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5.1 Hepatitis B vaccination in juvenile idiopathic arthritis
Objective—To evaluate the responsiveness to hepatitis B vaccination in children with juvenile idiopathic arthritis (JIA) and to determine a useful vaccination schedule.
Patients and methods—39 (18 female, 21 male) children with JIA who were all in remission and HBsAg negative were enrolled into the study group. The control group consisted of 41 healthy children (21 female, 20 male). The children were divided into two groups and given two different vaccination schedules. The first group were vaccinated at 0, 1, and 3 months while the children in the second group were vaccinated at 0, 1, and 6 months respectively. Those weighing above 20 kg were vaccinated with a 20 μg dose of DNA recombinant vaccine and those below 20 kg were given 10 μg. Positive responsiveness to the vaccine was defined as an anti-HBs titre >10 mIU/ml.
Results—All children with the exception of one child with systemic JIA developed antibody response. None of the patients with JIA had a flare up or clinical deterioration related to the vaccination. There was no statistical difference of antibody levels between the subgroups of patients with JIA. The mean (SD) antibody levels in the children with JIA were significantly lower (175.5 (118.4) mIU/ml) than those of the healthy subjects (317.08 (180.5) mIU/ml) There was no difference between the sexes in vaccine responsiveness. When the antibody levels between the two vaccination schedules were compared in healthy children, there was no statistical difference. However, there was a slightly higher, but statistically insignificant, response in JIA subjects vaccinated in group II than in those in group I. The vaccine responsiveness was not influenced either by methotrexate or prednisolone treatment. However, there was a negative correlation between prednisolone dose and anti-HBs titre (r=−0.23).
Conclusion—Children with JIA responded adequately to hepatitis B vaccination, and this response was not negatively influenced by immunosuppressive treatment. The more appropriate vaccination schedule for children with JIA is the schedule given at 0, 1, and 6 months.
5.2 Prevalence of HLA class II in Sydenham chorea
Background—The relation between acute rheumatic fever (ARF) and human leucocyte antigens (HLA) is available for rheumatic heart disease. Susceptibility to Sydenham chorea (SC), a major manifestation of ARF, has been associated with the D8/17 antigen present in B lymphocytes, but data about HLA class II antigens are scarce.
Objective—To study the prevalence of HLA class II antigens among patients with SC. This was the first part of a prospective study to obtain data about HLA class I and II in patients with the different major manifestations of ARF.
Patients and methods—Patients with SC, isolated or in combination with other major manifestations of ARF, seen in our paediatric rheumatology units between 1989 and 1998, were tested for HLA class II antigens by the polymerase chain reaction with sequence-specific primers technique, with genomic DNA extracted from peripheral blood with EDTA. The frequency of HLA class II alleles was compared with that of 85 healthy volunteers using the χ2 and/or the Fischer's exact test.
30 patients (17 female, 13 male) were enrolled in the study—6 with isolated chorea and 24 with chorea and other major criteria. The mean age at diagnosis was 14.3 years and mean follow up was 45 months. A negative association with HLA-DR8 (p<0.03) was seen, and 4 of the 6 patients with chorea alone presented HLA-DR1 (χ2 with Mantel-Haenszel = 7.61; p<0.006).
Conclusions—Although the number of patients studied up to now is small, we conclude that there seems to be a gene in the HLA region which may be related to susceptibility or protection for SC.
5.3 Incidence of rheumatic fever in children in Latvia
Background—During the past five years the incidence of acute rheumatic fever has increased.
Methods—A retrospective case history analysis over the period 1994–2000 was carried out using John's criteria, including incidence, sex, age, progression and outcome of illness.
Results—107 patients were studied. 11 (10%) were aged under 7 years, 92 (86%) were aged 7–16 years, 4 (4%) were aged 16–18 years. 49 (46%) were female and 58 (54%) were male. In 44 (41%) patients the illness was accompanied by fever, in 46 (43%) by an increased C reactive protein level, in 47 (43%) by leucocytosis, in 52 (49%) by an increased erythrocyte sedimentation rate (>40 mm/1st h), in 68 (64%) by antistreptolysin O titres (from 500 to 3000 IU/l). In 61 (57%) patients arthralgia was detected and poly/monarthritis in 56 (53%). Endocarditis was detected in 60 (56%) patients, damage of the mitral valve in 34 (31%), of the aortal valve in 16 (15%), and of both the mitral and aortal valves in 10 (9%). In 5 (5%) cases pancarditis and in 84 (79%) cases myocarditis were detected. In 6 (6%) cases chorea minor was seen. A relapse of the rheumatic fever was seen in 13 (12%) children.
Conclusions—The current study underlines the fact that the severity and incidence of rheumatic fever in Latvia have increased during the past 5 years. The illness more often proceeds with endocarditis (damage of the mitral or combined mitral/aortal valves) and has reached a level of 5.1/100 000. The risk group is school age children.
5.4 PANDAS case in Latvian girl
Background—PANDAS (paediatric autoimmune neuropsychiatric disease associated with streptococci) is an acronym describing neuropsychiatric symptoms resulting from autoimmune responses to streptococcal (group A β haemolytic) infection. The diagnostic criteria for PANDAS are (a) the presence of an obsessive compulsive disorder and a tic disorder; (b) paediatric onset of symptoms (age 3 years to puberty); (c) an episodic course of symptom severity; (d) association with group A β haemolytic streptococcal infection; and (e) association with neurological abnormalities.
Objective—To describe cases of rare syndromes related to rheumatic fever.
Results—An adolescent girl aged 15 who had arthritis of both knees and feet suddenly developed emotional lability, cognitive deficits, oppositional behaviours, and motor hyperactivity. Investigation showed mitral valvulitis, regurgitation, a raised erythrocyte sedimentation rate, and an antistreptococcal antibody titre. During a six month follow up the heart disease appeared and the obsessive compulsive and tic disorders improved.
Conclusion—The PANDAS case corresponds with described diagnostic criteria (Kleinsasser, 1999, Schulman, 1999).
5.5 Juvenile spondyloarthropathy associated withMycoplasma pneumoniae infection
Objective—Reactive arthritis (ReA) has been sporadically reported as triggered byM pneumoniae. This study examined the potential relation between acute M pneumoniae infection and juvenile spondyloarthropathy (jSpA).
Patients and methods—Seven patients (4 female, 3 male) with jSpA secondary to M pneumoniae were examined. Their mean age at onset was 8.3 years (range 2–13), and the mean duration of follow up was 5.5 months (range 2.5–11). All patients had <4 joints affected. M pneumoniae-specific IgM, IgG, and IgA antibodies were serologically confirmed by enzyme linked immunosorbent assay (ELISA) tests (Savyon Diagnost, Israel). Owing to the early appearance and relatively short lifetime ofM pneumoniae-specific IgM antibodies, their detection allowed the diagnosis of acute infection using a single serum sample, confirmed by a parallel serum in 4/7 patients. Immunoglobulin concentrations higher than 10 U/l are considered positive and those higher than 50 U/l as highly positive. Specific IgA antibodies were detected in only patient.
Results—The mean recovery time was 2.5 weeks (range 1–4) in 5 patients with ReA; one patient developed juvenile rheumatoid arthritis (pauci-type II) and in one case juvenile ankylosing spondylitis was diagnosed. Two patients were HLA-B27 positive, and one patient was HLA-B7 positive. Four patients had preceding respiratory symptoms, and only two were treated with antibiotics.
Conclusion—These findings provide evidence of jSpA after an acute M pneumoniae infection. Our results suggest that detectingM pneumoniae-specific antibodies in serological screening of patients with jSpA might be useful. It is presently unclear whether antibiotic treatment would change the disease course in such patients.
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