Juvenile rheumatoid arthritis in African Americans

OBJECTIVE: To examine racial differences in disease expression in African American and Caucasian children with pauciarticular and polyarticular juvenile rheumatoid arthritis (JRA). METHODS: A retrospective chart review was conducted of 35 African American and 137 Caucasian children with pauciarticular and polyarticular JRA. RESULTS: African American children were significantly older than Caucasian children at the time of presentation. This was true both for the group as a whole and for each of the disease onset subtypes. African American children were less likely to have positive antinuclear antibody tests than Caucasian children. This finding paralleled a low incidence of uveitis in African American children. African American children were also more likely to have IgM rheumatoid factors (detected by latex agglutination) than Caucasian children. This was true even for African American children with pauciarticular JRA. CONCLUSION: There are significant phenotypic differences between African American and Caucasian children with JRA.     

Comparative sequence analysis of the human T cell receptor beta chain in juvenile rheumatoid arthritis and juvenile spondylarthropathies: evidence for antigenic selection of T cells in the synovium

OBJECTIVE: To identify features of the T cell receptors (TCRs) present on clonally expanded T cells in the joints of patients with similar types of childhood rheumatic disease. Vbeta8 and Vbeta20 TCRs were selected as prototypic for polyarticular juvenile rheumatoid arthritis (JRA) and pauciarticular/juvenile spondylarthropathy (SpA), respectively. METHODS: The portion of the TCR beta chain involved in antigen recognition in the synovial tissue, synovial fluid, and peripheral blood from patients with JRA and juvenile SpA was cloned and sequenced. The frequency of expanded clonotypes, size of expansions, the Jbeta region, and sequence motifs were determined for >2,000 sequences. RESULTS: The majority of Vbeta20 and Vbeta8 clonal expansions were found in the joint rather than the peripheral blood. While instances of both Vbeta8 and Vbeta20 clonal expansion were detected in all disease types, the features of these expanded clonotypes were specific for disease type and Vbeta family. For example, Vbeta20 clonal expansion was characterized by many small expanded clonotypes in samples from patients with pauciarticular JRA and juvenile SpA while single large Vbeta8-specific expansions were found only in patients with polyarticular disease. Motifs specific to individual patients were identified, and for Vbeta20 clonotypes, a motif was found in synovial tissue samples. CONCLUSION: Identification of common TCR features in oligoclonal expansions within individual patients and between patients with the same type of JRA suggests the recognition of a common or limited group of antigens in these diseases.     

Autopsies in children: are they still useful?

BACKGROUND: Juvenile chronic arthritis (JCA) is the commonest autoimmune rheumatic disease in childhood and presents different clinical subtypes. Juvenile chronic arthritis is considered to be of a polygenic nature and its genetic background is still under investigation. The clinical profile of JCA in the Greek population has not been studied completely. This study retrospectively analyzed the clinical and immunological features of JCA in Greek children presented between 1989 and 1994. Human leukocyte antigen (HLA)-positive or -negative associations in the different clinical subtypes were also detected. The findings of this study were correlated with those reported from other populations. METHODS AND RESULTS: Antinuclear antibodies (ANA) anti-ds DNA and anti-extractable nuclear antigen antibodies were estimated by immunofluorescent and ELISA assays. Human leukocyte antigen typing was performed by microlymphocytotoxicity, using immunobeads. The peak ages of JCA onset were between 2 and 5 years and also between 9 and 12 years. There was a high female predominance in pauciarticular and polyarticular groups. The most common disease was pauciarticular (58.7%) followed by systemic (25%) arthritis. The incidence of eye involvement was 12.5% and presented only in the pauciarticular group. Overall, ANA positivity was 53.7%, increasing to 90% in pauciarticular cases associated with chronic uveitis. In the early onset (EOPA) pauciarticular subtype, positive-HLA associations with alleles DR11 and DR8 were shown. In the late onset pauciarticular (LOPA) group only B27 allele was increased. CONCLUSIONS: The results of this retrospective study did not reveal major differences between JCA in Greek children compared with other Caucasian series.     

Interleukin 8 and monocyte chemoattractant protein-1 in patients with juvenile rheumatoid arthritis. Relation to onset types, disease activity, and synovial fluid leukocytes

OBJECTIVE: To measure serum and synovial fluid (SF) levels of interleukin 8 (IL-8) and monocyte chemoattractant protein-1 (MCP-1) in patients with juvenile rheumatoid arthritis (JRA) and to compare them with adult rheumatoid factor-positive rheumatoid arthritis (RA). METHODS: IL-8 and MCP-1 were measured by immunoassay (1) in sera obtained from 55 children with JRA and from 16 adults with RA, and (2) in SF obtained from 30 children with JRA and 11 adults with RA. RESULTS: Patients with active systemic JRA had serum levels of IL-8 and MCP-1 higher than in controls (p<0.01) and in patients with active polyarticular or pauciarticular JRA (p<0.05). In patients with RA serum MCP-1 levels were higher than in patients with the 3 JRA onset types, while no difference was found for IL-8 levels. Patients with systemic JRA and with current systemic features had serum levels of IL-8 and MCP-1 higher (p = 0.03 and p = 0.04, respectively) than patients in which systemic features had subsided. No significant differences in SF IL-8 or MCP-1 levels were found among the 3 JRA onset types or adults with RA. In patients with JRA SF leukocyte counts were correlated with SF IL-8 levels (p = 0.002), but not with MCP-1 levels. Moreover, SF levels of both IL-8 and MCP-1 were correlated with those of IL-1beta (p<0.001) and IL-6 (p<0.01), but not with those of TNF-alpha. CONCLUSION: Elevated serum levels of IL-8 and MCP-1 in patients with systemic JRA with current systemic features at sampling suggest systemic production of the 2 chemokines during systemic phases of the disease. Similar SF levels of IL-8 and MCP-1 among the 3 JRA onset-types and RA suggest comparable local production of the 2 chemokines.     

Juvenile rheumatoid arthritis in affected sibpairs

OBJECTIVE: To describe the demographics and clinical disease in affected sibpairs (ASPs) with juvenile rheumatoid arthritis (JRA), and to compare JRA as it occurs in ASPs with that from non-ASP JRA populations described in the literature. METHODS: A rare disease research registry was established with a focus on JRA ASPs to facilitate accrual of patients for genetic, epidemiologic, and clinical studies. Physicians likely to care for patients with JRA were made aware of the registry and its goals by a variety of methods and asked to refer patients for entry. RESULTS: To date, 71 ASPs have been registered and complete information has been obtained. These affected sibs differed in age by a mean of 4.1 years (SD 3.4) and in age at disease onset by 2.8 years (SD 3.0). The actual time difference between onset in sib 1 versus sib 2 averaged 4.4 years (SD 4.2). Sixty-three percent of the sibpairs were concordant for sex, and 76% for JRA onset type. Onset type within sibpairs did not appear to be random, based upon comparisons with non-ASP populations. Greater than expected concordance was seen among those with pauciarticular-onset and polyarticular-onset JRA. Seventy-nine percent of the pairs were concordant for course type. Seven sets of twins were included (approximately 10% of the total), all were concordant for onset and course type (6 sets with pauciarticular, 1 set with polyarticular), and disease onset was separated by a mean of only 3.3 months. Within the onset and course types, the clinical disease, such as the female:male ratio, age at onset, and serologic findings, in ASPs resembled that which has been described in the literature. CONCLUSION: A higher than expected degree of concordance for onset type of JRA exists between sibpairs, indicating that genetic influences play a role. Affected sibs do not tend to develop their disease at approximately the same point in time, except for the twin sets. Clinical features of the disease within the various subtypes appear similar to those in non-ASP populations.     

Immune complexes from sera of patients with juvenile rheumatoid arthritis reveal novel 40 and 60 kd bands

OBJECTIVE: Immune complexes (IC) have been detected in the majority of sera of patients with juvenile rheumatoid arthritis (JRA). Our aim was to determine the possible constituents of these IC. METHODS: One hundred and four sera from patients with JRA were separated on a Sepharose 4B column to which were bound F(ab')2 fragments of goat anti-human IgM antibody to separate IgM-containing IC. The column was sequentially eluted with 1 M ammonia and 0.1 M glycine-HCl buffer, pH 3. The eluted material was treated with sodium dodecyl sulfate (SDS) and simultaneously reduced with 2-mercaptoethanol. Individual components were then separated by SDS-gradient polyaclylamide gel electrophoresis and were transferred to nitrocellulose by Western blotting. The nitrocellulose strips were overlaid with the patient's own serum and developed with specific antiserum to human IgM and IgG. RESULTS: Four bands were noted in the majority of JRA patients, including a band in the 70-80 kD area to the IgM heavy chain and in the 50 kD area to the IgG heavy chain. Additional bands specific for JRA patients' sera were noted in the 40 kD and 60 kD areas. Overall, 61 of 104 sera demonstrated all four bands; 78 showed the 40 kD band and 73 the 60 kD band. CONCLUSION: These IC were previously shown to contain IgM rheumatoid factor (RF), IgG-RF, and IgG in addition to the 40 and/or 60 kD constituents present in the isolates. Preliminary studies on these constituents suggest the possibility of the 60 kD band being the human 60 kD mitochondrial heat shock protein. Further investigations of these immune complex components may aid in the understanding of the pathophysiology of JRA.     

Imaging approaches to the correlation of structure and function in the kidney

OBJECTIVES: To translate into Argentine Spanish and cross-culturally adapt the Childhood Health Assessment Questionnaire (CHAQ) and validate the adapted instrument in Argentine patients with juvenile rheumatoid arthritis (JRA). METHODS: Five bilingual Argentine pediatric rheumatologists translated into Argentine Spanish and cross-culturally adapted the United States English CHAQ. Pretesting was done in a sample of 23 parents using a probe question technique. Parents of 70 patients with JRA and 21 healthy children (controls) participated in the validation phase. All were from Argentina. RESULTS: The mean disability index (DI) scores for patients with systemic, polyarticular, or pauciarticular onset JRA were 0.64, 0.32, and 0.1, respectively. Healthy controls averaged 0.2. Intercomponent correlations were between 0.4 and 0.9, suggesting internal consistency, but also some redundancy. Test-retest reliability, studied at a 1-week interval, was moderate (mean DI 0.44 [in clinic] and 0.29 [one week later], Pearson's correlation = 0.82). We compared CHAQ scores from 15 parents with those of their children > 10 years of age. Significantly higher DI scores were given by patients than their respective parents (P > 0.019), but the pairwise scores (parent-patient) were highly correlated (r = 0.986). CONCLUSIONS: Cross-cultural adaptation of the US CHAQ to Argentina required few changes. Although DI scores for all patient subgroups were higher than for controls subjects, the scores were low, particularly for those with pauciarticular disease. Prospective studies designed to examine the sensitivity to change and predictive validity will help to assess further the usefulness of the adapted CHAQ in the Argentine population.     

Long-term health outcomes and quality of life in American and Italian inception cohorts of patients with juvenile rheumatoid arthritis. I. Outcome status

OBJECTIVE: To assess the long-term health outcomes and quality of life of patients with juvenile rheumatoid arthritis (JRA) using health and functional assessment questionnaires in 2 populations, one from the USA and one from Italy. METHODS: Patient eligibility criteria: (1) first examined in our units between 1958 and 1990 during the first 6 months after onset of symptoms, (2) diagnosis of JRA by the American College of Rheumatology criteria, (3) disease duration of at least 5 years at the time of assessment of outcome. Instruments used: (1) the Health Assessment Questionnaire (HAQ, short form, or childhood HAQ (CHAQ), and (2) Quality of Life Scales (QOLS, adults only). Eligible patients were identified by computer search and chart review and were then mailed a packet containing a consent/assent form and the assessment instruments. RESULTS: Of 346 patients who met the eligibility criteria were able to locate 301, and 290 verbally agreed to participate and were mailed packets. Signed consent and complete information were received from 227 of the 290 (78%), 178 from the USA and 49 from Italy. Mean duration of disease at the time of outcome assessment was 15 yrs. 127 had pauciarticular, 55 polyarticular, and 45 systemic onset disease. Mean and (median) scores of the outcomes are shown in the table. [table: see text] CONCLUSION: Long-term outcome, as assessed by the instruments used, is very favorable in most patients with JRA 5 years or more after onset of symptoms.     

Homo- and heterosynaptic long-term potentiation in the medial cortex of the turtle brain in vitro

Juvenile rheumatoid arthritis (JRA) is the most commonly diagnosed rheumatic disease in children and may represent not a single disease, but rather a syndrome of diverse aetiologies in which inflammation is an exceedingly complex process. Oxidative free radical production at inflammation sites contributes to tissue damage and could also play a significant role in the pathogenesis of JRA. The aim of this study was to evaluate the antioxidant status and lipid peroxidation parameters related to the clinical form of JRA. Plasma malondialdehyde and hydroperoxide concentrations in children with polyarticular and systemic JRA subtypes were significantly higher than in controls. Plasma vitamin E and beta-carotene levels of the JRA children were lower in the three forms compared with healthy children. Patients with JRA present an imbalance in the oxidant-antioxidant system that manifests clearly in the polyarticular and systemic forms through an increase in lipoperoxidation products and significant decrease in the lipid-soluble antioxidants vitamin E and beta-carotene.     

Antineutrophil cytoplasmic antibodies (ANCA) in rheumatoid arthritis: a prospective study

To investigate a possible relationship between the presence of antineutrophil cytoplasmic antibodies (ANCA), rheumatoid factor (RF), antinuclear antibodies (ANA), complement, disease activity and disease severity, 111 clinically well-documented RA patients were studied prospectively for ANCA, RF, ANA, C-reactive protein (CRP), total haemolytic complement (CH50) and complement split product C3d. Disease activity and severity were also assessed clinically, as well as anamnestically, using the Hannover Activity of Daily Living Questionnaire, the functional Steinbrocker grades, and numeric and verbal rating scales. At a serum dilution of 1:50, 20% of the 111 sera showed predominantly an atypical perinuclear staining pattern. There was no correlation between ANCA positivity and serological markers, disease activity and disease severity. Regarding previous therapies with disease-modifying antirheumatic drugs, ANCA+ patients took sulphasalazine significantly more often than ANCA- patients.     

Juvenile rheumatoid arthritis-like polyarthritis in chromosome 22q11.2 deletion syndrome (DiGeorge anomalad/velocardiofacial syndrome/conotruncal anomaly face syndrome)

OBJECTIVE: To investigate the association of polyarthritis and chromosome 22q11.2 deletions. METHODS: Eighty patients with chromosome 22q11.2 deletion syndrome followed up at The Children's Hospital of Philadelphia were examined for evidence of arthropathy or arthritis. Patients with chromosome 22q11.2 deletion syndrome and polyarthritis underwent laboratory evaluations of immunologic function to determine the relationship of their immunodeficiency to the polyarthritis. RESULTS: The prevalence of polyarthritis in patients with chromosome 22q11.2 deletion syndrome was markedly increased over the prevalence of polyarticular juvenile rheumatoid arthritis (JRA) in the general population. All 3 patients with polyarthritis had evidence of impaired T cell function. Two of the patients with polyarthritis also had IgA deficiency. CONCLUSION: The chromosome 22q11.2 deletion syndrome represents a primary T cell disorder which can be associated with a JRA-like polyarthritis. All 3 patients with polyarthritis had evidence of more extensive immunoregulatory derangements than those typically seen in patients with chromosome 22q11.2 deletion, and these derangements may have predisposed to the development of polyarthritis.     

Clinical and radiographic evaluation of juvenile rheumatoid arthritis: report of a case

Rheumatoid arthritis (RA) is an inflammatory disease of the synovium which may lead to proliferative and degenerative changes in the body's joints, including the temporomandibular joint (TM Joint). Although the exact etiology of rheumatoid arthritis remains unknown, it is suspected that the disease is often initiated by an infectious organism, or by genetic and/or environmental factors. Juvenile rheumatoid arthritis (JRA) is a chronic disease of childhood with a spectrum of joint involvement and associated systemic and other organ involvement. Five percent of all rheumatoid arthritis patients are children. In the United States, approximately 150,000 children are affected by JRA. With upper limb involvement, routine oral hygiene procedures become difficult. Dental evaluations/screenings may not be included in the initial team assessment of these patients until the TM Joint is affected; however, prior to this time, the patient may have had years of poor oral hygiene which could contribute to severe decay and early tooth loss. This case report describes the oral health status of a child with polyarticular juvenile rheumatoid arthritis and the specific recommendations for dental management.     

Role of hydrophobic amino acids at position 74 of DRB1 chain in rheumatoid arthritis

We have analyzed HLA class II alleles in a group of 153 Czech children with rheumatoid arthritis by PCR and hybridization with oligonucleotide probes. When we try to find a common sequence for all DRB1 alleles involved in juvenile and adult arthritis, we can notice hydrophobic amino acid at position 74, which is present in all these alleles, but not in nonsusceptible alleles, where is the hydrophilic amino acid at position 74. In our model, we speculate that the hydrophilic amino acid at position 74 creates a such kind of epitope which is not suitable for rheumatoid-associated peptides or T cells, and only hydrophobic amino acid can permit binding of these peptides or recognition by certain T cells. Analyses of the DPB1 sequences have shown that alleles which have a negatively charged amino acid at position 69, are more frequent in pauciarticular patients while those with a positively charged amino acid are more frequent in polyarticular patients. A positively charged amino acid at position 69 might present the same rheumatoid associated peptide as susceptible DRB1 alleles. The presence of more rheumatoid-associated peptide on the cell surface may cause conversion to more severe polyarticular forms. A negatively charged amino acid at position 69 could not present this peptide and a low concentration of the peptide on the cell surface presented just by DRB1 molecules keeps disease in a relatively benign condition of pauciarticular forms.     

The binding constants of IgM rheumatoid factors and their univalent fragments for native and aggregated human IgG;

IgM rheumatoid factors (RF) were isolated from the sera of patients with rheumatoid arthritis and a serologically active Fabmicron RF fragment prepared by papain digestion. A radioimmunoassay was developed for the determination of interaction of 19S IgM RF and Fabmicron RF with human 7S IgG, heat-aggregated IgG, rabbit 7S IgG, and human pFc'. RF isolated under neutral conditions had a very low binding constant for human 7S IgG (of the order of 10(2) to 10(3) 1 mole-1) and a considerably higher value (ca. 10(5)) for the aggregated protein and monomeric rabbit IgG. RF obtained under acid conditions which dissociate the complexes with endogenous Ig, had a higher avidity for human IgG monomer as expected and also a comparable reactivity with rabbit IgG. Monovalent Fabmicron fragments of 'acid' RF had closely similar affinities for 7S and aggregated IgG suggesting that the enhanced binding with the aggregated protein is essentially dependent on its multivalency rather than the exposure of a new determinant lacking in the native molecule.     

Chlorella virus NY-2A encodes at least 12 DNA endonuclease/methyltransferase genes

OBJECTIVE: To describe outcome and determine predictive factors in juvenile rheumatoid arthritis (JRA) and juvenile spondyloarthopathy (JSpA). METHODS: Seventy-two children with chronic arthritis were studied on first admission to the pediatric rheumatology clinic and after a mean of 9.7 +/- 1.8 yrs of disease duration. RESULTS: At followup, 53 patients had JRA and 19 had JSpA. Eleven (21%) of the patients with JRA did not meet the criteria for JRA on first admission, and 12 (22%) of 54 children diagnosed as having JRA on first admission were later reclassified as having another disease. Remission occurred in 43 (60%) of the 72 patients with JRA and JSpA. Forty-four patients (60%) reported no disability by the childhood or adult Health Assessment Questionnaire and 18 patients (25%) had developed joint erosions. Disease modifying antirheumatic drugs (DMARD) were given to 49 patients (68%) after a median of 0.8 yrs (range 0.2-10.8) disease duration. The patients who developed erosions and disability tended to have started treatment later than those who did not (NS). Active disease 5 years after onset was a predictor of disability in JRA and JSpA (OR 4.5, 95% CI 1.6-12.5). Predictors of joint erosions were long duration of elevated erythrocyte sedimentation rate (ESR) (OR 3.7/yr of elevated ESR, 95% CI 1.9-7.2), long disease duration before first admission (OR 1.5/yr of duration, 95% CI 1.1-2.1), long disease duration before treatment with DMARD (OR 1.8, 95% CI 1.0-3.3), and IgM rheumatoid factor (OR 12 x 10(4), 95% CI 0-1.2 x 10[52]). CONCLUSION: The longterm outcome in JRA and JSpA was more favorable than previously reported. This may be explained by less selection in favor of severely diseased patients and by the use of early aggressive treatment regimes.     

Autoreactivity to human heat-shock protein 60 predicts disease remission in oligoarticular juvenile rheumatoid arthritis

OBJECTIVE: To determine whether T lymphocyte reactivity to endogenous human hsp60 plays a regulatory role in the course of oligoarticular juvenile rheumatoid arthritis (JRA). METHODS: A prospective, longitudinal study of T cell reactivity to HSP in 15 patients with newly diagnosed HLA-B27 negative oligoarticular JRA was performed. Results were compared with those in a group of 20 patients with newly diagnosed polyarticular or systemic JRA or with acute arthritis caused by other systemic diseases or viral infections, as well as with those in a group of 9 healthy control subjects. RESULTS: In 86% of the patients with oligoarticular JRA (13 of 15), significant T lymphocyte proliferative responses to hsp60 were found in peripheral blood mononuclear cells and/or synovial fluid mononuclear cells within 3 months after the onset of arthritis. Only 5% of the patients in the rheumatologic disease control group (1 of 20) showed such positivity. All patients with oligoarticular JRA and positive responses to human hsp60 developed a remission of their disease within 12 weeks. During this period of remission, blood samples were taken from 8 patients and showed significantly lower and even negative responses to hsp60, compared with active disease, when all 8 patients had good responses. CONCLUSION: The results show that significant proliferative responses to human hsp60 can be found early in the course of oligoarticular JRA. Furthermore, these responses correlate with disease activity in such a manner that T cell reactivity to human hsp60 seems to be associated with disease remission.     

An analysis of the factors involved in the diagnostic accuracy of colposcopically directed biopsy

We encountered a case of a girl where Human Parvovirus B19 infection was considered to have been concerned with the development of systemic type juvenile rheumatoid arthritis (JRA). While the affected child did not show any evident infectious erythema-like findings, changes in the serum antibody titer by the EIA method presented the pattern of first infection. During the clinical course the condition of the disease as JRA was serious and hemophagocytic syndrome developed concurrently. Furthermore, the resistance to the treatment was also noted. So the patient was treated with prednisolone combined with low dose weekly MTX therapy. The possibility of Human parvovirus B19 being concerned with the development of rheumatoid arthritis in one form or another has been suggested in recent years. In the disease type with systemic angititis as main pathophysiology, which is called systemic JRA we encountered this time, it is not clear how Human Parvovirus B19 was concerned with the development of this disease, but it appeared to hold a key position in studying pathophysiology of the development.     

Aortic valve replacement through the transected aorta in a patient with aortic stenosis and a calcified ascending aorta

BACKGROUND: Uveitis associated with juvenile rheumatoid arthritis (JRA) is an important cause of visual impairment in children. Because uveitis is often asymptomatic in this age group, frequent ophthalmologic screening examinations are recommended. Recent reports have found a decrease in the prevalence and severity of uveitis in JRA when compared to older data. METHODS: The charts of 52 consecutive patients with JRA seen over a 30-month period were retrospectively reviewed. RESULTS: Eye examination identified uveitis in five (12%) patients. All patients with uveitis were female, ANA positive, and had pauciarticular-onset arthritis. Three patients had the onset of uveitis before the age of 2. All patients have maintained good visual acuity and have not developed serious sight-threatening ocular complications over the follow-up period. CONCLUSIONS: Although the prevalence and severity of JRA-associated uveitis may be decreasing, we strongly recommend continued strict adherence to the current screening guidelines.     

Association of methotrexate treatment with a decrease of double negative (CD4-CD8-) and gamma/delta T cell levels in patients with juvenile rheumatoid arthritis

OBJECTIVE: It has been suggested that double negative (CD4-CD8-) (DN) and gamma/delta T cells may be involved in some autoimmune diseases. We investigated peripheral blood DN and gamma/delta T cell levels in patients with active juvenile rheumatoid arthritis (JRA). METHODS: DN and gamma/delta T cell levels were measured in 42 patients with active JRA and in 10 healthy controls comparable for age by an immunofluorescence double staining procedure. RESULTS: All 3 JRA onset types had DN and gamma/delta T cell levels not significantly different from those of controls, although a wide scattering of data was present. No correlation was found between DN or gamma/delta T cell levels and erythrocyte sedimentation rate values or the number of active joints. When patients were divided according to treatment, we found that DN and gamma/delta T cell levels were significantly lower (p = 0.001, p = 0.02, respectively) in patients receiving methotrexate (MTX) than in patients not receiving MTX. The association of MTX treatment with a decrease in DN and gamma/delta T cell levels was also confirmed in a followup study of individual patients. Among patients not receiving MTX, patients with systemic JRA presented DN T cell levels significantly higher than those of controls. In 5 patients with pauciarticular JRA DN and gamma/delta T cell levels were higher in synovial fluid than in the peripheral blood. CONCLUSIONS: We found an increase in peripheral blood DN T cell levels in systemic JRA; treatment with MTX appears to be associated with a decrease in DN and gamma/delta T cell levels.