Juvenile Arthritis

What is juvenile arthritis?

Juvenile arthritis is a disease in which there is inflammation (swelling) of the synovium in
children aged 16 or younger. The synovium is the tissue that lines the inside of joints.
Juvenile arthritis is an autoimmune disease. That means the immune system attacks the body
itself. The disease is also idiopathic, which means that no exact cause is known. Researchers
believe juvenile arthritis may be related to genetics, certain infections, and environmental
triggers.

What causes it?

No known cause has been pinpointed for most forms of juvenile arthritis, nor is there evidence to
suggest that toxins, foods or allergies cause children to develop the disease. Some research points
toward a genetic predisposition, which means the combination of genes a child receives from
family members may cause the onset of arthritis when triggered by other factors.

What are the different types of juvenile arthritis?

There are basically five types of juvenile arthritis:

Systemic arthritis, also called Still's disease, can affect the entire body

or involve many systems of the body. Systemic juvenile arthritis

usually causes high fever and a rash. The rash is usually on the trunk,
arms, and legs. Systemic juvenile arthritis can also affect internal
organs, such as the heart, liver, spleen, and lymph nodes, but usually
not the eyes. Boys and girls are equally affected.
Oligoarthritis, also called pauciarticular juvenile rheumatoid arthritis,
affects fewer than five joints in the first six months that the child has
the disease. The joints most commonly affected are the knee, ankle,
and wrist. Oligoarthritis can affect the eye, most often the iris. This is
known as uveitis, iridocyclitis, or iritis. This type of arthritis is more
common in girls than in boys, and many children will outgrow this
disease by the time they become adults.

Polyarthritis, also called polyarticular arthritis, involves five or more

joints in the first six months of the disease -- often the same joints on
each side of the body. This type of arthritis can affect the joints in the
jaw and neck as well as those in the hands and feet. This type also is
also more common in girls than in boys and more closely resembles
the adult form.
Psoriatic arthritis affects children who have both arthritis and the skin

disorder psoriasis. The child might get either the psoriasis or the
arthritis years before developing the other part of the disease. Children
with this type of arthritis often have pitted fingernails.
Enthesitis-related arthritis is a type of arthritis that often afflicts the
spine, hips, eyes, and entheses (the places where tendons attach to
bones). This type of arthritis occurs mainly in boys older than 8 years
of age. There is often a family history of arthritis of the back (called
ankylosing spondylitis) among the child's male relatives.

What are the symptoms of juvenile arthritis?

Children with juvenile arthritis can have no symptoms at all. Symptoms may also vary
depending on the type of arthritis. Symptoms of juvenile arthritis may include:

joint stiffness, especially in the morning

pain, swelling, and tenderness in the joints
limping (In younger children, it may appear that the child is not able to

perform motor skills he or she recently learned.)

persistent fever
rash
weight loss
fatigue
irritability
eye redness, eye pain, and/or blurred vision

Pathophysiology
1.

Systemic inflammatory process originating in the synovium or synovial fluid involving

connective tissue and characterized by destruction and proliferation of synovial membrane.

2.

Phagocytosis produces enzymes within the joint, causing inflammation.

3.

Collagen is destroyed over time and pannus formations occur, narrowing the joint space.

4.

May result in joint destruction, ankylosis and deformity with loss of articulation and joint
motion.

5.

Inflammatory process can also affect the spine, blood vessels, the pleural membrane of
the lungs or the pericardial sac.

6.

Condition may be short lived and limited or progressive and severe.

7.

Spontaneous remissions and unpredictable exacerbations can occur.

How is it diagnosed?

Laboratory tests--Laboratory tests, usually blood tests, cannot by themselves provide the
doctor with a clear diagnosis. But these tests can be used to help rule out other conditions
and to help classify the type of JRA that a patient has. Blood may be taken to test for RF
and ANA, and to determine the erythrocyte sedimentation rate (ESR).
o

ANA is found in the blood more often than RF, and both are found in only a small
portion of JRA patients. The RF test helps the doctor tell the difference among the three
types
of
JRA.

ESR is a test that measures how quickly red blood cells fall to the bottom of a test
tube. Some people with rheumatic disease have an elevated ESR or "sed rate" (cells fall
quickly to the bottom of the test tube), showing that there is inflammation in the body.
Not all children with active joint inflammation have an elevated ESR.

X rays--X rays are needed if the doctor suspects injury to the bone or unusual bone
development. Early in the disease, some x rays can show cartilage damage. In general, x
rays are more useful later in the disease, when bones may be affected.

What are the treatment options?

Unfortunately, there is no cure for juvenile arthritis. The goal of treatment for JA is to relieve
inflammation, control pain and improve your childs quality of life. Most treatment plans involve
a combination of medication, physical activity, eye care and healthy eating.
Every treatment plan is unique and requires that your child's health care team, which might
include a pediatric rheumatologist, dentist, ophthalmologist, nurse practitioner and physical
therapist, among others.
Medications used to treat JA can be divided into two groups: those that help relieve pain and
inflammation (nonsteroidal anti-inflammatory drugs, or NSAIDs, corticosteroids and analgesics)
and those that can alter the course of the disease, put it into remission and prevent joint damage,
a category known as disease-modifying anti-rheumatic drugs (DMARDs) and a newer subset
known as biologic response modifiers (biologics).
Each child responds to his or her treatment plan differently, so theres no set course of attack for
JA. Your child's doctor might try several different medications and/or dosages until your child
responds positively to treatment. Some medications affect the immune system or have other side
effects, making careful and frequent monitoring very important.

Med-Surg. Management
Management may include one or all of the following areas:

Pharmacologic management consisting of nonsteroidal anti-inflammatory drugs

(NSAIDs), disease-modifying antirheumatic drugs (DMARDs), biologic agents, and intraarticular and oral steroids
Psychosocial factors, including counseling for patients and parents
School performance, such as academic counseling, school-life adjustments, and physical
education adjustments
Nutrition, particularly to address anemia and generalized osteoporosis; often microcytic,
anemia is refractive to treatment with iron
Physical therapy to relieve pain and to address range of motion, muscle strengthening,
activities of daily living, and conditioning exercises

Occupational therapy, including joint protection, a program to relieve pain, range of

motion, and attention to activities of daily living

Nursing Management
1.

Alleviate pain.

2.

Increase mobility.

3.

Promote positive self-concept.

4.

Support independence.

5.

Provide information about disease process/prognosis and treatment needs.