Rheumatol Int (2013) 33:2315–2322
DOI 10.1007/s00296-013-2707-2
ORIGINAL ARTICLE
Prevalence of juvenile idiopathic arthritis in Sharkia
Governorate, Egypt: epidemiological study
Amany M. Abou El-Soud • Amany R. El-Najjar •
Eman E. El-Shahawy • Hanan A. Amar • Tamer H. Hassan
Somia H. Abd-Allaha • Hosnia M. Ragab
Received: 24 May 2012 / Accepted: 12 February 2013 / Published online: 20 March 2013
 Springer-Verlag Berlin Heidelberg 2013
Abstract Our objective was to determine the prevalence
juvenile idiopathic arthritis (JIA) in Sharkia Governorate,
Egypt. Population-based study was performed to identify
the prevalence of JIA in Sharkia Governorate, Egypt,
between November 2009 and November 2010. Prevalence
of JIA was 3.43 per 100,000 (95 % CI 3.1–4.3). Prevalence
in boys was 2.58 per 100,000 (95 % CI 2.4–3.6) and in
girls 4.33 per 100,000 (95 % CI 3.3–5.1). Uveitis presented
in 19.7 % of cases, antinuclear antibody in 48.5 %, and
rheumatoid factor in 27.2 %. Oligoarthritis representing
52.2 % of the total population, and enthesitis-related
arthritis presented only in 6 patients. No cases of undif-
ferentiated arthritis or psoriatic arthritis were found. This is
the first epidemiological study of JIA in Sharkia, Egypt.
Oligoarthritis was the most common subtype.
Keywords Prevalence
Juvenile idiopathic arthritis

Sharkia
Egypt
A. M. Abou El-Soud
A. R. El-Najjar (&)

E. E. El-Shahawy
H. A. Amar
Rheumatology and Rehabilitation Department,
Faculty of Medicine, Zagazig University, Zagazig, Egypt
e-mail: drnemr33@yahoo.com
T. H. Hassan
Pediatric Department, Faculty of Medicine,
Zagazig University, Zagazig, Egypt
S. H. Abd-Allaha
Medical Biochemistry Department, Faculty of Medicine,
Zagazig University, Zagazig, Egypt
H. M. Ragab
Community Medicine, Faculty of Medicine,
Zagazig University, Zagazig, Egypt
•
Introduction
Epidemiology is the study of the distribution and deter-
minants of disease in human populations. Thus, epidemi-
ologic studies include simple descriptions of the manner in
which disease appears in a population (levels of disease
frequency: incidence and prevalence, comorbidity, mor-
tality, trends over time, geographic distributions, and
clinical characteristics) and studies that attempt to quantify
the roles played by putative risk factors for disease
occurrence [1]. Juvenile idiopathic arthritis (JIA) is a het-
erogeneous group of chronic arthritis diseases in childhood
[2]. JIA is the most common chronic arthropathy of
childhood. Previous terminology identified this entity as
juvenile rheumatoid arthritis [3]. It is also the most com-
mon inflammatory joint disease in pediatric patients [4].
JIA is defined as arthritis of unknown cause that starts
before 16 years of age and lasts longer than 6 weeks [5].
The chronic, inflammatory arthritis in children has differ-
ences in nomenclature (e.g., ‘‘juvenile rheumatoid arthri-
tis’’ (JRA), ‘‘juvenile chronic arthritis’’ (JCA), and most
recently ‘‘juvenile idiopathic arthritis’’ [6]). Few studies of
the prevalence of childhood arthritis have been performed,
and the results have varied [7]. The variations over time
indicate environmental influences, whereas ethnic and
familial aggregations suggest a role for genetic factors. The
genetic component of juvenile arthritis is complex, prob-
ably involving the effects of multiple genes [8]. The main
sources of prevalence variations in the pediatric population
are overestimation related to the inclusion of patients who
do not meet International League of Associations for
Rheumatology (ILAR) criteria for JIA and underestimation
related to hospital-based patient recruitment with no effort
to identify patients who have mild disease managed by
office-based physicians [9].
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Objective
Our objective was to determine the prevalence and distri-
bution of various patterns of juvenile idiopathic arthritis in
Sharkia Governorate of Eastern Egypt.
Materials and methods
Background population
We conducted a population-based, multicenter study
among rheumatologists and pediatricians in Sharkia
Governorate to identify patients with JIA less than 15 years
and seen between November 2009 and November 2010.
Sharkia Governorate is located in east of Egypt, and it
comprises 19 districts. According to national agency for
mobilization and statistics, it has a population of 8,566,465
inhabitants at the end of 2010. The total number of children
under the age of 15 years was 3,844,718 on that year.
A total of 829,496 were in the urban areas and 3,015,222
were in the rural areas. Boys comprise 1,976,715 while
girls were 1,868,003.
Recruitment
We recruited children under age of 15 years residing in
Sharkia Governorate who had at least one physician visit
between November 2009 and November 2010. Most
pediatric patients in our setting receive health assistance
close to their area of residence through the primary heath
care centers within the National Health Insurance Program
that provide more than 90 % of pediatric primary heath
care. Some cases of (JIA) were referred from the Hospital
of Health Insurance in Zagazig city to the rheumatology
department of Zagazig University Hospitals for better
health care, better treatment and follow up of the cases.
Those cases were also included in our study. Zagazig
University Hospitals is the biggest hospital in eastern
Egypt that provides health care to the population in that
part of Egypt, as it full of highly qualified professors and
doctors of various specialties. All practitioner, rheumatol-
ogist, and pediatrician were asked to refer children who
satisfied criteria to the rheumatology department in
National Health Insurance Hospitals in Sharkia Governor-
ate for diagnosis, for follow up and to receive their treat-
ment. Each patient encountered had the diagnosis, age, and
basic demographics recorded. Also, we searched the hos-
pitals computerized records for patients diagnosed as JIA at
the end of our study to identify any patients with JIA who
had not been included.
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Rheumatol Int (2013) 33:2315–2322
Inclusion criteria
Only patients residing in permanently in one of the districts
of Sharkia Governorate were included. Following the cur-
rent definition of arthritis in children, a patient had to have
swelling of one or more joint or limited range of joint
movement with pain or tenderness observed by physician.
The 2004 revised ILAR classification for JIA was used
in this study. Patients can be classified into seven sub-
groups: systemic arthritis, oligoarticular arthritis, polyar-
thritis with rheumatoid factor, and polyarthritis without
rheumatoid factor, psoriatic arthritis, enthesitis-related
arthritis (ERA), and undifferentiated arthritis [10].
The following information was collected from each
patient: age, sex, disease onset, disease duration, whether the
patient had uveitis or iridocyclitis by slit lamp examination,
results of tests for rheumatoid factors and antinuclear
antibodies, and the treatments used [nonsteroidal anti-
inflammatory drugs (NSAIDs), systemic glucocorticoids,
disease-modifying antirheumatic drugs (DMARDs), local
glucocorticoid injections, and physical therapy].
Exclusion criteria
Patients who had inflamed joints related to trauma or
malignant disease, septic arthritis, bone diseases, as dys-
plasia, or osteomyelitis were excluded.
Written informed consent was obtained from the parents
of the children included in the study.
Laboratory investigations
Patients included in the prospective part of the study were
tested for those laboratory data that characterize some of
subgroups. RF was tested by a semiquantitative latex test;
titers C30 IU/mL were considered positive. Antinuclear
antibodies (ANA) were detected by indirect immunofluo-
rescence on Hep-2 cells, with positive titers from 1/40.
According to the ILAR criteria, RF and ANA had to be
positive on at least two determinations 3 months apart
during the first 6 months of the disease. Human leukocytic
antigen-B27 (HLA-B27) detection by low-resolution poly-
merase chain reaction (PCR) analysis was carried out in all
patients thought to have enthesitis-related arthritis. Syno-
vial fluid analysis was done if we suspected septic arthritis.
Radiological examination
• Plain X-ray to both hands and both sacroiliac joints.
• Plain X-ray on any joint to exclude bone tumor or
dysplasia.
Rheumatol Int (2013) 33:2315–2322
Statistics
Definition of the prevalent case: All JIA patients younger
than 15 years diagnosed between November 2009 and
November 2010 and with active or inactive disease at
recruitment were eligible as prevalent cases. The estimated
population on December 31, 2010 was used for calculation.
The results for the continuous variables are expressed as
the mean, range, and standard deviation (SD). Categorical
variables are reported as the numbers of cases and per-
centages. Relationships between categorical variables were
examined using Fisher’s exact test. A P value of\0.05 was
considered significant. We estimated 95 % confidence
intervals (CIs) using the normal distribution approxima-
tion. The analyses were performed using SPSS for
Windows version 15 (SPSS Inc, Chicago, IL, USA).
Results
One hundred thirty-two prevalent cases of JIA were iden-
tified and fulfilled the diagnostic criteria for JIA and par-
ticipate in National Health Insurance Program. The point
prevalence of JIA was 3.43 per 100,000 (95 % CI 3.1–4.3).
The prevalence of JIA in boys was 2.58 per 100,000 (95 %
CI 2.4–3.6) and in girls was 4.33 per 100,000 (95 % CI
3.3–5.1). Girls predominated over boys (81/51) and showed
a relative risk of developing JIA of 1.68 (1.18–2.39,
P = 0.003).
When urban No = 54 is compared to rural populations
No = 78, the difference between these populations was
statistically significant (P B 0.01).
The overall mean age at diagnosis of prevalent patients
was 10.5 ± 3.6 (range 4–15) years. Among the total,
70.5 % had been diagnosed before the age of 7 and only
29.5 % patients had been diagnosed at the age of 12 or
older.
Uveitis was present in 26/132 prevalent cases (19.7 %)
diagnosed at the time of the study. ANA tested positive in
64 out of 132 patients, accounting for 48.5 % of prevalent
140
120
100
80
60
40
20
0
Frequency of JLA Privelance /100.000
Fig. 1 Frequency and prevalence of JIA in Sharkia governorate
2317
cases; RF tested positive in 27.2 % of the studied patients,
present in 36/132 prevalent cases (Figs. 1, 2, 3, 4, and 5).
According to subgroup distribution, we reported that
patients, oligoarthritis was the largest group, with 69 cases,
representing 52.2 % of the total population, 21 patients of
this group had uveitis (30.4 %), and 43 of them had posi-
tive tests of ANA (62.3 %). Enthesitis-related arthritis was
the least group represented only in 6 patients; HLA-B27
was positive in 4 out of 6 patients of ERA (66 %), while no
cases of undifferentiated arthritis or psoriatic arthritis could
be detected (Tables 1, 2, 3, and 4).
Discussion
The prevalence of JCA and/or JRA has been estimated in
several studies both in the USA and Europe [11]. In
developing countries, there may be difficulties in obtaining
accurate census data [12]. However, presence of social
insurance program for the entire children under 16 years in
Egypt helps for research purposes.
Our study indicated that the prevalence of JIA in chil-
dren in Sharkia Governorate (Egypt) was 3.43 per 100,000,
which was in agreement with the prevalence of JCA in
Chinese children in Taiwan that was 3.8 per 100,000 (95 %
CI 3.3–4.3) [4]. However, this prevalence was much lower
than previous studies of juvenile rheumatoid arthritis both
in the USA and Europe. Using EULAR criteria, the inci-
dence of JCA ranges from around 20 to 50 per 100,000 per
year in southwestern Sweden [13]. Laaksonen [14] esti-
mated the prevalence rate was 40 per 100,000 children
fewer than 15 years. Other studies carried out in the USA
during the 1970s estimated prevalence rates of JRA rang-
ing from 16 to 110 per 100,000 [15, 16]. Manners and
Diepeveen [17] measured point prevalence of JCA in an
entire urban by a rheumatologist. The resulting point
prevalence in 12 year olds was 40 per 100,000, most of
which were mild cases. Mielants et al. [18] found a prev-
alence of 167 per 100,000 with definite JCA and 301 per
100,000 with probable JCA. The incidence of JIA in
Frequency
90
80
70
60
50
40
30
20
10
0
Urban Rural
Residence
Fig. 2 Prevalence of JIA in Sharkia according to residence
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Frequency Table 3 Characteristics data of juvenile idiopathic arthritis patients

90
80 No = 132
70
60
50 Age (years)
40
30 Mean ± SD 10.5 ± 3.6
20
10
Range 15
0 Gender male/female no (%) 51/81 (38.6/61.4)
Male Female
Disease duration (years)
Gender
Mean ± SD 1.8 ± 0.6
Fig. 3 Prevalence of JIA in Sharkia according to gender Range 1–3
MS (min)
Age Mean ± SD 44.6 ± 28.7
16
Range 0.0–90
14
12 Knee effusion no (%) 35 (26.5 %)
10 No of tender joints
8
Mean ± SD 5.6 ± 2.95
6
4 Range 1–14
2 No of SWJ
0
1 Mean ± SD 2.35 ± 1.59
Range 0.0–8
Fig. 4 Prevalence of JIA in Sharkia according to age
ROM
Mean ± SD 2.2 ± 2.0
50
40
Range 0.0–10
30 ESR
20 Mean ± SD 44.5 ± 22.0
10 Range 14–120
0 CRP
Disease MS(min) No of No of ROM ESR CRP
duration tender SWJ Mean ± SD 16.7 ± 19.8
(yrs) joints Range 2–96
Fig. 5 Clinical and laboratory characteristics of JIA in Sharkia RF (-VE/?VE) 96/36 (72.7/27.2)
SC nodules
No (%) 0.0
X-ray abnormalities
Table 1 Prevalence of JIA in Sharkia Governorate No (%) 8 (6.1 %)
Total population in Sharkia Governorate 8,566,465 MS morning stiffness, SWJ swollen joint count

Total children 3,844,718

Frequency of JIA 132
Alsace (France) calculated to be 3.2 cases/100,000/year
Prevalence/100.000 3.43
and the prevalence 19.8 cases/100,000 children under age
16 years [19]. Hanova et al. [20] found that the prevalence
of JIA in children in Czech Republic was 140/100,000
Table 2 Prevalence of JIA according to residence and gender (95 % CI 117–280/100,000).
Total Frequency Prevalence/ RR The prevalence of chronic, inflammatory arthritis in
100,000 (95 % CI) children is difficult to estimate because of differences in
nomenclature [e.g., ‘‘juvenile rheumatoid arthritis’’ (JRA),
Residence
‘‘juvenile chronic arthritis’’ (JCA), and most recently
Urban 829,496 54 6.5 2.52
‘‘juvenile idiopathic arthritis’’ (JIA)] and classification
Rural 3,015,222 78 2.587 (1.78–3.56)*
criteria [1977 American College of Rheumatology (ACR);
Gender formerly, the American Rheumatism Association] [21],
Male 1,976,715 51 2.58 1.68 1978 European League Against Rheumatism [22], and
Female 1,868,003 81 4.33 (1.18–2.39)* 1997 International League of Associations for Rheuma-
* P \ 0.01 tology [23] with a revision published in 2004 [10], and the

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Table 4 Distribution of juvenile idiopathic arthritis subgroups according to ILAR
JIA subgroup Rate (%) Prevalence (95 % CI)
Systemic (no = 18) 13.6 8.5–20.9
Oligoarticular (no = 69) 52.2 43.4–60.9
Polyarticular (no = 39) 29.5 22.1–38.2
Polyarticular with RF ?ve (no = 11) 8.3 4.4–14.76
Polyarticular with RF -ve (no = 28) 21.2 14.77–29.3
ERA (no = 6) 4.5 1.86–9.2
Total (no = 132)
ERA enthesitis-related arthritis
Undifferentiated (no = 0), psoriatic arthritis (no = 0)
heterogeneity of the diseases and their subtypes encom-
passed under this rubric [24]. In addition, variability in
disease course among the subtypes of JIA may make it
difficult to compare prevalence estimates for this condition
across different study settings. In some types of the disease,
extended remissions occur, so that prevalence estimates
include individuals who were ever affected, but are not
currently affected.
In a study carried out in specific area of Norway, the
prevalence of JIA was 83.7 (95 % CI 72.4; 95.8) per 100
000 children aged 0–15 years [25]. Modesto et al. [26]
carried out prospective and retrospective studies in Cata-
lonia, a region in the north of Spain, based on ILAR
classification criteria; prevalence was 39.7 (36.1–43.7)/100
000 children younger than 16 years. It was the first popu-
lation-based study on the epidemiology of JIA in Catalonia.
Incidence and prevalence rates are lower than those
reported for several areas in Nordic countries of Europe.
Solau-Gervais et al. [5] yielded a prevalence of
15.7/100,000 in France. Many factors contribute to the
discrepancies between reported prevalence and incidence
for JIA. Studies based truly in the community reported the
highest prevalence, as previously undiagnosed cases were
included. Future studies involving standardized criteria and
standardized case ascertainment done by fully trained cli-
nicians should show greater consistency of results [20].
We noted a clear female preponderance of JIA in this
study, in which the prevalence of JIA in girls was 4.33 per
100,000 (95 % CI 3.3–5.1) and in boys was 2.58 per
100,000 (95 % CI 2.4–3.6). Girls predominated over boys
(81/51) and showed a relative risk of developing JIA of
1.68 (1.18–2.39, P = 0.003). Our results are similar to the
reports from Western countries in the female preponder-
ance of JIA. In East Berlin, the frequency of JCA is higher
for girls, with an incidence of 4.3 per 100,000 and a
prevalence of 2.3 per 10,000. The figures for boys are 2.7
per 100,000 and 1.7 per 10,000, respectively [27]. A 2-year
2319
Mean age at onset (years) F/M Uveitis no (%) ANA no (%)
5.7 ± 4.9 7/11 0 5 (27.8)
7.8 ± 3.8 49/ 21 (30.4) 43 (62.3)
20
25/ 3 (7.7) 16 (41)
14
11.5 ± 3.2 12/6 0 (0.0) 4 (36)
9.1 ± 4.1 13/8 3 (10.7) 12 (42)
13.3 ± 2.9 0/6 2 (33.3) 0
12.5 ± 4.56 81/ 26 (19.7) 64 (48.5)
51
(2004–2006), prospective, population-based study was then
carried out in Catalonia (Spain) calculated a relative risk of
girls having JIA was 2.1 [95 % confidence interval (CI)
1.7–2.7, P \ 0.001] [26]. In Taiwan, the prevalence of JCA
in girls was 4.1 per 100,000 (95 % CI 3.3–4.9) and for boys
was 3.5 per 100,000 (95 % CI 2.9–4.2) [4]. In contrast to
the previous results, Turkish children showed higher
prevalence of JIA among boys. Yilmaz et al. [28] found
that there were 102 boys and 94 girls with a mean duration
of disease of 4.1 years. Also, in another epidemiological
study in the republic of Bashkortostan (Russia), the pre-
valence of JIA in boys was higher, than in girls (93.9 and
73.7 per 100,000 children, respectively, P \ 0.001) [29].
Further studies are required to understand how genetic and
environmental differences affect JIA expression.
In this work, the overall mean age at diagnosis of pre-
valent patients was 10.5 ± 3.6 (range 4–15) years. Among
the total, 70.5 % had been diagnosed before the age of 7
and only 29.5 % patients had been diagnosed at the age of
12 or older. Our results are similar to the mean age of JIA
in Quebec (Canada) which was 9.8 ± 4.6 years, 68 %
were female, and more persons were diagnosed in winter
[30]. Yilmaz et al. [28] found that the mean age at the first
visit was 8.8 years, and the mean age at onset of disease
was 6.8 years (range 8 months–15 years). Approximately
similar results reported in Catalonia (Spain), the mean
annual incidence was 6.9/105 children aged less than
16 years (range 5.8–8.1 years; 9.0 years for girls and
4.8 years for boys) [26]. Also, in southwestern Sweden, the
peak incidence rate of 18.3 per 100,000 was found in girls
0 through 3 years old. The lowest incidence rate, 6.4 per
100,000, was found among boys 12 through 15 years old
[13]. Solau-Gervais et al. [5] reported that the mean age of
JIA at diagnosis was 6.6 years (range 1–15 years). In
another study done in France, age at appearance of the first
symptoms was 4.7 years (±3.2 years) in girls, as compared
to 7.2 years (±3.7 years) in boys [19].
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The subgroup distribution in our work reported that
oligoarthritis was the largest group (n = 69, 52.2 %),
followed by polyarticular group (n = 39, 29.5 %), and
systemic group (n = 18, 13.6 %), and then finally, enthe-
sitis-related arthritis group (n = 6, 4.5 %) of the total
population. There was no undifferentiated or psoriatic
arthritis. Solau-Gervais et al. [5] found that oligoarticular
disease was the most common pattern with 20 (41.6 %)
patients while enthesitis-related arthritis contributed eight
(16.6 %) patients, and there were nine patients with poly-
articular disease and seven with systemic disease. A 5-year
prospective population study in southwestern Sweden
found that oligoarticular onset type constituted 68.3 % of
the prevalence cases, while 21.9 % were polyarticular and
6.6 % had systemic onset [13]. Also, in France, Danner
et al. [19] reported the most frequent forms were oligoar-
thritis (n = 27, 40.3 %), polyarthritis without rheumatoid
factor (RF; n = 15, 22.4 %), and enthesitis-related arthritis
(n = 12, 17.9 %). Other forms, notably systemic arthritis
(n = 6, 8.9 %) and psoriatic arthritis (n = 3, 4.5 %), were
more rare, and in this study, there was no case of polyar-
thritis with RF. Only 4 patients (6 %) were classified in the
undifferentiated arthritis group. Arguedas et al. [31] found
that 77 % of the JCA cases in Costa Rica were of pauc-
iarticular onset, and 23 % were of polyarticular onset. No
cases of systemic JCA were diagnosed. Martinez Mengual
et al. [32] reported that the most frequent form of onset was
persistent oligoarticular arthritis (41.7 %), followed by
spondyloarthropathies (11.7 %), conditions that did not
meet the criteria for any category (11.7 %), polyarticular
arthritis (11.7 %), systemic disease (10 %), psoriatic
arthritis (6.7 %), and extended oligoarticular arthritis
(6.7 %). However, in Turkey, polyarticular JIA was the
most frequent onset type (37.2 %). Other subtypes included
oligoarthritis (34.2 %), systemic arthritis (15.3 %), psori-
atic arthritis (1 %), enthesitis-related arthritis (9.7 %), and
other arthritis (2.2 %) [28]. Also, an Indian study done by
Kunjir et al. [33] found enthesitis-related arthritis (ERA;
36 %), oligoarthritis (OLA-persistent; 17 %), polyarthritis
rheumatoid factor (RF) negative (17 %), polyarthritis RF
positive (12 %), systemic arthritis (8 %), OLA extended
(4 %), and psoriatic arthritis (1 %). The remaining 11
children (5 %) were classified with undifferentiated
arthritis. The discrepancies between the previous two
studies and those reported from Western countries are
possibly the results from true differences pertaining to
ethnicity, geography, or both. Future studies are necessary
to elucidate the implications suggested by these data.
Our study showed that uveitis occurred in 26 patients
(19.7 %) of the total 132 JIA patients. Oligoarthritis was
the largest group representing (n = 21, 30.4 %) followed
by polyarticular group without RF representing (n = 3,
10.7 %). Our results also highlight the frequent presence of
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Rheumatol Int (2013) 33:2315–2322
ANA and uveitis in patients with oligoarthritis (62.3 %)
and in polyarthritis without RF (42 %). Danner et al. [19]
found that uveitis occurred in 41 % of children with olig-
oarthritis and in 14 % of those with polyarthritis without
RF. Skarin et al. [34] showed that fifty-five out of 350
patients with JIA developed uveitis (15.7 %). Forty-six
(84 %) of these had oligoarthritis, 6 (11 %) had polyar-
thritis, and 3 (5 %) had systemic disease. Also, in a large
population-based nationwide study in Germany of patients
with JIA, the prevalence of uveitis was 12 % of all JIA
patients. The most frequent were oligoarthritis extended
(25 %) and persistent (16 %): ANA positive (86 vs. 42 %)
than the patients without uveitis [2]. Grassi et al. [35]
recorded sixty-two patients developed uveitis (20.1 %); 57
patients had oligoarticular-onset, 3 polyarticular-onset, and
2 systemic-onset JIA. Saurenmann et al. [36] found that
142 of 1,081 patients (13.1 %) had developed uveitis, and
the risk factors were young age at diagnosis, female sex,
antinuclear antibody positivity, and the subtype of JIA.
Berk et al. [37] demonstrated that uveitis was diagnosed in
11 patients (12.2 %). Of these, seven (63.6 %) had olig-
oarticular, two (36.4 %) had polyarticular, and one (9.1 %)
had systemic-onset juvenile rheumatoid arthritis (JRA).
Antinuclear antibodies (ANA) were positive in seven
(63.6 %) of the 11 uveitis patients, confirming ANA as a
significant determinant for uveitis in juvenile arthritis. The
previous results was unlike to that reported by Bolt et al.
[38], who found that the rate of uveitis was 13.2 % in
cohort of Swiss children with JIA and the subgroup with
the highest rate of uveitis was ‘‘other arthritis,’’ followed
by oligoarticular JIA. Extended and persistent course of
oligoarticular JIA had a similar uveitis incidence. Yilmaz
et al. [28] also reported that chronic uveitis occurred in two
patients with oligoarthritis; two patients with enthesitis-
related arthritis had acute uveitis. Authors considered the
factors to be the cause of the variations seen were diag-
nostic difficulties, development of new diagnostic criteria,
differing definitions of a clinical case, and small sample
sizes leading to larger variations in reported rates.
In this study, ANA tested positive account 48.5 % of
prevalent cases, RF tested positive in 27.2 % of the studied
patients, and HLA-B27 was positive in 4 out of 6 patients
of ERA (66 %). Uveitis was present in 26/132 prevalent
cases (19.7 %) diagnosed at the time of the study.
Modesto et al. [26] reported that ANA tested positive in
57.6 % of prevalent cases. Among ANA-positive patients,
79.5 % were girls, 80 % of ANA carriers were included in
the oligoarthritis group, and RF was documented in three
cases only (0.8 % of prevalent cases). HLA-B27 was
positive in 19.4 %. The latter group was distributed mostly
in the enthesitis-related arthritis group, few in the olig-
oarthritis and undifferentiated arthritis groups. Uveitis was
present in 12 % only of prevalent cases. In study done in
Rheumatol Int (2013) 33:2315–2322
Nordic countries, the number of ANA-positive children in
the whole group was 39 %; girls were ANA positive in
42 % and boys in 34 %. Uveitis developed in 8.6 % of the
children during the first 6 months of the disease [39].
In this study, when urban No = 54 is compared to rural
populations No = 78, difference between these popula-
tions was statistically significant. This is in agreement with
Kurahara et al. [40] who found a lower prevalence of JRA
in the urban area (38.3 per 100,000) when compared to the
rural neighbor islands (63.2 per 100,000). In Germany, von
Koskull et al. [41] reported that the prevalence in urban
areas was 14.8 per 100 000 subjects under 16 years of age.
Many factors contribute to the discrepancies between
reported prevalence and incidence for urban and rural
children with JIA. These factors include geographic dis-
tribution, genetic background, environmental factors,
infectious agents, health care resources, and increasing
knowledge.
Conclusion
In this first population-based epidemiologic survey of
pediatric JIA in Sharkia Governorate, Egypt, we provided a
good starting point in our understanding of the epidemi-
ology of this serious condition in the Egyptian population.
The discrepancies between our prevalence figures and
those reported from Western countries are possibly the
results from true differences pertaining to ethnicity, geo-
graphy, or both. Future studies are necessary to elucidate
the implications suggested by these data.
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