RHEUM WITH A VIEW- Perspectives on rheumatologic conditions
Juvenile Idiopathic Arthritis (JIA) – Dr Dzifa Dey
Arthritis in children? What an absurd thought. It doesn’t sound right does it?
But yes, children get arthritis too, and as you may rightly be thinking, it’s not just any kind of arthritis. It’s not the old ladies knees type of arthritis.
Juvenile idiopathic arthritis (JIA) previously referred to as Juvenile Rheumatoid Arthritis is the most common chronic autoimmune rheumatologic disease in children and is one of the most common chronic diseases of childhood. Arthritis is defined as pain, swelling and limitation of movement in a joint.
Apart from the physical pain the child goes through, Juvenile arthritis is as devastating as other autoimmune or inflammatory conditions and if not treated well and aggressively leaves lifelong damage, affecting the growth of the child, resulting in growth retardation, differences in limb length, permanent eye damage etc .
But with good treatment especially with the newer biologic agents the long term prognosis is very good.
This is unknown but likely to be a combination of genetic and environmental factors. Arthritis occurring in a child less than 16 years of age with some characteristic features would be classified into various types which have an impact on its outcome
- Systemic-onset juvenile idiopathic arthritis: in Systemic-onset JIA there is development of arthritis occurring at onset of the swinging fever and rash or may lag by months or, rarely, years.
- Oligoarticular juvenile idiopathic arthritis: in oligoarticular JIA, 4 or fewer joints (and in many cases, only 1 joint) are affected and large, weight-bearing joints, such as the knees and ankles, are typically affected. Your child may go on to develop arthritis in other joints after the first 6 months and this will then be called extended oligoarthritis.
- Anterior uveitis is present in up to 20percent of children with oligoarticular and polyarticular JIA, especially those who are antinuclear antibody (ANA) positive. The uveitis is characteristically asymptomatic at onset and must be screened for with an ophthalmologic slit lamp examination regularly.
- Polyarticular juvenile idiopathic arthritis: Polyarticular juvenile idiopathic arthritis involves 5 or more joints in the first 6 months after disease onset, often affecting weight-bearing joints, rheumatoid nodules may be seen in patients with RF-positive disease, and symmetrical involvement of small joints in the hands is typical.
- Psoriatic arthritis: associated with Psoriasis or history of psoriasis
- Enthesitis-related arthritis: enthesitis-related arthritis, or pediatric spondyloarthropathy, is characterized by episodes of inflammation of tendons and ligaments, predominantly at the area of insertion into bone (entheses) such as the Achilles tendon.
- Undifferentiated arthritis: undifferentiated JIA is diagnosed if the patient’s signs either do not fulfil the criteria for any one subtype or fulfil the criteria for more than one.
Symptoms can be varied and come in phases including
- Joint pain
- Joint swelling
- Painful red eyes
- Joint stiffness
- Persistent fever
These signs should alert a parent or guardian that all is not well with your child.
- Arthritis present for at least six weeks before diagnosis (mandatory for diagnosis of JIA)
- Morning stiffness
- Joint pains
- History of school absences
- Non participation in physical activity
- Spiking fevers occurring once or twice each day at about the same time of day
- Reddish rash on the trunk and extremities
- History of skin rash called Psoriasis
- Joint swelling
- Unequal limb lengths
- Swelling of the lymph glands
Investigations are needed for monitoring the disease as well as for diagnosis and for possible complications that may occur.
- Inflammatory markers: Erythrocyte sedimentation rate (ESR) or CRP level
- Full blood count (FBC)
- Kidney function tests
- Liver function tests
- Antinuclear antibody (ANA) (Those with positive results need regular eye checks for uveitis ie inflammation of a layer of the eye)
- Rheumatoid factor (RF) and anti–cyclic citrullinated peptide (CCP) antibody tests
- X-rays of the joint to exclude other diseases such as cancers or infections of the bone.
- Other imaging modalities that may be helpful include the following:
- Computed tomography
- Magnetic resonance imaging
- To control inflammation
- To prevent development of deformities
- To prevent growth retardation
- To prevent extra articular complications
- To reduce side effects of drug.
v Non-pharmacological treatment
Ø Psychosocial interventions
Ø Counselling to enhance school performance (e.g. academic counselling)
Ø Diet therapy
Ø Occupational therapy
v Pharmacological treatment include
Ø Nonsteroidal anti-inflammatory drugs (NSAIDs)
Ø Intra-articular and oral corticosteroids
- Disease-modifying antirheumatic drugs (DMARDs) – Mainly Methotrexate
- New Biologic agents Anti TNFα Inhibitors eg Etarnecept, Infliximab, Adalimumab
Many children who have JIA won't have any symptoms when they're adults, but it’s not possible to precisely envisage this. In most cases, childhood arthritis has a good outcome. You should look forward to a future that’s no different from those of your friends and classmates. In at least 30percent of cases, however, arthritis can remain active into adult life.
A successful outcome in JIA requires many things, including:
- a positive attitude
- an experienced team
- a caring, supportive environment with care from family, friends and teachers.
- You also need to know how to get help and advice from the right sources
The writer is a Physician Specialist & Rheumatologist
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