Rheumatoid arthritis in children, or juvenile rheumatoid arthritis, is a chronic systemic autoimmune inflammatory disease with a predominant lesion of peripheral joints of the synovial type, but in some cases internal organs are involved in the pathological process with the development of various complications.
As a rule, juvenile rheumatoid arthritis( JRA) affects children under 16 years old and differs from the course of a similar disease in adults, which served as a separate pathology. Prevalence of JRA is in the range of 2-3 cases per 1000 children. The peak incidence falls on the age of 3-5 and 12-14 years. Girls get sick almost 2 times more often than boys. The disease is characterized by steady progression and involvement of internal organs in the pathological process, which can result in even disability of the child. Rheumatoid arthritis( RA) ranks first among rheumatic diseases in children.
The reason for the JRA is not yet established. But most researchers associate the development of the disease with infectious diseases( bacterial and viral).If you refer to modern ideas about the etiology of RA, then JRA is a multifactorial disease that develops in children prone to it( genetic factor) after provocation, for example, of a viral, streptococcal infection or negative influence of the external environment.
In the JRA, autoantibodies are formed in the body that destroy the joints of
. Because of a certain genetic predisposition to the development of rheumatoid arthritis( associated with HLA antigens), the immune system reacts to the usual infection inadequately with hyperactivation and the formation of autoantibodies. These antibodies, after the destruction of all microorganisms, begin to attack their own human tissues, which leads to the development of autoimmune aggression against the components of the joints with their damage, and in some cases, damage to the internal organs.
Factors that may trigger the development of JRA:
- viral diseases( influenza, RS virus, rubella, chicken pox, adenovirus, herpetic infection);
- bacterial lesions( streptococcal: angina, pharyngitis, otitis media, pneumonia, bronchitis, intestinal infections);
- traumatic joint damage;
- general overheating or hypothermia of the body;
- increased insolation;
- climate change;
- hormonal disorders;
- introduction of vaccines.
It's important to understand! Rheumatoid arthritis does not develop in all children who are exposed to the above-described factors, but only in those who have this propensity embedded in DNA.
Symptoms of rheumatoid arthritis in children depend on which clinical form of the disease develops in a particular case and on the rate of debility of the pathology. Distinguish the acute and subacute beginning of RA in children.
Acute onset of rheumatoid arthritis is more common in preschool and primary school children. This is an unfavorable variant of the course characterized by rapid development of pathological symptoms of severe forms of the disease: generalized joint with involvement of a large number of joints and visceral with damage to the internal organs.
The subacute onset of rheumatoid arthritis is observed in most cases. It is characterized by a gradual onset of pathological symptoms, a prolonged chronic course of the disease. It corresponds to the articular form of the disease according to the type of monoarthritis( involving 1 joint) or oligoarthritis( 2-4 joints).
In rheumatoid arthritis all joints of the body
can be affected. We consider 2 main forms of rheumatoid arthritis in children.
The articular form begins subacute and can occur in 3 versions:
- Monoarthritis - occurs in 10-30% of cases of articular form, with 1 major joint - ankle or knee. The affected joint becomes inflamed, swollen, there is a pronounced pain syndrome, which often leads to a restriction of movement or complete loss of the patient's limb function. This variant of the disease course is not typical for adults and resembles rheumatoid arthritis. A distinctive feature can be considered stiffness in the joint in the morning, which disappears after some time after getting up from bed.
- Oligoarthritis - occurs in 45-50% of cases of articular form of the disease. In this case, 2-4 joints( knee, wrist, ankle, elbow, hip, interphalangeal joints of the hands) are involved in the pathological process. Unlike adults, inflammation of the joints is asymmetric.
- Polyarthritis - occurs in 20-30% of cases and corresponds to the generalized joint form of the disease, which often begins acutely and proceeds severely. In this case, more than 5 different joints are affected. In the pathological process, any joints of the extremities can be drawn in, also the joints of the cervical spine, temporomandibular, sternoclavicular joint can be affected. Arthritis is asymmetric, accompanied by a sense of morning stiffness and external signs of inflammation.
As a rule, monoarthritis and oligoarthritis are not accompanied by extra-articular manifestations and the general condition of the child is not violated. It is possible that the temperature rises to subfebrile numbers with a moderate increase in peripheral lymph nodes.
Generalized articular form always proceeds with pronounced extraarticular symptoms:
- peripheral lymphadenopathy;
- appearance of subcutaneous rheumatic nodules;
- weight loss;
- atrophy of certain muscle groups;
- muscle pain;
- eye damage( uveitis, iridocyclitis, cataract).
Knee inflammation in rheumatoid arthritis in a child
The joint form of the disease is considered benign, as it slowly progresses and is not accompanied by severe lesions of the internal organs. But with the progression of pathology in joints, there are persistent changes that manifest themselves in the form of various persistent deformations, muscle atrophy, dislocations and subluxations, changes in ligaments. All this can cause disability of the child.
Children's rheumatoid arthritis may in some cases proceed through the joint-visceral type. This is a serious variant of the disease, which begins acutely and proceeds with lesions of the internal organs, which in some cases can lead to death. This form of the disease exists in 2 versions:
- Still's syndrome;
- allergoseptic syndrome.
The Syndrome begins with acute disability, fever, allergic rash, generalized lymph node enlargement, enlargement of the liver and spleen, pain and inflammation in the joints. The defeat of the joints in the syndrome of the Still resembles a generalized joint form. Very quickly develop joint deformities and muscle contractures, which leads to severe functional insufficiency and disability of the child.
Liver enlargement is a sign of Still's syndrome
Along with articular manifestations, lesions of internal organs develop:
- of the heart - myocarditis, endocarditis, pericarditis, which can lead to the formation of heart disease;
- kidney - glomerulonephritis, renal amyloidosis with gradual development of renal failure;
- of the lungs - pneumonitis;
- of blood vessels - vasculitis;
- blood - anemia;
- amyloidosis of the liver, adrenal glands.
Allergoseptic syndrome ( Wissler-Fanconi syndrome) begins acutely, accompanied by a severe condition of the child with febrile fever, which persists for a long time( 2 weeks - 3 months).On the body appears a polymorphic rash of an allergic nature. Lymph nodes are enlarged all over the body, internal organs are affected - pericarditis, pleurisy, myocarditis. The liver and spleen are enlarged. At the beginning of the disease, joint damage is manifested only by pain syndrome. Arthritis develops 2-3 months after the onset of pathological symptoms.
The diagnosis of rheumatoid arthritis, especially at an early stage, is a very difficult task, since there are no specific methods that allow you to diagnose with 100% accuracy. In most cases, this is a clinical diagnosis. At present, clinical Eastern European criteria are used to diagnose juvenile rheumatoid arthritis, which include a set of symptoms, radiologic signs and laboratory tests.
Clinical criteria of JRA:
- arthritis lasts more than 3 months;
- after the defeat of the first joint of the second inflammation no later than 3 months;
- if minor joints of the hand are affected, the inflammation is symmetrical;
- signs of synovitis( effusion in the joint cavity);
- development of joint contracture;
- development of bursitis or tendovaginitis of any site;
- muscle atrophy;
- morning stiffness in the joints;
- Inflammation of the eye;
- subcutaneous rheumatoid nodules.
X-ray X-ray criteria:
- osteoporosis according to radiographs;
- reduction of the joint gap, marginal bone defects, joint ankylosis;
- dysplasia of the bones;
- signs of involvement of the cervical spine.
Radiography of damaged joints - an integral part of the diagnosis JRA
Laboratory criteria JRA:
- increase in ESR;
- is a rheumatoid factor in the serum;
- morphological study of the biopsy of the joint membrane.
If the child has 3 of the above criteria, then a diagnosis is possible;if 4, then there is no doubt, and arthritis should be sure;if there are 8, then the classic variant of rheumatoid arthritis in a child is diagnosed.
All children are required to carry out an ECG, ultrasound of the heart and internal organs, a chest radiograph and other examinations, depending on the signs, in order to identify lesions of the internal organs and prescribe their adequate treatment.
Principles of treatment
Treatment of juvenile rheumatoid arthritis is a very important and complex process. However, adequate and timely initiation of therapy can stop the progression of the disease, reduce the risk of complications and improve the prognosis of the disease.
The main tasks of treating rheumatoid arthritis in a child:
- elimination of active inflammation;
- removal of symptoms of arthritis and pain;
- saving the function of the joints, their mobility;
- prevention of functional limitation and disability;
- achievement of persistent remission;
- improving the quality of life of a sick child, for example, prosthetics in severe limb injury;
- prevention of side effects from medications.
The basis of treatment is medication permanent therapy, which is appointed to eliminate symptoms( symptomatic) and stop the autoimmune process( basic anti-inflammatory therapy).
Drug therapy - the basis of RA
treatment. Medications from the following groups are used:
- NSAIDs( diclofenac, ibuprofen, meloxicam) - these drugs do not affect the course of the disease, but only eliminate its symptoms, so for monotherapy they are not used, but only in a complex. All these drugs negatively affect the gastrointestinal tract, can cause an exacerbation of gastritis and bleeding.
- Glucocorticoid hormones( prednisolone, methylprednisolone) - prescribed with ineffectiveness of other symptomatic agents. Medication is prescribed by a short course( pulse therapy) with exacerbations or very severe forms of the disease with damage to the internal organs. Permanent intake of GCS for children is prescribed rarely( only in extremely severe cases).
- Cytotoxic drugs( drugs from various groups) that affect the course of the disease and are used as a basic therapy. These drugs suppress autoimmune aggression and inhibit the progression of pathology.
- Target therapy is a modern, highly effective and costly method of treatment when special biological preparations are used that block the production of autoantibodies and further damage to the joints.
In severe cases, extracorporeal methods of purifying blood from antibodies are used. With the development of complications( contractures, deformations) apply functional therapy, prosthetics, surgical orthopedic care.
- Reasons for
- Principles of treatment