Pediatric Annals

Guest Editorial 

Chronic Arthritis in Children

Diana Milojevic, MD

Abstract

Differentiating between arthralgia and arthritis is of the utmost importance for the pediatrician. Proper joint exam, aided by adequate use of laboratory and imaging tests, makes this differentiation possible.

Renee F. Modica, MD, Sukesh Sukumaran, MD, and myself give a comprehensive review of the joint exam in children, providing illustrations of the exam maneuvers and interpretations of different physical findings.

Although much rarer than arthralgia, arthritis may occur in children, most commonly as part of acute viral or post-viral syndromes. Chronic arthritis not part of any other chronic disease that lasts longer than 6 weeks and has onset before age 16 years, is termed juvenile idiopathic arthritis (JIA).

The JIA nomenclature was introduced by the International League of Associations for Rheumatology (ILAR) in an effort to improve and align the classification and diagnosis of chronic childhood arthritis across the world. Although it is likely that the better understanding of the underlying pathology of chronic arthritis in childhood will lead to changes of this classification in the future, JIA has largely replaced previously used nomenclature.

Three of the articles in this issue report on different types of chronic arthritis in children. Joyce S. Hui-Yuen, MD, MsC, and Lisa F. Imundo, MD, discuss the differential diagnosis of chronic arthritis and give a more detailed description of oligoarticular and polyarticular types of JIA. Arielle D. Hay, MD, and Norman D. Ilowite, MD, report on systemic JIA, a type of chronic arthritis seen almost exclusively in childhood, with prominent systemic inflammation, potentially destructive arthritis, and significant articular and extra-articular complications.

Children who have in the past been diagnosed with “spondyloarthropathy” rarely had spine involvement including sacroiliitis. However, these children frequently had other disease characteristics that closely resembled extra-axial symptoms of adult patients with spondyloarthropathy. Many will grow to develop sacroillitis or spine inflammation in early adulthood.

ILAR classification attempted to address these issues by creating a new type of JIA called enthesitis-related arthritis (ERA), stressing the frequent association of joint and enthesis inflammation. However, the diagnosis of ERA excludes patients with psoriasis (classified by ILAR criteria under psoriatic JIA) or inflammatory bowel disease–associated arthritis and reactive arthritis (not part of ILAR classification at all), although these conditions are associated with the higher risk of developing frank spondyloarthropathy. Clara Lin, MD, and myself address the confusing issue of juvenile arthritides related to spondyloarthropathy.

Pharmacology has provided the greatest gains in outcomes for chronic pediatric arthritis over the past decade. Alice Y. Chan, MD, PhD, and myself describe indications, doses, side effects, and recommendations for pretreatment screening and laboratory follow-up for JIA drug therapies.

Unfortunately, the saying “children outgrow arthritis” is often not true. In her short overview, Tara Valcarcel, RN, MSN, CPNP, provides recommendations on transitioning from pediatric to adult care for patients with this chronic condition.

We hope that this issue of Pediatric Annals provides practical, useful, and “user friendly” information about the diagnosis, treatment, and follow-up of patients with JIA.…

Differentiating between arthralgia and arthritis is of the utmost importance for the pediatrician. Proper joint exam, aided by adequate use of laboratory and imaging tests, makes this differentiation possible.

Renee F. Modica, MD, Sukesh Sukumaran, MD, and myself give a comprehensive review of the joint exam in children, providing illustrations of the exam maneuvers and interpretations of different physical findings.

Although much rarer than arthralgia, arthritis may occur in children, most commonly as part of acute viral or post-viral syndromes. Chronic arthritis not part of any other chronic disease that lasts longer than 6 weeks and has onset before age 16 years, is termed juvenile idiopathic arthritis (JIA).

The JIA nomenclature was introduced by the International League of Associations for Rheumatology (ILAR) in an effort to improve and align the classification and diagnosis of chronic childhood arthritis across the world. Although it is likely that the better understanding of the underlying pathology of chronic arthritis in childhood will lead to changes of this classification in the future, JIA has largely replaced previously used nomenclature.

Three of the articles in this issue report on different types of chronic arthritis in children. Joyce S. Hui-Yuen, MD, MsC, and Lisa F. Imundo, MD, discuss the differential diagnosis of chronic arthritis and give a more detailed description of oligoarticular and polyarticular types of JIA. Arielle D. Hay, MD, and Norman D. Ilowite, MD, report on systemic JIA, a type of chronic arthritis seen almost exclusively in childhood, with prominent systemic inflammation, potentially destructive arthritis, and significant articular and extra-articular complications.

Children who have in the past been diagnosed with “spondyloarthropathy” rarely had spine involvement including sacroiliitis. However, these children frequently had other disease characteristics that closely resembled extra-axial symptoms of adult patients with spondyloarthropathy. Many will grow to develop sacroillitis or spine inflammation in early adulthood.

ILAR classification attempted to address these issues by creating a new type of JIA called enthesitis-related arthritis (ERA), stressing the frequent association of joint and enthesis inflammation. However, the diagnosis of ERA excludes patients with psoriasis (classified by ILAR criteria under psoriatic JIA) or inflammatory bowel disease–associated arthritis and reactive arthritis (not part of ILAR classification at all), although these conditions are associated with the higher risk of developing frank spondyloarthropathy. Clara Lin, MD, and myself address the confusing issue of juvenile arthritides related to spondyloarthropathy.

Pharmacology has provided the greatest gains in outcomes for chronic pediatric arthritis over the past decade. Alice Y. Chan, MD, PhD, and myself describe indications, doses, side effects, and recommendations for pretreatment screening and laboratory follow-up for JIA drug therapies.

Unfortunately, the saying “children outgrow arthritis” is often not true. In her short overview, Tara Valcarcel, RN, MSN, CPNP, provides recommendations on transitioning from pediatric to adult care for patients with this chronic condition.

We hope that this issue of Pediatric Annals provides practical, useful, and “user friendly” information about the diagnosis, treatment, and follow-up of patients with JIA.

Authors

 

 

About the Guest Editor

Diana Milojevic, MD, is an Associate Clinical Professor and a Clinical Director at the Pediatric Rheumatology Division of the Benioff Children’s Hospital, the University of California San Francisco. She obtained her MD and MSc in Immunology at the University of Belgrade, Serbia. She has been board certified and practiced pediatrics at the Mother and Child Health Institute in Belgrade, Serbia, WITS University in Johannesburg, South Africa and the Schneider Children’s Hospital, now Cohen Children’s Medical Center of New York, where she also completed her pediatric rheumatology fellowship training.

Dr. Milojevic has been involved in numerous clinical trials in juvenile idiopathic arthritis and has received several research grants, including the American College of Rheumatology Academic Re-entry Award and the Arthritis Foundation Fellowship Award.

10.3928/00904481-20121022-07

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