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Published in: Clinical Rheumatology 4/2021

01-04-2021 | Bisphosphonate | Original Article

Clinical characteristics of pediatric synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome: the first Chinese case series from a single center

Authors: Nan Wu, Yuming Shao, Jianwei Huo, Yanan Zhang, Yihan Cao, Hongli Jing, Fa Zhang, Chenyang Yu, Yanying Yu, Chen Li, Hongmei Song, Wen Zhang

Published in: Clinical Rheumatology | Issue 4/2021

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Abstract

Introduction

Pediatric SAPHO syndrome is regarded as the equivalent of chronic recurrent multifocal osteomyelitis or chronic non-bacterial osteomyelitis. This study aimed to evaluate the clinical features and treatment options for Chinese pediatric patients with SAPHO syndrome.

Method

We conducted a single-center, retrospective study on a sample of 24 pediatric patients with SAPHO syndrome who were diagnosed at Peking Union Medical College Hospital from April 2014 to August 2018. The demographic, clinical, laboratory, imaging, histological, and therapeutic data were collected and analyzed.

Results

A total of 15 boys and 9 girls were included. The mean age of onset of bone and skin symptoms was 11.7 ± 3.8 and 14.4 ± 2.7 years, respectively. The mean follow-up period was 39.2 months. Seventeen patients had skin manifestations (46% had severe acne, 100% were boys; 21% had palmoplantar pustulosis, 100% were girls). Bone lesions were localized in four of the following major regions: anterior chest wall (42%), mandible (29%), peripheral bones (50%), and spine and sacroiliac joints (21%). Six patients had been treated with non-steroidal anti-inflammatory drugs, 10 with bisphosphonate, 10 with a tumor necrosis factor-α antagonist, and 1 with glucocorticoids, with variable responses. A total of 70% of the patients had complete remission after bisphosphonate or TNF-α antagonist therapy.

Conclusion

Pediatric patients with SAPHO syndrome have different characteristics from other cohorts in the sex ratio, frequency of mandibular involvement, and sex distribution of skin lesions. Bisphosphonate and TNF-α antagonists show a favorable response in pediatric SAPHO syndrome treatment.
Key points
•Being the first study that describes an Asian pediatric SAPHO case series.
•Chinese pediatric patients with SAPHO syndrome have different characteristics from Chinese adult patients and Caucasian pediatric patients.
Literature
1.
go back to reference Chamot AM, Benhamou CL, Kahn MF, Beraneck L, Kaplan G, Prost A (1987) Acne-pustulosis-hyperostosis-osteitis syndrome. Results of a national survey. 85 cases. Rev Rhum Mal Osteoartic 54(3):187–196PubMed Chamot AM, Benhamou CL, Kahn MF, Beraneck L, Kaplan G, Prost A (1987) Acne-pustulosis-hyperostosis-osteitis syndrome. Results of a national survey. 85 cases. Rev Rhum Mal Osteoartic 54(3):187–196PubMed
2.
go back to reference Nguyen MT, Borchers A, Selmi C, Naguwa SM, Cheema G, Gershwin ME (2012) The SAPHO syndrome. Semin Arthritis Rheum 42(3):254–265CrossRef Nguyen MT, Borchers A, Selmi C, Naguwa SM, Cheema G, Gershwin ME (2012) The SAPHO syndrome. Semin Arthritis Rheum 42(3):254–265CrossRef
3.
go back to reference Li C, Zuo Y, Wu N, Li L, Li F, Zhang W, Xu W, Zhao X, Jing H, Pan Q, Zhou W, Shi X, Fan Y, Wang J, Liu S, Liu Z, Zhang F, Zeng X, Chen H, Zhang S, Liu J, Qiu G, Wu Z, Dong Z, Zhang W (2016) Synovitis, acne, pustulosis, hyperostosis and osteitis syndrome: a single centre study of a cohort of 164 patients. Rheumatology (Oxford) 55(6):1023–1030CrossRef Li C, Zuo Y, Wu N, Li L, Li F, Zhang W, Xu W, Zhao X, Jing H, Pan Q, Zhou W, Shi X, Fan Y, Wang J, Liu S, Liu Z, Zhang F, Zeng X, Chen H, Zhang S, Liu J, Qiu G, Wu Z, Dong Z, Zhang W (2016) Synovitis, acne, pustulosis, hyperostosis and osteitis syndrome: a single centre study of a cohort of 164 patients. Rheumatology (Oxford) 55(6):1023–1030CrossRef
4.
go back to reference Zemann W, Pau M, Feichtinger M, Ferra-Matschy B, Kaercher H (2011) SAPHO syndrome with affection of the mandible: diagnosis, treatment, and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 111(2):190–195CrossRef Zemann W, Pau M, Feichtinger M, Ferra-Matschy B, Kaercher H (2011) SAPHO syndrome with affection of the mandible: diagnosis, treatment, and review of literature. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 111(2):190–195CrossRef
5.
go back to reference Wipff J, Adamsbaum C, Kahan A, Job-Deslandre C (2011) Chronic recurrent multifocal osteomyelitis. Joint Bone Spine 78(6):555–560CrossRef Wipff J, Adamsbaum C, Kahan A, Job-Deslandre C (2011) Chronic recurrent multifocal osteomyelitis. Joint Bone Spine 78(6):555–560CrossRef
6.
go back to reference Kahn MF (1995) Current status of the SAPHO syndrome. Presse Med 24(7):338–340PubMed Kahn MF (1995) Current status of the SAPHO syndrome. Presse Med 24(7):338–340PubMed
7.
go back to reference Anderson SE, Heini P, Sauvain MJ, Stauffer E, Geiger L, Johnston JO, Roggo A, Kalbermatten D, Steinbach LS (2003) Imaging of chronic recurrent multifocal osteomyelitis of childhood first presenting with isolated primary spinal involvement. Skelet Radiol 32(6):328–336CrossRef Anderson SE, Heini P, Sauvain MJ, Stauffer E, Geiger L, Johnston JO, Roggo A, Kalbermatten D, Steinbach LS (2003) Imaging of chronic recurrent multifocal osteomyelitis of childhood first presenting with isolated primary spinal involvement. Skelet Radiol 32(6):328–336CrossRef
8.
go back to reference Schilling F, Marker-Hermann E: [Chronic recurrent multifocal osteomyelitis in association with chronic inflammatory bowel disease: entheropathic CRMO]. Z Rheumatol 2003, 62(6):527–538 Schilling F, Marker-Hermann E: [Chronic recurrent multifocal osteomyelitis in association with chronic inflammatory bowel disease: entheropathic CRMO]. Z Rheumatol 2003, 62(6):527–538
9.
go back to reference Girschick H, Finetti M, Orlando F, Schalm S, Insalaco A, Ganser G, Nielsen S, Herlin T, Kone-Paut I, Martino S et al (2018) The multifaceted presentation of chronic recurrent multifocal osteomyelitis: a series of 486 cases from the Eurofever international registry. Rheumatology (Oxford) 57:1203–1211CrossRef Girschick H, Finetti M, Orlando F, Schalm S, Insalaco A, Ganser G, Nielsen S, Herlin T, Kone-Paut I, Martino S et al (2018) The multifaceted presentation of chronic recurrent multifocal osteomyelitis: a series of 486 cases from the Eurofever international registry. Rheumatology (Oxford) 57:1203–1211CrossRef
10.
go back to reference Jelusic M, Cekada N, Frkovic M, Potocki K, Skerlev M, Murat-Susic S, Husar K, Dapic T, Smigovec I, Bajramovic D (2018) Chronic recurrent multifocal osteomyelitis (CRMO) and synovitis acne Pustulosis hyperostosis Osteitis (SAPHO) syndrome—two presentations of the same disease? Acta Dermatovenerol Croat 26(3):212–219PubMed Jelusic M, Cekada N, Frkovic M, Potocki K, Skerlev M, Murat-Susic S, Husar K, Dapic T, Smigovec I, Bajramovic D (2018) Chronic recurrent multifocal osteomyelitis (CRMO) and synovitis acne Pustulosis hyperostosis Osteitis (SAPHO) syndrome—two presentations of the same disease? Acta Dermatovenerol Croat 26(3):212–219PubMed
11.
go back to reference Jansson A, Renner ED, Ramser J, Mayer A, Haban M, Meindl A, Grote V, Diebold J, Jansson V, Schneider K, Belohradsky BH (2007) Classification of non-bacterial osteitis: retrospective study of clinical, immunological and genetic aspects in 89 patients. Rheumatology (Oxford) 46(1):154–160CrossRef Jansson A, Renner ED, Ramser J, Mayer A, Haban M, Meindl A, Grote V, Diebold J, Jansson V, Schneider K, Belohradsky BH (2007) Classification of non-bacterial osteitis: retrospective study of clinical, immunological and genetic aspects in 89 patients. Rheumatology (Oxford) 46(1):154–160CrossRef
12.
go back to reference Roderick MR, Shah R, Rogers V, Finn A, Ramanan AV (2016) Chronic recurrent multifocal osteomyelitis (CRMO)—advancing the diagnosis. Pediatr Rheumatol Online J 14(1):47CrossRef Roderick MR, Shah R, Rogers V, Finn A, Ramanan AV (2016) Chronic recurrent multifocal osteomyelitis (CRMO)—advancing the diagnosis. Pediatr Rheumatol Online J 14(1):47CrossRef
13.
go back to reference Gikas PD, Islam L, Aston W, Tirabosco R, Saifuddin A, Briggs TW, Cannon SR, O'Donnell P, Jacobs B, Flanagan AM (2009) Nonbacterial osteitis: a clinical, histopathological, and imaging study with a proposal for protocol-based management of patients with this diagnosis. J Orthop Sci 14(5):505–516CrossRef Gikas PD, Islam L, Aston W, Tirabosco R, Saifuddin A, Briggs TW, Cannon SR, O'Donnell P, Jacobs B, Flanagan AM (2009) Nonbacterial osteitis: a clinical, histopathological, and imaging study with a proposal for protocol-based management of patients with this diagnosis. J Orthop Sci 14(5):505–516CrossRef
14.
go back to reference Pastore S, Ferrara G, Monasta L, Meini A, Cattalini M, Martino S, Alessio M, La Torre F, Teruzzi B, Gerloni V et al (2016) Chronic nonbacterial osteomyelitis may be associated with renal disease and bisphosphonates are a good option for the majority of patients. Acta Paediatr 105(7):e328–e333CrossRef Pastore S, Ferrara G, Monasta L, Meini A, Cattalini M, Martino S, Alessio M, La Torre F, Teruzzi B, Gerloni V et al (2016) Chronic nonbacterial osteomyelitis may be associated with renal disease and bisphosphonates are a good option for the majority of patients. Acta Paediatr 105(7):e328–e333CrossRef
15.
go back to reference Hospach T, Langendoerfer M, von Kalle T, Maier J, Dannecker GE (2010) Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate. Eur J Pediatr 169(9):1105–1111CrossRef Hospach T, Langendoerfer M, von Kalle T, Maier J, Dannecker GE (2010) Spinal involvement in chronic recurrent multifocal osteomyelitis (CRMO) in childhood and effect of pamidronate. Eur J Pediatr 169(9):1105–1111CrossRef
16.
go back to reference Jansson AF, Muller TH, Gliera L, Ankerst DP, Wintergerst U, Belohradsky BH, Jansson V (2009) Clinical score for nonbacterial osteitis in children and adults. Arthritis Rheum 60(4):1152–1159CrossRef Jansson AF, Muller TH, Gliera L, Ankerst DP, Wintergerst U, Belohradsky BH, Jansson V (2009) Clinical score for nonbacterial osteitis in children and adults. Arthritis Rheum 60(4):1152–1159CrossRef
17.
go back to reference Witt M, Meier J, Hammitzsch A, Proft F, Schulze-Koops H, Grunke M (2014) Disease burden, disease manifestations and current treatment regimen of the SAPHO syndrome in Germany: results from a nationwide patient survey. Semin Arthritis Rheum 43(6):745–750CrossRef Witt M, Meier J, Hammitzsch A, Proft F, Schulze-Koops H, Grunke M (2014) Disease burden, disease manifestations and current treatment regimen of the SAPHO syndrome in Germany: results from a nationwide patient survey. Semin Arthritis Rheum 43(6):745–750CrossRef
18.
go back to reference Colina M, Govoni M, Orzincolo C, Trotta F (2009) Clinical and radiologic evolution of synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: a single center study of a cohort of 71 subjects. Arthritis Rheum 61(6):813–821CrossRef Colina M, Govoni M, Orzincolo C, Trotta F (2009) Clinical and radiologic evolution of synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: a single center study of a cohort of 71 subjects. Arthritis Rheum 61(6):813–821CrossRef
19.
go back to reference Hayem G, Bouchaud-Chabot A, Benali K, Roux S, Palazzo E, Silbermann-Hoffman O, Kahn MF, Meyer O (1999) SAPHO syndrome: a long-term follow-up study of 120 cases. Semin Arthritis Rheum 29(3):159–171CrossRef Hayem G, Bouchaud-Chabot A, Benali K, Roux S, Palazzo E, Silbermann-Hoffman O, Kahn MF, Meyer O (1999) SAPHO syndrome: a long-term follow-up study of 120 cases. Semin Arthritis Rheum 29(3):159–171CrossRef
20.
go back to reference Salles M, Olive A, Perez-Andres R, Holgado S, Mateo L, Riera E, Tena X (2011) The SAPHO syndrome: a clinical and imaging study. Clin Rheumatol 30(2):245–249CrossRef Salles M, Olive A, Perez-Andres R, Holgado S, Mateo L, Riera E, Tena X (2011) The SAPHO syndrome: a clinical and imaging study. Clin Rheumatol 30(2):245–249CrossRef
21.
go back to reference Cao Y, Li C, Yang Q, Wu N, Xu P, Li Y, Shi X, Pan Q, Wu X, Sun X, Zhao Y, Gu Z, Yuan S, Zuo Y, Li L, Zhang W, Hao W, Liu J, Jing H, Zhang W (2019) Three patterns of osteoarticular involvement in SAPHO syndrome: a cluster analysis based on whole body bone scintigraphy of 157 patients. Rheumatology (Oxford) 58:1047–1055CrossRef Cao Y, Li C, Yang Q, Wu N, Xu P, Li Y, Shi X, Pan Q, Wu X, Sun X, Zhao Y, Gu Z, Yuan S, Zuo Y, Li L, Zhang W, Hao W, Liu J, Jing H, Zhang W (2019) Three patterns of osteoarticular involvement in SAPHO syndrome: a cluster analysis based on whole body bone scintigraphy of 157 patients. Rheumatology (Oxford) 58:1047–1055CrossRef
22.
go back to reference Xu W, Li C, Zhao X, Lu J, Li L, Wu N, Zuo Y, Jing H, Dong Z, Zhang W, Zhang W (2017) Whole-spine computed tomography findings in SAPHO syndrome. J Rheumatol 44(5):648–654CrossRef Xu W, Li C, Zhao X, Lu J, Li L, Wu N, Zuo Y, Jing H, Dong Z, Zhang W, Zhang W (2017) Whole-spine computed tomography findings in SAPHO syndrome. J Rheumatol 44(5):648–654CrossRef
23.
go back to reference Ziobrowska-Bech A, Fiirgaard B, Heuck C, Ramsgaard Hansen O, Herlin T (2013) Ten-year review of Danish children with chronic non-bacterial osteitis. Clin Exp Rheumatol 31(6):974–979PubMed Ziobrowska-Bech A, Fiirgaard B, Heuck C, Ramsgaard Hansen O, Herlin T (2013) Ten-year review of Danish children with chronic non-bacterial osteitis. Clin Exp Rheumatol 31(6):974–979PubMed
24.
go back to reference Wipff J, Costantino F, Lemelle I, Pajot C, Duquesne A, Lorrot M, Faye A, Bader-Meunier B, Brochard K, Despert V, Jean S, Grall-Lerosey M, Marot Y, Nouar D, Pagnier A, Quartier P, Job-Deslandre C (2015) A large national cohort of French patients with chronic recurrent multifocal osteitis. Arthritis Rheumatol 67(4):1128–1137CrossRef Wipff J, Costantino F, Lemelle I, Pajot C, Duquesne A, Lorrot M, Faye A, Bader-Meunier B, Brochard K, Despert V, Jean S, Grall-Lerosey M, Marot Y, Nouar D, Pagnier A, Quartier P, Job-Deslandre C (2015) A large national cohort of French patients with chronic recurrent multifocal osteitis. Arthritis Rheumatol 67(4):1128–1137CrossRef
25.
go back to reference Cao Y, Li C, Xu W, Wu X, Sun X, Zhang W, Jing H, Gu Z, Yuan S, Li L et al (2018) Spinal and sacroiliac involvement in SAPHO syndrome: a single center study of a cohort of 354 patients. Semin Arthritis Rheum Cao Y, Li C, Xu W, Wu X, Sun X, Zhang W, Jing H, Gu Z, Yuan S, Li L et al (2018) Spinal and sacroiliac involvement in SAPHO syndrome: a single center study of a cohort of 354 patients. Semin Arthritis Rheum
26.
go back to reference Sun X, Li C, Cao Y, Shi X, Li L, Zhang W, Wu X, Wu N, Jing H, Zhang W (2018) F-18 FDG PET/CT in 26 patients with SAPHO syndrome: a new vision of clinical and bone scintigraphy correlation. J Orthop Surg Res 13(1):120CrossRef Sun X, Li C, Cao Y, Shi X, Li L, Zhang W, Wu X, Wu N, Jing H, Zhang W (2018) F-18 FDG PET/CT in 26 patients with SAPHO syndrome: a new vision of clinical and bone scintigraphy correlation. J Orthop Surg Res 13(1):120CrossRef
27.
28.
go back to reference Beck C, Morbach H, Beer M, Stenzel M, Tappe D, Gattenlohner S, Hofmann U, Raab P, Girschick HJ (2010) Chronic nonbacterial osteomyelitis in childhood: prospective follow-up during the first year of anti-inflammatory treatment. Arthritis Res Ther 12(2):R74CrossRef Beck C, Morbach H, Beer M, Stenzel M, Tappe D, Gattenlohner S, Hofmann U, Raab P, Girschick HJ (2010) Chronic nonbacterial osteomyelitis in childhood: prospective follow-up during the first year of anti-inflammatory treatment. Arthritis Res Ther 12(2):R74CrossRef
29.
go back to reference Borzutzky A, Stern S, Reiff A, Zurakowski D, Steinberg EA, Dedeoglu F, Sundel RP (2012) Pediatric chronic nonbacterial osteomyelitis. Pediatrics 130(5):e1190–e1197CrossRef Borzutzky A, Stern S, Reiff A, Zurakowski D, Steinberg EA, Dedeoglu F, Sundel RP (2012) Pediatric chronic nonbacterial osteomyelitis. Pediatrics 130(5):e1190–e1197CrossRef
30.
go back to reference Huber AM, Lam PY, Duffy CM, Yeung RS, Ditchfield M, Laxer D, Cole WG, Kerr Graham H, Allen RC, Laxer RM (2002) Chronic recurrent multifocal osteomyelitis: clinical outcomes after more than five years of follow-up. J Pediatr 141(2):198–203CrossRef Huber AM, Lam PY, Duffy CM, Yeung RS, Ditchfield M, Laxer D, Cole WG, Kerr Graham H, Allen RC, Laxer RM (2002) Chronic recurrent multifocal osteomyelitis: clinical outcomes after more than five years of follow-up. J Pediatr 141(2):198–203CrossRef
31.
go back to reference Skrabl-Baumgartner A, Singer P, Greimel T, Gorkiewicz G, Hermann J (2019) Chronic non-bacterial osteomyelitis: a comparative study between children and adults. Pediatr Rheumatol 17:49CrossRef Skrabl-Baumgartner A, Singer P, Greimel T, Gorkiewicz G, Hermann J (2019) Chronic non-bacterial osteomyelitis: a comparative study between children and adults. Pediatr Rheumatol 17:49CrossRef
32.
go back to reference Costa-Reis P, Sullivan KE (2013) Chronic recurrent multifocal osteomyelitis. J Clin Immunol 33(6):1043–1056CrossRef Costa-Reis P, Sullivan KE (2013) Chronic recurrent multifocal osteomyelitis. J Clin Immunol 33(6):1043–1056CrossRef
33.
go back to reference Catalano-Pons C, Comte A, Wipff J, Quartier P, Faye A, Gendrel D, Duquesne A, Cimaz R, Job-Deslandre C (2008) Clinical outcome in children with chronic recurrent multifocal osteomyelitis. Rheumatology (Oxford) 47(9):1397–1399CrossRef Catalano-Pons C, Comte A, Wipff J, Quartier P, Faye A, Gendrel D, Duquesne A, Cimaz R, Job-Deslandre C (2008) Clinical outcome in children with chronic recurrent multifocal osteomyelitis. Rheumatology (Oxford) 47(9):1397–1399CrossRef
34.
go back to reference Ishikawa-Nakayama K, Sugiyama E, Sawazaki S, Taki H, Kobayashi M, Koizumi F, Furuta I (2000) Chronic recurrent multifocal osteomyelitis showing marked improvement with corticosteroid treatment. J Rheumatol 27(5):1318–1319PubMed Ishikawa-Nakayama K, Sugiyama E, Sawazaki S, Taki H, Kobayashi M, Koizumi F, Furuta I (2000) Chronic recurrent multifocal osteomyelitis showing marked improvement with corticosteroid treatment. J Rheumatol 27(5):1318–1319PubMed
35.
go back to reference Kerrison C, Davidson JE, Cleary AG, Beresford MW (2004) Pamidronate in the treatment of childhood SAPHO syndrome. Rheumatology (Oxford) 43(10):1246–1251CrossRef Kerrison C, Davidson JE, Cleary AG, Beresford MW (2004) Pamidronate in the treatment of childhood SAPHO syndrome. Rheumatology (Oxford) 43(10):1246–1251CrossRef
36.
go back to reference Deutschmann A, Mache CJ, Bodo K, Zebedin D, Ring E (2005) Successful treatment of chronic recurrent multifocal osteomyelitis with tumor necrosis factor-alpha blockage. Pediatrics 116(5):1231–1233CrossRef Deutschmann A, Mache CJ, Bodo K, Zebedin D, Ring E (2005) Successful treatment of chronic recurrent multifocal osteomyelitis with tumor necrosis factor-alpha blockage. Pediatrics 116(5):1231–1233CrossRef
37.
go back to reference Taylor JB, Young WO, Rutar T (2010) Posterior subcapsular cataracts in children receiving adrenocorticotropic hormone (ACTH) for infantile spasms. J Child Neurol 25(8):1017–1019CrossRef Taylor JB, Young WO, Rutar T (2010) Posterior subcapsular cataracts in children receiving adrenocorticotropic hormone (ACTH) for infantile spasms. J Child Neurol 25(8):1017–1019CrossRef
38.
go back to reference Allen DB, Julius JR, Breen TJ, Attie KM (1998) Treatment of glucocorticoid-induced growth suppression with growth hormone. National Cooperative Growth Study. J Clin Endocrinol Metab 83(8):2824–2829CrossRef Allen DB, Julius JR, Breen TJ, Attie KM (1998) Treatment of glucocorticoid-induced growth suppression with growth hormone. National Cooperative Growth Study. J Clin Endocrinol Metab 83(8):2824–2829CrossRef
39.
go back to reference Li C, Zhao Y, Zuo Y, Zhou Y, Zhang F, Liu S, Zhu Q, Chen J, Zhang W, Xu W et al (2019) Efficacy of bisphosphonates in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: a prospective open study. Clin Exp Rheumatol 37:663PubMed Li C, Zhao Y, Zuo Y, Zhou Y, Zhang F, Liu S, Zhu Q, Chen J, Zhang W, Xu W et al (2019) Efficacy of bisphosphonates in patients with synovitis, acne, pustulosis, hyperostosis, and osteitis syndrome: a prospective open study. Clin Exp Rheumatol 37:663PubMed
Metadata
Title
Clinical characteristics of pediatric synovitis, acne, pustulosis, hyperostosis, and osteitis (SAPHO) syndrome: the first Chinese case series from a single center
Authors
Nan Wu
Yuming Shao
Jianwei Huo
Yanan Zhang
Yihan Cao
Hongli Jing
Fa Zhang
Chenyang Yu
Yanying Yu
Chen Li
Hongmei Song
Wen Zhang
Publication date
01-04-2021
Publisher
Springer International Publishing
Published in
Clinical Rheumatology / Issue 4/2021
Print ISSN: 0770-3198
Electronic ISSN: 1434-9949
DOI
https://doi.org/10.1007/s10067-020-05393-w

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