Click here to view next page of this article Juvenile Rheumatoid ArthritisJuvenile rheumatoid arthritis (JRA) is a condition of chronic synovitis in children. The inflammation of JRA targets the synovial tissue in Still's disease. Affected joints are swollen, limited in motion, stiff, painful, warm, and occasionally erythematous. The etiology of JRA is unknown. Clinical manifestations The American Rheumatism Association currently recognizes three subgroups: systemic-onset disease, polyarticular-onset disease. Extraarticular manifestations of JRA include the iridocyclitis, rheumatoid nodules; fever, rash, polyserositis, hepatosplenomegaly, lymphadenopathy, anemia, leukocytosis, myocarditis, interstitial lung disease, disseminated intravascular coagulation, and amyloidosis. Growth retardation may occur. Diagnosis of JRA usually requires onset of disease during childhood, presence of chronic synovitis, and exclusion.
Therapy Nonsteroidal anti-inflammatory drugs (NSAIDs) remain front-line agents in the treatment of juvenile rheumatoid arthritis. NSAIDs available for use in children include salicylates, naproxen, tolmetin, ibuprofen, and indomethacin. Salicylism and salicylate hepatotoxicity may occur, and salicylates also have been associated with Reye syndrome. All of the NSAIDs may be associated with gastritis or duodenal ulcer disease. Methotrexate is an effective agent in severe JRA, and it is recommended for children whose disease is unresponsive to NSAIDs. Doses of 10 to 15 mg/m2 per week orally or intramuscularly. Disease-modifying therapies that are being tried in therapy of JRA include sulfasalazine, intravenous immunoglobulin, corticosteroid therapy, and cyclosporin. Sulfasalazine is used widely. Oral corticosteroids may be useful for severe systemic disease and iridocyclitis. Physical and occupational therapy should preserve joint range of motion. Synovectomy is of very limited usefulness. Leg length inequality, which may result from asymmetric arthritis affecting the knees, usually is transitory and can be managed by a temporary shoe lift. Soft-tissue releases can alleviate contractures, and total joint replacements.
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