JUVENILE

IDIOPATHIC
 INTRODUCTION
Juvenile idiopathic arthritis presents as chronic
joint swelling, pain with functional limitation
for at least 6 weeks of unknown cause that
starts before 16 year of age.

UNKNOWN E ATLEAST 6 ONSET

TIOLOGY WEEKS BEFORE
1 6yrs
 SIGN & SYMPTOMS

ARTICULAR EXTRA-ARTICULAR

1. Joint swelling 1. General

2. Joint pain 2. Growth disturbances
3. Joint stiffness / swelling 3. Skin
after periods of inactivity 4. Others
4. Joint warmth 5. Enthesitis*
5. Restricted joint movements
6. Limping gait

*Inflammation of the entheses (the sites of insertion of tendon, ligament or joint capsule into bone)
 SIGN & SYMPTOMS
EXTRA-ARTICULAR
General
 Fever, pallor, anorexia, loss of weight
 Growth disturbances

 General :growth failure, delayed puberty

 Local : Limb length / size decrepency

Skin
 Subcutaneous nodules
 Rash – systemic, psoriasis, vasculitis

Others
 Hepatomegaly, splenomegaly, lymphadenopathy
 Serositis, muscle atrophy / weakness
 Uveitis: Chronic (silent), acute in Enthesitis related arthritis
CLASSIFICATIO
N
There are 3 major types of JIA:
Oligoarticular JIA

Polyarticular JIA
RF positive
Systemic JIA RF negative

Some other less-common forms include:

 Enthesitis-related arthritis
 Psoriasis arthritis
 Undifferentiated arthritis
CLASSIFICATIO
N
 OLIGOARTHRITIS
WHAT IS OLIGOARTHRITIS?

Oligoarticular arthritis occurs in 50% to 60% of young people who have JIA. It is
the most common type of JIA in young people. It affects four or fewer joints in
the first six months after diagnosis. There are two types of oligoarticular JIA:
1. Oligoarticular-persistent JIA
2. Oligoarticular-extended JIA.

Subtypes Age at onset Diagnostic

 Persistent < 6 years old  Affects ≤4 joints throughout course of disease
 Extended  Affects >4 joints after the 1st 6 months of
disease
 OLIGOARTHRITIS
O L I G O A R T I C U L A R–P E R S I S T E N T
ARTHRITIS

 Mildest form of JIA.

 Affects female > male .
 It most often affects the large joints
such as the knee, ankle, wrist, and/or
elbow joints.
 It can be associated with an eye disease
called uveitis.
 It is rare to have permanent joint
damage with appropriate treatment of
this type of JIA.
 OLIGOARTHRITIS
O L I G O A R T I C U L A R–E X T E N D E D
ARTHRITIS

 This type of JIA also affects four or

fewer joints in the first six months
after diagnosis. However, after six
months or more, patients with
oligoarticular-extended arthritis
develop arthritis in five or more
joints.

 Oligoarticular-extended arthritis
can
affect both large and small joints.
OLIGOARTHRITIS
 POLYARTHRITIS
WHAT IS POLYARTHRITIS?

• The second most common type of JIA in children and teens. Affects five or
more joints within the first six months of being diagnosed with JIA.
• There are two types of polyarticular arthritis:
1. Rheumatoid factor positive polyarticular JIA, associated with the
presence of a rheumatoid factor antibody in the blood.
2. Rheumatoid factor negative polyarticular JIA, where there is no
rheumatoid factor antibody in the blood.
Subtypes Age at onset Diagnostic
 RF + 6 – 7 years  Affects ≥5 joints in the 1st 6 months of disease
 RF - 9 – 12 years with negative RF
 Affects ≥5 joints in the 1st 6 months of disease
with ≥2 positive RF tested at least 3 months
apart
 POLYARTHRITIS
P O L Y A R T I C U L A R–R F P O S I T I V E
ARTHRITIS

 Common in young people over 10 years

of age.
 Female > male
 It affects both the small joints of the
hands and feet, and large joints like the
knees, hips and ankles.
 It affects joints on both sides of the body.
 This type of JIA behaves the most like
adult rheumatoid arthritis
 POLYARTHRITIS

With this type of JIA, your child may also have

other symptoms:

 Rheumatoid nodules, which are hard

bumps under the skin.
 Anemia.
 Significant fatigue
 Poor appetite, with some weight loss.
 Low grade fever
 A general feeling of being unwell
These symptoms occur when the disease is
active and untreated. The symptoms will
improve with proper treatment.
 POLYARTHRITIS
P O L Y A R T I C U L A R –R F N E G A T I V E ARTHRITI
S

 It can occur at any age.

 Female > male
 Usually starts in many joints at the same
time.
 Some young people only have
polyarticular JIA for a limited period of
time while others may have it for many
years.
 This type of JIA is more likely to last
into
adulthood.
 SYSTEMIC
ARTHRITIS
WHAT IS SYSTEMIC ARTHRITIS?

Systemic arthritis is less common and affects only 10% to 15% of children and
teenagers with JIA. It is often a more severe form of JIA. Systemic means it
affects many parts of the body, rather than just the joints.

Subtypes Age at onset Diagnostic

 Systemic 2 - 4 years old Affects ≥1 joints with or preceded by fever of at
least 2 weeks duration, plus ≥1 of the following:
 Transient erythematous rash
 Enlargement of lymph nodes
 Hepatomegaly
 Splenomegaly
 Pericarditis ± pleuritis ± peritonitis
SYSTEMIC
ARTHRITIS
SYSTEMIC ARTHRITIS

 Boys = girls
 May range from mild to severe
 There is usually a spiking fever. This is a
fever that rapidly rises and falls. The
fever occurs once or twice every day.
 The JIA joint symptoms (joint pain or
swelling) begin within six months after
the fever first appears.
 Pale pink-red spots on the chest, upper
arms, thighs, and other parts of the body.
 Swollen lymph glands are common.
 Enlarged spleen and liver
SYSTEMIC
ARTHRITIS
SYSTEMIC ARTHRITIS
SYSTEMIC
ARTHRITIS
SYSTEMIC ARTHRITI
S
SYSTEMIC
ARTHRITIS
SYSTEMIC ARTHRITIS
ENTHESITIS
ARTHRITIS
WHAT IS ENTHESITIS ARTHRITIS?

Enthesitis-related-arthritis involves inflammation in both the joints and the

entheses.
Subtypes Age at onset Diagnostic
 Enthesitis 9 – 12 years Arthritis ± enthesitis plus ≥2 of the following:
related old  Presence or history of sacroiliac joint
tenderness &/or inflammatory lumbosacral
pain
 Positive human leukocyte (HLA) B27
antigen
 Onset of arthritis in male >6 years old
 Acute anterior uveitis
 History of ankylosing spondylitis, enthesitis -
related arthritis, IBD,uveitis
ENTHESITIS
ARTHRITIS
ENTHESITIS
ARTHRITIS
 Male > female
 Often lasts into adulthood.
 Usually involves just a few joints in the
legs. The hips are often affected.
 Enthesitis is most common around the
knees, ankles, and bottom of the feet.
Knee, heel, and foot pain are common
with activities.

 May affect the spine and the joint

between the base of the spine and
pelvis leading to neck or back pain and
stiffness.
ENTHESITIS
ARTHRITIS
ENTHESITIS
ARTHRITIS
ENTHESITIS ARTHRITIS

 Inflammation and swelling in the

tendons of the fingers and toes making
the fingers and toes look like sausages.
This is called dactylitis.

 Inflammation of the small joints of the

feet, called tarsitis.

 Enthesitis-related arthritis may be

associated with inflammation of the
skin or bowels.
PSORIATIC ARTHRITIS
WHAT IS PSORIASIS AND PSORIATIC ARTHRITIS?

Psoriasis is a skin disease. It is a scaly red rash that can develop on the scalp,
behind the ears, on the eyelids, elbows, knees, buttocks, or in the belly button.
Some people with psoriasis may also have pits or ridges in their fingernails.
Children or teenagers with psoriasis also have arthritis. This is called psoriatic
arthritis. Sometimes the psoriasis starts before the arthritis, but sometimes the
arthritis begins before the psoriasis. A family history of psoriasis is an important
clue to the correct diagnosis.

Subtypes Age at onset Diagnostic

 Psoriatic 7 – 10 years Arthritis ± psoriasis plus ≥2 of the following:
old  Dactylitis
 Nail pitting & oncholysis
 Family history of psoriasis
PSORIATIC ARTHRITIS
 It can occur at any age.
 Male = female
 It can affect a few or many joints.
 May involve the hips or back.
 Associated with dactylitis.
 There is a moderate risk of uveitis
CLASSIFICATIO
N
 INVESTIGATION
S
The diagnosis is essetially clinical – labolatory investigations are only
supportive.

1. Full blood count – anaemia, leukocytosis and elevated platelets

2. ESR and peripheral blood film – markers of inflammation
3. X-ray/s of affected joint(s) - to look for malignancy
4. Antinuclear antibody – identifies risk factors for uveitis
5. Rheumatoid fever – assess prognosis in polyarthritis for early tx
6. Others
 Complement levels
 ASOT
 Ferritin
 Immunoglobulins (IgG, IgA and IgM)
 HLA B27
 Synovial fluid aspiration
INVESTIGATION
S
 TREATMEN
T
There is no known cure for JIA. However, there are safe and effective
medications to help control the disease. These medications help to:

1. Decrease the inflammation

2. Decrease pain and swelling
3. Make it easier for your child to stay active and exercise
4. Prevent or lessen damage to the joints.
5. Increase quality of life

NSAIDs
Disease Modifying Anti-Rheumatic
Drugs (MRADs)
Corticosteroids

Corticosteroid Joint Injections Biologic Agents

 TREATMEN
1.
T
NSAIDs
Naproxen (Naprosyn)
Disease Modifying Anti-Rheumatic
Drugs (MRADs)
2. Ibuprofen (Advil)
3. Indomethacin (Indocid)
1. Methotrexate (Rheumatrex)
4. Diclofenac sodium (Voltaren)
2. Sulfasalazine (Salazopyrin)
3. Hydroxychloroquine (Plaquenil)
Corticosteroids 4. Leflunomide (Arava)
1. Prednisolone
2. Methylprednisolone Biologic Agents
1. Etanercept (Enbrel)
Corticosteroid Joint Injections 2. Infliximab (Remicade)
3. Adalimumab (Humira)
1. Triamcinolone hexacetonide 4. Rituximab (Rituxan)
2. Triamcinolone acetonide 5. Abatacept (Orencia)
3. Methylprednisolone 6. Tocilizumab (Actemra)
 TREATMEN
1.
T
Physiotherapy
 Avoid prolonged immobilization
 Strengthens muscles, improves and maintain range of movement
 Improves balance and cardiovascular fitness

2. Ophthalmologist
All patients must be referred to the ophthalmologist for uveitis
screening and have regular follow-up.

3. Nutritional Therapy
 Calcium intake
 Calcium + vitamin D is advised in patients on corticosteroids
 Ensure appropriate protein and calorie intake
 TREATMEN
4.
T
Orthotics Management
 Splints and foot orthotics may be recommended

5. Thermotherapy
 Heat treatments
 Massage
 Cold treatment
COMPARISO
N
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