Juvenile rheumatoid arthritis--Madras experience

Juvenile Idiopathic Arthritis

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children. The International League of Associations for Rheumatology (ILAR) has defined JIA as "arthritis of unknown etiology persisting for ≥6 wk with an onset at <16 y of age, after excluding other causes of joint inflammation". Synovial inflammation is the result of a complex interplay of aberrant immune systems (both adaptive and innate) in a genetically susceptible individual, with possible external stimuli/triggers. Diagnosis of JIA essentially remains clinical, and laboratory investigations usually help to assess the severity of disease activity. Few investigations like antinuclear antibodies (ANA), human leukocyte antigen (HLA)-B27, and rheumatoid factor (RF) help to categorize or prognosticate a child with JIA. Timely use of effective therapeutic interventions including biological has shown good long-term outcomes of JIA.

Rheumatology in India--quo vadis?

Rheumatology has been a neglected subspecialty in India. A staggering patient load, a severely inadequate number of trained rheumatology specialists, therapeutic nihilism and limited advocacy are some of the critical challenges that confront rheumatology care, and possibly explain the high rates of reliance on complementary and alternative medicines in India. Disease spectrum and treatment patterns are not remarkably different from those in other countries, but biologic agents have limited use and are administered for short periods only. Consequently, outcomes in India do not yet match those reported in developed countries. Furthermore, the high prevalence of infectious diseases continues to be a major contributor to mortality in patients with rheumatic disorders such as systemic lupus erythematosus. Several tropical diseases with rheumatic manifestations are relevant in India, including chikungunya, brucellosis, leptospirosis, dengue and melioidosis. To address the many problems with rheumatology care in India, curricular reforms, capacity building, patient education and political support are sorely needed.

Paediatrics Rheumatology Clinic Population in Singapore: The KKH Experience

Introduction:

The subspecialty of paediatric rheumatology (PR) is the newest discipline established at KK Women's and Children's Hospital, in 2009. The service provides tertiary care for children with rheumatic diseases in Singapore. Referral population to this subspecialty has not been described in this region.

Methods:

Using the Registry for Childhood Onset Rheumatic Diseases (RECORD), a dedicated web-based data entering system, case descriptions and diagnoses were captured. Standardised descriptions of diagnoses were used.

Results:

Data from January 1, 2009 to March 31, 2012 included 1158 referrals which were analysed. Almost half (42.2%) were diagnosed as non-rheumatic conditions. Systemic vasculitides (28.4%) with Henoch-schonlein purpura (HSP) and Kawasaki disease (KD) were the most common rheumatic diseases. Enthesitis related juvenile idiopathic arthritis (JIA) was common but JIA associated uveitis was rare, so as to antinuclear antibody (ANA) positivity (25.4%). The remaining 36.4% of patients with rheumatic disease had a variety of other conditions. Primary angiitis of the central nervous system (CNS) and recurrent aphthous stomatitis were seen more commonly in local patient than in patients from the west. Of the patients with non-rheumatic disease, 66.3% had orthopaedic/mechanical related conditions, 7.4% had a fever of unknown causes and 4.9% had infections. Mechanical joint pain (67.6%) and hypermobility syndrome (18.5%) were the most frequent referrals.

Conclusion:

Our report described, for the first time, a large single centre cohort of a PR clinic population. Local frequencies or burden of paediatric rheumatic diseases and unique findings were delineated. Targeted education and awareness to both healthcare professionals and members of the public were made possible. However, continuous prospective longitudinal data collection is on-going in order to confirm our initial observation.

Prevalence and clinical pattern of juvenile idiopathic arthritis in a semi-urban area of Bangladesh

OBJECTIVE

To determine the prevalence and clinical pattern of juvenile idiopathic arthritis (JIA) in a semi-urban area of Bangladesh.

METHODOLOGY

A cross-sectional study was carried out among 16 270 children who were selected by using multistage sampling technique from a community of approximately 105 986 children in the Narayanganj district, Bangladesh. Duration of the study was from November 2008 to December 2009. Examinations of the suspected JIA patients were done by the authors in the community as well as in the pediatric rheumatology follow-up clinic at Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh.

RESULTS

The estimated point prevalence of JIA was 60.5 per 100 000 children. In total 10 patients were identified among 16 270 children. Girl : boy ratio was 2.3 : 1.0. The subgroup distribution showed oligoarticular JIA in the majority of patients (60%).

CONCLUSIONS

Prevalence of JIA in this study in a semi-urban area of Bangladesh was consistent with established population-based studies in developed countries. Clinical pattern of JIA patients also had similarities with reports from Western countries.

Juvenile idiopathic arthritis-its rare presentation

The authors report a case of systemic onset juvenile idiopathic arthritis who presented with fever, excruciating neck pain and stiffness followed by respiratory difficulty after few days of onset of illness. The unusual features of the case were: cervical spondylitis without any peripheral joint involvement, myocarditis leading to congestive cardiac failure, though pericarditis being the common cardiovascular manifestation of SOJIA was also associated.

Incidence and outcomes of uveitis in juvenile rheumatoid arthritis, a synthesis of the literature

BACKGROUND

Juvenile rheumatoid arthritis (JRA) is the most common systemic cause of pediatric uveitis in Europe and North America. Uveitis is commonly perceived as a frequent sequela of JRA and JRA-associated uveitis is commonly considered to have a complicated course with frequent adverse visual outcomes.

METHODS

We performed a systematic literature search for series of consecutive patients with JRA (as defined by the American College of Rheumatology criteria) reporting on the frequency of uveitis and/or complications of uveitis, published between January 1980 and December 2004. The main outcome measures were: the cumulative incidence of uveitis in JRA, the cumulative incidence of adverse visual outcome and that of complications in JRA-associated uveitis. Additionally, the influence of gender, presence of antinuclear antibody (ANA) and disease onset subtype to the likelihood of developing uveitis were examined.

RESULTS

Analysis of pooled data from the 26 eligible series suggested a cumulative incidence of uveitis in JRA of 8.3% [95% confidence intervals (CI), 7.5-9.1%]. The cumulative incidence of uveitis varied according to geographic location, being highest in Scandinavia, then the US, then Asia and lowest in India. JRA-associated uveitis was more common in pauciarticular than polyarticular onset patients [odds ratio (OR) = 3.2, 95% CI, 2.33-4.36] and in ANA-positive than ANA-negative patients (OR = 3.18, 95% CI, 2.22-4.54). Female gender was only a weak risk factor for the development of uveitis in JRA patients (OR = 1.69, 95% CI 1.09-2.62) and was not statistically significant after considering disease onset subtypes. In JRA-associated uveitis the cumulative incidence of cumulative incidence of adverse outcome (visual acuity < 20/40 OU) was 9.2% (95% CI: 4.7-15.8) of cataracts 20.5% (95% CI: 15.5-26.3), of glaucoma 18.9% (95% CI: 14.4-24.2) and of band keratopathy 15.7% (95% CI: 10.9-21.7).

CONCLUSION

The cumulative incidence of uveitis in JRA varies according to geographic location, presence of ANA, type of JRA onset and gender. Uveitis, adverse visual outcome, and complications in JRA are less frequent than commonly accepted.