3 cohorts, the proportion of pts with ID (AIDAI score <9) was higher at Wk 40 versus BL (crFMF: 69.5% vs 5.1%; HIDS/MKD: 56.1% vs 6.1%; TRAPS: 42.9% vs 2.4%). AIDAI at Wk 40 correlated significantly with: SDS in all 3 cohorts; CHQ-PsCS in crFMF and HIDS/MKD; CHQ-PCS in crFMF; PGA in TRAPS; SF12–PCS in crFMF and TRAPS. SF12-MCS, CRP and SAA did not correlate with AIDAI (Table 1).
Conclusion: AIDAI scores decreased markedly over 40 weeks of treatment with canakinumab in crFMF, HIDS/MKD and TRAPS, with a relevant percentage of patients having inactive disease score. AIDAI improvements at Week 40 correlated with patient- and physician-driven evaluations. AIDAI is a validated patient-reported tool to assess disease activity and appears to have good sensitivity to change to be used in comparative trials. Patient’s experience on disease activity does not strictly correlate with CRP and SAA, as these reflect more closely biological inflammation than clinical symptoms.
1Piram M, et al. Ann Rheum Dis. 2014;73:2168-73. 2De Benedetti F, et al. N Engl J Med. 2018 (in press).
Trial registration identifying number: NCT02059291
Disclosure of Interest
I. Kone-Paut Grant / Research Support from: Novartis, SOBI, Roche, Consultant for: Novartis, SOBI, Pfizer, AbbVie, Roche, M. Piram Consultant for: Novartis, Pfizer, Abbvie, Speaker Bureau of: Novartis, S. Benseler Consultant for: Novartis, SOBI, AbbVie, J. B. Kuemmerle-Deschner Grant / Research Support from: Novartis, Consultant for: Novartis, SOBI, A. F. Jansson Grant / Research Support from: Novartis, I. Rosner: None Declared, A. Tomassini: None Declared, S. Murias: None Declared, O. Karadag: None Declared, J. Levy Consultant for: Novartis, S. Smeets Employee of: Novartis, F. De Benedetti Grant/Research Support from: Novartis, Roche, Pfizer, SOBI, AbbVie, Novimmune, BMS, Sanofi
Correlation between AIDAI and disease activity variables at Week 40
Correlation coefficient (95% CI)
0.54* (0.20; 0.76)
-0.83* (-0.95; -0.49)
-0.67* (-0.90; -0.16)
0.24 (-0.08; 0.51)
-0.47* (-0.77; 0.0)
-0.43 (-0.75; 0.05)
-0.07 (-0.38; 0.25)
-0.07 (-0.38; 0.24)
0.39* (0.05; 0.65)
-0.47* (-0.76; -0.03)
-0.32 (-0.67; 0.14)
0.24 (-0.03; 0.47)
-0.09 (-0.71; 0.61)
-0.19 (-0.76; 0.54)
0.06 (-0.22; 0.32)
0.08 (-0.19; 0.34)
0.41* (0.02; 0.69)
-0.07 (-0.62; 0.53)
-0.02 (-0.59; 0.56)
0.37* (0.02; 0.63)
-0.60* (-0.86; -0.11)
-0.13 (-0.62; 0.43)
-0.17 (-0.50; 0.20)
-0.18 (-0.51; 0.18)
O06 INTERRATOR RELIABILITY OF A STANDARDIZED SCORING TOOL TO REPORT MRI FINDINGS IN CHRONIC NONBACTERIAL OSTEOMYELITIS
Yongdong (Dan) Zhao1,2, T. S. Sato3, Meinrad Beer4, Mingqian Huang5, Ramesh S. Iyer6, Michael McGuire7, Anh-Vu Ngo6, Jeffrey P. Otjen6, Jyoti Panwar8, Jennifer Stimec9, Mahesh Thapa6, Paolo Toma10, Angela Taneja11, Nancy E. Gove2, Polly J. Ferguson12
1Seattle Children’s Hospital, Department of Pediatrics, University of Washington; 2Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle; 3Radiology, University of Iowa Carver College of Medicine, Iowa City, USA; 4Department of Diagnostic and Interventional Radiology, University Hospital of Ulm, Ulm, Germany; 5Department of Radiology, University of Stony Brook, Stony Brook; 6Department of Radiology, Seattle Children’s Hospital, University of Washington, Seattle; 7Department of Radiology, Hackensack University Medical Center, Hackensack, USA; 8Joint Department of Medical Imaging, University Heath Network, University of Toronto; 9Hospital for Sick Children, Department of Medical Imaging, Toronto, Canada; 10Department of Imaging, Bambino Gesù Children Hospital, IRCCS, Rome, Italy; 11Pediatric Rheumatology, Children’s Healthcare of Atlanta, Emory University, Atlanta; 12Department of Pediatrics, University of Iowa Carver College of Medicine, Iowa City, USA
Correspondence: Yongdong (Dan) Zhao
Introduction: CNO is an inflammatory bone disease that can result in bone destruction, persistent bone pain and pathological fractures. For clinical and research purposes, serial MRI exams are needed to determine the objective response to treatment. A previously developed MRI scoring tool for CNO in a single center showed sensitivity to detect imaging change after aggressive treatment.
Objectives: To use a nominal group technique to develop a practical and consensus-based MRI scoring tool for clinical and research use in CNO. Furthermore, inter-rater reliability were evaluated using whole body (WB) MRI from children with CNO.
Methods: Eleven pediatric radiologists, each with at least 5 years of experience reading musculoskeletal MRI from seven different pediatric hospitals in North America and Europe, discussed definitions and grading of signal intensity, extent of signal abnormality within bone marrow and surrounding tissue, physis damage and vertebral fracture on MRI through monthly conference calls and an in-person meeting (Seattle, July 2017). Nine sets of whole body MRIs were used as a pilot reading session at the conference that demonstrated greater than 70% of agreement among the radiologist attendees. Fifty sets of pre-existing WB MRI scans between Jan 2013 and August 2016 from children with CNO at the University of Iowa Children’s Hospital were anonymized and used for an inter-rater reliability study. Inter-rater agreement of presence of abnormal signal and severity were assessed using Fleiss kappa analysis.
Results: Signal intensity was rated as absent, < fluid signal or similar to fluid signal within bone marrow. Extent of abnormal signal intensity within bone or surrounding tissues were scored according to the relative affected proportion. Long bones were divided into proximal epiphysis, proximal metaphysis, diaphysis, distal metaphysis and distal epiphysis. Complex bony regions such as the pelvis were divided into easily identifiable anatomical subareas. The agreement among 11 radiologists in readings of femur and tibia were shown in Table 1. There was moderate to substantial agreement (0.44-0.63) in all parameters except the sizes of femoral proximal epiphyseal and femoral proximal metaphyseal lesions (0.28-0.34). There were 38 tibias and 30 femurs identified as active inflammation by at least 9 of 11 radiologists. Data from other bones are being analyzed.
Conclusion: A comprehensive standardized scoring tool for MRI in children with CNO was developed. There was moderate to substantial agreements among radiologists in majority of parameters of femur and tibia. If proven reproducible, this tool can be validated in a prospective study and will become a key element of disease activity assessment in CNO.
This study was funded by CARRA-AF small grant.
Disclosure of Interest
Y. D. Zhao Grant / Research Support from: Bristol-Myers Squibbs, CARRA, Clinical Research Scholar Program from Seattle Children's Research Institute, T. Sato: None Declared, M. Beer: None Declared, M. Huang: None Declared, R. Iyer: None Declared, M. McGuire: None Declared, A.-V. Ngo: None Declared, J. Otjen: None Declared, J. Panwar: None Declared, J. Stimec: None Declared, M. Thapa: None Declared, P. Toma: None Declared, A. Taneja: None Declared, N. Gove: None Declared, P. Ferguson Grant/Research Support from: R01AR059703 from NIH/NIAMS
See text for description
Kappa values (95% CI) of tibial lesions (n=100)
Kappa values (95% CI) of femoral lesions (n=100)
Max signal intensity
Size of proximal epiphyseal lesion
Size of proximal metaphyseal lesion
Size of diaphyseal lesion
Size of distal metaphyseal lesion
Size of distal epiphyseal lesion
Soft tissue inflammation
O07 IMPACT OF PEDIATRIC RHEUMATIC DISEASES ON CAREGIVERS MULTIASSESSMENT QUESTIONNAIRE: CAREGIVERS QUESTIONNAIRE
Marcia D. Torres-Made1, Nadina E. Rubio Pérez1, Ingris Peláez Ballestas2, Fernando García Rodriguez1, Ana V. Villarreal Treviño1, Brenda D. J. Fortuna Reyna1, Manuel E. De la O Cavazos1
1Pediatría, Hospital Universitario "Dr. José Eleuterio Gónzalez", Monterrey, Nuevo León; 2Reumatología, Hospital General Dr. Eduardo Liceaga, Mexico, DF. , Mexico
Correspondence: Marcia D. Torres-Made
Introduction: Most common pediatric rheumatic disease (PRD) is juvenile idiopathic arthritis (JIA), this influence affects quality of life (QoL) of children and families. Caregiver is a cornerstone to achieve disease control however, there are no information on how this conditions affects them; neither a tool to assess this impact was reported.
Objectives: To develop and validate psycho-social impact and financial burden questionnaire in caregivers of JIA patients (CAREGIVERS Questionnaire).
Methods: We development and validate the CAREGIVERS Questionnaire in two phases. Phase 1.Design the questionnaire based in non-systematic review and qualitative study: First version (1stQ), exploratory and open questions, was constructed based on literature review by an expert group (pediatric rheumatologists and methodologist). A qualitative study of pragmatic type was conducted on 15 caregivers to identify areas affected after JIA diagnosis. Interviews were reviewed using thematic analysis with Atlas-ti software. Questionnaire was adapted based on qualitative study and second version (2ndQ) was tested on 10 participants to evaluate comprehensibility. Changes in structure were made after pediatric rheumatologists, anthropologist/methodologist, psychologist, and pedagogue analyzed the answers (3rdQ).
Phase 2. Validation of questionnaire. 3rdQ was evaluated for face, content, reliability, internal consistency, convergent, and divergent validity. Construct validity was tested for anxiety/depression (Beck), coping strategies (Reyes-Lagunes), QoL (EuroQol), and social and economic factors (Socioeconomic burden). Correlation matrix to assess the construct validity using Cohen’s kappa, and internal consistency tests using Cronbach’s alpha were performed.
Results: Qualitative study (1stQ) identified topics like socioeconomic burden, family interactions, alternative medicine, religion, information access, and prognosis. 2ndQ was conformed by 75 items. After pilot study, six items were confuse and modified, 11 were eliminated for being redundant. Items were organized in five domains to develop 3rdQ: disease impact (social, economic, family and relationship), knowledge, future, alternative medicine, and religion (13, 27, 2, 2, and 2 items, respectively). Validity analysis included 32 participants (93% women). Mean age 39 (SD 8.5) years, mean EuroQol VAS 82, minimal depression in 90%. Socioeconomic tool demonstrated family income above 14 minimum wages (65 USD) in 68% and 59% have remunerated job. Reyes-Lagunes describes “life coping” with emotional-negative strategies in 31 caregivers and straight strategies in “children´s health coping” in 100%. Finally, in 3rdQ, 22% felt sadness at diagnosis, 84% change initial feeling and currently 43% are relief. Sixty two percent mention disease has influenced in their financial situation and 72% feel anxiety about their children future. Statistical analysis show adequate inter-item reliability in all domains except for religion, consequently items were adapted to create new dimensions (Table 1). Correlation matrix shown good results in all domains, except for social and economic due to redundant items. After changes, CAREGIVERS Questionnaire was created.
Conclusion: We design CAREGIVERS Questionnaire, a specific multidimensional tool to assess burden in caregivers of patients with PRD, and validated in JIA. Further efforts will be performed to validated in other PRD.
Disclosure of Interest
See text for description
Disease impact on:
II. Disease knowledge
IV. Use of social networks
O08 TREAT-TO-TARGET USING FIRST-LINE TREATMENT WITH RECOMBINANT IL-1 RECEPTOR ANTAGONIST IS HIGHLY EFFECTIVE FOR SYSTEMIC JIA: A 5 YEAR FOLLOW-UP STUDY
Nienke M. ter Haar1,2, Evert H. P. van Dijkhuizen2, Joost F. Swart2, Wilco de Jager1, Dirk Holzinger3,4, Arjen P. Leek2, Jorg van Loosdregt1, Annet Van Royen-Kerkhof2, Nico M. Wulffraat2, Sytze de Roock1,2, Sebastiaan J. Vastert1,2
1Laboratory for Translational Immunology; 2Paediatric Rheumatology and Immunology, University Medical Center Utrecht, Utrecht, Netherlands; 3Paediatric Rheumatology and Immunology, University of Muenster, Muenster; 4Paediatric Hematology-Oncology, University of Duisburg-Essen, Essen, Germany
Correspondence: Sebastiaan J. Vastert
Introduction: Systemic onset JIA (sJIA) is a multifactorial autoinflammatory disease. Historically, the prognosis of sJIA was very poor. The use of interleukin (IL)-1 and IL-6 blockade improved outcome, but still most studies report inactive disease in only 30-50% of patients within one year. It is hypothesized that innate immune activation is most prominent in the early phase of sJIA. To make use of this ‘window of opportunity’, we started a prospective cohort with recombinant IL-1 receptor antagonist (rIL-1RA) as first-line monotherapy in new-onset sJIA patients (Vastert et al. AR 2014).
Objectives: To analyse the long-term efficacy of this therapeutic strategy and to separately analyse a subset of sJIA patients without arthritis at disease onset.
Methods: In this single centre, prospective cohort study, new-onset sJIA patients with an unsatisfactory response to NSAIDs received rIL-1RA 2mg/kg. Inactive disease (ID) was defined according to the Wallace criteria. In patients reaching ID, rIL-1RA was tapered after 3 months and subsequently stopped. In patients with an incomplete response to rIL-1RA, our protocol directed to increase rIL-1RA dose, add prednisolone or switch to alternative therapy. Clinical data including damage (JADI) and patient reported outcomes (CHAQ and/or JAMAR) were completed in a standardized way. Cytokine profiling was performed using Luminex multiplex immunoassay.
Results: Forty-two patients were analysed, with a median follow-up of 5.8 years. At 3 months, 30/42 patients (71%) had ID with rIL-1RA monotherapy and another 6 had ID with rIL-1RA and prednisone. At one year, 32 patients (76%) had ID, of which 22 (52%) were off medication.
Twelve patients had no arthritis at onset; 4 of them developed arthritis during flares. The clinical phenotype, inflammatory parameters and cytokine profile of patients without arthritis at onset was similar to patients with arthritis. Hence, after extensive ancillary investigations to exclude other diseases, these non-arthritic patients also received rIL-1RA as first-line therapy. After 3 months, 11/12 non-arthritic patients had ID (10 on rIL-1RA monotherapy), at 1 year all 12 had ID (8/12 off medication).
Long-term outcome reflected the high efficacy of first-line rIL-1RA: 95% of all patients had ID and 72% had ID off medication at 3 and 5 years follow-up, only 5% reported articular damage and 5% extra-articular damage, no patient developed growth failure and only one developed obesity during follow-up. Moreover, around 60% of patients reported complete absence of pain and disease, no limitations in daily life and the highest possible score on well-being. One patient died due to MAS. In total, 24 patients (57%) never used other medication besides rIL-1RA and NSAIDs and only 14 patients (33%) used glucocorticoids.
Patients who achieved ID at one year were younger and had a significantly shorter disease duration, less active joints and higher neutrophil and leukocyte count before start of rIL-1RA. Multivariate analysis confirmed high neutrophil count as a significant predictor for ID at one year. Furthermore, ID at one year was highly associated with a good response at 1 month.
Conclusion: First-line, short course monotherapy with rIL-1RA is a highly efficacious strategy to induce and sustain inactive disease and to prevent disease- and glucocorticoid-related damage. Our data on sJIA patients without arthritis plea for leaving out arthritis as a prerequisite criterion in future disease classification criteria.
Disclosure of Interest
O09 CLINICAL OUTCOMES FOLLOWING MYCOPHENOLATE MOFETIL VS. CYCLOPHOSPHAMIDE INDUCTION TREATMENT FOR PROLIFERATIVE JUVENILE-ONSET LUPUS NEPHRITIS
Eve M. Smith1, Michael W. Beresford1, Christian M. Hedrich2
1Institute of Translational Medicine; 2Institue of Translational Medicine, University of Liverpool, Liverpool, UK
Correspondence: Eve M. Smith
Introduction: Treatment of proliferative class III/IV lupus nephritis (LN) in children is largely based upon adult studies. The largest study demonstrated a similar renal response rate with mycophenolate mofetil (MMF) or cyclophosphamide (CYC) induction treatment in adult patients with LN . A further smaller study showed MMF to be more effective than CYC . In both, MMF had a better safety profile [1,2].
Objectives: Within a predominantly Caucasian JSLE cohort, to compare efficacy of MMF vs. CYC in patients with LN, monitoring 1) response to treatment, 2) damage accrual, 3) time to achievement of inactive LN, and 4) time to subsequent LN flare, following MMF or CYC LN induction treatments.
Methods: Participants of the UK JSLE Cohort Study (2006-2018), <18 years at the time of diagnosis, with ³4 ACR criteria for SLE, were eligible for inclusion if they had ISN/RPS class III or IV LN. Median values and interquartile ranges quoted. Mann-Whitney U tests for continuous data and Fishers exact test for categorical data.
Results: 69/411 UK JSLE Cohort Study patients met the inclusion criteria; 18/61 were excluded due to insufficient follow-up. 34/51 (67%) received MMF (13/34 (38%) class III, 21/34 (62%) class IV LN), and 17/51 (33%) received CYC (8/17 (47%) class III, 9/17 (53%) class IV LN). No statistically significant differences were identified between treatment groups at 4-8, 10-14 months post renal biopsy, and last follow-up, in terms of the renal-BILAG score, urine albumin/creatinine ratio, serum creatinine, ESR, anti-dsDNA antibody, C3 levels and patient/physician global scores (all p>0.05, see Table 1). Standardised Damage Index (SLICC-SDI) scores did not differ between treatment groups at a median of 13 months, or last follow-up (all p>0.05, see Table 1). Inactive LN, following the definition of renal BILAG, was attained at 262 days [141–390] after MMF treatment, and 151 days [117-305] following CYC (p=0.17). Time to subsequent renal flare did not differ; 451 days [157–1266] for MMF, and 343 days [198–635] for CYC (p=0.47)).
Conclusion: This is the largest study to date investigating induction treatments for proliferative LN in children. In Caucasian JSLE populations, MMF and CYC may be comparably efficacious in regards to treatment response, damage accrual, and time to next flare. Remission may be reached quicker in patients treated with CYC. Future prospective comparison is warranted to inform LN treatment, given CYC’s poor safety profile.
1. Appel G, et al. JASN 2009, 20:1103-12.
2. Ginzler E, et al. NEJM 2005, 353:2219-28.
Disclosure of Interest
Comparison of clinical parameters and SLICC-SDI scores following MMF vs CYC treatment
Time post biopsy*
Renal BILAG score
A=1, B=5, C=3, D=18
A=1, B=3, C=2, D=8
O10 WORLDWIDE COHERENCE OF ASSOCIATION OF KAWASAKI DISEASE TO MASSIVE AGRICULTURAL CROPLAND BYPRODUCTS
Xavier Rodó1,2, Joseph Boyard-Micheau1, Silvia Borràs1, Dan Cayan3, Jane Burns4on behalf of International Kawasaki Disease Consortium, Yosikazu Nakamura5, Judith Sanchez Manubens6, Jordi Anton6, Josep-Anton Morguí7, Roger Curcoll7, Joan Ballester1 and International Kawasaki Disease Consortium
1Climate and Health Program, ISGlobal (Barcelona Institute of Global Health); 2ICREA, Barcelona, Spain; 3Climate, Atmospheric Sciences, and Physical Oceanography, Scripps Institution of Oceanography, UCSD; 4 Kawasaki Disease Research Center, Dept. of Pediatrics University of California San Diego, La Jolla, CA, USA; 5Jichi Medical Hospital, Tokyo University, Tokyo, Japan; 6Pediatric Rheumatology Unit, Hospital Sant Joan de Déu; 7Land, Atmosphere and Oceans Lab, ICTA, Universitat Autònoma de Barcelona, Barcelona, Spain
Correspondence: Xavier Rodó
Introduction: Long-standing debate continues on the factors and potential etiological agents of vasculitides and rheumatic diseases, such as Kawasaki disease (KD). Together with the genetic predisposition to suffer the condition, hitherto undefined environmental factors have been suggested to contribute to the onset of autoimmune vasculitis in susceptible individuals. A combined approach integrating research on atmospheric circulation and wind dynamics with a time-series study on Kawasaki disease epidemiology in Japan and the US led to a publication firmly pointing to the role of winds and large-scale circulation in the propagation of the potential aetiologic agent of this disease (Rodó et al., 2011).
Objectives: The hypothesis of a windborne role in the generation of KD etiology is further tested in this study for a series of other world locations where the disease is also prevalent and along the suspicion that the interaction between bioaerosols, the air chemistry and predisposed or genetically susceptible patients might similarly be associated with KD incidence there. Recovery of land source regions is attempted with the aim of exploring similarities/differences with those found for Japan. Exploration of the phenological status of vegetation in each of those region is performed to seek further mechanistic explanations on the epidemiological links to KD.
Methods: In this study, a retrospective time series analysis of historical daily hospital admissions of KD and reconstruction of air movements and source regions is presented for several locations in all continents (US and Canada, Chile, France, the United Kingdom, Catalonia, South Korea, India and Thailand). The FLEXPART v9 atmospheric particle dispersion model is used and land-surface cover and high-resolution vegetation data employed to explore relationships to stages of vegetation development.
Results: Source regions and their land-cover typology is reconstructed for all major KD world sites in terms of disease incidence. Similar strong relationships emerge to cereal croplands in all the different continents. The phenological cycle of vegetation in those areas shows a link to the stages where vegetation is decaying, indicating that a relationship between the major KD season and some kind of agricultural byproducts or remnants might play a role in the onset or exacerbation of this disease. An application of a statistical model integrating the air physics ssociated to the movement of winds from these sources further demonstrates predictive capacity to anticipate peaks in KD incidence.
Conclusion: Long-standing debate continues on the factors and potential etiological agents of vasculitides and rheumatic diseases, such as Kawasaki disease (KD) in susceptible children. Together with the genetic predisposition to suffer the condition, hitherto undefined environmental factors are now suggested to contribute to the onset of autoimmune vasculitis in susceptible individuals. The role of bioaerosols and air chemistry and physics is presented pointing to a much clearer combination of factors ultimately appearing to be crucial to the manifestation of epidemiological clusters of this pediatric vasculitis. A computational model integrating all this new environmental information in combination with epidemiological dynamics proves successful in predicting KD incidence in Japan.
Disclosure of Interest
O11 THE INTERACTION BETWEEN GENETIC RISK FACTORS AND AGE OF DISEASE ONSET IN JUVENILE DERMATOMYOSITIS
Claire T. Deakin1,2,3, John Bowes4, Meredyth Wilkinson1, Lucy R. Marshall1, Cerise R. Johnson-Moore1, Gulnara Mamyrova5, Rudolfo Curiel5, Kelly Rouster-Stevens6, Heinrike Schmeling7, Helga Sanner8, Adam M. Huber9, Brian M. Feldman10, Ann M. Reed11, Lauren M. Pachman12, Stephen Eyre4, Soumya Raychaudhuri13,14, Lucy R. Wedderburn1,2,3,15, JDCBS and MYOGEN
1UCL Great Ormond Street Institute of Child Health; 2ARUK Centre for Adolescent Rheumatology, University College London; 3NIHR Biomedical Research Centre, Great Ormond Street Hospital, London; 4ARUK Centre for Genetics and Genomics, University of Manchester, Manchester, UK; 5George Washington University, Washington; 6Emory University, Atlanta, USA; 7Department of Pediatrics, Alberta Children's Hospital, Calgary, Canada; 8Oslo University Hospital, Oslo, Norway; 9IWK Health Centre, Halifax; 10The Hospital for Sick Children, Toronto, Canada; 11Duke University, Durham; 12Northwestern University, Chicago; 13Brigham and Women's Hospital and Harvard Medical School, Boston; 14Broad Institute of MIT and Harvard, Cambridge, USA; 15Great Ormond Street Hospital for Children NHS Trust, London, UK
Correspondence: Claire T. Deakin
Introduction: Juvenile dermatomyositis (JDM) is a rare, severe autoimmune disease characterised by proximal muscle weakness and skin rash. While JDM and adult-onset dermatomyositis (DM) share similar clinical and biological features, there are differences in prevalence of these features, including cancer, calcinosis and myositis-specific autoantibodies, suggesting a possible influence of age on pathogenesis.
Objectives: To investigate genetic risk factors for JDM and age of disease onset.
Methods: Caucasian JDM cases from the UK (n=312) were genotyped (Illumina HumanCoreExome). Caucasian control data (n=2808) were obtained from the Wellcome Trust Case Control Consortium (Affymetrix 500K). Following quality control, classical human leukocyte antigen (HLA) alleles and HLA amino acids were imputed using SNP2HLA. Logistic, linear and Cox regression were performed using PLINK and R package GenABEL, with adjustment for the first two principal components. Genome-wide association was set at P<5×10-8 and suggestive association at P<1×10-5. We subsequently built an international consortium to create a replication cohort of Caucasian cases (n=479). Genotyping of the replication cohort is ongoing using the HumanCoreExome array.
Results: Case-control analyses confirmed involvement of HLA including multiple loci within HLA-C (p=1.35×10‑8, OR=2.49, 95% CI = 1.82-3.42) and HLA-DRB1 (p=2.73×10-8, OR=0.56, 95% CI=0.46-0.69). Outside the HLA region there was suggestive evidence of association at ZNF337 (p=7.49×10-6, OR=1.81, 95% CI=1.40-2.34). Analyses of association with age of disease onset did not implicate HLA involvement, suggesting age does not influence the association between HLA and JDM/DM. Analysis of age of onset as a quantitative trait revealed suggestive associations at PDE1A (p=1.56×10‑6, β=-1.61, 95% CI = -2.26--0.97) and AGPAT3 (p=2.26×10-6, β=1.63, 95% CI = 0.97-2.30), genes involved in regulating intracellular cyclic nucleic acid concentrations and phospholipid biosynthesis/Golgi-to-endoplasmic reticulum retrograde transport, respectively. In addition, we now have a replication cohort via our international consortium to validate these findings. Genotyping of the replication cohort is ongoing using the HumanCoreExome array.
Conclusion: This study confirms previous findings regarding HLA involvement. Analyses of associations with age of JDM onset identified novel loci, PDE1A and AGPAT3, which if validated in an independent replication cohort could suggest novel processes involved in pathogenesis. Together with the replication cohort, this study will be the largest GWAS of JDM to date.
Disclosure of Interest
O12 CORRELATIONS OF TYPE I INTERFERON SCORE AND INTERFERON INDUCED CHEMOKINES (CXCL10 AND CXCL9) WITH CUTANEOUS AND MUSCULAR DISEASE ACTIVITY IN JUVENILE DERMATOMYOSITIS
Gian Marco Moneta1, Ivan Caiello1, Lucilla Rava’2, Silvia Rosina3, Luisa Bracci-Laudiero1,4, Angelo Ravelli3, Fabrizio De Benedetti1, Rebecca Nicolai1
1Division of Rheumatology; 2Epidemiology Unit, Ospedale Pediatrico Bambino Gesù, Rome; 3Rheumatology, Giannina Gaslini Institute, Genoa; 4Institute of Translational Pharmacology, CNR, Rome, Italy
Correspondence: Gian Marco Moneta
Introduction: Interferons (IFNs) seem to play an important role in the pathogenesis of juvenile dermatomyositis (JDM). We previously reported that expression of both type I and type II IFN related genes is increased in muscle biopsies of JDM patients and correlates with histological and clinical features of the disease. Interferon regulated genes (IRGs) have also been reported to be upregulated in peripheral blood of JDM patients and could represent valuable biomarkers of disease activity.
Objectives: The aim of this study was to investigate expression of IRGs (measured as type I IFN score), as well as serum levels of two type I and type II IFN induced chemokines (CXCL9, CXCL10) in peripheral blood of JDM patients and to assess their correlations with clinical and laboratory findings.
Methods: We collected 125 blood samples from 28 JDM patients at different time points during follow-up. We measured expression of IRGs (IFI27, IFI44L, IFIT1, ISG15, RSAD2, SIGLEC1) by quantitative PCR (qPCR) and calculated the type I IFN score; serum levels of CXCL9 and CXCL10 were analyzed by ELISA. At each visit, the following clinical data were recorded: physician’s global assessment of disease activity VAS (Visual Analogue Scale), cutaneous VAS, Cutaneous Assessment Tool (CAT) activity score, Childhood Myositis Assessment Score (CMAS), serum levels of creatine phosphokinase (CK, IU/l), antinuclear antibody (ANA) status, presence of myositis specific or myositis associated antibodies (MSA/MAA), prednisone (or equivalent) dose (mg/kg/daily), ongoing immunosuppressive medications.
Results: Type I IFN score was significantly higher in patients with features of active disease (physician’s global VAS >0.2, CAT activity score≥1, CK>150 IU/l). CXCL10 levels were significantly higher in patients with features of active muscle disease (CMAS<46, CK>150 IU/l) whereas CXCL9 levels were significantly higher only in patients with abnormal CK levels. In a multilevel mixed effect approach, type I IFN score was significantly associated with physician’s global VAS, cutaneous VAS, CAT activity score, CMAS and CK levels; CXCL9 showed no significant association with the evaluated clinical features; CXCL10 levels were significantly associated with CK levels and CMAS. Including time from disease onset to sampling did not change the results. Immunosuppressive medications negatively modulated expression of IRGs and IFN induced chemokines.
Conclusion: Our findings indicate that expression of IRGs, measured as type I IFN score, and serum levels of CXCL10 reflect specific features of disease activity in JDM, further supporting their role as valuable disease biomarkers.
Disclosure of Interest
G. M. Moneta: None Declared, I. Caiello: None Declared, L. Rava’: None Declared, S. Rosina: None Declared, L. Bracci-Laudiero: None Declared, A. Ravelli: None Declared, F. De Benedetti Grant/Research Support from: BMS, Pfizer, Abbvie, Novartis, Novimmune, Roche, SOBI, Sanofi, UBC, Consultant for: Roche, Novartis, Novimmune, SOBI, R. Nicolai: None Declared
O13 EARLY AGGRESSIVE TREATMENT DECREASES PAIN IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS
Maarit Tarkiainen1,2, Pirjo Tynjälä3, Paula Vähäsalo4, Liisa Kröger5, Kristiina Aalto6, Pekka Lahdenne7 and ACUTE-JIA working group
1Department of Pediatric Rheumatology, Children’s Hospital, Helsinki University Central Hospital; 2University of Helsinki; 3Poison Information Centre, , Helsinki University Central Hospital, Helsinki; 4Department of Pediatrics, Oulu University Hospital, Oulu; 5Department of Pediatrics, Kuopio University Hospital, Kuopio; 6Department of Pediatric Rheumatology; 7Helsinki University Central Hospital, Helsinki, Finland
Correspondence: Maarit Tarkiainen
Introduction: Patients with Juvenile Idiopathic Arthritis (JIA) experience more pain than normal population. Pain has become an important outcome measure in JIA.
Objectives: To measure the level of pain during the first year of early aggressive treatment in JIA and at three years from disease onset.
Methods: This study was performed along with Acute-JIA study, in which 60 new-onset patients with polyarticular JIA were randomized to receive either infliximab plus methotrexate (IFX), combination of hydroxychloroquine, sulphasalazine, and methotrexate (Triple) or methotrexate monotherapy (MTX). Disease activity and quality of life were measured at 7 study visits during the first year from onset, and at 3 years’ follow-up visit during open-label extension. Pain VAS (0-100) was utilized. Patients continued on their originally randomized treatment until they failed the strategy or achieved inactive disease (ID) on medication for at least 6 months.
Results: All 60 patients in the original trial completed the 3-year follow-up and 56 pain surveys. 50 (83%) switched treatment strategies between 1 to 3 years. Pain-VAS decreased from 37.0 (SD 24.3) at onset to 8.5 (15.6) at 1 year (Wilk’s Lambda p<0.005). During the open-label extension, the level of pain increased to 10.1 (15.4) at 3 years (p=0.068, compared with 1 year). No differences between treatment groups were detected (p=0.21). CHAQ and JADAS at each time point associated with level of pain. Cumulative time spent in inactive disease (ID) associated with lower level of pain at 3 years (coefficient beta -0.63, p=0.004)
Conclusion: During one-year early aggressive treatment, pain decreased as disease activity diminished. Small, although not statistically different increase in pain was noted during open-label extension. The treatment strategy seemed to have no influence on pain.
Trial registration identifying number: Trial registration: ClinicalTrials.gov NCT01015547
Disclosure of Interest
O14 PHARMACOVIGILANCE IN JUVENILE IDIOPATHIC ARTHRITIS PATIENTS TREATED WITH BIOLOGIC AGENTS AND/OR METHOTREXATE. COMBINED DATA OF MORE THAN 15,000 PATIENTS FROM PHARMACHILD AND NATIONAL REGISTRIES
Gabriella Giancane, Joost Swart, Gerd Horneff, Bo Magnusson, Michael Hofer, Ekaterina Alexeeva, Violeta Panaviene, Brigitte Bader-Meunier, Jordi Anton, Susan Nielsen, Fabrizio De Benedetti, Sylvia Kamphuis, Valda Stanevicha, Maria Trachana, Laura M. Ailioaie, Elena Tsitsami, Ariane Klein, Kirsten Minden, Ivan Foeldvari, Johannes-Peter Haas, Jens Klotsche, Alessandro Consolaro, Francesca Bovis, Francesca Bagnasco, Angela Pistorio, Alberto Martini, Nico Wulffraat, Nicolino Ruperto and for the Paediatric Rheumatology International Trials Organisation (PRINTO), BiKeR and the board of the Swedish Registry.
Clinica Pediatrica e Reumatologia - PRINTO, Istituto Giannina Gaslini, GENOA, Italy
Correspondence: Gabriella Giancane
Introduction: The availability of methotrexate (MTX) and the introduction of multiple biological agents have revolutionized the treatment of juvenile idiopathic arthritis (JIA). Several international and national drug registries have been implemented to monitor accurately the long-term safety/efficacy of these agents.
Objectives: This study aims to present the combined data coming from “Pharmacovigilance in JIA patients treated with biologic agents and/or MTX” (Pharmachild)/Pediatric Rheumatology International Organization (PRINTO) registry and the national registries from Germany (BiKeR) and Sweden.
Methods: Descriptive statistics for demographic, clinical data, drug exposure, adverse events (AE) and events of special interest (ESI) were reported. For the Swedish register, AE data were not available.
Results: A total of 15,284 patient’s data were reported, 8,274 (54%) from the Pharmachild registry, 3,990 (26%) and 3,020 (20%) from the Germany and the Swedish registries, respectively. Pharmachild children showed a younger age (median of 5.4 years versus 7.6) at JIA onset and shorter disease duration (5.3 versus 6.1-6.8) when compared to the other registries. The most frequent JIA category was the rheumatoid factor negative polyarthritis (range 24.6-29.9%). Methotrexate (61-84%) and etanercept (24%>61.8%) were the most frequently used synthetic and biologic disease-modifying anti-rheumatic drug (DMARD), respectively. There was a wide variability in glucocorticoid use (16.7-42.1%). Serious AE were present in 572 (6.9%) patients in Pharmachild versus 297 (7.4%) in BiKeR. Infection and infestations were the most frequent AE (29.4-30.1%) followed by gastrointestinal disorders (11.5-19.6 %). The most frequent ESI were infections (75.3-89%),(Table 1).
Conclusion: Sharing of data from national and international registries represents the most powerful tool for future analysis of safety and effectiveness of immunosuppressive therapies in JIA.
Trial registration identifying number: NCT01399281
Disclosure of Interest
G. Giancane: None Declared, J. Swart: None Declared, G. Horneff: None Declared, B. Magnusson: None Declared, M. Hofer: None Declared, E. Alexeeva: None Declared, V. Panaviene: None Declared, B. Bader-Meunier: None Declared, J. Anton: None Declared, S. Nielsen: None Declared, F. De Benedetti: None Declared, S. Kamphuis: None Declared, V. Stanevicha: None Declared, M. Trachana: None Declared, L. Ailioaie: None Declared, E. Tsitsami: None Declared, A. Klein: None Declared, K. Minden: None Declared, I. Foeldvari: None Declared, J.-P. Haas: None Declared, J. Klotsche: None Declared, A. Consolaro: None Declared, F. Bovis: None Declared, F. Bagnasco: None Declared, A. Pistorio: None Declared, A. Martini: None Declared, N. Wulffraat: None Declared, N. Ruperto Grant/Research Support from: The G. Gaslini Hospital, which is the public Hospital where I work as full time public employee, has received contributions from the following industries for the coordination activity of the PRINTO network: BMS, GlaxoSmithKline (GSK), Hoffman-La Roche, Novartis, Pfizer, Sanofi Aventis, Schwarz Biosciences, Abbott, Francesco Angelini S.P.A., Sobi, Merck Serono. This money has been reinvested for the research activities of the hospital in fully independent manners without any commitment with third parties., Speaker Bureau of: I received speaker’s bureaus and consulting fees from the following pharmaceutical companies: AbbVie, Amgen, Biogenidec, Alter, AstraZeneca, Baxalta Biosimilars, Biogenidec, Boehringer, BMS, Celgene, CrescendoBio, EMD Serono, Hoffman-La Roche, Italfarmaco, Janssen, MedImmune, Medac, Novartis, Novo Nordisk, Pfizer, Sanofi Aventis, Servier, Takeda, UCB Biosciences GmbH.
Most frequent events of special interest ordered by decreasing frequencies. Data are absolute numbers and frequencies (%)
N = 2,022 (%)
Serious/targeted infections (Epstein‐Barr virus, cytomegalovirus, papilloma virus, herpes zoster primary and reactivation, and opportunistic infections)
Infusion/injection related reactions:
Infusion related reaction
Injection related reaction
Blood cells related ESI:
Macrophage activation syndrome
Inflammatory Bowel Disease (IBD)
Other autoimmune diseases excluding IBD, uveitis and demyelinisation disorders
Lupus erythematosus systemic/lupus-like syndrome
Haematopoietic neoplasms (excluding leukaemias and lymphomas)
O15 REMISSION STATUS AFTER 18 YEARS OF FOLLOW-UP IN THE POPULATION-BASED NORDIC JUVENILE IDIOPATHIC ARTHRITIS (JIA) COHORT.
Mia Glerup1, Veronika Rypdal2, Ellen Arnstad3,4, Maria Ekelund5,6, Suvi Peltoniemi6,7, Kristiina Aalto8, Marite Rygg4,9, Peter Toftedal10, Susan Nielsen10, Anders Fasth11, Lillemor Berntson6, Ellen Nordal2, Troels Herlin12
1Pediatrics, Aarhus University Hospital, Aarhus N, Denmark; 2University Hospital of North Norway, Tromsø; 3Levanger Hospital, Nord-Trøndelag; 4Fac. of Med. and Health Sci., NTNU, Norway; 5Ryhov County Hospital, Jonkoping; 6Uppsala University, Uppsala, Sweden; 7University of Helsinki; 8Hospital for Children and Adolescents, Helsinki, Finland; 9St. Olavs Hospital, Trondheim, Norway; 10Rigshospitalet, Copenhagen, Denmark; 11Sahlgrenska Academy, Gothenburg, Sweden; 12Aarhus University Hospital, Aarhus N, Denmark
Correspondence: Mia Glerup
Introduction: Innovative changes towards targeted treatment have improved the outcome dramatically for juvenile idiopathic arthritis (JIA) during the last two decades. The question remains how well these children perform during long-term follow-up.
Objectives: To study the disease activity, remission rate and damage 18 years after JIA onset.
Methods: 510 consecutive cases of JIA with disease onset in 1997 to 2000 from Denmark, Norway, Sweden and Finland were prospectively included in a longitudinal, close to population-based 18-year (mean 17.5 years; range 14.2-20.2) follow-up study. The last follow-up visit included an update on the family history, medication and clinical data such as a clinical joint examination and remission status according to the preliminary Wallace criteria.
Results: 434 (85%) out of 510 eligible JIA participants with a mean age (S.D) of 24.0 (± 4.4) years were included. 76 patients (15%) were lost to follow-up. Out of the included patients 329 (76%) attended a follow-up visit, and 105 patients (24%) were evaluated by a telephone interview.
The distribution of the JIA categories was as follows: 3% systemic, 27% persistent oligoarticular, 20% extended oligoarticular, 16% polyarticular RF negative, 1% polyarticular RF positive, 7% psoriatic, 10% enthesitis-related arthritis (ERA) and 15% undifferentiated JIA.
For all 329 patients attending a clinical visit the median active joint count was 0 (range 0-15), however during the 18 years of disease course the median cumulative joint count was 8 (range 1-59). 66 participants (15 %) received disease-modifying anti-rheumatic drugs (DMARDS) and 84 patients (19%) were treated with biologics at the last follow-up.
At the final study visit the median composite juvenile arthritis disease activity score JADAS71 was median 1.5 (range 0-31.6) with the ERA category having the highest median score of 4.5 (range 0-16.5) (p=0.003). In the follow-up cohort 48% had a JADAS71 score <1 indicating inactive disease.
Articular damage (JADI-A) was found in 20% of the patients who had a follow-up visit and 12.5% had developed extra-articular damage (JADI-E), most commonly ocular damage, found in 26/41 (63%). The highest JADI-A and JADI-E scores were found in the polyarticular RF negative and psoriatic categories.
Less than half (44%) of the participants were in remission off medication 18 years after disease onset, but 39.8% had active disease. Achievement of remission off medication was observed in the following order: persistent oligoarticular 39/72 (54%), systemic 7/13 (54%), psoriatic 9/22 (41%), undifferentiated 21/55 (38%), extended oligoarticular 19/66 (29%), RFneg poly 16/59 (27%), RFpos poly 1/5 (20%), and ERA 4/37 (11%), the latter being significantly different from the other categories (p<0.001).
Conclusion: A significant proportion of the JIA cohort do not reach remission despite new treatment options and notably more than one third receive systemic treatment even 18 years after disease onset. The worst outcome was evident in the ERA category and in general the JIA disease burden in adulthood remains extensive.
Disclosure of Interest
O16 RESULTS AFTER 24 MONTHS OF DRUG-FREE INACTIVE DISEASE AND FLARE FREQUENCY IN JUVENILE IDIOPATHIC ARTHRITIS PATIENTS IN A TREATMENT-TO-TARGET STRATEGY STUDY
Petra Hissink Muller1,2, Danielle M. Brinkman1,3, Dieneke Schonenberg-Meinema4, Wytse B. van den Bosch1, Yvonne Koopman-Keemink5, Peter Bekkering6, Taco Kuijpers4, Marion van Rossum7, Lisette van Suijlekom-Smit2, J M. van den Berg8, Stefan Boehringer9, Cornelia F. Allaart10, Rebecca ten Cate1
1Pediatric Rheumatology, LUMC, Leiden; 2Pediatric Rheumatology, Erasmus MC, Sophia Children's Hospital , Rotterdam; 3Pediatrics , Alrijne, Leiderdorp; 4Pediatric Hematology, Immunology, Rheumatology and Infectious Diseases , Emma Children's Hospital AMC, Amsterdam; 5Pediatrics , Juliana Children's Hospital, The Hague; 6Pediatric Oncology, Princess Maxima Center of Pediatric Oncology, Utrecht; 7Pediatrics; 8Hematology, Immunology, Rheumatology and Infectious Diseases, Emma Children's Hospital AMC, Amsterdam; 9Medical Statistics and Bioinformatics; 10Rheumatology, LUMC, Leiden, Netherlands
Correspondence: Petra Hissink Muller
Introduction: Reaching early inactive disease is the goal in Juvenile Idiopathic Arthritis (JIA) patients. How to proceed after reaching inactive disease is subject of ongoing research. Tapering and stopping disease modyfying anti-rheumatic drug (DMARD) therapy, including observation of subsequent flares, was applied in all three arms of the BeSt for Kids study.
Objectives: The aim of the BeSt for Kids study was to investigate, which of three treatment strategies was most effective and safe, by comparing them directly. The therapeutic target, in all arms, was inactive disease. If inactive disease was reached and maintained for a specific period of time, medication was tapered and stopped.
Methods: We conducted a randomized, single-blinded, multicenter, treatment strategy study with 24 months of follow-up. DMARD-naive JIA (oligoarticular, rheumatoid factor negative polyarticular, and juvenile psoriatic arthritis patients) were randomized to 1) sequential DMARD monotherapy, 2) combination therapy: MTX and prednisolone-bridging, 3) combination therapy MTX with etanercept. For all arms, the treatment protocol described a number of subsequent treatment steps in case medication failed. After reaching inactive disease for 3 (oligoarticular) or 6 (polyarticular) months, medication was tapered and stopped according to protocol. Flare frequency was observed.
Missing data were imputed. In case of drug-free clinically inactive disease often intentionally no blood was drawn causing non-random missing ESR, and here ‘0’ was imputed for the analysis of inactive disease.
Primary outcome was time to inactive disease and time to flare after tapering and stopping DMARD therapy calculated using Kaplan Meier curve with log rank test. Secondary outcomes are adjusted ACRPedi 30/50/70/90 scores, toxicity, functional ability and quality of life. Generalised Estimated Equations were used for longitudinal data analyses.
In this abstract we share time-to-flare, flare frequencies and flare characteristics in all three arms.
Results: During 24 months 59% (19 (3 oligo)/31 (61%) of patients in arm 1, 16 (1 oligo)/32 (50%) in arm 2 and 19 (1 oligo)/29 (65%) in arm 3) had tapered and stopped all DMARDs (drug-free inactive disease) after median 15.0 (IQR 12.0-18.0) months (arm 1), 19.5 (12.0-24.0) months (arm 2) and 18.0 (12.0-21.0) months (arm 3) of therapy. However, 26% (6 (1 oligo) patients in arm 1, 3 in arm 2 and 5 in arm 3) subsequently had to restart treatment before end of study, after median time-to-flare 18.0 (15.0-21.0) months (p=0.7).
Flares were characterised by JADAS-10 of 9.7 (8.1-11.3), which improved 3 months after restart of treatment to JADAS-10 of 3.9 (1.8-6.0).
Conclusion: During 24 months of treatment to target inactive disease, including tapering and stop-strategies, flare frequency was 26% after median 18 months. After 24 months, 71% of patients had inactive disease and 39% were in drug-free inactive disease.
It is feasible to incorporate strategies for tapering and stopping DMARD-therapy in juvenile idiopathic arthritis patients, when tight control is maintained.
Trial registration identifying number: Trial registration number: Dutch trial register 1574
Disclosure of Interest
O17 NEW JADAS10- AND CJADAS10-BASED CUTOFFS FOR JUVENILE IDIOPATHIC ARTHRITIS DISEASE ACTIVITY STATES: VALIDATION IN A MULTINATIONAL DATASET OF 4830 PATIENTS
Chiara Trincianti1, Giedre Janukeviciute1, Pieter Van Dijkhuizen2, Carolina Montobbio1, Gabriella Giancane1, Alessandra Alongi1, Nicola Ruperto1, Joost Swart2, Angelo Ravelli1,3, Alessandro Consolaro1,3, on behalf of EPOCA Study Group
1ISTITUTO GIANNINA GASLINI, Genova, Italy; 2University Medical Center, Utrecht, Netherlands; 3University of Genova, Genova, Italy
Correspondence: Chiara Trincianti
Introduction: The measurement of disease activity plays a pivotal role in the care of patients with juvenile idiopathic arthritis (JIA). To serve this purpose, the Juvenile Arthritis Disease Activity Score (JADAS) and its clinical version excluding the acute phase reactant (cJADAS) were developed.
Cutoffs for the state of remission, low disease activity (LDA), moderate disease activity (MDA) and high disease activity (HDA) are necessary to interpret the scores and are ideally suited for pursuing tight disease control in a treat-to-target strategy.
Aiming to obtain cutoffs suitable for any clinical setting, new values were recently developed for JADAS10 and cJADAS10 in oligoarthritis and polyarthritis, based on a large multinational dataset of JIA patients (Consolaro A, et al. Arthritis Rheumatol. 2017;69s10).
Objectives: To externally validate the new cutoffs for JADAS10 and cJADAS10 disease activity states.
Methods: Four not selected for cutoffs development JIA patients dataset were considered: 1) 4397 oligoarthritis and polyarthritis patients from the EPOCA study; 2) 148 oligoarthritis patients from the TRIMECA trial; 3) 172 polyarthritis patients from the Abatacept trial, 4) 113 oligoarthritis and polyarthritis patients first starting methotrexate from a monocentric retrospective cohort (Swart et al, Ann Rheum Dis. 2018;77:336-342).
Face validity was assessed in dataset 1) by plotting the proportion of patients in remission and LDA against the values of the 6 parameters in the ACR JIA core set.
Discriminative ability was assessed in datasets 2) and 3) by comparing the percentage of patients below the cutoff values in the different ACR pediatric categories of response. In dataset 1) we compared in each disease activity state, the level of pain (0-10 VAS), functional ability impairment, and number of restricted joints and the frequency of patients satisfied with disease outcome, starting a new medication for JIA, and having morning stiffness.
Predictive ability was assessed in dataset 4) by calculating the sensitivity and specificity of the cutoffs for remission and LDA after 3 months for treatment response after 12 months.
Results: Only most relevant results are described. JADAS10 and cJADAS10 cutoffs for remission allowed up to 1 active joint for polyarthritis and 0 for oligoarthritis.
In dataset 2), 42% and 63% of patients achieving an ACRp70 response met the JADAS10 cutoffs for remission and LDA, respectively. In dataset 3), these percentages were 48% and 82%, respectively. In dataset 1), the median level of pain was 0, 1.5, 3, and 5.5 for polyarthritis patients in cJADAS10 remission, LDA, MDA, and HDA, respectively (Kruskal-Wallis p<0.001). The frequency of satisfaction with disease outcome was 94%, 76%, 56%, and 24% for oligoarthritis patients in cJADAS10 remission, LDA, MDA, and HDA, respectively (Chi2 test p <0.001).
In dataset 4), 100% and 71% of patients with oligoarthritis classified as non-responders after 12 months had JADAS levels after 3 months above the cutoffs for remission and LDA, respectively. For polyarthritis, 90% and 80% of non-responders had JADAS levels after 3 months above the cutoffs for remission and LDA, respectively.
Conclusion: New JADAS cutoffs showed good face and content validity; achievement of remission and LDA defined by the cutoffs predicted the response to therapy. Cutoffs were developed and validated in a large multinational dataset and they are ready for use in clinical trials and routine practice.
Disclosure of Interest
O18 JUVENILE INFLAMMATORY MYOPATHY WITH POSITIVE MDA5 AUTO-ANTIBODIES: A SPECIFIC SUBGROUP WITH SYSTEMIC UPREGULATION OF INTERFERON-ALPHA PATHWAY.
Isabelle Melki1, Vincent Bondet2, Cyril Gitiaux1, Hervé Devilliers3, Marie-Louise Fremond4, Darragh Duffy2, Yanick Crow4, Mathieu Rodero4, Brigitte Bader-Meunier1
1APHP; 2Pasteur Institute, Paris; 3Médecine interne 2 CHU Dijon, Dijon; 4Imagine Institute, Paris, France
Correspondence: Isabelle Melki
Introduction: Juvenile dermatomyositis (JDM) and overlap myositis (OM) represent heterogeneous subtypes of juvenile inflammatory myopathy (JIM). Chronic evolution may occur in 60% of cases, and morbidity/mortality is substantial (gastro-intestinal; pulmonary; organ failure).
Objectives: Clinico-biological description of JDM and OM with positive MDA5 auto-antibodies in comparison to other JIM.
Methods: Retrospective and prospective study of patients fulfilling Bohan and Peter criteria for JDM and Troyanov for OM, aged less than 16 years at diagnosis, ascertained from 3 French paediatric rheumatology reference centres between 2013 to 2018. Severe forms were defined as requiring ICU management, and/or more than 3 treatment lines and/or with fatal outcome. Muscle biopsies were reviewed. Type I interferon pathway activity was assessed by dosage of interferon alpha (IFNa) through digital elisa (Simoa) with a Pan-IFNa antibody in patient sera and myoblast lysate, mRNA expression of interferon stimulated genes (ISGs) by RTqPCR and phosphorylation of STAT by flow cytometry on whole blood.
Results: 67 patients were included, 12 (group 1) and 54 (group 2) with and without anti-MDA5 antibodies respectively. Group 1 demonstrated more arthritis (100% vs 24%), cutaneous ulcerations (42% vs 26%), interstitial lung disease (ILD) (33% vs 14%) and a milder muscular involvement (median of CK: 96 vs 149 UI/l), with better preserved muscular function (MMT and C-MAS, respectively 79/80 vs 70/80 and 50/52 vs 38/52). Total muscle biopsy scores were lower for group 1 than group 2 (respectively 5.5 vs 20). Group 1 included more severe forms (36% vs 19%). 133 IFN signatures (ISGs) and 210 IFNa Simoa measurements were assessed. Correlation between ISG expression and protein at 79 simultaneous data points was high (Pearson: r = 0,74 ****). ISGs and IFNa (signature and dosage) were higher in group 1 than 2 (median of ISGs 21 vs 7.4 and median of Simoa 3807.5 vs 49.6 fg/ml). In contrast, IFNa levels in patient myoblasts were similar to controls for group 1 (1 patient), whilst those in group 2 were higher (10 patients). A constitutive phosphorylation of STAT1 and STAT3 was observed in T and B lymphocytes and monocytes of 5 patients, including one from group 1. Treatment with steroids, tacrolimus, rituximab and immunoadsorption in one group 1 patient correlated with the disappearance of MDA5 auto-antibodies, the normalisation of IFNa levels and the induction of complete remission (normalisation of clinical, laboratory and radiological parameters).
Conclusion: This study indicates a higher frequency of cutaneous ulcerations, arthritis and ILD, and milder muscular involvement in JIM with positive MDA5 auto-antibodies compared to other JIM. These data suggest an important role of systemic IFNa in the pathology of the disease. In severe and refractory forms, IFNa may be a potential therapeutic target.
Disclosure of Interest
O19 PREDICTING NON-RESPONSE TO BIOLOGICALS IN JUVENILE IDIOPATHIC ARTHRITIS PATIENTS; A BIOMARKER HUNT IN PERIPHERAL BLOOD SERUM
Koen Willemsen1, Sytze de Roock1, Wilco de Jager1, Nienke ter Haar1, Pieter van Dijkhuizen1, Rae Yeung2, Trang Duong2, Nico Wulffraat1, Joost Swart1, Sebastiaan Vastert1
1Department of Pediatric Rheumatology and Immunology, Wilhelmina Children’s Hospital, University Medical Centre Utrecht, Utrecht, Netherlands; 2Hospital for Sick Children, Toronto, Canada
Correspondence: Koen Willemsen
Introduction: Patients with Juvenile Idiopathic Arthritis (JIA) who fail to reach a state of clinically inactive disease might start biological treatment (TNFa-blockers) . Currently little is known in relation to which patients will respond or not to specific biologicals, potentially leading to a delay in achieving acceptable clinical state .
Objectives: To investigate the possible predictive value of serum proteins on therapeutic (non-)response prior to start of biological therapy.
Methods: This study presents a retrospective analysis of a prospectively collected and followed cohort of non-systemic JIA patients from a single pediatric rheumatology center. Non-response to biological was defined as a necessity to switch biological or when criteria for clinically relevant improvement (a change of ≤-5.5 in JADAS27  while not achieving clinically inactive disease i.e. a JADAS27 ≤1 ) were not met and was evaluated 6 months after start of biological therapy. Serum protein concentration was analysed by Luminex® multiplex assay (44-plex including cytokines, chemokines and growth factors). We performed basic statistics, including univariate analysis (Mann-Whitney U test) to assess whether protein concentrations associate with response to therapy. Proteins associating with a p<0.1 were included for further analysis later on whereas proteins with a p<0.05 were considered significant. If proteins correlated with a Spearman’s rho >0.6 the more significant protein was included.
Results: 67 Patients were included (Table 1). 36 patients received etanercept, 30 adalimumab and 1 golimumab. Of the oligo articular JIA patients 14 (60.9%) were persistent oligo articular and 13 (56.5%) were ANA+. At t=6 months 15 patients were non-responsive (34.1% of cases with JADAS27 available). We found a significant association with non-response for TNF-ligand-1a (TL1a) and haptoglobin. With a p<0.1 interleukine-8 (IL-8) and vascular endothelial growth factor (VEGF) were of interest for further analysis.
Conclusion: This preliminary analysis yielded various proteins of which the serum concentration relates to non-response to biological therapy. These proteins might serve as biomarkers predicting therapeutic response. Further research and analyses, including a planned validation in a separate prospective cohort, is required to predict non-response.
Disclosure of Interest
See text for description
Female n (%)
Age at sampling years median (1st;3rd quartile)
Oligo articular JIA n (%)
Poly articular JIA RF- n (%)
Poly articular JIA RF+ n (%)
Enthesitis related JIA n (%)
Psoriatic JIA n (%)
JADAS27 t=0 median (1st;3rd quartile)
O20 PEDIATRIC OPEN-LABEL CLINICAL STUDY OF RITUXIMAB FOR THE TREATMENT OF GRANULOMATOSIS WITH POLYANGIITIS (GPA) AND MICROSCOPIC POLYANGIITIS (MPA)
Paul Brogan1, Gavin Cleary2, Ozgur Kasapcopur3, Satyapal Rangaraj4, Rae Yeung5, Paul Brunetta6, Jennifer Cooper6, Pooneh Pordeli7, Patricia B. Lehane8
1UCL Institute of Child Health and Great Ormond Street Hospital NHS Foundation Trust, London; 2Alder Hey Children's Hospital, Liverpool, UK; 3Cerrahpasa Medical School, Istanbul University, Istanbul, Turkey; 4Nottingham University Hospitals NHS Trust, Nottingham, UK; 5Hospital for Sick Children and University of Toronto, Toronto, Canada; 6Genentech, Inc., South San Francisco, USA; 7Hoffmann-La Roche Ltd, Mississauga, Canada; 8Roche Products Ltd, Welwyn Garden City, UK
Correspondence: Paul Brogan
Introduction: Rituximab in combination with glucocorticoids (GC) is approved to treat adult patients with GPA or MPA; however, limited data exist on the safety and efficacy of rituximab in pediatric patients with these potentially life- and organ-threatening diseases.
Objectives: To report the interim safety, pharmacokinetics (PK) and exploratory efficacy data from the 6-month remission induction phase of a Phase IIa international, open-label, 18-month clinical study of rituximab in pediatric patients with GPA or MPA.
Methods: Patients aged ≥2 to ≤18 years with newly diagnosed or relapsing GPA/MPA received 4 intravenous (IV) rituximab infusions of 375 mg/m2 body surface area (BSA) on Days 1, 8, 15 and 22 with concomitant GC 1 mg/kg/day (max 60 mg/day) tapered to 0.2 mg/kg/day minimum (max 10 mg/day) by Month 6. All patients received 3 doses of pulse IV methylprednisolone (30 mg/kg/day, max 1g/day) prior to first rituximab infusion and mandatory prophylaxis for Pneumocystis jiroveci infection. Patients were also pre-medicated with acetaminophen and an antihistamine, 1 hour before each rituximab infusion. Adverse events (AEs) and laboratory data were measured at each study visit (1, 2, 4 and 6 months). Plasma samples for PK analysis were collected throughout the study; clearance and area under the curve (AUC) were calculated using population PK modeling from the RAVE study of rituximab in adult patients with GPA/MPA (Stone et al. NEJM. 2010;363:221-32). For exploratory efficacy assessment, the Pediatric Vasculitis Activity Score (PVAS) was measured at each study visit.
Results: Of the 25 patients enrolled, 19 (76%) had GPA and 6 (25%) had MPA (median [range] age 14 [6-17] years; 80% female). Median (range) disease duration was 0.5 (0.2-0.7) months; 2 patients had received prior cyclophosphamide therapy. All received 4/4 rituximab infusions and completed the 6-month induction phase. By Month 6, all patients had experienced ≥1 AE. The most common AEs by system organ class were infections and infestations in 16 patients (64%). Eleven serious AEs occurred in 7 patients (28%), including 3 serious infections (viral gastroenteritis, one lower and one upper respiratory tract infection). 32% of patients had ≥1 infusion related reaction (IRR). No serious IRRs or deaths were reported. The relationship between AUC and BSA was flat and comparable to adult patients. A total of 13 patients (52%) achieved remission by 6 months, defined as PVAS of 0 and GC dose 0.2 mg/kg/day (max 10 mg/day) or PVAS of 0 on 2 consecutive readings ≥4 weeks apart irrespective of GC dose.
Conclusion: In the initial 6 months of this first global clinical trial of rituximab in pediatric patients with GPA/MPA, rituximab was generally safe and well tolerated. The overall safety profile and PK parameters were comparable to rituximab-treated adults with GPA/MPA. No new safety signals were observed. However, the study size and interim nature of the analysis limit firm conclusions. The clinical trial and additional efficacy, PK and safety analyses are ongoing.
Trial registration identifying number: NCT01750697
Disclosure of Interest
P. Brogan Grant / Research Support from: Roche, SOBI, Novartis, Chemocentryx, Consultant for: Roche, SOBI, UCB, Speaker Bureau of: SOBI, Novartis, G. Cleary Speaker Bureau of: AbbVie, O. Kasapcopur: None Declared, S. Rangaraj: None Declared, R. Yeung Consultant for: Novartis, Eli Lilly, P. Brunetta Shareholder of: Roche, Employee of: Genentech, Inc., J. Cooper Employee of: Genentech, Inc., P. Pordeli Employee of: Roche, P. Lehane Employee of: Roche
O21 JUVENILE SYSTEMIC LUPUS ERYTHEMATOSUS WITH A BASELINE HIGH INTERFERON SIGNATURE ASSOCIATES WITH INCREASED IMMUNE CELL TLR7 EXPRESSION AND ENHANCED TLR7 DEPENDENT INTERFERON ALPHA PRODUCTION
Kate Webb1, Gary Butler2, Coziana Ciurtin1, Hannah Peckham1, Anna Radziszewska1, Fraser Simpson3, Paola Oliveri3, Lucy Wedderburn1,4, Yiannis Ioannou1
1ARUK Centre for Adolescent Rheumatology; 2Paediatric Endocrinology; 3Department of Genetics, Evolution & Environment, Nanostring Facility, UCL; 4NIHR Biomedical Research Centre, UCL, GOSH, London, UK
Correspondence: Kate Webb
Introduction: Juvenile onset systemic lupus erythematosus (jSLE) is characterised by a type 1 interferon (IFN) transcription signature. Up to 80% of patients with jSLE of varying severity express a predominant IFN signature which correlates with disease activity, and is abrogated by steroids. Investigating the IFN signature outside of a flare may provide insight into the true prevalence of high IFN signature disease, and underlying differences in disease pathogenesis, that may be masked by steroid or disease activity.
Objectives: To investigate the prevalence of high IFN signature in low disease activity jSLE, and to assess whether toll like receptor (TLR) 7 or 9 dependent IFNα production pathways differ between high and low IFN signature patients.
Methods: Blood was collected, with consent, from healthy volunteers (n=24:10 female; 14 male, age=12-19) and young people with jSLE (n=29:20 female; 9 male, age=14-21). Clinical data were recorded. Peripheral blood mononuclear cells (PBMC) were separated by Ficoll gradient centrifugation. Ex vivo RNA was assessed by Nanostring Plex Set. IFN score was calculated from counts of 5 IFN inducible genes (MX1+BST2+MCP1+ISG15+ IFIT1/5). Samples were classed as IFN positive (IFN+) if >2SD from the healthy mean. Separately, PBMC were stimulated with TLR7 agonist, R848, or TLR9 agonist, CPGODN2216, before assessing for secretion of IFNα and TNFα by luminex. Statistical analysis was performed using SPSS with linear regression.
Results: There was a significantly higher IFN score in jSLE than healthy controls (p=0.001). 14/29 (48.27%) jSLE patients were IFN+ vs 1/23 (0.04%) healthy controls (p=0.005). Patients with jSLE had a mean SLEDAI of 3.0 (range=0-12); 15 (52%) were on prednisone (mean= 6.9mg). In patients with jSLE, the only autoantibody that significantly predicted IFN score was towards RNP (p=0.018). There was no association between any specific organ involvement and IFN score. Four patients with jSLE were B cell depleted (<2%), with no effect of B cell depletion on IFN score. There were no significant differences in markers of disease activity (SLEDAI, CRP, ESR, C3, C4 and double stranded DNA antibodies) between IFN+ and IFN- jSLE patients. Only jSLE patients who were IFN+ produced significantly more IFNα (p=0.046) and TNFα (p=0.031) than healthy controls after TLR7 stimulation. After TLR9 stimulation, however, IFNα production was decreased in jSLE compared to healthy, regardless of IFN score. IFN+ patients with jSLE had significantly higher PBMC RNA expression of TLR7 than those who were IFN- (p=0.001), and healthy controls (p=0.04). IFN+ patients with jSLE showed a significant decrease in TLR9 expression when compared to healthy controls (p=0.023). We confirmed that TLR7 was not an IFN inducible marker, by assessing expression in healthy controls with and without IFNα pre-stimulation, which showed no significant difference.
Conclusion: We present novel data, showing that, in non-flaring patients with jSLE on low doses of steroid, half are IFN signature positive. This is lower than reported in studies that include flaring patients and may better represent prevalence of high IFN signature disease at baseline. In jSLE, IFN signature score associates with autoantibodies to RNP. PBMC from IFN+ patients produce more IFNα after TLR7 stimulation, and have a significantly higher expression of TLR7, along with a decrease in TLR9 expression compared to samples from patients with a negative IFN signature, and healthy controls.
Disclosure of Interest
O22 STERILE INFLAMMATORY ACTIVATION OF HUMAN CORONARY ARTERY ENDOTHELIAL CELLS DEPENDS STRICTLY ON INTERLEUKIN 1Β: IMPLICATIONS FOR KAWASAKI DISEASE PATHOLOGY
Giulia Armaroli1, Emely Verweyen1, Carolin Pretzer1, Katharina Kessel1, Keiichi Hirono2, Fukiko Ichida2, Mako Okabe2, David Cabral3, Dirk Foell1, Kelly Brown3, Christoph Kessel1
1Pediatric Rheumatology & Immunology, University Children’s Hospital, Muenster, Germany; 2Department of Pediatrics, University of Toyama, Toyama, Japan; 3Department of Pediatrics, University of British Columbia, Vancouver, Canada
Correspondence: Christoph Kessel
Introduction: The granulocytic protein S100A12 is expressed at high levels in Kawasaki Disease (KD) but it is unclear whether S100A12 does actively participate in KD pathology or is a bystander of neutrophil activation.
Objectives: Kawasaki disease (KD) is an acute vasculitis of childhood, predominantly affecting coronary arteries. S100A12 is an endogenous pattern recognition receptor (PRR) ligand, which is strongly upregulated in KD and S100A12 serum levels track with KD disease activity and response to intravenous immunoglobulin (IVIG) treatment. While S100A12 was originally described as agonist of the multi-ligand receptor for glycation endproducts (RAGE), we described human monocytes to respond to S100A12-stimulation in an exclusively TLR4-dependent manner. Here, we aimed to investigate whether and how serum S100A12 might be actively involved in inflammatory processes in KD.
Methods: Serum samples (n=75) from patients with KD at different stages pre- and post-intravenous immunoglobulin (IVIG) treatment were analyzed for S100A12, cytokines, chemokines and soluble markers of endothelial activation. Primary human coronary artery endothelial cells (HCAECs) were analyzed for responsiveness following direct stimulation with S100A12 or lipopolysaccharide (LPS). Alternatively, HCAEC were cultured in conditioned medium obtained from primary human monocytes stimulated with LPS or S100A12 in the absence or presence of IVIG or cytokine antagonists.
Results: Multiple correlation analyses revealed, that in KD patients’ sera in course of IVIG-therapy soluble vascular cell adhesion molecule-1 (sVCAM-1) titers as indicator of endothelial activation exclusively associated with pre-treatment S100A12 levels. Yet, in contrast to stimulations with LPS, HCAECs were not responsive to direct treatment with S100A12, despite the presence of appropriate receptors (RAGE, TLR4). Unresponsiveness of HCAECs to S100A12 was due to lack of membrane CD14 expression. Addition of recombinant soluble CD14 or human serum benefitted LPS- but could not establish response to S100A12. Instead, HCAECs strongly responded to supernatants obtained from S100A12-stimulated primary human monocytes, as evidenced by expression of inflammatory cytokines and adhesion molecules. Inflammatory activation of HCAECs by S100A12-stimulated monocytes required monocyte-co-stimulation with ATP. Endothelial cell stimulation was completely abrogated upon IL-1β blockade but remained unaffected by treatment with IVIG or anti-TNFa and IL-6 receptor blocking antibodies.
Conclusion: We identified IL-1β-signaling in coronary artery endothelium as particularly relevant in course of sterile inflammation as induced by damage associated molecular pattern (DAMP) molecules such as S100A12. These data are in support of a potential key role for IL-1 in KD pathology but also highlight the coronary artery endothelium, which is critically involved in early KD pathology and aneurysm formation as particularly sensitive to IL-1β blockade during DAMP-induced sterile inflammation.
Disclosure of Interest
O23 LONG-TERM EFFICACY AND SAFETY OF CANAKINUMAB-TREATED PATIENTS WITH COLCHICINE-RESISTANT FMF, TRAPS AND HIDS/MKD: RESULTS FROM THE PHASE 3 CLUSTER TRIAL
F. De Benedetti1, J. Frenkel2, A. Simon3, J. Anton4, H. Lachmann5, M. Gattorno6, S. Ozen7, I. Kone-Paut8, E. Ben-Chetrit9, M. B. Wozniak10, J. G. Wang11, E. Vritzali11
1IRCCS Ospedale Bambino Gesú, Rome, Italy; 2University Medical Center Utrecht, Utrecht; 3Radboud University Medical Centre, Nijmegen, Netherlands; 4Hospital Sant Joan de Déu, Barcelona, Spain; 5UK National Amyloidosis Centre, University College London Medical School, London, UK; 6Pediatric Rheumatology, G. Gaslini Institute, Genoa, Italy; 7Hacettepe University, Ankara, Turkey; 8Hôpital Kremlin Bicetre, University of Paris SUD, Paris, France; 9Hadassah—Hebrew University Medical Center, Jerusalem, Israel; 10Novartis Ireland Ltd, Dublin, Ireland; 11Novartis Pharma AG, Basel, Switzerland
Correspondence: F. De Benedetti
Introduction: Canakinumab (CAN) has demonstrated efficacy and safety in patients with colchicine-resistant familial Mediterranean fever (crFMF), TNF receptor-associated periodic syndrome (TRAPS), and hyper-IgD syndrome (HIDS)/mevalonate kinase deficiency (MKD) in epoch 2 and 3 (E2 and E3 up to week 40) of the pivotal, randomised CLUSTER study.1
Objectives: To assess long-term maintenance of optimal control of disease activity (median of no or 1 flare, and no uptitration) and safety of CAN dosing regimens of every 4 weeks (q4w) and every 8 weeks (q8w) in patients with crFMF, TRAPS or HIDS/MKD from the epoch 4 (E4 up to week 112) of CLUSTER.
Methods: CLUSTER comprised 4 epochs (E1-E4). After lead-in E1, efficacy of CAN 150/300 mg q4w to induce complete response was assessed in E2, a 16-week randomised, double-blind, placebo (PBO)-controlled epoch. E3, a 24-week randomised withdrawal epoch, evaluated whether responders to CAN 150/300 mg q4w in E2 could maintain clinical efficacy on 150/300 mg q8w or PBO. In E4, a 72-week, open-label epoch, the long-term maintenance of efficacy and safety of CAN 150/300 mg q4w or q8w in patients with crFMF, TRAPS or HIDS/MKD was evaluated. Patients who did not maintain clinical response on q8w could be uptitrated to 150/300 mg q4w. Safety assessments included incidence of adverse events (AEs) and serious AEs.
Results: Five patients discontinued from the study in E4 (one TRAPS patient discontinued due to AE). A substantial proportion of patients maintained optimal control of disease activity following treatment with 150/300 mg q4w or q8w in all 3 cohorts at week 112 (Table 1). HIDS/MKD patients more often required uptitration to 300 mg q4w. Majority of patients had 1 or no new flare (crFMF: 96.6%, TRAPS: 94.3%, HIDS/MKD: 83.3%). In all 3 cohorts, the median SAA levels decreased rapidly from baseline and remained suppressed through E4 (crFMF: 618 to 21 mg/L, TRAPS: 243 to 12 mg/L and HIDS/MKD: 2061 to 16 mg/L). No new safety findings were reported in CAN-treated patients through week 112.
Conclusion: Long-term treatment with canakinumab 150/300 mg q4w in epoch 4 of the CLUSTER study showed that optimal control of disease activity can be maintained in patients with crFMF, TRAPS or HIDS/MKD. There were no new or unexpected safety issues reported over 112 weeks of treatment.
1. De Benedetti F, et al. NEJM 2018, in press.
Trial registration identifying number: NCT02059291
Disclosure of Interest
F. De Benedetti Grant / Research Support from: Novartis, Roche, Pfizer, SOBI, AbbVie, Novimmune, BMS, Sanofi, J. Frenkel Grant / Research Support from: Novartis and SOBI, A. Simon Grant / Research Support from: Novartis, Xoma/Servier, CSL Behring, Consultant for: Novartis, Takeda, SOBI, Xoma, J. Anton Grant / Research Support from: Novartis, Pfizer, Abbvie, GSK, BMS, Roche, Sanofi, Consultant for: Novartis, Sobi, Roche, Pfizer, Abbvie, H. Lachmann Consultant for: Novartis, SOBI, Takeda and GSK, Speaker Bureau of: Novartis and SOBI, M. Gattorno Grant/Research Support from: Novartis and SOBI, Consultant for: Novartis and SOBI, Speaker Bureau of: Novartis and SOBI, S. Ozen Speaker Bureau of: Novartis and SOBI, I. Kone-Paut Grant/Research Support from: Novartis, SOBI and Roche, Consultant for: Novartis, SOBI, Pfizer, AbbVie and Roche, E. Ben-Chetrit Consultant for: Novartis, M. B. Wozniak Employee of: Novartis, J. G. Wang Employee of: Novartis, E. Vritzali Employee of: Novartis
Proportion of responders who maintained optimal control of disease activity* at the end of epoch 4, following treatment with canakinumab (Week 112 analysis)
150 mg q8w
150 mg q4w
300 mg q8w
300 mg q4w
O24 EXPRESSION OF THE INTERLEUKIN 1 FAMILY MEMBERS IL-1B AND IL-18 BY HUMAN MONOCYTES IS CONTROLLED BY DIFFERENT REGULATORY PATHWAYS
Emely Verweyen1, Melissa van Dülmen1, Dirk Holzinger2, Dirk Foell1, Christoph Kessel1
1Pediatric Rheumatology and Immunology, University Children's Hospital, Münster; 2Department of Child and Adolescent Medicine, University Hospital, Essen, Germany
Correspondence: Emely Verweyen
Introduction: Regulation of IL-18 gene expression by primary human monocytes is poorly understood but may provide insights into the cytokine’s still unclear role in autoinflammation.
Objectives: The interleukin (IL) 1 family cytokine IL-18 is overabundant in plasma and serum of familial mediterranean fever (FMF) and systemic juvenile idiopathic arthritis (sJIA) patients and its levels coincide with hypersecretion of the damage associated pattern (DAMP) proteins S100A8/A9 and S100A12. Comparable to IL-1b it is thought to require caspase-dependent processing to render an immature pro-form into bioactive mature IL-18. Yet, in stark contrast to IL-1b, it seems largely unknown whether and how IL-18 gene expression is regulated.
Methods: Primary human monocytes isolated from healthy donors were analyzed for kinetics of cytokine expression on gene and protein level following different stimulations and drug treatments.
Results: Initially, we performed endotoxin desensitization experiments on primary human monocytes, which suggested TNFa, IL-6 and IL-1b but not IL-18 gene expression to be subjected to LPS-tolerance. However, when studying time kinetic gene expression of cytokines, we found that IL-1b and IL-18 followed identical secretion but completely different gene expression patterns. In contrast to IL-1b, we observed human monocytes to maintain a cytoplasmic store of mature, bioactive IL-18 from which it could be readily secreted upon LPS stimulation and, following the observed attenuated IL-18 gene expression, this intracellular bioactive IL-18 store replenished. Importantly, colchicine as the mainstay of todays FMF-therapy, as well as the the microtubule polymerisation inhibitor nocodazole abrogated IL-18 expression, while IL-1b gene expression was massively enhanced.
Conclusion: We propose monocytic IL-18 transcription to be subjected to negative feedback regulation by an intracellular store of IL-18 protein. The cellular efforts to maintain such a store may suggest IL-18 to rather operate as DAMP than classical cytokine. This may explain the orchestrated hypersecretion of IL-18, S100A8/A9 and A12 in diseases such as FMF or sJIA.
Disclosure of Interest
O25 SUPPRESSION OF T-CELL ACTIVATION VIA SIRT1 INHIBITION USING NICOTINAMIDE (VITAMIN B3)
Lotte Nijhuis1, Isabelle Houtzager1, Arief Lalmohamed2, Bas Vastert3, Jorg Van Loosdregt1
1Laboratory of Translational Immunology; 2Department of Clinical pharmacy; 3Department of Pediatric Rheumatology, UMC UTRECHT, Utrecht, Netherlands
Correspondence: Lotte Nijhuis
Introduction: Juvenile Idiopathic Arthritis is hallmarked by a disturbed immunological balance between regulatory T-cells (Treg) and effector T-cells (Teff). Restoring this balance by either enhancing the suppressive function of Treg or inhibiting activation and proliferation of pro-inflammatory T-eff is therefore a promising therapeutic strategy. Previously we demonstrated that inhibition of the lysine deacetylase SIRT1 resulted in an increase in FOXP3 positive cells in vitro. Since the transcription factor FOXP3 is essential for Treg differentiation and function, this approach could positively influence immunological tolerance. Interestingly, SIRT1 can be inhibited by the well known food additive, Vitamin B3, also known as Nicotinamide (NAM). We therefore aim to translate these laboratory findings into clinical practice and envision a role for NAM as a novel therapeutic strategy in maintaining the immunological balance in patients with JIA. We demonstrated a distinctive effect of NAM on Treg, however the effect of NAM on the other side of the balance; Teff cells is still unexplored.
Objectives: To investigate the effect of SIRT1 inhibition on proliferation, activation and cytokine production of Teff cells.
Methods: T-cells were isolated from the blood of healthy controls and JIA patients as well as the synovial fluid from JIA patients. Cells were stimulated with aCD3/aCD28 and cultured in the presence of increasing concentrations of NAM (0-9mM) for 1-4 days. Proliferation and expression of activation makers were determined using flow cytometry. Cytokine production was determined by qPCR, luminex and flow cytometry. The specific SIRT1 inhibitor EX-527 was used as a control to determine the pathway involved.
Results: In vitro NAM treatment of human CD4+ T-cells significantly decreased the production of the pro-inflammatory cytokines IL-2 and IFNy measured both on mRNA and protein level. In line with this, surface activation markers were downregulated after NAM incubation. Furthermore proliferation of both CD4+ and CD8+ T-cells was inhibited with NAM treatment in a dose dependent manner in both PBMC from HC and SFMC from JIA patients. Results were verified by using another SIRT 1 inhibitor; EX-527.
Conclusion: In addition to the previously demonstrated increase of Treg numbers and function, these data demonstrate that NAM treatment in vitro inhibits proliferation and activation of Teff cells. Therefore NAM treatment could modulate the immunological balance by both increasing tolerance and suppressing immune activation. We envision that NAM treatment as an adjuvant therapy has the potential to benefit JIA patients and potentially other autoimmune diseases. To translate these findings to clinical practice and determine if NAM treatment is useful as a strategy to maintain disease remission after stopping DMARD or biologicals we are in preparation of a phase III clinical trial.
Disclosure of Interest
P001 NEXT GENERATION SEQUENCING ANALYSIS OF FAMILIAL HAEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) RELATED GENES IN MACROPHAGE ACTIVATION SYNDROME (MAS) AND SECONDARY HLH (SHLH)
Chiara Passarelli1, Manuela Pardeo2, Ivan Caiello2, Francesca R. Lepri1, Antonella Insalaco2, Francesca Minoia3, Andrea Taddio4, Francesco Licciardi5, Antonio Novelli1, Fabrizio De Benedetti2, Claudia Bracaglia2
1Unit of Laboratory of Medical Genetics; 2Division of Rheumatology, IRCCS-Paediatric Hospital Bambino Gesù, Rome; 3Reumatologia Pediatrica, IRCCS Istituto Giannina Gaslini, Genoa; 4Institute for Maternal and Child Health - IRCCS “Burlo Garofolo”, University of Trieste, Trieste; 5SCDU Pediatria II, Immunoreumatologia, Ospedale Pediatrico Regina Margherita, Turin, Italy
Correspondence: Claudia Bracaglia
Introduction: Macrophage activation syndrome (MAS), a severe complication of paediatric rheumatic disease, is currently classified among the secondary forms of HLH (sHLH). Primary HLH (pHLH) are caused by mutation of genes coding for proteins involved in cytotoxic functions. Mice carrying heterozygous mutations in more than 1 pHLH gene carry a higher risk to develop HLH following viral infection, suggesting that accumulation of partial genetic defects may be relevant in HLH.
Objectives: To analyse, with next generation sequencing (NGS), genes involved in pHLH in MAS in the context of different rheumatic diseases and in sHLH.
Methods: We performed Targeted resequencing on all patients using a panel including the 7 principal HLH-related genes (PRF1, UNC13d, STX11, STXBP2, Rab27a, XIAP, SH2D1A) on MiSeq® and NextSeq550® platforms (Illumina, San Diego, CA); all variants identified were confirmed by Sanger. We took into account variants with an allelic frequency in the global population up to 5% in the dbSNP and Ensembl databases.
Results: We analysed 125 patients: 47 MAS (40 developed this complication in the context of systemic Juvenile Idiopathic Arthritis (sJIA) and 7 in the context of different rheumatic diseases), 32 sHLH, 22 sJIA (without history of MAS) and 24 with different autoinflammatory diseases (AID). sJIA and AID patients were used as control groups.
We identified at least 1 heterozygous variant in one of the pHLH-related genes in 41 patients with a detection rate of 52%, 45% of MAS and 62% of sHLH patients. More than one variant was identified in 37% patients from both groups, with 19% of both MAS and sHLH patients carrying polygenic variants. In control groups, 54% of sJIA and 33% of AID patients carry at least a variant in the analysed genes, while polygenic variants have been detected in 14% and 8% of control patients, respectively. The most involved genes in both MAS and sHLH groups were PRF1 and UNC13d, while variants in RAB27a and XIAP have been found only in sHLH patients. The most frequent variants identified in both groups were A91V in PRF1 gene and R928C in UNC13d gene. The A91V variant in PRF1 gene was identified in 19% of both MAS and sHLH patients, while this variant was present, respectively, in only 5% of sJIA and 4% of AID patients. The R928C variant in UNC13d gene was identified in 32% of MAS and 18% of sHLH patients, and in the control group in 9% of sJIA and 17% of AID patients. Considering the patients’ clinical characteristics, relapse, CNS involvement, ICU admission and death, in sHLH we observed that three of the 6 patients (50%) carrying multiple variants had recurrent episodes of HLH and that two of them (33%) presented a severe disease with exitus.
Conclusion: Monoallelic variants in pHLH-related genes are more frequent in MAS, sHLH and sJIA and less in AID patients, suggesting different molecular mechanisms involved in the diseases.
Re-occurrence and severity of disease seem to be more frequent and more severe in patients who carry mutations in two genes in sHLH group. These data may support a polygenic model of sHLH.
Disclosure of Interest
C. Passarelli: None Declared, M. Pardeo: None Declared, I. Caiello: None Declared, F. Lepri: None Declared, A. Insalaco: None Declared, F. Minoia: None Declared, A. Taddio: None Declared, F. Licciardi: None Declared, A. Novelli: None Declared, F. De Benedetti Grant/Research Support from: Novartis, Novimmune, Hoffmann- La Roche, SOBI, AbbVie, Pfizer, C. Bracaglia: None Declared
P002 RISK SCORE OF MACROPHAGE ACTIVATION SYNDROME IN PATIENTS WITH SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS
Simone Carbogno1, Denise Pires Marafon2, Giulia Marucci3, Manuela Pardeo3, Antonella Insalaco3, Virginia Messia3, Rebecca Nicolai3, Fabrizio De Benedetti3, Claudia Bracaglia3
1Pediatric Area, University of Milan; 2Pediatric Unit, Fondazione IRCCS Ca' Grande Ospedale Maggiore Policlinico, Milan; 3Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Simone Carbogno
Introduction: Macrophage Activation Syndrome (MAS) is a severe, life-threatening, complication of rheumatic diseases in childhood, particularly of systemic Juvenile Idiopathic Arthritis (sJIA), occurring in approximately 25% of the patients with sJIA. The mortality rate of MAS is still significantly high. A score that identify sJIA patients who are at high risk to develop MAS would be useful in clinical practice. There are no parameters available to identify from onset sJIA patients with high risk to develop MAS in their disease course.
Objectives: To evaluate whether routine laboratory parameters at disease onset may predict the development of MAS in patients with active sJIA. To define a risk score of MAS for sJIA patients using these parameters.
Methods: Laboratory parameters of disease activity and severity (WBC, N, PLT, Hb, ferritin, AST, ALT, gGT, LDH, TGL, fibrinogen, D-dimer and CRP), were retrospectively evaluated in 56 sJIA patients referred to our Division of Rheumatology from 1998 to 2016 with at least one year of follow-up. Laboratory parameters were evaluated during active sJIA, without MAS, at time of hospitalization (T1) and before treatment for sJIA was started (T2). Patients were divided in two groups: group 1 (patients without history of MAS), group 2 (patients with at least one MAS episode during disease course). To calculate a MAS risk score, laboratory parameters, collected at T2, with a statistical significant difference between the two groups of patients were selected.
Results: Fourteen patients, that fulfilled the 2016 classification criteria for MAS  at time of sampling, were excluded from the analysis. Therefore, we analyzed laboratory parameters of 42 patients with sJIA, 27 of whom without history of MAS (group 1) and 15 who developed at least one episode of MAS during disease course (group 2). Levels of ferritin, AST, LDH, gGT and TGL, collected at T2, were statistically significant higher in patients with a history of MAS compared to those without a history of MAS. For each of these parameters an arbitrary cut-off was defined. In order to define the final score an arbitrary rate was attributed to each parameter. Sensitivity (Se), specificity (Sp), positive predictive value (PPV) and negative predictive value (NPV) were calculated to define the best scoring system. The scoring system with the best sensitivity was chosen (Table 1). A MAS risk score >3 identified 14 out of 15 sJIA patients with a history of MAS and 3 out of 27 sJIA patients without history of MAS.
Conclusion: In conclusion we developed a MAS risk score based on routine laboratory parameters that are available worldwide, that can help clinicians to identify these patients early in the disease course. Our results need to be validated in a larger population.
1. Ravelli A et al. 2016 Classification Criteria for Macrophage Activation Syndrome Complicating Systemic Juvenile Idiopathic Arthritis: A European League Against Rheumatism/American College of Rheumatology/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Ann Rheum Dis. 2016 Mar;75(3):481-9.
Disclosure of Interest
S. Carbogno: None Declared, D. Pires Marafon: None Declared, G. Marucci: None Declared, M. Pardeo: None Declared, A. Insalaco: None Declared, V. Messia: None Declared, R. Nicolai: None Declared, F. De Benedetti Grant/Research Support from: Novartis, Novimmune, Hoffmann-La Roche, SOBI, AbbVie, Pfizer, C. Bracaglia: None Declared
Laboratory parameters and cut-off used to create the MAS risk score in sJIA patients
Positive predictive value (PPV)
Negative predictive value (NPV)
P003 IDENTIFICATION OF OPTIMAL SUBCUTANEOUS DOSES OF TOCILIZUMAB IN CHILDREN WITH SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS
Fabrizio De Benedetti1, Nicola Ruperto2, Daniel Lovell3, Gerd Horneff4, Maria Luz Gámir Gámir5, Markus Hufnagel6, Joy C. Hsu7, Min Bao7, Wendy Douglass8, Navita L. Mallalieu7, Chris Wells8, Christopher M. Mela8, Hermine Brunner3 and PRINTO and PRCSG Investigators
1IRCCS Ospedale Pediatrico Bambino Gesù, Rome; 2Pediatric Rheumatology International Trial Organization (PRINTO), Istituto Giannina Gaslini Pediatria II–Reumatologia, Genoa, Italy; 3Pediatric Rheumatology Collaborative Study Group (PRCSG), Cincinnati Children’s Hospital Medical Center, Cincinnati, USA; 4Asklepios Clinic Sankt Augustin and University Hospital of Cologne, Sankt Augustin and Cologne, Germany; 5Hospital Ramon y Cajal Unidad de Reumatologia Pediatrica, Madrid, Spain; 6Universitätsklinikum Freiburg, Freiburg, Germany; 7Roche Innovation Center, New York, USA; 8Roche Products Ltd, Welwyn Garden City, UK
Correspondence: Fabrizio De Benedetti
Introduction: The efficacy and safety of intravenous (IV) tocilizumab (TCZ) were demonstrated in patients (pts) with systemic juvenile idiopathic arthritis (sJIA) in the phase 3 TENDER study.1
Objectives: To investigate dosing regimens of subcutaneous (SC) TCZ in pts with sJIA by bridging from TENDER data for TCZ IV to identify the optimal SC regimen through characterization of the pharmacokinetics (PK), pharmacodynamics (PD), and safety of TCZ SC in pts with sJIA; efficacy was an exploratory objective.
Methods: This was a multicenter, open-label, phase 1b study to evaluate the PK, PD, and safety of TCZ SC in pts aged 1-17 years with sJIA and inadequate response to glucocorticoids. Interim analysis was conducted after 24 pts had received TCZ SC for 14 weeks. Pts could be TCZ naive or could switch from TCZ IV to SC. TCZ SC was administered for 52 weeks according to body weight: pts <30 kg received either 162 mg every 10 days before interim analysis or 162 mg every 2 weeks (Q2W) after interim analysis; pts ≥30 kg received 162 mg every week (QW).
Results: We enrolled 51 pts, including 25 weighing <30 kg (8 before and 17 after interim analysis) and 26 weighing ≥30 kg. Twenty-six pts (51%) were TCZ naive and 25 (49%) switched from TCZ IV. Median steady state Cmin was similar for pts <30 kg receiving TCZ 162 mg Q2W and pts ≥30 kg receiving TCZ 162 mg QW; the ranges largely overlapped (Table 1). More than 95% (49/51) of pts treated with TCZ SC had steady state Cmin higher than the 5th percentile achieved with TCZ IV. The median and range of AUC2weeks were similar for both body weight groups (Table 1). Changes in interleukin-6, C-reactive protein, and erythrocyte sedimentation rate were similar for both body weight groups. Almost all pts had ≥1 adverse event (AE; n = 50; 98.0%). Injection site reactions (ISRs) occurred in 21 pts (41.2%); most were mild, and none led to treatment interruption or withdrawal. The AE rate was 1200.3/100 pt-years (PY) (909.3/100 PY, excluding ISRs). The most common AEs were viral upper respiratory tract infection (13; 25.5%), neutropenia (13; 25.5%), and cough (12; 23.5%). Nine serious AEs occurred in 7 pts (13.7%; 19.3/100 PY); 5 were infections, all in the <30 kg group. Two deaths occurred, both in the <30 kg group. Median JADAS-71 improved from baseline to week 52 for TCZ-naive pts (<30 kg, –13.9; ≥30 kg, –12.4) and was maintained or improved further for pts who switched from TCZ IV (<30 kg, –0.7; ≥30 kg –0.2). At week 52, 29/43 pts (67.4%) had inactive disease (JADAS-71 <1.0).
Conclusion: A PK-based strategy was successful in bridging TCZ SC to TCZ IV in pts with sJIA. Dosing regimens of 162 mg Q2W in pts <30 kg and 162 mg QW in pts ≥30 kg provided adequate exposure to support efficacy comparable to that of TCZ IV. Except for ISRs, safety results were consistent with the known safety profile of TCZ in sJIA.
1. De Benedetti F et al. N Engl J Med. 2012;367:2385-95.
Trial registration identifying number: ClinicalTrials.gov NCT01904292
Disclosure of Interest
F. De Benedetti Grant/Research Support from: Novartis, Roche, Pfizer, SOBI, AbbVie, Novimmune, BMS, Sanofi, N. Ruperto Consultant for: AbbVie, Amgen, Biogenidec, Alter, AstraZeneca, Baxalta Biosimilars, Biogenidec, Boehringer, BMS, Celgene, CrescendoBio, EMD, Speaker Bureau of: AbbVie, Amgen, Biogenidec, Alter, AstraZeneca, Baxalta Biosimilars, Biogenidec, Boehringer, BMS, Celgene, CrescendoBio, EMD, D. Lovell Grant/Research Support from: National Institutes of Health, NIAMS, Consultant for: AstraZeneca, Bristol-Myers Squibb, AbbVie, Pfizer, Roche, Novartis, UCB, Forest Research Institute, Horizon, Johnson & Johnson, Biogen, Takeda, Genentech, GlaxoSmithKline, Boehringer Ingelheim, Celgene, Janssen, Speaker Bureau of: Genentech, G. Horneff: None Declared, M. L. Gámir Gámir: None Declared, M. Hufnagel: None Declared, J. C. Hsu Employee of: Roche, M. Bao Employee of: Roche, W. Douglass Employee of: Roche, N. L. Mallalieu Employee of: Roche, C. Wells Shareholder of: Roche, Employee of: Roche, C. M. Mela Employee of: Roche, H. Brunner: None Declared
See text for description
<30 kg TCZ
162 mg Q2W
n = 25
≥30 kg TCZ
162 mg QW
n = 26
<30 kg TCZ
12 mg/kg Q2W
n = 46
≥30 kg TCZ
8 mg/kg Q2W
n = 43
Model-computed steady state PK parameters, median (range)
P004 INTERSTITIAL LUNG DISEASE IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS PATIENTS IN THE PHARMACHILD REGISTRY
Jelle De Groot, Bas Vastert, Gabriella Giancane, Michael Hofer, Ekaterina Alexeeva, Violeta Panaviene, Susan Nielsen, Jordi Anton, Florence Uettwiller, Valda Stanevicha, Maria Trachana, Denise P. Marafon, Constantin Ailioaie, Elena Tsitsami, Troels Herlin, Pavla Dolezalova, Gordana Susic, Berit Flato, Flavio Sztajnbok, Angela Pistorio, Francesca Bagnasco, Alberto Martini, Nico Wulffraat, Nicola Ruperto, Joost Swart
PRINTO, Genova, Italy
Correspondence: Jelle De Groot
Introduction: Lung disease might be an underreported complication in patients with systemic juvenile idiopathic arthritis (SJIA). Recently a study describing 25 patients with interstitial lung disease (ILD), pulmonary arterial hypertension (PAH) and alveolar proteinosis (AP) emerged. To what extent these complications occur in the SJIA population is still uncertain.1
Objectives: This study will investigate how often pulmonary complications occur in children with SJIA in the Pharmachild registry. Possible associated factors and/or complications of lung disease will also be investigated.
Methods: Data of the Pharmachild registry, the world's largest pharmacovigilance database, was used. 914 Patients with SJIA were included. Focus lied primarily on pulmonary complications reported in these children. Secondarily, possible correlated events like the macrophage activation syndrome (MAS), death and adverse drug reactions will be analysed.
Results: Eighty pulmonary complications were found in 65/914 patients suffering from SJIA (7%). Complications highly suspect for ILD were found in only 9 children (1%). Patients with pulmonary complications had significantly longer follow-up (7.6 years versus 5.1), were younger at diagnosis (3.7 years versus 5.3 years), had significantly more often non-pulmonary complications and were more likely to have ever used Tocilizumab (55.4% to 40.6%) and/or Rituximab (30.8% to 5.8%) (see Table 1).
MAS occurred more often in patients with pulmonary complications (20.0% to 11.5% P=0.050) and they had significantly more adverse drug reactions, especially to Tocilizumab (9.2% to 2.7% p=0.013) and Rituximab (12.3% to 1.2% P<0.001). Fatal disease occurred more often in patients with pulmonary complications compared to those without it (4.6% to 0.6% p= 0.006).
Conclusion: Pulmonary complications were found in 7% of the SJIA population. Pulmonary complications are also associated with significant more non-pulmonary comorbidities like MAS, adverse drug reactions and even death. More adequate monitoring of pulmonary function and consistent documentation of lung disease might be helpful especially in patients at highest risk of ILD.
1) Kimura Y, Weiss JE, Haroldson KL, Lee T, Punaro M, Oliveira S, et al. Pulmonary hypertension and other potentially fatal pulmonary complications in systemic juvenile idiopathic arthritis. Arthritis Care Res (Hoboken). 2013 May;65(5):745-52. doi: 10.1002/acr.21889.
Trial registration identifying number: NCT01399281
Disclosure of Interest
Patients with pulmonary complications
Patients without pulmonary complications
Observation years total (IQR)
Age diagnosis SJIA (IQR)
Patients with non-pulmonary AE/ESI
Synthetic DMARDs ever
P005 THE INTERFERON-GAMMA PATHWAY IS ACTIVATED IN THE LIVER AND IN THE BLOOD OF PATIENTS WITH ACTIVE SECONDARY HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS
Giusi Prencipe1, Claudia Bracaglia1, Antonia Pascarella1, Ivan Caiello1, Paola Francalanci1, Manuela Pardeo1, Alessandra Meneghel2, Giorgia Martini2, Antonella Insalaco1, Giulia Marucci1, Francesco Zulian2, Fabrizio De Benedetti1
1Bambino Gesù Children's Hospital, Rome; 2University of Padua, Department of Woman and Child Health, Padua, Italy
Correspondence: Giusi Prencipe
Introduction: An increasing body of evidence obtained both in patients and experimental models of secondary hemophagocytic lymphohistiocytosis (sHLH), including macrophage activation syndrome (MAS), supports the pathogenic role of Interferon-gamma (IFNγ). Nevertheless, to date, few data demonstrating the activation of the IFNγ pathway in target tissues of patients with sHLH during the active phase of the disease are available.
Objectives: In this study, in order to further clarify the involvement of IFNγ in the pathogenesis of sHLH, we investigated the activation of the IFNγ pathway in the affected liver of patients with active sHLH. In addition, we evaluated the circulating levels of IFNγ inducible chemokines CXCL9 and CXCL10 and assessed the activation of the IFNγ pathway in peripheral blood mononuclear cells (PBMCs) of patients collected during the course of the disease.
Methods: We analysed by real-time PCR the mRNA expression levels of IFNγ and IFNγ-inducible genes in the liver and in peripheral blood mononuclear cells (PBMCs) from two patients with active sHLH and one patient with active MAS, in which the disease was limited to the liver, without systemic involvement. Moreover, both in liver and PBMCs protein lysates, we evaluated by Western Blot analyses the levels of total and Tyrosine (701)-phosphorylated Signal transducer and activator of transcription 1 (STAT1), the transcription factor mainly involved in the activation of the IFNγ signaling pathways. Circulating CXCL9 and CXCL10 have been measured by ELISA.
Results: The expression levels of IFNγ and IFNγ-inducible genes were markedly up-regulated in livers from all three patients, compared to control livers. Conversely, slight differences in the expression levels of Type I IFN-inducible genes and other classical pro and anti-inflammatory cytokines were found. Further supporting the activation of the IFNγ pathway, higher protein levels of phosphorylated and total STAT1 were detected in patient livers. Accordingly, we found that mRNA levels of IFNγ-regulated genes and phosphorylated STAT1 protein levels were markedly increased in patient PBMCs collected during the active phase of the disease. Finally, circulating levels of IFNγ-inducible CXCL9 and CXCL10 were markedly increased during the active phase of the disease, paralleling the ferritin’s trend.
Conclusion: Our data provide evidence of selective and marked up-regulation of the IFNγ pathway in liver tissue as well as in PBMCs and blood of patients with active sHLH, further supporting the key role of IFNγ in the pathogenesis of the disease, and provide the rationale for the therapeutic use of an anti-IFNγ antibody in sHLH.
Disclosure of Interest
G. Prencipe: None Declared, C. Bracaglia: None Declared, A. Pascarella: None Declared, I. Caiello: None Declared, P. Francalanci: None Declared, M. Pardeo: None Declared, A. Meneghel: None Declared, G. Martini: None Declared, A. Insalaco: None Declared, G. Marucci: None Declared, F. Zulian: None Declared, F. De Benedetti Grant/Research Support from: Novartis, Novimmune, Hoffmann- La Roche, SOBI, AbbVie, Pfizer
P006 LUNG DISEASE IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS (SJIA)
Vivian Saper1, Gail Deutsch2, Paul Guillerman3, Ray Balise4, Ann N. Leung5, Layla Bouzoubaa4, Scott Canna6, Grant Schulert7, Alexei Grom7, Tushar Desai8, Elizabeth Mellins1 and 52 Case Reporters representing 42 contributing institutions
1Pediatrics, Stanford University, Stanford, CA; 2Pathology, Seattle Children's Hospital, Seattle, WA; 3Radiology, Texas Children's Hospital, Houston, TX; 4Public Health Sciences, University of Miami, Miami, FL; 5Radiology, Stanford University, Stanford, CA; 6Pediatrics, Children’s Hospital of Pittsburgh, Pittsburgh, PA; 7Pediatrics, Cincinnati Children’s Hospital, Cincinnati, OH; 8Pulmonary Medicine, Stanford University, Stanford, CA, USA
Correspondence: Vivian Saper
Introduction: Although not known to be a manifestation of sJIA, high mortality lung disease, including alveolar proteinosis (AP) and pulmonary hypertension (PH), have been increasingly noted.
Objectives: To describe clinical, radiologic and biopsy findings in children with sJIA as they develop life threatening parenchymal lung disease.
Methods: This retrospective observational case series included children diagnosed until age 18 with sJIA or sJIA-like illness and lung disease. Chest CT and/or lung biopsy was required for inclusion and underwent expert review.
Results: 61 included cases were contributed by 52 case reporters (Abulaban,K, Baszis,K, Behrens, E, Birmingham, J, Canna, S, Casey, A, Cidon,M, Cron,R, De, A, DeBenedetti,F, Deterding, R, Ferguson, I, Fishman, M, Goodman, S, Graham, B, Grom,A, Haines, K, Hazen, M, Henderson, L, Ibarra, M, Inman, CJ, Jerath,R, Kingsbury, D, Klein-Gitelman,M, Khawaja, K, Lai, K, Liptzin,DR, Lin, C, Lin, J, Lapidus,S, Milojevic, D, Mombourquette,J, Onel,K, Ozen,S, Perez, M, Phillippi,K, Prahal,S, Radhakrishna,S, Reinhardt, A, Riskalla, M, Rosenwasser,N, Roth, J, Schneider, R, Schonenberg-Meinema,D, Schulert,G, Shenoi,S, Smith,J, Sonmez,E, Stoll, M,Towe, C, Vehe,R, Young, L). 45 sJIA and 16 sJIA-like cases from the United States (54), Europe, the Middle East and Asia were studied. Median age of sJIA onset was 2 years; median time to lung disease was 2 years. Onset characteristics matched reported cohorts with the exception of younger onset age (p<.0001) and a 50x increased odds of Trisomy 21. Prior to lung disease, 46 cases were exposed to one or more inhibitors of IL-1 or IL-6. This pre-exposed group demonstrated unusual clinical and radiologic features including acute erythematous clubbing, a non-evanescent rash, and CT features not typical for the pathology observed. Respiratory symptoms, if present, were subtle. Lung pathology was primarily AP and PH and did not distinguish those pre-exposed from those who were not. Systemic inflammation typically occurred immediately prior to or with lung disease detection. Extent of evaluation for infectious causes varied and did not reveal a consistent pathogen. Of 6 cases with PCR for pneumocystis pneumonia (PCP) on BAL fluid, 4 cases were positive, and these children exhibited PCP compatible disease. Overall fatality rate was 37% and, of those surviving, only 3 report resolution of lung disease.
Conclusion: This study is the first to describe a set of unusual clinical and CT features in children with sJIA who developed lung disease during treatment with inhibitors of IL-1 or IL-6. However, this group shared (rare) lung pathologic diagnoses with subjects unexposed to these drugs. Further work is urgently needed as fatality rate is high, incidence appears to be increasing, mechanisms remain unknown and appropriate treatment is yet to be defined.
Disclosure of Interest
V. Saper Grant / Research Support from: Novartis, G. Deutsch: None Declared, P. Guillerman: None Declared, R. Balise: None Declared, A. Leung: None Declared, L. Bouzoubaa: None Declared, S. Canna: None Declared, G. Schulert: None Declared, A. Grom: None Declared, T. Desai: None Declared, E. Mellins Grant/Research Support from: Novartis
P007 PREDICTORS OF EFFECTIVENESS OF INTERLEUKIN-1 INHIBITORS IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS
Jessica Tibaldi1, Benedetta Saccomanno1, Francesca Minoia2, Francesca Bagnasco3, Angela Pistorio3, Andressa Guariento3, Roberta Caorsi3, Alessandro Consolaro4, Marco Gattorno3, Angelo Ravelli4
1Università degli Studi di Genova, Genoa; 2Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, Milan; 3Istituto Giannina Gaslini; 4Università degli Studi di Genova/Istituto Giannina Gaslini, Genoa, Italy
Correspondence: Jessica Tibaldi
Introduction: Systemic juvenile idiopathic arthritis (sJIA) is the most severe and a rather distinct subtype of JIA. It is common view that sJIA is the most severe form of childhood arthritis and the most difficult to treat. Recently the use of interleukin(IL)-1 antagonists has led to a significant improvement of the disease’s long-term evolution and has confirmed this cytochin’s key-role in the pathogenesis of sJIA. A number of potential predictors of the therapeutic effectiveness of IL-1 inhibitors have been reported, which include less severe joint disease and increased white blood cell count, shorter disease duration, older age at disease onset and use of IL-1 blockade as first-line therapy. However, because the experience gained so far is still limited, there is a need of further data to better characterize the profile of sJIA patients who are more susceptible to respond to IL-1 blockade.
Objectives: To seek for predictors of therapeutic response to interleukin (IL)-1 inhibitors in children with systemic juvenile idiopathic arthritis (sJIA).
Methods: The clinical charts of all patients with sJIA who were newly treated with anakinra or canakinumab at our center between 2004 and 2017 were reviewed retrospectively. Predictors included baseline demographic, clinical and laboratory variables as well as previous or concomitant therapies. The effectiveness of IL-1 antagonists was assessed at 1 year after treatment start. Complete clinical response (CCR) was defined as absence of fever, physician’s global assessment ≤ 1, count of active joints ≤ 1, negative C-reactive protein (CRP), and ≥ 75% reduction of corticosteroid dose. According to the intention-to-treat principle, patients who had IL-1 antagonists discontinued before 1 year for any reasons other than disease remission were classified as nonresponders. Statistics included univariate and multivariable analyses.
Of the 65 patients included in the study, 25 (39%) met the criteria for CCR at 1 year, whereas 40 (61%) did not. On multivariable analysis, independent correlations with achievement of CCR were identified for shorter disease duration, lower active joint count, higher ferritin level, and greater activity of systemic manifestations (Table 1). The area under the curve (AUC) of the model was 83%.
Conclusion: Our findings help to delineate the clinical profile of sJIA patients who are more likely to benefit from IL-1 blockade. They also underscore the critical need of randomized controlled trials aimed to explore the therapeutic role of IL-1 inhibition early in the disease course.
Disclosure of Interest
See text for description
OR (95% CI)
Disease duration ≤ 3.9 years
Active joint count ≤ 10
Ferritin > 444 ng/dL
Systemic manifestation score > 3
P008 DISEASE EVOLUTION IN SYSTEMIC-ONSET JUVENILE IDIOPATHIC ARTHRITIS: PRELIMINARY DATA FROM JIRCOHORTE
Michelle Wallimann1, Katerina Theodoropoulou1, Elvira Cannizzaro2, Daniela Kaiser3, Traudel Saurenmann4, Federica Vanoni5, Andreas Woerner6, Alexandre Belot7, Isabelle Kone-Paut8, Etienne Merlin9, Olivier Richer10, Carine Wouters11, François Hofer12, Veronique Hentgen13, Michaël Hofer1
1Department Femme Mère Enfant, Pediatric Immunology and Rheumatology Romande, Lausanne University Hospital, Lausanne; 2University Children's Hospital, Zurich; 3Children's Hospital Lucerne, Lucerne; 4Winterthur Cantonal Hospital, Winterthur; 5Bellinzona Regional Hospital, Bellinzona; 6University Children's Hospital, Basel, Switzerland; 7Hôpital Femme Mère Enfant, University Hospital, Lyon; 8University Hospital Kremlin-Bicêtre, Paris; 9Hôpital d'Estaing, University Hospital, Clermont-Ferrand; 10University Hospital Bordeaux, Bordeaux, France; 11University Hospital Leuven, Leuven, Belgium; 12JIRcohorte, Lausanne, Switzerland; 13Hospital Center Versailles, Versailles, France
Correspondence: Michelle Wallimann
Introduction: Systemic onset juvenile idiopathic arthritis (SoJIA) is a potentially severe disease with both systemic and joint inflammation; different evolutive forms were described (monophasic, polyphasic or persistent), but the outcome is hardly predictable at diagnosis.
Objectives: This study aims to identify early predictors of disease evolution within the SoJIA population enrolled in the Juvenile Inflammatory Rheumatism cohort (JIRcohorte), an international prospective cohort study.
Methods: 152 SoJIA patients with a minimum of two-year follow-up were enrolled. 5 patients were excluded due to missing data on diagnostic visit. Demographics and clinical data were collected (retrospectively if diagnosis < 2015 and prospectively if diagnosis ≥ 2015) and described for 147 patients. At diagnosis, median age and disease duration was 5.3 years and 1.9 months, respectively, male to female ratio was 1:1.2. Median follow-up was 6.7 years. 123 and 98 patients were treated with biologics and DMARDs, respectively. Monophasic evolution is determined by the occurrence of active disease (systemic symptoms and/or arthritis) followed by inactive disease. No recurrence of active disease is observed, and remission is obtained. The polyphasic course is defined by the recurrence of active disease at any time after having achieved remission. A persistent evolution is characterized by the persistence of systemic symptoms and/or arthritis and/or abnormal laboratory results (for at least 24 months).
We present the preliminary results in 30 patients with complete data for disease activity and medication use.
Results: Corresponding to their evolution, patients were classified in the monophasic (n=10; MONO), polyphasic (n=14; POLY) or persistent group (n=6; PER). Females were predominant in the MONO and POLY group with 80% and 79%, respectively. No female patient was in the PER group. At diagnosis, all patients in the PER and POLY group had arthritis; only 80% did in the MONO group. Hepatomegaly and splenomegaly was present in 30% and 50% of MONO patients versus 17% and 0% of PER patients, respectively. Joint count during first 6 months was ≥ 5 joints for 83% of the PER population compared to 30% for the MONO. Four patients in the MONO group (40%) did not have any biologics, whereas all patients from the other groups had one or more (POLY: 7 patients had one, 5 patients had two and 2 patients had three different biologics). Disease Modifying Anti-Rheumatic Drugs (DMARDs) were used in 4 patients of the MONO (40%), 13 of the POLY (93%) and 5 of the PER group (83%). Median duration of corticoid-use for the MONO group and the POLY group was 0.3 years and 2.68 years, respectively.
Conclusion: Systemic presentation seems to be more prevalent in the MONO group whereas arthritis in the POLY and PER groups. Polyarticular arthritis at 6 months is suggesting persistent disease evolution. Biologics, DMARDs and corticoids are more often and longer used in the POLY and PER groups correlating with a more severe disease course. Early recognition of a monophasic evolution could help the physician to limit the use of treatments, in particular steroids.
Data are under completion for all 152 patients. Precise description of disease evolution and deep phenotypic analysis will be performed.
Disclosure of Interest
P009 INSUFFICIENT INTERLEUKIN-10 PRODUCTION AS A MECHANISM UNDERLYING PATHOGENESIS OF SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS
Maya Imbrechts1, Anneleen Avau1, Jessica Vandenhaute1, Bert Malengier-Devlies1, Karen Put1, Tania Mitera1, Nele Berghmans1, Oliver Burton2, Adrian Liston2, Lien de Somer3, Carine Wouters3, Patrick Matthys1
1Rega Institute KULeuven; 2VIB KULeuven; 3University Hospital Leuven, Leuven, Belgium
Correspondence: Carine Wouters
Introduction: Systemic juvenile idiopathic arthritis (sJIA) is a severe childhood immune-inflammatory disorder with unknown etiology.
Objectives: One of the concepts is that the disease results from an inappropriate control of immune responses to an initially harmless trigger. In the current study, we investigated whether sJIA may be caused by defects in IL-10, a key cytokine in controlling inflammation.
Methods: IL-10 production was analyzed in a sJIA mouse model, which relies on injection of Complete Freund’s Adjuvant (CFA) in IFN-γ deficient mice. Corresponding wild type (WT) mice develop a subtle and transient inflammatory reaction and were used to study the effect of IL‑10 neutralization. Cytokines and CRP were analyzed in plasma of sJIA patients (active: n=10; inactive: n=8) and healthy controls (n=15). Their PBMCs were used to study cell-specific defects in IL-10.
Results: Diseased IFN-γ deficient mice showed a defective IL-10 production in Treg cells, B cells and NK cells, with B cells as the major source of IL-10. Neutralization of IL-10 in WT mice resulted in a chronic immune-inflammatory disorder clinically and hematologically reminiscent of sJIA. In sJIA patients, IL-10 plasma levels were strikingly low as compared to pro-inflammatory mediators. In addition, B cells from sJIA patients showed a decreased IL-10 production, both ex vivo and after stimulation.
Conclusion: Cell-specific IL-10 defects in sJIA mice and patients result in an insufficient IL‑10 production to counterbalance their pro-inflammatory cytokines. IL-10 neutralization in CFA-challenged WT mice converts a transient inflammatory reaction into a chronic disease and represents a model for sJIA in IFN-γ competent mice.
Disclosure of Interest
P010 EFFECTIVENESS OF MTX BEFORE BIOLOGICS IN SYSTEMIC JIA: SINGLE CENTER EXPERIENCE
Hatice Adıguzel Dundar1, Ceyhun Acari2, Serkan Turkucar2, Sevket Erbil Unsal2
1Department of Pediatrics, Pediatric Rheumatology, Dokuz Eylül Univercity Faculty of Medicine; 2Department of Pediatrics, Pediatric Rheumatology, Dokuz Eylul University Faculty of Medicine, Izmir, Turkey
Correspondence: Hatice Adıguzel Dundar
Introduction: Systemic juvenile idiopathic arthritis (SJIA) accounts for 10-20% of all JIA patients. It is characterized by findings of systemic inflammation such as fever, rash, serositis, lymphadenopathy, and hepatosplenomegaly, and arthritis. Arthritis may develop later in life with variable clinical features. Macrophage activation syndrome is the most life threatening complication. Progress in the understanding of pathogenesis has led to the development of cytokine-targeted therapies, biologics.
Objectives: This study aims to evaluate the treatment options in SJIA, particularly effect of methotrexate prior to biologics.
Methods: A retrospective review of 52 cases of systemic JIA in the last 20 years was performed.
Results: Thirty one (59.6%) of the patients were female. The mean age of diagnosis was 89.8 ± 7.88 months and the mean follow-up was 32 ± 18.5 months. Twenty seven (51.9%) had monocyclic, 9 (17.3%) had polycyclic and 16 (30.8%) had polyarticular course. All of the patients had intermittant fever at onset, followed by rash and arthritis, and the least common symptom was serous involvement.
Ten (19.2%) cases had macrophage activation syndrome (MAS). Four of them presented with MAS as the initial diagnosis. The laboratory values of MAS cases were significantly lower in ESR, platelet and fibrinogen levels and higher in ferritin and triglyceride levels when compared with other cases. Eight of the MAS cases (80%) had monocyclic, 1 (10%) had polycyclic and 1 had polyarticular course. In 8 of the MAS cases (80%) the disease was controlled by pulse steroid followed by methotrexate alone.
Fifty (96.2%) cases received pulse steroids. Methotrexate (MTX) treatment was added in 47 (88.5%) cases. Thirty two (61.5%) cases were in remission with methotrexate treatment, whereas 14 (27%) cases required an additional biological agent. Majority of patients with biologics (56.3%) had polyarticular course. Adalimumab (1), anakinra (3), tocilizumab (6), etanercept (8) and canakinumab (9) were the biologics. In 4 cases, cyclosporin was added to control the disease.
Eight patients (15.4%) were transferred to adult rheumatology clinic for persisting arthritis. Two (4.3%) of the patients died due to sepsis and MAS, respectively. Seventeen (32.7%) were in remission under medication, and 25 (48.1%) were in remission without medication.
Conclusion: Randomized controlled trials have evidence about effectiveness of biologics, particularly IL-1 and IL-6 inhibitors, in treatment of SJIA. However, this study shows that methotrexate could control the disease in about two thirds of patients, particularly in “monocyclic” SJIA. Biologics such as anakinra, canakinumab, or tocilizumab could be preferred in cases with systemic onset and polyarticular course. Multicentered studies with more patients are needed to support this “real-world data”.
Disclosure of Interest
P011 AN UNUSUAL PRESENTATION OF PURINE NUCLEOSIDE PHOSPHORYLASE DEFICIENCY MIMICKING SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS (SJIA) COMPLICATED BY MACROPHAGE ACTIVATION SYNDROME (MAS)
Alessia Arduini1, Emiliano Marasco2, Gian Marco Moneta2, Ivan Caiello2, Giulia Marucci2, Manuela Pardeo2, Antonella Insalaco2, Giusi Prencipe2, Fabrizio De Benedetti2, Claudia Bracaglia2
1Pediatric Department, La Sapienza University of Rome; 2Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Alessia Arduini
Introduction: Monogenic primary HLH (pHLH) are caused by mutations of genes coding for proteins involved in cytotoxic activity or occur in the context of immunodeficiency.
Objectives: To demonstrate that the evidence of unusual clinical and laboratory findings in a well-known condition needs further investigations to rule out a different diagnosis.
Methods: Serum CXCL9, CXCL10 and IL-18 levels measured using ELISA.T cell proliferation was assessed stimulating PBMCs with either anti-CD3 or PMA/ionomycin for five days.
Results: A 14 months old Caucasian male was admitted with a history of persistent fever, small palpable cervical lymphnodes, rash, pericardial effusion and arthralgia. He developed overt swelling of wrists and ankles. Laboratory findings showed: elevated CRP and ESR, neutropenia, lymphopenia and anaemia, with normal platelet count. Serum ferritin levels were markedly elevated and lactate dehydrogenase aspartate aminotransferase and triglyceride were also elevated. Fibrinogen was normal. Bone marrow biopsy showed haemophagocytosis. Based on the presence of arthritis in a child with fever and rash a diagnosis of sJIA was made with onset complicated by MAS. Treatment with glucocorticoid was started. Functional tests and genetic analysis of pHLH related genes were negative. After two weeks the patient presented normalization of laboratory parameters except for persistent anaemia and profound lymphopenia. Moreover, a mild muscle hypotone became apparent. These features, unusual in sJIA, triggered additional investigations. These revealed: reduced aptoglobin, high reticulocyte count and positive Coombs test, all suggestive of haemolytic anaemia. Immunological phenotyping revealed a reduced number of B cells, CD4+T cells, CD8+T cells and a defective proliferative response of T cells to phytohemagglutinin (PHA) and anti-CD3 (OKT3). A metabolic screening showed an increase in urine orotic acid, with normal citrulline serum level and low serum level of uric acid. Based on the presence of haemolytic anaemia, T lymphocyte defect and increase in urinary orotic acid, purine nucleoside phosphorylase (PNP) deficiency was suspected. The diagnosis was confirmed by marked reduction of enzymatic activity of PNP and by genetic analysis. The patient received an haplohydentical bone marrow transplantation (BMT) with a subsequent progressive clinical improvement. Serum levels of CXCL9 and CXCL10, two chemokines directly induced by IFNgamma (IFNγ) and of IL-18, were found markedly elevated at disease onset during active phase of MAS. Cytokines levels decreased progressively during disease course and completely normalized after the BMT.
Conclusion: This patient with a clinical presentation highly suggestive for sJIA onset complicated by MAS was later diagnosed with PNP deficiency with HLH. The diagnostic process was driven by some unusual features that became apparent when HLH clinical and laboratory features were controlled with glucocorticoids. Low T cells and profoundly defective response to mitogens suggested an immunodeficiency, low haptoglobin with positive Coombs test suggested an haemolytic anemia and increased urinary orotic acid suggested an alteration of the pyrimidine biosynthetic pathway. These findings were consistent with a diagnosis PNP-deficiency. CXCL9, CXCL10 and IL-18 levels suggested that patients with PNP-deficiency may have a subclinical activation of the IFNγ pathway and indeed they are predisposed to develop sHLH. Informed consent to publish had been obtained from the parents.
Disclosure of Interest
A. Arduini: None Declared, E. Marasco: None Declared, G. M. Moneta: None Declared, I. Caiello: None Declared, G. Marucci: None Declared, M. Pardeo: None Declared, A. Insalaco: None Declared, G. Prencipe: None Declared, F. De Benedetti Grant/Research Support from: Novartis, Novimmune, Hoffmann- La Roche, SOBI, AbbVie, Pfizer, C. Bracaglia: None Declared
P012 SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS: A SINGLE CENTER EXPERIENCE
Kenan Barut, Gurkan Tarcin, Gulberk Tahaoglu, Sezgin Sahin, Amra Adrovic, Ozgur Kasapcopur
Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey
Correspondence: Kenan Barut
Introduction: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in childhood, divided into several subgroups. The sJIA could be presented by monocyclic, polycyclic or persistent polyarticular clinical course. Macrophage activation syndrome (MAS) represents the most devastating complication that could appear during the disease course. Studies on follow up, treatment response and disease complications of the sJIA patients are spare and rare.
Objectives: To evaluate demographic and clinical characteristics and to explore the long-term treatment response and disease complications in a large cohort of sJIA patients from the single center.
Methods: Demographic and clinical features of the sJIA patients were reached from the patient’s recrods. The frequency of disease flares, treatment response and side effects were recorded for each patient.
Results: A total of 168 sJIA patients were included in the study: 87 (51.8) female, 81 (48.2) male. The clinical features are shown in Table 1. Fifty-three (31.5) patients had monocyclic while 23 (13.7) patients had polycyclic clinical course (mean recurrency of attacks 2.5±2 (IQR:1-4)): in 38 (42). Polyarticular course was present in 92 (54.8) patients. Initially diagnosis of patients were: infection in 86 (51.1), sJIA in 34 (20.4), acute rheumatic fever in 19 (11.3), urticaria in 10 (5.9), Kawasaki disease in 4(2.4) and juvenile systemic lupus erythematosus in 2 patients.
The most common disease complications were: MAS in 20 (11.9), growth retardation in 19 (11.3) and vertebral fracture due to osteoporosis in 3 (1.9) patients. Gastrointestinal symptoms secondary to methotrexate intolerance that led to cessation of treatment were present in 9 (7.1) patients. Among 5 (2.9) patients that developed tuberculosis, 4 (2.3) were under etanercept treatment.
All of the patients were treated with corticosteroids: a doses of 2 mg/kg/day in 118 (70.2) patients and pulse steroids in 50 (29.8) patients with severe clinical presentation. The methotrexate was used in 126 (75), leflunomide in 5(3), cyclosporine A in 29 (17.3), intravenous immunoglobulin in 19 (11.3), anakinra in 27 (16.1), canakinumab in 27 (16.1), tocilizumab in 18 (10.7), etanercept in 50 (29.8) and adalimumab in 7(4.2) patients. The median time to remission after the initial treatment with corticosteroids was 4 (IQR:2-4) months. The remission off medications was achieved in 82 (48.8) while remission on medications was achieved in 83 (49.4) of patients.
Conclusion: Systemic JIA is a subtype of JIA characterized by significant morbidity and mortality rate with macrophage activation syndrome being the most severe disease complication. Corticosteroids represent the main treatment modality. Biological agents should be considered in the steroid-resistant patients. The clinical remission could be achieved and chronic arthritis sequelae could be prevented in a majority of patients with biological agents.
1. Dewoolkar M, et al. Course, Outcome and Complications in Children with Systemic Onset Juvenile Idiopathic Arthritis. Indian J Pediatr 2017;84:294-8
2. Cimaz R. Systemic-onset juvenile idiopathic arthritis. Autoimmunity reviews. 2016;15(9):931-4.
3. Barut K, Adrovic A, Sahin S, Kasapcopur O. Juvenile Idiopathic Arthritis. Balkan medical journal. 2017;34(2):90-101
Disclosure of Interest
Demographic, clinical features of sJIA
Mean age at disease onset
76.7±54.5 months (IQR: 28-118)
Mean age at diagnosis
79,7±54.5 months (IQR: 33-121)
Mean delay of diagnosis
3.9 ± 8.7 months (IQR:1-3)
Clinicalfeatures, n (%)
P013 CHARACTERISTICS OF PATIENTS ENROLLED IN THE FIRST LINE OPTIONS FOR SYSTEMIC JIA TREATMENT (FROST) CONSENSUS TREATMENT PLAN STUDY
Timothy Beukelman1, Peter A. Nigrovic2, George Tomlinson3, Vincent Del Gaizo4, Marian Jelinek4, Laura E. Schanberg5, Anne Dennos5, Mary Ellen Riordan6, Yukiko Kimura6, for the CARRA Registry FROST Investigators
1University of Alabama at Birmingham, Birmingham; 2Brigham and Women's Hospital, Harvard University, Boston, USA; 3University of Toronto, Toronto, Canada; 4CARRA Parent/Patient Partner; 5Duke University, Durham; 6Hackensack University Medical Center, Hackensack, USA
Correspondence: Timothy Beukelman
Introduction: The optimal initial treatment for systemic juvenile idiopathic arthritis (sJIA) is unclear. Uncontrolled reports suggest that early treatment with biologic agents likely produces superior short-term clinical outcomes, but many patients may respond well to non-biologic therapies. To further study the initial treatment of sJIA, the Childhood Arthritis and Rheumatology Research Alliance (CARRA) developed Consensus Treatment Plans (CTPs) to formalize and standardize current treatment practices. Subsequently, 4 CTPs were developed: initial systemic glucocorticoid (GC); initial methotrexate (MTX) +/- GC; initial IL-1 inhibition (IL-1i) +/- GC; and initial IL-6 inhibition (IL-6i) +/- GC.
Objectives: The FiRst Line Options for Systemic JIA Treatment (FROST) is an observational study designed to assess the effectiveness and safety of each of the 4 CTPs and to the compare the CTPs containing initial biologic therapy (IL-1i and IL-6i) to those that do not contain initial biologic therapy (GC and MTX).
Methods: Patients with recent onset sJIA who are initiating therapy are considered for enrollment in FROST. In order to be eligible for FROST, participants must have fever for ≥2 weeks, arthritis for ≥ 10 days, and at least 1 of the following: evanescent rash, generalized lymphadenopathy, hepatomegaly, splenomegaly, or serositis. Treatment assignment is at the discretion of the treating physician and family. All data are collected in the CARRA Registry. To date, 43 CARRA Registry sites have been activated to enroll FROST patients. Biosamples are collected at baseline and at 6 months. Patient reported outcomes (PRO) of presence of fever and rash and pain scores are collected at home using mobile devices every 2 days during the first 2 weeks of the study. The primary study outcome is clinical inactive disease (Wallace ACR provisional definition) and cessation of glucocorticoid therapy at 9 months.
Results: Enrollment in the FROST study began in November 2016. As of April 2018, 26 patients have been enrolled at 13 sites, and their baseline characteristics are shown in Table 1. The proportion of patients with specific SJIA disease manifestations was: rash 89%, lymphadenopathy 31%, hepatomegaly 15%, splenomegaly 23%, serositis 8%, polyarthritis 46%. Overall, 15 participants (58%) have completed every requested home PRO during the first 2 weeks of the study, and 19 (73%) have completed ≥50% of the requested home PRO. Study follow-up continues to accrue. Eight patients (31%) have completed the 9-month study visit when the primary study outcome is assessed.
Conclusion: Enrollment in the FROST study has begun. Participants enrolled thus far appear to be representative of the general population of patients with sJIA. Home PRO collection is feasible through the CARRA Registry. Additional time is needed to enroll and observe a sufficient number of patients to assess the comparative effectiveness of initial treatments for sJIA.
Disclosure of Interest
T. Beukelman Consultant for: UCB, Bristol-Myers Squibb, Sobi, Novartis, P. Nigrovic Grant/Research Support from: AbbVie, Sobi, Novartis, Consultant for: AbbVie, Sobi, Novartis, Bristol-Myers Squibb, G. Tomlinson: None Declared, V. Del Gaizo Consultant for: Sobi, M. Jelinek: None Declared, L. Schanberg: None Declared, A. Dennos: None Declared, M. E. Riordan: None Declared, Y. Kimura: None Declared
See text for description.
Age (Mean (SD))
Elapsed Days Since Onset of Symptoms (Mean (SD))
Elapsed Days Since Diagnosis (Mean (SD))
Physician Global Assessment (Mean (SD))
Parent Global Assessment (Mean (SD))
Number of Active Joints (Median (IQR))
ESR (Median (IQR))
Ferritin (Median (IQR))
P014 THE FREQUENCY OF MACROPHAGE ACTIVATION SYNDROME IN SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS CASES AND LONG TERM FOLLOW-UP RESULTS
Mustafa Çakan, Şerife Gül Karadağ, Nuray Aktay Ayaz
Pediatric Rheumatology, Kanuni Sultan Süleyman Research And Training Hospital, İstanbul, Turkey
Correspondence: Mustafa Çakan
Introduction: Systemic juvenile idiopathic arthritis (sJIA) is a multisystemic disease characterized by fever, rash, arthritis and polyserositis. The most dreadful complication of sJIA is macrophage activation syndrome (MAS) that is seen in 10-25% of the cases. sJIA cases may follow monocyclic, polycyclic and chronic polyarticular course.
Objectives: The aim of this study was to demonstrate the frequency of MAS in sJIA cases and to see whether sJIA cases complicated with MAS follow a more severe course in the long term.
Methods: Files of sJIA cases that were followed in our clinic between May 2010 and September 2017 were reviewed. To be included in the study, the patient had to be coming regularly to follow-up visits and had to be completed the first six months of the disease.
Results: The cohort consisted of 53 sJIA cases. Mean duration of follow-up was 39.0 ± 24.1 months. Mean age at the time of diagnosis was 7.9 ± 4.5 years. There was a female predominance in the cohort (32 females, 21 males). The frequency of MAS was 33.9% (18 cases). MAS was observed much more common in male patients than female patients; 42% vs 28%, respectively.
Bone marrow aspiration was performed to all patients to exclude malignancy. In 27.7% of MAS cases hemophagocytosis was not observed and hemophagocytosis was observed in 8.5% of cases without MAS. Initial laboratory test at the time of diagnosis of sJIA (leukocyte, hemoglobin, platelet, ferritin, triglyceride, ESR, CRP, fibrinogen, AST, ALT, albumin, and LDH) were compared in between patients with MAS and without MAS. Only ferritin and fibrinogen levels showed significant difference in between the groups (p<0.01). Patients that developed MAS had higher ferritin (4482 mg/dl) and lower fibrinogen (371 mg/dl) values than patients without MAS (ferritin 2060 mg/dl, fibrinogen 466 mg/dl) at the time of diagnosis of sJIA. When these laboratory parameters were compared at the time of diagnosis of sJIA and at the time of diagnosis of MAS, all parameters showed significant differences except CRP.
Long term follow-up results showed that monocyclic course was observed in 45%, polycyclic course in 32% and chronic polyarticular course in 23% of the cases. We have observed that patients with MAS segregated equally into three groups.
All MAS patients were initially treated with high-dose methylprednisolone and intravenous immunoglobulin. Additional treatments in MAS were cyclosporine (12 cases), anakinra (7 cases) and plasmapheresis (4 cases).
Biologics were used in 38.8% of all cases. Biologic treatments were needed in 12.5% of monocyclic cases, in 50% of polycyclic cases and in 77% of chronic polyarticular cases. At the time of enrollment, 58% of patients were under remission without medication and 38% were under remission with medication. Only two cases were active and both cases were in the group of chronic polyarticular course.
Conclusion: All sJIA patients should be followed for the development of MAS. High ferritin and relatively lower fibrinogen levels at the time of diagnosis of sJIA may be early warning signs of impending MAS. sJIA patients that develop MAS do not seem to portend more guarded prognosis in the long term follow-up. sJIA patients that follow a chronic polyarticular course are possibly one of the hardest group of patients to treat in pediatric rheumatology.
Disclosure of Interest
P015 THE IMPORTANT ROLE OF BONE MARROW BIOPSY TO DIAGNOSIS OF MACROPHAGE ACTIVATION SYNDROME
Kwangnam Kim1, Jong Gyun Ahn2, Young Dae Kim3
1Pediatrics, Hallym Sacred Heart Hosptal, Hallym University Medical Center, Anyang; 2Pediatrics, Severance Children's Hospital, Yonsei University, Seoul; 3Pediatrics, Ilsan Paik Hospital, Inje University, Goyang, Korea, Republic Of
Correspondence: Kwangnam Kim
Introduction: The diagnosis of MAS is difficult. A fall in platelet count and ESR, in combination with high CRP, are early signs of impending MAS in a febrile patient with an active rheumatologic condition. Other features indicative of MAS are hyperferritinemia, cytopenia involving other cell lines (WBC and RBC), liver dysfunction, coagulopathy, decreasing serum fibrinogen and increasing triglycrides.
2016 criteria for classification of MAS in patients with systemic JIA was conducted of real patient data. These data are based on clinical and laboratory features at the time of disease onset.
Objectives: The patient with a condition that could potentially be confused with MAS and active systemic JIA without evidence of MAS. To evaluate the diagnostic convenience and efficiency of the 2016 EULA/ACR/PRINTO classification for MAS in patients with systemic JIA, it will be compared with confirmed MAS by BM biopsy.
Total 13 MAS is confirmed by BM biopsy. All of these patients are applied 2016 EULA/ACR/PRINTO classification for MAS in patients with systemic JIA.
Methods: 2016 new criteria was simplified the diagnostic process for the convenience. The MAS diagnosis tools are Ferritin, Platelet count, Aspartate aminotransferase, Triglycerides and Fibrinogen. This study was a retrospective chart review conducted in the pediatric department of a tertiary level teaching hospital from 2002 through 2016. The ILAR criteria were identified in each patient at the time of first presentation to our hospital. Seventy-four patients were diagnosed with sJIA. 12 boys and 15 girls formed this study cohort. A comparison of the baseline laboratory characteristics of patients who fulfilled the ILAR criteria and those with suspected sJIA has been shown in Table 1.
Results: Diagnosis of MAS is confirmed by presence of haemophagocytic histiocytes in bone marrow. Bone marrow biopsy confirmed activated histiocytes engulfing a band neutrophil.
Conclusion: A cytokine storm is a consistent feature in patients with MAS, and it is a potentially life-threatening complication of rheumatic diseases. The fact that highly effective treatment is needed in the early stage. So do that, early diagnosis is necessary. The conduct of the new 2016 classification critieria for MAS also underscored potential limitations. Additional validation of these criteria will be necessary. The BM biopsy will make up the weakness of limitation and early diagnosis will be more possible.
1. Ravelli A. Minola F. Davi S. Horne A. Bovis F. Pistorio A. et al. 2016 Classification Criteria for Macrophage Activation Syndrome Complicating Systemic Juvenile Idiopathic Arthritis: A European League Against Rheumatism/American College of Rheumatology/Paediatric Rheumastology International Trials Organisation Collaboratve Initiative. Atrhritis Rheumatol. 2016;68(3):566-76.
2. Grom A. Horne A Benedetti F. et al. Macrophage activation syndrome in the era of biologic therapy. Nat Rev Rheumatol. 2016;12(5):259-268.
Disclosure of Interest
K. Kim Consultant for: pediatric clinical immunology, J. G. Ahn: None Declared, Y. D. Kim: None Declared
See text for description
sJIA without MAS
Age at onset (yrs)
Bone marrow biopsy
Platelet count <181k
AST >48 u/L
Triglycerides > 156 mg/dL
Fibrinogens <360 mg/dL
P016 SYSTEMIC TYPE OF JUVENILE IDIOPATHIC ARTHRITIS IS A RISK FACTOR OF INFLUENZA INFECTION -A MULTI-INSTITUTIONAL QUESTIONNAIRE SURVEY IN JAPAN-
Tomohiro Kubota1, Yasuo Nakagishi2, Nami Okamoto3, Hiroaki Umebayashi4, Ken-ichi Nishimura5, Naomi Iwata6, Yuka Okura7, Masaki Shimizu8, Mao Mizuta8, Kosuke Shabana3, Masato Yashiro9, Takahiro Yasimi10, Junko Yasumura11, Hiroyuki Wakiguchi12, Noriko Kinjo13, Syuji Takei14, Masaaki Mori15
1Pediatrics, KAGOSHIMA UNIVERSITY HOSPITAL, Kagoshima City; 2pediatrics, Hyogo Prefectural Kobe Children’s Hospital, Kobe; 3Pediatrics, Osaka Medical College, Takatsuki; 4Pediatrics, Miyagi Children’s Hospital, Sendai; 5Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama; 6 Immunology and Infectious Diseases, Aichi Children’s Health and Medical Center, Obu; 7Pediatrics, KKR Sapporo Medical Center, Sapporo; 8Pediatrics, Graduate School of Medical Sciences, Kanazawa University, Kanazawa; 9Pediatrics, Okayama University Hospital, Okayama; 10pediatrics, Kyoto University Graduate School of Medicine, Kyoto; 11Pediatrics, Hiroshima University Graduate School of Biomedical & Health Sciences, Hiroshima; 12Pediatrics, Yamaguchi University Graduate School of Medicine, Ube; 13Pediatrics, graduate school of medicine, University of the Ryukyus, Nakagami; 14Pediatrics, KAGOSHIMA UNIVERSITY HOSPITAL, Kagoshima; 15Lifetime Clinical Immunology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, Tokyo, Japan
Correspondence: Tomohiro Kubota
Introduction: The influenza (Flu) is one of the most prevalent infections in the world and the vaccination is recommended for the patients treated with immunosuppressive therapy and there is some immunological research on the Flu vaccination in the patients with juvenile idiopathic arthritis (JIA). However, the morbidity of Flu in the patient with JIA in the real-world is unknown.
Objectives: We aimed to evaluate Flu morbidity and side effect of vaccination in patients with JIA in comparison with the general population in Japan. And clarify the risk factor of Flu infection for the patient with JIA.
Methods: From October 2016 to May 2017, a total of 13 participating medical institutions collected questionnaires from patients with JIA. The questionnaires focused on the incidence of Flu infection and Flu vaccination, and the efficacy and side effects of Flu vaccination. The frequency of each item was compared to that in the general population. Multivariable logistic regression analysis was performed to determine the risk factor on the Flu infection.
Results: A total of 473 patients with JIA (159 males [34%]; 314 females [66%]) were enrolled (mean age, 13.3 years; range, 2.4-37.3 years). Two hundred sixty-eight (57%) patients got the Flu vaccine; side effects were observed in 58 patients (22%), with no severe cases. Patients were treated with methotrexate (n=235 [50%]; mean dose, 7.35 mg/m^2/week), prednisolone (n=110 [23%]; mean dose, 0.14 mg/kg/day), and biological disease-modifying anti-rheumatic drugs (n=327 [69%]). Seventy-four patients (15.6%) had a Flu infection and the influenza morbidity was significantly smaller in patients with JIA compared to that in the general population in Japan (21%)(p=0.005). JIA disease activity flared in one patient after Flu infection, but no one flared after Flu vaccination. In logistic regression analysis, the patients with systemic JIA were high risk for Flu infection (odds ratio:2.666, 95% confidence interval: 1.321-5.475, p=0.007).
JIA: juvenile idiopathic arthritis, MTX: methotrexate, PSL: prednisolone, bDMARDs: biological disease-modifying anti-rheumatic drugs, OR: odds ratio; CI: confidence interval
Conclusion: Influenza vaccination is safe and effective for patients with JIA treated with glucocorticoids and disease-modifying antirheumatic drugs. The risk of Flu infection is significantly high in the patient with systemic JIA.
Disclosure of Interest
Multivariable logistic regression analysis to determine the risk factor on the influenza morbidity
P018 LIPID BIOMARKERS IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS: IS THERE A DIFFERENCE BETWEEN THE POLYARTICULAR AND SYSTEMIC SUBTYPES?
Wellington D. Rodrigues, Roseli S. Sarni, Fernando A. Fonseca, Patricia P. Aires, Claudio A. Len, Maria T. Terreri
Pediatric Rheumatology, Universidade Federal de São Paulo, São Paulo, Brazil
Correspondence: Claudio A. Len
Introduction: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in the pediatric population. These patients coexist with the chronic disease, and present to a greater extent negative outcomes such as osteoporosis and cardiovascular diseases.
Objectives: To describe the biomarkers of lipid metabolism related to the cardiovascular risk of children and adolescents with JIA and to relate them to variables of the disease, lipid and glucose profile, nutritional status and food consumption.
Methods: Cross-sectional study with 62 JIA patients. The following were evaluated: disease activity and medications used, body mass index, height for age (z score), food intake (24 hour recall), lipid profile (total cholesterol - CT, low density lipoprotein - LDL, high density lipoprotein – HDL, triglycerides - TG and non - HDL), lipid markers such as apolipoproteins A-I and B (Apo A-I and Apo B). The association analyses were stratified as follows: HDL-c and Apo A-I into adequate and borderline/low; LDL-c, CT, TG, NHDL-c and Apo B into adequate and borderline/high; levels of C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR). For statistical analysis: Exact Fischer, Chi-square, Mann-Whitney and Spearman Correlation tests; p <0.05.
Results: The mean age and time since diagnosis were 7.7 years (± 4.3) and 5.0 years (± 3.4), respectively. Active disease was observed in 33.9% of the patients and the prevalence of dyslipidemia was 62.9% overall when we considered lipid profile alone (CT, LDL-c, HDL-c, non-HDL-c and TG) and 82.3% when we included altered apolipoproteins (Apo A-I and Apo B). HDL-c and Apo A-I were the most frequently altered lipid markers. When comparing the subtypes, the systemic subtype had a higher value and higher frequency of altered LDL-c and NHDL-c and increased Apo B/Apo A ratio, when compared to the polyarticular subtype (p = 0.017, 0.042 and 0.03, respectively). When we cross-referenced the adequate or borderline/low HDL-c variable against other variables, patients with borderline/low HDL-c presented lower values and higher frequency of altered Apo A-I (p<0.001 and 0.001, respectively). There was no significant correlation between us-CRP and variables related to lipid metabolism. However, ESR showed a negative correlation with Apo A-I levels (r = -0.25, p = 0.047).
Conclusion: We conclude that dyslipidemia and alteration of lipid biomarkers are common in patients with JIA. The systemic subtype and elevated ESR were associated with lower concentrations of Apo A-I, indicating the participation of the inflammatory process in this alteration. Furthermore, the systemic subtype presented higher value and frequency of atherogenic particles, suggesting that patients with this subtype are at increased risk for the development of cardiovascular disease.
Disclosure of Interest
P019 HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS (HLH) MIMICKERS: CXCL9 AS A POTENTIAL BIOMARKER DISTINGUISHING HLH FROM OTHER HYPERFERRITINEMIC SYNDROMES
Giulia Marucci, Ivan Caiello, Manuela Pardeo, Virginia Messia, Giusi Prencipe, Antonia Pascarella, Fabrizio De Benedetti, Claudia Bracaglia
Division of Rheumatology, IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy
Correspondence: Giulia Marucci
Introduction: Increased ferritin is considered biomarker highly suggestive of primary and secondary HLH and it is one of the HLH-2004 diagnostic and MAS guidelines (1, 2), nevertheless it could also be elevated in other inflammatory conditions. Interferon-gamma (IFNγ) and IFNγ induced chemokines, particularly CXCL9, have been demonstrated to be markedly elevated in patients with primary and secondary HLH.
Objectives: To describe eight patients with hyperferritinemia who fully or partially met the HLH-2004 diagnostic guideline, but in which the subsequent clinical course and further investigations led to different diagnosis that required different therapies and to investigate the CXCL9 levels in identify diseases that may mimic HLH. To be noted that soluble CD25 was not measured in these patients.
Methods: Serum CXCL9 levels were analyzed by DuoSet ELISA KIT DY392 (R&D Systems, Minneapolis, Minn). Normal values of CXCL9 are lower than 700 pg/ml.
Results: We identified 8 patients with laboratory features suggestive of HLH, included high ferritin levels (>500 ng/ml). Three of these patients met five of the HLH-2004 criteria, two of them met four criteria and the others two met three criteria. One patient presented only high serum ferritin level and cytopenia. CXCL9 levels were <300 pg/ml in seven of them and approximately 600 pg/ml in one patient. The clinical disease course and the other investigations ruled out the diagnosis of HLH and every patient received a different diagnosis. None of them received treatment for HLH (Table 1).
Conclusion: Since HLH is a life-threatening condition, early recognition and promptly therapy are essential to modify the disease course. One of the most typical feature of primary and secondary HLH is high ferritin levels. Due to the severity of the disease, sometimes patients need to be treated before all criteria are fulfilled. The eight patients reported had features highly suggestive of HLH and met the HLH-2004 criteria, or part of them. However they all received a different final diagnosis. Despite all presented with high ferritin levels, CXCL9 was low in all. CXCL9 is a chemokine specifically induced by IFNγ, and has been demonstrated to be markedly elevated in patients with primary and secondary HLH due to the activation of the IFNγ pathway. In these cases CXCL9 was able to differentiate diseases with high ferritin that mimics HLH. High CXCL9 levels appear to be a potential specific biomarker for HLH diagnosis. Early dosage of CXCL9 levels in patients with hyperferritinemia and with clinical suspicion of HLH may be helpful for a timely differential diagnosis.
1. Henter JI et al. HLH-2004: diagnostic and therapeutic guidelines for hemophagocytic lymphohistiocytosis. Pediatr Blood Cancer 2007 Feb; 48(2):124-31.
2. Ravelli A et al. 2016 Classification Criteria for Macrophage Activation Syndrome Complicating Systemic Juvenile Idiopathic Arthritis: A European League Against Rheumatism/American College of Rheumatology/Paediatric Rheumatology International Trials Organisation Collaborative Initiative. Ann Rheum Dis. 2016 Mar;75(3):481-9.
Disclosure of Interest
G. Marucci: None Declared, I. Caiello: None Declared, M. Pardeo: None Declared, V. Messia: None Declared, G. Prencipe: None Declared, A. Pascarella: None Declared, F. De Benedetti Grant/Research Support from: Novartis, Novimmune, Hoffmann-La Roche, SOBI, AbbVie, Pfizer, C. Bracaglia: None Declared
Months at onset
Vitamin B12 deficiency
Chronic granulomatous disease
Short bowel syndrome
Shaken baby syndrome
Ghosal hematodiaphyseal dysplasia
P020 THROMBOTIC MICROANGIOPATHY: AN UNDER-RECOGNIZED, DREADFUL COMPLICATION OF MACROPHAGE ACTIVATION SYNDROME
Francesca Minoia1,2, Jessica Tibaldi2,3, Valentina Muratore4, Romina Gallizzi5, Concetta Micalizzi2, Angelo Ravelli2,3
1Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan; 2Istituto G. Gaslini; 3Università degli Studi di Genova, Genoa; 4IRCCS Policlinico San Matteo, Pavia; 5Università degli Studi di Messina, Messina, Italy
Correspondence: Francesca Minoia
Introduction: Macrophage activation syndrome (MAS) is part of the spectrum of hemophagocytic disorders and is a serious complication of rheumatologic conditions, mainly systemic juvenile idiopathic arthritis (sJIA). Thrombotic microangiopathy (TMA) is a heterogeneous group of life-threating diseases characterized by microangiopathic hemolytic anemia, thrombocytopenia and organ injury. The association between TMA and hemophagocytic syndromes has been described only in single reports in adult renal transplant recipients and in two pediatric cases of virus-induced hemophagocytic lymphohistiocytosis. TMA complicating MAS has never been reported so far
Objectives: To describe clinical and laboratory features, treatment and outcome of a cohort of patients with MAS complicated by TMA
Methods: The clinical charts of patients with MAS and TMA seen at 3 Italian tertiary-care pediatric rheumatologic centers were reviewed retrospectively. Demographic, clinical and laboratory data at the time of TMA diagnosis were collected. Therapeutic intervention and outcome were also recorded
Results: Five patients who met the criteria for MAS and developed TMA during the course of MAS were identified; one patient was excluded due to insufficient data. The underlying disease was sJIA or a sJIA-like disease in all patients. The median age at MAS onset was 8.6 years (4.2–12.8 yr), and the median interval between onset of MAS and occurrence of TMA was 13.5 days. TMA was characterized in all patients by renal failure with hematuria, and presence of schistocytes in blood smear. Three of the 4 patients experienced severe CNS involvement, with lethargy, seizures, or coma. The main laboratory features at TMA onset are shown in Table 1. For the management of MAS, all patients received high-dose corticosteroids and cyclosporine; in 3 cases anakinra was added. All TMA episodes were treated with plasma-exchange; two patients were also given biologics (rituximab or eculizumab) with good results. During the course of TMA, aggressive and prolonged management in the Intensive Care Unit was required in all cases. All patients survived
Conclusion: TMA is a dreadful complication of MAS, which is likely under-recognized. If not diagnosed timely and treated appropriately, TMA may precipitate the course of MAS and lead to a fatal outcome. Clues to suspect TMA in a patient with MAS are the increase in lactic dehydrogenase and decrease in platelet count out of proportion of the other laboratory abnormalities, the drop in haptoglobin level, the finding of schistocytes in blood smear, and the new onset of hematuria. Biologic medications, particularly rituximab and eculizumab may offer an adjunctive therapeutic option for refractory cases
Disclosure of Interest
See text for description
Platelet count, x 109/l
Aspartate aminotransferase, U/l
Lactic dehydrogenase, U/l
P021 AN INTERNATIONAL CONSENSUS SURVEY OF DEVELOPING CLASSIFICATION CRITERIA FOR JUVENILE DERMATOMYOSITIS-SCLERODERMA OVERLAP
Parichat Khaosut1,2, Clarissa Pilkington2, Lucy R. Wedderburn2,3,4, Sandrine C. Lacassagne2, on behalf of JDCBS and JDCBS
1Paediatrics, Faculty of medicine, Chulalongkorn University, Bangkok, Thailand; 2Paediatric Rheumatology, Great Ormond Street Hospital; 3ARUK Centre for Adolescent Rheumatology, University College London; 4NIHR Biomedical Research Centre, Great Ormond Street Hospital, London, UK
Correspondence: Parichat Khaosut
Introduction: There is no internationally agreed definition of ‘JDM-Scleroderma overlap’ in children and little data on the clinical characteristics, laboratory features and outcome in this specific group of JDM have been published. The goal of this survey is to achieve consensus on a meaningful definition of JDM-Scleroderma overlap in paediatric population and to determine whether overlap features affect outcome and management.
Objectives: To develop criteria for the diagnosis of JDM-Scleroderma overlap using an international consensus process.
Methods: A survey was circulated to all investigators in the Juvenile Dermatomyositis Cohort and Biomarker Study and Repository (JDCBS) and extended to other members of the Network for JDM in Paediatric Rheumatology European Society (PReS JDM working party) through a Delphi survey. Each individual was asked to identify those clinical manifestations that were felt to be most characteristic to enable them to make the diagnosis of JDM-Scleroderma overlap. The opinions on the importance of identification this subtype of JDM ware collected and the role of myositis autoantibodies has been mentioned in the questionnaire.
Results: The survey had a response rate of 26.9% (41 individuals) from both JDCBS and PReS JDM working party. The most common clinical features identified by survey responders as found in JDM patients with scleroderma overlap were sclerodactyly, sclerodermatous skin change proximal to MCP joints, Raynaud phenomenon and ulceration at the tip of fingers, respectively. 95.1% of responders though the scleroderma overlap presentations influence the outcome of JDM, while 86.4% agreed that these features influence the choice of treatment. Interestingly, all of responders (100%) thought that negative myositis autoantibodies could not exclude the diagnosis JDM-Scleroderma overlap, but almost 11% used positive myositis autoantibodies to diagnose this subgroup of JDM. Myositis associated autoantibodies occurring in systemic sclerosis overlap (anti PM-Scl, anti U1-RNP and anti Ku) were thought to be the most commonly associated autoantibodies with JDM-Scleroderma overlap (78%), followed by systemic sclerosis specific autoantibodies (anti Scl70, anti RNA polymerase III) (44%). Although 83% felt that autoantibody profile influences the outcome, only 49% thought that autoantibody profile would influence the choice of medication. 89% of participants in this survey have seen patients with JDM-Scleroderma overlap.
Conclusion: This process identified clinical features that clinicians felt to be helpful or important in the diagnosis of JDM-Scleroderma overlap. A further process of secondary survey is necessary to agree an internationally acceptable, clinically usable set of classification criteria.
Disclosure of Interest
P022 DEFINING THE RISK OF INTRAVENOUS IMMUNOGLOBULIN RESISTANCE IN NON-ASIAN PATIENTS WITH KAWASAKI DISEASE
Maryam Piram1,2, Martha Darce3, Stéphanie Tellier4, Sylvie Di-Filippo5, Franck Boralevi6, Fouad Madhi7, Ulrich Meinzer8, Rolando Cimaz9, Celine Piedvache10, Isabelle Kone-Paut1,2, Kawanet study group
1Pediatric Rheumatology, CEREMAIA, CHU de Bicêtre; 2Univ Paris Sud; 3Pediatric Rheumatology, CHU de Bicêtre, Le Kremlin Bicêtre; 4Pediatric Rheumatology, Nephrology and Internal medecine, CHU de Toulouse, Toulouse; 5Cardiology, Hospices civils de Lyon, Lyon; 6Dermatology, CHU de Bordeaux, Bordeaux; 7Paediatrics, CHIC, Créteil; 8Paediatrics, CHU Robert Debré, Paris, France; 9Pediatric Rheumatology, Meyer Hospital, Firenze, Italy; 10Clinical Research Unit, CHU de Bicêtre, Le Kremlin Bicêtre, France
Correspondence: Isabelle Kone-Paut
Introduction: About 10-20% of patients with Kawasaki disease (KD) are resistant to intravenous immunoglobulin (IVIg) and are at increased risk of coronary artery abnormalities (CAAs). Early identification is critical to initiate aggressive therapies, but available scoring systems lack sensitivity in non-Japanese populations.
Objectives: We investigated the accuracy of 2 Japanese scoring systems and studied factors associated with IVIg resistance in a large multiethnic French population of children with KD to build a new scoring system.
Methods: Children admitted for KD between 2011-2014 in 65 centers were enrolled. For patients fulfilling American Heart Association (AHA) criteria, we identified factors predicting resistance to IVIg by multivariate regression analysis. The performance of our score and the Kobayashi and Egami scores were compared in our population and in ethnic subgroups.
Results: Overall, 465 children were reported by 84 physicians; 355 (76%) fulfilled AHA criteria (55% European Caucasian, 12% North African/Middle Eastern, 10% African/Afro-Caribbean, 3% Asian and 11% mixed). Eighty patients (23%) needed second-line treatment. Japanese scores had poor performance in our whole population (sensitivity 52-44.5%). Predictors of IVIg resistance were ALT≥30 IU/L, hemoglobin level <10 g/dl, lymphocyte count <1500/mm3, modification of extremities, CAAs at initial echocardiography, and time to treatment <5 days. The best sensitivity (80%) and specificity (65%) of this model was with weighted variables and cut-off ≥ 17.5/50 points. The sensitivity remained good in our 3 main ethnic subgroups (78-83%).
Conclusion: We identified predictors of IVIg resistance and built a new score with good sensitivity and specificity in a non-Asian population.
Disclosure of Interest
P023 THE USE OF INTERLEUKIN 1 RECEPTOR ANTAGONIST (ANAKINRA) IN KAWASAKI DISEASE: A RETROSPECTIVE CASES SERIES
Isabelle Koné-Paut1, Rolando Cimaz2, Jethro Herberg3, Oliver Bates3, Aurelia Carbasse4, Jean Pierre Saulnier5, Maria Cristina Maggio6, Jordi Anton7, Maryam Piram8
1Pediatric rheumatology, APHP, hôpital de Bicêtre, CEREMAIA, university of Paris Sud, Le Kremlin Bicêtre, France; 2Pediatric rheumatology, Meyer hospital, Firenze, Italy; 3Pediatrics, Imperial college of London, London, UK; 4Pediatric rheumatology, Hôpital arnaud de villeneuve, Montpellier; 5Intensive Care Unit, Poitiers university hospital, Poitiers, France; 6Pediatrics, University Department Pro.Sa.M.I.G d’Alessandro, Palermo, Italy; 7Pediatric rheumatology, Hospital San Joan de Deu, Espluges de Llobregat, Spain; 8pediatric rheumatology and dermatology, APHP, hôpital de Bicêtre, CEREMAIA, university of Paris Sud, Le Kremlin Bicêtre, France
Correspondence: Isabelle Koné-Paut
Introduction: Persistent fever and inflammation after infusion of 2g/kg of IVIG, the standard treatment of KD represents a high-risk situation for coronary aneurysms in Kawasaki disease. Identifying patients at risk for IVIG resistance is difficult outside the Asian population, and there remains a critical unmet need to identify an anti-inflammatory treatment that is efficacious in all KD patients. Recent evidence from studies in animals and humans suggest a critical role for interleukin-1 (IL-1) α and β in the pathogenesis of KD.
Objectives: To identify the clinical characteristics, reasons for use and response to treatment with anakinra in a retrospective series of patients with Kawasaki Disease (KD).
Methods: A retrospective chart review of patients treated with anakinra for KD diagnosed according to the AHA criteria. We compared clinical, biological and echocardiographic characteristics of KD before and after anakinra use. We analysed reasons for use of anakinra, and compared treatment regimens used in 7 European KD referral centres.
Results: Eight boys and 3 girls with treatment-refractory KD, aged 4 months to 9 years old, received at least 2 different KD treatments prior to anakinra, which was given on mean at 25 days after disease onset (8 to 87 days). The main reasons for use of anakinra were clinical and biological inflammation, progression of coronary dilatations, and severe myocarditis with cardiac failure. Doses of anakinra ranged from 2 to 8 mg/kg and duration varied from 6 to 81 days. On anakinra treatment, fever disappeared within hours (<24 h) in 3 patients, and within 2 and 6 days in two patients respectively. Six others patients were not febrile at onset of anakinra. In addition, CRP levels fell two to three fold within 48 hours in 7/9 evaluable patients. In terms of its effect on coronary artery dilatation, Z scores decreased in 10/11 patients and increased in one who died suddenly of pericardial hemorrhage.
Conclusion: Anakinra used late in the disease course led to a rapid and sustained improvement in clinical and biological inflammation. However, our retrospective analysis did show neither a striking nor a rapid decrease of coronary dilatations and we cannot determine if anakinra itself had an effect on coronary artery dimensions. More robust data will be available soon from the two Phase II ongoing trials, KAWAKINRA using anakinra treatment early after one failure of IVIG treatment (European Clinical Trials no. 2014-002715-41) and ANAKID (ClinicalTrials.gov identifier: NCT02179853), focused on patients with coronary giant aneurysms.
Disclosure of Interest
P024 OUTCOME OF 24 PATIENTS WITH CHILDHOOD-ONSET TAKAYASU ARTERITIS: A RETROSPECTIVE STUDY IN TWO TERTIARY CENTRES IN JAPAN
Kenichi Nishimura1, Seira Hattori1, Ayako Murase1, Ai Ohnishi1, Ryoki Hara1, Masao Ogura2, Kenji Ishikura2, Shuichi Ito1
1Department of Pediatrics, Yokohama City University Graduate School of Medicine, Yokohama; 2Division of Nephrology and Rheumatology, National Center for Child Health and Development, Tokyo, Japan
Correspondence: Kenichi Nishimura
Introduction: Takayasu arteritis (TA) is a chronic large-vessel vasculitis affecting the aorta and its major branches. Glucocorticoids (GCs) can achieve remission in most patients with TA. As most patients suffer relapse after reducing GCs, additional therapy such as methotrexate, azathioprine and intravenous cyclophosphamide (IVCY) has been applied. Recently, the efficacy of TNF-α inhibitors or tocilizumab (TCZ) has been reported. However, there remain insufficient data on clinical characteristics and outcomes of patients with childhood-onset TA, including recent therapeutic advances.
Objectives: We aimed to retrospectively analyse the characteristics and outcomes of patients with childhood-onset TA in two tertiary centres in Japan.
Methods: Subjects were 24 patients with TA diagnosed when younger than 18 years. Follow-up duration was more than 2 years. Diagnosis of TA was based on the EULAR/PRINTO/PRES criteria. We divided the subjects into two groups: those who did and did not experience relapse. Relapse was defined as NIH criteria for active disease in TA.
We analysed the patients’ background, treatment and complications. We additionally compared two groups according to prednisolone (PSL) reduction rate and whether or not they carried HLA-B52.
Binary data were analysed by Fisher’s exact test, and quantitative data by Mann-Whitney U test. The cumulative relapse rates after the diagnosis were estimated using the Kaplan-Meier method; differences between two groups were assessed by the log-rank test.
Results: Median age at onset was 13.0 (range; 0.5-18.0) years old (male:female, 11:13). Thirteen patients (54%) had HLA-B52. Period from onset to diagnosis was 1 (0-66) months. Angiographic classifications were I, IIa, IIb, III, IV and V (n=3, 2, 4, 1, 2 and12), respectively. Four patients and one patient had pulmonary artery involvement and coronary involvement, respectively.
Three patients achieved drug-free remission. Median dose of prednisolone (PSL) was 0.8 (0.4-2.4) mg/kg/day at initiation of treatment and 0 (0-0.3) mg/kg/day at the last visit. Immunosuppressants were used in 13 (54%) from the onset and in 21 (88%) at the last visit. IVCY was used in 10 patients (42%) from the onset, and 4 after the relapse. Some biologics were used in 4 (17%) from the onset, and in 12 (50%) at the last visit.
Twelve patients (50%) experienced relapse, and median number of relapses was 3 (1-6) times. The ratio of relapse was not significantly different between the HLA-B52 positive and negative patients (69% vs 27%, P=0.099). However, median duration from diagnosis to the first relapse was significantly shorter in HLA-B52 positive patients than negative patients (6 vs 51months, P=0.016). The reduction pace of PSL was significantly greater in relapsed patients than non-relapsed patients (0.058 vs 0.025 mg/kg/month, P=0.017). The cumulative relapse rates after the started IVCY or TCZ were not significantly difference between the patient who introduced IVCY (n=14) and TCZ (n=12) (P=0.10).
Nine patients (38%) had cardiovascular complications (aortic valve regurgitation (AR) (n=4), annuloaortic ectasia (AAE) (n=1) and AR+AAE (n=4)). Two patients underwent cardiac surgery. Ten patients had osteoporosis, 2 had surgery for glaucoma and 5 had some mental disorders in their clinical coarse.
Conclusion: Approximately half of the patients with childhood-onset TA experienced relapse despite using immunosuppressants and/or biologics. HLA-B52 positivity and rapid reduction rate of PSL significantly increased risk of early relapse. Furthermore, cardiovascular involvement and GCs-related complications were common. Our study suggests the outcome of childhood-onset TA remains unfavourable.
Disclosure of Interest
P025 MYOSITIS DAMAGE INDEX IN A COHORT OF INDIAN CHILDREN WITH JUVENILE DERMATOMYOSITIS
Santan Godad, Pallavi Pimpale Chavan, Raju P. Khubchandani
Pediatric Rheumatology Clinic, Department of Pediatrics, Jaslok Hospital and Research Centre, Mumbai, India
Correspondence: Pallavi Pimpale Chavan
Introduction: International Myositis Assessment and Clinical Studies Group (IMACS) developed the Myositis Damage Index (MDI) structured separately for pediatrics and adults, to provide consistency in myositis outcomes. The MDI documents persistent changes in 11 organ systems thought to be related to damage. There is a dearth of studies on damage caused by Juvenile Dermatomyositis (JDM) especially from less resourced countries and hence our study.
Objectives: Primarily to assess the myositis damage index in a cohort of children with JDM from a single centre in Mumbai, India and secondarily to study associations of factors leading to long term damage in these children.
Methods: After ethics approval and consents, a total of 23 patients with JDM under regular treatment and at least a 2 year follow up, at first study visit were identified. Specifically excluded were children with overlap syndromes eg scleromyositis. The MDI was assessed as severity of damage and extent of damage at the first study visit and reassessed at a second visit at least six months later and only damage present at both visits were scored to give a final severity and extent of damage score. There were no drop outs.
Results: 23 children with age range at disease onset 1y - 17.9 y (mean 6.9 y, median 6.8 y, IQR 3.5-8.8) were diagnosed as JDM after a duration of symptoms ranging 1m-30 m (mean 6.8 m, median 5 m, IQR 3-8.5). Their age at the study visit ranged from 5.5 y - 24.8 y (mean 13.4 y, median 12.9 y, IQR 10.4-15.3) after a follow up duration ranging from 2 y - 20.1 y (mean 5.9 y, median 4.2 y, IQR 2.6-8.5, Total 136.5 patient years). The disease course was monocyclic in 14, continuous in 6 and polycyclic in 3. The total MDI extent of damage score ranged from 0- 8 / 35 (children) or 37 (adolescents) (mean 2.04, median 2.0, IQR 0.5-2.5) and severity of damage score ranged from 0-24.7 /110 (mean 4.7, median 3.5, IQR 1.3-6.4). 17/23 children had damage in one or more organ systems, with 9 showing damage in one organ system, 4 in two organ systems, 3 in three organ systems and 1 child showed damage in six systems. Cutaneous (16/23), endocrine ie growth retardation (6/23) and muscle (5/23) were the most commonly damaged organ systems with 2 children showing skeletal damage while ocular, gastrointestinal and cardiac domains were involved in one each. Importantly, over this duration of follow up there were no children with infection, pulmonary, peripheral vascular disease or malignancy. Correlation between age at onset, gender, time to diagnosis, course of disease and duration of follow up did not yield statistically conclusive results.
Conclusion: This is amongst the earliest studies to report damage due to JDM from less resourced countries. Over the median follow up period of 4.2 years about 75% of the children suffer damage in one or more domains, cutaneous damage being the commonest. Uniquely despite high infection rates in the community, this domain was unaffected in our population. Continued enrolment with longer duration of follow up are needed to shed light on factors influencing damage.
Disclosure of Interest
P026 PRELIMINARY PROSPECTIVE VALIDATION OF THE JUVENILE DERMATOMYOSITIS ACTIVITY INDEX (JDMAI)
Silvia Rosina1,2, Giulia Camilla Varnier1,2,3, Alessandro Consolaro1,2, Pieter van Dijkhuizen1, Kiran Nistala3, Nicolino Ruperto1, Angela Pistorio1, Clarissa Pilkington3, Angelo Ravelli1,2
1Istituto Giannina Gaslini; 2Università degli Studi di Genova, Genova, Italy; 3Great Ormond Street Hospital, London, UK
Correspondence: Silvia Rosina
Introduction: The first composite disease activity score for juvenile dermatomyositis (JDM), named JDMAI, has recently been developed and validated in retrospective patient datasets. It is composed of 4 domains and takes into account the parents’ perception of disease status. The 6 preliminary versions of the tool performed similarly in previous validation analyses.
Objectives: To test prospectively the validity of the JDMAI in a sample of JDM patients seen in daily practice.
Methods: A total of 53 JDM patients seen consecutively at 2 tertiary-care paediatric rheumatology centers, either at disease onset or at a follow-up visit, a median of 2.3 years after disease onset, were enrolled. Each patient received a retrospective assessment and a cross-sectional evaluation at study entry. Twenty-two patients also underwent a second (prospective) assessment after a median of 3.5 months from study entry. Physician-centered evaluations included assessment of muscle, skin and overall disease activity on a visual analogue scale (VAS) or through the Disease Activity Score (DAS), rating of disease state and course and measurement of disease damage with the Myositis Damage Index (MDI). Laboratory data comprised muscle enzymes and ESR. Parent-reported outcomes were collected through the administration of the Juvenile Dermatomyositis Multidimensional Assessment Report (JDMAR). Validation analyses included assessment of construct validity, internal consistency (with Cronbach’s α), discriminant ability, and responsiveness to change in disease state over time (with standardized response mean, SRM).
Results: All JDMAI versions showed strong (r>0.7) correlations with muscle disease activity VAS (0.85-0.87), muscle section of DAS (0.81-0.83), total DAS (0.89-0.92), pain VAS (0.72-0.75), and fatigue VAS (0.92-0.93). The correlations of the different JDMAI versions with the skin index not contained in the specific version (skin disease activity VAS or skin section of DAS) were strong (0.74-0.79). As expected, JDMAI correlations were moderate (r=0.4-0.7) or low (r<0.4) with laboratory parameters (CK, LDH, AST, ALT, and ESR) and with the MDI (0.1-0.11). The SRM was greater in patients judged as improved by the physician or the parent (1.26-1.56) than in those judged as not improved (0.88-1.11). Cronbach’s α was very high (0.89-0.91) for all JDMAI versions. All JDMAI versions discriminated strongly between patients classified in different disease activity states by the physician (p<0.0001) or by the parent (p=0.002-0.005), and between patients whose parents were satisfied or not satisfied with their children’s disease status (Mann-Whitney U test, p=0.0005-0.0008).
Conclusion: Validation analyses in this prospective patient sample confirmed that the JDMAI possesses good measurement properties and is a suitable and reliable tool for the assessment of disease activity in children with JDM both in clinical practice and research. Importantly, the new tool revealed a strong capacity to capture the improvement of disease activity over time.
Disclosure of Interest
P027 QUALITATIVE NAILFOLD VIDEOCAPILLAROSCOPY ASSESSMENT OF MICROVASCULAR INVOLVEMENT IN JUVENILE DERMATOMYOSITIS
Ana V. Villarreal Treviño1, Fernando García-Rodríguez1, Vicente Baca2, Samara Mendieta-Zerón3, Manuel de la O-Cavazos4, Dionicio Á. Galarza-Delgado5, Nadina E. Rubio-Pérez1
1Pediatric Rheumatology, Hospital Universitario "José Eleuterio González", Monterrey; 2Pediatric Rheumatology, Centro Médico Nacional Siglo XXI, Ciudad de México; 3Pediatric Rheumatology, ISSEMYM Hospital Materno Infantil, Toluca; 4Pediatric; 5Rheumatology, Hospital Universitario "José Eleuterio González", Monterrey, Mexico
Correspondence: Ana V. Villarreal Treviño
Introduction: Juvenile dermatomyositis (JDM) is the most common of the pediatric inflammatory myopathies characterized by inflammatory microvasculopathy.
Nailfold videocapillaroscopy (VCP) is an in vivo, rapid, and inexpensive imaging technique that allows quantitative assessment of microcirculation. VCP has demonstrated a key role in diagnosis and disease monitoring. The most severe videocapillaroscopy semi-quantitative changes previously reported as loss of capillaries, enlarged loops and brushy capillaries are associated with longer disease duration1. There is a lack of specific quantitative measures of the capillaries during disease curse.
Objectives: To describe qualitative and semi-quantitative VCP assessment in Mexican patients with JDM
Methods: The present study was a cross-sectional observational study that analyzed 192 images from 24 patients with JDM during different of the disease course, form 3 diferent centers in Mexico. VCP was performed by the same examiner (AVT), images were obtained from all fingers except thumbs of both hands using a videocapillaroscope with a 200x optical probe. The images were collected, coded, and stored using OptiPix software (version 1.7.16).Semi-quantitative assessment for architecture were scoredfollowing the international definitions for the capillary abnormalities.2 Quantitative assessment consist in the measurement of the number of capillaries per millimeter, capillary loop length, capillary width, intercapillary distance in micron (μm)3.
Results: Twenty four patients with JDM were included, 62.5% female. The qualitative assessment reveal only 4 images with normal capillaroscopy pattern, nonspecific alterations were found in 31.2%.
Conclusion: VCP is a noninvasive image method that’s provides a window to microcirculation and allows quantitative assessment of nailfold capillaries with a grave reliability and gave reproducible results. This study found more quantitative alterations than previously reported. A combination of qualitative and quantitative measures can be used for JDM diagnosis, monitoring and response to treatment.
To our knowledge this study is the first in measuring quantitative, semi-quantitative and qualitative parameters of the microvasculature in juvenile dermatomyositis.
Disclosure of Interest
See text for description
Mean in n/mm and in μm (S.D)
P028 EMERGING UNIQUE IMMUNE SIGNATURES FOR THE IDIOPATHIC INFLAMMATORY MYOPATHIES: SIMILARITIES AND DIFFERENCES COMPARING ADULT AND JUVENILE DISEASE
Meredyth Wilkinson1,2, Anna Radziszewska2, Elizabeth Jury3, Jessica Manson4, David Isenberg3, Centre for adolescent rheumatology biobank
1IIR, Great Ormond Street Institute of Child Health; 2Centre for adolescent rheumatology, Division of Medicine; 3Rheumatolgy, Division of Medicine, UCL; 4Rheumatology, UCLH, London, UK
Correspondence: Meredyth Wilkinson
Introduction: The inflammatory idiopathic myopathies (IIM) are a rare group of myopathic autoimmune diseases diagnosed in both adults and children. Patients’ present with proximal muscle weakness with associated skin changes in dermatomyositis. Immunohistochemical analysis of muscle tissue from these patients has identified immune cell infiltrate and the expression of pro-inflammatory cytokines however, little is known about the peripheral immunological profile in juvenile and adult patient groups.
Objectives: To identify specific immune cell signatures and cytokine profiles for disease subtypes and correlate this data with measurements of disease activity.
Methods: 44 adult myositis (AM) patients, 15 Adolescent-onset juvenile dermatomyositis (JDM) patients, 25 age-matched adult healthy controls (AHC), and 15 age-matched teenage healthy controls (THC) were recruited with appropriate ethical approval after obtaining written informed consent. Peripheral blood mononuclear cells (PBMC) were isolated from patient and control samples. PBMC from all groups were analysed by flow cytometry to quantify 32 lymphocyte populations including; T-cell, B-cell and monocyte subsets. The AM patients were grouped according to myositis subtype; 19 dermatomyositis (DM), 9 polymyositis (PM), 7 DM + overlap, 4 DM + cancer and 5 PM + overlap). Disease activity was determined by MITAX score and clinicians’ decision on treatment; remission off treatment, remission/mildly active/active on treatment. Cell populations were analysed by group for differences in fold change/adjusted p value (1-way ANOVA with Tukey’s multiple comparison).
Results: There was an idenified T cell signature in ADM (increased Th17, Tregs and CD4+ naïve), a B cell signature in APM (CD27+/- B cell ratio) and a T cell signature in JDM (CD4/CD8+ T cell ratio). A decrease in CD8+ central memory T-cells was observed in both AM and JDM patients compared to healthy controls, this reduction was most significant in active disease. AM patients also had reduced CD27+ memory B-cells compared to both JDM patients and healthy controls. AM patients in remission off treatment had increased non-classical monocyte subset frequencies, whereas JDM patients off treatment had elevated CD8+ EMRA T-cells. Th17 cells were significantly increased in ADM compared to JDM samples (mean = 3.68 vs. 0.64, adjusted p value = 0.0032). More specifically increased Th17 cells were found in ADM but not APM (mean = 3.67 vs. 0.68, adjusted p value = 0.0019). However, the Th17 population was highest in AM patients that were in remission on treatment (remission on treatment vs AHC, mean = 2.68 vs. 0.84, adjusted p value = 0.038).
Conclusion: This group of diseases are notably heterogeneous both clinically and immunologically as shown by the complex immunophenotyping patterns identified within myositis subgroups. This study identified signatures unique to adult compared to juvenile disease, and between AM patients on treatment and during remission. The Th17 signature concurs with studies pinpointing these cells within the muscle tissue. This data supports the need for further investigation for the use of IL-17A inhibitors in the treatment of the IIM.
Disclosure of Interest
P029 VALIDATION OF THE EULAR/ACR CLASSIFICATION CRITERIA FOR JUVENILE IDIOPATHIC INFLAMMATORY MYOSITIS IN JAPAN
Kazuko Yamazaki1, Akiko Ohta2, Shinji Akioka3, Tomo Nozawa4, Asami Ohara4, Haruna Nakaseko5, Yuichi Yamasaki6, Norimoto Kobayashi7, Yutaka Nishida8, Satoshi Sato9, Shunichiro Takezaki10, Naomi Iwata5, Ichiro Kobayashi10, Masaaki Mori11
1Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe; 2Division of Public Health, Department of Social Medicine, Saitama Medical University Faculty of Medicine, Moroyama; 3Pediatrics, Kyoto Prefectural University of Medicine, Kyoto; 4Pediatrics, Yokohama City University School of Medicine, Yokohama; 5Infection and Immunology, Aichi Children’s Health and Medical Center, Ohfu; 6Pediatrics, Graduate School of Medical and Dental Sciences, Kagoshima University, Kagoshima; 7Pediatrics, Shinshu University School of Medicine, Matsumoto; 8Pediatrics, Gunma University Graduate School of medicine, Maebashi; 9 Infectious Diseases and Immunology, Saitama Children's Medical Center, Saitama; 10Pediatrics, Hokkaido University Graduate School of Medicine, Sapporo; 11Lifetime Clinical Immunology, Tokyo Medical and Dental University, Tokyo, Japan
Correspondence: Kazuko Yamazaki
Introduction: There are various diagnostic and classification criteria for myositis, but they are not always suitable for juvenile idiopathic inflammatory myositis (JIIM). To establish standard diagnostic criteria, the International Myositis Classification Criteria Project (IMCCP) published the EULAR/ACR classification criteria for idiopathic inflammatory myositis (IIM) in 2017.
Objectives: To evaluate the validity of the EULAR/ACR classification criteria with JIIM cases in Japan.
Methods: We used clinical and laboratory data from a group of JIIM patients and a comparator group comprised of non-JIIM patients with mimicking conditions collected at seven major pediatric rheumatology centers in Japan between 2008 and 2015. A diagnostic confirmation made at least 6 months prior to the study by a pediatric rheumatologist was used as the inclusion criterion for this study.
Results: The total of 117 patients (68 JIIM patients and 49 non-JIIM patients) were included to the study. For the validation analysis, we applied 55% probability cutoff, which corresponds to “probable IIM”, based on the IMCCP study. The IMCCP’s diagnostic standard gave us an almost equivalent sensitivity (86.7% without muscle biopsies; 92.1% with muscle biopsies) and a higher specificity (100% without/with muscle biopsies) compared to the data reported in the IMCCP study. We also confirmed an improved sensitivity with the EULAR/ACR classification criteria, compared to other traditional diagnostic criteria (e.g. 86.7 % with the EULAR/ACR criteria vs 80.9% with the Bohan and Peter criteria). In terms of the diagnostic accuracy, the agreement proportions between the classification subgroups of the EULAR/ACR criteria and the physician-diagnosed subgroups in our dataset were 100% for Juvenile amyopathic dermatomyositis (DM) and Juvenile hypomyopathic DM. The proportions were 93.2% for JDM and 43.2% for Juvenile polymyositis (JPM), for seven cases (3 JDM patients and 4 JPM patients) were not properly classified as JIIM.
Conclusion: Our validation study with Japanese JIIM cases indicates that the EULAR/ACR classification criteria for IIM generally perform better than existing diagnostic criteria for myositis in diagnosing JIIM.
Disclosure of Interest
P030 A CHILD WITH SEVERE NXP2-POSITIVE JUVENILE DERMATOMYOSITIS SUCCESSFULLY TREATED WITH RUXOLITINIB
Florence A. Aeschlimann1, Marie-Louise Fremond1,2, Darragh Duffy3, Gillian I. Rice4, Jean-Luc Charuel5, Vincent Bondet3, Benedicte Neven1, Christine Bodemer6, Laurent Balu7, Anne Hulin8, Cyril Gitiaux9, Yanick J. Crow2, Brigitte Bader-Meunier1,10
1Pediatric Immunology, Hematology and Rheumatology, Necker - APHP; 2Laboratory of Neurogenetics and Neuroinflammation, INSERM UMR 1163; 3Immunobiology of Dendritic Cells, Institut Pasteur, Paris, France; 4Division of Evolution and Genomic Sciences, Manchester Academic Health Science Centre, Manchester, UK; 5Laboratory of Immunology, La Pitié-Salpêtrière; 6Dermatology and Pediatric Dermatology, Necker - APHP, Paris; 7Pediatrics, CHU de La Réunion, Saint Denis; 8Pharmacology and toxicology laboratory, Mondor, Créteil; 9Pediatric Neurolophysiology and referral center for neuromuscular diseases, Necker - APHP; 10Laboratoty of Immunogenetics of paediatric autoimmune diseases, INSERM UMR 1163, Paris, France
Correspondence: Florence A. Aeschlimann
Introduction: Juvenile dermatomyositis (JDM) is a rare and heterogeneous inflammatory myopathy. Clinical features may be severe and disease course refractory to standard treatment with corticosteroids and methotrexate (MTX). Evidence for a critical role of the type I interferon (IFN) pathway in the pathophysiology of dermatomyositis exists in both childhood and adult forms of the disease.
Objectives: To report the first case of severe vasculopathic JDM successfully treated with the JAK 1/2 selective inhibitor ruxolitinib.
Methods: Retrospective chart review from initial presentation to last follow-up. We assessed type I IFN status by IFNα digital-ELISA quantification in serum, STAT1 phosphorylation and RNA expression of IFN-stimulated genes in whole blood.
Results: A previously healthy 13-year-old girl presented with cutaneous lesions and a severe proximal muscle weakness (Childhood Muscular Assessment Score, CMAS 2/52, and Manual Muscle Testing, MMT 38/80) characteristic of JDM. CK level was elevated and anti-NXP2 antibodies positive. Muscle biopsy revealed severe vasculopathic lesions. Despite treatment with prednisone (1.2mg/kg/day) and MTX, she developed tetraplegia, dysphonia, dysphagia, intestinal involvement, and new skin lesions. Treatment escalation with IVIG, plasma exchange (5/week), rituximab, and increased prednisone resulted in clinical improvement. Thus, plasma exchanges were subsequently spaced out and discontinued 6 months after diagnosis. However, three weeks later, recurrent muscle weakness necessitated the restart of plasma exchanges, increase of prednisone, a 4th dose of rituximab, and initiation of mycophenolate mofetil (MMF). While prednisone and the frequency of plasma exchanges were slowly tapered, she developed two further muscular, cutaneous and intestinal relapses, as well as a diffuse fascia calcinosis, at 12 and 18 months after diagnosis. High levels of IFNα protein in the serum (238, 75, and 46 fg/mL, normal < 10 fg/mL) and an increased expression of ISGs were documented. A constitutive phosphorylation of STAT1 and STAT3 was recorded in T lymphocytes and monocytes from the patient compared with controls. Considering these results, ruxolitinib was started (10mg x 2/day). Rituximab and MMF were discontinued. Within 2 months, CMAS and MMT scores increased from 47 to 52 and from 57 to 79, respectively. Plasma exchanges were discontinued and prednisone decreased. Eight months post initiation of ruxolitinib, JDM was clinically inactive according to the PRINTO criteria and prednisone was tapered (0.15mg/kg/day). Ruxolitinib was well tolerated. Serum levels of IFNα stabilized and STAT1 phosphorylation in monocytes was comparable to a control 4 hours after drug intake. Informed parental consent was obtained for the use of ruxolitinib on a compassionate basis and for conducting the experiments.
Conclusion: Efficacy of JAK1/2 inhibitors has previously been reported for severe dermatomyositis in adults and for certain monogenic interferonopathies in children. Our findings suggest that JAK inhibition may also represent an efficacious and well-tolerated therapeutic option in a subset of patients with recalcitrant JDM. Informed consent for publication had been obtained from the parents.
Disclosure of Interest
P031 UNDERSTANDING THE LIVED EXPERIENCE OF JUVENILE DERMATOMYOSITIS
Polly Livermore1,2, Suzy Gray3, Kathleen Mulligan4, Jennifer Stinson5, Lucy R. Wedderburn6, Faith Gibson7,8
1Institute of Child Health, University College London Great Ormond Street Institute of Child Health; 2Orchid, Nursing Research, Great Ormond Street Hospital for Children; 3Psychology/Rheumatology, Evelina Hospital; 4School of Health Sciences, City, University of London, London, UK; 5Chronic Pain, Hospital for Sick Children, Toronto, Canada; 6Rheumatology/NIHR GOSH Biomedical Research Centre, University College London Great Ormond Street Institute of Child Health, London; 7Nursing Research, University of Surrey, Surrey; 8Orchid, Nursing Research, Great Ormond Street Hospital for Children, London, London, UK
Correspondence: Polly Livermore
Introduction: Juvenile Dermatomyositis (JDM) is a rare, potentially life threatening condition. Beginning with mild fatigue and weakness, the condition can occur at any age, and currently there is no known cure. Some children and young people can experience fluctuations between remission and relapse throughout their childhood, into adolescence and beyond. There is very little evidence about the psychological impact this condition has on children and young people, and none that has asked them directly, however, through experience from clinical practice and conversations with those affected, we know the effects can be profound.
Objectives: The aim of this study was to identify the lived experience of children and young people between the ages of 8 and 19 years of age diagnosed with JDM. This study constitutes the first part of a larger mixed-methods study.
Methods: Ethical approval was gained to interview children and young people who were enrolled in a wider cohort study. Young people were interviewed either using creative arts based methods, such as drawing in a comic book and parallel discussion, or with a standard verbal interview. Young people were all asked: ‘what it is like to have JDM?’ Further questions were used to probe or to add clarity. Interviews took place when attending a specialist Rheumatology clinic or the inpatient Rheumatology Ward of a tertiary specialist Rheumatology Centre or during a specially arranged home visit.
Results: Fifteen young people offered to share their story, their demographics are shown in Table 1. The interviews lasted between 18 to 130 minutes and all, with permission, were audio recorded. They were transcribed verbatim and analysed using Interpretive Phenomenology.
The overarching metaphor of a ‘Rollercoaster’ was developed from the interview transcripts, to depict the ups and downs of having JDM. From initial difficulties with diagnosis by local health professionals of a rare disease to feeling comfort at getting a diagnosis, to the low of not being able to walk, to the relief when medications start to work and some improvement is felt. The ‘Rollercoaster’ metaphor is visual, easy to explain and understand, and will allow young people to feel some support from seeing the journey ahead.
Within this overarching construct, there are five themes which emerged from the data. These are: being-confused in the beginning; being-different; sick-steroidal-and-scared of the medicines; being-uncertain; and having-acceptance, as the JDM journey continues for many years.
Conclusion: This study is the first to ask children and young people what it is like to have JDM, and to recount the ‘ups and downs’ of their lives and describe the ways that JDM affects them. The results from this study will lead to a wider study asking young people all over the United Kingdom to share their story through surveys examining aspects which have been highlighted so far, this will lead into dissemination workshops to share the results found not only with children, young people and their families, but also with health professionals.
Disclosure of Interest
P. Livermore Grant / Research Support from: Doctoral Nursing Fellowship funded by NIHR HEE/CDRF, S. Gray: None Declared, K. Mulligan: None Declared, J. Stinson: None Declared, L. Wedderburn Grant/Research Support from: NIHR GOSH BRC & Arthritis Research UK, F. Gibson: None Declared
Demographics of the 15 young people interviewed
6 males, 9 females
12 White British, 3 other
Age at interview
8 – 18 years (median 12 years)
2 – 16 years (median 8 years)
3 weeks – 16 years (median 5 years)
From acute inpatients to remission off medicines
P032 DISTINCT CLINICAL FEATURES BETWEEN ADULT AND JUVENILE DERMATOMYOSITIS PATIENTS
A. T. Melo1,2, S. Sousa3, A. Cordeiro3, I. Cordeiro1,2, P. Costa-Reis4, F. Oliveira-Ramos1,2, J. E. Fonseca1,2, R. Campanilho-Marques1,2
1Unidade de Reumatologia Pediátrica, Serviço de Reumatologia e Doenças Ósseas Metabólicas, Hospital de Santa Maria, CHLN, Centro Académico de Medicina de Lisboa; 2Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisboa; 3Serviço de Reumatologia, Hospital Garcia de Orta, Almada; 4Serviço de Pediatria, Hospital de Santa Maria, CHLN, Lisboa, Portugal
Correspondence: A. T. Melo
Introduction: Adult and juvenile patients share several hallmark features of dermatomyositis (DM) but important clinical differences may reflect different disease triggers between children and adults.
Objectives: We aimed to compare the disease characteristics between children with juvenile dermatomyositis (JDM) and adults with DM and to explore the presence of nailfold capillaroscopy (NFC) changes abnormalities between the two populations.
Methods: Data were analyzed from children and adults who met Bohan-Peter criteria for DM. Childhood Myositis Assessment Scale (CMAS), Manual Muscle Testing (MMT8), muscle enzymes and physicians global assessment (PGA) were recorded at the time of last clinical appointment. Skin disease was assessed using modified skin disease activity score (DAS). By NFC was assessed nailfold capillary density, capillaries shape, presence of hemorrhage and neovascular pattern. Fisher's test was used to test differences between categorical variables and Mann-Whitney U test for continuous not-normally distributed variables.
Results: In total 23 patients were analyzed and compared (13 JDM and 10 adult DM). The female:male ratio was 9:4 in JDM and 9:1 in DM. The median age at disease onset was 5.6 years [2.7-10.1] for JDM and 50.6 years [43.3-60.4] for adult DM, the median disease duration was 8.4 years [4.4-15.38] for JDM and 2.3 years [1.2-12.5] for adult DM (p=0.1) and the median time of disease follow-up was 6.7 years [4.3-9.3] for JDM and 2.3 years [1.3-11.3] for adult DM. Table 1 reports the clinical characteristics for both groups. Adult DM had a significantly higher proportion of lung involvement and ANA positivity compared with JDM (p=0.002 and p=0.02, respectively). Dilated capillaries, giant capillaries, hemorrhage and neovascular pattern were found in 86%, 0%, 29% and 14% of JDM patients, respectively, and in 71%, 26%, 43% and 29% of adult patients, respectively, but with no statistically significant difference between children and adults. Clinically inactive disease was found in 38% and 10% of JDM and adult DM patients, respectively. All of those children have stopped medication. There was one case of malignancy in an adult DM patient.
Conclusion: Nailfold microvascular abnormalities were found in most of the NFC parameters, in JDM patients assessed for after a median of 8 years of disease, which might reflect the long-term microangiopathy associated with this disease. Regarding the studied clinical features, in our cohort, the adult DM patients have higher lung involvement when compared to JDM.
Disclosure of Interest
Clinical characteristics of children with JDM and adults with DM
Adult DM (=10)
MMT 80 median [IQR]
DAS skin median [IQR]
PGA median [IQR]
Presence of Calcinosis (%)
Interstitial lung disease (ILD) (%)
ANA positivity (%)
CK U/L median [IQR]
Monotherapy/ Biologic agents with other DMARDs
4 (31%)/3 (23%)
3 (30%)/1 (10%)
P033 JUVENILE DERMATOMYOSITIS: DESCRIPTION OF A COLOMBIAN COHORT
Angela C. Mosquera1, Clara Malagon1, Maria del Pilar Gomez2, Tatiana Gonzalez3, Ricardo Yepez2, Camilo Vargas4, on behalf of GRIP and Grupo de Reumatología e Inmunología Pediátrica (GRIP) Colombia
1Pediatric Rheumatology, UNIVERSIDAD EL BOSQUE, Bogota; 2Pediatric Rheumatology, Postgraduate of pediatrics, Libre University, Cali; 3Pediatric Rheumatology, Postgraduate of pediatrics, Cartagena University, Cartagena; 4Pediatric Rheumatology, Postgraduate of pediatrics, Del Valle University, Cali, Colombia
Correspondence: Angela C. Mosquera
Introduction: Idiopathic myopathies are heterogeneous disorders characterized by muscle weakness and inflammation. Dermatomyositis is the most frecuent subgroup in pediatrics. Juvenile Dermatomyositis (JDM) in addition to muscle involvement is characterized by typical skin rashes (Gottron´s sign and heliotrope rash). Recently, a new proposal of diagnostic criteria was presented but patients at debut may had a great variety of manifestations due to the multisystemic nature of this condition. Close to the diagnosis and in the long term, a great variety of complications can occur and affect the survival and the quality of life of patients
Objectives: To descrive debut and course of a group of Colombian patients with Juvenile dermatomyositis
Methods: Multi-center, retrospective, descriptive, case series study. The review of medical records with a unique format was carried out in Bogotá, Cali, Cartagena and Barranquilla. The data analysis was performed with SPSS 20
Results: N = 94 patients. 67% female with an average age at diagnosis of 7,78 years (range of 1-18 years) and follow-up time of 46 months (SD 39 months). The average time between the onset of symptoms and the definitive diagnosis was 7,6 weeks (1-60). In 37% of patients, skin manifestations preceded muscle involvement and was moderate-severe in 67%. Clinical manifestationts at debut: 88% heliotrope rash, 90% Gottron´s sing, malar erythema 78%, periungueal erythema 67%, skin ulcers 25%, 37% arthritis (31% polyarticular), pulmonary compromise 4%, vasculitis 14% fever 19% and 25% calcinosis (22% mild-moderate). Seventy five percent of patients had CPK < 5000 at debut and 49% had positive antinuclear antibodies. Monocyclic course in 53% of patients. During the follow-up 33% presented calcinosis, 44% muscular atrophy, 52% persistent muscular weakness, 14% osteoporosis and 14% short stature. 99% of patients received steroid at debut (44% intravenous) and 86% during follow-up. 97% received methotrexate and 13% required a biological medication (92% Rituximab). 70% of the patients were classified by the treating rheumatologist as adherent to the treatment and 14% of patients had associated other autoimmune diseases. Patients with mild skin involvement at debut had a higher frequency of monocyclic course (p 0,009)
Conclusion: The skin involvement can be the initial manifestation in an important percentage of patients with JDM. The severity of skin involvement can be variable and related to the type of course. JDM requires an intensive, dynamic and monitored management that allows a rapid control of the disease, monitor the appearance of short and long term complications and the association with other autoimmune diseases
Disclosure of Interest
P034 POST-STREPTOCOCCAL POLYMYALGIA (3 CASES): PROPOSED COIMBRA CRITERIA
João Nascimento1, Paula Estanqueiro1, Teresa S. Simão2, Manuel Salgado1
1Pediatric Rheumatology Unit, Hospital Pediátrico Coimbra - CHUC, Coimbra; 2Pediatrics, Hospital da Senhora da Oliveira, Guimarães, Portugal
Correspondence: João Nascimento
Introduction: Post-streptococcal syndrome consists of a wide spectrum of non-suppurative disorders: erythema nodosum, uveitis and/or scleritis, post-streptococcal glomerulonephritis, periostitis, vasculitis, rheumatic fever and post-streptococcal reactive arthritis. It can also include an entity with myalgia as the solitary presenting symptom called post-streptococcal polymyalgia (PSPM).
Objectives: To alert to clinical features of PSPM and present Coimbra classification criteria.
Methods: Retrospective study. Selection of the patients with post-streptococcal reactive polymyalgia followed in Coimbra’s pediatric rheumatology department in the last 30 years.
Patients were included based on the following criteria (all):
1) Diffuse myalgia – acute onset, incapacitating and severe pain;
2) Palpation induced muscle pain;
3) Normal serum creatine kinase (CK);
4) Supporting evidence of a recent preceding streptococcal infection (elevated streptococcal antibodies, or (+) cultures or rapid antigen tests for streptococcus groups;
5) No Exclusion criteria: a) > 1. major manifestations of the revised Jones criteria for rheumatic fever (2015); b) periostitis.
Results: The unit followed 119 children with poststreptococcal reactive musculoskeletal symptoms: 61 rheumatic fever, 55 poststreptococcal reactive arthritis and 3 had only diffuse myalgia - acute onset, incapacitating and severe pain (one girl and two boys).
The mean age at diagnosis was 5,7 years. Tonsillitis was the previous streptococcal infection in all patients (one scarlet fever). The time span between the infection and myalgia presentation had a variation between 25 and 30 days. The longest myalgia duration was nine weeks and the shortest was one week and four days. Lower limbs were involved in all patients and upper limbs in two. Arthralgia without arthritis was present in two patients. At diagnosis visual analog score (VAS) of muscle pain was ≥ 80 mm and all patients had elevation of inflammatory markers (erythrocyte sedimentation rate between 86 and 102mm/h and C-reative protein between 4,9 and 6 mg/dl) and normal creatine kinase (CK) values. The antistreptolysin O titre (ASLO) performed in all patients were strongly positive (≥ 800 U/l and ≤ 1820 U/I) and echocardiography was normal. Two patients had full recovery with NSAIDs but one refractory patient also needed prednisolone (1mg/kg) during four weeks.
Conclusion: Severe diffuse pain and tenderness of skeletal muscles without accompanying arthritis is an under-recognized feature of post-streptococcal disease. High ASLO titre with normal CPK in a child with myalgia should alert PSPM diagnosis. We propose the Coimbra diagnostic criteria for PSPM.
1. Jansen TL, Janssen M, Macfarlane JD, de Jong AJ. Poststreptococcal reactive myalgia: a novel syndrome secondary to infection with group A or G streptococci. Br J Rheumatol. 1998;37:1343–8
2. Subramanian S, Carty JE, Gaywood I. A rare case of recurrent poststreptococcal myalgia. Rheumatology. 2002;41:827–8
3. Arun Babu T, Venkatesh C. Post Streptococcal Myalgia: An Under-recognized Clinical Syndrome. Indian J Pediatr. 2012; 79(3):383–385
Disclosure of Interest
P035 EFFECTIVENESS OF ULTRASONOGRAPHY FOR MYOSITIS SCREENING IN CLINICALLY AMYOPATHIC JUVENILE DERMATOMYOSITIS: A CASE SERIES
Kazutaka Ouchi1,2, Shinji Akioka1, Hiroshi Kubo1, Norio Nakagawa1, Hajime Hosoi1
1Pediatrics, Kyoto Prefectural University of Medicine, Kyoto; 2Pediatrics, Ayabe city hospital, Ayabe, Japan
Correspondence: Kazutaka Ouchi
Introduction: Juvenile dermatomyositis (JDM) is a systemic autoimmune capillary vasculopathy that predominantly affects the muscles and cutaneous tissues. In JDM cases, myosonography can reportedly be used to evaluate disease activity and perform follow-up monitoring. However, the effectiveness of myosonography in clinically amyopathic JDM (CA-JDM) is undetermined.
Objectives: To investigate the myosonographic findings in patients with CA-JDM.
Methods: Myosonography was performed in three patients with CA-JDM. Case 1 was a 2-year-old male with full range of motion in manual muscle testing (MMT), positive anti-TIF-1γ antibody results, and superficial perivascular dermatitis; case 2 was a 4-year-old male with full range of motion in MMT, negative myositis-specific autoantibody results, and superficial perivascular dermatitis; case 3 was a 14-year-old female with full range of motion in MMT, positive anti-MDA5 antibody results, interstitial pneumonia, and superficial perivascular dermatitis. Case 3 had minimal evidence of myositis on MRI and in a biopsied specimen. Laboratory testing revealed normal creatinine kinase concentration in all three cases. The ultrasonographic assessment was performed in the bilateral biceps brachii and quadriceps femores.
Results: In case 1, the right biceps and quadriceps had increased echo intensity compared with the left side, and the power Doppler signal was positive on the perimysium in the left biceps and quadriceps. In case 2, the echo intensity was increased in the bilateral biceps and quadriceps, and there was a positive power Doppler signal on the perimysium in all muscles. In case 3, there was a high echo intensity and positive power Doppler signal on the perimysium in the left quadriceps, and there was a suspected positive power Doppler signal on the epimysium in the left quadriceps.
Conclusion: Myosonography detected muscle abnormalities in CA-JDM. Myosonography may be effective for JDM screening in patients with no clinical muscular abnormalities who are suspected of having JDM due to skin characteristics. Informed consent to publish had been obtained from the parents.
Disclosure of Interest
P036 EARLY FEATURES OF KAWASAKI DISEASE WITH PYURIA IN FEBRILE INFANTS YOUNGER THAN 6 MONTHS
Jong Gyun Ahn1, Young Dae Kim2, Kwang Nam Kim3
1Department of Pediatrics, Severance Children's Hospital, Yonsei University College of Medicine, Seoul; 2Department of Pediatrics, Ilsan Paik Hospital, Inje University College of Medicine, Goyang; 3Department of Pediatrics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea, Republic Of
Correspondence: Jong Gyun Ahn
Introduction: Children with Kawasaki disease (KD) and pyuria have been misdiagnosed with urinary tract infection (UTI).
Objectives: We compared clinical and laboratory features at admission between two groups of infants under 6 months of age, who showed initial pyuria, to find useful clinical clues to the initial suspicion of KD.
Methods: We reviewed the medical records of febrile infants under 6 months of age with pyuria over a 10-year period (2007-2017). We included infants with sterile pyuria who were finally diagnosed with KD and those with UTI.
Results: During the 10-year study period, a total of 121 patients under aged 6 months were diagnosed as KD. 41 (33.9%) of the 121 KD children had pyuria. Of the 41 pyuria patients, 12 had sterile pyuria, 7 had concomitant UTI, and 16 had combined bacterial growth which had to be excluded. The other 6 patients were unidentified because they did not perform the urine culture tests. Two patients satisfied the diagnostic criteria of complete Kawasaki disease, whereas the others were diagnosed with incomplete Kawasaki disease.
During the same period, 378 infants under 6 months of age were diagnosed with UTI. We compared the clinical and laboratory features between the 12 KD infants with sterile pyuria and the 378 UTI infants. The median age of the KD group (5.2 months; range,2.5-5.9 months) was higher than that of the UTI group (3.6 months; range 0.9-6 months) (P =.002). The male/female ratios in the KD and UTI infants were 1.4 (7/5), and 2.8 (277/101), respectively.
The days of fever before admission and total duration of fever were longer in the KD group than in the UTI group (P < 0.01). Compared with the UTI group, the KD group demonstrated a significantly higher platelet count (P = .04), level of C-reactive protein (CRP) (P < 0.01) and erythrocyte sedimentation rate (ESR) (P < 0.01). UTI group showed higher presence of positive urine nitrite test (P < 0.01). No significant differences were evident in blood leukocyte count, absolute neutrophil count, haemoglobin, alanine transaminase, aspartate aminotransferase, albumin, sodium, total bilirubin and urine β2-microglobulin (β2-MG)
Conclusion: Our study can provide early clues to suspect KD in febrile infants with pyuria.
Disclosure of Interest
P037 ACUTE PANCREATITIS ASSOCIATED WITH TWO COMMON CHILDHOOD VASCULITIS: KAWASAKI DISEASE AND HENOCH-SCHÖNLEIN PURPURA
Nuray Aktay Ayaz, Gul Karadag, Ayse Zopcuk
Pediatric Rheumatology, Saglik Bilimleri University KSSEAH, Istanbul, Turkey
Correspondence: Nuray Aktay Ayaz
Introduction: Henoch Schönlein purpura (HSP) and Kawasaki disease (KD) are the most common childhood vasculitis. Rare conditions like pancreatitis, aseptic menengitis, pneumonia do not belong to the classical criteria of KD and defined as atypical KD. Similarly gastrointestinal involvement are excepted features of HSP. Few cases of HSP and KD related pancreatitis have been reported. Herein, we report two acute pancreatitis cases associated with KD and HSP.
Objectives: A 10-year-old boy consulted with a 6-days history of fever, abdominal pain, vomiting and a scarlatiniform rash. Initial blood tests showed Hb 9.7 g/dl, WBC 14.2 × 10 9/L, platalet count 442 ×10 9/L, C-reactive protein 68.8 mg/L, erythrocyte sedimentation rate 65 mm/hr, albumine: 2.8 g/dL, increased amylase of 639 U/L and lipase 2056 U/L. In echocardiographic examination myocarditis was seen and pro-BNP level was 11418 pg/ml. Intravenous immünoglobulin (IVIG) at a dose of 2 g/kg and aspirin 40 mg/kg/day was given with a preliminary diagnosis of atypical Kawasaki disease. The patient became afebrile 24 hours later. In the second week of the disease thrombocytosis (platelet count, 780 ×10 9/L) and periungual desquamation of his fingers and toes were observed. Coronary arteries were normal and cardiac contractions were good in echocardiography. His pancreatitis had resolved with a normal amylase of 97 U/L and lipase of 29 U/L within two weeeks.
Methods: A 6-year-old girl was referred with a 4-days history of vomiting and abdominal pain. Her physicial examination was normal except abdominal tenderness. Initial investigations showed Hb 14.4 g/dl, WBC 41.8 × 10 9/L, platalet count 443 ×10 9/L, C-reactive protein 50.6 mg/L, erythrocyte sedimentation rate 1mm/hr, albumin: 1.9 g/dL. In abdominal ultrasonograpy hydrops of gallbaldder was detected. Few days later purpuric rash on her legs was observed. She was diagnosed as HSP and prednisolone at a dose of 2 mg/kg/day was given to her. Despite steroid treatment, back and chest pain added to abdominal pain. Increased amylase of 344 U/L and lipase 294 U/L levels were detected at the seventh day of disease, but ultrasonographic pancreatitis was not observed. In addition to fat free diet intravenous fluids and pulse steroid treatment (30 mg/kg, for 3 days) was given. In the second week of the disease proteinüria was detected in 24 hour urine testing, and mesengioproliferative glomerulonephritis was diagnosed in renal biopsy. Pulse cyclophosphamide treatment was started her for HSP nephritis. Her pancreatitis resolved within a month
Results: HSP and KD are most common types of vasculitis in children. But, HSP and KD associated pancreatitis is uncommon. There are autopsy studies about KD associated pancreatitis. The association between pancreatitis and HSP is rare.
Conclusion: In conclusion HSP and KD related pancreatitis is rare. HSP-related pancreatitis should be considered when abdominal pain is prolonged and present with changing character of pain. KD should be considered in the presence of acute pancreatitis and prolonged fever even the patient does not meet all the criteria. Informed consent to publish had been obtained.
Disclosure of Interest
P038 CAN WE PREDICT THE COURSE OF KAWASAKI DISEASE: A SINGLE CENTER SERIES FROM THE EASTERN MEDITERRANEAN
Elif Arslanoglu Aydin1, Erdal Sag2, Selcan Demir2, Hafize E. Sönmez2, Ezgi D. Batu2, Yelda Bilginer2, Seza Ozen2
1Department of Pediatrics; 2Division of Pediatric Rheumatology, Department of Pediatrics, Hacettepe University, Ankara, Turkey
Correspondence: Elif Arslanoglu Aydin
Introduction: Kawasaki disease (KD) is one of the most common vasculitis of childhood. Coronary artery involvement is the most important complication of the disease and the major cause of the mortality. IVIG resistance is defined as persisting or recurring fever at least 36 hours after the end of intravenous infusion of immunoglobulin (IVIG). Although there are some scoring systems trying to predict, it is not always possible to forsee the IVIG resistance and coronary artery involvement.
Objectives: The aim of this study is to assess the success of the Kobayashi scores and other parameters in predicting IVIG resistance and coronary artery involvement in Turkish population.
Methods: Patients who were diagnosed in the acute phase of Kawasaki disease at Hacettepe University Faculty of Medicine (Ankara,Turkey) between June 2007- January 2016 were retrospectively and January 2016- February 2018 were prospectively reviewed and included in this study. Clinical findings, laboratory parameters, echocardiographic findings, response to IVIG treatment, Kobayashi, Egami, Formosa, Harada scores were evaluated. The diagnosis of Kawasaki disease was made using the criteria of the American Heart Association.
Results: A total of 100 patients with Kawasaki disease were included in this study. Of the patients with KD, 61 (61 %) were male and 39 (39%) were female. The mean age at diagnosis of Kawasaki disease was 48.9 ± 34.9 months, with an age range of 4–164 months. All of the patients had fever while, 77 (77%) of them had conjunctival congestion, 74 (74%) of them had mucosal, 72 (72%) of them had rash, 69 (69%) of them had lymphadenopathy and 68 (68%) of them had extremity changes. Fifty two (52%) patients had complete KD and 48 (48%) patients had incomplete KD.
Patients younger than 1 year (p<0,001) were found to be associated with a significantly higher risk for coronary artery involvement. No significant differences were found between the IVIG-resistant and IVIG-responsive groups in terms of age (p:0.215).
Significant differences were found between the coronary artery lesions (CAL) and non-CAL groups in terms of age, white blood cell and erythrocyte sedimentation rate.
Compared with the IVIG-responsive group, the IVIG-resistant group had higher C-reactive protein (CRP) and gamma glutamyl transferase (GGT) levels.
Of the 100 patients who were administered IVIG, 85 (85%) responded to IVIG treatment, whereas 15 (15%) were IVIG resistant. Coronary artery involvement was detected in echocardiography at diagnosis in 38 patients. Twenty patients had Kobayashi high-risk scores, 9 patients had Egami high risk scores. The Formosa score assigned 45 patients as high-risk. The Harada score assigned 54 patients as high-risk. Only the Egami score predicted IVIG resistance in the Turkish population, none predicted coronary artery involvement.
Conclusion: Studies from different countries revealed that the risk scores were incapable of defining the IVIG resistance in KD. This may be atributed to ethnic differences. The Kobayashi score, Harada score, Formosa score in Turkish population did not predict the IVIG resistance and coronary artery involvement, but high white blood cell count, high erythrocyte sedimentation rate and age ≤1 were associated with coronary artery involvement; high CRP, high GGT, and Egami score are associated with IVIG Resistance in Turkish population.
Disclosure of Interest
P039 EOSINOPHILIC GRANULOMATOSIS WITH POLYANGIITIS-A CLINICAL CASE
Ana Barbosa Rodrigues1, Filipa Oliveira Ramos2,3, Patrícia Costa Reis1,3
1Pediatrics Department, Hospital de Santa Maria, Centro Académico de Medicina de Lisboa; 2Pediatric Rheumatology Unit, Rheumatology Department, Centro Académico de Medicina de Lisboa Hospital de Santa Maria; 3Unidade de Investigação em Reumatologia, Instituto de Medicina Molecular, Faculdade de Medicina, Universidade de Lisboa, Centro Académico de Medicina de Lisboa, Lisbon, Portugal
Correspondence: Ana Barbosa Rodrigues
Introduction: Eosinophilic granulomatosis with polyangiitis (EGPA) is a rare small and medium-sized-vessel vasculitis characterized by the presence of vasculitis manifestations and eosinophilia in a previously asthmatic patient.
Objectives: Increase awareness for the diagnosis of EGPA and discuss possible treatment strategies.
Methods: Description of a patient with EGPA.
Results: 13-year-old male with allergic rhinitis, asthma and history of dust mite allergy, under therapy with montelukast and inhaled and nasal corticosteroid, with multiple episodes of wheezing and shortness of breath in the last year. The patient presented to the emergency department after seven days of arthralgias, myalgias and asthenia and two days of fever. On physical exam a diffuse petechial rash with hemorrhagic suffusions was detected. Blood tests revealed hemoglobin 15.9g/dL, leukocytes 34990/μL, neutrophils 27.4%, eosinophils 63.2%(23160/μL), platelets 202000/μL, C-reactive protein (CRP) 10.56mg/dL, ALT 129UI/L, AST 92UI/L, LDH 529UI/L and CK 515UI/L. Ceftriaxone and doxycycline were started and the patient was admitted to the hospital. Blood cultures were negative, as well as the aspergillus galactomannanantigen and serologies for Rickettsia conori, erlichia, brucella, leptospira, cytomegalovirus, Ebstein Barr virus, parvovirus, adenovirus, cocsakie and echovírus. Within 72 hours a deterioration of the clinical status was observed. The patient had dyspnea, chest pain, signs of respiratory distress, hypoxemia, tachycardia, hipotension and olyguria. It was detected leukocytosis 48390/μL, eosinophilia 30000/μL and elevated CRP 16.5mg/dL, CK 962 mg/dL, troponin 1686ng/L and NT-proNBP 14800pg/mL. Tryptase was normal (3.9mcg/L). Bilateral pulmonary insterstitial infiltrates with bilateral pleural effusion were identifed on chest x-ray and ECG and echocardiogram were suggestive of myopericarditis. The patient was admitted to the pediatric intensive care unit. Antibiotherapy was switched to vancomicin plus meropenem and anti-inflammatory drugs, furosemide, espironolactone and immunoglobulin were started. Due to hemodinamic instability, mechanic ventilation and aminergic support were needed. Further exams were performed: bronchoalveolar lavage was negative for bacteria and fungi; myelogram showed hypercellular medulla with increased non-clonal eosinophils (41%); skin biopsy revelead leukocytoclastic vasculitis with eosinophils and direct immunofluorescence compatible with vasculitis. Anti-myeloperoxidase (MPO) antineutrophil cytoplasm antibodies (ANCA) were negative. The genetic analysis for hypereosinophilia syndrome mutations was negative. The pediatric rheumatology team was called to observe the patient and, according to the clinical presentation and laboratory results, the diagnosis of EGPA was made. The patient was started on methylprednisolone i.v. 1 g per day for three days. A fast clinical, laboratory and radiological improvement occurred, including complete regression of eosinophilia. Currently, more than six months after this episode, the patient is followed at the pediatric rheumatology outpatient clinic and there are no signs of disease activity under therapy with azathioprine (2mg/kg) and prednisolone in progressively lower doses.
Conclusion: We present a patient with EGPA, fulfilling 5 of 6 criteria (asthma, eosinophilia exceeding 10% of the total white blood cell count, history of allergy, pulmonary infiltrates, extravascular eosinophils), associated with musculoskeletal and cardiac abnormalities and negative anti-MPO ANCA. In conclusion, EGPA is a potentially life-threatening condition, clinical suspicion and early treatment of these patients are thereby crucial.
For this case submission written informed consent was obtained from the patient and family.
Disclosure of Interest
P040 HENOCH-SCHÖNLEIN PURPURA NEPHRITIS IN CROATIAN CHILDREN: A RETROSPECTIVE STUDY IN FIVE TERTIARY CARE CENTERS
Mateja Batnozic Varga1, Nastasia Cekada2, Mario Sestan2, Sasa Srsen3, Lucija Ruzman4, Maja Zaninovic4, Aleksandar Ovuka4, Ivana Ozdanovac1, Marija Pecnjak5, Domagoj Kifer6, Marijan Frkovic2, Alenka Gagro7, Marija Jelusic2
1Department of Paediatrics, University Hospital Centre Osijek, Osijek; 2Department of Paediatrics, University Hospital Centre Zagreb, University of Zagreb, School of Medicine, Zagreb; 3Department of Paediatrics, University Hospital Centre Split, Split; 4Department of Paediatrics, University Hospital Centre Rijeka, Rijeka; 5Department of Paediatrics, University Hospital Centre Zagreb; 6Faculty of Pharmacy and Biochemistry, University of Zagreb; 7Children's Hospital Zagreb, Zagreb, Croatia
Correspondence: Mateja Batnozic Varga
Introduction: Henoch-Schönlein purpura nephritis (HSPN) is the most severe complication of Henoch-Schönlein purpura (HSP) that can occur at any time of the disease process and includes isolated microscopic or macroscopic hematuria, mild or heavy proteinuria with or without nephrotic syndrome, renal failure and hypertension.
Objectives: To determine a possible prognostic factor for earlier HSPN onset, to explore indications for kidney biopsy according to urine analysis and the correlation between 24-h urinary protein levels and biopsy findings, as well as biopsy findings and patient outcome.
Methods: The cross-sectional study included all children with HSPN diagnosed by EULAR/PRES/PRINTO criteria from 2009 to 2017 at 5 tertiary care centres in Croatia.
Results: Out of 540 patients diagnosed with HSP, 91 children who developed HSPN (16.85%) were included. The patient population with HSPN included 52 boys (57.14%) and 39 girls (42.86%). Median (range) age of HSP diagnosis was 8 years (1.5-17.5) and from the HSP diagnosis to HSPN onset was 1.5 (0-60) months. Median (range) follow-up time was 44 (4-167) months. Nephritis was present in 18.68% of cases at the HSP onset. No statistically significant difference or correlation was found between the time of HSP diagnosis to HSPN onset and gender, age, purpura distribution, joint and gastrointestinal involvement. Kidney biopsy was done in 26 patients (28.57%). Among them, 3 patients had isolated persistent hematuria, 3 had isolated proteinuria and 20 patients had both hematuria and proteinuria. Median (range) 24-h urinary protein levels in patients who underwent biopsy was 1.28 (0-7.46) g/dU. The leading indication for biopsy was simultaneous hematuria and proteinuria (p<0.001), while isolated proteinuria was not a determining factor (p=0.592). Isolated hematuria was a statistically significant factor in detecting patients who were not likely to have a biopsy (p<0.001). Biopsy findings were graded with different classifications: 7 with Oxford classification, 6 with Haas, 1 with ISKDC, while 4 were classified simultaneously with Oxford and ISKDC. Only descriptive findings were available for 8 biopsy specimens. No statistically significant difference was found in 24-h urinary protein levels between different biopsy findings. 68% of HSPN patients were treated with corticosteroids out of which 17.6% patients took immunosuppressive or/and antihypertensive drugs in addition to corticosteroids. Most patients had good outcome, with normal physical exam findings and no signs of renal disease in laboratory tests (78%), or with microhematuria and proteinuria <1g/dU (17.6%), while only 4 patients (4.4%) had a more severe outcome with proteinuria >1g/dU. No significant difference was found in patient outcome for different biopsy findings (p=0.214).
Conclusion: Simultaneous hematuria and proteinuria was a statistically significant factor for kidney biopsy. However, while isolated proteinuria was not the sole determining factor, excessive levels of 24-h urinary proteins should be taken in consideration. Due to the small number of patients and no uniform classification generally used in grading biopsy findings, a statistically significant difference in regard to outcome could not be confirmed, indicating the need for both in future research.
Disclosure of Interest
P041 POLYARTERITIS NODOSA: OVER 20 YEARS’ EXPERIENCE.
Hafize E. Sönmez1, Ezgi D. Batu1, Gizem Ayan2, Kenan Kenan Barut3, Berkan Armağan4, Abdulsamet Erden4, Serdal Uğurlu5, Yelda Bilginer1, Özgür Kasapçopu6, Ömer Karadağ4, Sule A. Bilgen4, Huri Özdoğan5, Seza Özen4
1Department of Peditarics, Division of Rheumatology, Hacettepe University Faculty of Medicine, Ankara; 2Department of Internal Medicine, Cerrahpasa Medical School, Istanbul University, İstanbul; 3Department of Peditarics, Division of Rheumatology, Cerrahpasa Medical School, Istanbul University; 4Hacettepe University Vasculitis Centre, Ankara; 5Division of Rheumatology, Department of Internal Medicine; 6Department of Peditarics, Division of Rheumatology, Cerrahpasa Medical School, Istanbul University, İstanbul, Turkey
Correspondence: Ezgi D. Batu
Introduction: Polyarteritis nodosa (PAN) is a necrotizing vasculitis of predominantly medium size vessels.
Objectives: The present study aimed to summarize the characteristics of PAN patients, and also analyse the trend of decreasing PAN frequency in the last 25 years, in Turkey.
Methods: Paediatric and adult PAN patients followed up in Hacettepe University and Istanbul University Cerrahpasa Faculty of Medicine between 1990 and 2015, were included. The demographics, clinical findings and outcomes were evaluated retrospectively.
Results: One hundred thirty-three patients, including 66 children, were enrolled in the study. The median (minimum-maximum) age at symptom onset and diagnosis were 16 (2-75) years and 17 (3-75) years, respectively. The mean follow-up duration was 13 (2-27) years. Among 133 patients, 86 (64.7%) had fever, 108 (81.2%) had skin involvement, 54 (40.6%) had renal involvement, 43 (32.3%) had neurological involvement, 32 (24.1%) had gastrointestinal involvement, 10 (7.5%) had cardiac involvement, 6 (4.5%) had pulmonary involvement. The median (minimum-maximum) leukocyte count, erythrocyte sedimentation rate and C-reactive protein levels at the time of diagnosis were 10400 (6100-32000)/mm3, 58 (2-132) mm/h and 5.22 (0-46) mg/dL, respectively. All patients were ANCA negative. Hepatitis serology was analyzed in 121 patients and found positive in 13 of them. MEFV mutations were screened among 65 patients, 24 of them had mutations in at least one allele. Biopsy was performed in 109 patients and computerized tomography (CT) angiography was performed in 92 patients. Myalgia and skin involvement were significantly more frequent in children whereas neurologic involvement was much more common among adults (Table 1). The number of PAN patients declined significantly after 2010. 9 patients were re-categorized as DADA2 after 2014 and no patient were diagnosed with FMF+PAN after 2008.
Conclusion: Our results suggest a decrease in PAN in our country which may be due to improved healthcare and dissecting mimicking diseases. Further prospective studies with prolonged follow-up could help us to better understand the disease characteristics.
Trial registration identifying number:
Disclosure of Interest
Characteristics of paediatric and adult PAN patients
Features, n (%)
Paediatric patients (n=66)
Adult patients (n=67)
P042 GENERATION OF ADA2 GENETIC KNOCKOUT IN A MYELOID CELL LINE USING CRISPR/CAS9 GENOME EDITING: AN IN VITRO CELL LINE MODEL TO STUDY GENE THERAPY FOR DADA2.
Marina S. Casimir, Ying Hong, Paul Brogan, Despina Eleftheriou
Infection, Inflammation and Rheumatology, UCL Great Ormond Street Institute of Child Health, London, UK
Correspondence: Marina S. Casimir
Introduction: Deficiency of adenosine deaminase type 2 (DADA2) is an autosomal recessive genetic disease causing systemic inflammation and vasculitis resembling polyarteritis nodosa, caused by loss of function mutations in the ADA2 gene. Treatment of DADA2 with biologic agents targeting TNF-alpha is particularly effective, but has side effects, is expensive and is required to be given by injection for life. We are curently exploring an alternative treatment strategy for DADA2 using gene therapy. Since there is no rodent orthologue of ADA2 an important first objective for this programme of work was to develop a cell line model to explore if it is possible to correct in vitro the defects associated with DADA2 using gene transfer strategies.
Objectives: To develop an ADA2 knockout (KO) monocyte cell line (THP-1) derived using Clustered Regularly-Interspersed Small Palindromic Repeats (CRISPR)/CAS9 and to confirm that this KO has comparable immunophenotype to macrophages from DADA2 patients as indicated by reduced ADA2 expression and M1/M2 skewing and pro-inflammatory cytokine production.
Methods: A plasmid delivered CRISPR/CAS9 system was used to generate the ADA2 KO THP-1 cell line. ADA2 enzyme activity was assessed using a modified commercially available assay and ADA2 protein expression using immunoblotting. THP-1 cells were treated with PMA to induce differentiation into macrophages before polarisation into M1 through LPS/INF-γ stimulation; and M2 polarisation through IL-4, IL-10 and Il-13 stimulation. Immunophenotyping was assessed using qPCR.
Results: We first confirmed effective knockout of ADA2 at both genetic sequencing and protein expression level. We further established reduction of ADA2 enzyme activity by almost 50% in culture supernatants when compared to scramble control THP-1 cells (p<0.01). There was significant upregulated gene expression for several proinflammatory molecules: TNF-α (p<0.001), CXCL-10 (p<0.001), STAT-1 (p<0.01), CCL2 (p=0.05) and IL-1β (p<0.001) in M1 polarised ADA2 KO THP-1 cells when compared to control THP-1 cells. M2 polarisation of ADA2 KO THP-1 cells did not affect expression of CD200R and CD206 compared to control cells.
Conclusion: We have successfully generated an ADA2 genetic KO myeloid cell line using the CRISPR/Cas9 system. We confirmed that ADA2 KO THP-1 cells have a comparable immunophenotype to macrophages from DADA2 patients and exhibit reduced ADA2 enzyme activity. This in vitro cell line model can now be used to examine the possibility of reversing the defects associated with DADA2 using gene editing strategies.
Disclosure of Interest
P043 KAWASAKI DISEASE IN INTENSIVE CARE UNIT: ARE COMPLETE AND INCOMPLETE FORMS DIFFERENT?
Helene Yager1, Fleur Le Bourgeois2, Blandine Vanel3, Isabelle Kone-Paut1, Maryam Piram1, Bilade Cherqaoui1
1Pediatric Rheumatology, CHU Bicetre - APHP, CEREMAIA, LE KREMLIN BICETRE; 2Pediatric Intensive care unit, CHU Robert Debré - APHP, Paris; 3Pediatric Intensive care unit, HFME - HCL, Lyon, France
Correspondence: Bilade Cherqaoui
Introduction: Kawasaki disease (KD) is an acute vasculitis occurring mainly in children under 5 years of age. The central issue is the prevention of cardiac damage that may occur early and be life-threatening, requiring admission in intensive care unit (ICU). At admission in ICU, clinical features of KD may be incomplete or atypical; especially difficult to distinguish from a severe sepsis. In this context, the criteria defined by the American Heart Association (AHA) are not always conclusive to guide the management in acute phase, including initiation of appropriate treatment, such as intravenous immunoglobulin (IVIG).
Objectives: The aim was to compare phenotype and evolution of KD hospitalized in ICU (KD-ICU) with complete AHA criteria (cKD-ICU) or incomplete criteria (iKD-ICU).
Methods: Complete criteria of KD were defined as: ≥5 days of fever and ≥4 main clinical items. Incomplete criteria were defined as: ≥5 days of fever and ≥2 main clinical items (or ≥7 days of unexplained fever) and inflammatory syndrome with either ≥3 evocative biological abnormalities or coronary dilatation. All patients had to be hospitalized in ICU. We collected retrospectively KD-ICU cases between 2001 and 2018, from a national appeal of French medical societies (SOFREMIP, GRFUP). Data regarding clinical, biological, ultrasound and therapeutic features were recorded. Statistics were performed with Fischer test (PRISM 5.0); averages were compared with significance defined as p <0.05 (MedCalc).
Results: 25 patients met the criteria of cKD-ICU, 23 patients met the criteria of iKD-ICU. Patients were hospitalized in ICU for: shock (37.5%), unstable hemodynamics (16.7%), acute neurological disorder (10.4%), myocarditis (8.3%), large coronary artery aneurysm (6.2%); ICU hospitalization duration was 7.8 ± 6.2 days, intubation rate of 45.8%, amines / cardiotropes of 45.8%, vascular filling 33.3% (all similar in both groups). 2 patients died of myocardial infarction. Differential diagnoses initially suggested were: unexplained fever / poorly tolerated bacteremia (45.8%), peritonitis / severe colitis (25%), toxin shock (12.5%); the diagnostic delay was 4.4 ± 1 days (similar in both groups). No significant differences were found concerning age at baseline (3.6 ± 0.6 vs. 2.1 ± 0.5 years old), sex ratio (0.9 vs 0.5 M / F, p> 0.05) respectively in cKD-ICU and iKD-ICU patients; total duration of fever, initial biology or extreme values (hemoglobin, platelets, leucocytes, CRP, ASAT, ALAT, natremia) were also similar in both groups. iKD-ICU patients were more frequently hospitalized in ICU before onset of fever (43.4 vs 8%, p = 0.01). The delays between onset of signs or hospitalization in ICU and the first course of IGIV were similar in both groups. Intravenous corticosteroid therapy was used in 36% of cKD-ICU vs 20% of iKD-ICU patients (p = 0.2); a second course of IGIV was used in 52% of cKD-ICU vs 47% of iKD-ICU patients (p = 0.7). All patients received a broad-spectrum antibiotic. Other therapeutics and evolution features were not significantly different between 2 groups.
Conclusion: KD-ICU patients had no initial or evolutive differences whether they met complete or incomplete AHA criteria. The strong suspicion of KD is therefore enough to initiate specific therapeutics even in severe complicated forms. An upcoming study will precise the phenotype of patients with KD-ICU to target them earlier, comparing them to KD patients who did not need ICU stay, via the KAWANET French database.
Disclosure of Interest
P044 PULMONARY RENAL SYNDROME IN HENOCH SCHONLEIN PURPURA: A RARE BUT SERIOUS COMPLICATION.
Katherine Clarke1, Elena Kurteva2, Neil Sebire3, Muthana Al Obaidi1
1Great Ormond Street Hospital, Department of Paediatric Rheumatology; 2Great Ormond Street Hospital, Department of Paediatric Gastroenterology; 3Great Ormond Street Hospital, Department of Paediatric Histopathology, London, UK
Correspondence: Katherine Clarke
Introduction: We present the case of a five year old male presenting with fever, abdominal pain and rectal bleeding. He had a history of rash and arthralgia, diagnosed as Henoch Schonlein Purpura (HSP).
Objectives: To illustrate the life threatening complications that can infrequently occus with HSP
Methods: He had a widespread purpuric rash with necrotic lesions and swollen extremities (figure 1). He was anaemic. Urine dipstick detected proteinuria and erythrocytes. Renal biopsy showed proliferative glomerulonephritis with strong deposition of IgA (figure 2). Anti-neutrophil antibodies, Anti- nuclear antibodies and double stranded DNA were negative with normal complement. IV methyl-prednisolone was commenced. He continued to deteriorate with worsening renal function and respiratory deterioration. Chest X Ray showed bilateral focal abnormalities (figure 3). During intubation, he bled secondary to pulmonary haemorrhage. He required high frequency oscillation ventilation.
Results: He received cyclophosphamide and plasmapheresis followed by prednisolone and enalapril. He made slow improvement. He continued to have heavy proteinuria and haematuria but his renal function gradually improved. He made good recovery. Within two weeks he was mobile, off oxygen, with no cutaneous scars and no gastrointestinal symptoms.
Conclusion: Henoch-Schönlein purpura (HSP) is the most common type of IgA vasculitis in childhood. It usually runs a benign and self-limiting course . Pulmonary-Renal involvement is a rare but life-threatening complication requiring early recognition and aggressive treatment . In the deteriorating child with HSP, one must be aware of this serious complication.
(1) Petty R, Laxer RM, Lindsley CB, Wedderburn LR (eds): Textbook of Pediatric Rheumatology, ed 7. Philadelphia, Elsevier, 2016.
(2) Aeschlimann FA, Yeung RSM, Laxer RM, et al. A toddler presenting with pulmonary renal syndrome. Case Rep Nephrol 2017; 7:73-80
Disclosure of Interest
P045 ANAKINRA AND ABCIXIMAB. SUCCESSFUL MANAGEMENT OF AN INFANT WITH REFRACTARY KAWASAKI DISEASE
María Isabel García Ruiz-Santa Quiteria1, Marisol Camacho Lovillo1, María José Lirola Cruz2, Esther Perez Borrego1, Israel Valverde Pérez1, Ana Mendez Santos1, Peter Olbrich1, Laura Fernández Silveira1
1Hospital Universitario Virgen del Rocío; 2Instituto Hispalense de Pediatría, Sevilla, Spain
Correspondence: María Isabel García Ruiz-Santa Quiteria
Introduction: Kawasaki Disease (KD) is an acute and self-limited vasculitis, potentially leading to severe complications such as coronary artery aneurysms (CA). Patients with giant aneurysms (z score> 10 or > 8 mm) are at high risk of complications such as thrombosis and stenosis. Young infants and those with refractory KD have a high risk of developing CA. These patients would likely benefit from an early and aggressive treatment, although the most appropriate treatment strategy remains unknown. To date 3 cases of pediatric patients with giant aneurysms have been published showing a good response to anti IL-1 (anakinra). In addition, 3 clinical trials with antiIL-1 are currently ongoing. Abciximab (monoclonal antibody against the GPIIb / IIIa glycoprotein receptor located on the surface of platelets) has been used in cases with giant aneurysms and preliminary data suggests a positive effect on the vascular remodeling.
Objectives: We highlight the favorable medium term outcome and suggest the potential benefit of anti-Il-1 therapy and abciximab in this clinical setting.
Methods: We report the case of KD with a severe clinical course and the development of multiple, large CA despite an early and aggressive treatment.
Results: A 6 months-old male Asian infant was admitted with high fever for 4 days, submandibular adenopathy, conjunctival injection, red lips and macular rash. He was initially treated as a bacterial infection but lack of clinical improvement despite empirical intravenous antibiotic therapy and the development of clinical symptoms suggestive of KD lead to the performance of a trans-thoracic echocardiogram revealing a dilatation of the left coronary artery and an aneurysm of the anterior descending coronary artery. Treatment with intravenous immunoglobulins (IVIG) 2 mg/kg and ASA 50 mg/kg/d was initiated (day 6). Due to the persistence of fever and raised acute phase reactants a second IVIG dose was administered at day 8. Given the severity of symptoms, laboratory tests (49160/mcl leukocytes, PCR 295 mg/l, proBNP 1261pg/ml), the patients’ age and the echocardiographic findings, corticosteroids (30mg/kg/dose) were prescribed (day 8, 9 and 10) without clinical improvement and the patient was therefore transferred to our center.
Because of the refractory clinical picture and the remarkable coronary findings(multiple CA, the highest in right coronary artery:14mm, z-score: 39.89) anakinra(4mg/kg/day) was started on day 11. The dose was increased to 8mg/kg/day, and abciximab(initial dose of 2 mg/kg/day followed by a 12 hour intravenous infusion of 1.6 mg with ICU monitoring) was added to the treatment plan on day 14 with resolution of the clinical symptoms and normalization of the laboratory parameters (except trombocytosis 1295000/mm3). He was discharged 1 month after the onset of symptoms and managed as an outpatient with anakinra (8mg/kg/day), ASA, heparin and tapered corticosteroids. At discharged the ecocardiogram showed a significant dilation of the coronary aneurysms, with 2 giant aneurysms of 9.7 mm, z-score 26.17 and 12 mm, z-score 33.59 in the right coronary artery. Anakinra was stopped one month after discharge. Subsequent echocardiographic controls (seven months later), showed a significant improvement (largest aneurysm 2.5 mm, z-score: 2.93). Current treatment is limited to AAS and heparin.
Conclusion: Despite adequate initial KD management, there remains a group of patients which develop serious cardiac complications. The identification of these high risk patients and the establishmentof guidelines forrisk-adjusted therapy are needed in order to optimize the management and subsequently the outcome of these patients. Informed consent had been obtained from the parent.
Disclosure of Interest
P046 ARTHRITIS IN THE SUBACUTE PHASE OF KAWASAKI DISEASE
Seira Hattori, Ayako Murase, Ai Ohnishi, Kenichi Nishimura, Ryoki Hara, Shuichi Ito
Pediatrics, Yokohama City University graduate school of medicine, Yokohama, Japan
Correspondence: Seira Hattori
Introduction: Kawasaki disease (KD) is a systemic vasculitis of medium-sized arteries in young children. KD has various complications, including arthritis, which is a common complication. Arthritis in the febrile acute phase of KD is likely to resolve following improvement of systemic symptoms. However, some patients have persistent or new-onset arthritis in the subacute phase of KD. There have been few studies of arthritis in the subacute phase of KD.
Objectives: This study aimed to evaluate the clinical characteristics, laboratory findings, imaging findings, treatment, and prognosis of arthritis in the subacute phase of KD.
Methods: We assessed patients with arthritis in the subacute phase of KD in our institute, a tertiary medical facility in Yokohama city, from April 2008 to January 2018. We retrospectively examined the treatment for KD, coronary artery lesions (CALs), affected joints, C-reactive protein (CRP) levels, matrix metalloproteinase-3 (MMP-3) levels, imaging findings, treatment for arthritis, and outcome of arthritis using the patients’ electronic medical records.
Results: Fifteen patients were enrolled. The median age of patients was 46 months (range, 10–116 months) and most were boys (60%). Five (33%) patients had arthritis in the acute phase of KD, and the arthritis resolved once with acute treatment of KD, except for one patient. Four (27%) patients were treated with single administration of intravenous immunoglobulin (IVIG) and 11 (73%) required additional IVIG. Infliximab (IFX) was administrated to seven (47%) patients and plasma exchange was performed in one because of IVIG resistance. One patient developed CALs. Arthritis was detected most in the knees (67%), followed by the ankles (47%) and hip joints (40%). Six (40%) patients had a consistent fever. At diagnosis of arthritis, CRP levels increased again in 14 (97%) patients and MMP-3 levels were elevated in 14 (97%) patients. Ultrasound showed joint fluid in all patients, but none showed synovial proliferation accompanied by a positive power Doppler signal. Nonsteroidal anti-inflammatory drugs, steroids, and methotrexate were administered for arthritis in 13 (87%), 11 (73%), and one (6.7%) patient, respectively. Among these treatments, steroids promptly improved arthritis without developing CALs. The median administration period of steroids was 46 days (range, 12–249 days). The arthritis resolved without sequelae in all of the patients, and they successfully discontinued treatment.
Conclusion: Arthritis in the subacute phase of KD is relatively common, and the arthritis does not cause destruction of joints and cartilage. However, some patients suffer from persistent arthritis for several weeks. For persistent arthritis, short-term steroid therapy can help to ensure rapid improvement without a new complication of CALs. The pathogenesis of arthritis in the subacute phase of KD remains unclear, but arthritis occurs, despite administration of IFX. Therefore, this condition appears to be unrelated to tumor necrosis factor-α.
Disclosure of Interest
P047 THE FIRST REPORT OF POST PENTAVALENT VACCINATION ACUTE HEMORRHAGIC EDEMA OF INFANCY
Shabnam Hajiani, Mohsen Jari, Reza Shiari
Pediatrics rheumatology, Shahid Beheshti university of medical sciences, Tehran, Iran, Islamic Republic Of
Correspondence: Mohsen Jari
Introduction: Background:Acute hemorrhagic edema of infancy (AHEI) is an immune complex-mediated leukocytoclastic vasculitis and rare disease that age of onset for it usually is 4-24 months. Clinical findings such as low grade fever,edema of face, upper and lower limbs and generalized petechiae,purpura or ecchymosis develop rapidly over 24-48 hours. Upper respiratory tract infection, gastroenteritis, or vaccination have been reported to cause of this disease. AHEI was reported after heptavalent vaccination ( Hemophilus influenza type B, diphtheria, tetanus, acellular pertussis, hepatitis B, polio, and conjugate pneumococcal vaccines).To our knowledge there is’nt any report of post pentavalent vaccination ( Hemophilus influenza type B, diphtheria, tetanus, acellular pertussis and hepatitis B)AHEI. asystemic involvement such as arthritis/arthralgia,abdominal pain,intussusception and scrotal pain and testicular torsion are rare.Diagnosis of AHEI is clinical and routine laboratory tests are nondiagnostic, although leukocytosis and thrombocytosis ,elevation of erythrocyte sedimentation rates((ESR), c-reactive protein(CRP) and liver function test may be occured. No effective therapy need for AHEI. The use ofantihistamines and steroids has been controversial . systemic corticosteroids may be used to sever conditions or systemic involvement such as abdominal pain,intussusception ,nephritis ,scrotal pain and testicular torsion. Monitor patients for rare systemic involvement such as renal involvementhas been controversial.
Objectives: Case report:Our patient was a 6-month boy injected by pentavalent vaccine 5days ago.since 3 days ago he had low grade fever,edema of face, upper and lower limbs and generalized petechiae,purpura and ecchymosis. His condition was good.Mild scrotal swelling was seen. Other review of system and physical examinations were normal. Labratoary findings showed only high ESR,CRP.Abdominal-pelvic and testicular ultrasonographies were normal. We treated this patient with supportive treatment and after ruled out of infectious diseases single dose 10mg/kg methlprednisolon infusion. There were no complications in follow up. Informed consent for publication had been obtained.
Methods: case report
Results: case report
Conclusion: Conclusion: Pentavalent vaccination can induced AHEI.
Disclosure of Interest
P048 TAKAYASU ARTERITIS INITIALLY DIAGNOSED WITH FEVER OF UNKNOWN ORIGIN
Özlem Üzüm1, Ali Kanık2, Kader Vardı1, Yeliz Pekçevik3, Kayı Eliaçık1, Belde Kasap Demir4
1Departments of Pediatrics, Tepecik Training and Research Hospital; 2Departments of Pediatrics, İzmir Katip Çelebi University; 3Department of Radiology, Tepecik Training and Research Hospital; 4Pediatric Nephrology and Rheumatology, İzmir Katip Çelebi University, İzmir, Turkey
Correspondence: Belde Kasap Demir
Introduction: Fever of unknown origin (FUO) in children is defined as fever >38.3°C (101°F) at least once per day for ≥8 days with no apparent diagnosis after initial outpatient or hospital evaluation that includes a detailed history, thorough physical examination, and initial laboratory assessment. The most common causes are infectious diseases, rheumatologic diseases and malignant diseases. This case is presented to emphasize that Takayasu Arteritis should be considered in patients examined for FUO.
Objectives: An 11-year-old girl presented with a fever increasing up to 38.3°C 1-2 times a day for one month, and up to 39°C for the last five days, despite continued antibiotic therapy. It has been learnt that she had a pain in the upper abdominal region for a week and she had lost 10 kilograms in the last two months after using a teeth retainer. On physical examination, body weight was under 3th percentile, while height was at 25-50 percentile. Vitals were normal except a fever reaching up to 38.5°C. There was no finding in systemic examination except general sensitivity in the abdomen. Hemoglobin was 8.1 g/dL. Biochemical values, immunoglobulin levels, and complements were normal. C-reactive protein (14.9 mg/dL) and erythrocyte sedimentation rate (140 mm/h) were high. Rheumatoid factor and viral serology were negative. No microorganism was yielded in the blood, throat or urine cultures. There was no sign of active tuberculosis on chest X-ray and PPD evaluation. Anti-nuclear antibody, anti-dsDNA, and p/c-anti-cytoplasmic antibodies were negative. Ophthalmologic evaluation, echocardiography and abdominal USG were normal. No additional features were found in peripheral smear and bone marrow examination.
Methods: Abdominal Doppler USG was performed upon ongoing fever, abdominal pain and high levels of acute phase reactants. The patient was diagnosed with Takayasu Arteritis due to the wall thickening in the first 4-5 cm proximal segment of the anterior mesenteric artery and severe thickening in the left carotid artery wall.
Results: She was treated with steroids and azatioprin. Abdominal pain regressed and acute phase reactants decreased to normal limits at the end of the second week.
Conclusion: Although Takayasu arteritis is included in the etiology of FUO, diagnosing a patient may take time in the absence of common findings including pulselessness or claudication. Takayasu Arteritis should be kept in mind in patients with FUO and further investigation should be considered. Written consent for publication was obtained from the parents.
Disclosure of Interest
P049 GENDER DIFFERENCES IN RISK FACTORS (OF IVIG-RESISTANT) IN PATIENTS WITH KAWASAKI DISEASE
Young Dae Kim1, Jong Gyun Ahn2, Kwang Nam Kim3
1Department of Pediatrics, Inje University Ilsan Paik Hospital, Goyang; 2Department of Pediatrics, Severance Children’s Hospital, Yonsei University College of Medicine, Seoul; 3Department of Pediatrics, Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea, Republic Of
Correspondence: Young Dae Kim
Introduction: Kawasaki disease (KD) is one of the most common vasculitis that may cause coronary artery complications. KD is more common in boys than in girls with a male-to-female ratio of 1.36:1 to 1.62:1. Thus, it has been suggested that the susceptibility is closely associated with sex differences.
Objectives: This study investigated the gender differences in clinical and laboratory findings in patients with KD.
Methods: We reviewed the medical records of 148 patients (78 boys and 70 girls) with KD who had been treated at our hospital between September 2012 and March 2017.
Results: The incidence of coronary artery aneurysm and intravenous immunoglobulin (IVIG) -resistant KD was significantly higher in the boys as compared with the girls (P=0.02). But there were no significant differences in WBC, Hb, CRP, ESR and urine abnormalities, such as proteinuria, pyuria and microscopic hematuria, between the two groups (P>0.05). There were significant differences in % neutrophil counts (>80), CRP (>8mg/dL), AST (>100IU/L), ALT (>80IU/L), hyponatremia (<134mmol/L), total bilirubin (<0.9mg/dL) and illness at initial treatment (≤4 days) between IVIG-responsive and IVIG-resistant groups (P<0.05).
Conclusion: Coronary artery aneurysm and intravenous immunoglobulin (IVIG) -resistant KD was more common in boys and there were several risk factors, such as % neutrophil counts, CRP, illness at initial treatment to progress IVIG resistant KD.
Disclosure of Interest
P050 EVALUATION OF THE ROLE OF SIGNAL PEPTIDE-CUB-EGF DOMAIN-CONTAINING PROTEIN (SCUBE)1 AND SCUBE2 IN IMMÜNOGLOBULIN A VASCULITIS
Gülbahar Kurt1, Ferhat Demir2, Suleyman C. Karahan3, Mukaddes Kalyoncu2
1Department of Pediatrics; 2Department of Pediatric Rheumatology; 3Department of Biochemistry, Karadeniz Technical University, Faculty of Medicine, Trabzon, Turkey
Correspondence: Gülbahar Kurt
Introduction: Immünglobulin A vasculitis (IgAV) is a systemic, inflammatory, leucocytoclastic vasculitis which is caused by IgA deposit to small blood vessels. It is a self-limiting disease and etiopathogenesis of IgAV is still unclear and cytokines such as TNF-α, IL-6 have been implicated in the active phase of the disease. Signal peptide-CUB (complement C1r/C1s, Uegf, and Bmp1)-EGF (epidermal growth factor)-like domain-containing protein (SCUBE)1 is a new described, can be secreted cell surface protein. It has been proven that SCUBE1 and SCUBE 2 has a role in various pathophysiologic processes like vascular endothelial cells, inflammation, cancer metastasis and vascular diseases.
Objectives: We aimed to research whether there is a relationship between SCUBE1 and SCUBE2 proteins and IgAV.
Methods: Between January 2016 and May 2017, the patient admitting to outpatient clinics in pediatric department of Farabi Hospital in Karadeniz Technical University and diagnosed with IgAV according to Ankara 2008 diagnostic criteria were included. Patients who used steroid or non-steroidal inflammatuary drug in last three months were excluded. Blood samples collected from patients who were in active and recovery phases of their diseases and healhty control group. IL-1, IL-6, TNF-α, SCUBE1 and SCUBE2 levels studied by ELISA method.
Results: A total of 26 patients, 13 (50%) male and 13 (50%) female, aged between 3 and 17 years, who were diagnosed with IgAV, were included in the study. The average age in healthy control group was 7.15±3.34 years. There was skin involvement in all of the patients who were diagnosed with IgAV. Twenty three (88.4%) patients had joint involvement, seven (26.9%) patients GI involvement, five (19.2%) patients kidney involment and three (11.5%) patients testicular involvement. IL-1 levels are significantly higher in active phase of disease than in healthy control group and recovery phase of disease (p=0.03). IL1, IL-6 levels were statistically significant higher then in healthy control group (p=0.006 and p=0.01, respectively). SCUBE1 and SCUBE2 levels were not different in active and VIII recovery phases of the disease. SCUBE2 levels have found significantly higher in recovery phases of the disease when compared to healthy control group (p=0,008).
Conclusion: Increase of SCUBE2 levels in the recovery phase of disease suggests that SCUBE proteins has a different role from inflammation in tissues and various cell types. We believe that this situation can be elucidated by studies on more patients in this regard.
Disclosure of Interest
P051 TOCILIZUMAB AS TREATMENT OPTION FOR ACHIEVING SUSTAINED REMISSION IN A CHILD WITH TAKAYASU ARTERITIS
Dragana S. Lazarevic1, Jelena Vojinovic1,2
1Pediatric Rheumatology, Clinic of Pediatrics, Clinical Center Nis; 2Pediatrics, Faculty of medicine, University of Nis, Nis, Serbia
Correspondence: Dragana S. Lazarevic
Introduction: Takayasu arteritis represents idiopathic large vessels vasculitis of aorta and its main branches, rarely affecting children.
Objectives: Diagnostic and treatment delay can lead to potentially life treating complications if neurological and cardiovascular injuries occur. Reducing inflammation and achieving sustained remission is important therapeutically goal, but not yet standardized.
Methods: We report a case of sixteen year old girl with refractory Takayasu arteritis to standard treatment who entered remission and could stopped steroids after inducing tocilizumab
Results: Sixteen year old girl was treated with antibiotics as having pneumonia due to fever and cough. After two weeks she was admitted to the pulmology department of our hospital due to prolonged fever, dizziness and weakness, but without reporting other symptoms. After excluding respiratory tract infection and tuberculosis she was transferred to the department of pediatric rheumatology and immunology. Possible infection causes were ruled out as procalcitonin, all cultures, virusology and atypical infections testing were negative. Bone marrow biopsy, detailed immunological and endocrinological laboratory testing were not proved hematological, immunodeficiency or autoimmune disease background. Due to persistently elevated inflammatory markers we suspected on autoinflammatory disease, but feritin was mildly elevated. Slit lamp examination and angiotenzin converting enzym have excluded possibile diagnosis of sarcoidosis. Abdominal ultrasound and echocardiography were normal. After the treatment with non-steroid anti-inflammatory drugs (NSAIDs) fever has gone, but elevated inflammatory markers persisted with profound feeling of fatigue, weakness, and dizziness. Physical examination has revealed less palpabile right radial pulse and higher blood pressure on the same side. F-fluorodeoxyglucose positron emission tomography (PET-CT) have confirmed diagnosis of Takayasu arteritis of thoracic and abdominal aorta. Magnetic resonance angiography (MRA) of the brain was normal. Methyl-prednisolon pulses were induced with gradually steroid tappering and metotrexate treatment, but unfortunately this could not stopped inflammation. Six months later she was steroid dependent with chronic fatigue and persistently elevated inflammatory parameters. MRA of the heart and large blood vessels have revealed evidence of still active inflammation in the thoracic aorta. Decision was made and tocilizumab was added on regular basis treatment. Four months after inducing tocilizumab she was without any symptoms with normalized inflammatory markers and steroids could be tapered and stopped.
Conclusion: In the cases of the fever of unknown origin we should consider Takayasu arteritis, even though it is rarely seen in childhood. Early diagnosis and treatment could prevent serious systemic complications. Although we lack treatment algorithm recommendations in children, this is the evidence that early and aggressive inducing of tocilizumab could lead to sustained remission in Takayasu artertitis in children. Informed consent to publish had been obtained.
Disclosure of Interest
P052 AUDITORY EVOKED POTENTIALS AND VISUAL EVOKED POTENTIALS: A HELPFUL TEST IN THE DIAGNOSIS AND FOLLOW UP OF KAWASAKI DISEASE
Maria Cristina Maggio1, Giuseppe Salvo1, Rolando Cimaz2, Domenico Puma3, Crocifissa Maria Ministeri4, Giovanni Corsello1
1University Department Pro.Sa.M.I. “G. D’Alessandro”, University of Palermo, Palermo; 2NEUROFARBA Department University of Florence, and AOU Meyer, University of Florence, Florence; 3Paediatric Neuropsychiatry Operative Unit, Children Hospital “G. Di Cristina”; 4O.U.of Neurophysiopathology, ARNAS, Palermo, Palermo, Italy
Correspondence: Maria Cristina Maggio
Introduction: Kawasaki disease is a systemic vasculitis affecting mainly children; the most serious complications are coronary artery lesions (CAL). Nonetheless, the spectrum of complications involves all the vascular districts, such as the eyes, skin, kidneys, gallbladder, liver, central nervous system. Sensorineural hearing loss is a low diagnosed complication of KD, however, it may be permanent.
Objectives: Auditory evoked potentials (ABR) and visual evoked potentials (VEPs) are useful in evaluating children without auditory and/or visual symptoms but with diseases that could sub clinically involve these functions.
Methods: We enrolled 52 children (31 M, 21 F; age: 3 months-10 years) with KD and evaluated ABR and VEPs in the acute phase of the disease and during the follow up. We correlated the neurophysiological study with clinical, biochemical parameters, the type of KD (typical, atypical, incomplete) with cardiac involvement and time of IVIG and/or other non-conventional treatment in the acute phase of KD.
Results: VEPs were pathological in 6 children (4 M; 2 F) (1 patient with CAL had monoliteral alterations; 2 patients had ABR pathological as well). ABR were pathological in 36/52 patients (69%) (2 patients without CAL had monoliteral alterations). Furthermore, in those patients (31M; 21 F) there were no significant differences in age, time of the diagnosis, time of the first dose of IVIG, biochemical parameters (leukocytes, neutrophils percentage, AST, ALT, gamma-GT, albumin, Na, fibrinogen, D-Dimer) vs KD patients without alterations of ABR and VEPs.
One patient showed a persistent sensorineural auditory loss.
During the follow up, ABR and/or VEPs alterations persisted in the 80% of the patients.
Most of the patients showed alterations of the wave V and the I-V, expression of mesencephalic involvement.
Conclusion: We suggest evaluating ABR and VEPs in patients with KD, both in patients with precocious diagnosis and treatment either in children treated later than 10 days with IVIG.
We suggest studying also patients without CAL, in whom neurophysiological study may contribute to the complete follow up of these patients.
Disclosure of Interest
P053 ASSOCIATION OF INCREASED SUN EXPOSURE OVER THE LIFE-COURSE WITH A REDUCED RISK OF JUVENILE IDIOPATHIC ARTHRITIS
Justine A. Ellis1, Rachel Chiaroni-Clarke1, Jane Munro2,3, Angela Pezic4, Joanna Cobb1, Jonathan Akikusa2,3, Roger Allen2,3, Terence Dwyer4,5, Anne-Louise Ponsonby4
1Genes, Environment & Complex Disease, Murdoch Children's Research Institute; 2Paediatric Rheumatology, Royal Children's Hospital; 3Arthritis & Rheumatology; 4Environmental & Genetic Epidemiology Research, Murdoch Children's Research Institute, Parkville, Australia; 5George Institute for Global Health, University of Oxford, Oxford, UK
Correspondence: Justine A. Ellis
Introduction: Cutaneous sun exposure is an important determinant of circulating vitamin D. Both sun exposure and vitamin D have been inversely associated with risk of autoimmune disease, including multiple sclerosis and rheumatoid arthritis. In children with juvenile idiopathic arthritis (JIA), low circulating vitamin D is reportedly common, but disease-related behavioural changes may have influenced sun exposure behaviours (reverse causation).
Objectives: We aimed to determine whether sun exposure across the life-course prior to diagnosis is associated with JIA.
Methods: Using validated questionnaires, we retrospectively measured sun exposure for 202 Caucasian JIA case-control pairs born and living in Victoria Australia and recruited to the CLARITY JIA Biobank. Cases and controls were matched for year of birth and time of recruitment. All subtypes of JIA were included in the analysis. Measures included maternal sun exposure at 12 weeks of pregnancy, and child sun exposure across the life-course pre-diagnosis. We converted sun exposure to UVR dose using location-specific (Melbourne Australia, latitude 37.5°S) UVR data. We looked for case-control sun/UVR exposure differences at various ages pre-diagnosis, and cumulatively across the pre-diagnosis life-course, using logistic regression, adjusting for potential confounders.
Results: Higher cumulative child pre-diagnosis UVR exposure was associated with reduced risk of JIA (e.g. total UVR dose quartile 1 vs 4, adjusted odds ratio (AOR) 0.19, 95% CI 0.04 – 0.85, p = 0.030), with a clear dose response relationship (test for trend p=0.025). UVR exposure at 12 weeks of pregnancy was similarly inversely associated with JIA (e.g. UVR quartile 1 vs 4, AOR 0.32, 95% CI 0.13 – 0.80, p = 0.014) with evidence of a dose response (test for trend p=0.031). Associations were robust to sensitivity analyses for disease duration, and for pre-diagnosis behavioural changes and knowledge of the hypothesis as collected by parent questionnaire.
Conclusion: Increased UVR exposure across the pre-diagnosis life-course is associated with reduced risk of JIA in our setting. This suggests lower circulating vitamin D in JIA may be causative, but prospective studies that directly measure pre-disease vitamin D in JIA are required. If confirmed, the associations point to an environmental factor amenable to intervention that may reduce risk of JIA in the population.
Disclosure of Interest
P054 AN ACTIVE PRONGF/P75NTR AXIS IN ARTHRITIS PATIENTS INFLUENCES CYTOKINE PRODUCTION IN SYNOVIAL FIBROBLASTS
Gaetana Minnone1, Luciapia Farina1, Marzia Soligo2, Luigi Manni2, Antonio Manzo3, Pierre Miossec4, Fabrizio De Benedetti1, Luisa Bracci-Laudiero1
1Division of Rheumatology, Bambino Gesu’ Children Hospital; 2Institute of Translational Pharmacology, CNR, Rome; 3Division of Rheumatology and Translational Immunology Research Laboratories, IRCCS Policlinico S Matteo Foundation/University of Pavia, Pavia, Italy; 4Immunogenomics and Inflammation Research Unit, Edouard Herriot Hospital, Hospices Civils de Lyon and University Claude Bernard Lyon 1, Lyon, France
Correspondence: Luciapia Farina
Introduction: In addition to its well-known neurotrophic activity, the nerve growth factor (NGF) is involved in the immune regulation. Our previous studies showed that the immature NGF, proNGF, is the prevalent form in synovial fluids of patients with juvenile idiopathic arthritis (JIA) and rheumatoid arthritis (RA). The distinct roles of NGF, pro-NGF and their different receptors (TrkA and p75NTR) in the regulation of the inflammatory response are still unclear.
Objectives: To investigate if p75NTR and its specific ligand proNGF modulate the activity of synovial fibroblasts and mononuclear cells playing a role in the inflammatory response in the synovia of arthritis patients.
Methods: Mononuclear cells (MNC) were purified from blood and synovial fluids of JIA patients. Fibroblasts-like synoviocytes (FLS), obtained from synovial tissue of RA patients (RA FLS), were used to evaluate pro-inflammatory activity of proNGF. Skin fibroblasts (SF) from healthy donors (HD) were used as controls. TrkA, p75NTR, Sortilin, NGF, and cytokines expression were evaluated by quantitative PCR (qPCR). Specific ELISA were used to analyze NGF, proNGF and cytokine concentrations. p75NTR was inhibited using a synthetic inhibitors (LM11A-31) or by small interference RNA in order to evaluate how its inhibition can modify pro-inflammatory pathways.
Results: Our data showed that p75NTR expression was significantly up-regulated in MNC purified from blood and synovial fluid of JIA patients and in FLS of RA patients. TrkA expression was highest in HD cells and down-regulated in patient cells. Patient FLS but not MNC expressed high levels of NGF mRNA and high amounts of proNGF. On the contrary, low levels of mature NGF were detected in their conditioned media. Inflammatory stimuli, such as IL-1β, IL-6, LPS, TNFα, further up-regulated both p75NTR expression and proNGF production in synovial FLS. The inhibition of the binding of proNGF to its specific receptor p75NTR using synthetic inhibitor LM11A-31 in synovial FLS resulted in a marked reduction of IL-6 release induced by either IL-1β or other inflammatory stimuli.
Conclusion: The abnormal p75NTR expression levels and the modified p75NTR/TrkA ratio observed in JIA and RA patients might have a crucial role in the chronicity of the inflammatory response. In addition to inducing p75NTR up-regulation, inflammatory stimuli increased the release of proNGF in synovial FLS. ProNGF further enhances pro-inflammatory cytokine production, creating a vicious circle that amplify the inflammatory response. Blocking the binding of endogenous proNGF to its receptor p75NTR, using a specific p75NTR inhibitor, strongly reduces the production of inflammatory mediators and suggests the use of p75NTR inhibitors as a new therapeutic approach to chronic arthritis.
Disclosure of Interest
G. Minnone: None Declared, L. Farina: None Declared, M. Soligo: None Declared, L. Manni: None Declared, A. Manzo: None Declared, P. Miossec: None Declared, F. De Benedetti Grant/Research Support from: BMS, Pfizer, Abbvie, Novartis, Novimmune, Roche, SOBI, Sanofi, UBC, Consultant for: Roche, Novartis, Novimmune, SOBI, L. Bracci-Laudiero: None Declared
P055 COMPARISON OF B CELL AND T CELL SUBSETS, CYTOKINE EXPRESSION AND SYNOVIAL PATHOLOGY IN DA AND JIA
Charlene Foley1, Achilleas Floudas2, Mary Canavan2, Monika Biniecka2, Emma J. MacDermott1I, Ronan Mullan3, Orla G. Killeen1, Ursula Fearon2
1NCPR, OLCHC; 2TBSI; 3Rheumatology, Tallaght, Dublin, Ireland
Correspondence: Charlene Foley
Introduction: Down syndrome (DS) is a common chromosomal disorder associated with the development of a range of medical and immune abnormalities such as haematologic malignancies, increased susceptibility to infections, and a high incidence of autoimmune diseases, including Down’s Arthritis (DA). Previous work by our group suggests that the prevalence of DA is 18-21 fold greater than JIA, much higher than the previously reported DA prevalence of 8.7/1000. Children with DA most often follow a polyarticular course of disease, with erosive joint damage observed more frequently in this cohort when compared to a cohort of children with JIA. Small joint involvement is frequently observed, again in a significantly greater proportion (p<0.01) of children with DA than expected in a typical JIA cohort. These characteristics suggest that DA may be distinct from JIA, however little is known about the differences in synovial pathology or immunological regulation. Indeed no studies to date have examined synovial pathology in DA
- To examine B-cell and T-cell subsets, and cytokine profiles in children with DA and JIA
- To characterise & compare the synovial membrane immunohistochemistry in DA & JIA.
Methods: Multicolour flow cytometry was used to analyse the phenotype of B and T cells in peripheral blood mononuclear cells (PBMCs) from 40 children (n=10 per group; Healthy Control (HC), JIA, DS, DA). Cells were stained with the following panels; Panel 1 B cells (CD38, CD24, CD20, CD80, CD27, IgM, CD138, CD45, CD19, MHCclassII, BCMA, CD40, CD86, IgD); Panel 2 T cell cytokines analysed after 5hours PMA/Ionomycin stimulation (CD3, CD8, CD161, IFN-γ, TNF-α, IL-17a, GM-CSF). Flow cytometry data was assessed by Flowjo software analysis.
Synovial tissue obtained through ultrasound guided biopsy and analysed by immunohistochemistry for CD3, CD20, CD68, Factor VIII (DA n=3; JIA n=6). Synovial Inflammation and lining layer thickness were also scored. Analysis was performed using semiquantification scoring method.
Flow cytometry was performed on PBMC samples from 4 distinct gps; HC (50%F, age 9.2y (2.5-15.6)), JIA (91%F, age 13.2y (8.2-16.1)), DS (45%F, age 6.5y (1-11.9)) & DA (60%F, age 11.4y (3.8-17.8)). All of the children in the DA & JIA cohorts had a polyarticular RF negative pattern of disease. Synovial tissue was obtained from 3 children with DA & 6 JIA cases.
Results: Flow cytometry analysis revealed that children with DA have a significantly lower number of circulating CD19+CD20+ B cells when compared to children with JIA (p<0.05) & HC (p<0.001). However, children with DA have a greater proportion of memory B cells (CD27+) when compared to children with DS & no arthritis (p<0.05).
Analysis of cytokine production by CD8+/CD8- T cells showed that IFN-γ & TNF-α production was greater in DA compared to both JIA (CD8+IFNγ+ p<0.001; CD8+TNFα+ p<0.01; CD8-IFNγ+ p<0.05; CD8-TNFα p<0.05) and HC (CD8+IFNγ+ p<0.05; CD8+TNFα+ p<0.05; CD8-IFNγ+ p<0.05; CD8-TNFα p<0.01).
Examination of synovial tissue demonstrated higher levels of CD3+ cells (p<0.05), Macrophages (p<0.05), CD20+ cells & FVIII in the joints of children with DA.
Conclusion: There are significant differences in B cell populations, cytokine production and immunohistochemical features of synovial tissue in children with DA & JIA. More work is required to verify these results. Preliminary findings may begin to help explain the differences observed in the clinical picture of children with DA & JIA.
Disclosure of Interest
P056 MICROENVIRONMENT DRIVEN RE-SHAPING OF PATHOGENIC T EFFECTOR AND REGULATORY SUBSET IN ACTIVE JUVENILE IDIOPATHIC ARTHRITIC PATIENTS
Jing Yao Leong1, Pavanish Kumar1, Phyllis Chen1, Joo Guan Yeo1,2, Camillus Chua1, Sharifah Nur Hazirah1, Suzan Saidin1, Thaschawee Arkachaisri1,2, Alessandro Consolaro3, Marco Gattorno3, Alberto Martini3, Salvatore Albani1
1Translational Jing Yao Leong Institute/Duke-NUS Academic Medical Centre; 2KK Women’s and Children’s Hospital, SINGAPORE HEALTH SERVICES PTE LTD, SINGHEALTH, Singapore, Singapore; 3Second Paediatric Division, University of Genoa and G Gaslini Institute, Genova, Italy
Correspondence: Jing Yao Leong
Introduction: We have previously published and identified two dichotomous dysregulated populations within the Teff (CPLs) and Treg (iaTreg) compartments that are inflammatory, antigen experienced, correlating with disease activity and exhibiting similar TCR oligoclonality with synovial T cells. Their commonality in phenotype despite being in two functionally distinct compartments, signal the possibility of a common pathogenic origin during active disease manifestation.
Objectives: To determine the common transcriptomic drivers influencing dysregulation in both Teff and Treg compartments during active disease in JIA patients.
Methods: Next generation RNA sequencing was performed on sorted CPLs (CD3+ CD4+ CD14- HLADR+ CD25/CD127 Teff gate) and iaTregs (CD3+ CD4+ CD14- HLADR+ CD25hi CD127lo Treg gate) from 16 active disease JIA PBMCs, 8 age-matched healthy PBMCs, and 8 paired SFMCS. The corresponding total pool of Teff (Non-CPLs) or Treg (Non-iaTreg) was also sorted as a comparative control. Sorted cells were lysed and extracted for RNA, and cDNA conversion/amplification were then carried out using SMART-seq v4. Libraries are prepared and multiplexed using Nextera XT DNA library preparation kit, and ran on the Illumina HiSeq High output platform. RNA-Seq raw reads were mapped to human genome using STAR aligner with default options and reads were counted/summarised at gene level by feature Count programme. Differential expression analysis were performed using edgeR package, and pathway enrichments were done under R statistical environment and Reactome.
Results: Comparative differential gene expression (DEG) reveal strong transcriptomic convergence between CPLs and iaTregs as compared with the common pool of Teff and Treg. Phylogenetic analysis indicate the convergence has uncoupled the CPLs or the iaTregs away from their respective original compartments (Teff or Treg) into a common branch point. Restriction in TCR sequence oligoclonality in CPLs/iaTregs versus that of the common Teff/Treg pool reinforce the possibility of a common selection pressure. Pathway enrichment analysis reveal similar dysregulated pathways (IFN-g, PD1, CD28 costimulation) within T cell signalling for both CPLs and iaTregs. Furthermore, Weighted gene correlation network analysis (WGCNA) identified strongly coordinated HLA-DR gene network module and suggests its potential role as the driver of pathogenic T cell subsets away from conventional subsets. Gene set enrichment analysis (GESA) suggest that HLA-DR module genes are involved in TNFA signalling, inflammatory response, complement, and apoptosis. Global transcription factors gene regulatory network (TF-GRN) analysis identified several key regulatory molecules (FOXP3, CEBP, SPI and E2F1) driving the convergence of pathogenic CPLs and iaTreg populations. Taken together , we have shown that reveal several layers of mechanism operate to drive the convergence of CPLs and iaTregs, suggesting the possibility of common disease drivers in active JIA patients.
Conclusion: Overall the transcriptomic data indicate strong similarity in both pathogenic populations and underscore a potential mechanistic role of the inflammatory microenvironment in shaping two functionally dichotomic populations.
Disclosure of Interest
P057 ASSOCIATION BETWEEN THE IL2-IL21 RS6822844 LOCUS POLYMORPHIC VARIANTS AND AGE AT JUVENILE IDIOPATHIC ARTHRITIS ONSET
Liliia S. Nazarova1, Kseniia V. Danilko1, Tatiana V. Viktorova1,2, Viktor A. Malievsky1
1Bashkir State Medical University; 2Institute of Biochemistry and Genetics, Ufa, Russian Federation
Correspondence: Viktor A. Malievsky
Introduction: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease in pediatrics and is characterized by marked clinical heterogeneity, including the age-related features of the disease onset [1, 2].
Objectives: The aim of the study was to analyze the relationship between the IL2-IL21 rs6822844 locus polymorphic variants and age at JIA onset.
Methods: The study included 328 patients with JIA from the Republic of Bashkortostan, Russia. Genotyping was performed by real-time PCR method and statistical processing of the results – with the Mann-Whitney U test.
Results: The study of the IL2-IL21 rs6822844 single-nucleotide polymorphism showed, that in the carriers of the GG genotype (n=271), JIA developed statistically significantly earlier than in the carriers of the T allele (4.16 (2.14;8.09) vs 6.00 (3.03;8.78) years respectively, p=0.045). In contrast, patients with the GT genotype (n=54) tended to have a later onset of the disease than the other patients had (6.00 (3.01;8.78) vs 4.19 (2.19;8.09) years respectively, p=0.072). In a sex-stratified analysis, similar patterns for the GG and GT genotypes were found only for girls with JIA, being even more pronounced and in both cases reaching a statistical significance level (GG (n=174) vs GT+TT (n=42): 3.19 (1.90;6.79) vs 4.97 (3.01;9.65) years, p=0.008 and GT (n=41) vs GG+TT: 4.64 (3.01;8.25) vs 3.21 (1.90;6.99) years, p=0.013 respectively). It should be noted, however, that there was only one girl with the TT genotype in the studied JIA patients’ sample, and age at the disease onset of this girl was 9.65 years.
Conclusion: In this study, the association between the IL2-IL21 rs6822844 locus polymorphic variants and age at JIA onset in girls was established.
1. Ravelli A, Martini A. Juvenile idiopathic arthritis. Lancet. 2007 Mar 3; 369 (9563): 767-78.
2. Donn R, De Leonibus C, Meyer S, Stevens A. Network analysis and juvenile idiopathic arthritis (JIA): a new horizon for the understanding of disease pathogenesis and therapeutic target identification. Pediatr Rheumatol Online J. 2016 Jul 2;14(1):40.
Disclosure of Interest
P058 MOLECULAR AND CELLULAR BIOMARKERS THAT DISCRIMINATE JUVENILE IDIOPATHIC ARTHRITIS FROM SEPTIC ARTHRITIS
Nadege Nziza1,2,3, Mailys Cren1,3, Aurelia Carbasse4, Perrine Mahe4, Marion Delpont5, Djamel Louahem5, Hugues Chevassus6, Mirna Khalil6, Thibault Mura7, Christian Jorgensen1,3,8, Isabelle Duroux-Richard1,3, Eric Jeziorski4, Florence Apparailly1,3,8, Pascale Louis-Plence1,3
1National Institute of Health and Medical Research, Montpellier; 2Arthritis R&D, Neuilly sur Seine; 3University of Montpellier; 4Paediatric Department; 5Pediatric Orthopedic Surgery Unit; 6Centre d'Investigation Clinique, University Hospital of Montpellier; 7Department of Medical Information, La Colombière Hospital; 8Clinical department of Osteoarticular diseases and Biotherapy, University Hospital Lapeyronie, Montpellier, France
Correspondence: Nadege Nziza
Introduction: Juvenile idiopathic arthritis (JIA) and septic arthritis (SA) are the most frequent cause of arthritis among children under the age of 16 years. JIA is an auto-immune disorder involving articular inflammation that persists for more than 6 weeks, while SA is caused by bacterial infection in children joints. Although these diseases have different physiopathological basis and involve different treatments and prognoses, they share clinical similarities.
Objectives: To date, there are no markers sufficiently reliable to discriminate between these two forms of arthritis at the onset of the disease. Our goal is to respond to this clinical need by identifying diagnostic biomarkers capable of discriminating between JIA and SA. To that end, we focused on microRNAs (miRNAs) and myeloid cell subsets, both playing a major role in inflammation and autoimmune disorders.
Methods: We analyzed serum and synovial fluid (SF) samples from patients with inflammatory or septic arthritis using a miRNAs Whole Transcriptome Assay associated with a next-generation sequencing detection technology to measure the expression level of 2083 miRNAs in a pilot study (oligoarticular JIA (oJIA): n=5; SA: n=3) and validated using RT-qPCR in a replicative study (oJIA: n=9; SA: n=9). In parallel, we performed a phenotypic characterization of peripheral blood (PB) and SF myeloid subpopulations using a flow cytometer in order to identify cellular biomarkers (oJIA: n=9; SA: n=8).
Results: Principal component analysis and hierarchical clustering characterizations did not show significant differences between serum miRNAs of oJIA and SA patients. However, we observed a distinct miRNA profile signature in SF between the two diseases with 16 upregulated miRNAs and 5 down-regulated that perfectly discriminates oJIA and SA (p<0.01). In addition, phenotypic characterization revealed the existence of 5 myeloid cell subsets with distinct accumulation profile between the SF of oJIA and SA (p<0.05). A study of their activation profile indicated differences in the expression of cellular markers between the two groups.
Conclusion: In this study, we propose for the first time a synovial fluid-based miRNA signature as well as 5 myeloid cell subsets that discriminate between oJIA and SA and might be used as potential diagnosis markers in juvenile arthritis.
Disclosure of Interest
P059 EVALUATION OF PLASMA MICRORNA EXPRESSIONS IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS
Ferhat Demir1, Alper H. Çebi2, Mukaddes Kalyoncu1
1Department of Pediatric Rheumatology; 2Department of Medical Genetics, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
Correspondence: Ferhat Demir
Introduction: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disease of childhood and its etiology is unknown. Microribonucleic acids (miRNAs) are small (16–24 nucleotides), non-coding RNA molecules that have roles on the regulation of gene expression at the post-transcriptional stage. It is also known that microribonucleic acid (miRNA)s play a role in immunoregulation.
Objectives: We aimed to evaluate plasma expression of some candidate miRNAs that associated with pathogenesis of autoimmunity.
Methods: Thirty-one patients diagnosed with JIA and age-sex matched 31 healthy children were enrolled for the study. Plasma levels of four candidate miRNAs (miRNA-16, miRNA-155, miRNA-204 and miRNA-451), which is known to be associated with autoimmunity were examined in all subjects. Plasma levels of miRNAs were measured with Real Time PCR in patients in active and inactive period and in healthy controls. Groups were compared with each other.
Plasma miRNA-155 levels were found to be increased in JIA patients compared to the healthy controls and it was statistically more significant in inactive period. We found that JİA patients had higher levels of miRNA-16 and lower levels of miRNA-204/miRNA-451 expressions compare with the control group, but there was no statistically significant difference. A statistically significant decrease in plasma levels of miRNA-204 was found in patients that were in inactive disease with only methotrexate therapy. Plasma miRNA expressions were compared in JIA subtypes and it was observed that miRNA-204 levels were higher in polyarticular JIA and miRNA-451 levels were higher in entesitis related arthritis without statistical significance.
Conclusion: Significant alterations in the plasma expression of miRNA-155 and miRNA-204 suggest to us that these molecules may be related to pathogenesis of JIA. More comprehensive and functional researches about the role of this molecules are needed in this regard.
Disclosure of Interest
The mean plasma miRNA 2-ΔCT level of patients in aJIA, iJIA and HC groups and comparison of it (include JIA patients that treated with only methotrexate)
Fold change/p value
P060 RENAL AUTOIMMUNITY IN IPEX SYNDROME
Cécile Frachette1, Alain Lachaux2, Marc Nicolino3, Irene Loras-Duclaux2, Frederique Dijoud4, Nicole Fabien5, David Goncalves5, Christophe Malcus6, Maud Rabeyrin7, Olivia Gillion-Boyer8, Gwenaëlle Kesler-Roussey9, Alexandre Fabre10, Bertrand Roquelaure10, Michel Tsimaratos11, Joelle Terzic12, Anne-Laure Mathieu13, Sebastien Viel13, Justine Bacchetta1, Thierry Walzer13, Pierre Ray14, Alexandre Belot1
1Pediatric nephrology and rheumatology; 2Pediatric Gastroenterology department; 3Pediatric endocrinology; 4Pathologist departement, Hôpital Femme Mère Enfant, Bron (Lyon); 5Immunology, CHU de Lyon, Groupe hospitalier Sud, Pierre-Bénite (Lyon); 6Immunology; 7Pathologist department, Hôpital Edouard Herriot, Lyon; 8Pediatric nephrology, Hôpital Necker-enfants-malades, Paris; 9Pediatric nephrology, CHU de Nantes, Nantes; 10Pediatric Gastroenterology; 11Pediatric nephrology, Hôpital de La Timone Enfants, Marseille; 12Pediatric nephrology, Hôpital de Hautepierre, Strasbourg; 13Innate Immunity and Autoimmune diseases, Centre international de Recherche en Infectiologie, Lyon; 14Genetic department, CHU Grenoble-Alpes, Grenoble, France
Correspondence: Cécile Frachette
Introduction: Immune dysregulation, polyendocrinopathy, enteropathy, X-linked (IPEX) syndrome is a rare monogenic primary immunodeficiency affecting T regulatory lymphocytes caused by FOXP3 mutation and is associated with multiple autoimmune disorders including enteropathy, diabetes and atopic dermatitis. Kidney involvement is uncommon but has been already reported. Little is known regarding the impact of Tregs deficiency on renal tolerance.
Objectives: This study is intended to describe the renal phenotype of IPEX patients and to determine the self reactivity of patient’s sera using a protoarray assay enabling the detection of the autoimmune repertoire across 8000 peptides.
Methods: We retrospectively collected clinical, histopathological and immunological data from IPEX patients seen in French pediatric immunology, rheumatology or nephrology centres. We retrieved patients sera and analyse the autoimmune repertoire targeting the kidney with a combined strategy of immunofluorescence crossreactivity on rats cell lines and direct crossreactivity on 8000 peptides (Protoarray, Thermofisher).
Results: In the index case, immunofluorescence staining showed linear deposits along the tubular basal membrane suggesting a B-cell mediated immunopathogeny. The patient serum was tested on regular renal cells from rats and indirect immunofluorescence showed crossreaction over species suggesting the presence of autoantibodies targeting the basal membrane in the serum of the patient.
Four other pediatric patients were included in this study in order to better characterize nephropathy in IPEX syndrome. A total of three patients had tubulonephritis, and this feature was the first manifestation of the disease for two of them. One of the patients had membranous nephritis and the other one presented microangiopathy secondary to calcineurin inhibitors toxicity. All patients were treated with immunosuppressive drugs, two underwent hematopoetic stem cell transplantation and one had kidney transplantation. The results of the protoarray in the first patient elicited more than 100 antibodies with high titers. Among them, about 15 were kidney specific. Additional samples may help to detect a common tubulointerstitial autoantibody.
Conclusion: This study highlights genetic and clinical heterogeneity of renal lesions in IPEX patients. Autoimmune nephropathy is rare but does exist in IPEX syndrome and may appear as glomerulopathy or tubulopathy. It is noteworthy to define specific autoantibodies that may help clinician to screen IPEX patients for renal lesions.
Disclosure of Interest
P061 COMPARISON BETWEEN BIOMARKERS IN SYNOVIAL FLUID AND PLASMA IN JUVENILE IDIOPATHIC ARTHRITIS: PRELIMINARY DATA.
Mikhail Kostik1, Daria Kozlova2,3, Alexandr Popov2,4, Dmitry Vasiliev2,3, Vera Masalova1, Eugenia Isupova1
1SAINT-PETERSBURG STATE PEDIATRIC MEDICAL UNIVERSITY; 2Ltd. "Scientific and Production Firm" ABRIS +; 3Sechenov Institute of Evolutionary Physiology and Biochemistry Russian Academy of Sciences; 4St. Petersburg State Technological Institute (technical university), Saint-Petersburg, Russian Federation
Correspondence: Mikhail Kostik
Introduction: Juvenile idiopathic arthritis (JIA) – is a chronic immune-mediated inflammatory joint disease in children under the 16 years. The peculiarities of JIA pathogenesis depend on JIA category and related to autoimmune or autoinflammatory mechanisms. Currently there are no unique approaches to evaluate JIA activity. The classical clinical and laboratory test, such as ESR and CRP no always correlate with local inflammation, joint erosions and so on. The finding of new biomarkers is actual, because can help more precise evaluate JIA activity, choose the appropriate treatment and better prognosis of outcomes.
Objectives: The aim of our study was to demonstrate possibility using of calprotectin, 14-3-3η and butirylcholinesterase (BUCHE) as a potential JIA biomarkers.
Methods: in pilot study were included 13 patients with JIA (4 boys and 9 girls) with enthesitis-related (n=3) and oligoarticular (n=9) JIA categories in whom calprotectin and 14-3-3η levels and activity of BUCHE in blood plasma - BP (n=12) and synovial fluid -SF (n=7) were measured. The onset age of patients was 3.9 (3.1; 8.9) years, disease duration – 3.7 (1.3; 6.6) years. Plasma and synovial fluid supernatant were used to determine the content of interleukin-6, calprotektin, protein 14-3-3η by the ELISA. Statistical analysis of data was carried out with the program Statistica 10.0. We utilized descriptive statistics (Me; IQR), Mann-Whitny and Wilcoxon tests, Pirson’s and Spearmen’s correlation analysis.
Results: Obtained data showed that the content of calprotectin in JIA in SF - 57.3 (47.3; 102.8) ng/ml was higher than in blood plasma – 5.8 (3.6; 15.0) ng/ml (р=0.02). It was shown that the content of 14-3-3η protein in JIA SF – 66.7 (56.4; 98.6) ng/ml is also higher than in BP- 46.4 (37.1; 53.1) ng\ml (р=0.02) that is also coincides with literature data obtained for blood plasma 14-3-3η levels in adult persons with rheumatoid arthritis (Walter P. et al., 2014). Activity of typical fraction of BUCHE was higher in BP -47.3 (39.8; 60.6) U/l than in SF - 30.2 (22.8; 39.1) U/l (р=0.027). Activity of atypical fraction of BUCHE was 14.2 (11.6; 16.7) U/l and 6.2 (5.0; 9.1) U/l in BP and SF, relatively (р=0.046), and activitiy of minor fraction of BUCHE was 0.46 (0.1; 1.1) U/l and 14.7 (12.2; 15.5) U/l in BP and SF, relatively (р=0.027). There weren’t found correlation between studied biomarkers and JIA measures, such as onset age, JIA duration, active joints count, ESR, CRP, JIA category, beside positive correlation between minor fraction of BUCHE in BP and active joints count (r=0,998; r<0,05) and negative correlation between CRP and 14-3-3η (r=-0.999; p<0.05) in SF. It was found that levels of calprotectin, 14-3-3η and minor fraction of BUCHE more effective reflect local inflammation than routine markers. We have found positive correlation between BP and SF for calprotectin (r=0.997; r<0.05) and 14-3-3η (r=0.958; r<0.05), but not for minor fraction of BUCHE.
Conclusion: We suppose that calprotectin and 14-3-3η in BP can be used as possible non-invasive biomarkers of JIA activity. Further investigations required.
Disclosure of Interest
P062 MOLECULAR MECHANISMS OF PATHOGENIC T CELL RESILIENCE IN HUMAN ARTHRITIS
Pavanish Kumar1, Leong Jing Yao1, Bhairav Paleja1, Joo Guan Yeo2, Jorg van Loosdregt1, Suzan Saidin1, Camillus Chua1, Thaschawee Arkachaisri3, Alessandro Consolaro4, Marco Gattorno4, Alberto Martini4, Gary W. Williams5, Ken D Pischel5, Martin Lotz6, Salvatore Albani1
1Translational Immunology Institute, SingHealth, DukeNUS; 2Translational Immunology Institute,SingHealth DukeNUS; 3Duke-NUS Graduate Medical School and Rheumatology and Immunology Service, KK Women's and Children's Hospital, Singapore, Singapore; 4Second Pediatrics Division, University of Genoa and G Gaslini Institute, Genova, Italy; 5Scripps Clinic, La Jolla, California; 6Department of Molecular Medicine, The Scripps Research Institute, La Jolla, Callifornia, USA
Correspondence: Pavanish Kumar
Introduction: One of the key elements of immune pathogenesis of human autoimmune arthritis is the resilience of pathogenic T cells. We have previously described that CD4+ T cells in patients with arthritis have an increased level of autophagy than their healthy equivalents. Here, we sought to explore at epigenetic and transcriptional levels the concept of persisting increased autophagy as the consequence of “autophagic memory”, as one of the mechanisms conferring resilience to pathogenic T cells, in particular to a subset of CD4+ T cells (CPL: Circulating Pathogenic-like Lymphocytes), which are significantly more represented in patients with active arthritis and resistant to therapy with biologics
Objectives: T-cell resilience is critical to the immune pathogenesis of human autoimmune arthritis Autophagy is essential for memory T cell generation and associated with pathogenesis in rheumatoid arthritis (RA). Our aim was to delineate the role and molecular mechanism of autophagy in resilience and persistence of pathogenic T cells from autoimmune arthritis
Methods: Autophagy was assessed in CD4+ T cell subsets from autoimmune arthritis pateints and healthy subjects using flow cytometry. RNA sequencing and methylation array analysis was performed to understand the molecular mechanism of autophagic memory. Transcription-factor gene regulatory network analysis was build to identify key regulators. qPCR was used to confirm the gene expression level of key regulator
Results: We demonstrate “Autophagic memory” as elevated autophagy levels in CD4+ memory T cells compared to CD4+ naive T cells and in Jurkat Human T cell line trained with starvation stress. We then showed increased levels of autophagy in pathogenic CD4+ T cells subsets from autoimmune arthritis patients. Using RNA-sequencing, transcription factor gene regulatory network and methylation analyses we identified MYC as a key regulator of autophagic memory. We validated MYC levels using qPCR and further demonstrated that inhibiting MYC increased
Conclusion: The present study proposes the novel concept of autophagic memory and suggests that autophagic memory confers metabolic advantage to pathogenic T cells from arthritis and supports its resilience and long term survival. Particularly, suppression of MYC imparted the heightened autophagy levels in pathogenic T cells. These studies have a direct translational valency as they identify autophagy and its metabolic controllers as a novel therapeutic target.
Disclosure of Interest
P063 EXTENDED OLIGOARTICULAR AND POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS PATIENTS HAVE A SIMILAR B CELL PHENOTYPE WHEN COMPARED TO ESTABLISHED RHEUMATOID ARTHRITIS
Rita A. Moura1, Alexandre Brito1, Susana Oliveira1, Rui L. Teixeira1,2, Vasco C. Romão1,2, Vítor Teixeira1,2, Raquel Campanilho-Marques1,2, Filipa Oliveira-Ramos1,2, João E. Fonseca1,2
1Instituto de Medicina Molecular João Lobo Antunes, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal; 2Rheumatology Department, Centro Hospitalar de Lisboa Norte, EPE, Hospital de Santa Maria, Lisbon Academic Medical Centre, Lisbon, Portugal
Correspondence: Rita A. Moura
Introduction: Our group has recently described that the majority of polyarticular juvenile idiopathic arthritis (pJIA) and a large fraction of extended oligoarticular JIA (oJIA) patients fulfil classification criteria for rheumatoid arthritis (RA) in adulthood. B cells play several important roles in RA pathogenesis, but it is still unclear if the pattern of B cell involvement in pJIA and extended oJIA follows what has been described for adults with RA.
Objectives: The main goal of this study was to characterize peripheral blood B cell phenotype and cellular activation in pJIA and extended oJIA patients when compared to established RA.
Methods: Blood samples were collected from JIA patients (N=10; mean age 10 ± 4 years), established RA patients treated with synthetic DMARDs (N=10; mean age 72 ± 7 years) and two corresponding groups of age- and sex-matched healthy donors. B cell phenotype was characterized by flow cytometry and B cell apoptosis was assessed after 48H of in vitro cell culture.
Results: JIA patients recruited in this study were either classified as extended oJIA (N=6) or pJIA (N=4). Seven JIA patients (4 extended oJIA and 3 pJIA) were treated with methotrexate and three patients (2 extended oJIA and 1 pJIA) were untreated. We found that JIA patients had similar CD19+ B cell levels in circulation when compared to controls, but significantly higher CD19+ B cell frequencies in comparison to established RA. In addition, increased frequencies of transitional (IgD+CD38++) and naïve (IgD+CD27+) B cell subpopulations were observed in JIA patients when compared to RA. However, established RA patients had significantly higher levels of CD21lowCD38low, post-switch (IgD-CD27+) and IgD-CD27- memory B cell subsets when compared not only to controls, but also to JIA patients. No significant differences were detected in pre-switch (IgD+CD27+) memory and plasmablasts (IgD-CD38++) levels in JIA patients when compared to both controls and RA. Furthermore, the frequency of CD5+ B cells, CD5 median fluorescence intensity (MFI), CD40 MFI and CXCR5 MFI B cell expression levels were significantly increased in JIA patients when compared to established RA, but not to controls. No significant differences were observed between JIA and established RA patients in BAFF-R, FcgRIIB, CD21, CD23, CD38, CD86, CD95, HLA-DR, TLR9 and RANKL expression on B cells. After 48H of in vitro cell culture a significantly higher B cell death was found in JIA in comparison to RA patients.
Conclusion: The increased frequencies of transitional, naïve and CD5+ B cells in circulation and reduced levels of memory B cell subpopulations in JIA patients when compared to established RA are probably related to an immature immune system present in children when compared to adults. Nevertheless, the similarity in B cell phenotype found between extended oJIA, pJIA and established RA patients suggests an early B cell involvement in the pathogenesis of these two categories of JIA.
Disclosure of Interest
P064 THE AUSTRALIAN ARTHRITIS AND AUTOIMMUNE BIOBANK COLLABORATIVE [A3BC] PROTOCOL
Jane E. Munro1, Lyn March2, Craig Willers3, Chris Jackson3, Meilang Xue3, Catherine Hill4, Mihir Wechalekar5, Susan Lester6, Helen Benham7, Tony Kenna7, Helen Keen8, Chandima Perera9, Davinder Singh-Grewal10, Kevin Murray11, Pavla Walsh12, Peter Gowdie13, Christina Boros14, Navid Adib15, Joanna Cobb1, Rachelle Buchbinder16, Marissa Lassere17, Jeff Chaitow18, Mike Inouye19, Claire Barrett20, Graeme Carroll21, Justine Ellis1
1Murdoch Children's Research Institute, Melbourne; 2Institute for Bone and Joint Research (IBJR): University of Sydney & Royal North Shore Hospital, NSW; 3Institute of Bone & Joint Research - Sydney University & Kolling Institute, Sydney; 4Royal Adelaide Hospital6; 5Flinders Hospital; 6Queen Elizabeth Hospital, Adelaide; 7University of Queensland Diamantina Institute, Brisbane; 8Fiona Stanley Hospital, Perth; 9Canberra Hospital, Canberra; 10Westmead Children's, Sydney; 11Princess Margaret Hospital21; 12Princess Margaret Hospital, Perth; 13Monash Children's, Melbourne; 14Women's and Children's, Adelaide; 15Wesley Hospital, Brisbane; 16Monash Univeristy, Melbourne; 17Uni NSW; 18Westmead Childrens, Sydney; 19Baker Institute, Melbourne; 20Royal Brisbane and Women’s Hospital25, Brisbane; 21Private practice, Perth, Australia
Correspondence: Jane E. Munro
Introduction: The australian arthritis and autoimmune biobank collaborative = a3bc a national paediatric and adult rheumatology clinical research network
Objectives: The A3BC seeks safer, more effective and evidence-based prevention, diagnosis, treatment and prognosis strategy in arthritis and autoimmune disease. Key A3BC aims are to
Develop a higher level of capability by collaborating across multiple disciplines and sector
Progress precision medicine by growing capacity in open-access, data-linked biobanking
Innovate preventive medicine by forming unique partnerships with population health research
Demonstrate a new era of data linkage and use to inform policy and practice decision-making
Methods: The A3BC protocol was developed in consultation with leading researchers, clinicians, industry and best practices. A3BC processes will initially run parallel to the Australian Rheumatology Association Database (ARAD), but will merge in the future. The initial A3BC disease focus is Rheumatoid Arthritis, Juvenile Arthritis, Psoriatic Arthritis and Ankylosing Spondylitis.
Recruited through over 40 sites nationally, participants donate blood (20-53mls) and synovial tissue/fluid, stored across 10 biobank nodes as plasma, serum, PBMCs, DNA and RNA. On a project basis, newborn screening cards, urine and/or faeces are accessed.
These samples are accompanied by standardised pre-analytical variables and clinical data, and linked datasets including the ARAD, electronic medical records, Commonwealth health (e.g. Pharmaceutical Benefits Scheme, Medicare)), registries (e.g. cancer, death), longitudinal/lifecourse data (e.g. Juvenile Arthritis national CLARITY project), and consumer entry (My Health Record).
Using cutting-edge capture, real-time analytics and dashboarding processes and systems, all data is integrated and mined for patterns and associations, then effectively communicated to practitioners and policy-makers.
Results: The A3BC protocol will result in new dataset integration systems, new multidisciplinary collaborations, and identification of new risk factors, biomarkers and cross-dataset associations. It will improve research by enabling innovative research questions and faster translation. And facilitate health policy/practice decision-making in precision and preventive medicine.
Conclusion: The A3BC protocol provides best-practice, quality assured and validated methods to realise its aims. Current experience from recruiting and processing participants demonstrates that the protocol’s methods and technologies are fit-for-purpose.
Disclosure of Interest
P065 ROLE OF THE ORAL MICROBIOME IN PEDIATRIC AUTOIMMUNE AND AUTOINFLAMMATORY DISEASE
Prasad T. Oommen, Benjamin Reinbeck, Arndt Borkhardt, Ute Fischer
1Clinic for Paediatric Oncology, -Hematology and Clinical Immunology, Heinrich-Heine-University, Medical Faculty, Duesseldorf, Germany
Correspondence: Prasad T. Oommen
Introduction: Neither genetic, epigenetic nor environmental factors alone have been able to unravel the pathogenesis of autoimmune and autoinflammatory diseases in children and adolescents. The specific aspects which determine the individual susceptibility to the development of a rheumatic disease are still to be elucidated. As of now, these conditions are seen as multifactorial in respect of pathogenesis. The microbiome has been under discussion as a contributing factor. Microbial communities who play an important role in the physiological development of the immune system may turn into "false friends" leading to the state of dysbiosis.
Objectives: We aimed to gain new data in this context via examing the oral microbiome in patients with different rheumatic diseases in children and adolescents.
Methods: We examined the oral microbiome by obtaining oral swabs of 11 patients with juvenile idiopathic arthritis and 20 patients with chronic non-bacterial osteomyelitis (CNO).
The hypervariable region V6–V7 of the 16S rRNA gene was amplified and subsequently sequenced. The following bioinformatic analysis was performed with QUIIME (Quantitative Insights Into Microbial Ecology).
Results: In accordance to previous studies we were able to identify Actinobacteria and Fusobacteria on the phylum level as microbiota only present in our JIA cohort. In the CNO cohort so far no distinct microbiotic players could be detected. For this entity the only data so far describe an advantage in mice who were fed with a high-fat diet resulting in a shift in the microbial environment leading to a better course of the disease. These mice data could - as of now - not be shown in our patients.
Conclusion: The microbiome may open a new door to a better understanding of multifactorial autoimmune and autoinflammatory disease. In accordance to previous studies we were able to identify specific microbiota present only in JIA patients. However, the clinical consequence and the exact immunological effects of dysbiosis are still to be unravelled. As of now, studies of the microbiome may enhance the pathophysiologic understanding of these diseases.
Disclosure of Interest
P066 EVALUATION OF THE ROLE OF SIGNAL PEPTIDE-CUB-EGF DOMAIN-CONTAINING PROTEIN (SCUBE)1 AND SCUBE2 IN JUVENILE IDIOPATHIC ARTHRITIS
Duygu Selimoğlu1, Ferhat Demir2, Süleyman C. Karahan3, Mukaddes Kalyoncu2
1Department of Pediatrics; 2Department of Pediatric Rheumatology; 3Department of Biochemistry, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
Correspondence: Duygu Selimoğlu
Introduction: Juvenile idiopathic arthritis (JIA) is a disease that begins in patients under sixteen years of age, continues longer than six weeks, and diagnosed with arthritis in at least one joint. Other causes of arthritis should be excluded for diagnosis of JIA. The etiopathogenesis is still unclear and it is thought that it is the result of the immunological response due to environmental and genetic factors. Signal peptide-CUB (complement C1r/C1s, Uegf, and Bmp1)-EGF (epidermal growth factor)-like domain-containing protein (SCUBE) is a newly defined, secreted cell surface protein. SCUBE1 and SCUBE2 have been shown to play a role in various pathophysiological processes such as vascular endothelial cells, inflammation, cancer metastasis, and vascular diseases.
Objectives: We aimed to research whether there is a relationship between SCUBE1 and SCUBE2 proteins, and JIA.
Methods: Between January 2016 and May 2017, the patients admitting to outpatient clinics in Pediatric Department of Farabi Hospital in Karadeniz Technical University and diagnosed with JIA according to ILAR criteria were included. Patients who used steroid or non-steroidal anti-inflammatory drugs in last three months were excluded. Blood samples collected from patients who were in active and recovery phases of their diseases and healhty control group. IL (interleukin)-1, IL-6, TNF (tumor necrosis factor)-α, SCUBE1 and SCUBE2 levels were studied by ELISA method. Patients with oligoarticular JIA were classified as Group 1, patients without oligoarticular JIA as Group 2 and these two groups were compared according to the blood results of cytokines and SCUBE’s mentioned above.
Results: A total of 24 patients, 11 (45.8%) were male and 13 (54.2%) female, aged between 2 and 17 years old, who were diagnosed with JİA, were included in the study. Fifteen (62.5%) patients were diagnosed as oligoarticular JIA, eight (33.3%) patients polyarticular JIA and one (4.2%) patient systemic JIA. İn the active phase of disease, IL-1 and IL-6 levels found significantly higher in Group 2 than in Group 1 (p=0.01 and p=0.004, respectively). TNF-α and SCUBE1 levels were higher in healing phase of the disease than in active phase (p=0.03 and p=0.01, respectively). TNF-α levels were higher in the active period of the disease than in the control group (p=0.02). SCUBE1 levels in the healthy control group were found to be significantly higher than the active period of the disease (p=0.009). TNF-α levels were higher in the recovery period of the disease than in the control group (p=0.004). SCUBE1 and TNF-α levels were found to be higher in the healing period of disease than in the active period (p=0.02 and p=0.03, respectively). SCUBE2 levels were found to be higher in patients with thrombocytosis in acute period (p= 0.01).
Conclusion: These results concluded that SCUBE can not be used as early biomarker in JIA, but SCUBE may has a role of JIA pathogenesis. We believe that this situation can be elucidated by studies on more patients in this regard.
Disclosure of Interest
P067 FEATURES OF IMMUNOLOGICAL PARAMETERS IN CHILDREN WITH VARIOUS ARTICULAR PATHOLOGIES.
Anna Y. Spivakovskaya1, Yuri Spivakovskiy1, Yuri Chernenkov1
1Depertment of Hospitality Pediatrics, Saratov State Medical University, Saratov, Russian Federation
Correspondence: Anna Y. Spivakovskaya
Introduction: Timely diagnosis of various diseases of their nature, manifested by inflammatory changes in the joint apparatus of the child, is one of the priority tasks of modern children's rheumatology. Juvenile idiopathic arthritis (JIA) remains one of the most serious and potentially disabling diseases. At the same time, one of the most complicated tasks is the timely differential diagnosis of various variants of the articular form of juvenile arthritis and reactive arthropathy (ReA).
Objectives: To determine the concentration of individual Th1- (IL-1β, IL-6, INF-γ), Th2- (IL-4) and Th17-associated interleukins (IL-17) in serum in children with JIA and ReA.
Methods: The study involved 78 children, aged 1.1 years to 16.11 years. A group of children with a verified diagnosis of JIA consisted of 56 patients - 30 patients with an oligoarticular variant of the course of the disease and 26 with a polyatricular variant, an average age of 10.2 ± 3.8 years, a group of ReA - 22 children an average age of 7.49 ± 3.95 years. To compare the revealed relationships, a similar analysis was carried out in the group (n = 20) of relatively healthy children, the average age was 9.2 ± 3.99 years.
The concentration of interleukins in the blood serum was determined by ELISA using ready-made commercial kits for the detection of IL-1β IL-4 IL-6 INF-γ from Vector-Best Europe (Novosibirsk, Russia) and IL-17 firm "eBioscience" (Vienna, Austria).The work was carried on the automated enzyme immunoassay analyzer "Lazurite" (Dynex Technologies Inc., USA).
Results: In children with JIA, a higher concentration of Th1-associated cytokines was observed with respect to similar parameters in children with ReA and from the comparison group, so the concentration of IL-1β was 1.5-2 times higher than in patients with ReA and in relatively healthy children , INF-ɣ was 1.9 times higher than in patients with ReA and 3.5 times higher than the values in the comparison group. At the same time, the concentration of Th2-associated cytokine (IL-4) in the blood serum of children with JIA was practically the same as for the comparison group and children with ReA.
In patients with ReA, in the absence of significant differences in the concentration of IL-1β, IL-6, IL-4 in the blood serum from similar parameters in relatively healthy children, 1.8-fold increase in the INF-отмеча level and a 1.5-fold decrease concentration of IL-17.
In children with articular form of JIA and ReA, there was a mixture of immune responses toward the activation of Th1-associated cytokines relative to the parameters of the comparison group, but with JIA this imbalance was greater than in patients with ReA. A key role in mixing immune responses towards the activation of Th1 cells in patients with ReA was played by a change in the ratio INF-ɣ / IL-4. A change in the balance in the Th1 / Th17 cell system was due to a change in the INF-ɣ / IL-17 ratio.
When performing the correlation analysis in patients with different variants of articular pathology, the following significant correlation pairs were obtained: for the oligoarticular version of JIA-INF-ɣ and IL-4; polyarticular JIA-IL-1β and IL-4, IL-1β and IL-17, IL-6 and IL-17; ReA-INF-ɣ and IL-17, 1β and IL-17.
Conclusion: The course of JIA and ReA is characterized by a definite unidirectional disorder in the Th1- and Th2-associated cytokines, which fits into the overall picture of the deployment of the cascade of immuno-inflammatory reactions, which is relatively universal, but both by the severity of the established imbalance and by the nature of the revealed relationships immunological parameters has its own characteristics. The most informative at the stage of the differential diagnostic process of the joint form of JIA and ReA can be considered an interrelated analysis of the immunological activity of the inflammatory reaction.
Disclosure of Interest
P068 ANTI-CYTOSOLIC 5′-NUCLEOTIDASE 1A AUTOANTIBODIES ARE COMMON IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS AND ARE NEGATIVELY ASSOCIATED WITH UVEITIS IN PATIENTS WITH OLIGOARTICULAR DISEASE
Sarah L. Tansley1, Zoe E. Betteridge2, Diana Bosneaga2, Eleanor Pring2, Daniel M. Slade2, Angela Midgley3, Michael Beresford3, Andrew Dick4, Wendy Thomson5, Lucy R. Wedderburn6, Athimalaipet Ramanan4, Neil J. McHugh2 and Childhood Arthritis Prospective Cohort Study
1Rheumatology, Royal National Hospital for Rheumatic Diseases; 2Pharmacy and Pharmacology, University of Bath, Bath; 3University of Liverpool, Liverpool; 4University of Bristol, Bristol; 5University of Manchester, Manchester; 6Institute of Child Health, UCL, London, UK
Correspondence: Sarah L. Tansley
Introduction: Autoantibodies targeting cytosolic 5′-nucleotidase 1A (cN1a) were first identified in adults with inclusion body myositis but have subsequently been reported in a variety of other autoimmune diseases. They have recently been described in patients with Juvenile Idiopathic Arthritis (JIA) but to date clinical associations are unknown .
Objectives: We aimed to determine the prevalence and clinical associations of anti-cN1a in a UK cohort of patients with JIA.
Methods: We screened sera from 227 patients with JIA enrolled in the Childhood Arthritis Prospective cohort study for anti-cN1a by ELISA (16 systemic, 98 oligoarthritis, 52 rheumatoid factor negative polyarthritis, 12 rheumatoid factor positive polyarthritis, 9 enthesitis related arthritis, 16 psoriatic, 12 undifferentiated). In addition, sera from 45 healthy juvenile controls, 52 patients with Juvenile-onset myositis (JDM) and 20 patients with Juvenile onset Systemic Lupus Erythematosus (JSLE) were also screened. The negative cut-off was defined as more than 5 standard deviations above the mean of 34 normal healthy (adult) serum controls.
Results: Anti-cN1a were not identified in any healthy controls nor children with JDM but were present in 3 (15%) of patients with JSLE.
Anti-cN1a were present in 19 (8%) of children with JIA. They were present in all ILAR defined subgroups with the exception of systemic-onset JIA and were most common in those with enthesitis related JIA (22% anti-cN1a positive).
JIA patients with anti-cN1a were typically older at disease onset, although the age range was wide, median 8.8 years (IQR 2.7-12.1) versus 5.5 (IQR (2.0-11.0). The proportion of females was similar in both groups (74% anti-cN1a positive and 66% anti-cN1a negative). Patients with anti-cN1a were more likely to be ANA positive 84% versus 53% (p=0.02) a dense fine speckle or homogenous immunofluorescence pattern was most common but different immunofluorescence patterns and ANA negative individuals were found in both groups.
Data on uveitis was limited to 139 JIA patients (10 patients with anti-cN1a). Three patients with anti-cN1a had a history of uveitis (one each of rheumatoid factor negative polyarthritis, enthesitis related arthritis and psoriatic arthritis) compared to 56 of 129 patients with available data who were anti-cN1a negative. Of the 68 patients with oligoarthritis with uveitis data, 10 were anti-cN1a positive and this group were less likely to develop uveitis than oligoarthritis patients who were anti-cN1a negative (p=0.03).
Conclusion: cN1a is a common target of circulating autoantibodies in UK children with JIA and are seen in all subtypes except systemic JIA. In patients with oligoartiuclar JIA, who are at a higher risk of uveitis, the presence of anti-cN1a was negatively associated with a history of uveitis. Further work is needed but patients with oligoarticular JIA and anti-cN1a may be at a lower risk of uveitis and may therefore not require as frequent ophthalmological screening.
1. Yeker, R.M., et al., Anti-NT5C1A autoantibodies are associated with more severe disease in patients with juvenile myositis. Ann Rheum Dis, 2018. 77(5): p. 714-719.
Disclosure of Interest
P069 ‘A FIRST-DEGREE RELATIVE WITH PSORIASIS’ AS A CRITERION FOR THE ILAR CLASSIFICATION SYSTEM FOR JUVENILE IDIOPATHIC ARTHRITIS
Roselie Achten1, Joost Swart1, Gabriella Giancane1, Tom Wolfs1, Michael Hofer1, Ekaterina Alexeeva1, Violeta Panaviene1, Susan Nielsen1, Jordi Anton1, Florence Uettwiller1, Valda Stanevica1, Maria Trachana1, Denise Pires Marafon1, Constantin Ailioaie1, Elena Tsitsami1, Sylvia Kamphuis1, Troels Herlin1, Pavla Dolezalova1, Gordana Susic1, Berit Flato1, Flavio Sztajnbok1, Angela Pistorio1, Alberto Martini1, Nicolino Ruperto1, Nico Wulffraat1
1PRINTO, Istituto Gaslini, Genova, Italy
Correspondence: Roselie Achten
Introduction: Literature showed the importance of classifying patients into the right Juvenile Idiopathic Arthritis (JIA) category to provide them with optimal treatment1. However, a substantial amount of patients were classified as ‘undifferentiated JIA’ (UJIA) due to the strict exclusion criteria, harbouring the risk of losing the indication of the preferred treatment.
Objectives: The aim of this study was therefore to investigate the influence of ‘a first-degree relative with psoriasis’, which is an inclusion criterion for psoriatic arthritis and an exclusion criterion for the ‘remaining five JIA categories’. This results in more insight in the accuracy of the classification system for JIA from the International League of Associations for Rheumatology (ILAR).
Methods: Analyses were made in a retrospective and prospective cohort of 8,309 patients with JIA. 606 patients were classified as UJIA, 303 patients as ‘psoriatic arthritis’ (PSA) and 7,400 patients as one of the ‘remaining five categories’.
Results: 225 (37.1%) patients with UJIA had ‘a first-degree relative with psoriasis’. No significant difference was found between the PSA and UJIA category in the number of patients with ‘a first-degree relative with psoriasis’. None of the abovementioned 225 patients developed psoriasis during the observation period. Only 60 (20.8%) patients were classified as PSA because of the inclusion criterion of having ‘a first-degree relative with psoriasis’ in the PSA category.
Conclusion: The exclusion criterion ‘a first-degree relative with psoriasis’ increases the number of patients classified as UJIA. No significant difference was found between the PSA and UJIA category in the number of patients with ‘a first-degree relative with psoriasis’, suggesting this criterion is not of added value for the ILAR classification system for JIA. We conclude that ‘a first-degree relative with psoriasis’ is not a necessary inclusion criterion for psoriatic arthritis. For these reasons, we suggest removing the inclusion and exclusion criterion ‘a first-degree relative with psoriasis’ for all the JIA categories.
1. Beukelman T, Patkar NM, Saag KG, Et Al. 2011 American College of Rheumatology Recommendations for the Treatment of Juvenile Idiopathic Arthritis: Initiation and Safety Monitoring of Therapeutic Agents for the Treatment of Arthritis and Systemic Features. Arthritis Care Res. 2011;63(4):465–82.
Disclosure of Interest
P070 THE FREQUENCY OF JUVENILE SPONDYLOARTHROPATHIES IN CHILDREN WITH FAMILLIAL MEDITERRANEAN FEVER
Emre Ozer1, Demet Seker1, Emir Taner1, Amra Adrovic1, Sezgin Sahin1, Kenan Barut1, Oya Koker1, Ozgur Kasapcopur1
1Department of Pediatric Rheumatology, Istanbul University, Cerrahpasa Medical School, Istanbul, Turkey
Correspondence: Amra Adrovic
Introduction: Familial Mediterranean fever (FMF) is the most common monogenic autoinflammatory disease characterized with fever, recurrent episodes of self-limiting polyserositis and arthritis. FMF arthritis is generally acute monoarthritis especially in the larger joints of the lower extremities, healing without a sequelae. However some of the patients develop different type of chronic arthritis, predominantly oligoarticular juvenile idiopathic arthritis (JIA) and juvenile spondyloarthropathies (JSpA). Studies on JSpA among childhood FMF patients are scarce.
Objectives: To evaluate the frequency of JSpA in a large childhood FMF cohort. Furthermore, we aimed to define main characteristics of JSpA among childhood FMF patients.
Methods: A total of 320 juvenile FMF patients were blindly questioned according to recently proposed criteria for JSpA by 3 researchers (EO, DS, ET). A standardized case report form including demographic data, clinical features, MEFV mutation and treatment was prepared and completed for each patient. Patients fulfilled the JSpA criteria were previously classified as probable JSpA. Afterwards, an expert in pediatric rheumatology (OK) reevaluated the classified patients and some of them were confirmed to be a definite while some of them were accepted as potential JSpA patients.
Results: 37 patients (11.5%) were initially classified as potential JSpA: 32 (10%) were accepted as definite and 5 (1.5%) as probable JSpA. Demographic, clinical and treatment data of definitive JSPA patients are shown in Table 1.
Conclusion: Articular involvement compatible with JSpA could be seen in childhood FMF patients. Spondyloarthropathies were detected in 10% of childhood FMF cases. The M694V mutation is the most common MEFV mutation among JSpA patients with FMF. JSpA should be considered in childhood FMF patients, especially in those chronic arthritis, axial involvement and enthesopathy.
Disclosure of Interest
See text for description
FMF + Definite JSPA
FMF + Probable JSPA
FMF patients without JIA and JSpA
FMF + JIA (except ERA or JSpA)
Female, n (%)
Age of disease onset, mean ±SD years
7.19 ± 3.68
5.60 ± 4.93
4.91 ± 3.40
4.93 ± 3.32
Age at study, mean ±SD years
14.84 ± 3.70
13.40 ± 1.67
12.51 ± 4.43
10.73 ± 3.57
M694V mutation n(%)
19 / 30 (63.33%)
148 / 245 (60.40%)
Disease onset >6 yrs
Inflammatory back pain
17 / 32 (53.1%)
3 / 5(60%)
3 / 5(60%)
0 / 1 (0%)
0 /5 (0%)
2 / 5(40%)
0 / 15 (0%)
1 / 5(20%)
1 / 7(14.3%)
HLA-B 27 Positivity
12 / 32 (37.5%)
0 / 1(0%)
0 / 3(0%)
4 / 5(80%)
Response to NSAID
9 / 22(40.9%)
4 / 5(80%)
2 / 7(28.6%)
Limitation in Schober test (< 4 cm)
2 / 5(40%)
0 / 7(0)
21 / 26(80.7%)
Family history of SpA group of disease, dactylitis, psoriasis or presence of IBD
7 / 32(21.87%)
1 / 5(20%)
10 / 32(31.3%)
P071 DIFFERENCES IN THE PERCEPTION OF DISEASE IMPACT BETWEEN US AND ITALIAN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS: A NETWORK ANALYSIS OF VIRTUAL FOCUS GROUPS
Alessandra Alongi1, Serena Calandra1, Susan Thornhill2, Jennifer Stinson3, Stephanie Luca3, Jennifer Horonjeff4, Angelo Ravelli5, Jane E. Munro6, Esi M. Morgan7, Alessandro Consolaro5, OMERACT JIA Core Set Working group
1UNIVERSITÀ DEGLI STUDI DI GENOVA, Genoa, Italy; 2Thornhill Associates, Hermosa Beach, USA; 3The Hospital for Sick Children, Toronto, Canada; 4Columbia University Medical Center, New York; 5Istituto Giannina Gaslini, Genoa, Italy; 6Murdoch Children’s Research Institute, Melbourne, Australia; 7Cincinnati Children’s Hospital Medical Center, Cincinnati, USA
Correspondence: Alessandra Alongi
Introduction: The OMERACT JIA Core Set Working Group formed in 2015 as an international initiative to revise the existing Core Set with relevant patient/caregiver input. In efforts to develop an updated, patient-centered Core Outcome, virtual focus groups (VFGs) to identify main patient/caregivers-valued themes regarding the physical, mental, and social impact of JIA disease activity states were conducted.
Objectives: To identify and prioritize key features defining patient-perceived inactive disease state and to examine possible cross-cultural differences in the main domains
Methods: Two sets of paired VFGs were conducted with JIA patients (adolescents and young adults) and parents (split by ages of their children) in two clinics, in the US and in Italy respectively. Eligibility included prior or current experience of JIA disease inactivity (>3 months). A 3-day facilitated online board was held per group, focusing on the impact of JIA on physical, mental and social health, and the perceived differences between active and inactive JIA. Participants were asked to identify and rank their five top priority features defining inactive disease. Content analysis of transcripts was conducted independently in the two centers and compared. Coded transcripts were further analyzed using network analysis, an approach that allows to study the structure of the connections between domains and the impact of specific items, measured by centrality indexes.
Results: 86 subjects were included. Caregiver were split by ages of their children (under and over 15 years old in the US sample; under and over 10 years old in the Italian sample). Patients were split in adolescents (15-17 years old in the US sample, 15-18 years old in the Italian sample) and young adults (18-24 years old in the US sample, 19-25 years old in the Italian sample). Qualitative analysis revealed psychosocial impact and limitations in daily activities emerged as main domains in both samples; fear of relapses and burden of medications were indicated as concerns mostly by Italian patients and caregivers, while the impact on children’s activities and family life appeared relevant in US groups. Network models of ranked “top five” remission-defining items identified absence of pain as the single item with the highest degree, closeness and between centrality, indicating high relevance; others central themes in both samples were absence of functional limitations, improved engagement and autonomy. When comparing network models by the two populations, reduction of anxiety and absence of uveitis showed the greatest differences in centrality across the samples, respectively showing higher centrality in the Italian and in the US groups.
Conclusion: Data analysis revealed several domains that need to be evaluated for the development of patient/parent-centered outcomes assessment instruments. Network models revealed the central role of pain, functional limitation and restricted participation in patient-perceived remission in both populations. Main differences in the two populations include the role of relapses, treatments and secondary demands in the impact of disease. Further analysis and cross-cultural validation of the results is planned to inform the development of patient/parent-centered outcomes measures.
Disclosure of Interest
P072 POLYARTICULAR JUVENILE IDIOPATHIC ARTHRITIS WITH RHEUMATOID FACTOR: A RETROSPECTIVE MONOCENTRIC STUDY OF 46 PATIENTS
Charlotte Boussard1, Ambre Hittinger1, Pierre Quartier-Dit-Maire1,2, Wouters Carine1, Brigitte Bader-Meunier1,2
1IMAGINE Institute and Pediatric Immunology, Hematology and Rheumatology Unit, Necker-Enfants Malades Hospital, Assistance Publique Hôpitaux de Paris; 2Paris-Descartes University, Paris, France
Correspondence: Charlotte Boussard
Introduction: Rheumatoid factor (RF) positive polyarticular juvenile idiopathic arthritis (JIA) with is a rare subtype of JIA (2-5%) of patients. No series have been published on this topic.
Objectives: Our objective was to describe the demographics characteristics and the course of RF positive polyarticular JIA.
Methods: We performed a monocentric retrospective study of patients with RF positive polyarticular JIA included between 2008 and February 2018 in the database CEMARA of the French reference center for juvenile arthritis and rare pediatric systemic autoimmune diseases (RAISE). This data base has been approved by the French Commission Nationale Informatique et Libertés. We recorded patients age at onset, gender, familiy history, comorbities, growth-height charts, acute phase reactants, positivity of antinuclear antibodies (ANA) and anti-citrullinated protein antibodies (ACPA), treatments, side effects and course. Clinical remission was defined according to Wallace criteria1.
Results: Fourty-six patients (40 girls, 6 boys) were included. The median age at onset was 13 years (5-23) and the median follow-up 3 years (1-15). Sixteen patients (35%) had a familial history of auto-immunity or juvenile inflammatory rheumatism. Two patients were siblings from the same non-consanguineous parents. Fourteen patients (30%, 4/6 boys, 10/40 girls) had associated conditions: 4 patients had auto-immune diseases (thyroiditis, vitiligo, Raynaud syndrome, insulin dependent diabetes), 3 (6,5%) had bronchiectasis, 5 (10,8%) a growth retardation. Finally two patients had a Mendelian diseases: Marfan syndrome and hereditary multiple osteochondromas resulting from heterozygote mutation of EXT1. ACPA and ANA were positive in 27/33 (82%) and 19/24 (79%) patients respectively. Twenty-one patients (45,6%) had an elevation of acute phase reactants at disease onset. Eight patients (17%) had erosive arthritis within the first year of evolution. The first line treatment was METHOTREXATE for 34 patients (74%) alone in 11 patients (32%)) or in association with anti-TNF in 23 patients (67%)). Twenty-four/27 patients (88%) were treated by anti-TNF: ETANERCEPT (74%), ADALIMUMAB (11%), and INFLIXIMAB (3.7%). Other biologic agents were RITUXIMAB (n=2), TOCILIZUMAB (n=4). ABATACEPT (n=6). Sixteen patients (35%) received short or sustained treatment with corticosteroids. Primary or secondary resistance for the first biological agent occurred in 3 (6.5%) and 4 patients (8.6%) respectively. Seventeen out of 35 patients (48%) were on remission on treatment or off treatment (mean follow-up without relapse: 7 and 8 years respectively). Four patients (15%) who were treated by at least one biological agent presented side effects, which required to stop the treatment.
Conclusion: Our study confirms the severity of RF positive polyarticular JIA and emphasizes its demographic and immunological heterogeneity. This first report of bronchiectasis in this population emphasizes the need for a careful pulmonary evaluation. The frequency of family auto-immunity history and the occurrence in two siblings suggest that some FR positive polyarticular JIA might be monogenic diseases.
1. Wallace CA, Giannini EH, Huang B, Itert L, Ruperto N, Null N, et al. American College of Rheumatology provisional criteria for defining clinical inactive disease in select categories of juvenile idiopathic arthritis. Arthritis Care & Research. 1 juill 2011;63(7):929‑36.
Disclosure of Interest
P073 FREQUENCY OF THORACOLUMBAR SPINE INVOLVEMENT IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS
Selcan Demir, Fatma B. Ergen2, Hafize E. Sönmez1, Erdal Sag1, Yelda Bilginer1, Ustun Aydıngöz2, Seza Ozen1
1Department of Pediatric Rheumatology; 2Department of Radiology, HACETTEPE MEDICAL FACULTY, Ankara, Turkey
Correspondence: Selcan Demir
Introduction: Juvenile idiopathic arthritis (JIA), is the most common chronic rheumatic disease among the world and the diagnosis is based on the exclusion of other causes in the presence of arthritis, lasting at least 6 weeks in children under 16 years of age.
Objectives: We aim to assess the frequency of thoracolumbar spine (TLS) involvement and Magnetic Resonance Imaging (MRI) findings in the patients with JIA.
Methods: Patients who underwent for thoracolumbar MRI, known or suspected JIA between January 2015–2017, were retrospectively re-examined by a musculoskeletal radiologist for the presence of inflammatory (central/corner lesion, costovertebral inflammation, supraspinous or interspinous enthesitis) and erosive (wedging, central erosion) lesions. At the time of spinal MRI we also investigated the presence of sacroiliac joint (SIJ) involvement, peripheral joint (PJ) involvement and symptoms for spine involvement.
Results: Totally 108 patients were re-examined. Finally, 52 patients (mean age: 14.5±3.4) with a definitive diagnosis of JIA were enrolled in the study. Among them 41 had enthesitis related arthritis (ERA), 4 had oligoarticular (OA), 5 had polyarticular (PA) JIA, one had psoriatic arthritis (PsA) and one had systemic JIA (sJIA). Among ERA patients there were at least one inflammatory lesion in 23 (56%), one erosive lesion in 3 (%7), and both inflammatory and erosive lesions in 3 (7%) patients. In ERA patients with positive findings at TLS MRI, 19 (82%) had sacroiliitis and 14 (60%) had peripheral arthritis concurrently. 15 (65 %) were clinically asymptomatic in terms of TLS involvement (none of them had inflammatory back pain or morning stiffness, the Schober’s test [>6 cm] and chest expansion [>10 cm] were normal). Among the patients with other subtypes of JIA, there were at least one inflammatory lesion in 5 (45%) and at least 1 erosive lesion in 1 (9%). In non-ERA patients with positive findings at TLS MRI, 6 (83%) were clinically asymptomatic for TLS involvement. Of note, one patient had sacroiliitis and 5 patients had peripheral arthritis in addition to TLS involvement.
Conclusion: Although current literature indicates that spinal MRI shows insufficient evidence for detecting early JIA; with this study we demonstrated that, Inflammatory and/or erosive lesions of thoracolumbar spine can be seen in asymptomatic patients of ERA and even in non-ERA JIA patients and the majority of spinal lesions detected in asymptomatic ERA and non-ERA JIA patients were inflammatory.
Disclosure of Interest
P074 DAILY PHYSICAL ACTIVITY AND SLEEP IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS AND HEALTHY CHILDREN IN RELATION TO PAIN
Simon Esbersen1, Troels Herlin1, Birgitte T. Mahler1
1Pediatrics and Adolescents Medicine, Pediatric Rheumatology, Aarhus University Hospital, Skejby, Denmark
Correspondence: Simon Esbersen
Introduction: Around 30% of children with juvenile idiopathic arthritis (JIA) suffer from daily pain regardless of medication. Pain in JIA causes disturbances in the circadian rhythm compared to healthy children.
Objectives: To study if pain is related to disturbed sleep, physical activity, and higher JIA disease activity compared to healthy age-matched controls.
Methods: A prospective observational study was conducted between 2016 and 2018. We wanted to include 100 JIA patients and 200 healthy age-matched controls between 6-16 years old. JIA patients were consecutively asked during their routinely visits to our outpatient clinic. Controls were invited by notice on the parents IT-based communication platform in schools. They were asked to complete a sleeping schedule and a pain app daily for one week. One time they answered retrospective surveys about pain, sleep, and activity.
Results: 93 with JIA and 188 controls were included. 76% of JIA patients and 43% of controls reported pain in retrospective questionnaires. In one week's observation, 84% with JIA and 70% of controls had pain minimum once. 32% with JIA and 6 % of controls reported daily pain. Pain intensity (VAS score 0-10) reported as median [min;max] was: 1.00 [0;8.25] for JIA patients and 0.29 [0;6.29] for controls. Pain prevalence and pain intensity were significantly higher in JIA patients compared to controls (p<0.05). 55% with JIA and 90% of controls always participated in physical education, thus JIA patients were significantly less active than controls. Pain did not reduce physical activity in JIA, but pain significantly lowered the level of activity in controls (p<0.001). No significantly relation between neither sleep disturbances and study groups nor sleep disturbances and pain was found. Disease activity (JADAS-27) in JIA was significantly positively correlated to pain intensity, and significantly related to reduced physical activity (p<0.05).
Conclusion: Pain is common in JIA patients and controls. JIA patients are significantly less active compared to controls. Low physical activity in JIA is not related to pain, but to increased disease activity. Higher pain intensity is related to higher disease activity in JIA. In controls, pain is related to reduced activity.
Disclosure of Interest
P075 MUSCULOSKELETAL CONDITIONS AMONG PERINATALLY HIV-INFECTED ADOLESCENTS IN THE CAPE TOWN ADOLESCENT ANTIRETROVIRAL COHORT
Sana Mahtab1,2, Chris Scott1, Takwanisa Machemedze1,2, Susan Joubert1,2, Nana Akua Asafu-Agyei1,2, Landon Myer3, Heather J. Zar1,2
1Department of Pediatrics & Child Health, Red Cross War Memorial Children's Hospital, University of Cape Town; 2SA MRC Unit on Child & Adolescent Health; 3Epidemiology & Biostatistics, School of Public Health & Family Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
Correspondence: Sana Mahtab
Introduction: Perinatally HIV-infected adolescents (PHIVA) have been shown to have a higher risk of developing musculoskeletal diseases. Increasing access to antiretroviral therapy (ART) has dramatically improved life expectancy but little is known about musculoskeletal disease in PHIVA who are on ART in Africa.
Objectives: To study the prevalence and spectrum of musculoskeletal abnormalities in PHIVA on ART using the pediatric Gait, Arms, Legs, Spine (pGALS) screening tool.
Methods: HIV-infected and matched HIV-uninfected adolescents (HIV-) enrolled in the Cape Town adolescent antiretroviral cohort (CTAAC) had pGALS examination and screening musculoskeletal questionnaires completed by trained study clinicians. Childhood Health Assessment Questionnaires (CHAQ) were used to assess participants’ musculoskeletal health status; participants with abnormal pGALS examinations were referred to rheumatology.
Results: pGALS was performed on 473 PHIVA (median age: 13.1 years; 49% female; median age at ART initiation: 4.3 years) and 101 HIV negative adolescents (median age: 12.8 years; 54% female). Median duration on ART was 8.8 years (IQR 5.8-10.5) with 38% initiating ART at ≤2 years of age. Twenty-three percent of PHIVA were WHO HIV stage 4 at time of HIV diagnosis. At the time of pGALS screening, 60% were on two nucleoside reverse transcriptase inhibitors and a non-nucleoside reverse transcriptase inhibitor and 36% were on two nucleoside reverse transcriptase inhibitors and a protease inhibitor. Eighty percent of the PHIVA had viral load ≤100 copies/ml and the median CD4 count was 711cells/uL.
Of the 23 (4%) participants with abnormal pGALS screening, 21 (4.4%) were PHIVA and 2 (2%) were HIV negative adolescents, p=0.25. 45% of those with abnormal pGALS had abnormal CHAQ, or a positive musculoskeletal screening question. Ten (44%) of participants with abnormal pGALS screening reported physical symptoms (4 had joint pain, 3 had difficulty in getting dressed and 2 had difficulty in both getting dressed and taking stairs, 1 had joint pain along with difficulty in getting dressed and taking stairs).
Fifty percent of the PHIVA with abnormal pGALS were WHO HIV stage 4 while 22% of those with a normal pGALS were WHO stage 4, p=0.02. An abnormal pGALS was associated with longer duration of ART (median duration: 9.9 years vs 8.7 years with normal pGALS, p=0.01).
Amongst the 23 participants with abnormal pGALS, 2 PHIVA were diagnosed with Osgood-Schlatter Disease, 6 (4 PHIVA and 2 controls) with orthopedic conditions including scoliosis or osteochondroma, 9 PHIVA had underlying neurological conditions including cerebral palsy or a prior stroke and 6 PHIVA had mechanical joint conditions.
Conclusion: There was a low prevalence of musculoskeletal abnormalities in this group of PHIVA established on ART. Advanced HIV stage and longer exposure to ART were associated with musculoskeletal abnormalities. Screening for musculoskeletal abnormalities may target these subgroups of PHIVA.
Disclosure of Interest
P076 LONG-TERM PRESERVATION OF MEASLES AND RUBELLA SPECIFIC-IGG ANTIBODIES IN CHILDREN WITH JUVENILE SPONDYLARTHRITIS ON ANTI-TNF TREATMENT- A PROSPECTIVE CONTROLLED STUDY
Despoina Maritsi1, Stavroula Papailiou1, John Kopsidas1, Olga Vougiouka1, Maria Tsolia1
1Second Department of Paediatrics, Medical School, National and Kapodistrian University of Athens, Athens, Greece
Correspondence: Despoina Maritsi
Introduction: Patients with autoimmune diseases are susceptible to infections due to their defective immune system and the receiving immunosuppressive treatment. Juvenile spondylarthritis (jSpA) often requires life-long treatment with biologics, which manage to fully control the disease. However, data regarding response and long-term immunological memory to specific vaccines are lacking.
Objectives: We aimed at a comprehensive assessment of how anti-TNfα therapy interferes with vaccine-specific-IgG titers in children with jSpA.
Methods: Prospective controlled study including 41 patients with jSpA and 149 matched-healthy controls. All patients had received two doses of MMR vaccine in early childhood. Demographic, clinical and laboratory data were collected. Type and duration of treatment was recorded. Samples were collected at diagnosis and at one and two years’ follow-up. Seroprotection rates as well as measles and rubella-IgG titers were measured and expressed as GMC's. The Hospital’s Research and Ethics’ Committee approved the study; written informed consent was obtained. Statistical significance was set at p<0.05 and analyses were conducted using STATA (version 13.0).
Results: The two groups had similar demographic characteristics, vaccination history and immunization status. No significant differences were detected in terms of vaccine type, time interval between the two vaccines as well as mean elapsed time from last vaccination to blood sampling. All patients in the ERA group were HLA-B27 positive. Seroprotection rates were adequate for both groups at all times. Both rubella and measles GMC’s were significantly lower in the jSpA compared to the control group (p<0.01) at one and three years’ follow up but not at diagnosis. During the follow-up period, the jSpA group had greater decrease in antibody levels as indicated from the significant interaction effect of analysis. Subgroup analysis showed that longer disease duration was directly correlated to lower antibody concentrations (p<0.01). Subgroup analysis on other parameters tested such as uveitis, sacroileitis, enthesitis, JADAS scores and type of anti-TNFa treatment did not specifically correlate with antibody loss. The same was true for comcommitant use of synthetic DMARD's.
Conclusion: Ant-TNFα treatment seems to reduce measles and rubella GMC’s. Further studies are required to assess long-term immunity conveyed by immunizations given at an early stage in children with rheumatic diseases, especially the ones receiving biologics. However, evaluation of immunization status against all vaccine preventable diseases in such patients may be beneficiary.
Disclosure of Interest
P077 DISCORDANCES BETWEEN THE PARENT GLOBAL ASSESSMENT OF DISEASE ACTIVITY AND GLOBAL ASSESSMENT OF GENERAL WELL-BEING IN A MULTINATIONAL COHORT OF 9137 CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS
Ellen Nordal1,2, Alessandro Consolaro3, Marite Rygg3, Ingrida Rumba-Rozenfelde3, Nahid Shafaie3, Tadej Avcin3, Pierre Quartier3, Violeta Panaviene3, Nico Wulffraat3, Daniel Lovell3, Chris Pruunsild3, Gordana Susic3, Gaëlle Chédeville3, Soamarat Vilaiyuk3, Yosef Uziel3, Maria Trachana3, Pavla Doležalová3, Pekka Lahdenne3, Alberto Martini3, Nicolino Ruperto3, Angelo Ravelli3, For the EPOCA study group
1Department of Pediatrics, University Hospital of North Norway; 2UiT The Arctic University of Norway, Tromsø, Norway; 3Pediatria II Reumatologia, PRINTO, Istituto Giannina Gaslini, Genova, Italy
Correspondence: Ellen Nordal
Introduction: The parent global assessment of disease activity (PDA) has been suggested to replace the parent global assessment of overall well-being (PWB) as the main patient-reported outcome incorporated in the Juvenile Arthritis Disease Activity Score (JADAS). JADAS is an important tool in a treat-to target-strategy in children with juvenile idiopathic arthritis (JIA).
Objectives: To investigate any discordance between PDA and PWB among children with JIA.
Methods: The EPidemiology, treatment and Outcome of Childhood Arthritis (EPOCA) study collected information on the health status of children with JIA currently followed worldwide. More than 9137 children with JIA from 118 pediatric rheumatology centers in 49 countries were included, and we analyzed the PDA and PWB reported by the parents. The differences between the visual analogue 10-cm scale (VAS) (range 0-10) of PDA and PWB were assessed. Discordance was defined moderate for a VAS difference >1 and ≤3, high for a VAS difference >3, and agreement if VAS difference was ≤1.
Results: PDA and PWB were available in 8615/9137 (94.3%) of the EPOCA participants. Mean (SD) PDA was 2.1 (2.7), while mean (SD) PWD was 2.0 (2.6). Among the one-fourth of patients with a VAS difference >1, the number of active joints, percentage of children with morning stiffness, and pain scores were significantly higher in the group assessing PDA higher than PWB. In contrast, there was a higher score indicating impaired quality of life when PWB was higher than PDA (Table 1). Also, in parents assessing PWB higher than PDA, the number of girls and the age at visit were significantly higher.
Conclusion: Overall,there is a high rate of agreement between PDA and PWB. In parents rating PDA higher than PWB, patients have higher number of active joints and pain scores, and more morning stiffness, while parents rating PWB highest had lower quality of life scores.
Disclosure of Interest
Clinical characteristics of the cohort according to level of discrepancy between the parent assessment of overall disease activity (PDA) and the parent assessment of overall well-being (PWB).
PDA vs PWB
PDA >1-3 worse
PWB >1-3 worse
PDA >3 worse
PWB >3 worse
Female gender, n (%)
Age at visit (years)
11.6 (7.7; 14.8)
11.5 (7.6; 14.8)
11.3 (7.6; 14.8)
12.7 (8.7; 15.6)
10.8 (7.1; 14.9)
12.6 (9.3; 15.4)
4.0 (1.8; 7.0)
4.0 (1.9; 7.0)
3.5 (1.3; 6.7)
4.0 (1.8; 7.4)
3.5 (1.3; 6.6)
3.9 (1.8; 7.2)
0 (0; 2)
0 (0; 1)
1 (0; 3)
0 (0; 2)
1 (0; 2)
0 (0; 2)
Morning stiffness, n (%)
Stiffness duration (min)
1.0 (0; 3.5)
0.5 (0; 2.5)
3.5 (1.5; 5.5)
2.0 (0.5; 5.0)
2.5 (0.0; 5.0)
2.0 (0.0; 5.0)
Quality of Life
3 (1; 7)
2 (0; 6)
5 (3; 9)
7 (4; 11)
4 (2; 8)
8 (4; 11)
P078 BENIGN COURSE UVEITIS ASSOCIATED WITH JUVENILE IDIOPATHIC ARTHRITIS
Alessandro Poletto1, Maria Elisabetta Zannin1, Giorgia Martini1, Alessandra Meneghel1, Fabio Vittadello2, Francesco Zulian1
1Department of Woman and Child Health, University of Padua; 2Centro explora, Padua, Italy
Correspondence: Alessandro Poletto
Introduction: Up to now, few studies have been addressed to the natural history of uveitis associated to Juvenile Idiopathic-Arthritis (JIA-U) in order to properly select the treatment approach since the early disease manifestations.
Objectives: Aim of the present study was to identify the clinical characteristics of patients with benign course JIA-U in order to early select the appropriate treatment and predict the final outcome.
Methods: Patients with JIA-U with at least 3 year follow, classified according with the SUN criteria for uveitis and followed at our Pediatric Rheumatology/Ophthalmology unit entered the study. Information gathered for each patient included: sex, age at onset of arthritis and uveitis, interval time between arthritis and uveitis onset; uveitis laterality, intraocular inflammation grading, number and yearly distribution of flares, structural complications. Uveitis flare was defined as an increase of cells in the anterior chamber of 2+ or more as compared to the baseline. JIA-U patients in which DMARDs or biological agents have been started at first for arthritis have been excluded. Collected data were analyzed using descriptive statistics
Results: A cohort of 75 patients with JIA-U, with a median follow-up of 12.2 years (range 3-23.6), entered the study. In 21 (28%) uveitis has treated with just topical drugs (Group A), the remaining 54 (72%) with systemic treatments (DMARDs or biological agents etc.) (Group B). No relevant differences were found between the two groups as far as sex distribution, JIA subtype, ANA frequency or uveitis laterality. Age at uveitis onset was significantly higher in Group A (5.4 years) than in Group B (4.3 years). The interval time between arthritis and uveitis onset was also greater in Group A (1.56 years) as compared to Group B (0.85 years). No patient in Group A reported ocular complications while in Group B they were 0.61/patient. The mean number of uveitis flares during the observation period was significantly less frequent in Group A than in Group B (1.57 versus 6.96, p < 0.001). The same was observed considering the mean number of relapses/year. Interestingly, patients in Group A had no relapses during the second year of follow-up and achieved a complete uveitis remission, on just topical treatment, after mean 2.6 years from onset, significantly earlier than in severe forms (Group B) (7.37 years, p < 0.001).
Conclusion: Benign course JIA-U can be identified as self-limiting condition, with low number of relapses and lack of structural complications. Patients with uveitis onset after five years of age, interval time between arthritis and uveitis onset greater than one year and no relapses during the second year of follow-up are likely to have a mild uveitis course.
Disclosure of Interest
P079 IMPROVEMENT OF PATIENTS WITH JUVENILE IDIOPATIC ARTHRITIS IN TREATMENT WITH BIOLOGICAL THERAPY
Cespedes C. Adriana1, Villezcas C. Janeth2, Torres J. Alfonso2
1Pediatric rheumatology, High Specialty Medical Unit National Medical Center Hospital general "La Raza", Mexico; 2Pediatric rheumatology, High Specialty Medical Unit National Medical Center Hospital generates "La Raza", Coyoacan, Mexico
Correspondence: Cespedes C. Adriana
Introduction: Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in childhood. In the last two decades, advances in the knowledge of pathogenesis has allowed the development of specific biological therapies for the treatment of JIA with an improvement ACR 50 of 70% on average with anti TNF and Tocilizumab a year of treatment.
Objectives: To evaluate the improvement and adverse events in patients with juvenile idiopathic arthritis treated with biological therapy (Etanercept, Adalimumab and Tocilizumab.).
Methods: Were included patients with JIA, <16 years who received biological therapy (Adalimumab, Tocilizumab, Etanercept), for a minimum of 6 months, from 2012-2017, all had signed informed consent. Demographic variables were obtained at diagnosis, clinical characteristics, laboratory and improvement variables at the beginning of the biological, 6 months, a year and when entering the study (current).
Descriptive statistics were used, averages, frequencies and percentages for, Wilcoxon and McNemar test to measure differences between two related samples.
Statistical significance was considered p <0.05.
Results: Forty-three patients were included, 20 male and 23 female. Average age 12 years, average age at diagnosis 8 years, average evolution time before the biological 24 months. Subtypes: Polyarticular FR+ 16 (37%), Polyarticular FR– 14 (32%), enthesitis related arthritis 6 (14%), systemic 5 (12%), oligoarticular 2 (5%). Extra-articular symptoms: fever 6 (14%) uveitis 5 (12%). Average improvement ACR at 6 months, a year and current with adalimumab 66%, 76%, 74%; Tocilizumab 81%, 80%, 80% and Etarnecept 88%, 67%, 67%, respectively.
The adverse events reported were pain in the puncture site 40%, transaminasemia 9% and seroconversion of PPD 12%.
Conclusion: The ACR pedi improvement was greater than 70% with the 3 biological therapies used in this study during the first 6 months of treatment, which is maintained during 28 months of follow-up (ACR average of 66%). There is an adequate safety profile with the biological treatment, without having a tuberculosis case so far.
Disclosure of Interest
P080 A DECISION ALGORITHM TO PREDICT SYNOVITIS AND GUIDE CLINICAL MANAGEMENT IN JIA PATIENTS WITH CLINICALLY SUSPECTED TMJ INVOLVEMENT
Alessandra Alongi1, Gabriella Giancane1, Alessandro Consolaro1, Giacomo Chiappe1, Nicola Laffi1, Gian Michele Magnano1, Angelo Ravelli1
1Istituto Giannina Gaslini, Genoa, Italy
Correspondence: Alessandra Alongi
Introduction: Temporomandibular (TMJ) synovitis is a common but rarely symptomatic involvement that can lead to severe functional disabilities in children with Juvenile Idiopathic Arthritis (JIA). Individual clinical signs lack sensitivity and specificity to distinguish acute synovitis from chronic damage or functional alterations, while the current gold standard test to detect acute and chronic changes in TMJ - contrast-enhanced MRI- is demanding and not available everywhere.
Objectives: To identify potential patterns of clinical predictors of MRI findings useful to stratify risk of synovitis in patients with suspected TMJ involvement and select which patients mostly require MRI testing and which can be treated directly.
Methods: Reports from 166 JIA patients (332 TMJ) followed in our clinic who underwent contrast-enhanced MRI for suspected TMJ involvement between 2007 and 2017 were retrospectively collected and analyzed. Data included TMJ symptoms and their timing, clinical signs of rheumatological and orthodontic examinations preceding MR execution and MRI abnormalities. Using MR findings (synovial fluid, bone marrow edema, synovial enhancement, condylar head erosions, disc displacement) we estimated a latent class model that identified subgroups of patients with different synovitis probability. The ability of clinical findings to predict class membership was then assessed through a Tree Augmented Naive (TAN) Bayes model. Finally, decision analysis network and tree were estimated to identify the most advantage clinical strategy for different combinations of signs and symptoms.
Results: Latent class analysis of MR findings classified patients into low (class 1, n = 176) and high (class 2, n = 156) likelihood of TMJ synovitis. Condition probabilities of items in the two groups are showed in the table. The classes showed association with specific profiles of TMJ signs and symptoms. A TAN Bayes model predicted low (class 1), high (class 2), and intermediate (class 3) synovitis probability based on signs and symptoms with an AUC of 0,87 for class 2, 0,89 for class 1 and 0,97 for class 3. 9 variables (limitation since less than 3 months, previous TMJ synovitis, retrognathia, TMJ palpation pain, temporalis palpation pain, laterodeviation at visit, limitation for 3-6 months, reduced condylar translation, laterodeviation since < 3 months) showed direct association with class membership. Based on these variables a Bayesian decision analysis (DAN) was conducted, assigning higher rewards respectively to immediate treatment for patients in class 2, non-treatment for class 1 and testing with MR in subjects with intermediate probability (class 3). The DAN resulted in a decision tree that revealed 4 clinical scenarios where immediate treatment was most favorable, 3 where non-treatment was suggested, and 7 where testing with MR was indicated.
Conclusion: Our analysis has the potential to inform clinical practice as it can be used to stratify patients according to TMJ synovitis risk. Particularly in limited-resource settings, the model could provide a diffusible and potentially extendable tool to guide the clinical work-up selecting patients who are most likely to benefit from MR testing.
Disclosure of Interest
See text for description.
Bone marrow edema
P081 RISK FACTORS OF DEVELOPING AUTOIMMUNE THYROID DISEASE IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS
Laurie Baas1, Joost Swart1, Gabriella Giancane2, Gerd Horneff3, Michael Hofer4, Ekaterina Alexeeva5, Violeta Panaviene6, Brigitte Bader-Meunier7, Jordi Anton8, Susan Nielsen9, Fabrizio De Benedetti10, Sylvia Kamphuis11, Valda Stanevica12, Maria Trachana13, Laura Marinela Ailioaie14, Elena Tsitsami15, Ariane Klein16, Kirsten Minden17, Ivan Foeldvari18, Johannes-Peter Haas19, Jens Klotsche17, Alessandro Consolaro2, Francesca Bovis2, Francesca Bagnasco2, Angela Pistorio2, Alberto Martini2, Nico Wulffraat1, Nicolino Ruperto2
1Wilhelmina Children’s Hospital, Utrecht, Netherlands; 2Istituto Giannina Gaslini, Genova, Italy; 3Asklepios Klinic Sankt Augustin, Sankt Augustin, Germany; 4Lausanne University Hospital, Lausanne, Switzerland; 5Federal State Autonomous Institution, Saint-Petersburg, Russian Federation; 6Vilnius University, Vilnius, Lithuania; 7Université Paris-Descartes, Paris, France; 8Hospital Sant Joan de Deu, Barcelona, Spain; 9Juliane Marie Centret, Copenhagen, Denmark; 10IRCCS Ospedale Pediatrico Bambino Gesù, Rome, Italy; 11Sophia Children’s Hospital, Rotterdam, Netherlands; 12Bernu Kliniska Universitates Slimnica, Riga, Latvia; 13Hippokration General Hospital, Athens, Greece; 14“Alexandru I. Cuza” University, Iasi, Romania; 15Aghia Sophia Childrens Hospital, Athens, Greece; 16Asklepios Klinik Sankt Augustin, Sankt Augustin; 17German Rheumatism Research Centre Berlin, Berlin; 18Hamburger Zentrum für Kinder- und, Hamburg; 19German Center for Pediatric and Adolescent, Garmisch-Partenkirchen, Germany
Correspondence: Laurie Baas
Introduction: Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease of unknown origin which can be considered as an autoimmune disease.
Objectives: The aim of this study was to evaluate the frequency of symptomatic autoimmune thyroid disease (AITD) in children with JIA and to investigate if there are any factors contributing to a higher risk of developing AITD.
Methods: 8,309 patients, with a total observation time of 51,324 patient-years, were studied. PharmaChild, the largest JIA-registry was used for this, containing clinical and laboratory data. Patients who were members of the Paediatric Rheumatology INternational Trials Organisation (PRINTO) were enrolled for the registry. Numerous patient characteristics and the family history were calculated separately for the JIA patients with AITD and the patients without AITD.
Results: 96 of the 8,309 patients had AITD, which provided a prevalence of 1,2%. The median age of onset was significantly higher in the children with AITD (9,1 versus 7,1). Furthermore, significantly more females (84,4% versus 67,3%), ANA positivity (51,7% versus 40,8%), rheumatoid factor (RF) positive JIA (9,4% versus 3,8%) and psoriatic JIA (7,3% versus 3,4%) were seen in the AITD group. Additionally, the AITD group had significantly more first degree relative with any autoimmune disease (26,4% versus 13,4%), or more specific with Hashimoto’s thyroiditis (13,2% versus 2,6%). Systemic JIA was significantly less prevalent in the AITD group (3,1% versus 11,1%).
Conclusion: This study showed that there is a higher prevalence of AITD among children with JIA than in the general population. Older at diagnosis of JIA, not having systemic JIA, ANA positivity, RF positive JIA and psoriatic JIA seemed to be risk factors, as well as as having a family history of autoimmune diseases, especially first degree relatives or more specific having a family history of Hashimoto’s thyroiditis.
Disclosure of Interest
P082 PREDICTING RESPONSE TO METHOTREXATE IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS: ROLE OF BIOMARKERS
Narendra K. Bagri1, Subhradip Karmakar2, Partha Haldar3, Rakesh Lodha1, Sushil K. Kabra1
1Pediatrics; 2Biochemistry; 3Centre for Community Medicine, ALL INDIA INSTITUTE OF MEDICAL SCIENCES,NEW DELHI, INDIA, New Delhi, India
Correspondence: Narendra K. Bagri
Approximately 40% of the subjects fail to respond to 1st line therapy including methotrexate and DMARDs, thereby requiring additional therapy. This additional therapy is offered only after a failed trial of methotrexate owing to non-availability of a reliable predictive biomarker. This approach exposes children to ineffective drugs in addition to accrual of ongoing inflammation and joint deformities. Pretreatment estimation of inflammatory biomarkers like myeloid related protein (MRP) 8/14 may predict the response to methotrexate. We are presenting interim analysis of our ongoing study on role of biomarkers in predicting the response to methotrexate in children with JIA.
Objectives: To correlate baseline serum biomarkers; IL2, IL6, IL12, TNF a and MRP 8/14 levels in children with JIA before starting methotrexate with response to methotrexate as assessed by American college of Rheumatology (ACR) criteria at 3 months follow-up.
Methods: Baseline clinical characteristics of consecutive children with JIA were recorded and blood samples for estimation of biomarkers were collected prior to starting methotrexate. Clinical response at 3 months follow up was assessed as per ACR. Patients achieving ACR ≥50 were classified as responders, whereas those with ACR ≤ 30 were classified as Non-responders to methotrexate. The predictive ability of baseline levels of biomarkers for the response to methotrexate was studied using binary logistic regression models.
Results: 44 children (21 girls) with JIA who completed 3 months follow up after starting methotrexate were included for this interim analysis. 20 children were classified as responders while 14 were Non-responders. 10 subjects having an ACR between 30 and 50; have been excluded for this analysis. The median baseline values of MRP 8/14 and IL-6 were significantly higher in responders as compared to non-responders (Table 1). Children with higher baseline values of MRP8/14 and IL-6 were more likely to achieve ACR 50 or more; unadjusted OR (95%CI) 1.02 (1,1.04), p=0.047 and 1.28 (0.99,1.63), p=0.05 for MRP 8/14 and IL-6 respectively.
1. Moncrieffe H, Ursu S, Holzinger D, Patrick F, Kassoumeri L, Wade A, et al. A subgroup of juvenile idiopathic arthritis patients who respond well to methotrexate are identified by the serum biomarker MRP8/14 protein. Rheumatology. 2013 Aug;52(8):1467–76.
2. Singh G, Athreya BH, Fries JF, Goldsmith DP. Measurement of health status in children with juvenile rheumatoid arthritis. Arthritis Rheum. 1994 Dec;37(12):1761–9.
The interim analyses showed that higher levels of baseline serum MRP8/14 and IL-6 have prognostic value in predicting response to methotrexate. Estimating these biomarkers at baseline may help in predicting the therapeutic response and guiding initial therapy.
Disclosure of Interest
Baseline clinical and biomarker levels
Age at onset (months), median (IQR)
Mean delay in diagnosis (months), median (IQR)
JIA Subcategory, n
Entesitis related arthritis
Serum MRP 8/14 (pg/ml), median (IQR)
Serum IL-6 (pg/ml), median (IQR)
Serum IL-2 (pg/ml), median (IQR)
Serum TNFa (pg/ml), median (IQR)
Serum IL-12 (pg/ml), median (IQR)
P083 LEVELS OF IGG ANTIBODIES AGAINST COW’S MILK PROTEINS ARE RELATED TO DISEASE ACTIVITY IN JUVENILE IDIOPATHIC ARTHRITIS (JIA)
Anders Öman1, Miika Arvonen2, Martin Carlsson3, Panagiota Christoforaki1, Maryam Poorafshar4, Lillemor Berntson1
1Institution of Women´s and Children´s health, Uppsala University, Uppsala, Sweden; 2Department of Pediatrics, Kuopio University Hospital, Department of Pediatrics, Oulu University Hospital and University of Oulu, Oulo, Finland; 3Department of Pediatrics, Hudiksvall Hospital, Institution of Women´s and Children´s health, Uppsala University; 4Thermofisher Scientific, Uppsala, Sweden, Uppsala, Sweden
Correspondence: Lillemor Berntson
Introduction: The role of the gastrointestinal tract in pathogenesis of JIA has raised attention since some of the risk factors for JIA relate to an altered gastrointestinal immunological situation. Early introduction of cow’s milk is one such risk factor. Cow’s milk includes more than 25 different proteins. In bovine milk β-lactoglobulin is the main whey protein, but antibodies against α-lactalbumin are more common in cow´s milk allergy in children. IgG antibodies against cow’s milk antigens are produced in plasma cells in the intestinal canal. The role of these antibodies is unclear, they have been elevated in cow´s milk allergy but not in cow´s milk intolerance. IgG4 antibodies against a specific food antigen mainly relates to the degree of exposition. Antibodies against nutritional antigens in children with JIA are only scarcely studied.
Objectives: We wanted to investigate levels of antibodies against cow’s milk antigens in children with JIA, at high compared with low disease activity, and compare the results with antibody levels in healthy controls. We also wanted to evaluate whether a history of milk intolerance affected the results.
Methods: We investigated levels of IgG and IgG4 antibodies against β-lactoglobulin, α-lactalbumin and casein in serum of 65 children with different categories of JIA, at high and low disease activity, and in 30 healthy controls. The analyses were performed with an automated FEIA method, ImmunoCAP ThermoFisher. At low disease activity the majority of children were treated with metotrexat and/or biological agents. Disease activity was assessed by analysis of calprotectin by ImmunoCAP in plasma and E-SR. In the group of children reporting milk intolerance, IgE antibodies against milk antigens were analysed with ImmunoCAP.
Results: Analyses revealed a significantly higher concentration of IgG antibodies against all three milk antigens in high compared with low disease activity, Md 4.7 mgA/L compared to 3.4 (p=0.001) for IgG β-lactoglobulin, Md 2.2 mgA/L compared to 0.0 (p=0.032) for IgG α-lactalbumin, and Md 7.3 mgA/L compared to 6.9 (p=0.003) for IgG casein. There was no difference between high and low disease activity in concentration of IgG4 β-lactoglobulin. When comparing children in high disease activity with children in the control group, there was no difference regarding levels of β-lactoglobulin (p=0.29), α-lactalbumin (p=0.14) or casein (p=1.0). The levels of β-lactoglobulin in serum correlated with the levels of calprotectin in plasma in all samples at high and low disease activity, rs= 0.26 (p=0,004), as well as with E-SR, rs= 0.24 (p=0,007). There was a high correlation between E-SR and calprotectin, rs= 0.82 (p<0.001). None of the eight children with current or earlier milk intolerance had positive IgE antibodies against milk antigens and the milk intolerance did not influence levels of IgG antibodies against milk antigens.
Conclusion: In this study children with high disease activity in JIA had the same degree of antibody-production against milk antigens in serum as healthy children, but the levels were significantly decreased in lower disease activity. The stable concentration of IgG4 β-lactoglobulin was considered a sign of unchanged exposition of cow´s milk at high compared with low disease activity. Our results support influence on the gastrointestinal immune system by disease activity and treatment in JIA.
Disclosure of Interest
P084 APPLICABILITY OF THE CASPAR CRITERIA OF PSORIASIC ARTHRITIS IN A COHORT OF CHILDREN PATIENTS FOLLOWING IN A PEDIATRIC RHEUMATOLOGY UNIT OF A TERTIARY HOSPITAL
Alina L. Boteanu, Adela Alia Jimenez, Maria Angeles Blazquez Cañamero
Rheumatology, University Hospital RAMÓN Y CAJAL, MADRID, Spain
Correspondence: Alina L. Boteanu
Introduction: The ILAR consensus establishes classification criteria, dividing the JIA into 7 subcategories, with juvenile psoriatic arthritis (APsJ) being one of them. In the adult population, the CASPAR classification criteria are usually used to classify a patient with psoriatic arthritis. However, the two classifications have some differences that sometimes produce confusion
Objectives: To assess the applicability of the CASPAR classification criteria in a series of patients previously diagnosed in pediatric age of JPAs or undifferentiated arthritis by exclusion criteria to be male> 6 years old and HLA B27 positive, comparing these with the ILAR classification criteria, through the study of clinical features
Methods: Retrospective cross-sectional observational study. Clinical, epidemiological, sociodemographic and analytical variables were collected from 30 patients previously diagnosed with JPAs (6 years in HLA B27-carrying male. It was assessed whether the patients met the ILAR classification criteria as well as the CASPAR classification criteria, which, unlike the previous ones, did not exclude HLA B27 positive patients, considered the family history of the 2nd degree and added a test radiographic
Results: The mean age at diagnosis was 11.23 ± 4.6 years; 15 of them being women and 15 men. 15 (15/30) patients presented cutaneous psoriasis at some point during the follow-up, in 5/15 patients psoriasis began before arthritis while 7/15 patients were previously diagnosed with arthritis than cutaneous psoriasis; in 3/15 patients the diagnosis was simultaneous during the medical visit. 9 (9/30) patients presented a family history of 1st degree cutaneous psoriasis and 7/30 of them had a family history of 2nd grade psoriasis. Of the total number of patients, 10 of them would not meet the ILAR classification criteria, 8 because they presented as exclusion criteria being male, HLA-B27 positive and> 6 years of age, among which, 7/8 would fulfill CASPAR criteria, and 2 other patients who were not classified according to ILAR criteria, did meet the CASPAR classification criteria, given the presence in these criteria of negative RF, family history of the 2nd degree and typical radiological alterations, which are not present in the ILAR criteria. 1 (1/30) patient did not meet CASPAR criteria, and belonged to the group of patients excluded from the ILAR criteria for being male> 6 years HLA-B27 +. If we did not take into account the negative FR of the CASPAR criteria, 14 patients would not meet these criteria and if we eliminated the 2nd grade AF, 5 patients would not be classified (among them 2 who meet CASPAR and do not ILAR)
Conclusion: In our series of patients despite the fact that the presence of current skin psoriasis contributes 2 points in the CASPAR criteria, only 1 patient would not meet the CASPAR criteria, since the majority of patients present other clinical or analytical manifestations, such as the presence of negative rheumatoid factor or 2nd degree family history. Patients who do not meet criteria for PsA by exclusion criteria, practically all of them would be diagnosed with psoriasic arthritis by CASPAR criteria.
Disclosure of Interest
P085 METHOTREXATE RESPONSE IN JUVENIL IDIOPATHIC ARTHRITIS
Nilgun Cakar1, Ayten Guliyeva1, Elif Çelikel1, Fatma Aydın1, Beyza Doganay2, Z. Birsin Ozcakar1, Fatos Yalcinkaya1
1Department of Pediatric Rheumatology; 2Biostatistics, Ankara University School of Medicine, Ankara, Turkey
Correspondence: Nilgun Cakar
Introduction: Methotrexate (MTX) is a second line drug in the treatment of juvenile idiopathic arthritis (JIA), either alone or in combination with biologic agents. However, there is variation in the clinical response to MTX.
Objectives: The aim of this study was to investigate the role of factors such as age, gender, ANA status, number of active joints, and JADAS-10 in predicting MTX response.
Methods: Clinical and laboratory data of oligoarticular and polyarticular JIA patients diagnosed according to the International League of Association for Rheumatology (ILAR) criteria, who had received MTX treatment between January 2012 and March 2017, and continued MTX treatment for at least 12 months were evaluated retrospectively. The age at diagnosis, gender and ANA status were recorded. The number of active and tender joint and levels of acute phase reactants were assessed at baseline, and 3, 6, and 12 months. Disease activity score (JADAS-10) was calculated at onset of MTX and at months 3, 6 and 12. Patients' responses to MTX treatment were assessed according to the American College of Rheumatology Paediatric (PedACR) improvement criteria. At each time the patients were divided into responders and non-responders according to PedACR 30 and 70
Results: This study included 55 JIA patients (40 female). Thirt-four were oligoarticular (2 extended oligoarticular) and 21 were polyarticular (5 rheumatoid factor positive) JIA. The mean age at onset of the disease was 7.71± 4.83 years.(mean age was 6.75 ± x4.99 years in patients with oligoarthritis, 9.27 ± 4.21 years in polyarticular patients). The median JADAS 10 at beginning for all 55 children was 19 (10–40), and 16 (10-27) for oligoarticular, and 28 (19-40) for polyarticular JIA. At month 3, 45% of all patients, %41 of oligoarticular, and 52% of polyarticular JIA patients had a minimum PedACR 30 response. 13 patients (2 at 4th and, 11 at 7th months) received biologic agents along with MTX. These patients were not included in the evaluation of treatment responses at 12th month. The remaining 42 patients had PedACR 30 response at month 12. Moreover 81% of these patients (% oligoarticular, % polyarticular JIA) reached pedACR 70 response at month 12. Patients who had PedACR 30 response at 3 months had a higher rate of reaching the Ped ACR 70 response at 12 months (p=0.009). In patients with oligoarticular JIA, the 12th month Ped ACR response was negatively correlated with the number of involved joints (OR). The initial JADAS 10 did not effect the PedACR response at 3 months (OR), but it was found that the 6th month of JADAS 10, had a significant effect on PedACR 70 response at 12th month (p<0.05). Age, gender and ANA status had no effect on PedACR responses.
Conclusion: PedACR 30 response at the 3rd month, JADAS-10 at 6th month and number of active joints in oligoarticular JIA were found to be predictors of the ACR response at 12th month.
Disclosure of Interest
P086 CHARACTERIZATION OF PATIENTS WITH POLYARTICULAR IDIOPATHIC JUVENILE ARTHRITIS AND INFILTRATIVE LUNG DISEASE
Bilade Cherqaoui1, Brigitte Bader-Meunier2, Christophe Delacourt3, Isabelle Kone-Paut1, Alice Hadchouel-Duverge3
1Pediatric Rheumatology, CHU Bicetre, APHP - CEREMAIA, LE KREMLIN BICETRE; 2Pediatric Immunology & Rheumatology, Necker Hospital, APHP - RAISE; 3Pediatric Pneumology, Necker Hospital, APHP - RESPIRARE, Paris, France
Correspondence: Bilade Cherqaoui
Introduction: There is an association between juvenile idiopathic arthritis (JIA) and chronic lung disease. These pulmonary disorders are multiple - interstitial (ILD) or non-inflammatory - depending on the type of underlying JIA - mainly polyarticular or systemic. In children, because of absence of accurate and multi-center data, the management of these chronic lung diseases remain difficult.
Objectives: This work aimed to constitute a national cohort of JIA patients presenting chronic lung disease.
Methods: A retrospective multicenter study was conducted. The cases between 2007 and 2018 were obtained from appeal of French Medical societies (SOFREMIP, RespiRare, SFR, CRI, database of pediatric pulmonary arterial hypertension). JIA was defined according to ILAR criteria; all had to have chronic pulmonary disease. Exclusion criteria were: age at onset> 18 years old, systemic JIA, other documented auto-immune or auto-inflammatory disease, asthma, cystic fibrosis, bronchopulmonary dysplasia, chronic lung infection, pulmonary primitive malformation. Data regarding clinical, paraclinical, therapeutic and evolution items were collected.
Results: 8 files were selected; 4 met the study criteria. All patients had positive rheumatoid factor polyarticular JIA, with female predominance (3/4), mean age at rheumatism onset of 11.5 years (7.5-16). They all had disabling polyarthritis, involving small/big articulations, mostly symmetrical, involving neck in 3/4 and hips in 1/4 patients, X-ray erosions in 2/4 patients. All had markedly erythrocyte sedimentation rate (32-107 mm, mean=65), hypergammaglobulinemia (14.8-30.8 g/l, mean=22.5), high titers of CCP antibodies, elevated antinuclear antibodies (>1/320) - with specificities in patient 4 (SSA/SSB/RNP without criteria for any connective tissue disease); patient 2 had positive TRAK antibodies without functional consequences. Each patients had different subtypes of ILD (Table 1). Pulmonary symptoms at diagnosis were: cough (2/4), exercise dyspnea (2/4), dyspnea at rest (1/4), hemoptysis (1/4 – patient 4), digital clubbing (1/4 – patient 2), auscultation abnormalities (2/4). In patient 2, ILD/fibrosis was related to SFTPC mutation. She had familial history of dominant inheritance of lung fibrosis and 2 ascendants with inflammatory rheumatic disease (rheumatoid arthritis, unclassified). Treatment was based on oral steroids, that could be associated with variable immunomodulation. In contrast to methotrexate - used in all patients, Etanercept was associated in patient 2 with ILD worsening, that improved at treatment discontinuation. Among all patients at last visit, patient 2 was the only who needed nutritive and respiratory support, and died at age of 15 years old, 13 years after lung disease beginning, on a graft waiting list.
Conclusion: The chronic pulmonary diseases related to JIA are extremely scarce. In this cohort only ILD form was observed in positive rheumatoid factor polyarticular JIA patients. Treatment strategies of both combined diseases were heterogeneous: oral corticosteroid was used in all, methotrexate did not seem to aggravate ILD, conversely to etanercept. The long-term interest will be to propose consensual recommendations for management of these patients. Informed consent had been obtained from the parents.
Disclosure of Interest
See text for description
Patient / Sex
1 / F
2 / F
3 / M
4 / F
Bronchiolitis Obliterans with Organizing Pneumonia
Surfactant Protein C-associated ILD
Non-specific interstitial pneumonia
Age at ILD onset (y)
Chest X-ray and scanner abnormalities
Inflammatory alveolar liquid
Eta, Toci, Aba, Inflix
P087 “ONCE A DAY, ‘CAUSE YOU’RE GETTING LOTS OF INFORMATION”: HOW CHILDREN AND YOUNG PEOPLE WITH JUVENILE IDIOPATHIC ARTHRITIS WANT TO REPORT PAIN
Rebecca R. Lee1, Amir Rashid1, Wendy Thomson2, Lis Cordingley3
1NIHR Manchester Musculoskeletal Biomedical Research Centre, Arthritis Research UK Centre for Epidemiology, Division of Musculoskeletal and Dermatological Sciences; 2NIHR Manchester Musculoskeletal Biomedical Research Centre, Arthritis Research UK Centre for Genetics and Genomics, Division of Musculoskeletal and Dermatological Sciences; 3Centre for Musculoskeletal Research, Division of Musculoskeletal and Dermatological Sciences, University of Manchester, Manchester, UK
Correspondence: Lis Cordingley
Introduction: Digital, remote, mobile health (mHealth) pain assessments are increasingly used in the research and care of children and young people (CYP) with long-term conditions, such as Juvenile Idiopathic Arthritis (JIA). However, little is currently known about the influence, impact or patient preference for particular ecological momentary assessment (EMA) techniques in pain reporting.
Objectives: To explore patient preferences of different pain assessment timing and frequencies in CYP with JIA remotely monitoring pain at home.
Methods: The study was a randomised n-of-1 crossover trial. Participants aged between 5 and 16 years of age were recruited from The Childhood Arthritis Prospective Study, UK. Participants were loaned an iPad for the duration of the study. The iPads were uploaded with My Pain Tracker (MPT), a valid and acceptable multi-dimensional pain assessment application for CYP with JIA. MPT collects information about pain intensity, severity, location, qualities and interference and can be used by CYP to track their pain independently. Participants were randomised into one of four groups. Each group followed different administrative patterns of pain assessment reporting. Four different timing schedules (once-a-week, once-a-day, twice-a-day and as-and-when pain occurred) were randomised within the groups to occur twice within an eight-week data collection period. Semi-structured interviews were conducted over the telephone at the end of the study to explore which timing schedules participants and their parents preferred and why. Questions about subjective measurement reactivity (whether participants or parents noticed a change in pain or emotion in response to particular pain reporting schedules) were also included.
Results: Fourteen CYP took part in the study (M=11.93, SD=2.65). An equal number of CYP reported that they preferred once-a-day and as-and-when reporting schedules (42.9%). As-and-when reporting facilitated flexibility in pain tracking. Some participants considered this an advantage and others, a burden. Flexibility was problematic because participants did not know what level of pain was sufficient to report or how to report when they were in school. Furthermore, CYP were not able to record and review ‘good’ or pain free days with this schedule, which CYP found valuable for evaluating the contrast with ‘bad’ pain days. Creating habits or routines was one of the most important factors for successfully remembering to report pain. A priority for CYP was capturing comprehensive information about recent pain which they could still remember. The once-a-day schedule accommodated these advantages. Higher frequency of pain reporting (more than once-a-day) was perceived to affect mood and fatigue by some participants and their parents. One parent reported a perceived physical change in their child’s pain as a response to more intense pain reporting schedules. The majority of participants and their parents did not report any subjective measurement reactivity, with some suggesting frequent assessment served as a distraction from pain.
Conclusion: To our knowledge, this is the first study to investigate the impact of different EMA schedules with CYP with JIA and persistent pain. Findings suggest that daily reporting of pain using multi-dimensional mHealth assessment tools is feasible, sustainable and a reporting preference for CYP with JIA. Findings are important for the development of administrative guidelines for new mHealth pain assessment tools.
Disclosure of Interest
P088 ANTIBODIES AGAINST CITRULLINATED PEPTIDE PROTEINS (CCP, MCV AND CYCLIC MCV) IN JUVENILE IDIOPATHIC ARTHRITIS
Talia Diaz-Prieto1, Ana Villarreal-Treviño1, Rocío Maldonado-Velázquez1, Enrique Faugier-Fuentes1, Andrés Rodríguez-García1, Carlos Núñez-Álvarez2
1Pediatric Rheumatology, Hospital Infantil De México Federico Gómez; 2Laboratory of Immunology and Rheumatology, Instituto Nacional De Ciencias Médicas Y Nutrición Salvador Zubirán, Mexico City, Mexico
Correspondence: Talia Diaz-Prieto
Introduction: Juvenile Idiopathic Arthritis (JIA), is the most frequent rheumatic disease in Pediatrics. Within the JIA, there are different subtypes, better prognosis in oligoarticular JIA, but not in JIA polyarticular rheumatoid factor (FR) positive, recent treatments allow patients to be diagnosed and treated as soon as possible to prevent joint damage. It would be useful to have biomarkers for both diagnosis and prognosis. Citrulline vimentin was recognized as a target within the family of citrullinated proteins. The presence of mutated citrullinated vimentin antibodies in JIA has been little studied.
Objectives: To determine levels of anti-citrullinated cyclic peptide, citrullinated anti-vimentin and mutated citrullinated vimentin in patients with JIA. Describe clinical and epidemiological characteristics.
Methods: Cross-sectional study, patients with JIA from Pediatric Rheumatology of the HIMFG, June 2017. Informed consent, 1ml of blood serum. ELISA technique in INCMNSZ.
Results: Total of 62 patients (n = 62), female n = 46. Anti-CCP cut-off value of 9.1U / ml, sensitivity of 71% and specificity of 97.8%. Anti-VMCc value cut 18 U / ml, sensitivity 62.9% and specificity of 88.4%, Anti-VMC value cut 18.7 U / ml, sensitivity 56.5% and specificity of 86.96%, U of Mann-Whitney anti-CMVc patients vs healthy controls p0.5976, anti-CCP patients vs healthy controls p0.5220, anti-VCM patients vs healthy controls p0.003. 12 patients were reported with anti-CCP negative and positive for anti-VMC.
Conclusion: A significant difference was observed in anti-MCV levels compared to healthy controls. The anti-VMC could be supportive in the diagnosis of Juvenile Idiopathic Arthritis.
Disclosure of Interest
P089 ROLE OF ANTI-CCP, HSCRP AND MUSCULOSKELETAL ULTRASOUND IN DETECTION OF DISEASE ACTIVITY AND SEVERITY OF JUVENILE IDIOPATHIC ARTHRITIS
Mervat Eissa1, Mona M. Elmetwally2, Aldosoki A. Fouda2, Mohammed T. M. Abdelhak3, Samia A.-H. Abdel-Mageed2
1Department of rheumatology and rehabilitation, Cairo University; 2Department of rheumatology and rehabilitation; 3Department of Radiology, Al Azhar University, Cairo, Egypt
Correspondece: Mervat Eissa
Introduction: Juvenile idiopathic arthritis is a common systemic autoimmune inflammatory disease. Anti-CCP is important biomarker to differentiate those patients with aggressive JIA. hs CRP could identify patients in clinical remission and their risk of disease relapse. Ultrasound on the joints is more sensitive in the detection of disease activity than clinical examination alone. The aim: evaluate the role of anti-CCP 2and hs CRP, MSUS in early detection of activity of JIA.
Objectives: Evaluate the role of anti-CCP 2 and hs CRP, MSUS, and Doppler study in early detection of activity of JIA children
Methods: Assessment of the disease activity of JIA was done using the Juvenile Arthritis Disease Activity Score (JADAS27). Conventional radiography, musculoskeletal US examination in a minimum of two planes (longitudinal and transverse) and Global ultrasound score were done for all 60 patients. Blood tests included (IgM RF was assayed using quantitative immunonephelometry test, hs CRP and Anti-CCP 2 (IgG) was measured by commercially available second-generation ELISA kits DiastatTM Axis, Shield Diagnostics, Dundee, Scotland) were done for all patients and 20 healthy control.
Results: 60 JIA patients; (41.66%) males and (58.33%) females. Their mean age was 7.9. Their mean disease duration 3.5. They were divided according to disease activity into 2 groups: group 1: 30 patients with JADAS27 score <3.8, group 2: 30 JIA patients of high disease activity according to JADAS27 score ≥3.8 There was a highly significant positive correlation between ESR, CRP, hs CRP and JADAS27. On the other hand, there was a non-significant positive correlation between anti-CCP levels and JADAS27. Global ultrasound score had a highly significant positive correlation with JADAS27 P < 0.001. Global ultrasound score had a significant positive correlation with hs CRP. Diagnostic performance of different parameters in discrimination of disease activity of group I and group II ROC curve, hs CRP was more sensitive in early detection of disease activity followed by ultrasound score while anti-CCP and routine CRP showed lower global sensitivity
Conclusion: hs CRP, MSUS Doppler are important tools in detection of activity of JIA children.
Disclosure of Interest
P090 JUVENILE IDIOPATHIC ARTHRITIS AND THE TEMPOROMANDIBULAR JOINT:PREVALENCE, CLINICAL FACTORS AND DIAGNOSTIC TOOLS
Lina von Schuckmann1, Ivan Foeldvari1, Anna Suling2, Jens Klotsche3, Bärbel Kahl-Nieke4
1Hamburg Center for Pediatric and Adolescent Rheumatology, Am Schoen Klinik Eilbek; 2Department of Medical Biometry and Epidemiology, University Medical Centre Hamburg-Eppendorf, Hamburg; 3German Rheumatism Research Centre, Berlin; 4Department of Orthodontics, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
Correspondence: Ivan Foeldvari
Introduction: Temporomandibular joint (TMJ) involvement occurs around 30 to 80 % in children with Juvenile idiopathic Arthritis (JIA). The correlation with certain subtypes with hypothesized. There are several studies looeked at predictors of TMJ involvement. We reviewed in a monocentric study a large patient population to asses the prevalence in the different subtypes and prognostic markers for the TMJ involvement.
Objectives: To study the prevalence of TMJ involvement, as well as associated clinical signs, symptoms and factors in children with JIA.
Methods: We performed a retrospective chart review on 3,999 consecutive patients who were followed in the Hamburg Centre for Paediatric and Adolescent Rheumatology Eilbek between January 2010 and July 2012. Demographic, clinical, laboratory and radiographic data were collected. TMJ involvement was diagnosed clinically by the attending rheumatologist, or radiologically by MRI.
Results: 35 % of 2,413 included patients had TMJ involvement. In a multivariable analysis we found female sex (p = 0.021), increasing number of joints with active arthritis (p < 0.001) and antinuclear antibody (ANA) positivity (p = 0.023) were significantly associated with TMJ involvement. In the oligoarticular group (persistent and extended) was a positive association of TMJ involvement and age (OR = 1.07, p < 0.001), while this association was negative in the enthesitis related arthritis group (OR = 0.94, p = 0.015). A significant correlation revealed between pathological MRI results and laterotrusion of the chin (p = 0.012) and pain on palpation (p = 0.020).
Conclusion: Based upon our data we cannot recommend one unique clinical parameter to diagnose TMJ involvement, and MRI is still the gold standard to assure the diagnosis. Female sex, ANA positivity and disease activity were correlated significantly with an increased OR for TMJ involvement, and a significant interaction between age and JIA categories (oligoarticular and enthesistis related arthritis) was found. Further prospective controlled studies are still needed.
Disclosure of Interest
P091 VALIDATING AND DEVELOPING A SELECTED QUESTIONNAIRE TO PREDICT EARLY DIAGNOSIS OF JUVENILE IDIOPATHIC ARTHRITIS IN GERMAN POPULATION
Tristan Scheer1, Jens Klotsche2, Claudio Len3, Ivan Foeldvari4
1Asklepius campus Semmelweiss University Budapest, Hamburg; 2German Rheumatism Research Center, Berlin, Germany; 3Pediatric Rheumatology Unit, São Paulo Federal University, São Paulo, Brazil; 4Hamburg Center for Pediatric and Adolescent Rheumatology, Hamburg, Germany
Correspondence: Ivan Foeldvari
Introduction: Juvenile idiopathic arthritis (JIA) is the most common chronic inflammatory rheumatologic disease in children and adolescents with a prevalence of 1 in 1000 children in Germany. An early referral of children suspected to have JIA to a pediatric rheumatologist is essential for an early diagnosis and starting treatment in the therapeutic window to reach a better outcome. An easy-to-use and time efficient questionnaire originally developed by a Brazilian study group led by Claudio Len may detect children and adolescent under risk for JIA.
Objectives: To determine, whether the German version of the screening tool is reliable for the early diagnose of JIA and secondly, whether a weighting scheme of individual questions improves its diagnostic performance.
Methods: The original questionnaire was translated into German by Dr. med Ivan Foeldvari. The questionnaires were distributed among patients at the first clinical visit at the Hamburger Centre für Kinder- und Jugendrheumatologie. The questionnaire includes 12 disease-orientated questions each with three possible responses, either: “Yes”, “No” or “I don’t know”. A retrospective evaluation of patients diagnosed with JIA or with a non-inflammatory joint pain (NJP) was performed later on. The sample consisted of patients seen between August 2015 and July 2017. All patients were at least older than 2 years and younger than 17 years at the time of evaluation. Only questionnaires, which were fully answered, were evaluated. Subsequently, a weighting scheme (based on the factor loadings from a confirmatory factor analysis) of individual questions was applied in order to increase the sensitivity of the tool. Standard statistical techniques were used to find associations between the sum scores and clinical characteristics and to compare the weighted and non-weighted sum scores.
Results: In total 165 of 800 questionnaires could be evaluated for the study. 133 (81%) were diagnosed with JIA and 32 (19%) with NJP. The group of JIA patients consisted of 79 (59%) girls, whereas the control group consisted of 21 (66%) girls. The analysis of the individual questions was performed by comparing the rate of a positive response to the questions (“Yes”) between the two groups. Four questions showed a highly significant difference by comparing answers of the control group with a subgroup of JIA patients having at least one active inflammatory joint. In particular, questions regarding physical constraints (p= 0.20; AUC= 0.62), joint pain (p= 0.040; AUC = 0.61), swelling in the joints (p= 0.040; AUC =0.60) and stamina (p= 0.047; AUC = 0.60) seem to be relevant in the diagnostic approach. A weight of 3 was assigned to the first and seventh, 2.5 to the fourth and sixth, and 1.5 to the third and fifth item. The diagnostic accuracy of the respective weighted sum score increased from 64% to 68% to discriminate between patients with JIA with at least one active joint and the control group in comparison to the ordinary sum score. An optimal cutoff of 6.0 for referral to a pediatric specialist was calculated.
Conclusion: The validation of the questionnaire showed a discriminative difference in patients with clinical diagnosed JIA and a control group diagnosed with NJP. Furthermore, the weighted sum score performed better to differentiate between JIA and NJP patients. The modified questionnaire can be useful to screen for JIA and speed up the referral to a pediatric rheumatologist.
Disclosure of Interest
ROC-Analysis of the questionnaire in different groups
Weighted Sum Score
JIA vs. musculoskeletal pain
JIA with at least one active joint vs. musculoskeletal pain
P092 METHYLENETETRAHYDROFOLATE REDUCTASE 677 NUCLEOTIDE MUTATION IS A PREDICTIVE TOOL IN METHOTREXATE NON-RESPONSIVE JIA PATIENTS
Vladimir Iacomi, Ninel Revenco
Rheumatology, Mother and Child Institute I.M.S.P., Chisinau, Moldova, Republic of
Correspondence: Vladimir Iacomi
Introduction: One of the aim of the international child arthritis associations is to provide proper treatment regimens in children with juvenile idiopathic arthritis (JIA) with proving effectiveness and safety. Methylenetetrahydrofolate reductase (MTHFR) mutations, according to Genome-Wide Association Studies (GWAS) are being involved in most toxicities. The effective response to methotrexate (MTX) treatment in JIA is remaining contradictory.
Objectives: To assess the MTHFR gene mutations in children with JIA, treated with MTX for more than 6 months, and correlate them with the Juvenile Arthritis Disease Activity Score (JADAS71) and Pediatric ACR 20,50,70,90 Index.
Methods: There has been initiated a PhD observational case-control study, involving at least 24 patients using MTX for JIA treatment. All data is processed through IBM SPSS Statistics 22 programe.
Results: There has been examined 18 children yet, including 7 (38,9%) cases of no mutation, 2 (11,1%) cases of T/T homozygotes and 9 (50%) cases of C/T heterozygotes in the 677 nucleotide of the MTHFR gene. The JADAS71 score was higher in the heterozygote cases with the mean value 18,1(p=0,0013), compared to the non-mutation sample - 2,4 (p=0,0022). The Pediatric ACR index in heterozygote sample had a mean value of 22% (p=0,0011) improvement compared to the control group - 37% (p=0,001).
Conclusion: There has been determined a significant correlation between the MTHFR gene heterozygote mutation status and the MTX non-responsiveness. The MTHFR mutation screening is an available tool in assessing immunosuppressive therapy failure.
Disclosure of Interest
P093 ‘REAL-LIFE’ USE OF MRP8/14 SERUM LEVEL MEASUREMENT IN CLINICAL PRACTICE AS A PREDICTOR OF OUTCOME AFTER STOPPING METHOTREXATE IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS
Beverley Almeida1,2, Emma J. Jordan2, Jason Palman2, Peter Bale1, Elizabeth Ralph1, Clare Heard2, Emily Robinson2, Simona Ursu2, Kimberly Gilmour1, Lucy R. Wedderburn1,2,3,4
1Great Ormond Street Hospital for Children NHS Trust, London; 2University College London Great Ormond Street Institute Of Child Health; 3ARUK Centre for Adolescent Rheumatology; 4NIHR BRC at Great Ormond Street Hospital, London, UK
Correspondence: Emma J. Jordan
Introduction: Many patients with JIA who reach clinical remission on treatment harbour residual inflammation that is not detectable by standard measures. MTX remains the first line DMARD for JIA, but is frequently poorly tolerated due to gastrointestinal side effects. After stopping MTX there is a significant risk of disease flare. Myeloid related protein (MRP) 8/14 has been shown as a marker of subclinical disease activity and a predictor of patients with risk of disease flare after stopping MTX.
Objectives: This study reviewed the impact of measuring serum MRP8/14 concentration in clinical practice, to identify patients who have reduced risk of disease flare if they stop MTX therapy.
Methods: MRP8/14 tests performed at a single paediatric centre using a commercially available assay (Bühlmann) were analysed. Patients included all subtypes of JIA, treated by MTX monotherapy at time of test and had not previously been on a biologic or other disease-modifying drug. All were considering stopping MTX. Clinically inactive disease (CID) was defined by Wallace criteria. JIA subtype, gender, age at diagnosis, disease duration, age at sample and disease activity variables were recorded at time of test and over time. Disease flare in those off MTX was defined as a patient that no longer met Wallace criteria and required new intervention. Patients who met the inclusion criteria were divided into those who did or did not meet Wallace criteria, and whether they stopped, weaned or did not stop MTX. Statistical analyses were performed using Prism Graphpad, Version 7.
Results: A total of 72 serum MRP8/14 concentrations from 72 patients were analysed. In patients who met Wallace criteria, comparison of serum MRP8/14 concentration values in those who stopped versus those who didn’t stop MTX, demonstrated statistically significant difference (Mann-Whitney test). In the group who stopped MTX (n=18), sensitivity (high MRP8/14 indicating flare) was 86%, specificity (low MRP8/14 indicating no flare) was 18% and the positive predictive value (percentage of patients with a high MRP8/14 result who went on to flare) was 40%. Flares in patients who met Wallace criteria and stopped MTX treatment were plotted over time, split by the MRP8/14 result; low (<4000ng/ml), n=6 and high (>4000ng/ml), n=1. Statistical analysis showed no significant difference between groups, likely due to small numbers in the analysis, however the trend matched previous data.
Conclusion: Measurement of serum MRP8/14 can be used in clinical practice to assist therapy decisions and as a predictor of flare post stopping MTX therapy in JIA patients who have achieved CID. However, biomarkers providing greater predictive power are needed to enable more accurate tailoring of treatment.
Disclosure of Interest
P094 WHICH ONE IS MORE EFFECTIVE ON FUNCTION AND PSYCHOSOCIAL STATUS IN JIA?: NUMBER OF JOINTS INVOLVED OR PRESENCE OF PAIN
Nur Banu Karaca1, Hafize Emine Sönmez2, Gamze Arın1, Erdal Sağ2, Aykut Özçadırcı1, Selcan Demir2, Fatma Birgül Oflaz1, Yelda Bilginer2, Edibe Ünal1, Seza Özen2
1Department of Physiotherapy and Rehabilitation, Hacettepe University Faculty of Health Sciences; 2Department of Pediatric Rheumatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
Correspondence: Nur Banu Karaca
Introduction: Juvenile idiopathic arthritis is a chronic inflammatory childhood disease with symptoms such as joint inflammation, pain, loss of quality of life. The number of joints and presence of pain cause the child to be affected psychosocially as well as affecting functional activity.
Objectives: The aim of this study is to examine the results of functional and psychosocial status according to the type of joint involvement and the presence of pain symptoms in children with JIA.
Methods: The study included 71 children diagnosed with JIA who applied to Hacettepe University İhsan Doğramacı Children's Hospital Rheumatology Department. After demographic information of children was collected, functional and psychosocial status was assessed with the scale which was developed in Hacettepe University for children with rheumatism and functional status assessed with Child Health Assessment Questionnaire (CHAQ). Children were divided into groups according to joint involvement as oligoarthritis or polyarthritis and presence or absence of pain. Mann-Whitney U test was used to compare the data.
Results: Mean age and numbers of children were shown in Table 1. There were no difference between groups, according to disease type (p>0,05). On the other hand, comparing the scores according to pain presence, CHAQ total, CHAQ general VAS assessment, functional and psychosocial status were significantly different (p<0,05).
Conclusion: It is concluded that pain is an important determinative on functional, psychosocial and overall disease assessment comparing to number of joints involved. It can be implicated that affected joint number may be compansatible by muscle activation but pain may require a central organisation to be alleviated. Thus, it must be taken into consideration that he child’s ability to cope with pain should be improved.
Disclosure of Interest
See text for description
CHAQ (General VAS)
P095 EXPERIENCES OF PARTICIPATION IN ACTIVITIES AMONG CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS
Johanna T. Kembe
1Function Area Occupational Therapy & Physiotherapy, Karolinska University Hospital, Occupational Therapy, Stockholm, Sweden
Introduction: Children with JIA are affected in participation and according to Unicef every child is entitled to daily life participation. Through participating in activities children develop abilities that form upbringing and adult life. Children with JIA have effects on participation that is caused by the disease.
Objectives: The aim of the study was to describe experiences of participation in activities among children with JIA.
Methods: A qualitative design with an interview method where eight girls in ages 12-15 have been interviewed with semi-structured interviews. Data handling has been executed according to a content analysis.
Results: Based on collected data the theme Participation influences through interaction between the individual and the surroundings with corresponding categories symptoms’ immediate effect, physical environment, strategies, personal treatment, relations and the individual’s inner life were formed. Outcome shows that children with JIA experience participation in every day life is influenced by the disease symptoms, physical environment, social environment and the individual herself. Experiences of increased participation were affected by the individual’s choice of strategies, and social environment.
Conclusion: Children with JIA experienced that participation in activities was influenced by disease symptoms, which resulted in absence, and excluding participation. The social environment could increase participation through good treatment and understanding, but the social environment could also decrease participation through misunderstanding and misinterpretation about the disease. The individual’s attitude using strategies and adjustments during activities led to increased participation, and those that chose not to, experienced a decreased participation.
Disclosure of Interest
P096 PREDICTOR FACTORS OF Q ANGLE IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS AND HEALTHY CHILDREN
Eylul P. Kisa1, Serap Inal2, Ela Tarakcı3, Nilay Arman4, Ozgur Kasapcopur5
1Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Istanbul Aydin University; 2Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Istanbul Bahcesehir University; 3Department of Neurological Physiotherapy and Rehabilitation; 4Department of Physiotherapy and Rehabilitation, Faculty of Health Science, Istanbul University; 5Department of Pediatric Rheumatology, Medical Faculty of Cerrahpasa, Istanbul University, Istanbul, Turkey
Correspondence: Eylul P. Kisa
Introduction: Juvenile idiopathic arthritis (JIA) is the childhood disability from a musculoskeletal disorder. It generally affects large joints such as the knee and the ankle. Muscle weakness, poor flexibility, atrophy, pain, and decreased proprioception of the affected joints, abnormal biomechanics, articular cartilage damage are the most common problems in patients with JIA. A greater Q angle has been suggested as a risk factor for musculoskeletal problems in various disease.
Objectives: We aimed to investigate the factors affecting Q angle in patients with JIA having pes planovalgus and healthy children.
Methods: Thirty-six participants as age range 4-16 years (25 female, 11 male) were enrolled this study. Children divided 2 groups (Group I: patients with JIA have pesplanovalgus, Group II; Healthy children). Hand held dynamometry was used to assess the strength of the lower extremity muscles. Also, Range of Motion (ROM) of lower extremity was evaluated with a universal goniometer. While static balance evaluated with Flamingo Balance Test (FBT), dynamic balance evaluated with Prokin balance system. Prokin balance system assesses perimeter length, Medium equilibrium center (A-P, M-L). Q angle was calculated by universal desktop ruler. Universal Desktop Ruler allows you to measure not only a straight-line distance but any curved distance on the screen. For statistical analysis SPSS Version 19.0 program was used.
Results: The means of age were 11.33±4.51 (Group I) and 11.28±1.87 (Group II) years. When the groups were compared with each other, Q angle was significantly higher in Group I (p=0.001). Correlations were found between strength of knee extension (r=-0.560, p=0.016) and ROM of knee flexion (r=0.528, p=0.024 with Q angle for group I. Also, Correlations were found between strength of hip abduction (r=-0.504, p=0.033), strength of hip adduction (r=-0.564, p=0.015), strength of knee extension (r=-0.470, p=0.049) and strength of ankle dorsiflexion (r=-0.713, p=0.001) with Q angle for group I. But, there was no correlation between Q angle and any parameters in Group II (p>0.05). According to linear regression analysis, Q angle was affected by only strength of knee extension for Group I (β=-0.13, p=0.000). However, it was not found relationships between FBT, A-P and M-L with Q angle for both of the groups (p>0.05).
Conclusion: Q angle as excessive dynamic knee valgus is an abnormality of neuromuscular control over the lower limb. This study shows that Q angle was significantly increased and affected by strength of knee extension negatively in patients with JIA having pes planovalgus. So, this clear result suggests that the lower extremity should be evaluated holistically and strengthening of the knee extension should be considered in the treatment of patients with JIA even if the problem is only on the ankle. Besides, in future studies should assess educational status and quality of life.
Disclosure of Interest
P097 RECESSIVE MULTIPLE EPIPHYSEAL DYSPLASIA IN DIFFERENTIAL DIAGNOSIS OF JUVENILE ARTHRITIS
Aleksey Kozhevnikov1,2, Nina Pozdeeva1, Evgeniy Melchenko1, Michael Konev1, Vladimir Kenis1, Konstantin Afonichev1, Gennadiy Novik2
1Federal state budget institution “The Turner Scientific Research Institute for Children's Orthopedics” under the Ministry of Health of the Russian Federation; 2Federal state budget institution of higher professional education “Saint-Petersburg State Pediatric Medical University” of the Ministry of Health of the Russian Federation, Saint-Petersburg, Russian Federation
Correspondence: Aleksey Kozhevnikov
Introduction: Juvenile arthritis (JA, JIA) is an umbrella-term describing a heterogeneous group of musculoskeletal diseases characterized by chronic synovitis of unknown etiology. Typical classic forms of JIA (oligo, poly, psoria, entheso) are well known. Genetic disorders with musculoskeletal involvement that mimic chronic arthritis should be considered in the differential diagnostics of JIA. The topically of the problem in children is determined by frequent cases of treatment of skeletal dysplasia by the DMARDs.
Objectives: The goal of this study was to improve the diagnosis of skeletal dysplasia manifested as JIA.
Methods: We carried out a retrospective review of more than fifty children with past-onset chronic undifferentiated arthropathy (low laboratory activity; progressive idiopathic contracture with entheso/synovitis) which were hospitalized at Children Orthopedics Institute, Saint-Petersburg between 2006 and 2016. The data of clinical of joint involvement, laboratory, x-ray, ultrasound, MRI were analyzed.
Results: All children were divided into two groups based on their disease. The first group (large) consisted of children with recessive multiple epiphyseal dysplasia (rMED/MED4, gene SLC26A2 Mut, OMIM 226900) characterized by abnormal development of the bone and cartilage of the epiphyses. A second group (small) was children with JIA. Children with congenital or early-onset forms of skeletal dysplasia and other monogenic arthritis-like diseases were excluded from study.
1. Less of morning stiffness, bilateral painless joint contractures and axial deformation of the lower limbs were the main finding of children with pseudo-rheumatoid pathology. Most children with rMED in the early childhood were characterized by a lack of signs of physiological hypermobility, reduced daily motor activity and treated of bilaterally delayed ossification of femoral heads. Morning stiffness and painful joint contractures were actually for children with JIA.
2. Radiology of JIA was characterized by inflammatory dynamic picture: overgrowth of metaepiphysis and joint osteoporosis at onset of disease, development dystrophic and erosive changes of osteochondral tissue at progressive durated and arthros-arthritis deformation like outcome. Symmetric flattening of epiphyses of hands, hips, knees and feet, double-layered patella were x-ray hallmarks of rMED. Avascular necrosis may be superimposed on rMED. Dystrophic spondylolisthesis at the L5-S1 vertebrae to 10-12 years of life was a frequent sign of epiphyseal dysplasia.
3. Instrumental sign of synovitis (ultrasound, MRI) was detected in most children. Synovitis in cases of skeletal dysplasia was secondary nature due to chronic damage and degeneration of the genetic defective articular hyaline cartilage (erosive-like chondrolysis).
4. Sensitivity to anti-inflammatory therapy was not always verified of the genesis of arthropathy and in most cases was dictated by the presence of synovitis.
Conclusion: This comparative study was revealed some clinical and instrumental characteristics of the skeletal dysplasia which mimic JIA. Early orthopedic-related "hip problems" at anamnesis, symmetric deformity of epiphyses, double-layered of patella indicate a possible of pseudo-rheumatoid genesis of arthropathy. Sequence of SLC26A2 gene should be recommended for use in cases with the not typical clinical and x-ray findings for JIA.
Disclosure of Interest
P098 SERUM CALPROTECTIN LEVELS AS A MARKER OF DISEASE ACTIVITY IN CHILDREN WITH JUVENILE IDIOPATHIC ARTHRITIS
Sathish Kumar, Anish S. George
Pediatrics, Christian Medical College, Vellore, India
Correspondence: Sathish Kumar
Introduction: Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatic disorder of childhood and encompasses a complex group of disorders comprising several clinical entities with the common feature of arthritis. Calprotectin is a calcium- and zinc-binding protein that belongs to the S100 protein family and is released during the interaction of leucocytes with inflammatory activated endothelium at the sites of inflammation as occurs in JIA. We undertook this study to assess the usefulness of Calprotectin as a marker of disease activity in Indian children with JIA.
Objectives: To assess the effetiveness of serum Calprotectin levels as a marker of disease activity in children with JIA.
Methods: Children who fulfilled the International League of Associations For Rheumatology (ILAR) criteria for JIA were recruited into the study. Baseline demographic details were collected and Blood counts, ESR, CRP and Calprotectin levels were analyzed in all children after obtaining consent. Children were then divided into 2 groups based on disease activity as per Wallace criteria. Calprotectin levels were also analysed in 10 normal healthy children. Calprotectin levels were measured by using a “Human Calprotectin Kit” which works on the basis of sandwich-enzyme linked immune sorbent assay technology (ELISA).
Results: 121 children with JIA were recruited into the study, 63 had active disease and 58 had inactive disease. Systemic onset JIA constituted 42% of the study population and was the predominant disease subtype. Calprotectin levels were elevated in children with active disease compared to those with inactive disease. Mean Calprotectin value in active disease (3954ng/ml) was 2 fold higher than those with inactive disease (1899ng/ml) (p value ˂0.001) and 16 times higher than children who were normal healthy controls (mean of 233ng/ml). Area under curve for Calprotectin was 0.744. For a cut off value of 1760 ng/ml, Calprotectin had a sensitivity of 77% and specificity of 61% for assessment of disease activity in JIA.
Conclusion: Serum Calprotectin levels was found to be a good marker of disease activity in children with JIA. However, further studies which involve serial monitoring of Calprotectin levels in a study population will provide additional information about accuracy of these markers.
Disclosure of Interest
P099 CROSS-SECTIONAL STUDY OF SERUM CALPROTECTIN LEVELS IN NON-SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS PATIENTS AND CHILDREN WITH ACUTE INFLAMMATORY DISEASE
Lovro Lamot1,2, Lea Oletić1, Mandica Vidović1, Mirta Lamot1, Marijana Miler1, Nora Nikolac Gabaj1, Miroslav Harjaček1,2
1Sestre Milosrdnice University Hospital Center; 2University of Zagreb School of Medicine, Zagreb, Croatia
Correspondence: Lovro Lamot
Introduction: in the past few years, various indicators of disease activity in juvenile idiopathic arthritis (JIA) patients have been investigated, allowing for the interpretation of different aspects of underlying inflammatory process (e.g. clinical, immunological, radiological etc.). Nevertheless, there is still evident lack of satisfactory support in diagnostic and prognostic evaluations in everyday clinical practice, focusing research activities on discovery of adequate biomarker that would support initial diagnosis and allow feasible disease monitoring. While growing number of evidence indicates phagocytic S100 proteins, like MRP8/14 complex (i.e. calprotectin), can be used to detect subclinical inflammatory activity in systemic JIA, their performance in other forms of JIA is still debatable, while in acute infectious diseases it is almost unknown.
Objectives: compare serum calprotectin (sCAL), CRP and PCT levels in patients with various forms of non-systemic JIA and previously healthy children with acute febrile illness lasting <3 days, as well as with juvenile arthritis disease activity score (JADAS).
Methods: out of 37 patients included in study, 17 were diagnosed with polyarticular form of JIA (pJIA), 8 with oligoarticular form (oJIA), 2 with juvenile spondyloarthritis (jSpA) and 10 with acute febrile respiratory illness of possible viral etiology (AFI). sCAL, PCT and CRP were measured in all of the patients, while JADAS70CRP was measured in all of the JIA patients. Inactive disease was defined as JADAS ≤1. The average duration of JIA was 64,2 (7-132) month, and all of the JIA patients were treated with standard therapy, including biological (n=16) and conventional (n=20) DMARDs. sCAL was measured by a commercial ELISA assay (Buhlmann MRP8/14, Switzerland).
sCAL μg/mL (range)
CRP mg/L (range)
PCT ng/mL (range)
All JIA patients
All AFI patients
Conclusion: preliminary results of our cross-sectional study showed sCAL correlates with JADAS in non-systemic JIA patients, although there was no significant difference between those with active and inactive disease. Interestingly, sCAL concentrations in long lasting JIA patients were significantly lower than in children with short lasting viral illness. This is a novel observation that emphasizes the need for vigilance in interpreting sCAL levels in patients with concomitant acute communicable disease and gives a possible explanation for some of the high(er) values noted in patients with clinically inactive non-systemic JIA.
Disclosure of Interest
P100 STREPTOCOCCAL SEROLOGY IN A TWO-YEAR COHORT OF JIA PATIENTS - PRACTICAL GUIDANCE
Tanya Li1, Kathy Gallagher2, Peter Bale2, Kate Armon2
1University of Cambridge; 2Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
Correspondence: Tanya Li
Introduction: For a child presenting to the paediatric rheumatology clinic with a swollen, painful joint it can be difficult to differentiate between a post-infective reactive arthritis and JIA. Antistreptolysin O titre (ASOT) and anti-DNase B can be used, but the literature suggests taking two samples 10-14 days apart for interpretation. (1) This can be difficult in the clinical setting.
Objectives: · To analyse the use and interpretation of streptococcal serology in new onset JIA patients at a tertiary hospital in the UK
· To compare this to evidence in the literature to recommend practical clinical guidance
Methods: The cohort consisted of patients with a new diagnosis of JIA made in 2016-2017. Data was collected from patient records on the following: recent illness, serology results and action taken. P values were calculated using Fisher’s exact test.
Results: 36 of the 54 patients identified had streptococcal serology (ASOT and anti-DNase B) at presentation. 16 (84%) of the 19 patients who reported a recent illness received streptococcal serology, compared to 20 (57%) of the 35 patients without recent illness. This difference was not statistically significant (p = 0.06).
There was no difference between the proportion of patients with abnormal titres in those who reported recent illness (7 of 16, 44%) compared to those without (8 of 20, 40%; p = 1). Furthermore, reporting recent illness was not associated with antibiotic use (6 of 16 (38%) compared with 4 of 20 (20%) without; p = 0.29).
In total 10 patients received antibiotics after initial serology results. 10-14 days of penicillin was always given when both ASOT and anti-DNase B titres were raised, but the decision to treat when only one titre was raised was variable. 6 of 11 (54%) patients with one abnormal titre were given antibiotics. Antibiotics were not given to patients with normal serology, or borderline ASOT alone.
No patients had repeat serology within 10-14 days. 5 patients had serology repeated, varying from 5 weeks to 14 months later.
Conclusion: This cohort consisted of patients with JIA and did not include those diagnosed with reactive arthritis, which would be valuable. ASOT typically rises 1 week after a streptococcal infection, falling between 2-8 months to baseline. Anti-DNase rises 2 weeks after infection and returns to baseline from 3-12 months. (2) A fourfold rise in titres taken 10-14 days apart provides evidence of recent streptococcal infection. However, taking repeat blood tests in young children can be both traumatic and practically difficult, with limited access to age-appropriate phlebotomy. A history of recent illness is not predictive of a raised titre in the context of JIA. A pragmatic approach, therefore, is to treat a single abnormal titre.
1. Sen ES, Ramanan AV. How to use antistreptolysin O titre. Arch Dis Child - Educ Pract. 2014 Dec 1;99(6):231–7.
2. Ayoub EM, Wannamaker LW. Evaluation of the Streptococcal Desoxyribo-Nuclease B and Diphosphopyridine Nucleotidase Antibody Tests in Acute Rheumatic Fever and Acute Glomerulonephritis. Pediatrics. 1962 Apr 1;29(4):527–38.
Disclosure of Interest
Number of patients with abnormal serology results at initial presentation (% treated with antibiotics). Reference ranges from local laboratory. Titres given in international units (IU)
Anti-DNase B (% treated with antibiotics)
Normal (< 400)
Abnormal (≥ 400)
Normal (< 200)
Abnormal (≥ 400)
P101 A UK STUDY: VOCATIONAL EXPERIENCES OF YOUNG ADULTS WITH JUVENILE IDIOPATHIC ARTHRITIS
Laura E. Lunt1,2, Matthew Bezzant3, Ailsa Bosworth3, Janet E. McDonagh1,2, Kimme Hyrich1,2, Wendy Thomson2,4, Suzanne Verstappen1,2,5
1Arthritis Research UK Centre for Epidemiology, Centre for Musculoskeletal Research, Manchester Academic Health Science Centre, The University of Manchester; 2NIHR Manchester Biomedical Research Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester; 3National Rheumatoid Arthritis Society (NRAS), Maidenhead; 4Arthritis Research UK Centre for Genetics and Genomics, Centre for Musculoskeletal Research, The University of Manchester, Manchester; 5Arthritis Research UK/MRC Centre for Musculoskeletal Health and Work, University of Southampton, Southampton, UK
Correspondence: Laura E. Lunt
Introduction: Little is known about the experiences of young adults living with Juvenile Idiopathic Arthritis (JIA) preparing for employment and career development.
Objectives: The purpose of this study was to understand the impact JIA has on career planning and early employment experiences of young adults (16-30 years).
Methods: Using existing literature (including grey literature), an online survey (consisted of 152 questions, 29 items related to young adults two of which were free text questions) was developed and sent to National Rheumatoid Arthritis Society (NRAS) members and distributed to non-members via social media tools including Facebook, Twitter and HealthUnlocked. Data collected included views and experiences in career planning and employment. The data pertaining to young adults are presented here.
Results: Of 1241 respondents 19 were young adults with JIA (range 16-30 years), 89% were female and 84% had university or equivalent qualifications. Due to incomplete responses there is missing data on all 19 young adults. 4/13 young adults were studying at university, 9/13 were in paid employment. 9/17 respondents reported their school did not offer additional work-related activities to students with disabilities and/or additional needs. 10/14 young adults felt their school did not provide advice about coping with possible limitations on placements/traineeships due to their arthritis. 11/14 respondents thought about their condition when thinking about future career plans e.g. “I wanted to work as a ranger or similar for the National Trust but it’s a fairly physically demanding job and I knew my joints would suffer so I changed track slightly”. However, 8/14 felt their career advisors did not take their arthritis into account e.g. “I had to cease my physiotherapy master’s degree as my arthritis got too bad to continue and change career choice. I wish there would have been more discussion about it not being a reasonable choice for me at the time as we just didn't have the information then”. 8/14 young adults changed their career plans because of their arthritis. Managing JIA symptoms and a physically demanding role, as well as wanting to stay healthy, were the main reason for changing career. Important aspects of employment included: good relationships with your line manager, work you like doing and a job you can use your initiative.
Conclusion: Despite small numbers these results highlight potential current unmet vocational needs of young adults with JIA in the UK and the need for further research with this age group. There appears to be a lack of structured support within schools and universities offered to students with disabilities and/or additional needs, about work-related activities and careers. Young adults with JIA actively consider their condition whilst thinking about career opportunities and value a productive and challenging job with a good working environment, including relationships with colleagues and supervisors.
Disclosure of Interest
P102 BODY MASS INDEX AND JUVENILE IDIOPATHIC ARTHRITIS: IS THERE A CORRELATION WITH SEVERITY, PROGNOSIS AND TREATMENT RESPONSE?
Ilaria Maccora, Francesca Tirelli, Edoardo Marrani, Teresa Giani, Gabriele Simonini, Rolando Cimaz
Rheumatology Unit, University of Florence, A. Meyer Children's Hospital, NEUROFARBA Department, Florence, Italy
Correspondence: Ilaria Maccora
Introduction: There is evidence that obesity could be a risk of factor for the development of RA due both to the mechanical effect of overweight and to the potential pro-inflammatory effects of cytokines produced by adipose tissue.
Objectives: To evaluate the role of overweight and obesity in a cohort of JIA patients, in terms of incidence, disease activity, outcome and response to treatments.
Methods: This single-center retrospective cohort study evaluated 125 children affected by JIA under treatment with anti-rheumatic agents (NSAIDs/IAS, DMARDs, biologic agents). Change from baseline in ERS, CRP, number of active joints (with distinction between upper and lower limb joints), and BMI was analysed under each treatment until last visit. BMI categories of 5-84th (normal weight), 85-94th (overweight), and ≥ 95th (obese) percentile were used. Patients with systemic JIA or chronic comorbidity under potentially confounding systemic treatments were excluded. Informed consent was obtained by the patients and their family.
Results: One hundred twenty-five JIA patients (36% oligoarticular JIA, 42,4% RF-negative polyarticular JIA, 0,8% RF-positive polyarticular JIA, 8% enthesitis related arthritis, l’11,2% psoriatic JIA, and 1,6% undifferentiated unclassified arthritis) were enrolled in the study, 76,8% girls, 23,3 boys. The mean age was 5,9 years (± 3,8). Baseline BMI was ≤ 84th percentile in 73,22% of patients, 85-94th in 19,64%, and ≥ 95th in 7,14%.
We did not observe a significative association between BMI and ERS (p=0,29), CRP (p=0,24), or number of active joints (p=0,45) at baseline, while the involvement of the joints of lower limb was significantly greater (p=0,025) in overweight/obese patients.
We also demonstrated a substantial equality in remission and relapse rates in subjects with different BMI.
Conclusion: This study focuses on the complex relationship between overweight/obesity and JIA. A significant correlation between obesity and a greater involvement of the joints of the lower limbs was observed at baseline. Furthermore, we observed that obesity does not influence the course of the disease nor treatment response. These data seem to suggest a prevalent mechanical effect of ponderal excess on JIA, rather than a biochemical influence due to pro-inflammatory cytokines released by adipocytes.
Disclosure of Interest
P103 JUVENILE IDIOPATHIC ARTHRITIS AND FITNESS: A TEAMWORK
Maria Cristina Maggio1, Antonio Palma2, Giuseppe Messina2, Jessica Brusa2, Angelo Iovane2, Livia Cimino1, Giovanni Corsello1
1University Department Pro.Sa.M.I. “G. D’Alessandro”; 2Department of Psychology and Educational Science, University of Palermo, Palermo, Italy
Correspondence: Maria Cristina Maggio
Introduction: Patients with Juvenile Idiopathic Arthritis (JIA) have limited fitness and reduced aerobic and anaerobic exercise capacity vs. healthy peers. Furthermore, low intensity exercise programs are safe in children with JIA and may improve fitness, joint excursion and quality of life, reduce pain, fatigue and the employ to anti-inflammatory drugs.
Objectives: The purpose of the study was to evaluate postural and balance deficits and fitness with specific test battery in children and adolescents affected by JIA.
Methods: We enrolled 30 patients with JIA (13 M; 17 F; age: 8-18 years); among those, 7 were evaluated longitudinally in the period 2016-2018, comparing the tests in different periods of the illness. The posturography test was administered with the FreeMed posturography system (the FreeMed baropodometric platform and FreeStep v.1.0.3 software). A specific fitness test battery was used to evaluate the physical fitness level of the patients (Abalakov test, backsaver sit and reach, the toe touch test, sit-up test and hand grip test).
Results: 2 M and 5 F was in an acute phase of the disease (1 sJIA; 5 polyarticular JIA; 1 psoriatic JIA).
At the posturography test, the distribution of the weight between left and right was pathological in 15 (4 sJIA; 9 polyarticular JIA; 2 oligoarticular JIA).
The load distribution between forefoot and hindfoot was pathological in all the patients, with a more severe overload in polyarticular JIA patients.
Hand-grip test in 8 patients was <3°Centile; in 11 was < 20°Centile. The patients who performed a regular physical activity program showed fitness test in the normal range, and these parameters were not correlated with the type of JIA and/or the treatment for the arthritis.
Among the patients evaluated in follow up, 2 (1 with sJIA and 1 with polyarticular JIA) maintained an asymmetry in the weight distribution between left and right and a reduced fitness. 5 patients (2 M with sJIA and 3 F with polyarticular JIA) normalized their parameters.
Conclusion: The persistent asymmetry of the load distribution between left and right foot and the persistent pathological distribution between forefoot and hindfoot was more frequent in patients with polyarticular JIA.
A regular physical activity program is the best strategy to maintain an adequate fitness and the best control of the disease.
Disclosure of Interest
P104 TITLE: “SERUM CALPROTECTIN AND JOINT ULTRASOUND IN PATIENTS WITH JUVENILE IDIOPATHIC ARTHRITIS”
Manuela Marsili1, Marina Primavera1, Giovanni Cannataro2, Caterina Di Battista1, Giuseppe Lapergola1, Roberto Troiani1, Debora d'Angelo1, Raffaella Faricelli3, Francesco Chiarelli1, M. Loredana Marcovecchio4, Luciana Breda1
1Department of Pediatrics, University of Chieti; 2Department of Neuroscience, Imaging and Clinical Sciences; 3Unit of Clinical Pathology, SS Annunziata Hospital, Chieti, Italy; 4Department of Pediatrics, University of Cambridge, Cambridge, UK
Correspondence: Manuela Marsili
Introduction: The identification of new biomarkers, the development of more effective outcome measures and the refinement of imaging techniques may foster the implementation of targeted and personalized therapeutic interventions in patients with juvenile idiopathic arthritis (JIA). Among new biomarkers, serum calprotectin (MRP8/MRP14), a complex of calcium- and zinc-binding proteins, seems to be promising. Besides, musculoskeletal ultrasonography (MSUS) is a useful imaging tool for evaluating JIA patient disease activity. Many studies have demonstrated that MSUS can improve the sensitivity and the accuracy in the detection of the exact sites of inflammation in the joint compared to the clinical examination only.
Objectives: To evaluate MRP8/MRP14 and MSUS in a group of JIA patients and to verify which of these tools best identifies disease activity.
Methods: 70 children with JIA referred to the Rheumatology Unit of the Department of Pediatrics of Chieti, were enrolled. Serum MRP8/MRP14 of each patient was detected by PhiCal Calprotectin ELISA. MRP8/MRP14 was defined normal for values < 3 μg/ml. JADAS-27 was used to define disease activity. At study enrollment, all patients underwent an ultrasound assessment of all joints clinically affected. A total of 452 joints were scanned for the presence of synovial effusion (SE), synovial hyperplasia (SH) and power Doppler (PD) signal. The ultrasound examinations technique as well as definitions and scoring features were based on guidelines provided by the OMERACT study group. In each joint, SE, SH and PD signal were graded on a 0–3 scale. The threshold used for synovial abnormalities was 1.
Results: MRP8/MRP14 serum levels were increased in active vs inactive disease patients (p-value <0.001). Significant differences between active and inactive patients were found in CRP, ESR, JADAS score and the prevalence of synovitis (Table 1). According to the score evaluating SE or SH and PD, 20 out of 28 (71.4%) JIA patients with active disease had a score equal to 2 vs 2 out 40 (4.7%) patients achieving remission (p-value 0.001). ESR, CRP, MRP8/MRP14 and synovitis with its specifics components were all positively related to JADAS-27. MRP8/MRP14 was positively correlated with presence of synovitis and its specific characteristics.
Conclusion: To our knowledge, this is the first study comparing MRP8/MRP14 and MSUS in a group of JIA patients. We found a significant association between MRP8/MRP14 levels, clinical and laboratory markers of disease activity. Moreover, we demonstrated an association between MRP8/MRP14 serum levels and ultrasonography-determined synovitis. Our study confirmed that both MSUS and MRP8/MRP14 may be considered valid and reliable tools in the assessment of synovial inflammation in JIA. Larger longitudinal studies are needed to establish the role of MRP8/MRP14 and MSUS in the diagnosis and follow-up of childhood arthritis.
Disclosure of Interest
Clinical, laboratory and ultrasound data at baseline between active and inactive patients. Data represent means ± SD or median (interquartile range)
Age at enrollment (years)
Disease duration (years)
P105 CREATION OF AN ONLINE LEARNING RESOURCE FOR JIA IN ADULTS
Joanne May1,2, Nicola Smith2, Helen Foster2
1Paediatric Rheumatology, Oxford University Hospitals, Oxford; 2Institute of Cellular Medicine, Newcastle University, Newcastle, UK
Correspondence: Joanne May
Introduction: We present the development of an evidence based online learning resource for rheumatologists who manage adolescents and adults with JIA as part of their routine practice, including translation of a learning needs analysis into learning activity design and the creation of three interactive learning modules.
Objectives: Many children and young people with JIA will continue to have active disease as adults and will need treatment delivered by adult rheumatology services. A learning needs analysis of the UK adult rheumatology community identified key areas where further training in the management of JIA is required:
- Knowledge about JIA, including understanding JIA subtypes, how JIA manifests in adults, and how JIA differs from adult onset arthritis.
- Knowledge, skills and guidance for the management of adolescents and young adults with JIA.
- Approaches to management in adults with JIA.
The JIA in Adults e-learning series was developed with the British Society for Rheumatology (BSR) to target these educational needs.
Methods: The content and format were informed through our research to gather opinion from adult and paediatric rheumatologists in the UK (Smith et al, 2017). A PACT analysis (People, Activities, Context, Technology) informed the design process. Learning activities were based on constructivist learning theory with cognitive considerations for online learning activity design: activation of prior knowledge, construction of new knowledge and knowledge transfer.
Results: The ‘People’ element of the PACT analysis was an essential consideration – experienced clinicians with a varied prior exposure to adolescent and young adult (AYA) rheumatology, both through formal training and clinical practice. Therefore, learning activities designed to activate prior knowledge and therefore optimise the foundation for further leaning were key.
Social considerations and the wider, National and Global view were used to define purpose, motivate and prepare for learning. New knowledge was presented around clinical cases so that key concepts could be explored in depth and related back to prior experience. A series of interactive cases with questioning focusing on evidence, explanation, hypothetical reasoning, cause and effect and synthesis of understanding were used to develop clinical reasoning skills and to facilitate knowledge transfer to new clinical scenarios. The inclusion of the ‘more knowledgeable other’ in the form of feedback from an expert in the field of AYA rheumatology further enhanced the development of advanced clinical reasoning.
The learning needs analysis demonstrated that many find managing the complex psychosocial needs of AYA to be particularly challenging, therefore the cases explored these particular elements in more depth.
Further cognitive considerations in the module design included enhancing learning through the use of video media, data interpretation, interviews, pictures and quizzes, and through the reduction and segmentation of text.
Conclusion: An e-learning series for adult rheumatologists who manage JIA in adults as part of their routine clinical practice was successfully created through the application of an evidence-based learning needs analysis to inform learning activity design, appropriate to the prior experience of the learners through interactive case-based learning.
Biological treatments for adults with Juvenile Idiopathic Arthritis: a clear need for improved access to targeted education and training. Nicola Smith, Tim Rapley Flora McErlane Lianne Kearsley-Fleet, Kimme L Hyrich Helen E Foster.