Director, Division of Pediatric Rheumatology, Children’s Hospital of The King’s Daughters
Associate Professor of Pediatrics, Eastern Virginia Medical School
Physicians choose their specialties for as many reasons as there are specialties to choose from. For Dr. Chris Gabriel, it was simply a matter of seeing a need, and stepping up to fill it. He received his undergraduate degree in Environmental Health at Old Dominion University, intending to look for work in biology, but a good friend, with whom he was working at the Public Health Service Hospital, changed his path. “He told me he thought I’d make a good doctor,” Dr. Gabriel remembers. “So I applied to medical school.”
He earned his medical degree from Eastern Virginia Medical School, where he completed both his internship and residency in pediatrics. During his residency, he saw pediatric patients with rheumatic diseases being admitted to the hospital for treatment, and quickly realized there were no trained pediatric rheumatologists to take care of them. “They were being cared for by very good physicians,” Dr. Gabriel emphasizes, “infectious disease specialists, general pediatricians, a whole host of people who were very skilled, but who didn’t have specialized training in rheumatology.”
He therefore decided to do one year of clinical fellowship in pediatric nephrology at the Children’s Medical Center at Georgetown University Hospital in Washington, DC. He then completed fellowship training in pediatric rheumatology at Cincinnati Children’s Hospital Medical Center, where he served an additional year as a Procter Research Scholar/Clinical Instructor in Pediatrics.
“When I left for Georgetown and then Cincinnati, it was always with the idea of coming back here. This is home to me,” Dr. Gabriel says. “I have always been committed to CHKD and wanted to start a comprehensive program that offers specialized care for young patients with rheumatic and connective tissue diseases. That was really the impetus.”
Diagnosing patients with rheumatic disease can be a challenge. “Many of these disorders, such as juvenile idiopathic arthritis (JIA), are a diagnosis of exclusion,” Dr. Gabriel says. “While laboratory tests and X-rays are helpful, there is no single laboratory test that allows one to confirm the diagnosis. We have to rule out other possible causes of arthritis such as infection or malignancy before making the diagnosis.” It’s important, he says, because other causes must be eliminated: “We don’t want to start these kids on powerful medication and biologics if they have some other disease, so it’s important to go through that process.”
Dr. Gabriel’s patients range in age from infant through 21 – three years longer than many pediatricians see their patients. “These kids will probably go away to college,” he explains, “so I don’t want to send them to an adult rheumatologist here, only to have them move away and have to find another doctor in their new city.”
The majority of his practice involves treating juvenile arthritis, followed by juvenile systemic lupus and juvenile ankylosing spondylitis. The differences between pediatric and adult rheumatology cases can be significant. “Juvenile arthritis is really a very different disease than rheumatoid arthritis, and there are various subtypes of juvenile arthritis that exist as well,” Dr. Gabriel explains. “We think of adult rheumatoid arthritis as a pretty homogenous disease. With JIA, various subtypes exist. There’s pauciarticular juvenile arthritis (four or fewer joints involved); polyarticular juvenile arthritis (five or more joints are involved); and systemic juvenile arthritis (joint swelling accompanied by fever and rash). The prognosis can vary depending on the subtype the patient has.”
With systemic lupus and ankylosing spondylitis, there are differences between the juvenile and adult diseases, but the treatments are the same for the most part. “With systemic JIA, which we rarely see in adults, patients present with high fever and rash, and they are very ill, often requiring hospitalization,” Dr. Gabriel says.
For some of his patients, the prognosis can be poor. The introduction of biologic therapies has made a huge difference in the treatment of pediatric and adult rheumatology. “Back when I was a fellow, we’d put these kids on what was basically the equivalent of aspirin or ibuprofen or Motrin and slowly watch them become crippled as their joints deteriorated,” Dr. Gabriel remembers. “Now, with biologic therapy, we can treat them and keep their disease under control. They actually have the chance to live essentially normal lives.”
Most of his patients with juvenile arthritis attend school, are involved in sports and do all the other things that today’s kids do. “The only difference for these kids is they have to take medication,” Dr. Gabriel says. “It’s been a pretty remarkable revolution in terms of the biologic drugs that have allowed us to control the disease. We still don’t cure it with these drugs, but they’re so effective at controlling the inflammation that the patients basically are close to if not free of arthritis – as long as they take their medications.”
Dr. Gabriel is excited that the program he began is expanding. CHKD recently hired another pediatric rheumatologist, and the two now see patients in satellite locations in Virginia Beach, Newport News and Chesapeake. It won’t happen any time soon, he says, but, “When I’m ready to retire, I want to be sure there’s a strong program in place to take care of these kids.”