A Child with Joint pain

What we usually think…….

Joint pain…
Got injured…
Naughty Kids…

Treatment:
Analgesics…
Will recover within a few days…
 Hold On…

Could it be arthritis???
 Arthritis???

Disease of Adult’s !?!?

Children are little Adults
Juvenile Idiopathic Arthritis

Dr. Md. Ali Akbar Khan (Rakib)

MBBS
Honorary Medical Officer, MU 9
Dhaka Medical College Hospital.
 Definition
Definite arthritis of unknown origin that begins
before the age of 16 years and persists for at least 6
weeks.

Other names:
JRA,JCA

Idiopathic:
Syndrome of diverse etiologies.
Most common chronic rheumatic disease of
childhood.

True frequency is not known- 10 to 20 per

100,000 population.

Girls are affected more with the ratio of 2:1

Peak age: 1 to 3 years

 Clinical Manifestations
Joint Pain
Joint swelling
Restricted joint mobility
Tenderness/Warmth/Redness of joint
Gait disturbance

Fever, rash,serositis,red eyes,anorexia,fatigue

Weight loss,growth failure,sleep disturbance
Clinical manifestations
 Classifications
1. Systemic onset ( Juvenile Stills disease)
2. Oligoarthritis
a. Persistent
b. Extended
3. Polyarthritis (RF +ve or –ve)
4. Psoriatic
5. Enthesitis related arthritis
6. Undifferentiated arthritis
a. Fits no other category
b. Fits more than one category
Polyarticular pattern of JIA
Oligoarticular pattern of JIA
Psoriatic presentation
Enthesitis
 Systemic JIA (Juvenile Still)
Joints may or may not be involved at the
beginning.
Equal sex ratio.
Uveitis rare.
Systemic features like fever,rash may precede
joint complaints by years.
May occur at any ages( Even in adults-called
Adult Stills disease)
 Systemic JIA
Classic rash is flat toped that usually
come and go but may hive.
Rash is transient-Koebners phenomenon.
Rash can be very itchy.
 Systemic JIA
Diagnostic hallmark- High spiking fever with
daily return to normal
 Systemic JIA
Joints can be severly involved.
Hepatosplenomegaly.
Lymphadenopathy.
Heart and lungs involvement.
Investigations:
Wbc,platlets and esr are highly raised.
RF and ANA are usually negative.
 Diagnosis
Mainly clinical.

Laboratory evaluation:
Acute phase reactants- usually normal.
Rheumatoid factor- usually negative.
ANA- frequently positive
Fluid analysis -usually class 2 inflammatory
 Diagnosis cont’d
Radiographs:
X-ray soft tissue swelling, periarticular
osteoporosis, loss of joint space
USG,MRI,CT scan
 Management
Medical:
NSAID- Aspirin,Naproxen,Ibuprofen,Tolmetin
sodium.
Naproxen 10-15mg/kg in 2 divided doses.

Corticosteroids
Used for uncontrolled or life threatining
severe disease.
Intravenous pulse therapy for severly active
JIA.
 Management cont’d
Intraarticular injection.
Eye drop for uveitis.

Prednisolone dose:
Low dose 0.1 to 0.2 mg/kg/day
High dose 0.25 to 1 mg/kg/day
Maximum daily dose 40 mg
 Mangement cont’d
DMARD:
Used when NSAID fail to bring relief.
Agents commomly used:
Methotrexate
Starting dose 7.5mg/m^2/week
Maximum dose 15 mg/m^2/week
 Management cont’d
Sulfasallazine
40 to 60 mg/kg/day in 3 to 6 divided doses
Anti TNF
Cytotoxic drugs
 Supportive care
Physical therapy.
Occupational therapy.
Coordinated care:
Pediatric rheumatologist
Ophthalmologist
Psychological support
 Surgical treatment
Epiphysiodesis.
Athroplasty.
Soft tissue surgery
 Prognosis
Common misconception ‘Childhood arthritis
would disappear in adulthood’

Clinical remission (40-80%) over 10 to 28 yrs

Systemic onset, 0-50%
Oligoarticular , 50-80%
Polyarticular, 20-30%
Enthesitis,0-30%
Psoriatic, 30-40%
 Complications

Growth retardation and osteopenia

 Complications cont’d
Sequlae of chronic uveitis.
Amyloidosis.
Macrophage activation syndrome.
Drug toxicity
যে নদী হারায়ে স্রোত অচল অসার
পদে পদে বাঁধে তার জীর্ণ অনাচার
Review article.
Methotrexate First choice for most childs with
peripheral arthritis.

Sulfasalazine and Leflunomide 2ndary role.

Anti TNF First choice for polyarticular JIA and

might be the 1st choice in enthesitis and
psoriatic JIA.
Anti TNF+ Methotrexate Additional benefit in
polyarticular JIA

Systemic JIA IL 1 and IL 6 inhibitors highly

effective; especially anakinra with
cyclosporine and corticosteroids are very
effective.

Uveitis Methotrexate+ Anti TNF +Abatacept

Review article,198 articles were reviewed.

Methotrexate superior to conventional treatment

with NSAID with or without intraarticular
steroids.

Newer DMARDs are expected to improve

outcome but still now evidence is insufficient to
support superiority over methotrexate.
Moderate evidence of reduced risk of flare if
treated for 4 to 24 months by a DMARD to
which the patient initialy responded.

Safety of biological DMARD not established,may

be associated with cancer.

Effectiveness of DMARD varies from patient to

patient and according to disease category.
Early aggressive therapy in patients with high
disease activity had prolonged periods of
clinically inactive disease.
Safety profile of celecoxib and non selective
NSAID is similar.

Benefit risk of celecoxib treatment in JIA remains

positive.
Weak evidence of the efficacy of IACI.

Lack of quality studies.

More studies required to determine the efficacy.

Increased prevalence of latent TB with
immunosuppression.

Tuberculin test is better than the immunoassay

based tests.
Safe but subclinical diastolic invovement occurs .

False positive cardiac markers may be due to

inflammatory process.
 Its all that young
can do for the old
to shake them
and keep them

up to date

George Bernard Shaw (1856-

1950)
Thank you !