About The Author Dr Manoj R.

kandoi is the founder president of Institute of Arthritis Care & Prevention an NGO involved in the field of patient education regarding arthritis. Besides providing literature to patient & conducting symposiums, the institute is also engaged in creating patients Self Help Group at every district level. The institute also conducts a certificate course for healthcare professionals & provide fellowship to experts in the field of arthritis. The author has many publications to his credit in various journals. He has also written a book The Basics Of Arthritis for healthcare professionals. The author can be contacted at: Dr manoj R. kandoi C-202/203 Navare Arcade Shiv Mandir Road, Opposite Dena Bank Shiv mandir Road, Opposite Dena bank Shivaji Chawk, Ambarnath(E) Dist: Thane Pin:421501 State: Maharashtra Ph: (0251)2602404 Country: India Membership Application forms of the IACR for patients & healthcare professionals can be obtained from. Institute of Arthritis Care & Prevention C/o Ashirwad Hospital Almas mension, SVP Road, New Colony, Ambarnath(W) Pin:421501 Dist: Thane State: Maharashtra Country: India Ph: (0251) 2681457 Fax: (0251)2680020 Mobile ;9822031683 Email: drkandoi@yahoo.co.in Preface: Studies have shown that people who are well informed & participate actively in their own care experience less pain & make fewer visits to the doctor than do other people with arthritis. Unfortunately in India & many third world countries we do not have patient education & arthritis self management programs as well as support groups. This is an attempt to give a brief account of various arthritis, their prevention & self management methods which can serve as useful guide to the patients of arthritis. It would be gratifying if the sufferers of the disease knew most of what is given in the book. Acknowledgement\ I am thankful to Dr (Mrs) Sangita Kandoi for her immense help in proofreading & for her invaluable suggestions. The help rendered by Nisha Jaiswal is probably unrivalled. Thanks also to vidya, sheetal and parvati for their continous support throughout the making of the book. The author is grateful to his family for the constant inspiration they offered. The author alone is responsible for the shortcoming in this piece of work. He welcomes suggestions for improvement from the readers.

Juveline Arthritis
Introduction: Juvenile arthritis may be acute or chronic in nature. Under the EULAR criteria, arthritis is considered chronic if it is at least 3 months in duration. Causes of acute onset Juvenile arthritis: 1. Infections: a. Bacterial: staphylococcus Streptococcus Tuberculous b. Viral Rubella HIV Mumps Epstein barf viruses c. Others Mycoplasma 2. Reactive a. Rheumatic fever b. Postvaccination c. Hepatitis B d. Lyme disease e. Postsreptococcal arthritis f. Transient synovitis 3. Neoplastic a. Leukemia and other malignancies b. Hemolytic anaemia c. Neuro blastoma d. Familial mediterrean fever e. Metastasis 4. Vasculitis 5. Juvenile rheumatoid arthritis 6. Hemophilia Causes of chronic arthritis in children: 1. Idiopathic childhood arthritis (Juvenile rheumatoid arthritis): It may be a. Oligoarticular onset JRA b. Polyarticular onset JRA c. Systemic - onset JRA 2. Connective tissue disorder a. SLE b. Dermatomyositis c. Scleroderma

3. Vasculitides a. Kawasaki disease involving smaIl joints b. Henoch schonlein purpura c. Polyarteritis nodosa 4. Spondyloarthropathy a. Juvenile spondyloathropathy b. Ankylosing spondylitis c. Reiter's syndrome d. Psoriatic arthritis e. Inflammatory bowel disease 5. Others: a. Marfan syndrome b. Ehlers danlos syndrome c. Cystic fibrosis d. Hemolytic anaemia e. Sarcoidosis f. Villonodular synovitis g. Mucopolysaccharidoses h. Familial hypertrophic synovitis More commanly monoarticular / oligoarticular Differentiating features between organic and functional joint pains: Organic Joint Pains Symptoms: - Occurs day and night - Not related to school days - Interference with daily activity - Located in joints Functional Joint Pain

- Occurs at night or in morning before school - Occurs during school days. - Interference with day to day activity not there - May be located between joints at bones

Signs: - Limp ++ - Evidence of inflammation +ve -ve - ROM restriction ++ - Muscle weakness +- Systemic menifestation + 8.4 Juvenile rheumatoid arthritis: Juvenile rheumatoid arthritis: IRA usually starts between 1 and 4 years of age and near by 9 and 14 JRA usually starts between 1 and 4 years of age and near by 9 and 14 years of age. years of age. Classification: Classification: Depending upon the number of joints involved during the first 6 months Depending upon the number of joints involved during the first 6 months after disease after disease onset (not the number of joints involved when the child is onset (not the number of joints involved when the child is first seen by doctor) JRA is fIrst seen by doctor) JRA is classified into following subtypes: classified into following subtypes: A) Polyarticular; Multiple joints, small or large are involved in a symmetrical fashion, more common in female. It can be subclassified into following types.. a) RA-positive polyarticular: Usually late childhood onset, RA nodule is common. It is associated with poorer prognosis. b) RA-negative polyarthritis; Better prognosis, may present in early

A. Polyarticular: Multiple joints, small or large are involved in a symmetrical fashion, more common in female. It can be subclassified into following types a. RA-positive polyarticular: Usually late childhood onset, RA nodule is common. It is associated with poorer prognosis. b. RA-negative polyarthritis: Better prognosis, may present in early or late childhood. B. Pauciarticular: One or few (<5) Large joints, more commonly asymmetrically involved. They are further divided in to 2 subgroups: a. Early childhood (between 2-5years): Female more commonly involved, ANA is frequently positive, there is incidence of chronic iritis. Mild arthritis with usually good prognosis b. Late childhood (> 6 years): More often in males, more often HLA B-27 positive, ANA negative, some may have spondyloarthropathy like adults. c. Systematic onset: It is characterized by polyarthalgia, polyarthritis with systemic manifestations such as high fevers, evenescent rash etc. The gender frequency as well as age of onset is equally distributed throughout childhood. Usually RA and ANA negative. Differentiating features of three types of JRA: Polyarthritis Oligoarthritis Stills disease Incidence No of joints involved Sex ratio Chronic uveits RA positivity ANA positivity Prognosis 40% 5 F>M 5% + moderate to poor 50% 4 F<M 20% rare ++ better except for eyesight 10% variable F=M Rare rare rare moderate to poor

Extraarticular manifestations of systemic onset JRA: 1. Intermittent fever: A persistent intermittent fever with diurnal variation between 102 f and 106 f with returns to normal is a must for diagnosis. 2. Skin rash: Evanescent, pink, macular pale centre, on chest and limbs may be seen in associated with fever. 3. Hepatomegaly / mild liver dysfunction 4. Pericarditis 5. Splenomegaly 6. Leucocytosis 7. Lymphadenopathy 8. Severe anaemia 9. DIC syndome

Diagnostic criteria for JRA 1. Age of onset below 16 years 2. Polyarthritis or monoarticular arthritis lasting longer than 3 month 3. Swelling or presence of atleast 2 of following: a. Heat b. Pain c. Tenderness d. Restriction of motion 4. Type of onset, classified as: a. Polyarthritis b. Oligoarthritis c. Systemic illness: including arthritis, intermittent fever, rheumatoid rash. 5. Exclusion of other forms of arthritis Differentiating features between systemic JRA and SLE: Features Age LE cells Oral lesions Evanescent rash Leukocytosis Renal abnormalities ANA Absence of ANA rules out SLE Systemic JRA 1 -15 years of age + + SLE 5 years + + + +

Treatment: Medical management: A. Nonsteroidal antiinflammatory drugs 1. Salicylate: (80 -130 mg/kg 1 day) 2. Indomethacin: (0.5 -3 mg/kg 1 day) B. Slowly acting antirheumatic drugs: 1. 1M gold: 1 mg/kg weekly interval 2. Auranofin: 0.15 -0.20 mg/kg 1 day 3. Hydroxychroquine: 5 -7 mg/kg 1 day 4. Sulfasalazine: 40 mg/kg/day 5. Methotrexate: 0.15 -0.5 mg/kg/wk. 6. Etarnacept: 0.4 mg/kg C. Steroids 1. Prednisolone: 1 -2 mg/kg/day D. Conservative orthopaedic management: 1. Rest 2. Exercise: gradual excercise within pain tolerance limits 3. Heat therapy

4. Orthosis or plaster cast 5. Traction if needed E Family support F Regular eye-check ups and treatment G Surgery: Surgical options include 1. Synovectomy 2. Joints replacement / arthrodesis in severly affected joints 3. Corrective osteotomies in joint deformities 4. Soft tissue release in joint deformities