Response: Cricoarytenoid arthritis presenting as croup

Abstract

Following your recent case report ‘Cricoarytenoid arthritis presenting as croup’1 we felt it important to highlight some important points that arise. First, there is an issue of nomenclature. The report of quotidian fever, rash and polyarthritis is clearly a description of systemic onset juvenile idiopathic arthritis (JIA). While this condition has previously been termed juvenile rheumatoid arthritis (JRA) in North America and juvenile chronic arthritis (JCA), there has been a move away from these terms to JIA not least to emphasize that JIA is a condition quite pathophysiologically distinct from rheumatoid arthritis (RA). JIA encompasses the three sub-subsets of JCA previously used to classify patients on the basis of their clinical features and number of joints involved: systemic-onset; pauci-articular-onset; and polyarticular-onset.2,3 The change of classification is important to allow research into the causes, pathogenesis, epidemiology and outcomes of childhood arthritides. In this report we would suggest that it is more important to associate cricoarytenoid arthritis with other cases documented in association with childhood arthritis. While recognizing that cricoarytenoid arthritis is a rare association with JIA, we feel that more common causes of croup may have been overlooked in the case described. First, it is well-documented that non-steroidal anti-inflammatory drugs (NSAIDs) including ibuprofen can cause laryngeal oedema that may present respiratory distress.4 Second, patients with active autoimmune conditions such as JIA are essentially immunosuppressed, and given that croup is most commonly caused by infection this should have prompted a more thorough evaluation and earlier involvement of the ENT specialists during the first admission with respiratory distress. We suspect that, in this case, earlier ENT involvement would have identified the cricoarytenoid arthritis thereby altering the management of her JIA and possibly preventing subsequent readmission in extremis.