Arthritis, Juvenile Idiopathic

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Basics

Description

  • Juvenile idiopathic arthritis (JIA) is the most common chronic pediatric rheumatologic disease.
  • JIA is associated with significant disability.
    • Age of onset: <16 years
    • Common symptoms: joint swelling, restricted range of motion, warmth, redness, pain
    • Often ≥6 weeks of symptoms prior to diagnosis
  • Seven (International League of Associations for Rheumatology [ILAR]) subtypes, determined by clinical characteristics in first 6 months of illness (1):
    • Systemic (Still disease): 10%; preceded by febrile onset of ≥2 weeks with rash, serositis, hepatosplenomegaly or lymphadenopathy (1)
    • Polyarticular rheumatoid factor (RF) (+): 2–7%; ≥5 joints involvement (1); large and small joints; RF positive on two tests ≥3 months apart (2)
    • Polyarticular RF (−): 10–30%; ≥5 (large and small) joints involved (1); RF negative (2)
    • Oligoarticular: 30–60%; involvement of 1 to 4 joints; risk for chronic uveitis in antinuclear antibodies (ANA) (+) females (1) and axial skeletal involvement in older boys (2). Types: (i) persistent (40%): knee, ankle, elbow; (ii) extended type (20%): >4 joints after first 6 months
    • Psoriatic arthritis: 5%; arthritis with psoriasis or arthritis with >2 of: dactylitis, nail changes (pitting), psoriasis in first-degree relative (1)
    • Enthesitis-related arthritis: 1–11%; arthritis and enthesis or one of them plus at least two of the following: sacroiliac or lumbosacral pain, Reiter syndrome or acute anterior uveitis in first-degree relative, acute symptomatic anterior uveitis, HLA-B27 (+), history of ankylosing spondylitis, sacroiliitis with inflammatory bowel disease, onset of arthritis in male >6 years old (1)[C]
    • Undifferentiated arthritis (11–21%): presents with overlapping symptoms in ≥2 categories above or arthritis that does not fulfill above categories (2)
  • System(s) affected: musculoskeletal, hematologic, lymphatic, immunologic, dermatologic, ophthalmologic, gastrointestinal
  • Synonyms: juvenile chronic arthritis; juvenile arthritis; juvenile rheumatoid arthritis (JRA); Still disease (2)

Epidemiology

  • Male = female (1); onset: throughout childhood; 54% of cases occur in children 0 to 5 years.
  • Polyarticular RF (+): female > male, 3:1 (2); onset: late childhood or adolescence (1)
  • Polyarticular RF (−): female > male, 3:1; onset: early peak, 2 to 4 years; late peak, 6 to 12 years (2)
  • Oligoarticular: female > male, 5:1; onset: 2 to 4 years (2)
  • Psoriatic: female > male, 1: 0.95 (2); onset: early peak, 2 to 3 years; late peak, 10 to 12 years (1)
  • Enthesitis: female > male, 1:7; onset: early peak, 2 to 4 years; late peak, 6 to 12 years (2)
  • Affected patients have an increased risk of developing cancer, although short-term risk is low.

Incidence
2 to 20/100,000 children <16 years in developed nations

Prevalence
16 to 150/100,000 children <16 years in developed nations (1)

Etiology and Pathophysiology

  • Humoral and cellular immunodysregulation. T lymphocytes play a key role.
  • Genetic predisposition; IL2RA/CD25 and VTCN1 implicated as genetic loci
  • Environmental triggers, possibly infectious
    • Rubella or parvovirus B19 (3)
    • Heat shock proteins (3)
  • Immunoglobulin or complement deficiency

Genetics
  • Human leukocyte antigen (HLA) class I (A, B, C) and II (DR, DP, DQ) alleles
  • HLA-A2 = early onset oligoarthritis in females
  • HLA class II increases risk of systemic and oligo-JIA.
  • HLA-B27 increases risk of enthesitis-related arthritis.
  • HLA-DR4 is associated with polyarthritis RF (+) (3)[C].

Risk Factors

Female gender 3:1

General Prevention

None identified

Commonly Associated Conditions

Other autoimmune disorders, chronic anterior uveitis (iridocyclitis), nutritional impairment, growth issues (3)[C]

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Citation

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TY - ELEC T1 - Arthritis, Juvenile Idiopathic ID - 116945 Y1 - 2019 PB - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116945/all/Arthritis__Juvenile_Idiopathic ER -