Pediatric rheumatoid arthritis and its dangers. Juvenile rheumatoid arthritis of the systemic form. Folk remedies for juvenile arthritis

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. AT infancy cases of the disease are rare, more common in children after 5 years.

Juvenile rheumatoid arthritis- a disease with a wide range 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 characteristic features can be useful in making a diagnosis, monitoring the course of the disease, and adequate treatment 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- excessive formation of 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 during the entire childhood, as a rule, 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 affiliation of a particular clinical case to the seropositive or seronegative group, as a rule, are established on early stages diseases.

Joint damage can develop gradually (gradually increasing stiffness of the joints, swelling and decreased mobility) or at lightning speed with sudden appearance 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 of the 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 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).

Hip injury usually occurs on late stages illness. 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 lesions of the 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, there are subfebrile temperature, slight hepatosplenomegaly and lymphadenopathy.

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. It predominantly affects the knee, ankle and elbow joints, in some cases, there is an asymmetric lesion of other joints (temporomandibular, individual joints fingers, toes, wrist joints, or neck joints). 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 prone to increased risk development of 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.

Mainly large joints are affected lower extremities. 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 is characteristic appearance and is of a transitory nature. 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. However, on radiographs chest in some cases, thickening of the pleura and a small effusion in pleural cavity. Pericardial effusion may be significant and accompanied by ECG changes, although pericarditis is usually benign. During periods of exacerbations, interstitial infiltrates may appear in the lungs, but chronic rheumatoid lesion lungs 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 disappearance common 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 lesion 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 - definite, seven - classical (in all cases prerequisite is the presence of the first criterion).

• JRA system variant with high fever, pericarditis in the absence of the effect of taking large doses of 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 that does not stop local application 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 term juvenile rheumatoid arthritis (JRA) includes a clinically heterogeneous group of arthritis that begins before age 16 and lasts for 6 weeks. This type of arthritis is the most common chronic rheumatic disease in pediatrics. The diagnosis includes all forms of chronic childhood arthritis of unknown origin.

Although the exact etiology of autoimmune diseases such as remains unknown, it is believed that it develops when a combination of genetic changes and aggressive environmental influences lead to a violation of the body's reactivity. Although genetic methods of research are developing very persistently, but few studies have reported the identification of environmental factors that cause immunological disorders in JRA.

What is known to rheumatology at the moment about the nature and risk factors of this disease?

1. There are published studies that describe an association between infections early age smoking and the future development of JRA in children.
2. Recently, three studies have shown conflicting results regarding the association between atopic disorders and rheumatoid arthritis. However, the reports did not describe the impact of childhood allergic diseases on the risk of developing JRA.
3. One study from 2016 confirms allergic diseases associated with childhood as risk factors for JRA.

Clinical picture

JRA can manifest as arthritis, systemic changes, and uveitis. AT different occasions there are different combinations of these syndromes with varying degrees of severity.

Arthritis

JRA can affect any joint in the body, but large joints are usually more involved. However, small joints of the arms and legs are noted to be affected, especially if we are talking about the polyarticular form of JRA.

In an inflamed joint, there are a number of standard signs of inflammation: swelling, erythema, fever, pain, and loss of function. The affected joints are most often warm, but usually the hyperemia in them is not very pronounced. Notably, children with arthritis may not complain of pain at rest, while active or passive movement usually causes pain. Often, young children do not complain of pain either, and instead stop using the affected joint entirely.

Of note, cricoarytenoid arthritis is uncommon but may cause acute obstruction. respiratory tract due to edema, which is a manifestation of the inflammatory process. Morning stiffness without previous activity is a classic manifestation of joint inflammation, but such symptoms are rarely reported in children.

Inflammation of the joints in the middle ear was also detected by tympanometric studies. Also observed in JRA was damage to the temporomandibular joint, cervical, thoracic and lumbar spine. It is noteworthy that this disease often affects the cervical spine, because the most common changes in the upper cervical region spine are anterior atlantoaxial subluxations. Scoliosis can sometimes occur in children, which reflects asymmetric inflammation of the thoracolumbar joint.

During the first 6 months of illness, at least 50% of children develop oligoarticular juvenile rheumatoid arthritis. The clear distinction of this subtype is that it is the only form of juvenile arthritis without an adult equivalent. The oligoarticular form affects up to 4 joints. At the same time, they are mainly affected knee joints followed by the ankles. This subtype does not typically involve the hip joint, as well as the small joints of the arms and legs. The oligoarticular form is characterized by asymmetric arthritis, early onset (about 3-6 years), predominance and high risk development of iridocyclitis.

The ILAR classification recognizes 2 additional categories in oligoarticular JRA: persistent oligoarthritis, in which the disease is limited to 4 or fewer joints, and advanced oligoarthritis, in which arthritis extends to more than 4 joints after the first 6 months of disease. In 50% of patients with oligoarthritis, a generalized form of the disease develops, and in 30% this occurs in the first 2 years after diagnosis. Risk factors for generalized disease include upper limb joint involvement and increased ESR.

The polyarticular form is defined as the presence of arthritis in 5 or more joints during the 6th case history. Arthritis can be symmetrical and usually involves the large and small joints of the hands and feet, although axial skeleton, including the cervical spine and temporomandibular joints, may also be involved. This subtype includes children with RF-negative and RF-positive arthritis. Both types affect girls more often than boys. RF-negative patients are more likely to develop arthritis in early childhood, while RF-positive patients instead develop arthritis in late childhood and adolescence. Three different variants of RF-negative polyarthritis have been identified.

The first sub-variant is a form resembling early start oligoarthritic, except for the number of joints affected in the first 6 months of the disease. The second subvariant is similar to adult RF-negative rheumatoid arthritis and is characterized by overt symmetrical synovitis of large and small joints, onset in school years, an increase in ESR, a negative analysis for antinuclear antibodies.

The third subgroup is the form known as dry synovitis. Dry synovitis is characterized by slight swelling of the joint with its stiffness and motor contracture. These are primarily adolescent girls with symmetrical joint damage and early erosive synovitis. About a third of these patients have subcutaneous nodules (tender, persistent lesions over pressure points and tendons), usually located in the forearm and elbow.

A characteristic systemic manifestation of JRA is fever. Typically, the temperature rises to 39℃ or higher for 1-2 days, and then quickly returns to the original or lower. Fever can occur at any time of the day, but is most common late in the day with a rash. Fever associated with this kind systemic disease, often responds poorly to prescribed even at high doses.

The JRA rash consists of discrete, circumscribed, salmon-pink macules ranging in size from 2 to 10 mm, which may be surrounded by a ring of pale skin or have a central lumen. Lesions most commonly occur on the trunk and proximal extremities, including the axillae and groin, but may also appear on the face, palms, or even soles. The rash is migratory and disappears amazingly quickly: individual lesions are observed up to several hours and disappear without a trace. The rash is sometimes itchy, but never purplish.

Pericarditis and pericardial effusions may precede the development of arthritis or may occur at any time during the course of the disease and are usually accompanied by a systemic exacerbation of the disease.

Pericarditis is more common in older children. Most pericardial effusions are asymptomatic, although some children have shortness of breath or heart pain that may radiate to the back, shoulder, or neck. In many cases, pericardial effusions develop smoothly, without overt cardiomegaly or electrocardiographic changes. Physical examination may reveal decreased heart sounds, tachycardia, cardiomegaly, and pericardial friction.

Pneumonitis or pleural effusions may also occur without any clinical presentation. Found as incidental findings on chest radiographs.

Another feature the systemic course of the disease is an increase in the lymph nodes and spleen. Symmetric lymphadenopathy is particularly common in the anterior cervical, axillary, and groin areas and may mislead a diagnosis of lymphoma. Mesenteric lymphadenopathy can cause abdominal pain or bloating and misdiagnose an acute abdomen.
Hepatomegaly is less common than splenomegaly. In addition, moderate to severe liver enlargement is often associated with only mild dysfunction and relatively nonspecific histopathological changes. However, a massive enlargement of the liver is usually accompanied by bloating and pain. Progressive hepatomegaly is characteristic of secondary amyloidosis, which should be taken into account in the differential diagnosis.

Chronic non-granulomatous uveitis (iridocyclitis) develops in 21% of patients with oligoarticular and 10% of patients with polyarticular form. The only known independent risk factor for uveitis is positive test for antinuclear antibodies. The onset of chronic uveitis is usually asymptomatic, although up to half of affected children have some symptoms: eye pain, redness, headache, photophobia, vision change later. Complications of uveitis include posterior synechia, cataracts, keratopathy, glaucoma, and visual impairment.

Diagnostics

The diagnosis of JRA is based on the history and physical examination. Often, history data allow us to differentiate JRA from diseases of other etiologies, for example, from reactive arthritis or infectious mononucleosis. To the alleged laboratory research include the following:

• inflammatory markers: determination of C-reactive protein, ESR;
• general blood analysis;
• biochemical blood test to determine liver function and evaluate kidney function;
• determination of antinuclear antibodies;
• determination of rheumatoid factor and anticyclic citrullinated peptide;
• additional research: total protein, albumin, fibrinogen, ferritin, D-dimer, antistreptolysin 0 (AS0);
• general urine analysis.

When only one joint is involved, radiography is important for the differential diagnosis.

Other imaging modalities that may be helpful in diagnosis include the following:

• CT scan;
• Magnetic resonance imaging;
• ultrasonography and echocardiography;

Treatment and prognosis

The American College of Rheumatology has formulated conclusions regarding the treatment of JRA, which are now considered universal and are used in both Germany and Israel. College 5 treatment groups, depending on which one or another treatment strategy should be applied:

1. History of arthritis in 4 or fewer joints.
2. History of arthritis in 5 or more joints.
3. Active sacral arthritis.
4. Systemic arthritis without active arthritis.
5. Systemic arthritis with active arthritis.

• drug therapy, consisting of non-steroidal anti-inflammatory drugs that modify (, cyclosporine and other cytostatics), biological agents, intra-articular and oral steroids;
• psychosocial factors, including patient and parent counseling;
• school regimen (counseling, adjustments to school life and adjustments to physical education);
• nutrition, especially to combat anemia and generalized osteoporosis;
• physical therapy to relieve pain and to strengthen muscles, activities in daily life;
• specialized therapy including joint protection, pain relief program, etc.

The American College of Rheumatology formulated a protocol that specified the following criteria for complete remission:

• No inflammatory pain in the joints;
• no morning stiffness;
• no fatigue;
• no synovitis;
• no radiological progression of the disease;
• there is no increase in ESR and C-reactive protein.

Patients with JRA who have acquired a disability should receive an individual rehabilitation program that includes activities for medical, professional, sports and physical, social adaptation. Of course, such children are exempted from further military service.

Juvenile rheumatoid arthritis is a systemic autoimmune disease that affects children under the age of sixteen. Girls get sick several times more often than boys. The autoimmune nature of the disease suggests that the body, by unknown factors, begins to recognize its own cells as pathological and actively produces antibodies against them. It is systemic, because not only the joints, but also several internal organs and systems are involved in the pathogenic course.

During such a disease, the inflammatory process first attacks the joints, which leads to a slow breakdown of the integrity of the cartilage and deformation of the bones. A similar development in the internal organs entails a violation of their normal functioning. The articular form of the disease is manifested by symptoms such as swelling and visible deformation of the affected area of ​​the body, and the systemic form - an increase in body temperature to critical levels, the occurrence of rashes, as well as damage to organs such as the heart, lungs and kidneys.

Diagnostics consists in the implementation of a complete hardware examination child and joint puncture. Most often, this disease can be diagnosed before the age of two years. If this is not done in time, then such a pathology can lead to disability and loss of working capacity. Treatment of the disease is aimed at taking medications, performing physiotherapy and therapeutic massage courses. Since rheumatoid arthritis in children is lifelong disease, then the prediction depends on correct diagnosis and therapy tactics.

Etiology

To date, medicine does not know the causes of the progression of juvenile rheumatoid arthritis, but doctors agree that the basis of such a disease in children is a combination of external and internal factors, such as:

• genetic predisposition;
• severe course of viral diseases;
• bacterial infections;
• a wide range of joint injuries;
• prolonged exposure to cold temperatures or sunlight;
• complications after preventive vaccinations that may have been carried out during or immediately after recovery from;
• protein injections;
• congenital or acquired disorders of the immune system.

This disease is rare, but leads to irreversible changes in the affected joints, internal organs and systems. The main difference from in adults is that in children it affects not only the joints.

Varieties

Depending on the number of affected joints, juvenile rheumatoid arthritis is divided into:

• - characterized by damage to more than four joints;
• oligoarthritis - pathological process affects less than three joints;
• monoarthritis - the inflammatory process is observed in only one joint.

As the internal lesions progress, as well as the manifestation of symptoms, the disease can be:

• articular;
• limited - only one organ becomes inflamed;
• Still's syndrome - characterized by significant pain in the joints, the appearance of a rash, the absence of rheumatoid factor in blood tests and a rapid course. Several internal organs are involved in the process;
• allergoseptic - there is a multiple damage to organs and systems inside the body.

Depending on the presence of rheumatoid factor in the blood, such an ailment happens:

• seropositive - characterized by an aggressive and rapid course, as well as a disappointing prognosis;
• seronegative.

The course of juvenile rheumatoid arthritis is divided into several stages:

• slow;
• moderate;
• fast;
• acute;
• subacute.

According to the degree of activity of the inflammatory process, the disease in children is divided into phases:

• high;
• average;
• low;
• remission phase.

Symptoms

During the course of this disease, either only the joints or the joints and organs are affected. The articular form of the disease includes the following symptoms:

• feeling of stiffness after sleep. Duration is more than one hour;
• puffiness. Often, joints of medium and large sizes are exposed to the inflammatory process;
• during palpation, an increase in the temperature of the diseased joint relative to the whole body is felt;
• significant soreness - is noted not only during movement, but also at rest;
• joint deformities - observed in the later stages of the course of the disease;
• inability to fully bend or straighten the inflamed upper or lower limb.

The main symptoms of extra-articular manifestations of the disease are:

• a significant increase in the temperature of the whole body, up to a fever;
• occurrence on skin in the area of ​​\u200b\u200bthe nails of brown spots;
• the formation of rheumatoid nodules under the skin;
• soreness in the heart;
• decrease in blood pressure;
• dyspnea;
• significant weight loss;
• fast fatiguability;
• formation of rashes on the skin allergic nature, which carry a lot of uncomfortable sensations;
• cardiac arrhythmias.

Internal symptoms that can only be observed during diagnosis this disease in children:

• inflammatory process in the mucous membrane of the lungs;
• redness of the white of the eyes - can be either one-sided or spread to both eyes;
• fibrosis;
• an increase in the volume of organs such as the liver, spleen, regional lymph nodes.

Complications

At untimely appeal to a specialist for adequate help, there are many complications that can pose a threat to the life of the child. Among them:

• insignificant or total loss movements;
• blindness;
• organs such as kidneys, liver, intestines and myocardium;
• renal, cardiac and pulmonary insufficiency chronic nature;
• violation of the structural structure of the bones of the skeleton and associated fractures;
• complete loss of performance of the child.

Diagnostics

Diagnostic measures for juvenile rheumatoid arthritis are carried out by a pediatrician who needs to perform a number of measures:

• analysis of the medical history of children and close relatives - is carried out to exclude or confirm the hereditary nature of the disorder;
• clarification of the first time and degree of intensity of symptoms;
• a thorough general examination of the patient.

If necessary, the specialist prescribes several auxiliary examinations:

• laboratory - general and biochemical blood tests to detect specific proteins and antibodies. In addition, a puncture of the affected joints is carried out;
• hardware - ultrasound of the chest, abdomen and kidneys, ECG and radiography of the joints and spine;
• consultations of such specialists as a pediatric rheumatologist and an ophthalmologist.

After studying all the results of the examinations, the attending physician prescribes the most effective treatment juvenile rheumatoid arthritis. The prognosis for the patient will depend on the success of therapy.

Treatment

The main goal of therapy for such a disease is to freeze the process of destruction of joints and cartilage. That is why treatment must be carried out until the remission of the disease. Elimination of the disease is carried out in several ways. The first of them is the use of drugs - anti-inflammatory, glucocorticosteroids, anticoagulants. The second is the implementation of physiotherapy procedures:

• acupuncture;
• treatment with current, ultrasound, magnetic field and infrared radiation;
• electrophoresis.

During periods of subsidence of the symptoms of this disease in children, it is recommended to perform exercise therapy exercises and taking courses therapeutic massage. It is best if the treatment will take place in a sanatorium-resort environment.

Surgical intervention is addressed in cases where joint deformities are pronounced - their prosthetics are carried out. At adequate therapy the prognosis of the disease is quite favorable, especially considering that it is lifelong. The success of treatment is considered to be a long course of the remission stage.

There is no specific prevention of such a disorder, it is only necessary to be examined by a rheumatologist twice a year, and also to limit yourself from hypothermia or overheating of the body.

From 2 to 16 children fall ill per 100,000 children in the JCA population.

The cause of arthritis is also can be:

• vaccination (more often after DTP);
• joint injury;
• hypothermia;
• excessive insolation (stay in the sun);
• hereditary predisposition.

Juvenile rheumatoid arthritis often affects girls.

To understand the essence and classification of Juha, let's look at what the joint consists of.

A joint is a joint of the bones of the skeleton, immersed in the joint capsule, or bag. Thanks to them, a person can show any physical activity.

The articular bag consists of the outer and inner layers. The inner layer or synovial membrane is a kind of nutrition for the joint.

In children, the joints are abundantly supplied with a vascular network.

With JXA, inflammation occurs in the synovial membrane, hence the trophism (nutrition through the blood supply) of the joint is disturbed and further changes.

Juvenile arthritis in children and its classification

Number of affected joints arthritis is classified into:

• monoarthritis - one joint is affected;
• oligoarthritis - when no more than four joints are involved;
• systemic variant - damage to organs and tissues is added to the damage to the joints;
• polyarthritis - more than four joints are damaged.

By detecting rheumatoid factor in the patient's blood:

• seropositive;
• seronegative.

According to the development of complications:

• infectious complications;
• macrophage activation syndrome;
• pain joint syndrome in a child;
• pulmonary heart failure;
• growth retardation.

Painful joint syndrome in a child

Pain is the most common complaint of rheumatoid arthritis in children, so if arthritis is suspected, the mother should pay attention to the following factors:

• redness and swelling of the joint;
• the skin over the joint is hot to the touch;
• the child spares the joint, limiting movement in it;
• pain during flexion, extension of the affected limb;
• in the morning, stiffness in the joint, that is, the inability to get out of bed or brush your teeth on your own due to limited mobility in the joint.

Juvenile rheumatoid arthritis, seropositive

The prevalence is about 10%. They are more common in girls between the ages of 8 and 15.

Joint pain occurs symmetrically. The knee, wrist and ankle joints are most commonly affected.

This type is not the best option for the course of the disease, as it leads to destructive (destructive) changes in the joint already in the first six months of the disease. The child's function of flexion/extension of the joint is impaired, followed by disability.

Complications:

• growth retardation;
• severe disability;
• contractures (lack of mobility) in the joints.

Such a severe course and complications are associated with the presence of rheumatoid factor in the blood, which is quite aggressive to the synovial membrane of the joint and leads to irreversible consequences without adequate treatment.

Juvenile arthritis, seronegative

Distributed in 20 - 30%. Again, the female sex from 1 to 15 years old suffers more often, the age range is wider than that of the seronegative.

The course of this disease is benign.

Joints affected:

• knee;
• elbow;
• temporomandibular joints;
• cervical spine.

Also, with this form of JOHA, mothers may notice an increase in temperature and an increase in lymph nodes in a child.

comparison table

Oligoarthritis

Occurs in 50% of all cases.

Several joints are affected:

1. Knees.
2. Ankle.
3. Elbow.
4. Wrist.

The course of this form of the disease is quite aggressive, as it develops inflammatory changes in the shells of the eye.

Systemic variant of rheumatoid arthritis

Clinical manifestations:

• rash;
• enlargement of the liver, spleen;
• temperature rise;
• pain in the joints;
• inflammatory changes in organs.

1. Eye damage. In children with juvenile arthritis, inflammatory changes in the membranes of the eye may occur.

As a rule, this happens asymptomatically, and the child does not feel pain in the eyes at all, which is fraught with the threat of loss of vision without proper control of the ophthalmologist.

With juvenile arthritis, iritis or iridocyclitis, an inflammation of the iris, often occurs.

Complications of eye diseases:

• cataract - clouding of the lens;
• glaucoma - increased intraocular pressure;
• as the most unfavorable outcome - blindness.

Your attending rheumatologist is obliged to send the child for a check-up to an ophthalmologist 2 times a year.

The optometrist should examine such babies only with a slit lamp. Without it, the inspection will be incorrect. As a result, a doctor may miss an eye problem in juvenile arthritis.

If the doctor has identified the onset of inflammatory changes in the eye, treatment will be prescribed. Treatment will be with eye drops, which are based on a hormonal component to reduce dryness, swelling and inflammation.

Also, eye treatment is possible with the introduction into the eyeball. injectable drug. This significantly increases the effectiveness of the treatment of the underlying disease.

2. Damage to organs and systems. Juvenile rheumatoid arthritis is a disease that affects not only the joints, but also internal organs. The disease affects connective tissue, which is present in many organs, and blood vessels.

Main targets for arthritis:

1. Heart.
2. Lungs.
3. Kidneys.
4. Nervous system.

Inflammatory changes in the membranes of the heart are called carditis. They can also develop as complications after other diseases. For example, after suffering streptococcal tonsillitis or scarlet fever, for which damage to the heart valve system is more characteristic. In juvenile arthritis, changes in the myocardium and pericardium are more common. Carditis may be asymptomatic.

Changes in the lungs concern the lung tissue itself and the pleura. The bronchi and bronchioles themselves are affected less frequently. As complications in the pleural cavity, adhesions occur and fluid accumulates.

Pain in the arms, legs - a consequence of rheumatic damage to the nerve endings. Movement disorders may also occur.

Kidney damage occurs in the form of glomerulonephritis (inflammation of the tissues of the kidney). Moreover, glomerulonephritis occurs with high activity of arthritis. Violation of the kidneys does not occur, usually there are minimal changes in the urine.

1. If your child began to complain of pain in the joints, then immediately follow to pediatrician cardiorheumatologist or pediatric rheumatologist.

2. On initial stage examinations for a child should be submitted:

• general blood analysis;
• general urine analysis;
• biochemical blood test (liver enzymes, creatinine, total protein, blood sugar, C - reactive protein);
• blood for the presence of rheumatoid factor;
• blood for the study of antistreptolysin O titer (if there is a history of frequent sore throats), which indicates the presence of streptococcus in the body;
• blood test for immunological parameters (antinuclear factor, circulating immune complexes, concentration of immunoglobulins).

3. Then the doctor will direct the baby to instrumental examinations:

• Ultrasound of the affected joints;
• x-ray examination;
• Ultrasound of the abdominal cavity;
• Ultrasound of the heart (with suspicion of carditis);
• Ultrasound of the kidneys.

4. Expert advice. An oculist, an ENT doctor, a neurologist must examine the child if there are relevant complaints.

Only after the examinations passed above, the doctor should confirm or refute the diagnosis.

Mode moments in treatment

1. Indicated for active arthritis bed rest or significant limitation physical activity. Jumping, running, squatting are prohibited.

   Juha is always treated in a hospital setting.

2. Minimal dosed gymnastics for the joints is required. Joints are made for movement. Gymnastics should be carried out with an exercise therapy instructor. Important individual approach to each child, taking into account his functional abilities and pain.
3. With juvenile arthritis, you can not gypsum, apply splints, bandages on the affected joint.
4. A medical exemption from vaccinations is required.
5. Exclusion of hypothermia.
6. Sun exposure is allowed only with the use of sunscreen and hats.
7. A calcium-fortified diet, complete balanced meals are recommended.
8. Psychological support and the right attitude on the part of the parents, since the treatment of JCA can last for years.

Essential drugs for treatment

In this matter, it should be noted two areas of treatment:

1. symptomatic treatment. These are non-steroidal anti-inflammatory drugs and glucocorticosteroids.
2. Immunosuppressive therapy, which suppresses the activity of the immune system.

Non-steroidal anti-inflammatory drugs (NSAIDs)

These drugs relieve pain quite well, but not so well eliminate inflammatory changes in juvenile arthritis.

These include:

• ibuprofen;
• Diclofenac;
• Meloxicam.

In rheumatology, Nise, or Nimesulide, is often and widely used. It has been proven that of all non-steroids, it has the mildest effect on the children's body and has fewer manifestations of side effects.

Anti-inflammatory drugs of a hormonal nature

In the presence of systemic arthritis with organ damage, the so-called pulse therapy is prescribed.

Pulse therapy is an intravenous infusion hormonal drugs(Prednisolone) in sufficiently high doses. Not recommended for children under 3 years of age as it may cause growth retardation.

Immunosuppressants

Hormonal drugs give a quick, but short-lived effect.

Therefore, with inefficiency and high activity of the disease, as well as with a systemic variant, immunosuppressants are prescribed.

Methotrexate is the main drug for the treatment of rheumatoid arthritis. Immunosuppressive therapy should be long-term age dosages, without spontaneous cancellation.

Quite often it happens that during the treatment with methotrexate, the child has a remission, all the symptoms go away and the parents decide to stop the drug without the consent of the doctor. As a result, there is a sharp exacerbation of the disease and, possibly, with a more aggressive course.

Cancellation of Methotrexate is carried out only in a hospital setting and, at least, after a 2-year remission.

Methotrexate has enough high efficiency well tolerated in most cases. Possible nausea, vomiting, but this is at the initial stage of treatment.

The dosage of Methotrexate is selected in a hospital setting, calculated by weight, height. It happens both in tablet form and injectable, it is taken 1 time in 1 - 2 weeks as prescribed by a doctor.

Juha is a disease in which the child must be given the status of a disabled person. This entitles you to free receipt medicines. But, unfortunately, the commission does not always award disability to such children, and therefore they have to be treated at their own expense.

Recently, for the treatment of juvenile arthritis began to be used preparations - biological agents:

• Humira;
• Orencia;
• Remicade.

These drugs are proteins that bind to immune cells and suppress their activity. Treatment with these drugs is expensive and not available in all clinics.

1 ampoule of such a drug can reach a price of up to 70,000 rubles. Such treatment is possible at the expense of the MHIF budget.

How to achieve long-term remission?

Remission is considered:

• lack of joints with active arthritis;
• lack of systemic manifestations;
• normal blood and urine counts, negative C-reactive protein and rheumatoid factor;
• complete absence of complaints in the child;
• morning stiffness no more than 15 minutes.

If within six months the child meets these criteria, then we can safely talk about remission.

In general, the treatment of arthritis is a complex, and, most importantly, lengthy process. May take years. Of course, the child's quality of life suffers. An important role is played by the way the immune system for treatment, whether the dosage is correctly selected, whether the patient receives it.

Juvenile rheumatoid arthritis can be cured only through the coordinated work of the doctor and parents.

juvenile arthritis- a disease characterized by inflammation (swelling) of the synovial membrane in children under the age of 16 years. The synovial membrane is the tissue that covers the joint cavity. Inflammation is often accompanied by fever and skin rash.

Juvenile arthritis is autoimmune disease- a condition in which the immune system begins to mistakenly self-destruct. The disease occurs spontaneously, and the exact cause of its development has not yet been established. Researchers believe that juvenile arthritis may develop under the influence of genetic and infectious factors.

Types of juvenile arthritis

There are five main types of juvenile arthritis:

Systemic arthritis or Still's disease that strikes various systems organism. Systemic juvenile arthritis is usually accompanied by high fever and skin rash. The rash often appears on the trunk, arms, and legs. The disease can also affect internal organs, including the heart, liver, spleen, and lymph nodes, but excluding the eyes. Boys and girls are affected in equal proportions.

Oligoarthritis or pauciarticular juvenile arthritis the first six months is limited to the defeat of a maximum of five joints. At the same time, eye pathologies such as uveritis and iridocyclitis or iritis develop. This type of arthritis mostly affects girls. For most children, the disease resolves as they grow older.

Polyarthritis or polyarticular arthritis affects, as a rule, five or more joints during the first six months of the disease. Most often, this is a symmetrical lesion of the joints on both sides of the body. This type of arthritis can affect the jaw, cervico-occipital region, and joints of the extremities, and is also found mainly in girls.

It occurs in children with symptoms of arthritis and skin diseases. The child may have had psoriasis or another form of arthritis for several years before developing another disease. Children with this form of arthritis often have pitted nails.

Arthritis associated with muscle pathology of traumatic origin has another variety. The disease affects the spine hip joint, eyes and junction area of ​​tendons and bones. This type of arthritis is more common in boys over the age of 8. There is usually a family history of arthritis lower divisions back (spondylitis), usually in men.

Causes of juvenile rheumatoid arthritis

Doctors can't determine exact reason the development of the disease. However, it is assumed that the disease develops under the influence of certain factors:

Hyperactivity of the immune system that destroys healthy joint tissues.

Viruses and other infections that cause an autoimmune reaction.

Hereditary predisposition causing an autoimmune reaction.

Symptoms of juvenile arthritis

The disease is almost asymptomatic. Symptoms may vary depending on the type of arthritis:

Stiffness in the joints, aggravated after waking up.

Pain, swelling and soreness in the joints.

Lameness (in children younger age acquired motor skills may be impaired).

Constant elevated temperature.

Weight loss.

Weakness.

Irritability.

Redness, pain in the eyes, blurred vision.

Symptoms may get worse and worse. Young children can continue to crawl after learning to walk. The child may feel stiff in the morning or have difficulty walking.

Juvenile rheumatoid arthritis can also be accompanied by inflammation of the eyes, which, if left untreated, can cause blurred vision and blindness. Eye disease is often asymptomatic, and loss of vision can occur suddenly. Therefore, your child should have regular check-ups with an ophthalmologist. Treatment should be started before the child develops serious vision problems.

Diagnosis of juvenile rheumatoid arthritis

Your doctor will ask you to describe your child's symptoms, illnesses, and medical checkup. Your child's blood and urine tests may also be needed to check for symptoms of the disease. If symptoms are present, these tests will help your doctor determine the type of disease.

No visible symptoms signs of juvenile arthritis, as well as the presence of other diseases in a child, can complicate the diagnosis of juvenile arthritis. Due to the lack of an effective method for diagnosing juvenile arthritis, the diagnosis is established by excluding other diseases accompanied by similar symptoms such as pathologies or bone fractures, fibromyalgia, infection, Lyme disease, lupus, and cancer.

Before conducting a complete physical examination, the doctor will examine medical card child. Additional tests may be needed to determine the form of arthritis. Diagnostic methods may include:

A detailed blood test (blood test for leukocytes, erythrocytes and platelets).

Radiography (detection of bone fractures).

Scanning or magnetic resonance imaging (MRI).

A blood test to check for the presence of bacteria in the blood, which may indicate an infection in the bloodstream.

Virus testing.

Testing for Lyme disease.

Survey bone marrow used to detect leukemia.

Erythrocyte sedimentation rate test (in people with inflammation, the erythrocyte sedimentation rate is higher than normal).

Test for the detection of rheumatoid factors - antibodies present in the blood of people with arthritis (a positive result is observed mainly in adults).

A test for the presence of antinuclear antibodies to check for an autoimmune response. (An autoimmune reaction is a condition in which the body's defense system, the immune system, begins to self-destruct. This test also detects signs of eye disease in children with juvenile arthritis.)

Bone scan to detect bone and joint changes. (This test can also be used for joint pain of unknown origin.)

Analysis of samples of synovial fluid and synovial tissue, usually performed by an orthopedic surgeon.

Treatment Methods

The choice of treatment depends on the type and degree of arthritis your child has. Traditional treatment is to reduce pain and swelling with the help of painkillers and anti-inflammatory drugs (NSAIDs) in combination with physiotherapy procedures. Intra-articular steroid injections may also be used to reduce pain and swelling.