Search

Objective To describe clinical outcomes of juvenile idiopathic arthritis (JIA) in a prospective inception cohort of children managed with contemporary treatments. Methods Children newly diagnosed with JIA at 16 Canadian paediatric rheumatology centres from 2005 to 2010 were included. Kaplan–Meier survival curves for each JIA category were used to estimate probability of ever attaining an active joint count of 0, inactive disease (no active joints, no extraarticular manifestations and a physician global assessment of disease activity 12 months after discontinuing treatment) and of receiving specific treatments. Results In a cohort of 1104 children, the probabilities of attaining an active joint count of 0 exceeded 78% within 2 years in all JIA categories. The probability of attaining inactive disease exceeded 70% within 2 years in all categories, except for RF-positive polyarthritis (48%). The probability of discontinuing treatment at least once was 67% within 5 years. The probability of attaining remission within 5 years was 46–57% across JIA categories except for polyarthritis (0% RF-positive, 14% RF-negative). Initial treatment included joint injections and non-steroidal anti-inflammatory drugs for oligoarthritis, disease-modifying antirheumatic drugs (DMARDs) for polyarthritis and systemic corticosteroids for systemic JIA. Conclusions Most children with JIA managed with contemporary treatments attain inactive disease within 2 years of diagnosis and many are able to discontinue treatment. The probability of attaining remission within 5 years of diagnosis is about 50%, except for children with polyarthritis.

Objective To examine the temporal and dose-related effects of glucocorticoids (GCs) on body mass index (BMI) in children with rheumatic diseases. Methods Children initiating GCs for a rheumatic disease (n = 130) were assessed every 3 months for 18 months. BMI, weight, and height Z score trajectories were described according to GC starting dosage in prednisone equivalents: high (≥1.0 mg/kg/day), low (

Objective.To determine whether adult disease severity subclassification systems for antineutrophil cytoplasmic antibody-associated vasculitis (AAV) are concordant with the decision to treat pediatric patients with cyclophosphamide (CYC).Methods.We applied the European Vasculitis Study (EUVAS) and Wegener’s Granulomatosis Etanercept Trial (WGET) disease severity subclassification systems to pediatric patients with AAV in A Registry for Childhood Vasculitis (ARChiVe). Modifications were made to the EUVAS and WGET systems to enable their application to this cohort of children. Treatment was categorized into 2 groups, “cyclophosphamide” and “no cyclophosphamide.” Pearson’s chi-square and Kendall’s rank correlation coefficient statistical analyses were used to determine the relationship between disease severity subgroup and treatment at the time of diagnosis.Results.In total, 125 children with AAV were studied. Severity subgroup was associated with treatment group in both the EUVAS (chi-square 45.14, p < 0.001, Kendall’s tau-b 0.601, p < 0.001) and WGET (chi-square 59.33, p < 0.001, Kendall’s tau-b 0.689, p < 0.001) systems; however, 7 children classified by both systems as having less severe disease received CYC, and 6 children classified as having severe disease by both systems did not receive CYC.Conclusion.In this pediatric AAV cohort, the EUVAS and WGET adult severity subclassification systems had strong correlation with physician choice of treatment. However, a proportion of patients received treatment that was not concordant with their assigned severity subclass.

Results Case 1 An 8 yo boy was referred to our clinic in March 2008 for 2 episodes of orbital myositis. The first episode occurred in November 2007 and involved the left eye. Investigations with a CT scan and an MRI revealed changes in the left lateral rectus muscle, felt to be consistent with a myositis. This spontaneously resolved over a few days. In January 2008, the child’s right eyelid became swollen and he had an associated diplopia. The MRI revealed a normal left rectus muscle but inflammation was observed in the right rectus muscle. Again, without treatment, the symptoms resolved. It was at that time that the patient was referred to Rheumatology. On review of systems, he was noted to have longstanding epigastric pain associated with meals. His physical examination was unremarkable. Blood tests revealed iron deficiency, microcytic anemia and an elevated ESR. He was referred to Gastroenterology. He underwent an endoscopy which confirmed the diagnosis of Crohn’s disease. There has been no recurrence of the orbital myositis since the Crohn’s disease has been in remission.

Corticosteroid related changes in body mass index in children and adolescents with rheumatic diseases Natalie Shiff, Rollin Brant, David A Cabral, Jaime Guzman, Peter B Dent, Janet E Ellsworth, Kristin M Houghton, Adam Huber, Roman Jurencak, Bianca A Lang, Maggie Larche, Claire MA LeBlanc, Paivi M Miettunen, Kiem G Oen, Johannes Roth, Claire Saint-Cyr, Rosie Scuccimarri, Leanne M Ward, Canadian STOPP Consortium

Purpose To examine the remission rates and functional outcomes in an inception cohort of patients with juvenile idiopathic arthritis (JIA). Methods The Research in Arthritis in Canadian Children, emphasizing Outcomes (ReACCh-Out) cohort is a 16-centre inception cohort of patients with JIA enrolled within 1 year of diagnosis. All patients who completed 5 sixmonthly study visits from baseline to 24 months were included in this analysis. Disease activity and functional measures were collected at each visit. Criteria for disease remission status in this study were defined by Wallace et al (2006) modified by omission of ESR or CRP due to incomplete data. Inactive disease (ID) was defined as no active joints, physician global assessment 0, and no active extra-articular disease; clinical remission on medications (CRM) is ID for ≥ 6 months on medications; and clinical remission (CR) is ID for ≥ 12 months off medications. Health status was measured using the Juvenile Arthritis Quality of Life Questionnaire (JAQQ), and functional status using the Child Health Assessment Questionnaire (CHAQ). Results

Kawasaki disease is a systemic vasculitis and the leading cause of acquired heart disease in North American and Japanese children. The epidemiology, cause, and clinical characteristics of this disease are reviewed. The diagnostic challenge of Kawasaki disease and its implications for coronary artery outcomes are discussed, as are the recommended treatment, ongoing treatment controversies, concerns associated with treatment resistance, and the importance of ongoing follow up.

Background Hemolytic anemia is a rare but reported side effect of intravenous immunoglobulin (IVIG) therapy. The risk of significant hemolysis appears greater in those patients who receive high dose IVIG. The etiology is multifactorial but may relate to the quantity of blood group antibodies administered via the IVIG product. Findings We describe 4 patients with significant hemolytic anemia following treatment with IVIG for Kawasaki disease (KD). Direct antibody mediated attack as one of the mechanisms for hemolysis, in this population, is supported by the demonstration of specific blood group antibodies in addition to a positive direct antiglobulin test in our patients. Conclusions Clinicians should be aware of this complication and hemoglobin should be closely monitored following high dose IVIG therapy.

Most population-based series reporting on the coronary artery complications after Kawasaki disease (KD) originate from Japan. This study aimed to describe the complete series of KD patients from the province of Quebec in Canada, a predominantly Caucasian population. This retrospective case series was conducted by the Quebec Kawasaki Disease Registry, a multi-institutional collaboration reviewing 89.8 % of all KD cases identified by the Ministry of Health records of hospitalization for KD from the first recognized case in 1976 until 2008. This report describes the course of 38 patients (95 % Caucasians) with a diagnosis of giant coronary artery aneurysms, which represent 1.9 % of all reviewed cases and 26.2 % of those with a coronary aneurysm 5 mm or larger. The age at diagnosis was 5.52 ± 4.04 years, and the follow-up period was 9.26 ± 6.9 years. The KD diagnosis was retrospective at autopsy in two cases and via echocardiography in four cases. The overall freedom from coronary thrombi, coronary intervention, or death was respectively 63.9, 67.5, and 85.1 %. Five deaths occurred as follows: 21 days after onset of fever (2 cases), 1.8 months after onset of fever (1 case), 1 year after retrospectively presumed but previously undiagnosed KD (1 case), and 5.7 years after a KD diagnosis (1 case of sudden cardiac death). Percutaneous transluminal coronary revascularization was attempted in four cases (1 requiring cardiac transplantation), and two other cases underwent primary bypass graft surgery. Whereas this study investigated cases of KD with severe coronary sequelae in the Province of Quebec, larger collaborative studies should be conducted for further understanding of the disease in predominantly non-Asian populations.

Objective. To determine the frequency of incident vertebral fractures (IVF) 12 months after glucocorticoid (GC) initiation in children with rheumatic diseases and to identify children at higher risk. Methods. Children with rheumatic diseases initiating GC were enrolled in a prospective observational study. Annual spine radiographs were evaluated using the Genant semiquantitative method. Spine areal bone mineral density (aBMD) was measured every 6 months. Clinical features, including cumulative GC dose, back pain, disease and physical activity, calcium and vitamin D intake, and spine aBMD Z scores, were analyzed for association with IVF. Results. Seven (6%) of 118 children (95% confidence interval 2.9-11.7%) had IVF. Their diagnoses were: juvenile dermatomyositis (n = 2), systemic lupus erythematosus (n = 3), systemic vasculitis (n = 1), and mixed connective tissue disease (n = 1). One child was omitted from the analyses after 4 months because of osteoporosis treatment for symptomatic IVF. Children with IVF received on average 50% more GC than those without (P = 0.030), had a greater increase in body mass index (BMI) at 6 months (P = 0.010), and had greater decrements in spine aBMD Z scores in the first 6 months (P = 0.048). Four (67%) of 6 children with IVF and data to 12 months had spine aBMD Z scores less than-2.0 at 12 months compared to 16% of children without IVF (P = 0.011). Conclusion. The incidence of VF 12 months following GC initiation was 6%; most children were asymptomatic. Children with IVF received more GC, had greater increases in BMI, and had greater declines in spine aBMD Z scores in the first 6 months. © 2012, American College of Rheumatology.

Background/Purpose: To determine the incidence of vertebral fracture (VF) in the three years following glucocorticoid (GC) initiation, and the effect of GC on the risk of incident VF in children with rheumatic disorders (RD). Methods: Children with RD were enrolled within 30 days of GC initiation and followed for 3 years, with VF assessed at baseline and then annually using the Genant method on lateral spine radiographs. An incident VF was defined as a new fracture in a previously normal vertebral body or worsening of an existing VF. The annual and the 3 year cumulative incidences were calculated as the number of new cases divided by the number of subjects who completed VF assessment at the specified time periods. Six different time-dependent GC exposure measures were constructed: cumulative dose, average daily dose, duration on GC therapy, dose intensity (cumulative dose divided by duration on GC therapy) over 3 years, recent average daily dose and duration on GC therapy over the preceding 12 months. Extended Cox's models were used with alternative time-dependent variables, adjusting for factors at baseline including age, gender, body mass index, vitamin D and calcium supplementation, disease activity, bone mineral density, physical activity, and presence of prevalent VF. Results: 136 enrolled children (mean ± SD age 9.9 ± 4.4 years, 65% girls) held the following diagnoses: 22% juvenile dermatomyositis (JDM), 21% non-systemic juvenile idiopathic arthritis (JIA), 19% systemic lupus erythematosus (SLE), 18% systemic JIA, 12% systemic vasculitis, and 9% other RD. 9 children had VF at baseline (3 JDM, 2 systemic JIA, 2 SLE, 1 systemic vasculitis, 1 localized scleroderma), with an estimated prevalence of 6.6% (95% confidence interval (CI) 2.4–10.8%). 18 incident VF were identified in 15 children during the 3 years following GC initiation (6 JDM, 4 SLE, 2 systemic vasculitis, 2 systemic JIA, and 1 non-systemic JIA). The 3-year cumulative VF incidence was 13.0%, at a rate of 4.9 per 100 person-years. Of the 18 incident VF events, 7 occurred during the first year at an annual incidence of 6.0% (95% CI 1.7–10.3%); 6 VF occurred during the second year (annual incidence 5.6%; 95% CI 1.2–9.9%); 5 VF occurred during the third year (annual incidence 4.3%; 95% CI 1.0–8.1%). 64% of patients had mild incident VF as the worst grade, 36% had moderate fractures, and none had severe fractures. Of those with incident fractures, 21% had no complaints of back pain in the preceding 12 months. Multivariable models showed that every 100 mg/kg increase in cumulative GC dose was associated with a 30% increased incident VF risk (hazard ratio (HR) = 1.3, 95% CI 1.1, 1.6). Every 0.5mg/kg increase in average daily dose over the 3 year period was associated with a 4.2 fold increased VF risk (HR = 4.2, 95% CI 2.3, 7.7), and every 0.5 mg/kg increase in daily dose during the preceding 12 months was associated with a 2.7 fold increased incident VF risk (HR =2.7, 95% CI 1.3, 5.2). Conclusion: We have shown that 13.0% of children with RD sustained VF within three years followingGC initiation, of which 36% had moderate fractures. Cumulative dose, average daily GC dose, and recent average daily GC dose were associated with a significantly increased VF risk. Funded by CIHR FRN 64285

To the Editor: Juvenile dermatomyositis (JDM) is an autoimmune vasculopathy involving primarily the proximal muscles and skin but can involve other organ systems, particularly the gastrointestinal (GI) tract1. In the presence of cutaneous vasculitic ulcerations, one needs to monitor for signs and symptoms suggestive of GI vasculopathy2, which can lead to bowel ischemia, necrosis, ulceration, and perforation1,2,3,4,5. The presence of gas in the bowel wall, also referred to as pneumatosis intestinalis (PI), is an ominous finding when it is due to a GI vasculopathy3. PI is a radiographic finding that is associated with both benign and life-threatening causes. The benign variant of PI has been described in relation to immunosuppressive therapy6 and to JDM itself7. We describe a child with JDM complicated by cutaneous ulcerations and benign PI. An 8-year-old girl, following a 1-month history of rash and fatigue, was diagnosed with JDM based on the presence of Gottron sign, heliotrope rash, symmetric proximal muscle weakness, elevated serum muscle enzymes [creatine kinase (CK) 533 U/l (normal 44–189); lactate dehydrogenase 442 U/l (normal 142–261); aldolase 9.3 U/l (normal 0–7.6)] and findings consistent with myositis on magnetic resonance imaging of the proximal hip and shoulder girdle muscles. Antinuclear and anti-Jo1 antibodies were … Address correspondence to Dr. Scuccimarri; E-mail: rosie.scuccimarri{at}muhc.mcgill.ca

Objective To determine early outcomes and early improvements in a prospective inception cohort of children with juvenile idiopathic arthritis (JIA) treated with current standard therapies. Methods Patients selected were enrolled in an inception cohort of JIA, the Research in Arthritis in Canadian Children Emphasizing Outcomes Study. The juvenile rheumatoid arthritis core criteria set measures were completed at enrollment and 6 months later. Frequencies of normal values for each of the core set measures and the American College of Rheumatology (ACR) Pediatric 30, 50, and 70 (Pedi 70) criteria response rates achieved at 6 months after enrollment were calculated for each JIA-onset subtype group. Results Among 354 patients in the study, the median interval between diagnosis and enrollment was 0.7 months. At 6 months after enrollment, median values of active joint counts were highest in patients with rheumatoid factor (RF)–positive polyarthritis (4) and RF-negative polyarthritis (2), but were 0 or 1 for other subtypes. Fifty percent or more of patients with oligoarthritis, systemic arthritis, enthesitis-related arthritis, and undifferentiated arthritis had no active joints, and the ACR Pedi 70 criteria response rate was 48% or more in those with oligoarthritis, RF-negative polyarthritis, and systemic arthritis. Conclusion With current management strategies in clinical practice, improvement in disease activity was noted in considerable proportions of patients in all of the JIA subtype groups, but low levels of disease activity persisted in many. We expect that these early outcomes will prove to be significant predictors of long-term outcomes.

We report three pediatric cases of primary hypothyroidism presenting with musculoskeletal complaints, elevated muscle enzymes and increased creatinine. Thyroid hormone replacement led to improvement in both the clinical features and laboratory abnormalities.

To determine methotrexate (MTX) use and the degree to which Canadian pediatric rheumatologists adhere to the American College of Rheumatology (ACR) guidelines on monitoring for MTX toxicity.A 20-item questionnaire was e-mailed to 37 pediatric rheumatologists in 17 centers in Canada. A total of 28 (75.7%) responded.The oral route (PO) of administration was preferred initially by 78.6% in most cases, but for more severe cases, this fell to 42.8%. Those who chose not to start PO used the subcutaneous route (SQ). When PO was initial treatment, a switch to SQ was undertaken because of dose escalation, lack of efficacy, or GI toxicity. An initial mean dose of 0.35-0.5 mg/kg/wk was prescribed by 51.8%. For 75%, the maximum dose was 1 mg/kg/wk (up to 25 mg). Complete blood count, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) were determined by 100% at baseline and in followup; albumin and creatinine by 85.7% at baseline, but by only 71.4% and 67.8%, respectively, in followup. After a change in dose, 96.3% requested blood tests at least monthly; this was extended to every 6 to 8 weeks by 78.6% when the dose was stable. Side effects of recurrent nausea and/or vomiting were reported to occur frequently. No severe toxicity, and in particular no case of cirrhosis, was reported. Prophylactic folate supplementation was prescribed by almost all physicians.Most Canadian pediatric rheumatologists follow ACR guidelines to monitor for MTX toxicity in children with rheumatic diseases who were prescribed MTX. The variation in monitoring and response to toxicity raises the question whether specific pediatric guidelines should be developed.

Objectives To determine 1) height, weight and BMI trajectories in children with juvenile idiopathic arthritis (JIA) in a contemporary cohort; 2) their risk of growth delay, short stature, weight gain and obesity; and 3) the impact of disease activity and corticosteroid use on growth and weight gain. Methods 1154 children newly diagnosed with JIA from 2005 to 2010 at 16 Centres in the Research in Arthritis in Canadian Children emphasizing Outcomes (ReACCh-Out) inception cohort were included. Height and weight measurements scheduled at 0, 6, 12, 18, 24, 36, 48 and 60 months after enrolment were used to calculate age and sex standardized Z-scores for height, weight and body mass index (BMI). Locally weighted scatter plot smoothing was used to display mean Z-score trajectories. Growth delay meant a decrease of 1.0 height Z-scores or more from the child9s baseline. Short stature meant a height below the 2.5th percentile for age and sex. Weight gain meant an increase of 1.0 BMI Z-scores or more from the child9s baseline. Obesity meant a BMI above the 95th percentile for age and sex. The cumulative incidence of growth delay, short stature, weight gain and obesity was estimated with Kaplan Meier survival methods. The impact of disease activity and corticosteroid use on Z-scores was estimated with mixed effects models. Results Median age at diagnosis was 9.5 years (IQR 4, 13) and 64% were female. Median follow-up was 35.5 months (23, 49). Mean height Z-scores remained stable in children with enthesitis related, oligoarthritis and undifferentiated JIA. They decreased markedly in systemic JIA (from +0.2 to -0.3). In other categories, they decreased mildly during the first year and recovered afterwards. Mean BMI Z-scores increased in children with systemic JIA and RF-positive polyarthritis, decreased slightly in psoriatic arthritis and remained stable in other categories. At enrolment, the prevalence of short stature was 2.5% and the prevalence of obesity was 16%. The cumulative incidences of new-onset growth delay, short stature, weight gain and obesity within 3 years of diagnosis were 8.9% (95% CI 7.1-11.0), 3.1% (2.1-4.4%), 10.4% (8.6-12.6) and 10.5% (8.6-12.9), respectively. These were higher in systemic JIA (Figure) at 24.4% (15.3-37.5), 10.5% (5.1-20.8), 28.2% (19.1-40.5) and 34.7% (23.2-49.9), respectively. Systemic corticosteroids were prescribed for 85.5% of children with systemic JIA. One mg/kg of prednisone corresponded to a mean height decrease of 0.48 Z-scores (0.29-0.68) and a mean BMI increase of 0.45 Z-scores (0.25-0.65). After adjusting for prednisone dose, an increase of 1 cm in the physician global assessment of disease activity corresponded to a mean decrease of BMI of 0.023 Z-scores (0.006-0.039), with no effect on height (p=0.42). Conclusions The impact on growth and weight gain was marked in children with systemic JIA and those who received systemic corticosteroids. For most other children, growth and weight gain were similar to what is seen in the general population. Disclosure of Interest None declared

Lupus cystitis is a rare interstitial inflammatory disease of the bladder seen in systemic lupus erythematosus that usually occurs in association with gastrointestinal manifestations, and occasionally with central nervous system involvement. There are few reported pediatric cases. We describe this entity as the presenting manifestations of lupus in an adolescent female.

Over the past 10 years, at our center, 25 children diagnosed with systemic lupus erythematosus (SLE) have undergone an early renal biopsy; 15 underwent a second biopsy. The objective of this study was to determine whether clinical and laboratory parameters used to evaluate lupus disease activity and nephritis correlated with the WHO class on biopsy. At diagnosis, the presence of proteinuria, hematuria, a lower serum albumin, and the need for blood pressure medication were all associated with a worse class of lupus nephritis ( P

Accurate description of the risk and nature of flares will help counsel families when JIA is controlled and when considering discontinuing treatment.

Background/Purpose: Plain radiographs (x-rays) are useful in the evaluation of children with JIA. Bone erosions are one of the finding that can be seen on x-rays. However, they are most often reported in the polyarticular RF+ subtype of JIA and are rare in most other subtypes. Methods: Herein 3 patients with JIA are presented whose diagnoses were questioned after plain x-rays were obtained. MRI later revealed significant erosive disease in these patients. Results: Case 1: A 14 yo male presented with a monoarthritis of the left wrist. Initial x-rays were normal. His work-up was unremarkable. His inflammatory markers were normal. He was thus diagnosed with JIA–oligoarthritis. After 6 months in remission, after the use of an NSAID, he flared in the same joint. Repeat x-rays showed a radiolucent area with associated sclerosis in the scaphoid of unclear etiology. An MRI was thus requested. It revealed synovitis associated with erosive disease. Post gadolinium injection, a geode in the scaphoid bone with marked synovial enhancement visible within this erosion was detected. He underwent a joint injection which put him into remission. Repeat x-rays one year later, revealed unchanged findings likely corresponding to the non-healed erosion. Case 2: An 11 yo HLA B27 + male diagnosed with ERA with polyarthritis of the lower limbs and sacroiliac joints was treated with methotrexate and an NSAID. Investigations ruled out IBD and the arthritis was felt to be well controlled despite persistently elevated inflammatory markers of unclear etiology. He presented with a severe flare in his knees and ankles. X-rays revealed well-defined lytic lesions in the anterior aspect of the proximal tibial metaphysis just below the growth plate bilaterally. Given the concern of an infiltrative process, an MRI was obtained. Post gadolinium injection, a large erosion of the tibial plateau with marked synovial enhancement within this erosion was seen, as well as a knee synovitis. Etanercept was started. Case 3: An 8 yo male presented with a monoarthritis of the right wrist evolving for five months after an initial minor trauma. X-rays revealed advanced bone maturation of the right wrist as well as a sclerotic lesion of the hamate. Given the initial trauma, an MRI was obtained which demonstrated very extensive bone marrow edema, synovitis, tenosynovitis and a large erosion within the hamate. A diagnosis of JIA–oligoarthritis was made. He underwent a joint injection with good disease control. Conclusion: Large erosions are not typical for some JIA subtypes such as oligoarthritis and ERA. Findings on x-rays led the treating physicians to question the underlying diagnosis however, MRI revealed very aggressive synovitis of the wrist and knee in these patients. MRI was useful to demonstrate the presence of synovial enhancement within the eroded bone and helped rule out another diagnosis. Awareness of this type of aggressive arthritis is needed so that patients are not over-investigated and prompt treatment can be offered.

Osteochondrodysplasias are a heterogeneous group of genetic skeletal dysplasias. Patients with these diseases commonly develop an early degenerative arthritis or osteoarthritis. Occasional observations of inflammatory arthritis have been made in this population but such observations are based on clinical grounds alone without confirmatory imaging studies. Four patients followed up in a paediatric rheumatology clinic with three different skeletal dysplasias, who had both clinical and radiological evidence of an inflammatory arthritis and coexistent degenerative arthritis, are described.

DiGeorge syndrome or anomaly consists of a developmental field defect which is characterized by congenital absence or hypoplasia of the thymus and parathyroids, as well as facial dysmorphism and congenital heart defects. Other congenital malformations may coexist, in particular, thyroid abnormalities. A case of congenital hypothyroidism and DiGeorge syndrome is reviewed. Necropsy, clinical, and experimental studies also show that thyroid abnormalities may be a feature of DiGeorge syndrome. Although this could be purely coincidental, our case suggests that thyroid gland dysgenesis may be more common than previously thought. Thus, children with the DiGeorge syndrome may be at higher risk for hypothyroidism. Because of this potential association, patients who are considered to have this anomaly should have early newborn thyroid screening.

Incident vertebral fractures 12 months following glucocorticoid initiation in children with rheumatic disorders Bianca A Lang, Celia Rodd, Timothy Ramsay, David A Cabral, Peter B Dent, Janet E Ellsworth, Kristin M Houghton, Adam Huber, Roman Jurencak, Maggie Larche, Claire MA LeBlanc, Brian Lentle, MaryAnn Matzinger, Paivi M Miettunen, Kiem Oen, Johannes Roth, Claire Saint-Cyr, Rosie Scuccimarri, Nazih Shenouda, Leanne M Ward, Canadian STOPP Consortium

Thyroid Abnormalities as a Feature of DiGeorge Syndrome: A Case Report and Review of the Literature 416