BACKGROUNDJuvenile localized scleroderma (JLS), also known as morphea, is a spectrum of rare inflammatory pediatric disorders associated with skin and underlying tissue thickening and sclerosis. Clinical manifestations range from skin lesions to extracutaneous involvement that often vary with its subtype. Early recognition is important to reduce disease-related functional impact. METHODSReview of medical records of children and adolescents with diagnosis of JLS from 2015 to May 2022 and regularly followed up in the Pediatric Rheumatology Unit of a tertiary hospital in the state of Ceará was performed. Data included demographics, clinical manifestations, treatment and disease course. RESULTSTwenty patients were included and 13 (65%) were female. The median age at onset, age at diagnosis and time elapsed from symptom onset to diagnosis were, respectively, 6.60 (2-16.4), 9.05 (3.2-17) and 2.45 (0-10.5) years. The most prevalent subtype was mixed morphea (35%), followed by linear form (25%). Involvement was predominantly appendicular, distributing in upper and/or lower limbs in 75%. Five patients had disease restricted to the face, two with en coup de sabre variant and three with Parry-Romberg syndrome. Most of the patients (75%) already had characteristics of long-standing skin disease at diagnosis. Seventeen patients (85%) had extracutaneous manifestations, with a predominance of joint involvement (arthritis/arthralgia of small joints of the hands, wrists and knees) in 13 (65%) of them, followed by gastrointestinal tract (20%). Autoantibodies were positive in 9 (45%) patients, of which ANA (78%) and RF (22%) were the most prevalent. Eighteen patients used corticosteroids at diagnosis, with an average of 8.5 months treatment, and a partial response in 15 (83.3%) of them. Methotrexate was associated in 19 cases, allowing 12 (63.1%) patients to achieve remission. In refractory cases (35%), six received mycophenolate mofetil and two cyclophosphamide. After approximately 3 years of follow-up, 85% of patients had good disease control. CONCLUSIONThe female-to-male ratio (1.85) and the age at onset of symptoms (6.60) are in line with literature (1.7:1 to 3.7:1 and 6.1 to 8.1, respectively). Our study differs in the higher prevalence of mixed morphea subtype in relation to the linear one. Time until diagnosis was long, with most patients presenting already with chronic skin changes, warning about the lack of knowledge about the disease. Immunosuppressive standard treatment, mainly with methotrexate and corticosteroids, shows promising results in controlling the disease progression.

BACKGROUNDLeprosy, a chronic infectious disease caused by Mycobacterium leprae, affects the skin, peripheral nerves, upper respiratory tract, musculoskeletal system and eyes. As it presents a wide spectrum of clinical manifestations, it can be a diagnostic challenge, especially in early stages of disease. Some of these manifestations resemble pictures of rheumatic diseases that affect adults and children. Among the musculoskeletal manifestations of childhood leprosy are inflammatory chronic arthritis, mimicking juvenile idiopathic arthritis or spondyloarthritis, inflammatory swelling of the hands and feet, neuropathic arthritis, septic arthritis, arthralgias/ myalgias, soft tissue rheumatism and multisystem involvement similar to collagenases, including vasculitis and myositis. CASE REPORTWe report the case of a previously healthy 8-year-old boy admitted to the pediatric rheumatology unity due to the presence of puffy hands and fingers and hard and shiny edema of the lower limbs, suggesting systemic scleroderma diagnosis. He had an 11-month history of recurrent episodes of intermittent fever, plaque-like, erythematous, nonpruritic facial skin lesions and joint pain in the knees and ankles. On physical examination, he presented, in addition to the aforementioned findings, purpuric lesions on the toes, hepatosplenomegaly, arthralgias (wrist, small joints of the hands, knees and ankles) and erythematous plaques infiltrated in the bilateral malar region, nasal region and auricular pavilion. Complementary tests showed normocytic and normochromic anemia, leukocytosis, neutrophilia, thrombocytosis, elevation of inflammatory tests and negativity of ANA, RF, ANCA, anti-RNP and anti-Scl70. Due to the infiltrated skin lesions, lymph smear testing was performed, which was strongly positive, and a diagnosis of Virchowian leprosy associated with mixed leprosy reaction was made. There was clinical and laboratory improvement after initiation of multidrug therapy and systemic corticosteroid therapy. CONCLUSIONLeprosy is known as a great mimic of rheumatic diseases, often fulfilling diagnostic criteria for many of them. The multibacillary forms present greater musculoskeletal involvement. It should be considered in differential diagnosis of children with musculoskeletal symptoms, autoantibody positivity and cutaneous and/or neurological involvement.

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Introdução: Gangrena digital pode ser secundária a trombose ou vasculite de pequenos vasos. Doença vascular periférica levando a gangrena digital é uma complicação bem descrita da síndrome antifosfolípide (SAF), podendo também ser uma forma rara de injúria vascular do lupus eritematoso sistêmico (LES). Tal distinção pode ser difícil, especialmente em pacientes com associação de ambas as doenças. Relato de caso: Uma menina de 12 anos, previamente hígida, é trazida ao pronto-socorro com histórico de três dias de lesões purpúricas nos membros inferiores e gangrena digital em todos os dedos do pé direito e no segundo, terceiro e quarto dedos da mão esquerda. Houve rápida progressão para gangrena em todos os dedos acima mencionados, além de ulceração e gangrena de lesões purpúricas. O ultrassom Doppler arterial dos quatro membros não evidenciou alterações. A ressonância magnética de encéfalo mostrou infartos lacunares de provável etiologia microembólica. Os achados laboratoriais incluíram tripla positividade em altos títulos de anticorpos antifosfolípides, FAN e anti-DNA, além de hipocomplementenemia, sugerindo o diagnóstico de LES e SAF castrotófica provável. A biópsia das lesões cutâneas revelou vasculite cutânea de pequenos vasos não leucocitoclástica, levando à hipótese de vasculite lúpica. Foram realizadas pulsoterapia com metilprednisolona, ​​imunoglobulina humana, vasodilatadores e anticoagulação. Devido à presença de vasculite lúpica, optou-se pelo uso de ciclofosfamida. Houve interrupção da evolução do quadro vascular, mas a paciente evoluiu com autoamputação de algumas falanges distais acometidas dos dedos do pé direito e da mão esquerda. Após seis doses de ciclofosfamida em esquema quinzenal, iniciou-se azatioprina, estando a paciente atualmente assintomática com escore SLEDAI igaul a zero. Conclusão: Gangrena digital é uma manifestação rara tanto do LES como da SAF, no entanto, pode haver evolução para amputação digital em um importante número de casos. Apesar da raridade da apresentação e da dificuldade de distinção diagnóstica, o reconhecimento e tratamento precoces de ambas as doenças são essenciais para a redução de morbimortalidade.

BACKGROUNDCatastrophic antiphospholipid syndrome (APS) is a severe acquired thrombophilia characterized by rapid development of thromboses in several organs, in presence of antiphospholipid antibodies. For histopathologic confirmation, thrombosis should be present without significant evidence of vessel wall inflammation. APS is a known association of systemic lupus erythematosus (SLE) and, when present with lupus, has the worst outcome. Peripheral vascular disease leading to digital gangrene is a well-recognized complication of APS, particularly in patients with SLE. Digital gangrene in SLE is a rare form of vascular injury and generally leads to digital amputation. CASE REPORTA previously healthy 12-year-old girl is brought to the emergency department because of a 3-day history of purpuric lesions in the lower limbs and digital gangrene in all right toes and in the second, third and fourth fingers on the left hand. She had rapid progression to gangrene in all the aforementioned digits and ulceration and gangrene of purpuric lesions. Arterial Doppler ultrasound of the four limbs showed no changes. Brain magnetic resonance imaging (MRI) showed lacunar infarcts of probable microembolic etiology. Laboratory findings included triple positivity in high titers of antiphospholipid antibodies, ANA and anti-DNA and hypocomplementemia, suggesting SLE and probable catastrophic APS diagnosis. Biopsy of skin lesions showed nonleukocytoclastic cutaneous small vessel vasculitis, leading to the hypothesis of lupus vasculitis. Methylprednisolone pulse therapy, human immunoglobulin, vasodilators and anticoagulation were performed. Due to the presence of lupus vasculitis, it was chosen to use cyclophosphamide. There was a halt in the progression of the vascular condition, but the patient evolved with self-amputation of some of the affected distal phalanges of the right toes and the left hand. After six doses of cyclophosphamide in a biweekly schedule, azathioprine was started, and the patient is currently asymptomatic with a SLEDAI-2K score of zero. CONCLUSIONDigital gangrene may be secondary to thrombosis or small vessel vasculitis. This distinction can be difficult, especially in patients with lupus-associated antiphospholipid syndrome. Only 0.2% of patients with SLE presented initially as digital necrosis and less than 10% of pediatric APS patients present with small-vessel thrombosis. Despite the rarity of presentation and the difficulty in distinguishing the diagnosis, early recognition and treatment of both diseases are essential to prevent progression and reduce their morbidity and mortality.