2015
Pediatric Rheumatology
Division Introduction
Under the direction of Marilynn G. Punaro, M.D., Professor and Master of the Fashena
College, the Division of Pediatric Rheumatology at UT Southwestern Medical Center
serves as a major resource for pediatric rheumatology in North Texas. In the United
States there are approximately 364 board-certified pediatric rheumatologists, and five
of those are at UT Southwestern. The Division receives referrals from all other
children’s hospitals in the Dallas – Fort Worth metroplex, as well as more distant areas.
The Division operates the largest and longest established multispecialty clinic for
children with rheumatic diseases in the region. In the rheumatology clinics at Texas
Scottish Rite Hospital for Children (TSRHC) and Children’s Medical Center Dallas,
diseases managed include juvenile idiopathic arthritis, systemic lupus erythematosus,
juvenile dermatomyositis, and scleroderma. Faculty also have an interest in the
diagnosis and management of a variety of rarer rheumatic diseases, including systemic
vasculitis and auto-inflammatory conditions.
Marilynn G. Punaro, M.D.
The Division is actively involved in both translational and clinical research endeavors
directed toward improving pathophysiologic understanding, treatment options, and
outcomes in a variety of pediatric rheumatologic disorders.
Pediatric Rheumatology has a significant commitment to medical education, offering a rheumatology elective for pediatric
residents and fourth-year medical students. The fellowship training program is one of the only 36 ACGME-accredited
programs for pediatric rheumatology; it has continuously trained fellows from all over the world for more than 30 years.
Faculty
In addition to Dr. Punaro, the Division has two full-time and two part-time faculty members and two fellows.
Julie Fuller, M.D.
Assistant Professor
Lorien Nassi, M.D.
Assistant Professor
Katie Stewart, M.D.
Assistant Professor
Tracey Wright, M.D.
Assistant Professor
Honors / Awards
Julie Fuller

Best Pediatric Specialists in Dallas, D Magazine
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Pediatric Rheumatology
2015
Lorien Nassi

Best Pediatric Specialists in Dallas, D Magazine
Marilynn Punaro


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Best Pediatric Specialists in Dallas, D Magazine
Texas Super Doctor, Texas Monthly Magazine
Best Doctors of America
Katie Stewart

Best Pediatric Specialists in Dallas, D Magazine
Invited Lectures
Marilynn Punaro
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Childhood Arthritis & Rheumatology Research Alliance Annual Scientific Meeting, Austin, TX, April 2015
o “Academic Promotions 101”
th
78 International Congress of Familial Mediterranean Fever and Systemic Autoinflammatory Diseases (ISSAID),
Dresden, Germany, October 2015
o “How to Use Gene Expression Profiling in the Clinical Practice of AID”
Platform & Poster Presentations
Marilynn Punaro
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“Results from the Childhood Arthritis and Rheumatology Research Alliance Systemic JIA consensus Treatment Plans
Pilot Study”
Kimura Y, Beukelman T, Morgan-DeWitt E, Mieszkalski KL, Graham TB, Ibarra MF, Ilowite N, Klein-Gitelman MS,
Onel K, Prahalad S, Punaro M, et al.
o Platform Presentation: American College of Rheumatology, San Francisco, CA, November 2015
“Enteric Flora in Newly Diagnosed Spondyloarthritis: A Collaborative Study”
Stoll ML, Weiss PF, Weiss JE, Nigrovic PA, Punaro MG, et al.
o Poster Presentation: American College of Rheumatology, San Francisco, CA, November 2015
Katie Stewart and Marilyn Punaro

“Initial Results of a Pilot juvenile Localized Scleroderma (jLS) Comparative Effectiveness Study”
Li SC, Torok KS, Hong SD, Ferguson PJ, Rabinovich CE, Becker ML, Dedeoglu F, Ibarra MF, Fuhlbrigge RC, Stewart
KG, Punaro MG, et al.
o Platform Presentation: American College of Rheumatology, San Francisco, CA, November 2015
Tracey Wright

“Current Provider Practices and Perceived Barriers for Mental Health Care of Adolescents with SLE”
Knight A, Vickery M, Muscal E, Davis A, Harris J, Soybilgic A, Onel K, Schanberg LE, Rubinstein T, Gottlieb BS, Wright
T, et al.
o Poster Presentation: American College of Rheumatology, San Francisco, CA, November 2015
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2015
Pediatric Rheumatology
Education and Training
The Division of Pediatric Rheumatology has a significant commitment to medical education and is actively involved in the
teaching of fourth-year medical students and pediatric residents, in addition to its fully-accredited Pediatric Rheumatology
Fellowship Program. Trainees in other departments also spend time in the rheumatology clinics.
Medical Students
Third-year medical students rotate through the arthritis clinic during their
pediatric rotation, and an elective is available for fourth-year students. Marilynn
Punaro, M.D., preceptor for this elective, and the other pediatric rheumatology
faculty teach students to:
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Develop a working differential diagnosis of arthritis in childhood
Learn a complete joint examination and the physical evaluation of
rheumatologic patients
Examine and discuss patients from all major collagen vascular disease
categories: juvenile arthritis, dermatomyositis, scleroderma, and
systemic lupus erythematosus (SLE)
Trainees in other departments
also spend time in the Pediatric
Rheumatology clinics.
Residents in Physical Medicine
and fellows in Internal
Medicine Rheumatology
receive some of their training
in this Division.
Residents
The Division provides the major instruction to pediatric residents in the evaluation of the musculoskeletal system and the
assessment of the rheumatic diseases. Division faculty provide direct teaching for pediatric residents in the regular
departmental clinical conferences, as well as part of the inpatient consultation service. Didactic teaching for the pediatric
residents includes, but is not limited to:
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Differential diagnosis of arthritis in childhood
Juvenile idiopathic arthritis
Systemic lupus
Juvenile dermatomyositis
Evaluation of musculoskeletal pain in children
A rheumatology elective is available for pediatric residents. Dr. Punaro is the Course Director for elective; the objectives of
this elective are to:



Develop a working differential diagnosis of arthritis in childhood
Learn a complete joint examination and the physical evaluation of rheumatologic patients
Examine and discuss patients from all major collagen vascular disease categories: juvenile arthritis,
dermatomyositis, scleroderma, and systemic lupus erythematosus (SLE)
The residents see outpatients in the clinics under the supervision of the division faculty. A notebook of selected articles
about rheumatic disease, including original material, has been developed as curriculum for the elective. Residents are
encouraged to attend clinical conferences which offer didactic teaching for the fellows.
A postgraduate education program in clinical research provided through UT
Southwestern, culminating in a Master’s Degree, is an option for those fellows
preparing for a career in clinical research.
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2015
Pediatric Rheumatology
Fellows
The Division of Pediatric Rheumatology at UT Southwestern has one of only 36 ACGME-accredited fellowship training
programs in pediatric rheumatology in the United States.
Fellows develop competence in the diagnosis and management of rheumatic and other connective tissue diseases in
children and gain a background in laboratory techniques of basic immunology and molecular biology as well as experience
and education in application of the scientific method to clinical and laboratory research.
The clinical materials available at Children’s Medical Center Dallas and Texas Scottish Rite Hospital for Children (TSRHC) are
extensive. The Arthritis Clinic at TSRHC is one of the longest established pediatric rheumatology clinics in the country and is
the major regional referral center for North Texas.
Between the two hospitals, Division faculty see more than 4,500 outpatient visits per year in eight clinics per week. They
see more than 400 inpatient admissions per year and inpatient rounds are conducted daily. There are more than 1,000 new
patients per year. Trainees see and manage multiple patients of each major connective tissue disease and are exposed to
more rare disorders.
As required by the American Board of Pediatrics (ABP), all trainees spend a portion of their time involved in research. The
Division collaborates with Baylor Institute of Immunology Research (BIIR) to provide the facilities and latest equipment to
conduct basic immunology research. Lab activities include journal club, work in progress and seminars with invited
speakers. Research projects are tailored to the interests and capabilities of the individual trainees. Ongoing clinical trials
and the opportunity to do clinical research are also available.
The three-year Pediatric fellowship training program aims to provide individuals with sufficient background to pursue a
career of independent research, teaching and managing patients with a wide variety of pediatric rheumatic diseases.
Tracey Wright, M.D., is the Program Director for the Pediatric Rheumatology Fellowship Training Program. All other
pediatric rheumatology faculty are actively involved in training the pediatric rheumatology fellows.
Current Fellows
Leandra Woolnough, M.D.
nd
2 Year Fellow
Keiji Akamine, M.D.
st
1 Year Fellow
Research Activities
All division faculty are members of the Childhood Arthritis and Rheumatology Research Alliance (CARRA), which is
dedicated to collaborative multicenter research on the cause and treatment of childhood rheumatic disease. They have
participated in multiple clinical research studies including:
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Biologic therapies for treatment of resistant arthritis
Effects of nutrition on systemic lupus
Comparative effectiveness trials in localized scleroderma and systemic juvenile arthritis
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Pediatric Rheumatology
2015
A large and varied patient population has provided the ability to conduct studies in several areas, and faculty have been
involved in clinical research projects involving clinical trials of new therapies, as well as multicenter studies in pathogenesis
and epidemiology of childhood rheumatic diseases. They also have been involved in translational research, helping to make
a bridge between the basic science researchers in pediatric collagen vascular diseases and the patients.
Clinical Activities
The Division offers expert evaluation, counseling, and treatment of rheumatic diseases found in children, which include the
many forms of child arthritis, such as juvenile idiopathic arthritis, formerly known as juvenile rheumatoid arthritis. Faculty
also care for children with lupus, juvenile dermatomyositis, morphea/scleroderma, vasculitis, and a number of other
conditions.
Clinical services are offered at Children's Medical Center Dallas and at Texas Scottish Rite Hospital for Children’s Arthritis
Clinic, which is one of the longest-established pediatric rheumatology clinics in the country and the major referral center for
North Texas.
Services provided by UT Southwestern pediatric rheumatology physicians include:
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Evaluation and treatment of children with suspected rheumatic diseases
Physical and occupational therapy evaluations and recommendations
Coordination of team care, including ophthalmology, dental, and dietary counseling
Education about specific rheumatic conditions
Psychosocial support
2015 Patient Statistics
Texas Scottish Rite Hospital
Outpatient Visits
New Outpatient Visits
Infusions
2,575
276
596
Children’s Medical Center Dallas
Outpatient Visits
New Outpatient Visits
Inpatient Consults
1,337
338
79
Children’s Medical Center Legacy
Outpatient Visits
New Outpatient Visits
652
243
Children’s Medical Center Southlake
Outpatient Visits
New Outpatient Visits
114
48
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Pediatric Rheumatology
2015
Peer-Reviewed Publications
1.
Brunner HI, Bennett M, Abulaban K, Klein-Gitelman M, O’Neil K, Tucker L, Ardoin S, Rouster-Stevens K, Onel K,
Singer N, Eberhard BA, Jung L, Imundo L, Wright T, Witte D, Rovin B, Ying J, Devarajan P. Development of a novel renal
activity index of lupus nephritis in children & young adults. Arthritis Care and Research (Hoboken). 2015.
2.
Chiaroni-Clarke RC, Li YR, Munro JE, Chavez RA, Scurrah KJ, Pezic A, Akikusa JD, Allen RC, Piper SE, Becker ML,
Thompson SD, Lie BA, Flato B, Forre O, Punaro M, et al. The association of PTPN22 rs2476601 with juvenile idiopathic
arthritis is specific to females. Genes and Immunity 2015;16:495-8.
3.
Ellis JA, Scurrah KJ, Li YR, Ponsonby AL, Chavez RA, Pezic A, Dwyer T, Akikusa JD, Allen RC, Becker ML, Thompson
SD, Lie BA, Flato B, Forre O, Punaro M, et al. Epistasis amongst PTPN2 and genes of the vitamin D pathway contributes to
risk of juvenile idiopathic arthritis. The Journal of Steroid Biochemistry and Molecular Biology 2015;145:113-20.
4.
Li YR, Li J, Zhao SD, Bradfield JP, Mentch FD, Maggadottir SM, Hou C, Abrams DJ, Chang D, Gao F, Guo Y, Wei Z,
Connolly JJ, Cardinale CJ, Bakay M, Glessner JT, Li D, Kao C, Thomas KA, Qiu H, Chiavacci RM, Kim CE, Wang F, Snyder J,
Richie MD, Flato B, Forre O, Denson LA, Thompson SD, Becker ML, Guthery SL, Latiano A, Perez E, Resnick E, Russell RK,
Wilson DC, Silverberg MS, Annese V, Lie BA, Punaro M, et al. Meta-analysis of shared genetic architecture across ten
pediatric autoimmune diseases. Nature Medicine 2015;21:1018-27.
5.
Li YR, Zhao SD, Li J, Bradfield JP, Mohebnasab M, Steel L, Kobie J, Abrams DJ, Mentch FD, Glessner JT, Guo Y, Wei Z,
Connolly JJ, Cardinale CJ, Bakay M, Li D, Maggadottir SM, Thomas KA, Qui H, Chiavacci RM, Kim CE, Wang F, Snyder J, Flato
B, Forre O, Denson LA, Thompson SD, Becker ML, Guthery SL, Latiano A, Perez E, Resnick E, Strisciuglio C, Staiano A, Miele E,
Silverberg MS, Lie BA, Punaro M, et al. Genetic sharing and heritability of paediatric age of onset autoimmune diseases.
Nature Communications 2015;6:8442.
6.
Lovell DJ, Ruperto N, Mouy R, Paz E, Rubio-Perez N, Silva CA, Abud-Mendoza C, Burgos-Vargas R, Gerloni V, MeloGomes JA, Saad-Magalhaes C, Chavez-Corrales J, Huemer C, Kivitz A, Blanco FJ, Foeldvari I, Hofer M, Huppertz HI, Job
Deslandre C, Minden K, Punaro M, et al. Long-term safety, efficacy, and quality of life in patients with juvenile idiopathic
arthritis treated with intravenous abatacept for up to seven years. Arthritis & Rheumatology 2015;67:2759-70.
7.
Mina R, Abulaban K, Klein-Gitelman M, Eberhard A, Ardoin S, Singer N, Onel K, Tucker L, O'Neil K, Wright T, et al.
Validation of the lupus nephritis clinical indices in childhood-onset systemic lupus erythematosus. Arthritis Care & Research
2015.
8.
Mina R, Klein-Gitelman MS, Nelson S, Eberhard BA, Higgins G, Singer NG, Onel K, Tucker L, O'Neil KM, Punaro M, et
al. Effects of obesity on health-related quality of life in juvenile-onset systemic lupus erythematosus. Lupus 2015;24:191-7.
9.
Ombrello MJ, Remmers EF, Tachmazidou I, Grom A, Foell D, Haas JP, Martini A, Gattorno M, Ozen S, Prahalad S,
Zeft AS, Bohnsack JF, Mellins Ed, Ilowite NT, Russo R, len C, Hilario MO, Oliveira S, Yeung RS, Rosenberg A, Wedderburn LR,
Anton j, Schwarz T, Hinks A, Bilginer Y, Park J, Cobb J, Satorius CL, Han B, Baskin E, Signa S, Duerr RH, Achkar JP, Kamboh MI,
kaufman KM, Kottyan LC, Pino , Scherer SW, Alarcon-Riquelme ME, Docampo E, Estivill X, Gul A; British Society of Pediatric
and Adolescent Rheumatology (BSPAR) Study Group; Childhood Arthritis Prospective Study (CAPS) Group; Randomized
placebo Phase Study of Rilonacept in sJIA (RAPPORT) investigators; Sparks-Childhood Arthritis Response to medication
Study (CHARMS) Group; Biologically Based Outcome Predicttors in JIA (BBOP) Group, de Bakker pI, Raychaudhuri S,
Langefeld CD, Thompson S, Zeggini E, Thomson W, Kastner DL, Woo P; International Childhood Arthritis Genetics
(INCHARGE) Consortium; British Society of Pediatric and Adolescent Rheumatology BSPAR Study Group. HLA-DRB1*11 and
variants of the MHC class II locus are strong risk factors for systemic juvenile idiopathic arthritis. Proc Natl Acad Sci USA
2015.
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