Escolar Documentos
Profissional Documentos
Cultura Documentos
Learning Objectives
CASE:
A mother of a 2-year-old girl brings
her daughter to a pediatrician for a
third opinion. For the past five
weeks, the girl has been feeling not
quite herself in the morning. She
has been irritable and slow to get
out of bed, sometimes refusing to
get up altogether, and walks more
stiffly than usual. She gets better as
the day goes on but worsens again
after her afternoon nap, and seems
especially uncomfortable when her
diaper is being changed. Two weeks
after the onset of symptoms, the
mother consulted with the childs
family doctor, who surmised the
cause to be either normal growing
pains or a bad fall on the knee. He
referred the girl to an orthopedic
surgeon, who failed to detect any
evidence of a fall and referred the
child to the pediatrician in question.
EPIDEMIOLOGY AND
CLINICAL PRESENTATION
Juvenile arthritis (JA), encompasses the spondyloarthropathies and
reactive arthritis. Juvenile rheumatoid arthritis (JRA), also known as
juvenile idiopathic arthritis (JIA),
comprises three distinct presentations, the most common of which is
early-onset pauciarticular disease
seen most frequently in girls, as in
the above case. By definition, one of
the criteria for JRA requires the
exclusion of other forms of JA.
Estimates for the overall prevalence
of JRA in children under 16 cluster
around the 0.01% mark.
JRA is subdivided into three
types with distinct presentations
and courses:
Pauciarticular JRA (paJRA,
four or fewer joints involved)
accounts for 50% of JRA cases.
45
46
47
48
WHEN TO REFER
EXPECTED COURSE
& MANAGEMENT
Between 40% and 50% of JRA
patients have disease that persists
into adulthood, and more than 30%
have significant functional limitations after 10 or more years of
follow-up. The outcome for JRAassociated uveitis has improved
significantly over the past few
Treatment:
Physical and occupational therapy
Assistance with psychosocial
adjustments (for patient and family)
In milder cases: NSAIDs
In more severe cases: methotrexate
and/or other DMARD as well as
NSAIDs
Oral or injected steroids as needed
(in restricted cases)
49
50
QUESTIONS
1. In what respects does juvenile
rheumatoid arthritis differ from
adult rheumatoid arthritis?
JRA correlates much more poorly
with a positive RF test than does
adult RA. Several clinical manifestations of JRA, such as uveitis
(mostly with paJRA) and pale
pink rash (with sJRA), are not
seen in adult JRA.
2. What aspects of a young patients
history are most suggestive of
JRA?
Persistent arthritis in affected
joints, pain on motion, limitation
of motion, tenderness, joint
warmth, stiff or awkward movements (often noted by caregivers),
and difficulty or reluctance to get
out of bed.