Arthritis awareness - Red Hot Joints

Arthritis is not just an adult disease. I am writing this piece to raise awareness on a topic near and dear to my heart, namely Juvenile Idiopathic Arthritis (JIA). Arthritis, in general of various causes, is a well-known entity in adult patients, easily diagnosed and managed by various medical practitioners. JIA in contrast does not have the same awareness and ease of diagnosis and very few paediatricians and even fewer general practitioners have experience in the care of these children.

Complaints involving the musculoskeletal system are common in children. Most joint pains in children are attributed to “growing pains” that are assumed will get better as the child ages or due to overexertion of the child during sporting activities or even occasionally as possible “attention-seeking behaviour”. A thorough history and a good physical examination is of paramount importance in differentiating between a benign musculoskeletal condition and the possibility of JIA.

JIA affects between 1 and 4 per 1000 children. It is termed idiopathic as the cause of this condition is unknown. There are six different subtypes of JIA, namely oligoarticular (which may evolve into extended oligoarticular), polyarticular rheumatoid factor (RF) negative, polyarticular rheumatoid factor (RF) positive, enthesitis-related arthritis, psoriatic arthritis and systemic JIA.

The distinction between the various subtypes relies on the age of the child, the gender of the child, the number of joints involved (1-4 joints affected is in keeping with oligoarticular JIA, while 5 or more joints affected is in keeping with polyarticular JIA) and the presence or absence of certain factors, such as a positive or negative RF, antinuclear antibody positivity and the presence of psoriasis, dactylitis or nail pitting (in the case of psoriatic arthritis). Systemic JIA is a serious condition involving multiple organ systems besides the joints, and often presents with fever, a rash and enlargement of the liver and spleen. Misdiagnosis is common and without prompt recognition and treatment, morbidity and mortality rates are high.

Sadly, JIA in some cases may evolve to a severely debilitating disorder with marked morbidity, not only from the disease itself but also from the strong treatment the child requires, namely steroids and disease-modifying antirheumatic drugs. Many of these medications suppress the child’s immune system leaving them vulnerable to a large variety of infections that may require frequent hospitalisations and antibiotic therapy. These medications may also have negative effects on the liver and kidney functions of these children and may predispose them to obesity and high blood pressure.

The joint deformities themselves may often impair the child’s level of functioning. Even simple things we take for granted like walking, running, playing, doing activities of daily living like brushing your hair or teeth or even just writing becomes a challenge to these children. They may require splints, walkers or wheel chairs to assist them and need chronic follow-up lifelong with x-rays and blood investigations to monitor their disease activity.

There are certain clues that we name “red flag signs” that should alert a parent that they should seek medical attention for their child. These red flag signs include tiredness, loss of weight with or without decreased appetite and fever. Red flag signs regarding the joints specifically include pain at night (especially if the pain wakes the child up during the night), bone pain that is deep and throbbing in nature and swelling, deformity or warmth of a joint. The presence of any of these signs are worrisome and require further investigation by a medical professional.

JIA is more common than we think. I hope to enlighten and empower parents and junior doctors to recognise more children who are suffering from JIA and refer them promptly for early diagnosis and treatment. This will greatly impact the lives of our children and pave the way for a brighter pain free future for them without deformity and disability.

Dr M. Karsas, Paediatrician at University of Pretoria, Steve Biko Academic Hospital