Incidence and Characteristics of Arthritis in Norwegian Children: A

Population-Based Study
ystein Rolandsen Riise, Kai Samson Handeland, Milada Cvancarova, Karl-Olaf
Wathne, Britt Nakstad, Tore Gunnar Abrahamsen, Eva Kirkhus and Berit Flat
Pediatrics 2008;121;e299-e306; originally published online Jan 28, 2008;
DOI: 10.1542/peds.2007-0291

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ARTICLE

Incidence and Characteristics of Arthritis in

Norwegian Children: A Population-Based Study
ystein Rolandsen Riise, MD, MPHa,b, Kai Samson Handeland, MDa, Milada Cvancarova, MScc, Karl-Olaf Wathne, MD, PhDb,
Britt Nakstad, MD, PhDd,e, Tore Gunnar Abrahamsen, MD, PhDf, Eva Kirkhus, MDg, Berit Flat, MD, PhDa
Departments of aRheumatology, cBiostatistics, and gRadiology, Rikshospitalet Medical Centre, Oslo, Norway; bDepartment of Pediatrics, Ulleval University Hospital, Oslo,
Norway; dDepartment of Pediatrics, Akershus University Hospital, Nordbyhagen, Norway; e Akershus Faculty Division, University of Oslo, Nordbyhagen, Norway;
fDepartment of Pediatrics, Rikshospitalet Medical Centre and Faculty Division Rikshospitalet, University of Oslo, Oslo, Norway
The authors have indicated they have no nancial relationships relevant to this article to disclose.

ABSTRACT
OBJECTIVE. The purpose of this work was to assess the annual incidence of arthritis in
children and describe early disease and patient characteristics, microbiologic features,
and immunogenetic factors in children with different subgroups of childhood arthritis.
PATIENTS AND METHODS. A population-based multicenter study was performed in south-

eastern Norway between June 1, 2004, and May 31, 2005. The total population of
children under 16 years of age was 255 303. Physicians were asked to refer their
patients with suspected arthritis to the local department of pediatrics or rheumatology. The children were assessed on the basis of clinical, radiologic, and laboratory
examinations at inclusion and followed up at 6 weeks, 6 months, and thereafter as
long as clinically indicated. A chart review was performed to identify patients with
arthritis who had not been included prospectively.
RESULTS. The total annual incidence of arthritis was 71 per 100 000 children. Transient

arthritis, juvenile idiopathic arthritis, postinfectious arthritis, and infectious arthritis

were found in 43, 14, 9, and 5 of 100 000 children, respectively. The incidence was
higher in children under the age of 8 years than in older children (107 vs 34 per
100 000). Arthritis occurred more frequently in boys than in girls before the age of
8 years but not thereafter. The median age of onset was lower in children with
infectious arthritis than in those with other types of arthritis. Monarthritis was less
frequent in patients with juvenile idiopathic arthritis than in the other subgroups
(64% vs 83%100%). Ten percent of the patients had poststreptococcal reactive
arthritis, and only 1 had enteropathic arthritis. Autoantibodies and the presence of
HLA-B27 were associated with juvenile idiopathic arthritis.

www.pediatrics.org/cgi/doi/10.1542/
peds.2007-0291
doi:10.1542/peds.2007-0291
Key Words
incidence, arthritis, children
Abbreviations
PRSApoststreptococcal reactive arthritis
WBC, white blood cell
JIAjuvenile idiopathic arthritis
IgMimmunoglobulin M
ANAantinuclear antibody
anti-CCPanti cyclic citrullinated peptide
antibody
RFrheumatoid factor
CI condence interval
OR odds ratio
Accepted for publication Jun 21, 2007
Address correspondence to ystein Rolandsen
Riise, MD, MPH, Department of Rheumatology,
Rikshospitalet Medical Centre, N-0027 Oslo,
Norway. E-mail: oystein.riise@rikshospitalet.no
PEDIATRICS (ISSN Numbers: Print, 0031-4005;
Online, 1098-4275). Copyright 2008 by the
American Academy of Pediatrics

CONCLUSIONS. The annual incidence of childhood arthritis was 71 per 100 000 children. We found several factors that
may help in differentiating between subgroups of arthritis.

RTHRITIS IS AN inflammation of the synovia of the joints.1 It may be directly or indirectly caused by infectious
agents, transient or chronic idiopathic, or associated with other diseases.2 A delay in diagnosis, treatment, or
follow-up may result in heart disease in streptococcal-associated arthritis, visual impairment in chronic arthritis, and
joint damage and bone destruction in septic and chronic arthritis.37 Only 1 single study has been performed that dealt
with immunologic and microbiologic tests for identifying the different diagnostic groups, which would contribute to
early recognition of the disease.2
Only 2 studies of the incidence of childhood arthritis have been performed, and the results have varied. In a study
of Finnish children in 1986, Kunnamo et al8 found an incidence of 109 per 100 000 children, and in 2001, von
Koskull et al9 reported an incidence of 83 per 100 000 children in a German study. However, subgroups of childhood
arthritis were not described in detail in the German study, and the inclusion of patients was mainly based on
questionnaires distributed to primary care physicians. There are few reports on the incidence of subgroups of
childhood arthritis, such as enteropathic, Lyme, and poststreptococcal reactive arthritis (PSRA).8,10,11

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e299

The aim of this prospective, population-based study

was to estimate the annual incidence of arthritis in children and to describe the role of patient characteristics,
auto-antibodies, HLA-B27, and microbiologic variables
in early recognition of distinct subgroups of childhood
arthritis.
PATIENTS AND METHODS
Background Population
We conducted a population-based, multicenter study in
3 counties in southeastern Norway between June 1,
2004, and May 31, 2005. Twenty-seven percent of the
Norwegian population live in this region, and the total
population is 1 252 835. The total number of children
under the age of 16 years was 255 303 on January 1,
2004,12 93 688 in the city of Oslo, 112 129 in the mainly
suburban county of Akershus, and 49 486 in the smalltown and rural county of Buskerud. In Scandinavia the
majority of patients receive care within their county of
residence, and the homogeneous health care and social
security system, with its equality of access, facilitates
recruitment to epidemiologic studies.13
Recruitment
We recruited children under the age of 16 years with
possible or evident arthritis and/or osteomyelitis, determined on the basis of 1 of the following characteristics:
(1) joint swelling; (2) limited range of motion in 1 joint
and walking with a limp or other functional limitations
affecting arms and/or legs; and (3) pain in 1 joint or
extremity together with C-reactive protein level of 20
mg/L and/or an erythrocyte sedimentation rate of 20
mm/hour and/or white blood cell (WBC) count of 12
109/L. These signs should have lasted for 6 weeks and
should not have been caused by trauma.
All of the general practitioners, pediatricians, orthopedic surgeons, and rheumatologists in the 3 counties
(n 1300) were contacted. They received 4 letters, 1 at
the beginning and then every 3 months during the study
period. They were asked to refer children who satisfied
the criteria to a local hospital on the day the patient was
first seen. Within 1 to 3 days, the patient was examined
at 1 of the pediatric departments in the region or at the
regional department of pediatric rheumatology, (ie, Akershus University Hospital, Buskerud Hospital, Ullevl
University Hospital, or the Rikshospitalet Medical Centre). We searched the hospitals computerized records
for 181 relevant diagnoses based on the International
Classification of Diseases, 10th Revision,14 at the end of the
study, to identify any patients with arthritis who had not
been included.
Inclusion Criteria
Only patients with permanent residence in the counties
of Oslo, Buskerud, or Akershus were included, and the
arthritic disease had to include 1 of the following 3 signs:
(1) swelling of a joint; (2) restricted mobility of a joint
with warmth and/or tenderness and/or pain1; or (3)
arthritis demonstrated by ultrasound or MRI.
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RIISE et al

Exclusion Criteria
Patients who had been diagnosed with juvenile idiopathic arthritis (JIA) before June 1, 2004, or who had
inflamed synovia related to trauma or malignant disease
were excluded.
Classication Procedure
All of the follow-up data from the medical charts relevant to the final diagnosis were included up to March
2006 (range: 9 21 months). Two researchers recorded
the clinical information independently on a standardized
form. In case of disagreement, the classification was
established in consultation with specialists in pediatric
infectious diseases and pediatric rheumatology. Written
informed consent was obtained from the parents of the
children included in the study. The regional ethics committee for medical research and the ombudsman for
privacy in research at the Norwegian Social Science Data
Services approved the study.
Assessments
The number of swollen, tender, and mobility-restricted
joints1 was registered on admission, after 6 weeks, and
after 6 months. In addition, the children were reexamined within a few days if they had not improved significantly. An ultrasound of affected joints was performed
on admission. In addition, an ultrasound of the hips was
performed on all of the children 5 years of age with
symptoms from the legs. Joint aspiration and MRI were
recommended within 3 days if monoarthritis or oligoarthritis of 2 weeks duration occurred in combination
with 1 of the following: (1) fever of 38.5C; (2) C-reactive protein level of 30 mg/L, erythrocyte sedimentation rate of 30 mm/hour, or WBC count of 12
109/L; (3) excessively painful joint or bone; or (4) other
suspicious factors for septic arthritis or osteomyelitis. In
addition, we recommended that joint aspiration and
MRI be performed within 14 days if arthritis in 1 to 3
joints persisted for 1 week.
Classication Criteria
The classification criterion for septic arthritis was that either the synovial fluid tested positive for bacteria by culture
or microscopy or the synovial fluid WBC count was 50
109/L. Acute rheumatic fever was classified according to
the modified Jones criteria.4 PSRA was classified on the
basis of the criteria proposed by Ayoub.15 The criterion for
enteropathic arthritis was arthritis together with positive
bacterial stool culture (Yersinia, Salmonella, Shigella, or
Campylobacter species) or serologic evidence of Yersinia infection. Patients with no other obvious cause of arthritis
and Borrelia infection confirmed by serology were diagnosed with Lyme arthritis. Arthritis that had lasted 6
weeks, with no established association to infection, was
classified as transient arthritis. Arthritis with transient erythematous raised skin lesions was classified as urticaria
arthritis. Henoch-Schonlein purpura was classified according to the American College of Rheumatology criteria.16
JIA was classified according to the International League of
Associations for Rheumatology criteria, that is, arthritis of

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TABLE 1 Tests Performed on 182 Patients With Arthritis

Examination

No. of
Patients

Method

Antistreptolysin-O

148

Antideoxyribonuclease B

147

Neutralization of ASO (BioMerieux, Charbonnier les Bains, France, or

Dade Behring, Eschborn, Germany)
Neutralization of anti-DNase B (BioMerieux, Charbonnier les Bains,
France, or Dade Behring, Eschborn, Germany)
Immunoassay (Abbott Diagnostics, Wiesbaden, Germany)
Double-sandwich EIA, IgM antibodies (Bio-Rad, Hercules, CA)
ELISA for chlamydia and Chlamydia pneumoniae (Medac, Wedel,
Germany) or Chlamydia ornithosis-complemention xation test
(Dade Behring, Eschborn, Germany)
EIA (HiSS Diagnostics, Freiburg, Germany), indirect EIA with
recombinant antigen (Biotest AG, Dreieich, Germany), direct
particle-bound antigen-antibody reaction (Unipath Diagnostics,
Koln, Germany), or ELISA (Institute Virion/Serion, Wurzburg,
Germany)
ELISA (Medac, Wedel, Germany), indirect ELISA (Dade Behring,
Eschborn, Germany), or ELFA (BioMerieux, Charbonnier les Bains,
France)
EIA (Biotrin, Dublin, Ireland)
ELISA (Daco, Glostrup, Denmark) or Micro Widal Reaction (SIFIN,
Berlin, Germany)
ELFA (BioMerieux, Charbonnier les Bains, France), ELISA (Dako,
Glostrup, Denmark), quick ELISA (Immunetics, Boston, MA), or
determination based on an extract of Borrelia afzelii strain (Dade
Behring, Eschborn, Germany)
Routine culturing or rapid testing
Routine culturing of Yersinia, Salmonella, Shigella, and
Campylobacter
IC (Coris Bioconcept, Gembloux, Belgium; BioMerieux, Charbonnier
les Bains, France; or Orion Diagnostica, Espoo, Finland)
Routine
Routine rapid testing
Fluorescence or ELISA
ELISA
ELISA or immunonephelometry
Flow cytometry, serology, or genetic methods
Routine
Routine
Routine
Routine
Routine
Routine

Hepatitis B
Mycoplasma pneumoniae antibodies
Chlamydia antibodies

94
94
94

Epstein-Barr virus

94

Cytomegalovirus

94

Parvovirus B19
Yersinia enterocolitica

94
94

Borrelia burgdorfe

130

Throat streptococcal smear

Bacterial culturing of feces

120
86

Fecal rota and adenovirus

86

Blood culture
Urine analysis
ANA
Anti-CCP
IgM RF
HLA-B27
Joint aspiration
Ultrasound of joints
MRI of joints
C-reactive protein
Erythrocyte sedimentation rate
WBC

67
124
92
73
84
80
46
145
51
176
160
176

EIA indicates enzyme immunoassay; ELISA, enzyme-linked immunosorbent assay; ELFA, enzyme-linked uorescence immunoassay; IC,
immunochromatography.

unknown etiology that persisted for 6 weeks with onset

before the age of 16 years.17
Microbiologic, immunologic, radiologic, and HLAB27 tests were performed at each of the hospitals as part
of the routine diagnostic procedure (Table 1). The evidence of antecedent group A streptococcal infection was
defined as the presence of 1 of the following: (1) group
A streptococci in throat culture or rapid antigen testing
at inclusion or during the previous 4 weeks; (2) increasing antistreptolysin-O and/or anti-deoxyribonuclease B
titer of 2 dilution steps between the acute and convalescent phases; or (3) antistreptolysin-O and/or antideoxyribonuclease B titer of 600 during the first 6
weeks after inclusion. For other infections, positive immunoglobulin M (IgM) antibody or a significant change
in immunoglobulin G antibodies or titers determined on

the basis of the laboratory findings was considered positive. One antinuclear antibody (ANA) titer of 40 or a
ratio of 1.4 was considered positive. In addition, anti
cyclic citrullinated peptide antibody (anti-CCP) level of
25 U, 5 IU/mL, or IgM rheumatoid factor (RF) of
24.0 IU/mL was considered positive.
Statistics
Relations between categorical variables were studied using the 2 test or Fishers exact test, for groups composed
of 5 case subjects. The only 2 continuous variables in
our study were age and duration of symptoms. Because
these were not normally distributed, nonparametric tests
were used: the Mann-Whitney-Wilcoxon test for comparison between 2 groups and the Kruskal-Wallis test for
comparison between multiple groups. The continuous
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e301

FIGURE 1
Flowchart for identication of children with arthritis.

variables were described in terms of range, median, and

quartiles. We constructed 95% confidence intervals
(CIs) for incidence using the normal distribution approximation. A P value of .05 was considered significant.
All of the analyses were performed by using SPSS 13 for
Microsoft Windows (SPSS Inc, Chicago, IL).
RESULTS
A total of 427 children fulfilled the recruitment criteria
for possible arthritis, of whom 281 (66%) were part of
the prospective study and 146 (34%) were identified
through chart reviews (Fig 1). A total of 182 patients had
arthritis, of whom 154 (85%) were included prospectively and 28 (15%) were identified through chart reviews. The age and gender composition was comparable
in both groups (data not shown). Twenty-two arthritis
patients (28%) in Akershus were included on the basis
of chart reviews, compared with 6 patients (7%) in Oslo
and 0 patients (0%) in Buskerud (Oslo versus Akershus:
P .01). A total of 146 arthritis patients (80%) were
reexamined after 6 weeks and 111 patients (61%) at the
6-month follow-up. The prospectively enrolled patients
who did not attend the planned follow-up visit reported
(on their previous visit or by telephone) that they no
longer had symptoms of arthritis. Additional data on the
numbers of children with arthritis were collected from
chart reviews from 9 to 21 months after the start of the
study. Of the 245 patients without arthritis, 42 had an
orthopedic disease, 32 had arthralgia, 28 had osteomyelitis, 27 had vasculitis without arthritis, 6 had a malignant disease, and 110 had various other conditions.
Incidence
A total of 182 patients with arthritis corresponds with an
annual incidence of 71 per 100 000 children 16 years of
age (Table 2). The annual incidence per 100 000 children
was 43 for transient arthritis, 14 for JIA, 9 for postinfectious
arthritis, and 5 for infectious arthritis (septic arthritis or
arthritis with acute osteomyelitis). The overall incidence of
arthritis was higher in boys than in girls (odds ratio [OR]:
1.6; 95% CI: 1.22.1). Transient arthritis was more free302

RIISE et al

quent in boys than girls (OR: 2.1; 95% CI: 1.4 3.2),
whereas the proportion of JIA was higher among girls than
boys (OR: 2.9; 95% CI: 1.4 6.0).
In the urban population of Oslo, the overall incidence
of childhood arthritis was 88 per 100 000 (95% CI:
68 105) compared with 70 per 100 000 (95% CI: 55
86) in the suburban population of Akershus and 44 per
100 000 (95% CI: 26 63) in the small-town and rural
population of Buskerud. The incidence of JIA was similar in all 3 of the counties (range: 1215 per 100 000).
In 2 counties we compared the incidence of arthritis in
areas with a high versus those with a low average income, and there was no statistical difference (data not
shown).
The overall incidence of arthritis was higher in children under the age of 8 years than in older children (107
vs 34 per 100 000; P .0001). There was a higher
occurrence of arthritis among boys than among girls in
the age group 1 to 7 years (OR: 1.7; 95% CI: 1.32.2),
but no gender difference was found in older children.
Patient and Disease Characteristics in Subgroups of Arthritis
Transient arthritis was most frequent in the age group from
2 to 5 years (Fig 2). The peak age of onset in postinfectious
arthritis was 6 to 7 years. In JIA, the age distribution tended
to be bimodal, with a slightly higher incidence in the age
groups 1 to 3 and 8 to 9 years. Infectious arthritis occurred
before the age of 3 years in 10 of 12 patients. The median
age at study entry for patients with infectious arthritis was
1.9 years, which was lower than that for patients with all of
the other subgroups of arthritis (P .05; Table 3). The
median age at onset was 7.1 years for patients with postinfectious arthritis compared with 4.7 years for transient
arthritis (P .05). The median age at onset for patients
with PSRA was 7.6 years (range: 1.713.1 years). The
median duration of symptoms before inclusion was 31 days
(1 and 3 quartiles; range: 6 114 days) in patients with JIA
compared with 2 days (1 and 3 quartiles; range: 1 6 days)
in the other subgroups (P .001). Monarthritis was significantly less frequent in subjects with JIA than in the
other groups (P .05). At 6 weeks after inclusion, 169

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TABLE 2 Annual Incidence of Recent-Onset Arthritis in Children <16 Years of Age According to Diagnostic Group and Gender
Variable

Total

Total arthritis
Chronic arthritis
JIA
SLE
Infectious arthritis
Septic arthritis
Osteomyelitis associated
Postinfectious arthritis
Rheumatic fever
PSRA
Lyme
Enterobacterial
Transient arthritis
Idiopathic hip affection
Idiopathic affection of other joints
Henoch-Schonlein purpura
Urticaria
Unspecic vasculitis

Female

Male

No. of
Patients

Incidence
(95% CI)a

No. of
Patients

Incidence
(95% CI)a

No. of
Patients

Incidence
(95% CI)a

182
37
36
1
12
8
4
24
1
19
3
1
109
48
44
14
2
1

71 (6182)
14 (1019)
14 (1019)
0.4 (0.01.0)
5 (27)
3 (15)
2 (03)
9 (614)
0.4 (0.01.0)
7 (411)
1 (03)
0.4 (0.01.0)
43 (3551)
18 (1324)
17 (1222)
5 (38)
0.8 (0.02.0)
0.4 (0.01.0)

69
22
21
1
3
1
2
10
0
8
1
1
34
12
14
6
1
1

55 (4269)
18 (1025)
17 (1024)
1 (02)
2 (05)
1 (02)
2 (04)
8 (313)
NA
6 (211)
NA
NA
27 (1836)
10 (415)
11 (517)
5 (19)
NA
NA

113
15
15
0
11
7
2
14
1
11
2
0
75
36
30
8
1
0

86 (71102)
11 (617)
11 (617)
NA
8 (313)
5 (19)
2 (04)
11 (516)
NA
8 (313)
NA
NA
57 (4470)
27 (1836)
23 (1531)
6 (210)
NA
NA

P (Male vs
Female)

.003
NS
NS
NA
NS
NS
NS
NS
NS
NS
NS
NS
.0001
.0001
NS
NS
NS
NS

NA indicates not assessed; NS, not statistically signicant; SLE, systemic lupus erythematosus.
a Data are per 100 000 subjects.

patients (93%) had had lower limb disease, 28 patients

(15%) upper limb disease, and 16 patients (9%) upper and
lower limb disease. Knee joints were found to be the most
frequently affected joints at 6 weeks (n 72; 40%), followed by hip joints (n 69; 38%) and ankles (n 35;
19%; P .05 for knees or hips versus ankles; Fig 3).
Microbiologic and Immunologic Factors
Positive bacterial culture in a joint was found in 5 of 8
patients with septic arthritis. One patient with septic
arthritis had Gram-positive cocci on microscopy. In the
remaining 2 patients, the diagnosis of septic arthritis was
based on WBC counts of 100 109/L of synovial fluid.
Signs of current or recent infection were found in 50
patients (27%) with arthritis: 24 patients (100%) with
postinfectious arthritis, 8 patients with infectious arthritis (75%), 7 patients with JIA (19%) and 11 patients
with transient arthritis (10%; Table 4).
Twenty one (58%) of the 36 patients with JIA had
oligoarthritis, 7 (19%) had IgM RF-negative polyarthritis, 4 (8%) had enthesitis-related arthritis, 2 (6%)
had psoriatic arthritis, and 2 (6%) had undifferentiated arthritis. Of the patients tested for HLA-B27, the
test results were positive in 11 of 30 patients with JIA
(37%) compared with 4 of 54 patients (7%) in other
subgroups (P .001). ANA was positive within the
first 6 weeks in 8 patients with JIA (22%) and in 1
patient with Henoch-Schonlein purpura. IgM RF was
positive in 3 patients with JIA within the first 6 weeks
(2 of the patients tested positive on 2 occasions 3
months apart within the first 6 months). Anti-CCP
was positive in 3 patients with JIA. IgM RF or antiCCP was not positive in any of the children with other
subgroups of arthritis.

DISCUSSION
This is the third large prospective study of the total
annual incidence of arthritis in children. We found a
total annual incidence of 71 per 100 000 children. Arthritis was more common in the youngest age groups
and was more prevalent in boys. Transient arthritis was
by far the most frequent subgroup, followed by JIA,
postinfectious arthritis, and infectious arthritis. Children

FIGURE 2
Age distribution of children with arthritis according to diagnostic group.

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TABLE 3 Patient and Disease Characteristics in Children With Recent-Onset Arthritis

Variable

JIA
(n 36)

Infectious
(n 12)

Postinfectious
(n 24)

Transient
(n 109)

Total
(n 181)

Female, n (%)
Age at inclusion, median (range), y
White ethnicity, n (%)
Onset in autumn or winter, n (%)
Duration of symptoms before inclusion, median
No. of days (1 and 3 quartiles)
Monarthritis, n (%)d
Oligoarthritis (24 joints), n (%)
Polyarthritis (4 ), n (%)

21 (58)a
5.9 (1.015.0)
34 (94)
22 (61)
31 (6114)b

3 (25)
1.9 (0.013.0)b
11 (92)
8 (67)
2 (029)

10 (42)
7.1 (1.014.0)c
21 (88)
18 (75)
3 (111)

34 (31)
4.7 (0.015.0)
99 (91)
56 (51)
2 (15)

69 (38)
4.9 (0.015.0)
165 (91)
105 (58)
3 (114)

23 (64)b
8 (22)
5 (14)

12 (100)
0 (0)
0 (0)

22 (92)
1 (4)
1 (4)

90 (83)
17 (15)
2 (2)

147 (81)
26 (14)
8 (4)

are versus infectious arthritis and transient arthritis (P .05).

are versus all of the other diagnostic groups (P .05).
c Data are versus transient arthritis (P .05).
d Data are within the rst 6 weeks of follow-up.
a Data

b Data

with septic arthritis were younger than those in the

other groups, and patients with postinfectious arthritis
had the highest age of onset. Number and type of joint
involvement and association with ANA, anti-CCP, IgM
RF, and HLA-B27 differed between the diagnostic
groups. PSRA was frequent, whereas arthritis associated
with enteropathic bacteria was rare.
Although all of the physicians were repeatedly informed of the recruitment criteria, our incidence figures
must be considered minimum estimates. Because arthritis can be of short duration and/or migratory, some
patients may not have been referred. The fact that the
incidence was higher in the urban county (Oslo), where
the distance to primary health care centers and hospitals
is short, could be because of underrecruitment of patients outside of Oslo. Some children in our study had
suffered persisting symptoms for weeks and months before inclusion, which supports our assumption that not
all of the patients with mild cases were recruited. Children with disease duration of 6 weeks would also not
have been referred to our study, because recent onset
was 1 of the recruitment criteria. Incomplete data, differences between laboratory methods in the different
hospitals, and significantly different disease duration between patients with JIA and the other diagnostic groups
before inclusion mean that our data must be interpreted
with caution. Because of multiple testing, a P value of
.01 should be interpreted cautiously.
Our total incidence of 71 per 100 000 children is
similar to the study performed in a small city in Finland,
where the incidence was 64 per 100 000,18 and the prospective urban study from Germany, with an incidence
of 83 per 100 000.9 However, septic arthritis was not
included in the German study, and most of the patients
were recruited on the basis of a questionnaire returned
by primary care physicians. Interobserver disagreement
in the assessment of arthritis is high among rheumatologists19 and is probably even higher in primary health
care.
The total annual incidence of 109 per 100 000 subjects in the study by Kunnamo et al8 was higher than in
our study. This is mainly because of the incidence of
transient synovitis of the hip that they found in 52 per
e304

RIISE et al

100 000 subjects, whereas we only found 18 per 100 000

subjects. On the other hand, we classified several children with hip affection as having postinfectious arthritis.
Other studies from Germany (urban), Sweden (urban),
and the Netherlands (urban and nonurban) have found
incidences of transient synovitis of the hip ranging from
39 to 200 per 100 000 subjects using different classification criteria.9,20,21 In contrast to Kunnamo et al,8 we used
signs of inflammation as 1 of the criteria and did not ask
for referral of children with hip pain as the only symptom. We also included nonurban children and found a
lower incidence in the nonurban counties. On the basis
of these previous studies, this may indicate that our Oslo
data are the most representative. However, it cannot be
ruled out that there may be true differences between
Finland and eastern Norway or urban and nonurban
districts or that the incidence has declined over the last 2
decades.
The lower incidence of septic arthritis in our study
versus in the Finnish study could be because of the effect
of the Haemophilus influenzae type B vaccination, which

FIGURE 3
Joint involvement within the rst 6 weeks of follow-up in patients with arthritis. Thirty-four
patients had affection of 1 joint. a P .05 versus ankles or other joints; b nger joints (n 12),
wrist (n 6), elbow (n 4), foot (n 3), shoulder (n 4), sacroiliac (n 2) .

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TABLE 4 Microbiologic Findings in Patients With Arthritis by Diagnostic Group

Variable

JIA
(n 36)

Infectious
(n 12)

Postinfectious
(n 24)

Transient Except
HSP (n 95)

HSP
(n 14)

Total microbiologic ndings, n (%)

Bacteria in synovial uid, na
Blood culture positive, nb
GAS, throat smear, n
Positive stool culture, nc
Rotavirus in stool, n
Urinary tract infection, nd
ASO or anti-DNase B 600, n
Borrelia IgM and IgG positive, n
Other serology, ne

7 (19)
0
0
0
0
0
0
5
0
2

8 (75)
6
2
1
0
1
0
1
0
1

24 (100)
0
1
9
2
1
0
17
3
2

7 (7)
0
2
0
0
0
1
0
1
3

4 (29)
0
0
3
0
1
0
1
0
1

GAS indicates group A streptococci; HSP, Henoch-Schonlein purpura; ASO, antistreptolysin-O; anti-DNase B, anti-deoxyribonuclease B.
For positive tests within 6 weeks after inclusion, 4 patients tested positive for 1 bacteria or virus.
a Data include Staphylococcus aureus (n 1), Kingella kingae (n 1), -hemolytic streptococci group A (n 1), -hemolytic streptococci group
B (n 1), Streptococcus pneumonia (n 1), and Gram-positive cocci by microscopy (n 1).
b Data include S aureus (n 2), -hemolytic streptococci group A (n 2), and -hemolytic streptococci group B (n 1).
c Data include Shigella exneri (n 1) and Campylobacter species (n 1).
d Escherichia coli (n 1).
e Cytomegalovirus IgM (n 4), Epstein-Barr virus IgM (n 2), mycoplasma IgM (n 1), and varicella IgM (n 1). None of the patients were
Yersinia, hepatitis B, or parvovirus B19 positive.

was introduced in Norway in 1992, and this is in line

with other studies.22 Three of our patients had arthritis
and a positive bacterial blood culture without meeting
the criteria for septic arthritis. A positive blood culture
has been used as a criterion for the diagnosis of septic
arthritis in a few previous studies,23,24 and this would
have increased our incidence for septic arthritis.
Enteropathic arthritis was rare in our study: 0.4 per
100 000, as suggested previously by Rudwaleit et al.25 In
Finland and Italy, Yersinia infections seem to be frequent
in children, and geographical differences may exist.8,26,27
The incidence of PSRA was higher in our study than the
estimates from Florida and Finland.8,11 However, the
heterogenous use of the term and difficulties in diagnosing recent streptococcal infection may explain the variations in the results.3,15 The 14 per 100 000 annual incidence of JIA presented here is lower than the incidence
of juvenile rheumatoid arthritis reported by Kunnamo et
al,8 but our results are in accordance with those of other
Nordic studies.28,29
In line with previous studies, arthritis was found in
our study to be more frequent in boys than in girls and
more common in the youngest age groups.8,9 On the
other hand, we found that the gender difference was
only present in children under the age of 8 years. Septic
arthritis was most frequent in children younger than 3
years in our study, which is in accordance with results
reported previously.8,30,31 Our finding of a late age at
onset of postinfectious arthritis is also similar to that of
others.3,10,32,33 We found the knee, hip, and ankle to be
the most frequently affected joints. Hip involvement in
transient arthritis has been reported in very high numbers20,21 and may have been underestimated in our
study. Five of 6 patients with polyarthritis had JIA, and
knee and ankle involvement were frequent in JIA, as
found previously by others.3436 ANA, anti-CCP, or IgM
RF was positive in 31% of the patients with JIA but in
only 1 patient in the other subgroups, showing that

these test have high specificity and low sensitivity for the
classification of JIA.
Signs of possible previous or concomitant infection
were demonstrated microbiologically in 27% of our children, and there were microbiologic findings in all of our
diagnostic groups. In a Swedish population-based cohort
of patients with adult undifferentiated arthritis, 45%
had signs of previous infection based on patient histories
or microbiologic findings.37 Most cases of childhood arthritis are of unknown origin, and testing for other
agents could increase our knowledge of environmental
triggers. The infections for which we tested may vary
from one year to another, and inclusion of patients for
1 year might have provided a better estimate of the
annual incidence of postinfectious and parainfectious
arthritis. The effect of microbes in childhood arthritis
patients requires additional study.
CONCLUSIONS
Childhood arthritis is common, particularly transient arthritis that is 3 times as frequent as JIA. Young age at onset
was most frequent in infectious arthritis. Hip involvement
was associated with transient arthritis, whereas female
gender, extended joint involvement, and immunologic factors correlated with JIA. Signs of current or recent infection
were associated with the onset of arthritis in 27% of the
children. Our results suggest that the incidence of childhood arthritis may differ between geographic areas or
might have declined over the last 2 decades.
ACKNOWLEDGMENTS
This study was supported by a grant from the Norwegian
Foundation for Health and Rehabilitation via the Norwegian Rheumatism Association.
We are indebted to the patients, guardians, and primary
care physicians who made this work possible. We thank Dr
V. Halvorsen (Orthopedic Centre, Ulleval University HosPEDIATRICS Volume 121, Number 2, February 2008

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e305

pital) and Dr K. Mreihil (Department of Pediatrics, Akershus University Hospital) for assistance in planning the
study and recruiting patients. We are grateful to Professor
P. Gaustad, Department of Microbiology, Rikshospitalet
Medical Centre, for assistance in planning the study and
performing microbiologic tests. We also thank the staff in
the Departments of Clinical Chemistry, Microbiology, Immunology, and Radiology at Akershus University Hospital,
Sykehuset Buskerud, Ulleval University Hospital, and Rikshospitalet Medical Centre.

18.

19.

20.

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Incidence and Characteristics of Arthritis in Norwegian Children: A

Population-Based Study
ystein Rolandsen Riise, Kai Samson Handeland, Milada Cvancarova, Karl-Olaf
Wathne, Britt Nakstad, Tore Gunnar Abrahamsen, Eva Kirkhus and Berit Flat
Pediatrics 2008;121;e299-e306; originally published online Jan 28, 2008;
DOI: 10.1542/peds.2007-0291
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