Juvenile Rheumatoid Arthritis In Children

2024 Author: Josephine Shorter | [email protected]. Last modified: 2023-12-16 21:43

Juvenile rheumatoid arthritis in children

Content:

• What is juvenile rheumatoid arthritis?
• Pathogenesis of the disease
• Clinical picture
• Diagnostic signs
• Aspects of treatment
• Disease prognosis

What is juvenile rheumatoid arthritis?

Juvenile rheumatoid arthritis (JRA) is a systemic disease characterized by inflammation of the joints. The diagnosis of JRA is made with long-term arthritis (more than 1.5 months) in the absence of any other identified pathology of the joints in children under the age of 16. JRA is a rather rare disease.

Its etiology is currently quite unknown. It is assumed that genetic predisposition and characteristics of the immune system play an important role in the onset of this disease. The effect of viruses on immunity is not excluded.

According to statistics, girls are more susceptible to the occurrence of the disease. It was noted that the later the disease occurred, the more severe its course. The development and malignant course of the pathological process without adequate treatment often leads to disability and even death.

The international classification of juvenile rheumatoid arthritis includes several aspects:

• The type of lesion is systemic arthritis; oligoarthritis (persistent and widespread); polyarthritis.
• Depending on the nature of the course, juvenile arthritis is divided into acute (reactive) and subacute.
• By localization, articular and visceral-articular forms are distinguished (along with joints, internal organs are affected).
• Along the course, juvenile rheumatoid arthritis is divided into slowly progressive, moderately progressive and rapidly progressive.

Pathogenesis of the disease

Disease activation begins with the initiation of humoral immunity. In the synovial membrane of the affected joint, there is a violation of the internal microcirculation and destruction of cells. In response to this, altered immunoglobulins G, which are foreign to the body, begin to be produced. Accordingly, the cells of the synovium produce immunocompetent cells, namely anti-immunoglobulins G, which provide local immunity. They are also called rheumatoid factor. For the latter, the altered IgG is an antigen. As a result, IgG and anti-IgG form an immune complex, which, circulating in the articular cavity, destroys the vessels and the synovial membrane of the cartilage.

This leads to the production of a large amount of cytokines of macrophage origin and even greater destruction of the articular cavity. As a result, the process spreads to cartilage and bone. Neovascularization is activated under the action of cytokines. All these processes contribute to the maintenance of chronic inflammation in the joint. And the synovial membrane impregnated with immunocompetent cells and immune complexes prevents the flow of nutrients and drugs to the cartilage.

Anti-IgG is carried through the bloodstream throughout the body. This explains the damage to other internal organs and the severity of this disease.

The clinical picture of juvenile rheumatoid arthritis

The manifestations of juvenile arthritis are quite diverse, as are its forms. But a common symptom for all is arthritis. First, there is stiffness and soreness around the joint, then swelling and redness, local hyperthermia. Most often, in childhood, the main large and smaller joints are affected. Damage to the joints of the cervical spine and the temporomandibular joints is considered characteristic of juvenile rheumatoid arthritis. This further leads to the emergence of severe deformities and developmental disorders, as the child is still growing.

The acute course of the disease is typical for preschoolers and primary school students. Along with the onset of arthritis, the general body temperature rises to high febrile numbers, an allergic rash on the body may occur. Regional lymph nodes, liver and spleen are often enlarged. In this form of the disease, joint damage is usually bilateral. Sometimes clinical manifestations are initially more pronounced only on one side, and it can be mistakenly assumed that the process is one-sided. The acute course of JRA is malignant, rapidly progressing and with a poor prognosis.

The subacute course is characterized by a slow onset and development of the disease. The process usually starts from one side. Other joints are involved much later. There may be no severe pain. There is a swelling in the joint, a violation of its function. The child develops morning stiffness, which can last for an hour. The child is inactive, can hardly walk. Children under two years old stop walking altogether. An increase in overall body temperature is rare and only up to subfebrile numbers. The lymphatic vessels are slightly enlarged. The liver and spleen were unchanged. The subacute course of JRA is characterized by a more favorable prognosis and better response to treatment.

Systemic rheumatoid arthritis

This form of the disease is manifested by a combination of arthritis with symptoms of damage to internal organs. One of these symptoms is an increase in temperature, mainly in the morning. Often at the height of hyperthermia, the appearance of a rash is observed, which is papular in nature. Disappears on its own, does not itch. The usual localization of the rash is the area of the joints, face, lateral surfaces of the buttocks and thighs.

The most dangerous manifestations of the systemic form of JRA is the accumulation of serous fluid in cavities and internal organs, including in the heart muscle and in the lung cavity. Patients show signs of heart and lung failure.

Almost all groups of lymph nodes increase. They become large, palpable well, not adhered to the skin and to each other, painless, sometimes protrude above the skin surface.

The liver and spleen are enlarged due to the general intoxication of the body.

Oligoarthritis

Most common. Allocate persistent oligoarthritis, in which no more than four joints are affected during the entire period of the disease, and progressive. With it, the number of affected joints increases after six months of the course of the disease.

With the oligoarthritic type of juvenile arthritis, the process is one-sided. Both large and small joints can be affected. The disease can manifest itself at any age, starting from 1 year. Often accompanied by the development of uveitis (inflammation of the inner lining of the eyeball). Allocate oligoarthritis with early, late onset and occurring in all age groups of children. The consequences of this form of juvenile rheumatoid arthritis are severe: growth retardation, asymmetry of the limbs, including in length, cataracts and blindness (consequences of uveitis), disability.

Polyarthritis

The oligoarthritic form of JRA is less common. According to the presence or absence of rheumatoid factor, seronegative and seropositive subtypes are distinguished:

With a seropositive variant for the rheumatoid factor, the limb joints are affected. Irreversible changes in the articular surfaces of the bones are quickly formed. The disease is characterized by a subacute course and is considered an early manifestation of adult rheumatism.

The rheumatoid factor seronegative subtype usually affects the joints of the cervical spine and the temporomandibular joints. The disease occurs early enough (from 1 year) and is characterized by a benign course.

With the early onset of both subtypes of polyarthritis, severe, irreversible growth retardation and early disability occur. Complex contractures form in the joints that are difficult to treat.

It should be noted that any clinical form of juvenile rheumatoid arthritis has rather serious consequences. The early manifestation of the disease and frequent relapses are especially dangerous. Also, the development of the systemic form of JRA and younger childhood is also considered unfavorable. Therefore, it is important to correctly diagnose and begin treatment as soon as possible.

Read more: Causes, symptoms and treatment of polyarthritis

Diagnostic signs

First, you need to pay attention to the clinical manifestations:

• prolonged arthritis
• stiffness of movement
• rashes on the body, especially around the joints
• unexplained jumps in body temperature
• iridocyclitis
• swollen lymph nodes

If you have such symptoms, it is also worth finding out if there are relatives in the family suffering from rheumatoid arthritis.

Secondly, it is necessary to make an X-ray of the affected joints, where it is possible to determine the stage of the disease (there are four of them) and the nature of the joint damage. The picture will show a change in the articular surface of the cartilage, narrowing of the cavity, fusion of the synovial membranes between themselves and other changes.

Be sure to examine the patient's blood for the presence of rheumatoid factor and antibodies. They look at ESR, the level of leukocytes and hemoglobin. As a rule, JRA is characterized by high neutrophilic leukocytosis and anemia. The ESR level indicates the degree of disease activity. Accordingly, the higher the ESR indicator, the more active the process. Also, C-reactive protein, IgG and IgM appear in the blood. Often, a complete blood count can remain within the normal range.

EKG and ultrasound of the heart will show changes in the myocardium. It is imperative to undergo an examination by an ophthalmologist to exclude ocular manifestations of JRA (examination of the fundus, the middle of the eye and the angle).

Aspects of treatment

The mainstay of treatment for juvenile rheumatoid arthritis is suppression of a pronounced inflammatory reaction in the joints, elimination of systemic manifestations and minimization of the consequences of the disease.

An important aspect in treatment is adherence to the correct regimen of the child's physical activity. You cannot use full immobilization of the joints, as this will lead to an aggravation of the process and the development of persistent contractures. Relaxing walking, cycling, swimming should be recommended. However, you should avoid physical overload, running, jumping, falling. In case of an advanced pathological process and changes in the articular surfaces of the bones, special physiotherapy exercises under the supervision of a doctor or instructor are recommended. You should also use immobilization orthoses, corsets, crutches.

With an exacerbation of the disease, it is necessary to avoid exposure to solar radiation, hypothermia, stress.

Drug therapy is prescribed immediately after diagnosis. Treatment must be carried out in a hospital. First of all, drugs of the NSAID group are used, which relieve pain and inflammation. Drugs in this group are taken orally. The dose is calculated depending on the child's body weight.

Almost always, with a complicated and malignant course of JRA, they resort to intra-articular administration of glucocorticosteroids, which act quickly and effectively enough. However, these drugs must be treated with caution, given the children's age of the patients.

Immunosuppressive therapy (methotrexate, sulfosalazine) is used to influence the cause of the development of the disease - the activity of pathological humoral immunity. It is also toxic, therefore, during treatment, it is necessary to monitor the basic blood parameters and evaluate the effect on the bone marrow.

Surgical treatment is resorted to in the presence of pronounced changes in the joints, limiting mobility and significantly impairing the quality of life of patients. The essence of the operation is to remove contractures and prosthetics.

See also: Other treatments for rheumatoid arthritis

Disease prognosis

The prognosis for patients with juvenile rheumatoid arthritis is relatively favorable, especially with timely treatment and adequate rehabilitation. Mild forms of the disease can pass without consequences for the musculoskeletal system. Severe forms always leave changes in the joints and bones.

The systemic course of juvenile rheumatoid arthritis has a deeply unfavorable prognosis. In the absence of adequate treatment, death can occur. Even with success in treatment, there are always consequences, and not only in the joints. Such patients usually become disabled by childhood.

Author of the article: Kaplan Alexander Sergeevich | Orthopedist

Education: diploma in the specialty "General Medicine" received in 2009 at the Medical Academy. I. M. Sechenov. In 2012 completed postgraduate studies in Traumatology and Orthopedics at the City Clinical Hospital named after Botkin at the Department of Traumatology, Orthopedics and Disaster Surgery.