Systemic disease of unknown aetiology, which is symmetrical, peripheral, polyarthritic, most commonly involving the small joints of hands, wrists, metatarsophalangeal joints, ankles, knees and cervical spine.
Clinical Features
Symmetrical peripheral polyarthritis mostly of small joints (warm, painful, stiff, swollen). Stiffness worse in the morning. Muscle wasting. Deformity, ulnar deviation, boutonniere deformity. Extra-Articular: fever, weight loss, lassitude, anaemia, subcutaneous nodules, splenomegaly, lyinphadenopathy, keratoconjuctivitis, pericarditis, pleuritis.
Investigations
• Haemogram -moderate hypochromic, microcytic anaemia; or leucopaenia in Felty's syndrome
• ESR - elevated
• X-ray, especially hands and/or any other involved joint
• Rheumatoid factor
• Antinuclear antibodies.
Management
Outpatient:
• Physiotherapy
• Acetylsalicylic acid 600-900 mg 8 hourly (children 75-100 mg/kg QDS), 6 or 4 hourly preferably after food OR with antacid OR indomethacin 25-50 mg TDS (not recommended in children).
Refer If
• Deformities are present (seek surgical opinion)
• Disease not responding to non-steroidal anti-inflammatory (NSAIDs)
• Systemic organ involvement.
Admit For
• Acute exacerbation
• Bed rest (may need to splint the affected joint)
• Intensive physiotherapy
• Systemic complications
Complications
All the systems are involved in this disease; this would need specialists attention as would the use of steroids or chloroquine. Refer patients.
JUVENILE RHEUMATOID ARTHRITIS (JRA)
Arthritis beginning at or before the age of 16 years. Similar to adult rheumatoid arthritis (RhA). Tends to affect large and small joints and may interfere with growth and development.
• Classification: Three types. Systemic (Still's disease), Pauciarticular types I&II and Polyarticular.
(Presentation is shown in the table below)
Type |
Systemic disease |
Pauciarticular (JRA) |
Polyarticular (JRA) |
Percentage |
20% |
40% |
40% |
RhF |
-ve |
-ve |
+/-+ve/-ve |
ANF |
-ve |
75% |
|
HLA B27 |
|
+/-+ve/-ve |
-ve |
Presentation |
High fever, rash, splenomegaly, generalized |
Type I: mainly male |
As for adult rheumatoid arthritis. |
| |
lymphadenopathy, serositis. striking leucocytosis and thrombocytosis |
Type II: mainly female |
|
Management
Supportive treatment is as for adults.
Drug treatment is similar to that in adult type except that aspirin is used with caution because of concerns of Reyes syndrome. For dosage see under adult treatment or paediatric schedule (annex B).
Prognosis
Overall prognosis is better than adult rheumatoid arthritis.
Complete remission occurs in 50-75% of patients.
Those with polyarticular and RhF positive have a less favourable prognosis.
NB: For osteomyelitis and septic arthritis see chapter 20 (orthopaedics).
