Juvenile Rheumatiod Arthritis

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Juvenile rheumatoid arthritis is persistent inflammation of the joints (arthritis) that is similar to rheumatoid arthritis in adults but begins before 16 years of age. The cause is unknown. Hereditary factors may increase the risk of developing it.

Symptoms

This disorder affects only a few joints in about 40 percent of the children who have it; it affects many joints in another 40 per cent. In the remaining 20 per cent, it is systemic; that is, it affects the whole body, not just the joints, and is accompanied by fever - a condition called Still's disease.

Inflammation in only a few joints typically appears before age 4 (usually in girls) or after age 8 (usually in boys). The child has pain, swelling, and stiffness, most commonly in a knee, an ankle, or an elbow. Occasionally, one or two other joints, such as a single toe or finger, a wrist, or the jaw, become stiff and swollen. The joint symptoms may persist, or they may come and go.

Girls are particularly likely to have inflammation of the iris (chronic iridocyclitis), which often produces no symptoms and is detected only during an eye examination. Inflammation of the iris can cause blindness; therefore, the child must be examined for this condition and treated immediately.

Inflammation in many joints may occur in a child of any age, affecting girls more than boys. Joint pain, swelling, and stiffness may begin gradually or suddenly.

The joints usually affected first include the knees, ankles, wrists, and elbows. Later, both hands, the neck, the jaw, and the hips may be affected. The inflammation is usually symmetric, affecting the same joint on both sides of the body-for example, both knees or both hips.

Systemic juvenile rheumatoid arthritis affects boys and girls equally. Fever is intermittent, usually highest in the evening (often 103�F. or higher), then returns rapidly to normal. During the fever, a child may feel very ill.

A flat, pale pink or salmon rashmainly on the trunk and the upper part of the legs or arms appears for a short while (often in the evening), migrates and disappears, then returns. The spleen and some lymph nodes may become enlarged. Joint pain, swelling, and stiffness may be the last symptoms to appear.

Any type of juvenile rheumatoid arthritis can interfere with growth. When it interferes with growth of the jaw, it can result in a receding chin (micrognathia). Rheumatoid factor, an antibody that's usually found in the blood of adults who have rheumatoid arthritis, is rarely present in children who have juvenile rheumatoid arthritis. Rheumatoid factor is most likely to occur in girls who have many affected joints.

Prognosis and Treatment

Symptoms of juvenile rheumatoid arthritis completely disappear in up to 75 percent of the children. The prognosis is worse for those who have many affected joints and also have rheumatoid factor.

Large doses of aspirin can usually suppress pain and joint inflammation. Other nonsteroidal anti-inflammatory drugs, such as naproxen and tolmetin, are often used instead because taking aspirin increases the risk of Reye's syndrome.

The child may be given corticosteroids by mouth if the disease is severe and affects the whole body. but these drugs can slow the growth rate and are avoided if possible. Corticosteroids can also be injected directly into affected joints to relieve inflammation.

A child who doesn't respond to aspirin or other anti-inflammatory drugs may be given injections of gold compounds. Penicillamine, methotrexate, and hydroxychloroquine may be used when gold compounds are ineffective or cause side effects.

Exercises keep the joints from stiffening. Splints can prevent a joint from becoming locked in an awkward position. The eyes are examined every 6 months to look for inflammation of the iris. Inflammation is treated with corticosteroid eyedrops or ointment and drugs that widen (dilate) the pupil. Occasionally, eye surgery is needed.

Dr G. Noaz Md
The author is a paediatrician practising in New Jershy, USA.

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