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Zakiudin Munasir :

HERCULE POIROT IN :

JUVENILE RHEUMATOID ARTHRITIS


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Causes bone and joint pain in

children 43 medical conditions:

1. Trauma

2. Infection 3. Malignancy

4. Metabolic

5. Autoimmune 6. Growing pain


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Synonym:

Juvenile IdiopathicArthritis (JIA)

One of the most

frequent chronicillnesses in children

Short-termdisabilities

Long-term disabilitis

Juvenile

RheumatoidArthritis (JRA)


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A chronic arthritis that persists for a minimum of 6consecutive weeks in one or more joints, commencing

before the age of 16 years and after active exclusionother causes. (Cassidy et al.,1989:Ansell,1990)

Definition

High remittent fever with one or more of the following-rash, hepatomegaly, splenomegaly, generalizedlymphadenopathy, serositis, usually pericarditis.

Arthritis may be absent at the onset, but myalgia orarthralgia are ussualy present

Systemic disease

JUVENILE CHRONIC (RHEUMATOID) ARTHRITIS


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5 or more joints develop in theonset periodusually

insidiously and symmetrically

Further divided by thepresence of IgM rheumatoid

factor

Polyarthritic onset:


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Most common mode with 4 orfewer joints involved

Particularly knees and ankles

Young children with positiveantinuclear antibodies who are atrisk from chronic iridocyclitis, andolder boys (aged 9 upwards) who

frequently carry thehistocompatible leucocyte antigen(HLA) B27

Pauci-articular onset:


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Include:

Juvenile psoriatic arthritis

Arthritis of inflammatory bowel

diseaseReiters syndrome

While some are as yet

unclassified.

Polyarthritic onset:


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Classification:

By mode of onset during the first sixmonths(Cassidy et al.,1989:Prieur et al., 1990)


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Criteria for Classification of

Juvenile Rheumatoid Arthritis

1. Age at onset < 16 yr

2. Arthritis (swelling or effusion, or presence of two or more of the

following signs : limitation of range of motion, tenderness or pain

on motion, and increased heat) in one or more joints

3. Duration of disease 6 wk or longer

4. Onset type defined by type of disease in first 6 mo:

a. Polyarthritis : > 5 inflammed joints

b. Oligoarthritis (pauciarticular disease) : < 5 inflammed jointsc. Systemic-onset : arthritis with characteristic fever

5. Exclusion of other forms of juvenile arthritis

Modified from Cassidy JT, Levinson JE, Bass JC, et al :A study of classification criteria for a diagnosis ofjuvenile rheumatoid arthritis, 1986


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Treatment approach of

rheumatic diseases


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American College of

Rheumatology Guideline

The goalsof osteoarthritis (OA)management are :

To control pain and other symptoms,

Minimize disability, and

Educate the patient about the diseaseand its therapy


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Multidisciplineapproach

Non-pharmacologic

treatment

Pharmacologic

treatment

Surgery


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THERAPEUTICS PRINCIPLES

Nonsteroidal antiinflammatory drugs COX2 inhibitors

Steroids (systemic onset or uveitis)

Analgesics

Antiinflammatorymedications

Physical therapy

Ocupational therapy

Psychologic support

Exercise

Rehabilitationtechniques

Immunosuppressants

Biologic agentsAdvance therapy


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PHARMACOLOGIC THERAPY

Acetaminophen

Acetyl salicylic acidAnalgesics

Naproxen

Ibuprofen

Diclofenac

NSAIDThe main therapy

for rheumaticdisease

Only for systemic or uveitisCorticosteroid


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PHARMACOLOGIC THERAPY

Methotrexate, salazopyrin, hydroxychloroquine,

Other cytotoxics/immuno-suppressive drugs(Azathioprine, cyclophosphamide, cyclosporine,mycophenolate mofetil)

Disease modifyingantirheumatic

drugs

(DMARDs) :

Biphosphonate

Calcitonin

Antiosteo-porotic

Etanercept, infliximab

Biologic agents(biologicDMARDs)


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Table: Clinical Outcome-by Onset and Course Subtypes

Onset Type (N) Course Subtype

(n)

Profile Outcome

Polyarthritis

(78)

RF seropositive

(16)

Female

Older age

Hand-wrist

Involvement

Erosions

Nodules

Unremitting

Poor

ANA seropositive(38)

FemaleYoung age

Good

Seronegative (24) Variable Good


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ANA, anti nuclear antibodies; RF, rheumatoid factors

Cassidy JT, Levinson JE, et al: A sudy of classification criteria for a diagnosis of juvenile rheumatoidarthritis. Arthritis Rheum 29: 274-278, 1986

Table: Clinical Outcome-by Onset Type and Course Subtypes (cont.)

Onset Type (N) Course Subtype (n) Profile Outcome

Oligoarthritis

(121)

ANA seropositive

(66)

Female

Young ageChronic

uveitis

Excellent

(except eyes)

RF seropositive (8) Polyarthritis

Erosions

Unremitting

Poor

HLA-B27 positive

(120)

Male

Older age

Good

Seronegative (35) Variable Excellent

Systemicdisease (51)

Oligoarthritis (30) Variable Good

Polyarthritis (21) Erosions poor


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4343

Endoscopically Detected Bleeding UlcerEndoscopically Detected Bleeding Ulcer


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When pain strikes, it's natural for child to

want to sit still

But it's important to maintain a regular

exercise program

Muscles must be kept strong and healthy

so they can help support and protect joints

Regular exercise also helps to maintain

range of motion.


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GROWINGPAIN


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Positive connotation :

Most parents accept it as a benign condition

Negative connotation :

This diagnosis has been too frequently applied to children whoactually have a serious rheumatic or malignant disease

Most occur in preschool- to school-agedchildren

The pathophysiology is unknown

Growing pains

G i P i (B i N t l


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Growing Pains (Benign Nocturnal

Pains of Childhood)Age at onset 4 to 12 years

Sex ratio Probably equal, slightly more girls insome series

Symptoms Deep aching, cramping pain in thigh orcalf, usually in the evening or during the

night; never present in the morning;

bilateral; responds to massage and

analgesia

Signs Physical examination results are normal

Investigations Laboratory and radiographic studies (ifdone) have normal results

Modified from Cassidy JT, Petty RE, Laxer RM, Lindsley, ed. Textbook of Pediatric Rheumatology, 2005


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V

Children who have unusual

symptoms or abnormal

findings on examinationshould notbe diagnosed

as having growing pains


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