Juvenile rheumatoid arthritis persisting inot adulthood

Radiographic damage in hands and wrists of patients with juvenile idiopathic arthritis after 29 years of disease duration

BACKGROUND

There are few studies on radiographic outcome after long-term disease duration in juvenile idiopathic arthritis (JIA). We wanted to evaluate 29-year radiographic outcome in hands/wrists and predictors of damage in patients with long-term active JIA.

METHODS

Patients diagnosed from 1980 to 1985, who had active disease at 15-, 23- or 29-year follow-up and arthritis in the wrists during the disease course, were reexamined with radiographs of hands/wrists. We used the adapted version of the Sharp van der Heijde (aSvdH) score and Carpal Height Ratio (CHR) to evaluate radiographic outcome.

RESULTS

Sixty patients, mean age 38 years, were reexamined at median 29-year follow-up. 33 patients (55%) had an aSvdH score >0, median score was 4.0 (range 0-313), and 25% of the scores were high (≥53). Most patients with radiographic damage (88%) had both erosions and JSN. 52% of the patients had damage in the wrists, 43% in the MCP joints and 40% in the PIP joints. The CHR correlated strongly with the aSvdH. Both scores had high correlations with the Juvenile Arthritis Damage Index and the number of joints with limited range of motion (LROM) (r_s = -0.688 to 0.743, p ≤ 0.001). The aSvdH correlated weakly with measures of disease activity. The number of joints with LROM, ESR and the HAQ disability score at 15 years and HLAB27 positivity predicted the aSvdH score and the CHR at 29-year follow-up.

CONCLUSIONS

The majority of patients with long-term active JIA had modest radiographic damage, but more frequently in wrists than in fingers. The radiographic scores correlated well with measures of disease damage. Restricted mobility in joints at 15 years was the most important predictor of radiographic damage at 29 years.

Radiological peripheral involvement in a cohort of patients with polyarticular juvenile idiopathic arthritis at adulthood

OBJECTIVE

Radiographic damage was recently identified as a feature of poor prognosis in polyarticular juvenile idiopathic arthritis (pJIA). However, most radiographic studies did not differentiate pJIA from other subtypes of JIA and little is known about pJIA persisting into adulthood. We describe radiological peripheral involvement in young adults with pJIA compared to patients with rheumatoid arthritis (RA).

METHODS

All consecutive patients with pJIA followed in a transition program were included. Age, sex, disease duration, and medical or surgical treatment information was collected. Laboratory tests and standard radiographs of the hands and wrists, feet, and hips were analyzed by 2 independent radiologists blinded to the diagnosis. One RA control group (age < 55 yrs), matched for sex and disease duration, was recruited.

RESULTS

Forty-three patients with pJIA and 59 with RA were included. Radiographs showed hand lesions in 79% of pJIA and 86% of patients with RA, feet lesions in 74% of pJIA and 80% of patients with RA, and hip damage in 35% of pJIA and 17% of patients with RA (p = nonsignificant). Specific to the juvenile forms were lower frequency of proximal interphalangeal joint involvement (51% vs 76%; p = 0.03) and higher risk of bilateral hip damage (86% vs 25%; p < 0.01) than in adult RA.

CONCLUSION

Structural peripheral damage is as common and as severe in young adults with pJIA as in adults with RA. The main specific feature of pJIA seems to be a high risk of bilateral hip damage. This requires a particular monitoring of pJIA patients with unilateral hip involvement to detect bilateralization.

A critical appraisal of radiographic scoring systems for assessment of juvenile idiopathic arthritis

Assessing structural damage to joints over time is essential for evaluating the effectiveness of therapeutic interventions for patients with inflammatory arthritis. Although radiography is able to quantify joint damage, the changes found with conventional radiography early in the disease course are nonspecific, and late radiographic changes are often irreversible. Although many clinical trials on drug development for children still use radiographic scales as endpoints for the study, more specific therapies have been developed for juvenile idiopathic arthritis (JIA) that would enable imaging to "fine-tune" patients to placement into specific treatment algorithms. As a result, new imaging scales to identify early abnormalities are clearly needed. Many pediatric rheumatology centers around the world persistently apply adult-designed radiographic scoring systems to evaluate the progression of JIA. Few pediatric-targeted radiographic scales are available for assessment of progression of JIA in growing joints, and the clinimetric and psychometric properties of such scales have been poorly investigated. We present a critique to the evaluative, discriminative, and predictive roles of the van der Heijde modification of Sharp's radiographic method, a scale originally designed to assess damage to joints of adults with rheumatoid arthritis, when it is applied to a pediatric population. We discuss the advantages and drawbacks of this radiographic scoring system for assessing growing joints and the ability of MRI to overcome inadequacies of conventional radiography.

Ocular complications and visual outcome in juvenile chronic arthritis: a 25-year follow-up study

OBJECTIVE

Assessment of longterm ophthalmic outcome in juvenile chronic arthritis (JCA) with emphasis on visual acuity and identification of disease-related parameters associated with rheumatic eye affection.

MATERIAL

Sixty-five adults (52 females, 13 males) with a history of or still active JCA were assessed an average of 26.7 years after disease onset.

METHODS

Cross-sectional, longterm, follow-up study including complete ophthalmological and rheumatological examinations.

RESULTS

Evidence of ocular complications was found in 13 subjects (20%): 10 had had recurrent iritis, two band keratopathy, and one diplopia due to rheumatoid eye muscle involvement. The three single eyes with poor sight (<0.1) were all in the complication subgroup. Binocularly, all but one patient scored at least 6/9 as best corrected visual acuity; one, however, had severe glaucoma-impaired visual fields. The refractive range was -8.12 to +6.0 D. There were no cases of keratoconjunctivitis sicca. Iritis was associated with early disease onset (p = 0.02), longer disease duration (p = 0.02) and a positive antinuclear antibodies (ANA) (p = 0.02).

CONCLUSION

Ophthalmic complications were recorded in 20% of the study group, primarily in ANA positive patients with pauciarticular onset JCA. In addition to the two patients with severely affected bilateral visual status (3%), one of the 65 patients had acquired unilateral blindness. Half of the complications were late in that they were first recorded after the age of 16 years. Otherwise, the findings were in keeping with other studies of visual prognosis using non-selected series.

Outcome in adults with juvenile idiopathic arthritis: a quality of life study

OBJECTIVE

To evaluate quality of life (QOL) in adults with juvenile idiopathic arthritis (JIA), using validated measures of functional disability and generic health status, and to quantify their educational attainment and employment status.

METHODS

The adult rheumatology departmental database was used to identify patients. Functional disability and generic health status/QOL were assessed by the Health Assessment Questionnaire (HAQ) and the Short Form 36-item health profile (SF-36), respectively. Educational achievement and employment status were assessed by questionnaire.

RESULTS

Complete data were available for 82 of the 101 patients identified. The median age of patients was 30 years, and the median disease duration was 21 years. No deaths were recorded. All subtypes of JIA were represented. Thirty-nine percent of patients had active disease (based on the physician global assessment scale score). The median HAQ score was 1.125 (range 0-3). SF-36 scores for bodily pain, general health, physical functioning, vitality, emotion, and social isolation were significantly worse in patients compared with controls, and this trend increased with increasing age of the patients and disease duration. The SF-36 mental summation scores of patients were low compared with those of controls, for all subtypes of JIA, and this finding was independent of the degree of functional disability (by HAQ and SF-36 physical summation scores). The educational attainment of patients was comparable to that of local controls, but unemployment rates for patients were 3-fold higher than those for controls.

CONCLUSION

This is the largest study in which the SF-36 was used to assess generic health status and QOL in adults with JIA. Many patients had active disease in adulthood, and although the physical outcome of adults with JIA is relatively good, a profound effect on generic health status and QOL was demonstrated for all types of JIA. Furthermore, despite excellent educational attainment, there was a high rate of unemployment among patients.

The cervical spine in juvenile chronic arthritis

BACKGROUND CONTEXT

In patients with juvenile chronic arthritis (JCA) the cervical spine is often affected, leading to pain and functional limitations.

PURPOSE

To describe the frequency of the radiographic abnormalities in the cervical spine of a large series of patients with JCA, examined after skeletal maturity.

STUDY DESIGN

Consecutive patients with JCA, who had cervical spine radiographs available taken at adult age (>18 years) were included in the study from one outpatient clinic and one rheumatology ward in the Rheumatism Foundation Hospital, Heinola, Finland.

PATIENT SAMPLE

The series consisted of 159 patients fulfilling the diagnostic criteria of the European League Against Rheumatism for JCA.

OUTCOME MEASURES

Evaluation of cervical spine radiographs for inflammatory changes.

METHODS

Inflammatory changes in the cervical spine radiographs were measured as well as the size of the fourth cervical vertebra. Patient records were studied. The statistical analysis was calculated by Student's t-test or Mann-Whitney U test.

RESULTS

In 98 cases (62%) some inflammatory changes were detected in the cervical spine. Apophyseal joint ankylosis was noted in 65 patients (41%), anterior atlantoaxial subluxation in 27 (17 %) and atlantoaxial impaction in 39 (25 %). The fourth cervical vertebra was abnormally small in 41 patients (26%).

CONCLUSIONS

Radiographically, the most frequent inflammatory change in the cervical spine of patients with JCA was apophyseal joint ankylosis at multiple levels. Atlantoaxial impaction and anterior atlantoaxial subluxation were typical of the upper cervical spine. Clinically, these changes tend to limit neck movements. A small C4 vertebral body was seen in patients with early disease onset and short body stature.

The cervical spine in mutilant juvenile chronic arthritis

OBJECTIVE

To describe inflammatory cervical spine disorders in juvenile chronic arthritis (JCA) patients with arthritis mutilans (AM) hand deformity.

METHODS

The series consisted of 18 patients affected by AM hand deformity who fulfilled the European League of Associations for Rheumatology criteria for JCA. The patient records and the most recent cervical spine radiographs were evaluated for subluxations, atlantoaxial impaction (AAI) and apophyseal joint ankylosis.

RESULTS

Seventeen (94%) patients had subluxation, AAI or apophyseal joint ankylosis in the cervical spine. Apophyseal joint ankylosis was noted in 12 (67%) patients and AAI in 10 (56%). Anterior atlantoaxial subluxation was detected in five (28%) patients.

CONCLUSION

Almost all of the JCA patients with AM hand deformity evinced some inflammatory changes in the cervical spine. Apophyseal joint ankylosis, AAI and multiplicity of changes in cervical spine may be considered characteristic in this subset of JCA patients. Patients with JCA and AM hand deformity tend to have severe changes also in the cervical spine.

Juvenile chronic arthritis into adulthood: a long-term follow-up study

OBJECTIVE

To evaluate a group of 65 adults with a history of or persistent juvenile chronic arthritis (JCA), on average, 26.4 yr after disease onset.

METHODS

Disease status at the time of the study included an evaluation of disease-related parameters assessed by the patient and the investigator.

RESULTS

Active disease was present in 37% of the study participants, of which 80% had either extended pauciarticular or polyarticular JCA. Eleven per cent of the study subjects were in Steinbrocker functional classes III and IV and 22% had undergone JCA-related major surgery. The pain visual analogue scale, health assessment questionnaire, erythrocyte sedimentation rate and C-reactive protein (CRP) were significantly increased in those participants who had active JCA at the time of the study. Disease duration proved to be the parameter most strongly associated with an unfavourable disease outcome.

CONCLUSIONS

Although the study group was biased towards the more severe cases, the data suggest that the long-term functional outcome in JCA is, in more than one-third, associated with active disease persisting into adulthood, increasing residua and the need for surgery.

Psychosocial outcomes and health status of adults who have had juvenile rheumatoid arthritis: a controlled, population-based study

OBJECTIVE

The goal of this study was to evaluate the physical and psychosocial impact of juvenile rheumatoid arthritis (JRA) among a population-based cohort of adults who had the disease during childhood, compared with a control cohort of subjects with no history of JRA.

METHODS

The Rochester Epidemiology Project database was used to identify all cases of JRA (based on the American College of Rheumatology [formerly, the American Rheumatism Association] 1977 criteria) among Rochester, Minnesota residents first diagnosed between January 1, 1960 and December 31, 1993. Controls were age- and sex-matched to the cases as of the date of diagnosis of JRA. A pretested postal survey was mailed to all adult cases (whose date of birth was before December 31, 1975) and matched controls from the same population, to obtain information on socioeconomic issues and functional status (using the Health Assessment Questionnaire and the Health Status Questionnaire). The complete medical records of all cases and controls were reviewed to obtain information on demographics and clinical manifestations of JRA.

RESULTS

Of the 50 eligible cases, 44 (88%) responded to the survey. There were 102 age- and sex-matched controls (2-3 per case) who responded to the survey. Seventy-three percent of the cases had pauciarticular-onset JRA, 16% had polyarticular-onset JRA, and 11% had systemic-onset JRA. Average followup was 24.7 years and 24.5 years after the index date for cases and controls, respectively. Greater disability (P = 0.0002), more bodily pain (P = 0.0002), increased fatigue (P = 0.0112), poorer health perception (P = 0.0004), and decreased physical functioning (P = 0.0002) were reported by the cases compared with the controls. JRA cases reported significantly lower rates of employment (P = 0.015) and lower levels of exercise (P = 0.0002) than did controls. Level of educational achievement, annual income, health insurance status, and rate of pregnancy and childbirth were similar for both cases and controls.

CONCLUSION

Adults who have had JRA during childhood experience long-term physical and psychosocial impairment.

Pregnancy in patients with a history of juvenile rheumatoid arthritis

The present investigation was undertaken to study the relationship between pregnancy and juvenile rheumatoid arthritis (JRA), with regard to possible reactivation of the disease, complications at delivery, and postpartum complications. Data on 76 pregnancies in 51 JRA patients were collected retrospectively. Comparison of pre-pregnancy disease activity with the course during gestation showed that pregnancy did not cause reactivation of the symptoms of quiescent JRA. Patients with minor symptoms at conception and the majority of those with active inflammation experienced improvement or total remission in the second half of gestation. Four JRA patients with active anterior uveitis had active eye disease during pregnancy also. Seventy-four of the pregnancies resulted in births of infants that were healthy and of normal birth weight; 1 infant had low birth weight and 1 was stillborn. Twenty children were delivered by cesarean section, and in 15 cases this was related to sequelae of JRA. A flare 3-6 months postpartum was reported after 45 pregnancies. However, in none of the patients whose disease was quiescent before or during pregnancy did this cause permanent reactivation of the JRA. Comparison of these 51 patients with 45 age-matched female patients without children revealed that disease severity and functional impairment were the limiting factors in the decision for or against having children.

Clinical, HLA, and roentgenological follow up study of patients with juvenile arthritis: comparison between the long term outcome of transient and persistent arthritis in children

Fifty two patients with juvenile chronic arthritis (JCA) and 22 patients with arthritis of short duration (transient arthritis, TA) were studied in a follow up investigation. Nineteen (37%) of the patients with JCA had peripheral arthritis or sequelae in the form of contractures at follow up, and in addition one patient was treated with corticosteroids. In contrast, only one (5%) of the 22 patients with TA had peripheral arthritis at follow up. Back pain or limitation, or both, was registered in many of the men. Sacroiliitis, verified by x ray, was often found both in JCA (39/46, 85%) and in TA (16/21, 76%). For JCA an association was confirmed with HLA-A2 and HLA-DRw8 and a negative association with HLA-DR4, and in pauciarticular JCA, in addition, a decrease of DR7. A new finding was a low prevalence of HLA-B27 in women with JCA and grade 3 or 4 sacroiliitis (2/14, 14%).

Radiologic review: the cervical spine in juvenile rheumatoid arthritis

In our patients, zygapophyseal joint fusion was the most frequent and characteristic roentgenographic finding of cervical spine involvement in JRA. It was not associated with any subset of patients. Atlanto-dens interval greater than 4.5 mm was present in 20% of patients, but was not related to the development of neurologic manifestations. Mild enthesopathic-like changes around the upper cervical area were observed in some children. In patients with severe long standing disease and extensive zygapophyseal joint fusion, longitudinal ligament calcification was observed. Growth disturbances of the cervical spine were more frequently observed in patients with zygapophyseal joint fusion and earlier onset of disease.

Hidden 19S IgM rheumatoid factor in adults with juvenile rheumatoid arthritis onset

Forty-eight adult patients with juvenile rheumatoid arthritis (JRA) (onset before age 16 years) were evaluated at the age of 17 years or more for the presence of hidden 19S IgM rheumatoid factors (RF), i.e., 19S IgM RF that can be detected by the complement-dependent haemolytic assay in the IgM-containing fraction after separation of the serum by acid gel filtration. The average age of the patients was 25.3 years. The mean duration of disease was 16.5 years. Thirty-two of 48 patients (67%) showed the presence of hidden 19S IgM RF in their serum. Disease activity correlated with hidden RF titres in 62% (55/88) of the evaluations. The results indicate that patients with seronegative JRA onset continue to have significant titres of hidden 19S IgM RF in their sera into early adulthood.

A syndrome of seronegative enthesopathy and arthropathy in children

Thirty-nine children with a syndrome of seronegative enthesopathy and arthropathy were evaluated. The group included 25 patients with no apparent underlying primary disease and 13 with either ankylosing spondylitis, inflammatory bowel disease, reactive arthritis, or Reiter's syndrome. Significant distinguishing characteristics of the group included male predominance, late age at onset, positive family histories of arthritis, oligoarthropathy, axial skeleton involvement, and the presence of the B27 histocompatibility antigen. This syndrome is distinguishable from other childhood rheumatic disorders, including juvenile rheumatoid arthritis. Its recognition may reliably identify children with the prodromal manifestations of seronegative spondylarthropathies.

The social function of young adults who had arthritis in childhood

One hundred twenty-one young adults 18 years of age or older who had been seen at this hospital with juvenile arthritis since 1955 were surveyed by a series of questionnaires to determine current social function and financial status. Chart reviews and patient questionnaires were used to determine modes of onset and the social circumstances of the family at the onset of the arthritis. The patients as a whole were functioning well: 45 were working full time, 25 were in school full time, 23 were in school and working, and 14 were married women at home. Females had a higher prevalence of persisting disability. Patients who had had a polyarticular onset had lower monthly salaries. No other disease or social variables at onset were statistically associated with any of the outcome variables measured. Fifty of the patients were compared to matched siblings and were found to have achieved comparable educations and salaries, and proportionate numbers of marriages and children.

Mandibular growth, temporomandibular joint changes and dental occlusion in juvenile rheumatoid arthritis. A 17-year follow-up study

To evaluate the mandibular growth and temporomandibular joint (TMJ) changes in juvenile rheumatoid arthritis, a clinical and radiographic 17-year re-examination of 9 of 19 patients has been carried out. A varying degree of micrognathia (mandibular retrognathia, 'bird face') was observed by means of radiographic cephalometric analysis, at both the base-line and follow-up examination of 6 of the patients. No facial asymmetry was found. Rotation of the mandible in relation to the anterior cranial base during the follow-up period, observed in 5 of the 6 patients, indicated a further disturbance of mandibular growth. In 3 patients with mandibular rotation, a dental occlusion anomaly was observed. The TMJ revealed radiographic changes in 6 patients at the base-line examination and in all patients at the re-examination. Micrognathia and the dental occlusion anomaly were associated with radiographic TMJ changes.