Juvenile idiopathic arthritis in children: treatment and prevention. Decoctions of lingonberries and cranberries. How is the diagnosis made?

Juvenile polyarthritis is a very rare disease (the frequency of reported cases is 0.05 - 0.6% of the world's population), affecting mainly the human ligamentous apparatus. It occurs in children under 16 years of age. It is characterized by autoimmune disorders and self-destruction of its own cells. The main clinical syndrome of the disease is synovitis - inflammation of the synovial fluid.

long term arthritis

Where does rheumatoid arthritis come from in teenagers?

Almost all groups of lymph nodes are enlarged. They become large, well palpable, not soldered to the skin and to each other, painless, sometimes protrude above the surface of the skin.

The type of lesion is systemic arthritis; oligoarthritis (persistent and widespread); polyarthritis

In the event that the child nevertheless acquired juvenile arthritis, it is strictly forbidden to give him any vaccinations. All actions of such a plan must be agreed with the attending physician, since any even very necessary vaccination can cause extensive exacerbations of arthritis.

Symptoms and dangers of the disease

Reasons for development

The main mechanism that "triggers" the development of the inflammatory process in the joints is the failure of the immune system. Together with the following factors, the disease begins to develop at an accelerated pace:

• contact of a child with a carrier of a bacterial or viral infection;
• untreated joint injury;
• hypothermia of the body;
• prolonged exposure to direct sunlight;
• ignoring preventive measures;
• heredity.

The basis of any type of arthritis is an autoimmune reaction, characterized by the fact that the body begins to perceive its own cells as foreign. For diagnosis, in addition to the main diagnostic criteria, the results of radiological and laboratory research.

On an x-ray, juvenile arthritis manifests itself in violation of the integrity of the bone structure in the area of ​​​​the joints, damage to the structure of the vertebrae of the cervical region, and narrowing of the joint spaces. In laboratory studies, the so-called.

n. rheumatoid factor, and synovial biopsy data are also being studied.

The primary agent of the disease remains unknown to this day. For these reasons, juvenile arthritis is currently a disease of unknown etiology.

Presumably, the causative agent in some cases may be a foreign antigen of an infectious nature (vaccination) or its own protein. By activating the cellular link of immunity, the pathogen causes the release of a large amount of pro-inflammatory cytokines, which, in turn, secrete lymphocytes.

At the same time, the humoral link of immunity is activated with the production of a large number of antibodies and autoantibodies. All together leads to the development of inflammation and destruction. ligamentous apparatus.

Diseases of this nature can lead to the development of a serious pathological process, but before treating arthritis, it is necessary to find out the factors contributing to its development.

The most common reasons are:

• infectious processes in the body;
• weakening of the immune system, especially after SARS;
• injuries, bruises and damage to the joints;
• hereditary predisposition;
• general hypothermia of the body;
• Arthritis in children can be caused by improper metabolism.

This is just a small list of provoking factors of the disease, however, it is important to consider that in each case an individual treatment regimen is selected.

Why the disease develops in children is not fully defined. At the heart of development is the defectiveness of the immune system.

Because of it, the cells of the joints are accepted as non-native. Pathology originates in the synovial membrane.

It is located inside the joint. Initially, inflammation is observed, circulation is confused.

The body responds to the reaction by producing autoantibodies that intensely affect the tissue of the joint. The focus becomes inflamed, rheumatoid arthritis develops.

Elements that destroy their cells are called rheumatoid factor.

The immune system is the protector of the child's body, sometimes it deals crushing blows to it. The disease is felt by boys twice as rarely as girls.

Lead to the onset of the disease:

• Viral diseases.
• Intestinal infections, bacterial.
• Joint injury.
• Hypothermia.
• Long exposure to the sun.
• Change of climatic conditions.
• Vaccination.
• Hormonal surge during puberty.

At the same time, the humoral link of immunity is activated with the production of a large number of antibodies and autoantibodies. All together leads to the development of inflammation and destruction of the ligamentous apparatus.

A malfunction of the immune system is the true cause of JOHA. However, the direct provoking factor of this condition in children can be:

1. mechanical damage to the joint;
2. the presence of a bacterial or viral infection;
3. hereditary predisposition to rheumatoid arthritis;
4. overheating or vice versa, severe hypothermia, for example, when swimming in a pond;
5. carrying out a routine vaccination in a child who is not completely healthy at that time.

Depending on the localization of the inflammatory process, four types of chronic arthritis in children are distinguished.

Pauciarticular. This type is characterized by damage to 1-4 articular joints. It most often develops in the knee joint. Pauciarticular arthritis can even affect the eyeballs. In girls, the disease is observed much more often than in boys.

Polyarticular. This form of arthritis in children is very dangerous, as multiple inflammations occur, in which more than four joints are affected at the same time. Treatment of polyarticular arthritis is a very long and complicated process. Usually during this period the child is in a hospital.

System. This type of juvenile arthritis is dangerous because early dates flows from total absence symptomatic manifestations. And if signs are present, they can be confused with symptoms of other diseases.

Most often, the disease is manifested by night attacks: rashes, fever, enlarged tonsils, itching. Systemic juvenile arthritis can be diagnosed by excluding other diseases from the list. Unfortunately, precious time is often lost and the pathology enters a chronic phase.

Spondyloarthritis. This CA in children affects large joints - ankle, knee, hip. But there are cases when inflammation is localized in the vertebral or sacral zone.

Spondylitis is diagnosed when a specific antigen, HLA B27, is found in the blood.

The trigger for the development of juvenile arthritis can be such factors:

1. Severe hypothermia.
2. hereditary predisposition.
3. Joint and ligament injuries.
4. Inappropriate drug therapy.
5. Viral or bacterial infection.

In some cases, excessive exposure to the sun becomes the cause of the disease.

The reasons for the development of such a disease in children have not been precisely established to date. The researchers were able to identify a link between the development of this pathological process and Coxsackie B viruses, herpes, influenza A and B, entero- and rotaviruses, and a number of bacterial infections.

These infectious agents trigger nonspecific inflammation in the joints, which subsequently becomes the basis for the rheumatological process in a child.

The latent course of viral and bacterial infections does not allow either parents or doctors to establish even the very fact of a child's infection. But over time, this can lead to damage to the joints. In some cases, it is assumed that the starting point for the development of juvenile rheumatoid arthritis is frequent injuries musculoskeletal system.

Presumably, the development of juvenile rheumatoid arthritis is caused by a combination of various exogenous and endogenous damaging factors and the body's hypersensitivity to their effects. The manifestation of juvenile rheumatoid arthritis can be facilitated by an acute infection (most often viral, caused by parvovirus B19, Epstein-Barr virus.

retroviruses), joint trauma, insolation or hypothermia, injections of protein preparations. Collagen proteins (types II, IX, X, XI, cartilage oligomeric matrix protein, proteoglycans) can act as potentially arthritogenic stimuli.

An important role is played by family genetic predisposition to the development of rheumatic pathology (carriage of certain subloci of HLA antigens).

Activation of the disease begins with the initiation of humoral immunity. In the synovial membrane of the affected joint, internal microcirculation is disturbed and cells are destroyed.

In response to this, altered immunoglobulins G, which are foreign to the body, begin to be produced. Accordingly, immunocompetent cells are produced in synovial cells, namely anti-immunoglobulins G, which provide local immunity.

They are also called rheumatoid factor. For the latter, the altered IgG is the antigen.

As a result, IgG and anti-IgG form an immune complex, which, circulating in the joint cavity, destroys the vessels and the synovial membrane of the cartilage. ​

Drugs that can improve microcirculation cost quite decent money. They are necessary, so you still have to spend money.

But there is also a great folk way that perfectly performs such tasks. We are talking about ice cubes, which must be carried out on the affected areas.

Cold perfectly improves the outflow of blood. And if the ice is not from plain water, but from a decoction of parsley, then a doubly positive result can be achieved.

Related article: Gouty arthritis.

information to read

As a result of many years of research, scientists have not been able to develop a single hypothesis explaining the etiology of the disease. Previously, juvenile arthritis in children was associated with exposure to Epstein-Barr viruses, streptococci, staphylococci, and other infectious agents. However, laboratory and clinical tests this relationship has not been confirmed.

It is believed that juvenile rheumatoid arthritis in children is a polyetiological disease. Do not rule out the presence genetic predisposition, features of the immune system, the impact of past viral infections.

Important! JA is one of the diseases that threaten the patient with disability. The consequence of the disease may be the development of more severe rheumatoid pathology, ankylosing spondylitis, immobilization of the child.

Juvenile chronic arthritis slows down the physical development of children: disrupts the growth of joints in the affected area, the lower jaw remains underdeveloped, fingers are too short or long.

JA in children in the later stages causes eye damage: uevitis, mild conjunctivitis, episcleritis, dry keratoconjunctivitis.

Note. Juvenile idiopathic arthritis leads to the development of blindness in 15% of children, to disability - in 1-3%, to acute urethritis - in 12-30% of children.

Juvenile rheumatoid arthritis is a complex systemic disease, characteristic feature which is inflammation of the joints. The whole severity of the pathology lies in the fact that the patient has a high chance of getting a lifelong disability. In adults, this pathology occurs in a different form.

What is a disease?

So, the disease develops in children under 16 years of age, which is why it has such a name. Among all diseases support system he occupies one of the first places. Although, in general, there are only 1% of children in the world with such skeletal damage. This pathology mainly provokes irreversible consequences not only in the joints, but also in the internal organs.

Diagnosis and difference from other diseases

Diagnosis of juvenile rheumatoid arthritis is based on laboratory tests, radiography of the joints and the definition of diagnostic criteria. The latter were reliably established by a group of scientists, which helps to exclude the doctor's subjectivity in relation to the detection of this pathology. To confirm the juvenile form of rheumatoid arthritis in children, the following examinations are performed:

1. Collecting anamnesis and determining the presence characteristic symptoms diseases. A number of them (the duration of the course, the number of affected joints, the development of muscular dystrophy, rash, etc.) directly correlate with the severity of the course of the disease.
2. Clinical blood test. Changes in it are usually non-specific, but high level ESR (40-50 mm / h), as well as leukocytosis without general signs of infection, are always suspicious for the doctor and give reason to prescribe additional research.
3. Laboratory determination of the level of immunoglobulins, circulating immune complexes (CIC), rheumatoid factors and proteins of the acute phase of inflammation. The combination of an increase in the level of all these factors not only indicates inflammation in the joints, but also makes it possible not to doubt the autoimmune nature of the disease.
4. X-ray of damaged joints. Such a study allows you to determine how much the articular surfaces change as a result of chronic rheumatoid inflammation. Special scales for assessing the severity of such changes help to assess how much the function of the joint has suffered. Degree of change bone tissue and joint also reflect the severity of juvenile rheumatoid arthritis.

Since rheumatoid arthritis in a child aged 2 years and older (up to 16 years) can proceed in completely different ways, doctors use the so-called diagnostic criteria juvenile form of the disease.

If, according to them, the child has only 3 positive answers to the questions submitted for resolution, the diagnosis is doubtful, 4 positive criteria based on the results of the examination, it is definitely juvenile rheumatoid arthritis, if there are 8 or more such criteria, the course of the disease is classic, and the diagnosis does not cause doubt.

Further, depending on the number of affected joints, involvement of internal organs in the pathological process, positive or negative rheumatoid factor in the blood, radiological stage, rate of progression of the pathology, etc. a definitive diagnosis is made.

Clinical picture

Classification

There is no single JRA classification. In rheumatological practice, several options for the division of pathology are used.

Systemic juvenile arthritis is an articular pathology with the obligatory presence of fever for at least 2 weeks. Accompanied by 4 signs:

• transient rash;
• serositis;
• an increase in lymph nodes;
• changes in the size of the liver or spleen.

The oligoarticular variant is characterized by:

• damage to up to 4 joints in six months;
• progressive course.

In polyarticular JRA with a negative rheumatoid factor, more than 5 joints are involved in the pathological process. Distinctive features:

1. Starts at 3 years old.
2. symmetrical changes.
3. Presence of eye damage (uveitis).

If the values ​​​​of the rheumatoid factor are found, then the polyarticular variant of arthritis is evidenced by:

• the average age for the debut is over 10 years old;
• involvement in the process of symmetrical joints;
• more often found in girls.

In addition to the type of arthritis, the diagnosis displays:

1. The course of the disease: rapidly progressive, slowly progressive.
2. The degree of activity of the process.
3. X-ray stage - I, II, III, IV - is set according to changes in the picture of the affected joints. The degree of change in different areas may vary.
4. The functional class (1,2,3,4) indicates the preserved articular function. The most unfavorable - 4, when the ability to self-service is lost.

Such a detailed formulation of the diagnosis is needed to assess the severity of arthritis, the effectiveness of treatment, and determine the prognosis.

About the causes of arthritis knee joint can be read here.

AT childhood The following forms of joint damage may pose a danger.

Rheumatic

Rheumatoid arthritis in childhood is activated against the background of fever, the most common patients are children aged 5-15 years. The main symptomatology is characterized by hyperthermia, tissue tumors, often an acute inflammatory process is symmetrical. There is severe pain and limited joint mobility.

The pathological process can last from 2-3 days to 1-2 weeks. After anti-inflammatory therapy for arthritis in a child, as a rule, the motor activity of the joint is restored. It is important to bear in mind that with rheumatoid arthritis in a child, it is important to accurately determine the cause of the pathology, since it may be associated with other serious diseases.

Therapeutic measures include bed rest and NSAIDs (Diclogen, Ortofen, Ibuprofen). In the absence of a positive result, arthritis in children can be treated with corticosteroid drugs (Prednisolone, Hydrocortisone). This should be done under the supervision of a doctor, since drugs in this group can cause a number of side effects.

Children's arthritis of rheumatoid nature is dangerous with the possibility of damage to the heart muscle.

Infectious-allergic

This form of the disease can develop as a result of improper functioning of the immune system, as well as exposure to bacteria, fungi or viruses. Infectious-allergic arthritis in children in its symptoms resembles the classic form with swelling of the joints, hyperthermia, pain.

Infectious arthritis is most common in children under 3 years of age. Sometimes there is an atypical development of symptoms with shortness of breath and tachycardia. The course of viral arthritis in children is accompanied by stiffness and stiffness of the joint.

From what infection caused the development pathological condition depends on further therapy. As a rule, antibiotics (Erythromycin, Penicillin, Oxacillin), antiviral and antimycotic drugs are required for 7 days.

With this form of the disease, an allergy is clearly expressed. The immune system reacts to the impact of external and internal factors with an increased release of histamine, so it is necessary to prescribe such drugs as Diazolin, Suprastin, Zirtek.

To prevent relapse after the treatment of arthritis in children, rehabilitation measures are recommended (salt baths, exercise therapy, hardening).

Juvenile idiopathic (JIA)

Juvenile idiopathic arthritis is extremely rare, but, as a rule, almost every such case leads to disability little patient. According to statistics, juvenile idiopathic arthritis occurs in 1 case out of 1000 sick children. In 95% of patients, the disease, according to clinical and immunological signs, is fundamentally different from other forms of joint damage.

In other words, juvenile idiopathic arthritis develops against the background of a long-term joint swelling, but in the absence of obvious infection or other causes. Currently, idiopathic arthritis in children has more than 7 varieties. Prevention of exacerbations of arthritis in children involves the regulation of physical activity, spa treatment, as well as an individual complex of exercise therapy.

Youthful

One form of the disease is pauciarticular juvenile arthritis. The pathological process is quite often accompanied by various kinds of complications, however, with competent and timely therapy, the prognosis for recovery is favorable.

The main symptoms of arthritis in children occur with the simultaneous involvement of 4 joints in the inflammatory process. The main symptom of pathology is acute pain in the affected area, swelling and redness.

General symptoms are expressed increased fatigue fatigue, loss of appetite and worsening general condition.

It is characteristic that with simultaneous damage to the joints of the wrist, ankle and knee, the disease progresses rather slowly. This makes diagnosis difficult.

In order to cure juvenile arthritis with a systemic onset, it is recommended to take antibiotics (depending on the pathogen), corticosteroid drugs (topically, orally, by injection), vitamin therapy (mainly group B) and immunomodulators (Arbidol, Immudon).

Juvenile chronic (JXA)

The most severe type of lesion in children is juvenile chronic arthritis, which requires long-term therapy and preventive measures in the remission period of the disease.

It is an autoimmune disease and is most common in children under 16 years of age. JXA is accompanied by a long process of inflammation (from 1.5 months or more), which affects the joints and makes them stiff. The development of deformative and erosive formations on the cartilaginous tissue is noted.

Juvenile chronic arthritis in almost 90% of cases leads to disability of the patient, which is associated with deforming changes in the joint. In addition, there is a high risk of vision loss.

With a particularly severe course of the disease, its complete loss is possible. With prolonged inflammation of the hip and knee joint, juvenile arthritis in children is accompanied by lameness.

Sometimes, in the absence of joint pain, there is a limitation of its mobility.

Juvenile chronic arthritis is often accompanied by hyperthermia (up to 40 degrees). In laboratory diagnostics, which is prescribed by the attending physician, there is an increase in ESR, leukocytosis, and sometimes a positive C-reactive protein.

• Systemic
• Polyarticular with rheumatoid factor positive or negative
• Oligoarticular
• spread
• persistent

Juvenile rheumatoid arthritis is a rare disease, and in order to diagnose it in children, young patients sometimes have to be observed for up to one and a half months. Statistics show that more often inflammatory processes in the joints are found in girls.

The cause of the development of childhood arthritis has not yet been established by science. It is assumed that a genetic predisposition is manifested here, on the one hand, and the autogenicity of the immune system, on the other.

Arthritis juvenile has several categories, according to which it is classified:

• based on the type of lesion, systemic arthritis, oligoarthritis and polyarthritis are distinguished;
• according to the nature of the course of the disease - acute and subacute;
• along the course of the disease itself, slowly, moderately and rapidly progressive forms are distinguished;
• according to the place of localization, they are divided into articular and articular-visceral (when internal organs are also affected) form.

The primary symptoms of juvenile arthritis are:

• swelling of the joints;
• increase in body temperature;
• enlarged lymph nodes;
• lameness not associated with blows or bruises;
• refusal of the child to eat;
• enlargement of the liver and spleen;
• stiffness in the morning, unwillingness to get out of bed;
• the appearance of rheumatoid nodules (dense subcutaneous formations in the joints).

Another frequently observed symptom of juvenile arthritis is the appearance of a flat, pale pink rash on the body, shoulders or thighs, which is cyclical. The rash disappears after a short time returns.

In the acute form of the course of juvenile arthritis, there is a strong swelling of the joints, which subsequently flows into deformity.

The nature of the damage to the joints juvenile arthritis could be as follows:

• monoarticular (monoarticular) - only one joint is affected;
• oligoarticular - from 1 to 4 joints;
• polyarticular - 4 or more;
• systemic.

The most complex form of juvenile arthritis is systemic, when the inflammatory process spreads to the entire body.

The main clinical symptom of juvenile arthritis is inflammatory changes in the joint, which occurs due to increased reproduction of the synovial fluid and its damaging activity.

Synovitis leads to the formation granulation growths in the area of ​​the affected joint. Gradually, the panus (alien synovial membrane) grows, replacing cartilage cells (juvenile ankylosing spondylitis), and later bones. Total destruction is coming.

The clinical picture of juvenile arthritis depends on the age characteristics of the child's body. In infants, it is difficult to diagnose the development of joint inflammation, since at this age children are unable to explain the presence of pain, and external manifestations like gait, it is difficult for parents to understand anything, because in infancy the kids aren't walking yet.

Therefore, the main manifestations of juvenile arthritis in infants are:

• Restlessness, the child often cries when moving, especially when he is massaged or transferred to another place;
• In the place of articular inflammation, the tissues swell and acquire a red tint;
• There is general and local hyperthermia;
• Often the baby tries not to move the limb, the joints of which are affected by arthritis;
• The baby begins to lose weight, his appetite deteriorates, there is a lag in development and a lack of body weight to normal.

READ ALSO: Etiology and immunopathogenesis of rheumatoid arthritis

In older children (at preschool age), juvenile arthritis is characterized by:

• Limited mobility of the joint and pronounced pain at the site of inflammation;
• Puffiness, hyperemia and hyperthermia over the affected articular tissues;
• Increase in general temperature;
• Increased fatigue, frequent whims, unwillingness to eat, weakness;
• Refusal of active and outdoor games.

In school-age children and adolescents, the symptoms of juvenile arthritis are identical to those of adult patients.

In most cases, juvenile rheumatoid arthritis begins acutely or subacutely. Acute onset is more typical for generalized articular and systemic forms of the disease with a relapsing course.

With a more common articular form, mono-, oligo- or polyarthritis develops, often symmetrical in nature, with the predominant involvement of large joints of the extremities (knee, wrist, elbow, ankle, hip), sometimes small joints (2nd, 3rd metacarpal phalangeal, proximal interphalangeal).

Depending on the type of pathology, there are various groups symptoms. So the articular type of JRA will differ in symptoms from the systemic one.

The manifestations of articular juvenile arthritis include:

• damage to all groups of joints - there is swelling and swelling;
• "warmth" of the joint - increased temperature of the affected area;
• pain on movement and at rest;
• morning stiffness - should last at least half an hour, otherwise the symptom is not included in the clinical picture;
• the limbs do not bend, subluxations are observed;
• loss of joint function in the later stages of the disease.

Along with the general symptoms of systemic JRA, two syndromes are distinguished - Still and Wiesler-Fanconi. The first is characterized by the appearance of an allergic rash, inflammation serous membranes. The second has signs such as spots on the skin, inflammation of the tissues in the heart and fibrosis of the lungs. Both syndromes are accompanied by symptoms characteristic of the systemic type of the disease.

common feature for concern is the swelling of the joints, their swelling. That is, juvenile chronic arthritis initially appears, later rheumatoid arthritis is already diagnosed.

General inspection:

Diagnostics

laboratory research methods:

• general blood analysis,
• blood chemistry;

instrumental diagnostics:

• Ultrasound, X-ray, CT, MRI of the affected joint (and/or),
• CT scan of internal organs,
• puncture of synovial fluid.

To confirm the presence of JRA in a child, you must:

1. Thorough examination of all complaints.
2. Detailed collection of anamnesis of the development of the disease and life.
3. Physical examination.
4. Conducting laboratory tests:

• clinical and biochemical blood tests (it is worth considering if earlier a child had increase in monocytes);
• immunograms (rheumatoid factor, antinuclear antibodies, ACCP, CRP);
• virological tests.

1. Perform radiographs of the affected joints.
2. Appointment of instrumental methods - ECG, ultrasound of the heart and abdomen, examination of the lungs.
3. Conducting consultations with an ophthalmologist and other specialists.

Diagnosis of juvenile rheumatoid arthritis takes about 2 weeks. After evaluating the results of the data obtained, therapy is prescribed.

A study aimed at detecting juvenile idiopathic arthritis implies a standard diagnosis that an adult undergoes. The complex of techniques includes the collection of anamnesis, examination of the patient, laboratory tests, instrumental.

To identify the inflammatory process allows a blood test. This is evidenced by an increased level of leukocytes, ESR. Doctors pay special attention to anemia, its presence confirms the diagnosis, the symptom is one of the leading in JIA.

Children are sent for instrumental studies, which include:

• radiography;

Please note! Diagnosing idiopathic juvenile arthritis is impossible without a laboratory blood test and x-ray. Methods allow to determine the type of pathology, to identify osteoporosis, erosion, ankylosis, narrowing of the gaps between the joints, deformation.

The diagnosis is made after a thorough examination, exclusion of other pathologies that could cause similar symptoms, as in childhood idiopathic arthritis.

Since arthritis in children occurs with various symptoms, doctors of various specializations usually participate in the diagnosis process - pediatricians, rheumatologists, infectious disease specialists, etc. The child is examined, examined, parents are interviewed, and a complete anamnesis is collected.

Important! To diagnose arthritis, doctors must take into account the relationship between the patient's condition and past infectious diseases, rheumatism, hereditary predisposition, etc.

It is difficult to detect a disease at an early stage of development, it is difficult to make a prognosis. Symptoms are non-specific. Joint disease is similar to rheumatoid arthritis. A significant difference lies in the inadequate response of the body, causing rheumatoid inflammation. To facilitate the diagnosis, there are diagnostic criteria:

• small joints are affected symmetrically;
• muscles atrophy;
• the apparatus of the ligaments becomes inflamed;
• joints are limited in movement, the forecast is a complete loss of motor activity;
• in morning time slowness of movements is observed;
• fluid collects in the joints;
• rheumatoid inflammation of the eyes;
• bone growth is impaired;
• rheumatoid factor in the blood.

The probability of the presence of the disease is high when the doctor detects at least three of the signs listed in the child.

Rheumatoid arthritis in children is treated for a long time. If the course of treatment is started in a timely manner, it is possible to stop the development of the disease. The chance of complications is reduced to zero. Improves the prognosis of the disease.

The treatment of juvenile rheumatoid arthritis includes the use of the following groups of drugs:

• glucocorticosteroids - to suppress the inflammatory process;
• non-steroidal anti-inflammatory drugs - to relieve pain, relieve swelling and eliminate the inflammatory process;
• immunosuppressors - to suppress the response self-liquidating function of the body;
• cytostatics;
• biological agents.

With progressive deformity and possible disability of the patient, surgery with a complete replacement of the articular apparatus (endoprosthetics).

To diagnose the disease, the doctor will prescribe a group of tests.

1. General blood analysis. Anemia (decrease in the amount of hemoglobin and red blood cells), leukocytosis (increase in the number of white blood cells), increased erythrocyte sedimentation rate.
2. Urinalysis - no changes.
3. Blood chemistry.
4. Electrocardiogram.
5. Sometimes rheumatoid factor can be detected, which indicates a poor prognosis.
6. X-ray - narrowing of the joint space, erosion, expansion of the boundaries of the heart.

• suppression of inflammation;
• increase in the quality of life;
• slowing down the destruction of the joints;
• preservation of mobility and ability to work;
• achieving remission;
• decline side effects drug therapy.

Treatment of rheumatoid arthritis should have an integrated approach: diet, drug therapy, exercise therapy, orthopedic correction.

Drug therapy is divided into symptomatic and pathogenetic.

Symptomatic agents include non-steroidal anti-inflammatory drugs and glucocorticoids.

NSAIDs (Diclofenac, Nimesulide, Meloxicam) stop the symptoms of the disease well, but have a number of side effects. Therefore, no more than 6 to 12 weeks should be prescribed before the diagnosis is made. After the established diagnosis, a combination with immunosuppressive drugs is necessary.

Glucocorticoids (Prednisolone). Powerful hormones. They have a pronounced anti-inflammatory effect, can be used orally, intravenously, intraarticularly. But the range of their side effects is huge, and therefore the use in children is difficult.

To pathogenetic therapy includes immunosuppressive (Methotrexate, Cyclosporine A). This therapy is aimed at slowing down the course of the disease and takes leading place in the treatment of juvenile arthritis.

Surgery

With the development of ankylosis - joint prosthetics.

Children's rheumatoid arthritis must be diagnosed as early as possible in order to be on time, to make adjustments to the development of the child. Therefore, a trip to the doctor is mandatory even with mild symptoms.

It is the specialist who will say with accuracy whether the child has arthritis or not. And for this you need to pass the diagnosis:

• At least one suspicious clinical manifestation is already a reason to pay attention to family ties in order to identify the presence of a genetic predisposition to rheumatoid arthritis.
• The child is assigned an x-ray of diseased joints to determine the nature and stage of the lesion. The picture will show how the articular cartilages are changed, whether there is an fusion of the synovial membranes, a narrowing of the cavity, etc.
• The presence of antibodies and rheumatoid factor will show a blood test of a small patient. The presence of anemia and neutrophilic leukocytosis are already signs of arthritis. The ESR level will indicate how active the disease is. But sometimes blood counts can be within the normal range.
• During the examination, the child will be sent for an ultrasound of the heart and an electrocardiogram to detect changes in the myocardium.
• Obligatory observation by an ophthalmologist in order to notice changes in the fundus in time.

If the doctor diagnoses the presence of the disease, serious treatment should immediately begin.

In the group of rheumatic diseases in children, juvenile arthritis occupies a leading position. The diagnosis is based on complaints, a survey of parents, clinical symptoms detected during a thorough examination and laboratory and instrumental methods.

General blood and urine tests are mandatory. They will help identify inflammatory changes(increased ESR, low hemoglobin, a decrease in the number of red blood cells, a shift in the formula to the left), as well as initial changes in the functioning of the kidneys.

Biochemistry will determine the presence or absence of rheumatoid factor, C-reactive protein, antistreptolysin and a number of other important indicators.

X-ray studies and magnetic resonance imaging will confirm not only the diagnosis, but also the stage of JRA:

• osteoporosis of the epiphyses of bones;
• narrowing of the joint space and the appearance of marginal usury;
• multiple usura, destruction of not only cartilage, but also bone, subluxations are possible;
• deformation with proliferation of bone or connective tissue.

Diagnosis and treatment of rheumatoid arthritis depends on a number of criteria: onset in children under adolescence, duration of symptoms greater than six weeks, and number of reliable signs(3-4 - probable JRA, 5-6 - definite, 8 or more - reliable).

Diagnosis of juvenile rheumatoid arthritis is based on the history and examination of the child by a pediatric rheumatologist and pediatric ophthalmologist. laboratory tests (Hb, ESR, the presence of RF, antinuclear antibodies), radiography and MRI of the joints, joint puncture (arthrocentesis).

Criteria for juvenile rheumatoid arthritis are: onset before 16 years of age; disease duration over 6 weeks; the presence of at least 2-3 signs (symmetrical polyarthritis, deformities of the small joints of the hands, destruction of the joints, rheumatoid nodules, RF positivity, positive biopsy of the synovial membrane, uveitis).

X-ray stage of juvenile rheumatoid arthritis is determined by the following features: I - epiphyseal osteoporosis; II - epiphyseal osteoporosis with narrowing of the joint space, single marginal defects (usura); III - destruction of cartilage and bone, numerous uzura, subluxations of the joints; IV - destruction of cartilage and bone with fibrous or bone ankylosis.

Juvenile arthritis is diagnosed on the basis of instrumental and laboratory studies. Instrumental studies include:

• radiological;
• electrocardiography;
• CT scan;
• examination of internal organs.

Laboratory research methods include biochemical, immunological and general blood tests.

To make a diagnosis, a number of instrumental research- radiography, CT, MRI, arthroscopy. It is necessary to consult an immunologist, an allergist, an ophthalmologist.

As a result of laboratory tests, the values ​​​​of ESR (erythrocyte sedimentation rate), the presence of rheumatoid factors, antinuclear antibodies in the blood are established. / The doctor performs a puncture to examine the quality of the exudate and synovial fluid.

Primary Diagnosis"Juvenile idiopathic arthritis" is billed based on the following findings:

• the duration of the pathology is over 1.5 months;
• patient's age - up to 16 years;
• the presence of several characteristic symptoms of the disease.

As a rule, the diagnosis is confirmed after an X-ray examination. On the obtained images, narrowing of the joint space, rarefaction (decrease in density) of bone tissues, and destructive changes in cartilage are clearly visible.

Patients are also shown differential diagnosis to exclude ankylosing spondylitis, infectious arthritis, Crohn's disease (inflammatory intestinal pathology), malignant bone tumors.

Treatment

The most effective is the combination of different forms of treatment - drug and non-drug. Drug therapy includes symptomatic (the use of drugs aimed at neutralizing multiple symptoms of the disease) and pathogenic, aimed at "optimizing" the work of the immune system.

With symptomatic therapy, the so-called. NSAIDs (non-steroidal anti-inflammatory drugs) and GCs (glucocorticoids).

Non-drug therapy suggests the following measures:

1. Physiotherapy. With exercise therapy, exercises are practiced aimed at replenishing the volume muscle mass, elimination of flexion contractures, increased motor activity in the area of ​​diseased joints.
2. Restriction of motor mode during an exacerbation of the disease.
3. Orthopedic correction of joints using orthoconstructions: insoles, splints, splints, dynamic cuts, corsets.
4. Dieting. The nutrition of patients with juvenile arthritis provides for the restriction of fat- and carbohydrate-containing foods. The emphasis is on foods high in vitamin D and calcium.

Health program Juvenile arthritis in children

It is impossible to achieve a complete cure for juvenile arthritis, the diagnosis is the basis for disability. However, with an effective combination of different forms of treatment, it is possible to achieve a long-term remission, in which the patient's capabilities are limited to a minimum.

Therapeutic activities in juvenile arthritis necessarily suggest a complex effect. It is prescribed to take drugs of analgesic, anti-inflammatory and chondroprotective action.

Often treatment for childhood arthritis begins with minimum doses Methotrexate. Then the daily dosage is gradually increased until the child's body responds to therapy properly.

Such treatment reaches its maximum efficiency after six months of treatment, however, positive dynamics is found after a month of taking the drug.

Surgical intervention is indicated in the presence of severe deformity lesions that impede motor movements and reduce the quality of life.

Traditional treatment juvenile arthritis is based on:

1. At the reception of NSAIDs like Nimesulide, Diclofenac, etc .;
2. Glucocorticosteroid drugs - Betamethasone, Prednisolone, etc.

Exercise therapy classes, massage sessions, physiotherapy procedures, cryotherapy, etc. are also shown.

Given the serious development of symptoms, juvenile arthritis requires special integrated approach:

• taking non-steroidal anti-inflammatory drugs (Naproxen, Diclogen, Indomethacin);
• to suppress the activity of the inflammatory process and stop the destruction of the articular tissue, it is recommended to take cytostatics (Methotrexate, Sulfazalin);
• good healing effect noted after taking immunopreparations (Pentoglobin, Intraglobin);
• if therapy is ineffective, a short course of glucocorticosteroids (Prednisolone, Hydrocortisone) is recommended.

In addition, chronic arthritis in children requires a special diet with the inclusion of products with high content calcium (broccoli, spinach, cottage cheese, cheeses). With the timely implementation of all the necessary recommendations, it is possible to control chronic juvenile arthritis in order to avoid severe complications.

Treatment of arthritis in children begins with providing complete rest to the affected joint. Sick children are shown bed rest, immobilization of unhealthy joints with a bandage, plaster, splint or corset.

Prednisolone relieves inflammation, inhibits the destruction of bone tissue

JRA therapy is carried out in a complex way, while setting a certain regimen for the child, taking into account the form of the disease and the performance of the joints. The diet is issued with a small amount content fatty acids and a large number of polyunsaturated.

It is mostly low in calories and high in essential hypoallergenic vitamins. During the progression of JRA, inpatient therapy with the use of pathogenetic treatment is offered.

At the same time, in without fail the form and degree of rheumatoid arthritis are taken into account. When choosing the type of treatment, the pediatrician takes into account the following factors:

• how much the drugs will affect the activity of the process;
• type of immunopathology;
• the degree and dynamics of damage to bone and cartilage tissues;
• articular syndrome inflammatory nature at the local level.

Medical treatment is based on the use medications, glucocorticoids and non-steroidal anti-inflammatory drugs (NSAIDs). In general terms, the current therapy of juvenile rheumatoid arthritis does not give a complete recovery, but at the same time it helps to relieve pain, inflammation and does not allow the disease to progress and develop.

The child will be able to live fully with almost no difficulties.

JRA therapy includes:

1. Painkillers (diclofenac, aspirin, indomethacin), NSAIDs. They should be used with great caution, as they can cause certain complications. It is advisable to constantly monitor the attending pediatrician.
2. In the early stages of JRA, basic drugs such as methotrexate and sulfazine are prescribed.
3. Corticosteroids are used for short courses, otherwise they can interfere with the growth of the baby.
4. Selective inhibitors are used to relieve pain and inflammation.

If there is any infection, it is necessary to carry out therapy with antibacterial drugs. Plasmapheresis has good effect and is used in the case of the immunocomplex nature of the disease.

In especially complicated situations, it is necessary to administer intra-articular drugs that prevent the inflammatory process. If such treatment does not help, then arthroplasty is possible, which is carried out through surgical intervention.

Immunotherapy is carried out using intravenous administration immunoglobulin by drip. It is necessary to observe a certain mode when entering: approximately 10-20 drops per minute for a quarter of an hour.

After that, you need to increase the speed to 2 ml per minute. Infusion treatment can be repeated 1 time per month.

Therapy for rheumatoid uevitis is carried out by a specialist in rheumatology and an ophthalmologist. It is possible to use GCS in combination with mydriatics, as well as drugs that improve microcirculation.

If there is no result after two weeks of treatment and the disease still develops, then cytostatics are prescribed. They begin to be used when acute and seropositive forms of JRA are found in a child.

Juha is treated mainly with medicines, but proper nutrition, a special physical education complex and physiotherapy techniques play an important role in the fight against the disease.

To alleviate the condition of the child and stop the pain syndrome in juvenile arthritis in children, the following medications are prescribed:

• Non-steroidal anti-inflammatory drugs - NSAIDs.
• Glucocorticoids - GC.

They are prescribed only by a doctor who relies on the medical history, age and body weight of the child. For example, in younger children, GCs are not recommended for use due to their hormonal effects on the body, especially on the endocrine system.

Long-term use of NSAIDs can cause problems with the gastrointestinal tract.

Preparations from the group of biological agents are aimed at stopping the deformation articular cartilage. Immunosuppressants are recommended to be used in combination with other drugs.

The most commonly prescribed medications for juvenile arthritis are:

1. Leflunomide.
2. Sulfasalazine.
3. Methotrexate.

During the period of remission of the disease, in order to prevent exacerbation, maintenance doses of drugs are prescribed.

Complementary therapies

Daily exercise therapy helps to improve the activity of a small patient. However, adults should help the child with the exercises and monitor their correctness. It is very good if the child will go swimming and ride a bike.

An important role in the treatment of chronic childhood arthritis is played by physiotherapy procedures:

• infrared irradiation;
• magnetotherapy;
• applications with therapeutic mud or paraffin;
• electrophoresis (with Dimexide).

In the period of exacerbation, laser or cryotherapy is used. These methods have, albeit insignificant, anti-inflammatory effects. Massage treatments should be done carefully.

Treatment of juvenile rheumatoid arthritis in children is carried out taking into account the general condition of the joints and the whole body, the condition of the bone and cartilage tissue, and the nature of the immunological pathology.

The basic drugs of drug therapy are NSAIDs and glucocorticoids. Of the NSAIDs used: Naproxen, Ibuprofen, Indomethacin, Diclofenac, etc. They try not to use Aspirin, so as not to cause serious complications.

Corticosteroids are given in short courses, often administered intra-articularly, especially in severe inflammation of several joints with limited movement.

If iridocyclitis is present, corticosteroid eye drops are used. More severe cases require peribulbar or intraocular corticosteroid injections.

Immunotherapy is carried out by drip intravenous slow injection of Intraglobin, Pentaglobin, Sandoglobulin at a rate of 10-20 drops / min. Gradually increase the rate of administration to 2 ml / min. Repeat infusion therapy every month (if necessary).

Rheumatoid uevitis in acute and seropositive forms of JRA is treated by a rheumatologist and ophthalmologist with cytostatics (Cyclophosphan, etc.).

AT last years, as part of complex therapy, treatment with biological preparations was introduced:

• TNF blockers (Etanercept, Adalimumab, Infliximab) in combination with Methotrexate;
• CTL4Ig blocker (Abatacept);
• blockers of Interleukin 1 (Anakinar and Canakinumab) and Interleukin 6 (Tocilizumab).

Endoprosthetics

With a significant limitation of mobility in the joints, surgical treatment is carried out: endoprosthesis replacement of the knee or hip joint. Also practiced prompt removal muscle contractures.

Rehabilitation and prognosis

During rehabilitation, physiotherapy, exercise therapy, massage and non-traditional folk methods treatment. Much attention is paid to the nutrition of the child. When conducting complex therapy, the prognosis for juvenile arthritis in children is favorable, with long-term remission without relapse.

Important. Physical activity should be regulated, especially in pain syndromes.

Treatment of JRA should be started at the first symptoms in order not to lose joint mobility. Adequate treatment and diet will help to avoid deformation and destruction of the joints.

Given that the disease is chronic and progressive, the treatment of rheumatoid arthritis in children should be long-term. The complex includes drug therapy, physiotherapy, proper regimen and nutrition, physiotherapy exercises.

For a period of acute condition limit the load. The diet includes a large number of vegetables and fruits, dairy products. Animal proteins and fats are limited, salt and sugar intake is reduced. Additionally, vitamin complexes are prescribed.

In rheumatoid arthritis, several groups of drugs are used. First of all, these are non-specific anti-inflammatory drugs (nise, diclofenac, indomethacin, ibuprofen) and inhibitors of COX - a special enzyme (movalis, piraxicam).

They relieve pain and reduce inflammation. Cytostatics (methotrexate) are used as basic drugs - they suppress the autoimmune reaction.

As an addition, with insufficient effectiveness of immunosuppressants, glucocorticosteroids (prednisolone) are prescribed.

After removal acute manifestations Physiotherapy becomes an important link in treatment. Widely used phonophoresis with medicine, ultraviolet, ozocerite and paraffin applications, laser, mud therapy.

Surgery is indicated only in last resort when the joint is completely deformed and immobile.

Treatment of juvenile arthritis is based on the following principles:

1. Therapy of the disease should be complex:

• Conservative drug treatment;
• Physiotherapy;
• Treatment with traditional medicine;
• Detoxification therapy;
• Massage and exercise therapy;
• Spa treatment.

1. At acute arthritis the child is placed in a hospital;
2. The limb is completely immobilized with special splints or bandages;
3. If necessary, surgical treatment is used (if acute destructive changes in the structure of the joint develop).

The most common designation of an independent nosological form of chronic arthritis in children (those under 16 years of age). From rheumatoid arthritis in adults juvenile rheumatoid arthritis(JRA) differs both in articular and extra-articular manifestations.

The prevalence of the disease is 0.01-0.001%. Children of any age are ill, girls - 1.5-2 times more often than boys. In infancy, cases of the disease are rare, more common in children after 5 years.

Juvenile rheumatoid arthritis- a disease with a wide range of clinical manifestations. Rheumatoid factor-positive polyarthritis most closely resembles adult rheumatoid arthritis; polyarthritis without rheumatoid factor also occurs in adults. Type II oligoarthritis resembles the disorders grouped in adults as "spondyloarthropathies" (including ankylosing spondylitis, Reiter's syndrome, and arthritis associated with colitis). Arthritis with systemic onset is rare in adults. In addition, cases of oligoarthritis (type I) associated with chronic iridocyclitis have not been described in adults. Knowledge of these characteristics can be useful in making a diagnosis, monitoring the course of the disease, and for adequately treating children with chronic arthritis.

Etiology and pathogenesis

Not studied enough. Trigger factors can be intercurrent infections, especially viral ones, in genetically predisposed individuals. Studies of the histocompatibility system in children show that with an oligoarticular variant of the onset of the disease, the frequency of detection of HLA-A2, HLA-DR5, HLA-Dw6, HLA-Dw8 and HLA-Dw52, as well as HLA-DQwl and HLA-DRw2, 1 increases; and in seropositive polyarticular, as in adults, HLA-DR4, HLA-Dw4 and HLA-Dwl4. With a polyarticular seronegative variant of the onset of the disease, HLA-DRw8, HLA-DRwl, HLA-DQw4 and HLA-DR3 are detected. Attention is drawn to the susceptibility of this disease to children with deficiency of the C2 component of complement.

Among the mechanisms of development of JRA, violations of the humoral and cellular immunity - over-education autoantibodies to I and II types of collagen; antibodies that react with a subpopulation of CD4 T-lymphocytes. The mechanisms of development of synovitis of the membrane are similar to those observed in rheumatoid arthritis in adults.

Clinic

The polyarthritis form is typically characterized by lesions a large number joints, including small joints of the hands, in the absence of severe systemic manifestations. This form develops in 35-50% of all JRA patients. There are two subgroups of polyarthritis: polyarthritis with rheumatoid factor and polyarthritis without rheumatoid factor. In the first case, the disease occurs at an older age, arthritis is characterized by a severe course, rheumatoid nodules are often noted, sometimes rheumatoid vasculitis develops. In the second case, the disease can occur throughout childhood, as a rule, it proceeds relatively easily and is rarely accompanied by the formation of rheumatoid nodules. Both forms of juvenile rheumatoid arthritis are more common in girls. The multiple nature of joint damage and the belonging of a particular clinical case to a seropositive or seronegative group, as a rule, are established in the early stages of the disease.

Joint damage can develop gradually (gradually increasing stiffness of the joints, swelling and decreased mobility) or lightning fast with the sudden onset of symptoms of arthritis. The affected joints are enlarged due to swelling of the paraarticular tissues, effusion in the joint cavity and thickening of the synovial membrane, hot to the touch, but redness of the skin over the joint is rarely noted. In some cases, objective changes in the joints are preceded by their stiffness and discomfort. Palpation of the affected joints may be painful, pain may be noted during movement. However, severe pain syndrome is not typical for this disease, and many children do not complain of pain in inflamed joints.

morning stiffness joints is characteristic of rheumatoid arthritis in children and adults. In young children with multiple lesions of the joints, increased irritability is noted. They take a typical forced posture, protecting the joints from movement.

Arthritis often begins in large joints (knee, ankle, elbow, and wrist). Joint involvement is often symmetrical.

The defeat of the proximal interphalangeal joints leads to a fusiform or fusiform deformity of the fingers; often develops a lesion of the metacarpophalangeal joints; the distal interphalangeal joints may also be involved.

Approximately 50% of patients have arthritis of the cervical spine, characterized by stiffness and pain in the neck. The temporomandibular joint is often affected, leading to limited mobility. mandible and makes it difficult to open the mouth (the pain of this localization is often perceived as an earache).

The defeat of the hip joints usually occurs in the later stages of the disease. It is noted in half of children with polyarthritis and is one of the main causes of disability.

In some patients, radiographic changes in the ileosacral joints are determined, which are usually combined with damage to the hip joints. These changes are not accompanied by defeat lumbar spine.

AT rare cases arthritis of the cricoarytenoid joint leads to hoarseness and stridor. Damage to the sternoclavicular joints and costochondral joints can cause chest pain.

Growth failure in areas adjacent to inflamed joints can lead to excessive lengthening or shortening of the affected limb.

Extra-articular manifestations in the polyarthritis form are less pronounced than in systemic rheumatoid arthritis. However, most patients with active polyarthritis have malaise, anorexia, irritability, and mild anemia. In some cases, subfebrile temperature, slight hepatosplenomegaly and lymphadenopathy are observed.

Occasionally, the disease is accompanied by iridocyclitis and pericarditis. Rheumatoid nodules may appear in places of tissue compression, as a rule, in patients with rheumatoid factor. These same patients sometimes develop rheumatoid vasculitis and Sjögren's syndrome. During periods of exacerbation of the disease, the growth of the child may slow down, and during remissions, intensive growth often occurs.

Oligoarthritis. The process involves mainly large joints. Localization of arthritis is asymmetric. It is possible that only one joint is affected, then they talk about monoarthritis.

Oligoarthritis type I is observed in approximately 35-40% of patients with JRA. Mostly girls are ill, it usually debuts at the age of 4 years. Rheumatoid factor is usually absent; antinuclear antibodies are found in 90% of patients. The frequency of the HLA-B27 antigen is not increased. The knee, ankle and elbow joints are predominantly affected, in some cases there is an asymmetric lesion of other joints (temporomandibular, individual joints of the toes and hands, joints of the wrist or neck). The hip joints and pelvic girdle are usually not affected, and sacroiliitis is also not typical.

Clinical signs of joint damage and data histological examination synovial tissues are indistinguishable from those in the polyarthritis form of juvenile rheumatoid arthritis. Arthritis may be chronic or recurrent, but severe disability or joint destruction is not common.

Patients with type I oligoarthritis are at increased risk of developing chronic iridocyclitis (develops in 30%).

In some cases, iridocyclitis is the first manifestation of JRA, but more often it occurs 10 or more years after the onset of arthritis.

Other extra-articular manifestations of oligoarthritis are usually mild.

Oligoarthritis type II is observed in 10-15% of patients with JRA. Mostly boys are ill, the disease usually develops in children older than 8 years. A family history often includes oligoarthritis, ankylosing spondylitis, Reiter's disease, or acute iridocyclitis. Rheumatoid factor and antinuclear antibodies are absent. 75% of patients are carriers of the HLA-B27 antigen.

The large joints of the lower extremities are predominantly affected. Sometimes arthritis develops in the joints of the foot, temporomandibular joint, joints of the upper extremities. Often, the disease is accompanied by enthesopathy, and the inflammation affects the sites of attachment of the ligaments to the bones. Especially characteristic is tendinitis of the calcaneal tendon, accompanied by pain in the heel area.

Already in the early stages of the disease, the lesion often captures the pelvic girdle, and in many cases radiographic signs of sacroiliitis are determined.

Some patients experience changes typical of ankylosing spondylitis with lesions of the lumbar spine. Hematuria, urethritis, acute iridocyclitis, and lesions of the skin and mucous membranes (Reiter's syndrome) may occur. In 10-20% of patients, attacks of acute iridocyclitis occur, which is characterized by the severity early symptoms, but rarely leads to cicatricial changes.

The health status of children with type II oligoarthritis is ultimately determined by the development of any of the above types of chronic spondyloarthropathies.

The systemic form of JRA occurs in 20% of patients and is characterized by severe extra-articular manifestations, among which high fever and rheumatoid rash should be highlighted. Boys and girls get sick equally often.

The fever is intermittent. The rise in temperature usually occurs in the evening and is often accompanied by chills. During the rise in temperature, children look very sickly, and after its decrease, they are surprisingly cheerful.

The rheumatoid rash has a characteristic appearance and is fleeting and recurrent. The rash occurs mainly on the trunk and proximal extremities, but can appear on any part of the body, including the palmar and plantar surfaces. As a rule, the appearance of a rash coincides with an increase in body temperature, but its occurrence can be triggered by skin trauma, heat exposure, and even emotions.

Most patients with this form of JRA develop generalized lymphadenopathy (with a histological picture lymph nodes may resemble lymphoma) and often severe hepatosplenomegaly. Liver function may be slightly impaired.

In about 30% of patients, the disease is accompanied by pleurisy or pericarditis. At the same time, on chest radiographs, in some cases, a thickening of the pleura and a small effusion in the pleural cavity are determined. Pericardial effusion may be significant and accompanied by ECG changes, although pericarditis is usually benign. During periods of exacerbation, interstitial infiltrates may appear in the lungs, but chronic rheumatoid lung disease in children is very rare.

During periods of activation of the process, some children may experience bouts of abdominal pain.

On the part of the peripheral blood, leukocytosis (even leukemoid reactions) and anemia (sometimes severe) are often observed.

Signs of joint damage appear in most children with systemic JRA at the onset of the disease or after a few months, however, in the early stages, the symptoms of arthritis can be overlooked because they are masked by pronounced general symptoms. In a number of patients, only severe myalgia, arthralgia, or transient arthritis is initially noted. Sometimes arthritis develops only months or even years after the onset of the disease. As a result, joint damage takes the form of polyarthritis.

Systemic manifestations of juvenile rheumatoid arthritis usually disappear spontaneously within a few months, but in some cases they can recur. Ultimately, the health status of children with systemic JRA is determined by arthritis, which sometimes takes chronic course and persists after the disappearance of general symptoms. When patients reach adulthood, systemic manifestations rarely recur, even when signs of chronic arthritis persist.

Diagnostics

The diagnosis of JRA can be established only in the presence of persistent arthritis and the exclusion of other diseases with a similar symptom complex. Are used the following criteria diagnostics:

1. arthritis lasting 6 weeks or more (mandatory);
2. damage to 3 joints during the first 6 weeks of illness;
3. symmetrical damage to small joints;
4. damage to the cervical spine;
5. effusion in the joint cavity;
6. morning stiffness;
7. tenosynovitis or bursitis;
8. uveitis;
9. rheumatoid nodules;
10. epiphyseal osteoporosis;
11. narrowing of the joint space;
12. signs of height at the joint;
13. compaction of para-articular tissues (signs 10-13 - radiographic);
14. increase in ESR more than 35 mm/h;
15. detection of RF in blood serum;
16. characteristic biopsy data of the synovial membrane. In the presence of three criteria, the diagnosis is considered probable, four - certain, seven - classical (in all cases, the presence of the first criterion is a prerequisite).

• systemic variant of JRA with high fever, pericarditis in the absence of the effect of taking large doses acetylsalicylic acid (the initial dose of prednisolone is 0.5-1 mg / kg per day; when systemic manifestations subside, after 2-3 weeks, the dose is gradually reduced to a minimum and then completely canceled);
• the presence of uveitis, which is not stopped by the local use of glucocorticosteroids and anticholinergics;
• pronounced exacerbation of the articular syndrome in the polyarticular variant of JRA (the dose of prednisolone does not exceed 10-15 mg per day and is divided into several doses).

The problem of inflammatory diseases of the joints in children is one of the most discussed in pediatrics. It is juvenile chronic arthritis that often leads to disability in children. Over the past 10-15 years, some progress has been made in the treatment of this pathology. The number of children transferred to the adult network with a disability has been significantly reduced. However, not all problems have been solved. The statistics point to high percent children with a long-term progressive course of the disease, with functional insufficiency, with signs of a drug disease caused by antirheumatic drugs.

For a long time, a variety of terms have been used to refer to this pathology: Still's disease, juvenile arthritis, juvenile rheumatoid arthritis (JRA), infectious nonspecific arthritis, juvenile chronic arthritis (JCA), deforming arthritis.

In 1994, the WHO Standing Committee on Pediatric Rheumatology proposed to eliminate all previous terms and call all chronic inflammatory joint diseases in children juvenile idiopathic arthritis (JIA). In 1997, the pediatric subcommittee of ILAR (International League of Rheumatological Associations) in Durban (South Africa) modified the classification aspects, uniting under this name all arthritis of childhood with a chronic course.

Juvenile idiopathic arthritis is defined as arthritis of unknown cause, present for 6 weeks, onset before the age of 16 years, with other conditions excluded. In table. 1 presents three classifications of childhood chronic arthritis.

JIA is a collection of diseases that have a different onset, course and outcome, as well as a different etiology. According to the compilers, such a classification is necessary for the cooperation of scientific research and for better treatment JIA. The ILAR classification is not perfect and needs to be improved, as approximately 20% of children with arthritis either do not meet the criteria for any category or meet the criteria for several categories at once. This once again emphasizes the difficulty of diagnosing various forms of arthritis in children. Regardless of the classification used in each specific case, it must be remembered that juvenile rheumatoid (chronic, idiopathic) arthritis is a heterogeneous disease that needs early diagnosis and adequate therapy.

The experience of the specialized cardio-rheumatological department of the Children's City Hospital No. 2 of St. Petersburg, which for many years was led by Professor I. M. Vorontsov, Honored Scientist of the Russian Federation, made it possible to develop and confirm the main provisions regarding the nosology and therapy of juvenile arthritis. We traditionally use the name JRA and in the diagnosis we are guided by the JRA criteria developed by rheumatologists in Eastern Europe and Russia in the late 70s.

JRA diagnostic criteria:

Arthritis lasting 3 months or more;

Arthritis of the second joint, occurring after 3 months and later;

Symmetrical damage to small joints;

contractures;

tenosynovitis or bursitis;

Muscular atrophy;

morning stiffness;

Rheumatoid eye disease;

Rheumatoid nodules.

Radiological signs:

Osteoporosis, small cystic restructuring of the bone structure of the epiphysis;

Narrowing of the joint spaces, bone erosion, ankylosis of the joints;

Violation of bone growth;

Damage to the cervical spine.

Laboratory signs:

Positive rheumatoid factor;

Positive biopsy of the synovial membrane.

Total number of positive signs:

JRA probable — 3 signs;

JRA defined - 4 signs,

JRA classic - 8 signs.

Despite the imperfection of these criteria (as well as any criteria), they help with the greatest probability to make a diagnosis. JRA is a chronic inflammatory disease of the joints with an unclear etiology and a complex, predominantly autoimmune pathogenesis, leading to gradual destruction of the joints and, in a number of patients, combined with severe extra-articular manifestations. In cases of unclear and doubtful, the name JXA is applicable as a diagnosis of observation, trying to replace it with a clearer nosological form of arthritis in 3-6 months from the onset of the disease. The key to diagnosis is:

The desire for the maximum decoding of all forms of acute and recurrent arthritis to exclude their viral or bacterial nature;

Division of chronic arthritis into JRA and juvenile spondylitis (JSA). These groups have independent mechanisms of immunopathogenesis, different molecular genetic basis of the disease. The targets of immune attack are also different in these groups: synovial lining in JRA and cartilage cells in B27-associated arthritis (Table 2);

Identification of three main types of JRA: monooligoarthritis, polyarthritis, systemic form, radically different in course and outcomes.

The described distinctions made it possible to make therapy more targeted, to work out therapy algorithms for each type of lesion.

JRA drug therapy is divided into symptomatic (non-steroidal anti-inflammatory drugs (NSAIDs) and glucocorticoids) and pathogenetic (immunosuppressants).

According to the classification adopted at the 5th meeting of the International League against Rheumatism WHO (1993), antirheumatic drugs are divided into modifying the symptoms of the disease, modifying the course of the disease and controlling the course of the disease (Table 3).

In the treatment of juvenile rheumatoid arthritis, gold salts, D-penicillamine and chlorambucil are practically not used due to low efficiency and significant side effects. None of the modern drugs completely reliably prevents the development of bone destruction, and therefore there is not a single drug that could be attributed to the disease control group of antirheumatic drugs.

The main provisions of JRA therapy:

NSAIDs and glucocorticoids are symptomatic agents, have anti-inflammatory and analgesic effects, but do not stop the progression of the disease, destruction of the joints.

In the case of an accurate diagnosis of JRA of a progressive course, therapy should be "advanced", i.e., include "basic" agents that affect progression.

In some cases, even when using all variants of hormonal cytostatic therapy, it is not possible to achieve the desired effect, which forces us to look for new groups of drugs.

Therapy for any form of arthritis should be comprehensive and include orthopedic and rehabilitation measures, which should be started in a hospital and continued in an appropriate sanatorium and at home.

Oligomonoarthritis in young children. Much more common in girls. The knee, ankle joints are affected (usually one at a time, asymmetrically), sometimes individual fingers on the hands. The main danger is the addition of uveitis, which in this form takes a chronic course and leads to blindness.

In the absence of uveitis, arthritis is quite favorable course, although it can proceed for a long time (for several months and years). The spread of the process to other joints is rare. NSAIDs are used in therapy, although there are certain difficulties with the choice of the drug due to the younger age of the child. Indomethacin and Aspirin have age restrictions due to toxicity, Nise (nimesulide), approved for use, is also not safe for long-term use. Brufen, which has the least toxicity, has weak anti-inflammatory activity, mainly has an analgesic effect and can be used in some cases. With pronounced clinical activity, the most commonly used drug is Voltaren (diclofenac) (Table 4).

Any of the non-steroidal anti-inflammatory drugs has side effects associated primarily with the effect on the gastrointestinal tract (gastritis, ulcerative lesions, colitis) and kidneys (interstitial lesions). Therefore, their appointment must be justified.

There is individual sensitivity to various NSAIDs, both in terms of efficacy and tolerability of treatment. Do not exceed recommended doses. Inappropriate is the simultaneous use of two or more drugs. Patients receiving NSAIDs require monitoring of liver enzymes (ALT, AST) and serum creatinine levels, and if there are complaints from the organs of the gastrointestinal tract (GIT), a gastroenterological examination. Tolerability of NSAIDs in childhood is better than in adult patients, but still I would like to warn pediatric rheumatologists against excessive, thoughtless prescription of NSAIDs for any arthritis.

Some forms of oligomonoarthritis occur practically without pain, without paraclinical activity. The emphasis in therapy in such cases should be on topical application means (ointments and gels with NSAIDs, applications with Dimexide, physiotherapy treatment).

With insufficient effectiveness of NSAIDs, intra-articular administration of glucocorticoids (GC) is indicated. Currently, methylprednisolone acetate and Betamethasone are used for intra-articular administration. Betamethasone is a combined drug containing fast-acting (betamethasone diphosphate) and long-acting (betamethasone dipropionate) components. The effect of intra-articular administration of HA persists for 6 weeks. 1 ml of Betamethasone is injected into large joints, and 0.5 ml into medium joints. It should not be forgotten that the local administration of HA also gives a systemic anti-inflammatory effect. American pediatric rheumatologists prefer triamcinolone hexacetonide and triamcinalone acetonide for intra-articular administration of HA due to their longer local effect and minimal systemic effect. Intra-articular administration of HA is carried out no more than 3 times in one joint and no more than 1 time per month.

With the ineffectiveness of the therapy for 6 months, even with monooligoarthritis, immunosuppressive therapy in the form of methotrexate at a dose of 10 mg/m 2 /week is connected.

Oligomonoarthritis with uveitis. Involvement of the eyes in the process changes tactics towards increased therapy (prescription of stronger NSAIDs, local therapy for uveitis). Requires early appointment of immunosuppressive therapy in the form of methotrexate at a dose of 10 mg/m 2 /week. In the case of severe uveitis, a combination with cyclosporine at a dose of 3.5-5 mg/kg/day.

Immunosuppressive (basic) therapy is the main component in the treatment of various forms of JRA and, in the absence of contraindications, should be prescribed to each patient with this diagnosis. The appointment of immunosuppressive therapy in the early stages of the disease is especially important, which favorably affects the prognosis of JRA. The main property of basic preparations, regardless of the mechanism of action, is the ability to suppress the proliferation of immunocompetent cells, as well as synoviocytes and fibroblasts, which makes it possible to stop rheumatoid inflammation. A feature of all immunosuppressive drugs is the slow development of a significant clinical effect (usually within 1-3 months from the start of administration). Basic first-line drugs include methotrexate, leflunomide (Arava), cyclosporine A, sulfasalazine (Table 5). In case of insufficient effectiveness of monotherapy with any of the basic drugs, a scheme of combined basic therapy with first-line drugs can be chosen, but not more than two basic drugs in children.

The drug of choice among first-line immunosuppressive agents is methotrexate, which is administered orally or intramuscularly once a week, and on other days, in order to reduce toxic effects, it is recommended to prescribe folic acid from 1 to 5 mg per day. The optimal ratio of immunosuppression/toxicity in the treatment of methotrexate, most rheumatologists note with the introduction of 15-20 mg/m 2 body surface per week. Increasing the dose above 25 mg/m 2 per week increases the frequency of adverse reactions and, accordingly, changes this ratio in reverse - toxicity / immunosuppression.

Second-line immunosuppressive drugs: cyclophosphamide, chlorambucil, azathioprine are used in pediatric practice to a limited extent, mainly due to their side effects.

With the ineffectiveness of therapy within 6-12 months, biological preparations are prescribed. This term is applied to medicines, produced using biotechnology and carrying out targeted blocking of key moments of inflammation using antibodies or soluble receptors for cytokines, as well as other biologically active molecules. A feature of this group of drugs is the rapid (often within a few days) development of a pronounced improvement, which combines biological therapy with intensive care methods. Feature biological agents - potentiation of the effect in combination with basic drugs, primarily methotrexate. A drug from this group, infliximab (Remicade), has been registered in Russia. Remicade is a chimeric anti-tumor necrosis factor-α (TNF-α) monoclonal antibody. Indications for biotherapy with infliximab in children are severe forms of JRA that are not sensitive to previous immunosuppressive therapy. The standard dose is 3-6 mg/kg per injection. The initial dose of infliximab is 3 mg/kg. The next administration of the drug after 2 and 4 weeks from the start of treatment at the same dose. Thereafter, this drug is administered every 8 weeks. In case of insufficient effectiveness of the therapy, the dose of infliximab should be increased. The drug is administered intravenously by drip for at least two hours, at a rate of no more than 2 ml/min, using an infusion system with a built-in sterile pyrogen-free filter with low protein-binding activity (pore size no more than 1.2 μm). It is used in combination with methotrexate at a dose of at least 15 mg / m 2 / week. Remicade is more effective than methylprednisolone pulse therapy. Before starting treatment, it is necessary to completely exclude the patient's tuberculosis infection, HIV infection, chronic carriage of hepatitis B and C viruses. The most common adverse reactions: allergic reactions, induction of autoimmune syndromes, suppression of anti-infective immunity and, possibly, antitumor immunity. Currently, Remicade is the most effective drug in the treatment of severe forms of early and late JRA, but is an expensive drug, which limits its use in practice. In the long term for the treatment of JRA, especially those resistant to conventional DMARDs, biotherapy is likely to be the preferred technology for managing rheumatoid inflammation.

Polyarthritis. The classic polyarthritic variant in older girls is analogous to the adult form of rheumatoid arthritis and, especially in the presence of positive RF, means rapid progression. There are signs of arthritis of small joints of the hands, joints of the lower extremities. Very quickly, almost all joints can be involved in the process, including the cervical spine, the mandibular joint. It is with this variant that the use of NSAID monotherapy is insufficient, and early administration of immunosuppressive therapy is necessary. The drug of choice in this situation is methotrexate, administered at a dose of 12-15 mg/m 2 /week subcutaneously or intramuscularly. With ineffectiveness within 6-12 months, the dose of methotrexate can be increased to 20 mg / m 2 / week with good tolerance. The efficacy and tolerability of methotrexate improves when combined with glucocorticoids with intra-articular administration and / or a short course per os at a low dose (not more than 0.5 mg / kg), prescribed according to an alternating regimen with complete withdrawal. With the ineffectiveness of high doses of methotrexate for 3-6 months and / or the appearance of side effects, it is advisable to use combination therapy with the combined use of methotrexate with cyclosporine at a dose of 3.5-5 mg / kg / day or methotrexate at a dose of 10-12 mg / m 2 /week and leflunomide.

Generally speaking negatively about hormone therapy in articular forms of JRA, we note a positive effect of the use of Metipred pulse therapy (20-25 mg/kg per day for three days IV) in case of high paraclinical activity of the process.

With the ineffectiveness of the therapy within 6-12 months - the use of biological therapy (infliximab).

Systemic form JRA. The most severe variant of the course of the disease, characterized by high fever, rash, lymphadenopathy, hepatosplenomegaly. Polyserositis, myopericarditis, pulmonitis may occur. Pronounced reactive shifts in the blood are noted. The articular syndrome at the onset is unstable and is represented by arthralgias and/or unstable synovitis. In some patients, the "fixation" of the articular syndrome occurs very quickly with the rapid onset and progression of destruction.

Diagnosis of systemic forms of JRA at the onset of the disease is very difficult. It is necessary to exclude generalized forms of infection, sometimes - oncological pathology. In the treatment of such conditions, glucocorticoid therapy is necessary. It helps to quickly stop the activity of the process, to alleviate the condition of the child. In the debut pulse therapy with Metipred is used, in the future - a course of oral therapy with prednisolone. Doses (not less than 1 mg / kg per day) and the duration of the course are individual. As soon as possible, you should switch to an alternating scheme of application. When conducting pulse therapy with Metipred, antibiotic therapy is indicated.

In systemic variants, intravenous use of immunoglobulins (IVIG) is indicated. In systemic forms of JRA, IVIG is administered at a dose of 1-2 g/kg per course (daily, no more than 5 g per administration). This stops systemic manifestations, suppresses the activity of intercurrent infections. IVIG administration is contraindicated in selective immunoglobulin A deficiency.

With systemic forms of JRA in severe cases, rituximab (chimeric anti-CD20 monoclonal antibodies) can be prescribed as an intensive care drug.

Flow systemic form may be complicated by macrophage activation syndrome. This significantly complicates therapy and worsens the prognosis. The drug of choice in these situations is cyclosporine.

In conclusion, it should be noted that the therapy of various forms of JRA, especially severe, progressive ones, is not an easy task, requiring the joint efforts of a doctor, a sick child, his parents and the family as a whole. The main goals of treatment of patients with JRA are suppression of the immunopathological activity of the process, slowing down and preventing destructive processes in the joints, as well as maintaining the functional ability of the patient, improving his quality of life. Monthly and sometimes long-term drug therapy should be combined with physiotherapy exercises, special exercises aimed at maintaining joint function, preventing muscle atrophy, and orthopedic correction means. Close cooperation between a specialized department and a sanatorium is optimal, as well as teaching parents and a child the correct functional stereotype of behavior, methods of physical rehabilitation.

Effective therapy leads to the achievement of remission of the disease and an improvement in the quality of life of the patient. It should never be forgotten that the aggressiveness of therapy should correspond to the degree of aggressiveness of the disease. The emergence in recent years of new biological agents (infliximab, etanercept, rituximab, adalimumab, etc.), which significantly affect the course of the disease, and the first experience of using some of them gives hope for improving the outcome of the disease.

For literature inquiries, please contact the editor.

G. A. Novik, doctor of medical sciences, professor
L. N. Abakumova
N. M. Letenkova, Candidate of Medical Sciences, Associate Professor
N. V. Slizovsky, Candidate of Medical Sciences, Associate Professor
N. N. Slizovskaya
SpbGPMA, St. Petersburg

Juvenile rheumatoid arthritis is a complex systemic disease characterized by inflammation of the joints. The whole severity of the pathology lies in the fact that the patient has a high chance of getting a lifelong disability. In adults, this pathology occurs in a different form.

What is a disease

So, the disease develops in children under 16 years of age, which is why it has such a name. Among all occupies one of the first places. There are only 1% of children in the world with such a skeletal lesion. This pathology mainly provokes irreversible consequences not only in the joints, but also in the internal organs.

The disease is autoimmune in nature, so the treatment is lifelong. It is impossible to completely get rid of juvenile rheumatoid arthritis. The exact cause of its occurrence, experts also cannot yet determine. However, it is already possible to say what factors provoke its exacerbation.

It should be noted that the disease is more often diagnosed in girls. In addition, the later it begins to develop, the more difficult it is to treat.

How does juvenile rheumatoid arthritis develop?

The disease provokes humoral immunity. The fact is that pathological changes occur in the synovial membrane of the joint, as a result of which the blood microcirculation is disturbed, and there is a gradual destruction of hard tissues. In this case, altered immunoglobulins are produced in the affected joints.

The defense system begins to intensively produce antibodies, which attack the body's own tissues. Because of this, an inflammatory process begins to develop, which is almost impossible to eliminate. It is chronic and constantly maintained by the immune system.

Through the circulatory and lymphatic systems, antigens spread throughout the body, affecting other structures.

Disease classification

Juvenile, or juvenile, rheumatoid arthritis is a very complex and dangerous disease. In adults, it may develop more slowly. Pathology treatment should begin immediately - immediately after the patient's symptoms are described and differential treatment is carried out.

Naturally, one should also consider what types of diseases exist:

By type of injury:

1. Articular. This juvenile (juvenile) arthritis is characterized by the fact that the main inflammatory process is localized only in the joints, without affecting other structures.
2. System. In this case, the pathology additionally extends to the internal organs. This form of rheumatoid arthritis is very severe and dangerous. It often leads to permanent disability.

According to the spread of the lesion:

1. Juvenile oligoarthritis (oligoarticular). It is characterized by the fact that no more than 4 joints are affected in a child. In this case, not only large, but also small joints are affected. Such juvenile rheumatoid arthritis is diagnosed in children older than 1 year. This form of the disease can also be limited to only a few joints, but in some cases it progresses and spreads.
2. Juvenile. Here the pathology affects the upper and lower extremities. The number of diseased joints is more than 5. The cervical and jaw joints. Most often, such juvenile arthritis occurs in girls. Treatment of the disease is mainly carried out in a hospital.

By progression rate:

1. Slow.
2. Moderate.
3. Quick.

Learn more about the disease in this video:

On an immunological basis:

1. Juvenile seronegative rheumatoid arthritis. Its feature is that it is not found in the blood.
2. Juvenile seropositive rheumatoid arthritis. This type of disease is more severe. At the same time, it can be detected using the presence of a rheumatological marker in the blood.

By the nature of the flow:

1. (spicy). This is a malignant form of the disease that progresses rapidly. The prognosis in this case is unfavorable.
2. Subacute. It is characterized by slow development and course. It usually affects only one side of the body at first. In the future, the pathological process covers other joints. In this case, the prognosis is favorable, since the disease is treatable.

Juvenile rheumatoid arthritis can present in a variety of ways. However, in any case, its treatment is necessary, complex and lifelong.

What factors provoke the disease

Despite the fact that the exact causes of this disease have not yet been established, it is possible to determine those factors that can trigger the pathological mechanism:

1. Late vaccinations.
2. Joint injury.
3. hereditary predisposition.
4. Viral or bacterial infection.
5. General hypothermia of the body.
6. Prolonged exposure to direct sunlight.

Symptoms of pathology

Juvenile rheumatoid arthritis presents in a variety of ways. It all depends on its type. Can be distinguished the following symptoms this disease of the joints:

1. Sufficiently strong pain around the joint, as well as stiffness during movement (especially in the morning).
2. Redness of the skin in the affected area.
3. Swelling of the joint.
4. Sensation of warmth in the affected joint.
5. felt not only during movement, but also at rest.
6. The limbs cannot bend normally, and subluxations appear in the joints.
7. Brown spots appear near the nails.

These symptoms are basic and common to all forms of pathology. However, for each type of disease, additional signs are characteristic:

Reactive juvenile arthritis manifests as:

1. Increase in overall temperature.
2. Specific allergic rash.
3. Enlargement of the spleen and liver, as well as regional lymph nodes.
4. The symptoms of this disease are bilateral.

Subacute juvenile arthritis in children has the following clinical features:

1. Pain sensations are characterized by low intensity.
2. Swelling appears in the joint area, and its functionality is seriously impaired.
3. In the mornings, the child, just like adults, feels stiffness in movements.
4. A slight increase in body temperature, which appears extremely rarely.
5. A slight increase in lymph nodes, while the spleen and liver practically do not change their size.

Oligoarticular juvenile arthritis has the following clinical symptoms:

1. One-sided character.
2. Child growth retardation.
3. Inflammation of the inner membranes of the eyeballs.
4. Asymmetric arrangement of limbs.
5. Cataract.

In addition, juvenile rheumatoid arthritis is accompanied by severe muscle weakness, anemia, and pale skin. It is the systemic form of the disease that is of particular danger.

Diagnosis of the disease

Diagnosis of this type should be differential. To determine the disease, the following research methods are needed:

1. , which will make it possible to determine the level of ESR, the presence of rheumatoid factor.
2. X-ray of the affected joints, which will determine the degree of development of the disease, the condition of the bone and cartilage tissue.
3. Ultrasound of internal organs.
4. Collecting a detailed anamnesis, which will allow you to establish a hereditary predisposition.
5. Examination of the fundus.
6. External examination of the patient with fixation of his complaints.

Since juvenile chronic arthritis has non-specific symptoms, then only differential diagnosis can determine it. The effectiveness of treatment largely depends on its quality.

About the features of the treatment of the disease without pills, see the video below:

Features of treatment

Rheumatoid juvenile idiopathic arthritis is a complex disease that requires a comprehensive approach. Therapy is designed not only to relieve pain and symptoms inflammatory response joints, but also to minimize the consequences of pathology.

In addition to the treatment itself, the child needs to be provided with a normal motor regimen. Naturally, both adults (parents) and children must follow the recommendations of doctors. The child will have to learn to live with the disease. Complete immobilization of the joints in children cannot be allowed, as this will only aggravate his condition and provoke fast development pathology.

That is, the baby needs to move, but in moderation. For example, walking on a flat road, cycling without extra load, swimming will be useful for him. You can not jump, run and fall. If the phase of exacerbation of rheumatoid arthritis has come, then the child should try to stay away from direct sunlight, not to overcool.

The basis of treatment is drug therapy:

1. Non-steroidal anti-inflammatory drugs - Piroxicam, Indomethacin, Naproxen, Ibuprofen. These drugs should be taken after meals. If you need to provide a quick analgesic effect, the doctor can change the time of taking the drugs. After the child has taken the pill, he needs to move in the first 10-15 minutes so that esophagitis does not develop. cannot stop the process of destruction of the joint, they only relieve pain and other unpleasant symptoms.
2. - Prednisolone, Betamethasone. Because juvenile idiopathic arthritis is characterized by severe painful sensations, then these agents are used to quickly achieve an anti-inflammatory effect. In this case, the drug is quickly excreted from the body. However, corticosteroids have a large number of side effects. Therefore, they cannot be used for a long time.
3. Immunosuppressive drugs -, Cyclosporine, Leflunomide. These drugs inhibit the work of the body's defense system, so their main focus is to protect the joints from destruction. It takes a long time to take these drugs for juvenile rheumatoid arthritis, which is what they are designed for. However, their frequency of use is low. The child will need to drink such medicines no more than 3 times a week. In this case, drugs are prescribed taking into account the characteristics of the body and the development of pathology.

Chronic rheumatoid arthritis (oligoarticular or pauciarticular) can also be treated using non-drug methods:

1. exercise therapy. It is of great importance for improving the motor activity of the child. This treatment must be done daily. Naturally, exercises are often performed with the help of an adult, since stress on the joints is contraindicated. Treating chronic rheumatoid arthritis in children is best done by cycling on a flat road, as well as by swimming.
2. Physiotherapy treatment. Pediatrics in this case focuses on such therapy, as it improves the effect of medications. The recommendations of doctors in this case are as follows: electrophoresis with, magnetic therapy, infrared irradiation, paraffin baths, mud therapy, and laser therapy. If rheumatoid chronic arthritis is treated with such methods, then the prognosis can be good. Decreased intensity of symptoms immune status, muscles relax, as a result of which the joints return to their full functionality. Some procedures help to reduce the inflammatory process.
3. Massage. Juvenile idiopathic arthritis is characterized by the fact that periodically, and quite often, the patient experiences periods of exacerbation. Physiotherapy treatment in this case is limited. Massage can only be used during remission. This procedure is useful in that it allows you to restore normal blood circulation in the muscles and joints. In this case, all movements must be such as not to exert any load on the joint.

In some cases, juvenile chronic arthritis is treated with surgical intervention. The operation is used only as a last resort, when strong changes are observed in the joints, significantly limiting its mobility. During the operation, excess growths are removed, as well as the installation of a prosthesis.

- this is systemic disease autoimmune nature, which most often manifests itself in adults after reaching adulthood, but, unfortunately, children are also susceptible to it. For example, juvenile polyarthritis and juvenile rheumatoid arthritis in adults have similar causes and signs. Many parents who are faced with this disease are wondering: juvenile arthritis - what is it?

The mechanism of the disease is that when pathogenic bacteria enter the body, an immune response occurs - antibodies begin to destroy harmful cells. But with arthritis, a malfunction occurs in the immune system, "defender cells" for inexplicable reasons begin to perceive the cells of their own body as "enemy", destroying them and causing inflammation.

Diagnosing juvenile rheumatoid arthritis (JRA) in a child is not easy. The onset of the disease can be slow, the child and his parents in the daily bustle may not notice his signs.

In order not to waste precious time, let's try to understand this problem. In our article will be discussed about the causes and diagnosis of childhood arthritis, as well as the symptoms and treatment of rheumatoid arthritis in a child.

The causes of arthritis at a young age can be:

• transferred viral diseases(SARS, influenza);
• bacterial infections;
• trauma;
• hypothermia of the body;
• genetic factor.

Classification of arthritis in children

Depending on the cause, several types of the disease are distinguished:

1. appears after the child has had a viral infection (rubella, influenza). The joints of the lower extremities are most often affected.
2. (or reactive) arthritis is most common in children under 6 years of age. It is called pathogenic bacteria and most often affects the hip joint. The entry of harmful bacteria into the joint occurs with the blood flow; joint injury can also provoke the development of the disease.
3. Rheumatoid arthritis develops as a result of a malfunction in the immune system. It is more severe than others and has more serious consequences. It is accompanied by deformation of the joints, internal organs (heart, liver) can be affected. The prognosis of this form is most often unfavorable.
4. precedes the appearance of psoriasis or develops against its background.

If one joint (hip) is affected, monoarthritis is diagnosed, if two or more joints are affected, polyarthritis is diagnosed.

In childhood, neuro-arthritic diathesis is sometimes diagnosed, it is also called gouty arthritis. By origin, the disease could be attributed to psychosomatic, since metabolic disorders occur due to increased nervous excitability. The reason why this pathology is referred to as arthritis is the damage to the joints (mainly the hip).

AT infancy in children with diathesis, the disease is hardly noticeable. To a greater extent, it is expressed in the school period. If arthritis is suspected, parents should pay attention to the following changes in the child:

• nervous overexcitation, which can be expressed in fearfulness, poor sleep, excessive anxiety;
• fever for no apparent reason;
• poor appetite and lack of muscle mass;
• enuresis.

Oligoarticular juvenile rheumatoid arthritis is characterized by damage to up to 4 joints. As with other forms of arthritis, the joints of the lower extremities are primarily affected, hip joints and hands.

Girls are most commonly affected between the ages of 1 and 5 years. It is distinguished by the speed of deformation, the asymmetric nature of the affected joints is present, eye diseases (iridocyclitis) are diagnosed in parallel.

At the age of 8-15 years, this pathology is most common in boys.

According to International classification diseases 10 revision, There are several types of arthritis in adolescents:

1. Juvenile juvenile rheumatoid arthritis with positive or negative rheumatoid factor.
2. Juvenile juvenile arthritis with systemic onset.
3. Seronegative polyarthritis.
4. Pauciarticular juvenile arthritis.
5. Juvenile arthritis unspecified.
6. Other types of arthritis

International organizations dealing with rheumatoid arthritis also distinguish other classes of the disease. The International League of Rheumatological Associations classifies it thus:

1. Juvenile idiopathic arthritis.
2. System.
3. Polyarticular with positive and negative rheumatoid factor.
4. Juvenile oligoarticular, juvenile pauciarticular arthritis with systemic onset.
5. Persistent.
6. Progressive.
7. Psoriatic.
8. Enthesitic.
9. Other types.

According to the classification of the European League against rheumatism, the following types are distinguished:

1. Juvenile chronic arthritis.
2. System.
3. Polyarticular.
4. Oligoarticular.
5. Juvenile psoriatic arthritis.
6. Juvenile ankylosing spondylitis.

All listed types of arthritis have similar signs of the course of the disease and differences in the causes of origin and outcome of the disease. For example, signs of rheumatoid arthritis of the knee in 6-year-old children can manifest themselves in different ways. For correct diagnosis, a number of criteria have been identified, which will be described below.

Symptoms

In children, pathology has two forms of manifestation: articular and articular-visceral.

The articular form develops rather slowly. It has the following features:

The articular-visceral form is characterized by the following symptoms:

• rapid progression of the disease;
• the joint swells up quickly;
• the temperature rises sharply;
• significantly enlarged lymph nodes;
• there is pain in the joint and stiffness in movements;
• symmetrical joints are affected;
• small joints of the foot and hand are affected;
• the cervical spine is involved in the pathological process;
• internal organs (liver, spleen, kidneys, heart) are affected;
• allergic reactions or skin rash may occur;
• in blood tests, characteristic changes are recorded that are signs of inflammation;
• a severe course of the disease with damage to the joints can lead to disability.

Diagnostics

To diagnose arthritis, a thorough examination of the patient is carried out, the duration of the disease, the number of affected joints, the presence of eye diseases are determined, and whether close relatives have had similar diseases.

With the help of x-rays, the presence of joint deformity, the size of the interarticular gap, the condition of the vertebrae in the cervical spine are revealed.

Spend clinical researches blood, which show the presence of an inflammatory process, detect infections, determine rheumatoid factor and other specific markers of juvenile arthritis.

To diagnose the state of internal organs, ultrasound procedure, an electrocardiogram of the heart, computed tomography and magnetic resonance imaging may be required.

They give the most complete picture of the state of the spine, reveal the presence of damage to soft tissues, nerve roots and blood vessels in the spine and joints.

The photo shows inflammation of the joint in a 5-year-old child.

The most difficult thing is to identify arthritis in babies under 1 year old, when their activity is not yet fully developed.

The diagnosis is made according to the criteria if the child has at least 2-3 signs:

• age up to 16 years;
• the duration of the disease is more than 6 weeks;
• damage to 2-3 or more joints;
• the presence of eye diseases in history;
• indicators of blood tests (rheumatoid factor, C-reactive protein, ESR and others);
• joint deformity.

Treatment

Since the treatment of arthritis is a long process, the methods of its treatment in children are due to the minimal side effect of drug therapy.

Treatment of juvenile rheumatoid arthritis in children 2-4 years of age should be gentle, since drugs with long-term use can cause deterioration of the internal organs: they affect the stomach, liver, kidneys, and this has a very negative effect on the growing body. The treatment is carried out by a rheumatologist.

Medical

For treatment, drugs are used that have an anti-inflammatory effect, relieve pain and swelling, restore and nourish damaged tissues.

For pain relief, reduction of edema and inflammation prescribed anti-inflammatory non-hormonal agents . Treat if an infection is detected antibiotics.

To prevent the destruction and restoration of cartilage and bone tissues, various vitamin and mineral complexes.

In severe cases, when the main course of therapy does not give a positive effect, hormonal preparations of the glucocorticosteroid group and immunosuppressants are used.

Hormonal preparations are most often applied topically in the form of injections of blockades. In the form of tablets, hormones are not recommended for children under 5 years of age, and at the age of under 3 years, they are used only in very severe cases.

Surgical treatment is performed in cases where it is necessary to replace part of the joint or the entire joint. When replacing part of the synovial membrane, a synovectomy is performed.

Physiotherapy

Physiotherapy treatments are good additional treatment. They have a minimum of contraindications, do not cause any allergic reactions and side effects, so they are suitable for many.

The procedures include ultrasound therapy, , laser therapy, shock wave therapy, electro- and phonophoresis.

Physiotherapy favorably affects the acceleration of the healing and recovery process.

Due to its physical properties, it promotes deeper penetration of the medicinal substance into tissues, improves blood circulation and metabolism in tissues, relieves swelling, neutralizes inflammation, reduces pain, acts locally, directly on the affected area.

Along with physiotherapy, massage and physiotherapy exercises have a good effect.

Massage improves the condition of the muscles and tones them, and therapeutic exercises contribute to quick recovery mobility of the joints of the arms, legs and spine.

After the main course of treatment main task is to maintain a stable remission. Some forms of arthritis are successfully treated, while others remain chronic and may recur throughout life. Such forms require maintenance therapy and periodic examination by the attending physician.

Speaking about chronic juvenile arthritis, Dr. Komarovsky draws attention to the blurring of the signs of the disease. Because of this, it is difficult to diagnose. The doctor advises to be very attentive to this disease.

Often, not all signs may manifest themselves, for example, there may be no signs of infection in blood tests, the disease can be confused with other pathologies. A neglected form can lead not only to deformation of the joints, but also to diseases of internal organs (kidneys, heart).

Prediction and prevention of juvenile rheumatoid arthritis

Clinical recommendations and future prognosis depend on the form of arthritis and the degree of joint deformity. The current level of development of medicine does not completely solve the problems with pathology. The disease is chronic and can recur throughout life.

Although the prognosis of treatment and rehabilitation is positive, due to modern techniques it is possible to significantly alleviate the symptoms of the disease, improve well-being, restore mobility and maintain the usual quality of human life.

Juvenile polyarthritis in half of the cases has a positive outcome, it is possible to achieve stable remission for 10 years or more. There are no clear preventive recommendations for arthritis, since the origin of this disease is still unknown.

Conclusion

Arthritis is currently an incurable disease. The severe course of the disease and difficulties in its treatment can lead to disability and loss of mobility. At timely handling per medical assistance and periodic medical examinations, it is possible to achieve stable remission and maintain active life position without loss of employment in the future.