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Juvenile idiopathic arthritis (JIA) (Complications (Chronic anterior…
Juvenile idiopathic
arthritis (JIA)
Definition
Chronic idiopathic arthritis (>6w duration)
with onset in childhood/adolescence (<16y)
Epidemiology
Prepuberty/adolescents
F>M
Commonest chronic joint inflammatory disease
in children and adolescents
Pathophysiology
Types
Systemic arthritis
Oligoarthritis
Polyarthritis
Psoriatic arthritis
Enthesitis related arthritis
Mechanism
Unclear cause
Likely environmental trigger with
genetic susceptibility
Clinically very similar to adult RA
Clinical
presentation
Pain
Radiation
Pain may radiate to adjacent joint
e.g. hip to knee
Associated symptoms
Systemic e.g. SLE-like symptoms,
psoriasis, enthesitis
Character
Timing
Intermittent
Onset
Insidious, can be acute
Site
Any joint
Exacerbating/relieving factors
Severity
Variable
Variable systemic symptoms
Diagnosis
Examination
Musculoskeletal exam
Joint: effusion, warmth, tender, erythema, reduced ROM
May have antalgic gait if lower limbs affected
Investigations
Bedside
Obs (fever)
Measurements (height, weight, BMI)
Bloods
FBC (raised WCC), CRP/ESR (raised)
Immunology screen (may be Rh+, CCP+, ANA+)
HLA typing (often HLA-B27 +ve)
Imaging
USS joint: useful in children
X-ray joint (exclude other causes)
Joint aspirate
MCS (r/o septic arthritis)
History
FH
Arthritis, autoimmune disease
DH
Meds, allergies
PMH
Growth and development
Vaccinations
Known medical conditions (autoimmune)
PC/HPC
Joint pain (often symmetrical oligo/polyarthritis,
insidious/acute onset, worse in AM) stiffness after rest, gelling
Systemic symptoms (fever, rash, malaise)
SH
Living arrangements, school,
exercise, diet, smoking, alcohol, sexual activity
Management
Initial ABCDE
Definitive
Medical
Anti-inflammatories
Indication: 1L for pain
E.g. NSAIDs
Corticosteroids
Indication: acute flare
E.g. prednisolone PO, hydrocortisone IA
NB. avoid PO where possible (growth problems)
Immunosuppressants
Indication: long-term maintenance
E.g. DMRs (methotrexate etc.)
Biologics
Indication: refractory disease
E.g. TNF-a inhibitord, IL-1, IL-6
Conservative
Infomation, advice, support
Referral to paeds rheum, also ortho and ophthal
MDT (physiotherapy, occupational therapy, dietician, psychologist, social services, schools)
Regular FU and screening (slit lamp etc.)
Surgical
Joint replacement
Indication: severe, end stage disease
Complications
Chronic anterior uveitis
Often asymptomatic
Can progress to cataract anf glaucoma
Growth failure
Chronic disease, steroid use
Leg length discrepancy
Contractures
Fixed joint flexion contraction from
being held in most comfortable position
May then need joint replacement
Osteoporosis
Due to diet, steroids, poor weight bearing
Diet supplementation (Ca, vit D) and exercise
Delayed puberty
Amyloidosis
RARE
Psychological
Stress, anxiety, depression
Prognosis
Rearly tx improves outcomes