Pauciarticular Type Research Articles

Etanercept treatment for children with refractory juvenile idiopathic arthritis

Etanercept has been shown to be an effective treatment for juvenile idiopathic arthritis (JIA). In this study, we evaluated the effectiveness of etanercept therapy in the treatment of refractory JIA. This was a retrospective analysis of 11 patients with refractory JIA (polyarticular type n=7; pauciarticular type, n=2; systemic type, n=2) who received treatment with etanercept during the period 2005-2009 in a medical center. The indications for etanercept treatment included persistent fever, arthritis/arthralgia, or elevated levels of inflammatory mediators after treatment with methotrexate and/or prednisolone for more than 6 months. The patients were treated with etanercept (0.4 mg/kg, with maximal 25mg, subcutaneously, twice a week) for a total of 12 months. The degree of arthritis/arthralgia improved (range of motion and painful sensation of involved joints), and the levels of inflammatory markers (C-reactive protein and erythrocyte sedimentation rate) decreased progressively in 10 of the 11 patients (p<0.05) at 1-, 3-, 5-, and 12-month follow-up after treatment with etanercept. Mean hemoglobin levels significantly increased, whereas mean platelet counts decreased after etanercept treatment (p<0.05). Only one patient with systemic type of JIA failed to respond to the treatment after 6 weeks of etanercept therapy. Methotrexate, prednisolone, and other immunosuppressive drugs were successfully discontinued after a mean of 2.5 months (range, 1-5 months) of etanercept therapy in the 10 patients who responded to etanercept treatment. Etanercept is beneficial for patients with polyarticular and pauciarticular type of JIA that is refractory to conventional treatment but less beneficial for systemic type of JIA.

Longitudinal growth attainments of Indian boys with Juvenile Rheumatoid Arthritis

The objective is to study the pattern of distance and velocity growth in terms of weight and height in adolescent boys with Juvenile Rheumatoid Arthritis (JRA). This study was conducted on children diagnosed to have JRA (Cassidy and Petty in Juvenile Rheumatoid Arthritis, WB Saunders Co., Philadelphia, 2005) at the Pediatric Rheumatology and Immunology Clinic of Advanced Pediatrics Centre, Post Graduate Institute of Medical Education and Research, Chandigarh. A total of 203 observations made on 70 boys with JRA, between 9 and 17 years of age, comprised the sample for this prospective mixed-longitudinal growth study. Each subject was measured for body weight and standing height using standardized anthropometric techniques (Eveleth and Tanner in Worldwide variation in human growth, Cambridge University Press, New York, 1990) at half yearly age intervals. All anthropometric measurements were carried out in the Growth Laboratory of Advanced Pediatrics Centre. Boys with polyarticular and systemic onset types of JRA in general measured lighter than their pauciarticular counterparts throughout the period of study. Height attainments in boys with polyarticular and systemic onset JRA measured shorter than their pauciarticular counterparts till 15 years and 12 years, respectively, where-after they became comparable to boys with pauciarticular JRA. As compared to normal Indian (Bhalla and Kumar in Int J Anthropol 18:113-125, 2003; Aggarwal et al. in Indian Pediatr 29:1203-1282, 1992) and American (Ogden et al. in Pediatrics 109:45-60, 2002) counterparts boys representing all categories of JRA remained lighter and shorter. Onset of Peak Height Velocity (PHV) in boys with polyarticular JRA (i.e. 12.5 years) was delayed by 1 year as compared to boys with pauciarticular JRA (i.e. 11.5 years). Attainment of Peak Weight Velocity (PWV) in boys with polyarticular JRA (i.e. 13.5 years) was also delayed by 1 year when compared to those with pauciarticular type (i.e. 12.5 years). In conclusion, weight and height growth attainments in Indian adolescent boys afflicted with different categories of JRA in general remained impaired as compared to their normal counterparts. However, the magnitude of growth deficit experienced by them appears to be a disease severity related phenomenon. This is the first study of its kind from a developing country.

Analysis of juvenile idiopathic arthritis associated uveitis in India over the last 16 years

Juvenile idiopathic arthritis (JIA) associated uveitis is one of the most common causes of visual morbidity in children. We report the systemic, clinical and investigational features of a cohort of all cases of JIA associated uveitis seen at our referral uveitis clinic between 1988 and 2004. Retrospective case series All patients of JIA seen at the uveitis clinic of tertiary eye care hospital, between 1988 and 2004 with minimum follow up of 3 months were included. Complete history and ophthalmic evaluation and findings on each visit were noted. Ocular complications were identified and recorded. Results of laboratory investigations and diagnostic as well as therapeutic procedures were analyzed. A rheumatologist managed systemic status. There were 40 patients (64 eyes) with JIA. Thirty four patients (85%) had pauciarticular type and 6 patients (15%) had polyarticular type of JIA. Complicated cataract and band shaped keratopathy were seen in 38 eyes (63%) and 37 eyes (62%) respectively. Twenty-two patients (17 bilateral and 5 unilateral) were treated with immunosuppressives and in 19 of these patients, the disease went into remission. Twenty-three eyes (38%) had improvement in visual acuity while in 27 eyes (45%), the vision remained stable and in 10 eyes (17%), vision deteriorated despite therapy. In India, JIA associated uveitis commonly presented in pauciarticular type with preponderance in males. Rheumatoid arthritis factor and anti nuclear antibodies were not as common as compared to the western population. Among long-term treatment options, immunosuppressives are a better choice. Ocular surgery was performed when mandatory for visual rehabilitation.

Clinical observations of juvenile rheumatoid arthritis

Purpose:Juvenile rheumatoid arthritis(JRA) is one of the most common rheumatic diseases of childhood and is an important cause of short- and long-term disability. The purpose of this study was to determine the disease course and outcome in childhood patients with JRA. Methods:Fifty nine patients with JRA who were diagnosed and treated in the Department of Pediatrics, Asan Medical Center from August 1990 to November 2004 were enrolled in this study. Sex, age, type, affected joints, extra-articular manifestations, laboratory and radiologic findings, treatments, and outcomes of JRA patients were reviewed retrospectively. Results:Among JRA patients, 32.2 percent had pauciarticular type, 30.5 percent had polyarticular type and 37.3 percent had systemic type. The ratio of boys to girls was 1.7:1 and the mean age at onset was 9.3±3.7(1.3-15.9) years. The most commonly affected joints were knee, ankle and wrist. The extra-articular manifestations observed were fever, rash, myalgia and lymph node enlargement, etc. The main laboratory findings observed were leukocytosis, anemia, thrombocytosis, elevated ESR, and elevated CRP. Rheumatoid factor and antinuclear antibody(ANA) were positive in 5.3 percent and 18.0 percent. Nonsteroid anti-inflammatory drugs(NSAID) were used most frequently and methotrexate with or without steroids was added in 27.1 percent of patients unresponsive to NSAID. 88.1 percent of patients were cured without functional disability and only one patient was in functional status IV. One patient, who had pulmonary involvement, died. Conclusion:Our results showed an even distribution in type of onset, male predominance, older age of onset, low incidence of iridocyclitis, and low positivity of ANA in JRA patients; this differs from occidental data. This study may suggest regional differences and variability in disease groups of JRA among different racies, but further multi-center trials and large scale epidemiological studies are needed to confirm our conclusion.

Analysis of childhood reactive arthritis and comparison with juvenile idiopathic arthritis

There is currently no agreement on how to classify and diagnose reactive arthritis (ReA) and what kind of clinical and laboratory findings are specific for the diagnosis. This study retrospectively analyzed the initial clinical manifestations and laboratory findings in children diagnosed with ReA and juvenile idiopathic arthritis (JIA). A comparison was also made between these two groups to see if there were differences. A retrospective chart review was performed and 44 patients diagnosed with ReA and 80 patients with JIA were enrolled in this study. Their initial clinical manifestations and laboratory findings were also analyzed and compared. The initial clinical manifestations in ReA were analyzed including the demographic data, the preceding infection history, the duration of the infectious episode to the onset of arthritis, the duration of arthritic symptoms, and the involved joint pattern. Comparison of the initial laboratory findings between patients with ReA and JIA showed significant differences between erythrocyte sedimentation rates (ESR) in the first hour, platelet counts (p < 0.05), and ESR in the second hour (p = 0.052). Further, comparing ReA with the subtypes of JIA, significant differences were noted between ReA and the systemic type in terms of hemoglobin level, platelet counts, C-reactive protein, and first and second hour ESR (p < 0.05). However, if compared with the polyarticular or pauciarticular type, only the platelet counts showed any significant statistical difference (p < 0.05). This study summarizes clinical experiences in ReA. The differences in laboratory findings of ReA and JIA may provide a clue in making a differential diagnosis.

Clinical analysis of 570 cases with juvenile rheumatoid arthritis: results of a nationwide retrospective survey in Japan.

The purpose of the present study was to investigate the incidence of juvenile rheumatoid arthritis (JRA) among Japanese children and to evaluate the clinical features of this disease. A questionnaire was sent to the department of pediatrics of 1290 hospitals in Japan, in 1994, asking for the number of rheumatic patients during the past 10 years. Subsequently, a second questionnaire was sent asking for the type of onset, clinical features, treatment, and other details. The results of 570 cases were obtained. Of these, 310 cases (54%) were the systemic onset type, 140 cases were the polyarticular onset type (25%), and 120 cases (21%) were the pauciarticular onset type. Hence, in the present series of children, the proportion of the pauciarticular type was less than the other two types of JRA. In the laboratory findings of the systemic onset type, hyperferritinemia and thrombocytosis were noted, in addition to leukocytosis, positive C- reactive protein (CRP) and accentuated erythrocyte sedimentation rate (ESR). The rheumatoid factor was positive in 50% of patients with the polyarticular onset type. Chronic uveitis was recognized in 13 cases (10.8%) of the pauciarticular onset type. In four girls, uveitis started before the onset of arthritis. Non-steroidal anti-inflammatory drugs were used in almost one-third of cases, and methotrexate (MTX) was used in 12.8% of cases. The quality of life of children with JRA was disturbed in almost 20% of cases. Therefore, for the early and definitive diagnosis of the systemic type of JRA, diagnostic procedures including thrombocyte counts and serum ferritin level, should be performed. In order to obtain good results and to avoid side effects, a protocol for the use of disease modifying anti-rheumatic drugs and immunosuppressants, especially for the use of MTX, must be established.

Changes of mineral metabolism in juvenile chronic arthritis.

Thirty five children with ambulant JCA were studied to assess the biochemical parameters of bone metabolism. The mean age of the study group was 8.8 +/- 4.1 years and the mean duration of active disease 3.8 +/- 1.3 years. According to the onset of the disease the children belonged to the systemic (7), polyarticular (12) and pauciarticular type (16). All the patients were treated with NSAIDs. In addition the polyarticular group received either gold injections or D-penicillamine and the systemic group, steroids for at least 3 months. Two groups of controls were studied. The first one included fifteen children without chronic arthritis or bone disease and the second, four children who were treated with corticosteroids for a variety of reasons. In the group with systemic JCA Se Pi (1.28 +/- 0.29 mmol/l) and renal phosphate reabsorption (TmP/GFR = 1.07 +/- 0.18) were significantly lower than in the control groups (1.50 +/- 0.19; 1.54 +/- 0.25 mmol/l, p < 0.01 and 1.35 +/- 0.18; 1.29 +/- 0.23 mmol/l GF, p < 0.05). Also lower were serum alkaline phosphatase (58 +/- 16.4 versus 83 /- 24.2 and 80 +/- 15.6 IU/l, p < 0.05), osteocalcin (5.5 +/- 4.7 versus 11.0 +/- 4.5 and 10.0 +/- 5.7 ng/ml, p < 0.05), 25OHD (15.6 +/- 4.9 versus 27.3 +/- 6.2 and 20.6 +/- 9.8 ng/ml, p < 0.001) and 1,25(OH)2D (12.1 +/- 6.0 versus 20.9 +/- 11.0 and 27.6 +/- 3.2 pg/ml, p < 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

A study of prognosis in 52 cases with juvenile rheumatoid arthritis

The prognosis in 52 patients with juvenile rheumatoid arthritis (JRA) was studied. There were 35 cases of systemic onset, 12 of polyarticular onset and 5 of pauciarticular onset. Thirteen systemic cases developed a polycyclic course with chronic polyarthritis. Many monocyclic JRA in systemic cases subsided within 1 year. There were no instances of polyarticular cases or pauciarticular cases that shifted to other type. However, there were many cases with a long active polyarticular JRA and with remission at an early stage in the pauciarticular type. The stage and class were I or II in 90% of cases with a good prognosis for the joints, but there were some serious cases. Transient carditis or iritis which developed at an early stage subsided later. The intractable systemic cases had drug-induced complications. The cases with steroid-induced complications tended to be chronic. One death in a systemic case was caused by hepatic failure.

Aspirin plasma monitoring in juvenile chronic arthritis

AbstractThirty‐two patients from the Pediatric Rheumatology Clinic of the All India Institute of Medical Sciences, New Delhi, suffering from juvenile chronic arthritis (JCA) in the age group of 5–15 years were investigated for salicylate monitoring. Of these, 15 (46.9%) had polyarthritis and 11 (34.4%) suffered from systemic onset type of JCA while only 6 (18.7%) had the pauciarticular type of disease. Plasma salicylate and albumin levels were estimated on days 1, 7, 14, and 21, after initiation of therapy with aspirin. Serum SGOT and SGPT were also estimated, as well as clinical evidence of hepatotoxicity. The therapeutic plasma levels (15–25 mg/dl) of salicylates were achieved by a mean dose of aspirin of 81.8 mg/kg/day administered in three divided doses. On the surface area basis the mean dose of aspirin was 2.1 g/m2/day. Steady‐state level of aspirin in plasma was achieved by the seventh day, and the values were 2.8 times more than on the first day. In malnourished patients with low albumin levels, there was a proportional decrease in salicylate binding. Although increase in transaminase levels of 1 1/2 to 2 times the normal was observed in the patients on aspirin therapy, none of the children developed clinical evidence of hepatotoxicity during this short‐term study. The studies indicate that dosage of salicylates can be given either on a body weight or surface area basis. A malnourished child with lower levels of serum albumin may be more predisposed to salicylate toxicity, due to higher levels of free salicylates. There was no evidence of hepatotoxicity in the dosage range of 70–110 mg/kg/day or 1.9 to 2.8 g/m2/day.

Juvenile rheumatoid arthritis of the foot.

Rheumatoid arthritis occurring in children under 16 years of age is defined as juvenile rheumatoid arthritis. It is more common in females and the peak incidence is between 1 and 3 years of age. It can present in different forms. Mono- and pauciarticular type is complicated by iridocyclitis in 20%. Growth disturbances are common. Any conceivable combination of foot deformities can occur. Some of the secondary deformities can be prevented with conservative care. Principals of soft tissue and bony surgery have been outlined.