Juvenile Rheumatoid Arthritis
Juvenile rheumatoid arthritis (JRA) has become one of the most important and changing areas of research in rheumatology and treatment continues to get refined. It is one of the most common chronic illnesses of childhood and also a major cause of disability.
Depending on the presentation there are three types of JRA:
- Oligoarthritis (60%) reflects the involvement of four or less joints,
- Polyarthritis (30%) reflects involvement of five or more joints, and
- Systemic disease (10%) reflecting variable joint involvement.
These manifestations are defined by the presence of the manifestations during the first six months.
The major clinical manifestations of the subtypes are different from each other. Oligoarthritis is characterized by the female predominance in the ratio of 5:1, lack of extra-articular involvement, chronic uveitis in 20%, antinuclear antibody (ANA) positivity in 80% and an excellent prognosis. Polyarthritis is characterized by female predominance in the ratio of 3:1, moderate extra-articular involvement, infrequent chronic uveitis (5%), ANA positivity of 40% and a moderately good prognosis. Systemic onset disease has an equal sex predisposition, uveitis is rare, ANA positivity in 10% and a moderately good prognosis. Barring a rheumatoid factor (RF) positivity of 15% in the polyarthritis group, RF is infrequently positive in JRA.
Diagnosis of the disorder requires that the age of onset be less than 16 years of age, arthritis in one or more joints, disease duration of at least six weeks, type of onset in the first six months classified as oligoarthritis, polyarthritis and systemic disease and, finally, exclusion of other forms of juvenile arthritis.
Management of the disorder depends on the subtype concerned. Oligoarthritis should first be managed by using nonsteroidal anti-inflammatory drugs (NSAIDS). If there is no response on approach would be to use chloroquine, followed by intra-articular steroids, methotrexate and, finally, sulfasalazine and injectable gold in that order. Polyarthritis would be first managed by NSAIDS, followed by methotrexate, chloroquine, intra-articular steroids, followed by oral prednisolone, sulfasalazine, injectable gold and cyclosporine in that order. Systemic onset disease needs the use of NSAIDS and oral steroids initially, followed by glucocorticoid pulses, methotrexate, intra-articular steroids and, finally, injectable gold and cyclosporine.
Two other important aspects to be taken care of are nutrition and psychosocial management of the children. With these approaches most patients can lead a life that is as close to normal as possible.
Dr Ajay Wanchu, M.D., D.M.
Department of Internal Medicine, PGIMER, Chandigarh
