The term “rheumatologicaldisorders” refers to diseases that affect the major connective tissues of the body (e.g. skin, bone, blood vessels, cartilage and basement membrane).
Juvenile Idiopathic Arthritis (JIA) is the most common pediatric rheumatologic disease. It is associated with significant long term morbidity.
It was previously called as, Juvenile Rheumatoid Arthritis (by ACR –American College of Rheumatology) or Juvenile Chronic Arthritis (by ELAR –European League Against Rheumatism).
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease in children. It is classified into several subtypes based on symptoms and physical exam findings. Oligoarticular JIA affects 4 or fewer joints, typically large weight-bearing joints. Polyarticular JIA affects 5 or more joints within the first 6 months. Systemic onset JIA is characterized by spiking fevers and rash. Physical exam may reveal synovitis, limited range of motion, and joint swelling. Screening for uveitis is important for some subtypes.
This document discusses arthritis in children. It begins with definitions of arthritis and arthralgia and classifications of arthritis according to duration and number of joints involved. Common causes of acute, subacute, and chronic arthritis in children are described. Juvenile idiopathic arthritis is discussed in detail, including classification systems and management approaches. Specific conditions like septic arthritis, rheumatic fever, reactive arthritis, and sickle cell arthropathy are also summarized. The document concludes with a case scenario and emphasizes taking a thorough history and examination to diagnose childhood arthritis.
A 10-year-old girl presented with pain and swelling in multiple small and large joints of both upper and lower limbs for the past 7 months. On examination, her knees, elbows, and small joints of hands and feet were swollen, warm, tender with restricted movement. Based on the symmetrical involvement of multiple joints, she was provisionally diagnosed with polyarticular juvenile idiopathic arthritis.
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease affecting children under 16 years of age. It is classified into subtypes including oligoarticular, polyarticular, systemic, psoriatic, and enthesitis-related arthritis. Genetic and environmental factors may play a role in its etiology. Treatment involves medications like NSAIDs, DMARDs such as methotrexate, and biologics targeting cytokines. The goals of treatment are to control inflammation, relieve symptoms, prevent joint damage, and maintain physical function. A multidisciplinary approach including medications, physical therapy, and psychosocial support can help improve quality of life for children with JIA.
This document provides an overview of juvenile idiopathic arthritis (JIA), including its epidemiology, classifications, clinical presentations, and treatment approaches. JIA is the most common rheumatic disease in childhood, affecting about 1 in 1000 children. It encompasses a group of arthritides of unknown cause that begin before age 16. There are several subtypes of JIA classified by the ILAR system based on clinical features. Treatment involves medications like NSAIDs, corticosteroids, methotrexate, and biologics, with the goal of controlling inflammation and preventing long-term joint damage. Regular monitoring of patients on medications is important for safety.
This document provides guidance on evaluating and diagnosing childhood arthritis. It distinguishes arthritis from arthralgia based on clinical features. It lists various differential diagnoses for childhood joint pain or swelling including infectious, rheumatological, neoplastic and traumatic etiologies. It describes tender points seen in fibromyalgia. It outlines features that can distinguish inflammatory, mechanical and sinister causes of joint pain. The approach involves assessing onset, number and type of joints involved, associated systemic symptoms and precipitating factors. Key clues from history and physical exam are described. A review of systems guides evaluation of specific organ systems. Common clinical presentations like acute monoarthritis, chronic monoarthritis and polyarthritis are reviewed. Characteristics of juvenile idiopathic arthritis subtypes
1. Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis in children under 16 years old lasting over 6 weeks, with unknown cause thought to involve genetic and environmental factors like infection or stress.
2. JIA is classified into 7 subtypes based on symptoms and onset, including oligoarticular, polyarticular, and systemic, each with different characteristics and prognoses.
3. Treatment is individualized and aims to suppress inflammation and maintain function, using methods like medications, exercises, splints, and occasionally surgery. While remission is possible, JIA usually results in a chronic disease course with fluctuating symptoms.
Juvenile idiopathic arthritis (JIA) is the most common chronic rheumatologic disease in children. It is classified into several subtypes based on symptoms and physical exam findings. Oligoarticular JIA affects 4 or fewer joints, typically large weight-bearing joints. Polyarticular JIA affects 5 or more joints within the first 6 months. Systemic onset JIA is characterized by spiking fevers and rash. Physical exam may reveal synovitis, limited range of motion, and joint swelling. Screening for uveitis is important for some subtypes.
This document discusses arthritis in children. It begins with definitions of arthritis and arthralgia and classifications of arthritis according to duration and number of joints involved. Common causes of acute, subacute, and chronic arthritis in children are described. Juvenile idiopathic arthritis is discussed in detail, including classification systems and management approaches. Specific conditions like septic arthritis, rheumatic fever, reactive arthritis, and sickle cell arthropathy are also summarized. The document concludes with a case scenario and emphasizes taking a thorough history and examination to diagnose childhood arthritis.
A 10-year-old girl presented with pain and swelling in multiple small and large joints of both upper and lower limbs for the past 7 months. On examination, her knees, elbows, and small joints of hands and feet were swollen, warm, tender with restricted movement. Based on the symmetrical involvement of multiple joints, she was provisionally diagnosed with polyarticular juvenile idiopathic arthritis.
Juvenile idiopathic arthritis (JIA) is a chronic inflammatory disease affecting children under 16 years of age. It is classified into subtypes including oligoarticular, polyarticular, systemic, psoriatic, and enthesitis-related arthritis. Genetic and environmental factors may play a role in its etiology. Treatment involves medications like NSAIDs, DMARDs such as methotrexate, and biologics targeting cytokines. The goals of treatment are to control inflammation, relieve symptoms, prevent joint damage, and maintain physical function. A multidisciplinary approach including medications, physical therapy, and psychosocial support can help improve quality of life for children with JIA.
This document provides an overview of juvenile idiopathic arthritis (JIA), including its epidemiology, classifications, clinical presentations, and treatment approaches. JIA is the most common rheumatic disease in childhood, affecting about 1 in 1000 children. It encompasses a group of arthritides of unknown cause that begin before age 16. There are several subtypes of JIA classified by the ILAR system based on clinical features. Treatment involves medications like NSAIDs, corticosteroids, methotrexate, and biologics, with the goal of controlling inflammation and preventing long-term joint damage. Regular monitoring of patients on medications is important for safety.
This document provides guidance on evaluating and diagnosing childhood arthritis. It distinguishes arthritis from arthralgia based on clinical features. It lists various differential diagnoses for childhood joint pain or swelling including infectious, rheumatological, neoplastic and traumatic etiologies. It describes tender points seen in fibromyalgia. It outlines features that can distinguish inflammatory, mechanical and sinister causes of joint pain. The approach involves assessing onset, number and type of joints involved, associated systemic symptoms and precipitating factors. Key clues from history and physical exam are described. A review of systems guides evaluation of specific organ systems. Common clinical presentations like acute monoarthritis, chronic monoarthritis and polyarthritis are reviewed. Characteristics of juvenile idiopathic arthritis subtypes
1. Juvenile idiopathic arthritis (JIA) is an umbrella term for arthritis in children under 16 years old lasting over 6 weeks, with unknown cause thought to involve genetic and environmental factors like infection or stress.
2. JIA is classified into 7 subtypes based on symptoms and onset, including oligoarticular, polyarticular, and systemic, each with different characteristics and prognoses.
3. Treatment is individualized and aims to suppress inflammation and maintain function, using methods like medications, exercises, splints, and occasionally surgery. While remission is possible, JIA usually results in a chronic disease course with fluctuating symptoms.
This document discusses fever of unknown origin (FUO) in children. It defines FUO as a fever over 38°C that cannot be explained after 3 weeks of outpatient evaluation or 1 week of inpatient evaluation. Potential causes are divided into infectious and non-infectious categories. A thorough history, physical exam, and targeted investigations are important to identify the cause. Based on patient location and immune status, FUO can be further classified as classic, healthcare-associated, immune deficient, or HIV-related FUO. The most common causes vary according to these classifications.
A 14 year old boy presented with low grade fever, anemia, splenomegaly and polyarthritis of the left ankle, left knee and right middle finger for 6 months. Based on the findings, he was diagnosed with Juvenile Idiopathic Arthritis. Juvenile Idiopathic Arthritis is a chronic autoimmune disease characterized by arthritis in children under 16 years of age lasting more than 6 weeks, for which other causes have been excluded. Treatment involves medications like NSAIDs, DMARDs, corticosteroids and biologics to suppress inflammation and maintain function.
A case presentation on juvenile idiopathic arthritisDr. Tanvir
This document provides an overview of juvenile idiopathic arthritis (JIA), including its etiology, pathophysiology, classification, clinical manifestations, diagnosis, complications, treatment, and follow up. JIA is the most common chronic rheumatic illness in children, characterized by synovitis and inflammation of peripheral joints. While its exact cause is unknown, it involves both genetic and environmental factors. Treatment involves a multidisciplinary approach including medications like NSAIDs, DMARDs, steroids, and biologics, as well as physiotherapy, with the goals of relieving symptoms, slowing disease progression, and preserving joint function.
Pediatric Rheumatic Diseases by JJ LaspoñasJJLasponas
Pediatric rheumatic diseases, also known as juvenile arthritis, are autoimmune and inflammatory conditions that affect nearly 300,000 children in the United States. They include conditions such as juvenile idiopathic arthritis, juvenile dermatomyositis, juvenile lupus, and juvenile scleroderma. Symptoms can include joint pain, swelling, stiffness, and fatigue. Diagnosis involves physical exams, medical history, and tests like ANA titers and RF tests. Treatment aims to relieve inflammation and control symptoms, with goals of improving comfort, managing pain, and maintaining mobility. Education of patients and families is important for effective self-management.
is an umbrella term referring to a group of disorders characterized by chronic arthritis. JIA is the most common chronic rheumatic illness in children and is a significant cause of short-and long-term disability.
It is a clinical diagnosis made in a child less than16 years of age with arthritis (defined as swelling or limitation of motion of the joint accompanied by heat, pain, or tenderness) for at least 6 weeks’ duration with other identifiable causes of arthritis excluded.
Approach to a child with arthritis by dr praman kushwahDr Praman Kushwah
1. The document provides guidance on approaching a child presenting with arthritis. It defines arthritis and arthralgia and classifications based on number of joints involved.
2. It outlines the important aspects of history taking for a child with arthritis, including onset of symptoms, associated symptoms, nature of pain, and medications.
3. The key causes of acute and chronic monoarthritis are discussed, including septic arthritis, juvenile idiopathic arthritis, pigmented villonodular synovitis, and osteoarticular tuberculosis.
4. Examinations and investigations are described to differentiate between infectious, inflammatory, and malignant causes of childhood arthritis.
This document provides guidance on evaluating a child presenting with joint inflammation or arthritis. It discusses the differential diagnosis for monoarthritis vs polyarthritis and key aspects of the history, physical exam, and initial investigations. For monoarthritis, important considerations include infection (septic arthritis, reactive arthritis), trauma, inflammation (juvenile idiopathic arthritis), and malignancy. Transient synovitis of the hip is also reviewed. A thorough history, physical exam, and joint aspiration (if indicated) are critical for diagnosis.
1. Juvenile idiopathic arthritis (JIA) is an autoimmune disease characterized by chronic joint inflammation in children.
2. JIA is classified into subtypes based on the number of joints affected and symptoms present. The most common subtypes are oligoarticular JIA affecting fewer than 5 joints, and polyarticular JIA affecting 5 or more joints.
3. Diagnosis involves ruling out other causes through medical history, physical exam, blood tests, and joint fluid analysis. Treatment aims to suppress inflammation and prevent long-term joint damage and disability. Prognosis is generally good, though some subtypes are associated with greater functional impairment.
Henoch–Schönlein purpura (HSP) is the most common vasculitis of childhood that presents with a tetrad of purpura, arthritis/arthralgia, abdominal pain, and renal involvement. It is characterized by IgA-containing immune complexes depositing in small vessels, skin, GI tract, joints, and kidneys. The diagnosis is based on purpura with lower limb predominance and at least one of the other criteria. Imaging and labs help assess organ involvement while biopsy confirms the diagnosis.
Here are some key points regarding the feasibility of bacteriological diagnosis in children with TB:
- Sputum induction or gastric lavage are generally required to obtain specimens from children, as they typically cannot produce sputum on demand. This requires specialized equipment and trained personnel.
- Even with induced sputum or gastric lavage, specimen quality and volume may be low, reducing the sensitivity of bacteriological tests.
- Young children especially may not be able to cooperate with procedures like sputum induction.
- Extrapulmonary TB is more common in children than adults, so specimens from sites like lymph nodes, cerebrospinal fluid, etc. need to be obtained invasively via procedures like biopsy or lumbar puncture
An 11-year-old boy presented with fever, joint pain and swelling, and shortness of breath for 4 days. Examination found an enlarged heart, elevated inflammatory markers, and evidence of previous streptococcal infection. He was diagnosed with acute rheumatic fever. A 5-year-old boy had recurrent joint pain and swelling for 10 months. Testing found anemia and bone lesions. He was diagnosed with sickle cell disease. The document discusses approaches to evaluating joint pain, including questions to ask about symptoms and guidance for examining the joints, muscles, and skin.
Juvenile rheumatoid arthritis (JRA) is a term used to describe arthritis in children under 16 years old that lasts at least 6 weeks. It can be classified into oligoarticular JRA which affects 4 or fewer joints, polyarticular JRA which affects 5 or more joints, and systemic JRA which is characterized by arthritis, fever, and rash. Left untreated, JRA can lead to joint damage, deformities, limited movement, and growth issues.
This document provides guidance on evaluating a limping child. It begins with an introduction stating that limping is a common complaint in pediatrics that can be caused by benign or serious conditions. The document then covers pathophysiology, differential diagnosis, history taking, physical exam findings for normal and pathological gaits, investigations including imaging and labs, and key takeaways. The physical exam section describes assessment of gait, standing, supine, and prone positions as well as specific tests. Red flags include age under 3, inability to bear weight, fever or systemic illness. The conclusion emphasizes taking an acute limp seriously and considering age and trauma history in evaluations.
The document summarizes thyroid gland development, function, and congenital hypothyroidism. It discusses that the thyroid gland secretes thyroid hormones that regulate metabolism. Congenital hypothyroidism occurs when there is a deficiency of thyroid hormones at birth and can be caused by thyroid dysgenesis or defects in hormone synthesis. It is important to screen all newborns for congenital hypothyroidism through measuring TSH and T4 levels to detect cases early so treatment with thyroid hormone replacement can prevent intellectual and growth impairment.
Juvenile rheumatoid arthritis (JRA) is a general term for arthritis and related conditions occurring in children under 16 years old. It is characterized by inflammation of connective tissues causing joint swelling and pain. There are different subtypes classified based on the number and pattern of involved joints. Treatment has shifted to more aggressive early treatment with medications to prevent joint damage, and includes NSAIDs, DMARDs like methotrexate, biologics like etanercept, and corticosteroids. Outcomes depend on subtype, but can include long term joint damage, disability, and risk of continued arthritis into adulthood.
This document discusses septic arthritis in children. It notes that septic arthritis is a joint inflammation caused by infection, most commonly involving synovial joints. The most common age for septic arthritis is 1 month to 5 years. Staphylococcus aureus is the most common causative organism. Symptoms include fever, pain and reluctance to move the joint. Diagnosis involves blood tests, imaging like x-rays and ultrasound, and joint aspiration. Treatment involves antibiotics, rest, and sometimes surgical drainage of the joint. Complications can include joint destruction and deformity if not treated properly.
An apt yet detailed description of Polyarthritis for undergraduate level with basic definitions, classification, concept, clinical features along with descriptive images, diagnosis & assessment with distinguishing features along with differential diagnosis.
Approach to a patient with fever of unknown origin sunil kumar daha
Please find the power point on Approach to a patient with fever of unknown origin . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
This document discusses the evaluation and treatment of limping in children. It defines limping as a deviation from normal gait and lists common causes like pain, structural abnormalities, and neuromuscular problems. For evaluation, it recommends gathering history, performing physical exam including gait observation, and ordering lab tests and imaging starting with x-rays. Common etiologies are discussed for different age groups. Key parts of evaluation involve determining if symptoms are due to trauma, infection or other inflammatory condition. Treatment depends on identified cause but may include splinting, antibiotics, surgery or referral to specialists.
Inflammatory markers and disease activity in juvenile idiopathicSai Hari
This document discusses inflammatory markers and disease activity in juvenile idiopathic arthritis (JIA). It first defines JIA and its subcategories according to the International League of Associations for Rheumatology criteria. It then discusses the etiology and pathogenesis of JIA, including genetic susceptibility and abnormal immune responses involving both humoral and cellular mechanisms. The clinical manifestations of JIA are described for different subtypes, including symptoms involving joints, fever, rash, and visceral involvement. Laboratory findings and investigations for JIA are also outlined, such as elevated inflammatory markers and the role of imaging like MRI. Management of JIA is noted to be best provided in a specialized pediatric rheumatology setting.
This document discusses fever of unknown origin (FUO) in children. It defines FUO as a fever over 38°C that cannot be explained after 3 weeks of outpatient evaluation or 1 week of inpatient evaluation. Potential causes are divided into infectious and non-infectious categories. A thorough history, physical exam, and targeted investigations are important to identify the cause. Based on patient location and immune status, FUO can be further classified as classic, healthcare-associated, immune deficient, or HIV-related FUO. The most common causes vary according to these classifications.
A 14 year old boy presented with low grade fever, anemia, splenomegaly and polyarthritis of the left ankle, left knee and right middle finger for 6 months. Based on the findings, he was diagnosed with Juvenile Idiopathic Arthritis. Juvenile Idiopathic Arthritis is a chronic autoimmune disease characterized by arthritis in children under 16 years of age lasting more than 6 weeks, for which other causes have been excluded. Treatment involves medications like NSAIDs, DMARDs, corticosteroids and biologics to suppress inflammation and maintain function.
A case presentation on juvenile idiopathic arthritisDr. Tanvir
This document provides an overview of juvenile idiopathic arthritis (JIA), including its etiology, pathophysiology, classification, clinical manifestations, diagnosis, complications, treatment, and follow up. JIA is the most common chronic rheumatic illness in children, characterized by synovitis and inflammation of peripheral joints. While its exact cause is unknown, it involves both genetic and environmental factors. Treatment involves a multidisciplinary approach including medications like NSAIDs, DMARDs, steroids, and biologics, as well as physiotherapy, with the goals of relieving symptoms, slowing disease progression, and preserving joint function.
Pediatric Rheumatic Diseases by JJ LaspoñasJJLasponas
Pediatric rheumatic diseases, also known as juvenile arthritis, are autoimmune and inflammatory conditions that affect nearly 300,000 children in the United States. They include conditions such as juvenile idiopathic arthritis, juvenile dermatomyositis, juvenile lupus, and juvenile scleroderma. Symptoms can include joint pain, swelling, stiffness, and fatigue. Diagnosis involves physical exams, medical history, and tests like ANA titers and RF tests. Treatment aims to relieve inflammation and control symptoms, with goals of improving comfort, managing pain, and maintaining mobility. Education of patients and families is important for effective self-management.
is an umbrella term referring to a group of disorders characterized by chronic arthritis. JIA is the most common chronic rheumatic illness in children and is a significant cause of short-and long-term disability.
It is a clinical diagnosis made in a child less than16 years of age with arthritis (defined as swelling or limitation of motion of the joint accompanied by heat, pain, or tenderness) for at least 6 weeks’ duration with other identifiable causes of arthritis excluded.
Approach to a child with arthritis by dr praman kushwahDr Praman Kushwah
1. The document provides guidance on approaching a child presenting with arthritis. It defines arthritis and arthralgia and classifications based on number of joints involved.
2. It outlines the important aspects of history taking for a child with arthritis, including onset of symptoms, associated symptoms, nature of pain, and medications.
3. The key causes of acute and chronic monoarthritis are discussed, including septic arthritis, juvenile idiopathic arthritis, pigmented villonodular synovitis, and osteoarticular tuberculosis.
4. Examinations and investigations are described to differentiate between infectious, inflammatory, and malignant causes of childhood arthritis.
This document provides guidance on evaluating a child presenting with joint inflammation or arthritis. It discusses the differential diagnosis for monoarthritis vs polyarthritis and key aspects of the history, physical exam, and initial investigations. For monoarthritis, important considerations include infection (septic arthritis, reactive arthritis), trauma, inflammation (juvenile idiopathic arthritis), and malignancy. Transient synovitis of the hip is also reviewed. A thorough history, physical exam, and joint aspiration (if indicated) are critical for diagnosis.
1. Juvenile idiopathic arthritis (JIA) is an autoimmune disease characterized by chronic joint inflammation in children.
2. JIA is classified into subtypes based on the number of joints affected and symptoms present. The most common subtypes are oligoarticular JIA affecting fewer than 5 joints, and polyarticular JIA affecting 5 or more joints.
3. Diagnosis involves ruling out other causes through medical history, physical exam, blood tests, and joint fluid analysis. Treatment aims to suppress inflammation and prevent long-term joint damage and disability. Prognosis is generally good, though some subtypes are associated with greater functional impairment.
Henoch–Schönlein purpura (HSP) is the most common vasculitis of childhood that presents with a tetrad of purpura, arthritis/arthralgia, abdominal pain, and renal involvement. It is characterized by IgA-containing immune complexes depositing in small vessels, skin, GI tract, joints, and kidneys. The diagnosis is based on purpura with lower limb predominance and at least one of the other criteria. Imaging and labs help assess organ involvement while biopsy confirms the diagnosis.
Here are some key points regarding the feasibility of bacteriological diagnosis in children with TB:
- Sputum induction or gastric lavage are generally required to obtain specimens from children, as they typically cannot produce sputum on demand. This requires specialized equipment and trained personnel.
- Even with induced sputum or gastric lavage, specimen quality and volume may be low, reducing the sensitivity of bacteriological tests.
- Young children especially may not be able to cooperate with procedures like sputum induction.
- Extrapulmonary TB is more common in children than adults, so specimens from sites like lymph nodes, cerebrospinal fluid, etc. need to be obtained invasively via procedures like biopsy or lumbar puncture
An 11-year-old boy presented with fever, joint pain and swelling, and shortness of breath for 4 days. Examination found an enlarged heart, elevated inflammatory markers, and evidence of previous streptococcal infection. He was diagnosed with acute rheumatic fever. A 5-year-old boy had recurrent joint pain and swelling for 10 months. Testing found anemia and bone lesions. He was diagnosed with sickle cell disease. The document discusses approaches to evaluating joint pain, including questions to ask about symptoms and guidance for examining the joints, muscles, and skin.
Juvenile rheumatoid arthritis (JRA) is a term used to describe arthritis in children under 16 years old that lasts at least 6 weeks. It can be classified into oligoarticular JRA which affects 4 or fewer joints, polyarticular JRA which affects 5 or more joints, and systemic JRA which is characterized by arthritis, fever, and rash. Left untreated, JRA can lead to joint damage, deformities, limited movement, and growth issues.
This document provides guidance on evaluating a limping child. It begins with an introduction stating that limping is a common complaint in pediatrics that can be caused by benign or serious conditions. The document then covers pathophysiology, differential diagnosis, history taking, physical exam findings for normal and pathological gaits, investigations including imaging and labs, and key takeaways. The physical exam section describes assessment of gait, standing, supine, and prone positions as well as specific tests. Red flags include age under 3, inability to bear weight, fever or systemic illness. The conclusion emphasizes taking an acute limp seriously and considering age and trauma history in evaluations.
The document summarizes thyroid gland development, function, and congenital hypothyroidism. It discusses that the thyroid gland secretes thyroid hormones that regulate metabolism. Congenital hypothyroidism occurs when there is a deficiency of thyroid hormones at birth and can be caused by thyroid dysgenesis or defects in hormone synthesis. It is important to screen all newborns for congenital hypothyroidism through measuring TSH and T4 levels to detect cases early so treatment with thyroid hormone replacement can prevent intellectual and growth impairment.
Juvenile rheumatoid arthritis (JRA) is a general term for arthritis and related conditions occurring in children under 16 years old. It is characterized by inflammation of connective tissues causing joint swelling and pain. There are different subtypes classified based on the number and pattern of involved joints. Treatment has shifted to more aggressive early treatment with medications to prevent joint damage, and includes NSAIDs, DMARDs like methotrexate, biologics like etanercept, and corticosteroids. Outcomes depend on subtype, but can include long term joint damage, disability, and risk of continued arthritis into adulthood.
This document discusses septic arthritis in children. It notes that septic arthritis is a joint inflammation caused by infection, most commonly involving synovial joints. The most common age for septic arthritis is 1 month to 5 years. Staphylococcus aureus is the most common causative organism. Symptoms include fever, pain and reluctance to move the joint. Diagnosis involves blood tests, imaging like x-rays and ultrasound, and joint aspiration. Treatment involves antibiotics, rest, and sometimes surgical drainage of the joint. Complications can include joint destruction and deformity if not treated properly.
An apt yet detailed description of Polyarthritis for undergraduate level with basic definitions, classification, concept, clinical features along with descriptive images, diagnosis & assessment with distinguishing features along with differential diagnosis.
Approach to a patient with fever of unknown origin sunil kumar daha
Please find the power point on Approach to a patient with fever of unknown origin . I tried to present it on understandable way and all the contents are reviewed by experts and from very reliable references. Thank you
This document discusses the evaluation and treatment of limping in children. It defines limping as a deviation from normal gait and lists common causes like pain, structural abnormalities, and neuromuscular problems. For evaluation, it recommends gathering history, performing physical exam including gait observation, and ordering lab tests and imaging starting with x-rays. Common etiologies are discussed for different age groups. Key parts of evaluation involve determining if symptoms are due to trauma, infection or other inflammatory condition. Treatment depends on identified cause but may include splinting, antibiotics, surgery or referral to specialists.
Inflammatory markers and disease activity in juvenile idiopathicSai Hari
This document discusses inflammatory markers and disease activity in juvenile idiopathic arthritis (JIA). It first defines JIA and its subcategories according to the International League of Associations for Rheumatology criteria. It then discusses the etiology and pathogenesis of JIA, including genetic susceptibility and abnormal immune responses involving both humoral and cellular mechanisms. The clinical manifestations of JIA are described for different subtypes, including symptoms involving joints, fever, rash, and visceral involvement. Laboratory findings and investigations for JIA are also outlined, such as elevated inflammatory markers and the role of imaging like MRI. Management of JIA is noted to be best provided in a specialized pediatric rheumatology setting.
Rheumatoid arthritis (RA) is a chronic autoimmune disease that causes inflammation of the joints. The document summarizes the definition, epidemiology, risk factors, pathophysiology, signs and symptoms, complications, diagnosis, and treatment of RA. It describes the clinical presentation of a patient with possible RA and the steps to take which include performing a physical exam, ordering diagnostic tests, making a provisional diagnosis, and referring the patient to a rheumatologist for further evaluation and management. Non-pharmacologic and pharmacologic treatment options for RA are outlined.
Ankylosing spondylitis (AS) is a chronic inflammatory disease that primarily affects the spine and sacroiliac joints. It causes back pain and stiffness and can result in fusion of the vertebrae over time. Diagnosis is based on inflammatory back pain for over 3 months along with limited spinal movement or chest expansion and radiographic evidence of sacroiliitis. Treatment involves nonsteroidal anti-inflammatory drugs initially and tumor necrosis factor inhibitors if needed. Disease activity and function are assessed using measures like the Bath Ankylosing Spondylitis Disease Activity Index and Functional Index.
This document discusses pain management in rheumatic diseases. It presents a pain classification grid that categorizes different types of pain based on factors like duration, progression, and malignancy. It provides examples of common rheumatic conditions like osteoarthritis and rheumatoid arthritis. It discusses goals of treatment, which include reducing pain and disability as well as limiting joint damage progression. A variety of symptomatic treatment options are outlined, including education, exercise, medications, injections, and surgery.
This document discusses pain management in rheumatic diseases. It begins with a pain classification grid that categorizes different types of pain based on factors like duration and underlying pathology. Next, it reviews non-pharmacologic and pharmacologic treatment options for managing rheumatic pain, including education, exercise, analgesics, anti-inflammatory drugs and injections. It then focuses on osteoarthritis (OA) and rheumatoid arthritis (RA), discussing their prevalence, diagnostic criteria, management goals, and differences between the two conditions. Finally, it reviews the risks and benefits of NSAIDs and COX-2 inhibitors for pain relief in OA and RA patients.
Juvenile Idiopathic Arthritis (JIA) is defined as arthritis of unknown cause that begins before age 16 and lasts over 6 weeks. It is classified based on symptoms into subtypes including systemic onset JIA, oligoarticular JIA, and polyarticular JIA. Treatment involves a stepwise approach starting with NSAIDs and intra-articular steroids and escalating to DMARDs and biologicals. Complications can include chronic anterior uveitis, osteoporosis, and potentially life-threatening macrophage activation syndrome.
This document provides an overview of inflammatory joint conditions and childhood arthropathies. It defines synovial joints and describes the structure and functions of synovial fluid. Rheumatoid arthritis is characterized as an autoimmune disease that causes inflammation in the joints, commonly affecting the hands and feet. The stages of rheumatoid arthritis progression and its clinical features are outlined. Childhood arthropathies like juvenile idiopathic arthritis can affect multiple joint types and have different subtypes depending on symptoms. Diagnosis and treatment of both conditions involve examinations of synovial fluid, blood tests, imaging and medications.
This document discusses several joint and connective tissue diseases including osteoarthritis, rheumatoid arthritis, osteomyelitis, and septic arthritis. Osteoarthritis is characterized by the progressive deterioration of articular cartilage in the joints. It is the most common joint disease and has minimal inflammation. Rheumatoid arthritis is an autoimmune disease that causes inflammation of the synovial membrane in multiple joints. Osteomyelitis is a bone infection that is usually caused by Staphylococcus aureus. Septic arthritis refers to a bacterial infection that causes inflammatory destruction of joints.
Juvenile arthritis is a common condition in children that causes joint inflammation and pain. It can be classified as acute, sub-acute, or chronic based on the duration of symptoms. The most common type is juvenile idiopathic arthritis, which refers to conditions characterized by chronic joint inflammation. Treatment involves medications like NSAIDs and DMARDs to reduce inflammation and pain, physical or occupational therapy to maintain mobility, and surgery in severe cases to correct joint deformities. Nursing care focuses on alleviating pain, increasing mobility through exercise, promoting independence in self-care, and ensuring patients understand their condition and treatment plan.
Osteomyelitis is an inflammatory process of bone caused by bacterial infection. It can be acute, subacute, or chronic depending on duration. The most common causative organism is Staphylococcus aureus. Acute osteomyelitis typically affects children and causes fever, pain, and swelling near the infected bone. Chronic osteomyelitis results from inadequate treatment of acute osteomyelitis and causes persistent infection, bone necrosis, and sinus tract formation. Surgical debridement along with long-term antibiotics is usually required to treat chronic osteomyelitis. Rehabilitation focuses on restoring range of motion and strength through exercises.
This document discusses spondyloarthritis (SpA), a group of inflammatory diseases that share features like axial joint inflammation, asymmetric oligoarthritis, and enthesitis. The main types of SpA are ankylosing spondylitis, psoriatic arthritis, undifferentiated spondyloarthritis, and reactive arthritis associated with inflammatory bowel disease. SpA is strongly associated with the HLA-B27 gene. Clinical features include inflammatory back pain, peripheral arthritis, enthesitis, dactylitis, and eye and bowel inflammation. Diagnosis involves assessing clinical features, lab tests like elevated CRP/ESR and HLA-B27 status, and imaging of the sacroiliac joints and spine
Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children. It is classified into seven subtypes based on the number of involved joints, presence of specific symptoms or antibodies. The subtypes include systemic, oligoarticular, polyarticular (RF-negative and RF-positive), psoriatic, enthesitis-related, and undifferentiated arthritis. JIA is diagnosed clinically based on joint swelling or pain and exclusion of other causes. Laboratory tests like ANA, RF, and HLA-B27 can help classify the subtype but are not diagnostic. Imaging like X-ray and MRI are more sensitive than clinical exam in detecting early joint changes. Treatment
Osteomyelitis is an inflammatory process of bone and bone marrow caused by a bacterial infection. It can be acute, subacute, or chronic depending on the duration of infection. Acute osteomyelitis most commonly affects children and is usually caused by Staphylococcus aureus in the metaphysis of long bones. Chronic osteomyelitis results from inadequate treatment of acute osteomyelitis and is characterized by persistent infection, bone necrosis, sinus tract formation, and bone destruction seen on imaging. Treatment involves long-term antibiotics and surgical debridement to remove infected bone. Physical therapy focuses on restoring range of motion, strength, and mobility while protecting the infected bone during recovery.
Rheumatoid arthritis and osteoarthritis are common forms of arthritis. Rheumatoid arthritis is a systemic inflammatory disease that affects the joints and other organs, causing progressive joint deformity if not treated early. It can be a potentially fatal illness with increased risks of infections, renal impairment and cardiovascular disease. Osteoarthritis is the most common joint disorder and affects older individuals, particularly the weight-bearing joints like the hips and knees. It involves the breakdown of cartilage and bone within a joint. Management of both conditions involves conservative measures as well as medications aimed at reducing pain and inflammation.
Rheumatoid arthritis is a chronic inflammatory disease that causes swelling and stiffness in the joints. It is the most common form of inflammatory arthritis. It can affect other parts of the body as well as the joints, causing extra-articular manifestations like fatigue, lung involvement, and vasculitis. The disease typically affects women between 25-55 years of age and causes symptoms like morning joint stiffness lasting over an hour that improves with activity. Treatment involves medications like NSAIDs for pain relief, DMARDs like methotrexate to slow disease progression, and corticosteroids or biologics for more severe cases. Early treatment can help prevent long-term joint damage and deformities.
rheumatoid arthritis details ins and outsBosan Khalid
Rheumatoid arthritis is a chronic inflammatory joint disease that commonly causes pain, stiffness, swelling, and limitation of motion in the joints. It occurs when the immune system mistakenly attacks the joints, causing inflammation and damage over time. If not managed properly, it can lead to joint deformity and disability. Treatment aims to reduce inflammation and pain, prevent further joint damage, and improve quality of life through a combination of medications, surgery, exercise and assistive devices.
Osteoarthritis and rheumatoid arthritis are chronic joint disorders. Osteoarthritis involves the progressive breakdown of articular cartilage in a joint. It is associated with aging and risk factors like obesity, joint injury, and genetics. Rheumatoid arthritis is an autoimmune disease where the immune system attacks the joints, causing pain, stiffness, and swelling. It can eventually damage cartilage and bone within joints and may affect other organs. Both diseases are diagnosed based on symptoms, physical exam, x-rays, and blood tests. Treatment focuses on reducing pain and inflammation, maintaining joint mobility, and may include medications, weight loss, or joint replacement surgery.
Rheumatoid arthritis (RA) facts
Rheumatoid arthritis is an autoimmune disease that can cause chronic inflammation of the joints and other areas of the body.
It can affect people of all ages.
The cause of rheumatoid arthritis is not known.
In rheumatoid arthritis, multiple joints are usually, affected in a symmetrical pattern.
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Recent Advances In The Management Of Juvenile Idiopathic Arthritis
1. Recent Advances
In The Management Of
Juvenile Idiopathic Arthritis
Dr C Naveen Kumar,
1st Year PG,
Department of Pediatrics
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
2. Introduction
• The term “rheumatological disorders” refers to diseases that
affect the major connective tissues of the body (e.g. skin,
bone, blood vessels, cartilage and basement membrane).
• Juvenile Idiopathic Arthritis (JIA) is the most common
pediatric rheumatologic disease. It is associated with
significant long term morbidity.
• It was previously called as, Juvenile Rheumatoid Arthritis
(by ACR – American College of Rheumatology) or Juvenile
Chronic Arthritis (by ELAR – European League Against
Rheumatism).
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
3. Definition
International League of Associations for Rheumatology
(ILAR) proposed uniform definition and classification criteria
for JIA.
• Arthritis in ≥ 1 joints
(Swelling OR effusion OR the presence of 2 or more of the
following signs: limitation of range of motion, pain or
tenderness on motion, increased heat.)
• Age of onset – before 16 years
• Duration ≥ 6 weeks
• Exclusion of other forms of juvenile arthritis
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
5. Category Definition Exclusions
Systemic-onset
JIA
Arthritis in ≥1 joints with, or
preceded by, fever of at least 2 wk
in duration that is documented to
be daily (“quotidian”) for at least 3
days and accompanied by ≥1 of the
following:
1. Evanescent (nonfixed)
erythematous rash.
2. Generalized lymph node
enlargement.
3. Hepatomegaly or splenomegaly
or both.
4. Serositis.
a)Psoriasis or a history of psoriasis in the patient or a
1st-degree relative.
b)Arthritis in an HLA-B27–positive boy beginning
after the 6th birthday.
c)Ankylosing spondylitis, enthesitis-related arthritis,
sacroiliitis with inflammatory bowel disease, Reiter
syndrome, or acute anterior uveitis, or a history of
one of these disorders in a 1st-degree relative.
d)Presence of Ig-M RF on at least 2 occasions at least
3 months apart.
Oligoarticular
JIA
Arthritis affecting 1-4 joints during
the 1st 6 mo of disease. Two
subcategories are recognized:
1. Persistent oligoarthritis -
affecting ≤4 joints throughout the
disease course.
2. Extended oligoarthritis -
affecting >4 joints after the 1st 6
mo of disease
a, b, c, d (above)
plus
e) Presence of systemic JIA in the patient.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
6. Category Definition Exclusions
Polyarthritis
(RF-negative)
Arthritis affecting ≥5 joints during the 1st 6 months of
disease; a test for RF is negative.
a, b, c, d, e
Polyarthritis
(RF-positive)
Arthritis affecting ≥5 joints during the 1st 6 months of
disease; ≥2 tests for RF at least 3 months apart
during the 1st 6 months of disease are positive.
a, b, c ,e
Psoriatic arthritis
Arthritis and psoriasis, or arthritis and at least 2 of the following:
1. Dactylitis.
2. Nail pitting and onycholysis.
3. Psoriasis in a 1st-degree relative.
b, c, d, e
Enthesitis-related
arthritis
Arthritis and enthesitis, or arthritis or enthesitis with at least 2 of the
following:
1. Presence of or a history of sacroiliac joint tenderness or
inflammatory lumbosacral pain or both.
2. Presence of HLA-B27 antigen.
3. Onset of arthritis in a male > 6 yr old.
4. Acute (symptomatic) anterior uveitis.
5. History of ankylosing spondylitis, enthesitis-related arthritis,
sacroiliitis with IBD , Reiter syndrome, or acute anterior uveitis in a
1st-degree relative.
Undifferentiated
arthritis
Arthritis that fulfills criteria in no category or
that fits in ≥2 of the above categories.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
7. Glossary of terms used in ILAR
classification of JIA
• Arthritis: Swelling within a joint, or limitation in the range of joint movement with
joint pain or tenderness, which persists for at least 6 weeks.
• Nail pitting: A minimum of 2 pits on one or more nails at any time.
• Onycholysis: Detatchment of nail from nail bed.
• Quotidian fever: Daily recurrent fever that rises to 39°C or above once a day and
returns to 37°C or below between fever peaks.
• Serositis: Pericarditis, pleuritis, and/or peritonitis.
• Enthesitis: Tenderness at the insertion of a tendon, ligament, joint capsule, or
fascia to bone.
• Spondyloarthropathy: Inflammation of entheses and joints of the lumbosacral spine.
• Serositis: Pericarditis, pleuritis, or peritonitis, or some combination of the three.
• Dactylitis: Swelling of ≥1 digits, usually in an asymmetric distribution, that extends
beyond the joint margin.
• Inflammatory lumbosacral pain: Lumbosacral pain at rest with morning stiffness
that improves on movement.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
8. Etiology & Pathogenesis
Immunogenetic susceptibility
HLA I, HLA II alleles
Non HLA candidate loci
TNF-α, MIF, IL-6, IL-1α encoding gene polymorphisms
External trigger
Bacterial and viral infections
(Parvo virus B19, Rubella, EBV)
Bacterial or mycobacterial Heat Shock Proteins
Abnormal reproductive hormone levels
Joint trauma
ABNORMAL IMMUNE
RESPONSE
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
9. ABNORMAL IMMUNE RESPONSE
Humoral
B-Cell activation
• Complement consumption
• Immune complex formation
• Auto antibodies (ANA etc.)
• Elevated serum Ig
Cell mediated
TNF-α, IL-6, IL-1 are
pro-inflammatory cytokines
Favour TH1 response over TH2
• Enhanced adhesion molecules expression in synovium results in T cell recruitment
into synovium. >> Dense infiltrates, inflammatory synovitis; villous hyperplasia,
hypertrophy, hyperemia & edema; vascular endothelial hyperplasia and pannus
formation.
• Activation of metalloproteinase enzymes which lead to damage of synovium and
adjacent tissues.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
10. Pathogenesis
• All forms of JIA other than sJIA, are disorders of adaptive
immunity – autoimmune disorders. Lymphocytes (TH1 cells)
play major role in the pathogenesis.
• JIA (Systemic onset JIA) is a disorder of innate immunity –
an auto inflammatory disorder. Neutrophils, monocytes &
macrophages play a major role in the pathogenesis.
• Balance between pro inflammatory cytokines (TNF-α, IL-1,
IL-6, IL-8) and anti-inflammatory cytokines (IL-4, IL-10, IL-
1 receptor antagonists) determines the degree of joint damage
(severity of arthritis).
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
11. Clinical manifestations
• Involved joints are often swollen, warm to touch, and painful on
movement or palpation with reduced range of motion but usually
are not erythematous.
• Morning stiffness with a limp or gelling after inactivity.
• Easy fatigability and poor sleep quality may be associated.
• Arthritis in large joints, especially knees, initially accelerates linear
growth, causing the affected limb to be longer and resulting in a
discrepancy in limb lengths.
• Continued inflammation stimulates rapid and premature closure of
the growth plate, resulting in shortened bones.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
12. Clinical manifestations - SoJIA
• SoJIA characterized by arthritis, fever, and prominent visceral
involvement, including hepatosplenomegaly, lymphadenopathy,
and serositis (pericarditis).
• Quotidian fever. The fever is often present in the evening.
• Characteristic faint, erythematous, macular rash.
The evanescent salmon-colored lesions are linear or circular and are
most commonly distributed over the trunk and proximal extremities.
Nonpruritic and migratory with lesions lasting <1 hr.
Koebner phenomenon often present.
Heat, such as from a warm bath, also evokes rash.
• Arthritis is classically polyarticular, may be very destructive, and
includes hip, cervical spine, and TMJ.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
13. Clinical manifestations –
Oligoarthritis
• Oligoarthritis large joints of the lower extremities, such as the
knees and ankles . Often only a single joint is involved.
• Involvement of the hip almost never occurs and if present
suggests a spondyloarthropathy or nonrheumatologic cause.
• The presence of a positive antinuclear antibody (ANA) test result
confers increased risk for asymptomatic anterior uveitis, requiring
periodic slit-lamp examination.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
14. Clinical manifestations –
Polyarthritis
• RF positive polyarticular disease resembles the characteristic
symmetric presentation of adult rheumatoid arthritis.
• Rheumatoid nodules on the extensor surfaces of the elbows and
over the Achilles tendons are associated with a more severe course
and almost exclusively occur in RF-positive individuals.
• Chronic Temporomandibular joint (TMJ) disease results in
micrognathia.
• Cervical spine involvement, manifesting as decreased neck
extension, occurs with a risk of atlantoaxial subluxation and
neurologic sequelae.
• Hip disease may be subtle, with findings of decreased or painful
range of motion on exam.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
15. Subtype Peak
age of
onset
Female
:Male
ratio
Arthritis pattern Extraarticular features
Systemic
onset
2-4 Yrs 1:1 Poly articular, often affecting knees, wrists
and ankles; also fingers, neck and hips
Daily fever; evanescent rash;
pericarditis; pleuritis
Oligoarthritis <6 Yrs 4:1 Knees ++; ankles, fingers + Uveitis in 30% of cases
Polyarthritis
RF negative
RF positive
6-7 Yrs
9-12 Yrs
3:1
9:1
Symmetric or asymmetric; small and large
joints; cervical spine; TMJ involvement
Aggressive symmetric polyarthritis
Uveitis in 10% cases
Rheumatoid nodules in 10%,
low grade fever
Psoriatic
arthritis
7-10 Yrs 2:1 Asymmetric arthritis of small or medium
sized joints
Uveitis in 10%, Psoriasis in
50%
Enthesitis
related
arthritis
9-12 Yrs 1:7 Predominantly lower limb joints affected;
sometimes axial skeleton (but less than in
adult, ankylosing spondylitis)
Acute anterior uveitis;
association with reactive
arthritis and IBD
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
16. Laboratory findings & investigations
• Elevated WBC and platelet counts and a microcytic anemia
(anemia of chronic disease).
Low WBC count, low platelet count >> suspect MAS (Macrophage
Activation Syndrome)
• Eevated ESR and C-reactive protein (CRP)
• Elevated ANA titers are present in 40-85% of children with
oligoarticular or polyarticular JIA but are rare with SoJIA. It is
associated with increased risk of chronic uveitis in JIA.
• 5-10% of patients with polyarticular JIA are seropositive for RF.
• Anti–cyclic citrullinated peptide (CCP) antibody, like RF, is a
marker of more aggressive disease.
• HLA-B27 is positive in enthesitis related form.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
17. Laboratory findings & investigations
MRI is more sensitive than radiography to early changes most sensitive
radiologic indicator of disease activity. It can depict synovial hypertrophy,
define soft tissue swelling, and demonstrate excellent detail of the status of
articular cartilage and overall joint integrity.
Early radiographic changes of
arthritis include
• Soft tissue swelling
• Periarticular osteoporosis and
• Periosteal new-bone apposition
around affected joints .
Continued active disease may lead
to
• Subchondral erosions
• Loss of cartilage
• Varying degrees of bony
destruction and,
• Fusion.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
19. Management
• Children with JIA are best managed in a specialist multidisciplinary set
up.
Management may include one or all of the following areas:
• Pharmacologic management
• Psychosocial factors, including counseling for patients and parents
• School performance, such as academic counseling, school-life
adjustments, and physical education adjustments
• Nutrition, particularly to address anemia and generalized osteoporosis
etc.
• Physical therapy, to relieve pain and to address range of motion, muscle
strengthening, activities of daily living, and conditioning exercises
• Occupational therapy, including joint protection, a program to relieve
pain, range of motion, and attention to activities of daily living
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
20. Pharmacologic management
Primary goals of medical therapy are:
• To eliminate active disease
• To normalize joint function
• To preserve normal growth
• To prevent long-term joint damage
Children with JIA need individualized treatment plans, and
management is tailored according to
• Disease subtype
• Severity
• Presence of poor prognostic indicators, and
• Response to medications.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
21. Commonly used drugs in the present
day treatment of JIA
NSAIDs Steroids
Disease Modifying
Anti-rheumatologic
Drugs (DMARD)
Biologicals
• Ibuprofen
• Naproxen
• Indomethacin
• Meloxicam
• Intra articular
triamcinolone
hexacetonide
• Oral prednisolone
• Topical ocular
preparations
• Intravenous
methyl
prednisolone
• Methotrexate
• Sulfasalazine
• Leflunomide
• Cyclosporine
• Adalimumab
• Etanercept
• Infliximab
• Abatacept
• Toclizumab
• Rituximab
• Anakinra
• Canakinumab
• Rilonacept
• Toclizumab
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
22. Non steroidal anti-inflammatory drugs
(NSAIDs)
• NSAIDs have been the mainstay of treatment for inflammatory arthritis for
decades because of their analgesic and anti-inflammatory properties.
• But the approach today is to introduce disease modifying agents DMARDs
early in the course of the disease.
• NSAIDs control the symptoms but don’t alter the natural history of the
disease.
• In general, NSAIDs should only be considered as monotherapy for initial
therapy in low disease activity. If control is not achieved in 1 to 2 months,
additional therapy should be considered.
• NSAIDs are frequently used for symptom control as an adjunctive therapy to
more definitive therapies.
• One of the main actions of NSAIDs is the inhibition of cyclooxygenase
(COX) with resultant decrease in the production of prostaglandins resulting in
analgesia.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
23. NSAIDs side effects:
• Bleeding - inhibition of platelet function
• Gastrointestinal (GI) toxicity
• Pseudoporphyria - Naproxen
• Headache, mood change, and decreased school performance
• Liver toxicity
• Renal toxicity
ACR Recommendations for monitoring of NSAIDs in JIA patients:
What to monitor?
Complete blood cell count, liver enzymes, serum creatinine
When to monitor?
• Prior to or soon after initiation of routine use
• Repeat twice yearly for chronic daily use
• Repeat once yearly for routine use (3-4 days per week)
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
24. Corticosteroids - Mechanism of action
In physiologic or low-dose,
Bind to cytosolic receptors >> translocate as a complex to the
nucleus >> the complex binds to DNA >> induces mRNA
transcription of some genes encoding for anti-inflammatory
proteins and decreases the transcription of genes encoding pro-
inflammatory proteins.
As the dose increases,
Very rapid, non-receptor mediated events occur, causing
apoptosis (programmed cell death) of lymphocytes and other
inflammatory cells.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
25. Intra articular corticosteroids
• The use of intra-articular Triamcinolone hexacetonide (THA), 1 mg/kg
in large joints such as the knee and 0.5 mg/kg in smaller joints such as the
ankle, has been found to be superior to Triamcinalone acetonide.
• Early treatment is associated with better outcome.
• Intra articular steroids are expected to result in clinical improvement of
arthritis for at least 4 months.
• Difficult-to-reach joints such as the hip, sacroiliac (SI) joint,
temporomandibular joint (TMJ), and subtalar joint may be injected using
ultrasound or fluoroscopy.
• The use of IASs for active arthritis has been recommended by the ACR
guidelines regardless of concurrent therapy, JIA subtype, disease
activity, prognostic features, or joint contracture.
• If the duration of clinical improvement is shorter than 4 months, systemic
treatment (e.g.,MTX) may be indicated.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
26. Systemic corticosteroids
ACR recommendations for JIA treatment were unable to make
any recommendations for systemic corticosteroid use, except
• In systemic juvenile idiopathic arthritis (sJIA) for severe
systemic features and
• In polyarticular JIA, in order to bridge constitutional features
of pain and fatigue while waiting for DMARDs or biologic
therapies to reach their therapeutic effect. (Bridge therapy)
Toxicity: obesity, short stature, hypertension, osteoporosis,
cataracts, mood changes, diabetes mellitus, avascular necrosis,
and susceptibility to infection.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
27. Methotrexate
• Methotrxate is the most commonly used DMARD in JIA.
• Starting MTX early will lead to a better response.
• Mechanism of action: Inhibits Dihydro folate reductase
(DHFR).
• Maximum dose of 0.6 mg/kg once weekly (equivalent to 15
mg/m2/week, maximal 25 mg/week) of parenteral MTX.
• Daily folate supplementation at 1 mg/day.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
28. Methotrexate
• Side effects: Nausea, vomiting, oral ulcerations, hepatitis,
blood dyscrasias and immunosuppression.
ACR Recommendations for monitoring of Methotrexate in JIA
patients:
What to monitor?
Complete blood cell count, liver enzymes, serum creatinine
When to monitor?
• Prior to initiation
• 1 month after initiation
• 1–2 months after increase in dose
• Every 3–4 months if prior results normal and dose stable
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
29. Sulfasalazine
• Mechanism of action: Sulfasalazine and its metabolites are weak
inhibitors of cyclooxygenase (both COX-1 and COX-2).
Sulfasalazine inhibits folate metabolizing enzymes such as DHFR.
• Sulfasalazine is efficacious particularly in Enthesitis-Related
Arthritis.
• It is contraindicated for use in Systemic Arthritis, at least during
the acute phase of the disease, because of good evidence of
increased toxicity in this situation
• Adverse effects: GI upset, allergic reaction, pancytopenia, renal
and hepatic toxicity.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
30. TNF – alpha inhibitors
• Act by inhibiting pro inflammatory cytokine TNF-α
• Adalimumab, Etanercept, Infliximab
• Adverse effects: Serious infections, demyelinating processes, optic
neuritis, injection site reactions or infusion reactions, development
of autoimmune conditions and reactivation of tuberculosis.
ACR Recommendations for monitoring of TNF-α inhibitors in JIA
patients:
Complete blood cell count, liver enzymes, serum creatinine
• Prior to initiation and then at every 3–6 months
Tuberculosis screening
• Prior to initiation and then, once yearly
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
31. Other biologicals
Abatacept (CTLA4-Ig) T cell co-stimulatory inhibitor
Canakinumab Human monoclonal antibody targeted at interleukin-1 β
Rilonacept Interleukin-1 inhibitor
Anakinra Interleukin-1 receptor antagonist
Toclizumab Humanized monoclonal antibody against the IL-6 receptor
Rituximab Chimeric monoclonal antibody against CD-20
Adverse effects: Immunosuppression, malignancy.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
32. 2013 ACR recommendations for pharmacotherapy of
Juvenile Idiopathic Arthritis
ACR treatment subgroups The ACR issued recommendations for the treatment of
JIA on the basis of the following 5 treatment groups:
1. History of arthritis in 4 or fewer joints
2. History of arthritis in 5 or more joints
3. Active sacroiliac arthritis
4. Systemic arthritis with active systemic features and without active arthritis.
5. Systemic arthritis with active arthritis and without active systemic features.
Within each treatment group, choice of therapy is guided by
• Severity of disease activity (Number of joints with active arthritis, inflammatory
marker levels ESR & CRP, fever, physician/parent/patient global assessment
scales etc.)
• Presence or absence of features indicating a poor prognosis (defined
separately for each group)
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
33. 1. History of arthritis in 4 or fewer joints
This group includes patients with the ILAR categories of persistent
oligoarthritis, as well as patients with psoriatic arthritis, enthesitis-related
arthritis, and undifferentiated arthritis who have developed active arthritis
in only four or fewer joints total throughout the history of their disease
course.
Features of poor prognosis:
• Arthritis of the hip or cervical spine
• Arthritis of the ankle or wrist AND marked or prolonged inflammatory
marker elevation
• Radiographic damage (erosions or joint space narrowing by radiograph)
In this treatment group, escalation of therapy typically proceeds from
NSAIDs TO intra-articular glucocorticoid injections TO
methotrexate/sulfasalazine TO TNF-α inhibitors.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
34. 1. History of arthritis in 4 or fewer joints
• NSAIDs alone may be adequate for patients with involvement of a single joint
and other indications of low disease activity (eg, normal inflammatory marker
levels); response should be evident within 2 months. For other patients, NSAIDs
may be used as adjunctive treatment, as needed.
• Intra-articular injections of triamcinolone can be used for any joint involved with
active arthritis.
• Methotrexate can given to patients who fail to show adequate response to
NSAIDs and/or joint injections. It is recommended as initial treatment for patients
in this treatment group who have high disease activity and features indicating
poor prognosis.
• In patients with enthesitis-related JIA, sulfasalazine rather than methotrexate is
recommended for patients who have an inadequate response to joint injection or
an adequate trial of NSAIDs.
• Patients in this treatment group who fail to respond adequately to joint injections
and to 3-6 months of methotrexate/sulfasalazine are candidates for Anti TNF-α
treatment.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
36. 2. History of arthritis in 5 or more joints
This group includes patients with the ILAR categories of extended
oligoarthritis, RF negative polyarthritis, RF positive polyarthritis, as
well as patients with psoriatic arthritis, enthesitis-related arthritis,
and undifferentiated arthritis who have developed active arthritis in
five or more joints total throughout the history of their disease.
Patients in this group need not currently have five or more active
joints.
Features of poor prognosis:
• Arthritis of the hip or cervical spine
• Positive rheumatoid factor OR anti-cyclic citrullinated peptide
(anti CCP) antibodies
• Radiographic damage (erosions or joint space narrowing by
radiograph)
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
37. 2. History of arthritis in 5 or more joints
• After 1 month of NSAID treatment in patients with low disease activity, or 1-2
months in those with moderate disease activity but without poor prognostic
features it is appropriate to escalate to methotrexate, plus adjunctive NSAIDs and
joint injection as needed.
• In patients with moderate disease activity and poor prognostic features, as well as
in patients with high disease activity, treatment may start with methotrexate.
Leflunomide may be used as an alternative to methotrexate.
• Interleukin (IL)-6 inhibitor Tocilizumab can be used for the treatment of
polyarticular JIA in children 2 years of age and older with active disease, either
alone or in combination with Methotrexate.
• Escalation to a TNF-α inhibitor follows if 3-6 months of methotrexate or
leflunomide provides inadequate control.
• If there is inadequate response after 3-4 months of TNF-α inhibitor treatment can
be switched to a different TNF-α inhibitor or to Abatacept.
• If these agents prove inadequate, patients may be started on Rituximab (especially
useful in RF positive polyarthritis)
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
39. 3. Active Sacroiliac Arthritis
• This group includes patients from any of the ILAR JIA category
with clinical and imaging evidence of active sacroiliac arthritis.
Features of poor prognosis:
• Radiographic damage of any joint (erosions or joint space
narrowing by radiograph).
• Use of a TNF-α inhibitor is recommended more readily for patients
in this group.
• A TNF-α inhibitor may be started after failure of an adequate trial
of NSAIDs or after 3-6 months of methotrexate or sulfasalazine
proves inadequate.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
40. 4. Systemic arthritis with active systemic
features and without active arthritis
• This group includes all patients who fulfill the ILAR criteria
for systemic arthritis and who have active fever of systemic
JIA with or without other systemic features, but without
active arthritis.
Features of poor prognosis:
• 6 month duration of significant active systemic disease,
defined by: fever, elevated inflammatory markers, or
requirement for treatment with systemic glucocorticoids
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
41. 4. Systemic arthritis with active systemic
features and without active arthritis
• A 2-week trials of NSAIDs may be used in patients who have
fever and less severe disease, and have had significant active
systemic disease for less than 6 months; after that, patients
should be started on systemic glucocorticoids, with adjunct
NSAIDs as needed.
• Patients with high systemic disease activity (eg, significant
serositis) may be started on steroids as a first step.
• Patients who sustain or develop active fever while on
systemic steroid therapy can be started on Anakinra.
• Toclizumab abd Canakinumab are also approved for use in
children with systemic JIA.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
43. 5. Systemic arthritis with active arthritis
(and without active systemic features)
• This category includes all patients who fulfill the ILAR
criteria for systemic arthritis AND who have active arthritis,
but without active systemic features.
Features of poor prognosis:
• Arthritis of the hip
• Radiographic damage (erosions or joint space narrowing by
radiograph)
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
44. 5. Systemic arthritis with active arthritis
(and without active systemic features)
• NSAID therapy, with intra-articular joint injections as
needed, may be adequate for patients with low disease
activity who do not have hip involvement or radiographic
signs of joint damage.
• Methotrexate can be added for patients with any degree of
disease severity who continue to have active arthritis.
• After 3 months of Methotrexate therapy, the next step in
escalation is to Anakinra or a TNF-α inhibitor.
• Patients who show inadequate response to TNF-α inhibitor
treatment can be started on Abatacept.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
46. Macrophage activation
syndrome (MAS)
• It is a rare but potentially fatal
complication of SoJIA, that can
occur at anytime during the
disease course.
• Also referred to as secondary
hemophagocytic syndrome or
hemophagocytic
lymphohistiocytosis (HLH).
• The erythrocyte sedimentation
rate (ESR) falls because of
hypofibrinogenemia and hepatic
dysfunction, a feature useful in
distinguishing MAS from a flare
of systemic disease.
CLINICAL FEATURES
• Profound anemia
• Thrombocytopenia or
leukopenia
• High, spiking fevers
• Lymphadenopathy
• Hepatosplenomegaly
• Purpura
• Mucosal bleeding
• Elevated fibrin split
product
• Prolonged PT, aPTT
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
47. PRELIMINARY DIAGNOSTIC GUIDELINES FOR MACROPHAGE
ACTIVATION SYSTEM (MAS)
LABORATORY CRITERIA
1. Decreased platelet count (≤262 × 109/L).
2. Elevations of aspartate aminotransferase (>59 U/L).
3. Decreased white blood cell count (≤4.0 × 109/L).
4. Hypofibrinogenemia (≤2.5 g/L).
CLINICAL CRITERIA
1. Central nervous system dysfunction (irritability, disorientation, lethargy, headache,
seizures, coma).
2. Hemorrhages (purpura, easy bruising, mucosal bleeding).
3. Hepatomegaly (edge of liver ≥3 cm below the costal arch).
HISTOPATHOLOGIC CRITERION
• Evidence of macrophage hemophagocytosis in the bone marrow aspirate
The diagnosis of MAS requires the presence of any 2 or more laboratory criteria or of any 2 or 3 or
more clinical and/or laboratory criteria. A bone marrow aspirate for the demonstration of
hemophagocytosis may be required only in doubtful cases.
MAS often responds to cyclosporin A, and some case reports have detailed a
response toAnakinra. Treatment of MAS is a medical emergency.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
48. Nonpharmacologic Therapy – Exercise
• Exercise preserves joint range of motion and muscular strength, and it
protects joint integrity by providing better shock absorption.
• Types of exercises: Muscle-strengthening program, range-of motion activity,
stretching of deformities, and endurance and recreational exercises.
• Hydrotherapy is a good form of exercise that helps achieve the
aforementioned objectives.
• Leg-length discrepancy can result from neovascularization of growth plates
of an affected knee. Treatment consists of a shoe lift on the contralateral
side.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
49. Surgical Treatment
Synovectomy It may be used in children in whom a single joint
or just a few joints are involved and who have very active,
proliferative synovitis.
Osteotomy and arthrodesis are salvage procedures for patients
whose JIA is associated with severe joint destruction or deformity.
Arthrodesis is superior to arthroplasty for children who have
rheumatic disease in the wrist and fingers and in the ankle.
Total hip and knee replacements provide excellent relief of pain
and restore function in a functionally disabled child with
debilitating disease. Joint replacement is usually delayed until
bone growth has completed, as indicated by epiphyseal closure.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
50. Treatment of Uveitis
• Uveitis is often asymptomatic.
• Patients are typically young girls who have positive levels of
ANA.
• Treatment with topical corticosteroid medication and with
mydriatic agents (to prevent closed-angle glaucoma) often can
prevent progression of disease to development of calcium
deposition in the lens and posterior synechiae.
• Methotrexate or cyclosporine, may help control chronic uveitis.
Infliximab can be effective in some patients who are resistant to
immunosuppressive agents.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
51. Diet and Activity
• Because active JIA has been associated with decreased
osteoblastic activity and a risk of osteopenia, encourage the
inclusion of at least 3 servings of calcium-rich foods each day.
Consider supplementation when poor calcium intake persists.
• Encourage patients to be as active as possible. Bed rest is not a
part of the treatment. In fact, the more active the patient, the
better the long-term prognosis.
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati
52. PROGNOSIS
• Children with persistent oligoarticular disease fare well, with a majority
achieving disease remission. Those in whom more extensive disease
develops have a poorer prognosis.
• The child with polyarticular JIA often has a more prolonged course of
active joint inflammation and requires early and aggressive therapy.
Predictors of severe and persistent disease include
• Young age at onset
• RF seropositivity or rheumatoid nodules
• The presence of anti-CCP antibodies
• Large numbers of affected joints
• Disease involving the hip and hand and wrist
• Fever lasting >3 months
• Increased inflammatory markers for >6 months
Dr Naveen Kumar Cheri
S.V. Medical College, Tirupati