Initial manifestations and clinical course of systemic onset juvenile idiopathic arthritis: a ten-year retrospective study

Systemic Juvenile Idiopathic Arthritis in two children; case report on clinical course, challenges in diagnosis and the role of FDG-PET/CT-scan

Systemic juvenile idiopathic arthritis (sJIA, also called Still's disease) is a rare childhood auto-inflammatory disease with significant morbidity. This case report illustrates the clinical course and highlights diagnostic challenges. FDG-PET/CT imaging may be beneficial in the diagnostic process for some cases, in order to achieve rapid diagnosis and early treatment.

[Still's syndrome-similarities and differences between the juvenile and adult forms]

Still's syndrome includes systemic juvenile idiopathic arthritis (sJIA) and the adult form of Still's disease (adult-onset Still's disease, AOSD). Except for age, there are many similarities between sJIA and AOSD. A biphasic disease model is currently put forth. At disease onset, autoinflammation predominates, which is caused by dysregulation of the innate immune system. Later on, the disease can progress to a chronic-articular form, which is predominantly mediated by the adaptive immune system and is consequently due to autoimmunity. The "window-of-opportunity" hypothesis is based on this biphasic model and supports the assumption that an early, targeted therapy with cytokine blockade can prevent disease progression to chronic destructive arthritis. Macrophage activation syndrome (MAS) is a serious complication of the so-called cytokine storm during the systemic phase of the disease. Clinically, there are many similarities between sJIA and AOSD. Recurrent fever, a fleeting, salmon-colored rash, and arthralgia/arthritis are common signs and symptoms of both sJIA and AOSD. The few differences are mainly related to the therapies and their side effects in children versus adults. In addition, the contribution of genetics to pathogenesis is more pronounced in sJIA compared to AOSD, but there are also smooth transitions in this respect and both diseases are heavily influenced by exogenous factors such as microbial triggers. Future research aspects could include additional investigation of these triggers such as viruses, bacteria, or dysbiosis of the human microbiome.

Adult-Onset Still's Disease: Clinical Aspects and Therapeutic Approach

Adult-onset Still's disease (AoSD) is a rare systemic autoinflammatory disease characterized by arthritis, spiking fever, skin rash and elevated ferritin levels. The reason behind the nomenclature of this condition is that AoSD shares certain symptoms with Still's disease in children, currently named systemic-onset juvenile idiopathic arthritis. Immune dysregulation plays a central role in AoSD and is characterized by pathogenic involvement of both arms of the immune system. Furthermore, the past two decades have seen a large body of immunological research on cytokines, which has attributed to both a better understanding of AoSD and revolutionary advances in treatment. Additionally, recent studies have introduced a new approach by grouping patients with AoSD into only two phenotypes: one with predominantly systemic features and one with a chronic articular disease course. Diagnosis presupposes an extensive diagnostic workup to rule out infections and malignancies. The severe end of the spectrum of this disease is secondary haemophagocytic lymphohistiocytosis, better known as macrophage activation syndrome. In this review, we discuss current research conducted on the pathogenesis, diagnosis, classification, biomarkers and complications of AoSD, as well as the treatment strategy at each stage of the disease course. We also highlight the similarities and differences between AoSD and systemic-onset juvenile idiopathic arthritis. There is a considerable need for large multicentric prospective trials.

Juvenile idiopathic arthritis in Southeast Asia: the Singapore experience over two decades

OBJECTIVES

To examine the clinical characteristics, treatment and outcomes of juvenile idiopathic arthritis (JIA) patients evaluated in Singapore and compare those with reports elsewhere.

METHODS

Patients with JIA were recruited from our Singapore pediatric rheumatology registry from January 1997 to December 2015. Demographic, clinical, treatment, and outcome data were retrospectively collected. Nonparametric statistics were used to describe the data. Chi-squared, Mann-Whitney U, or Kruskal-Wallis tests were applied to compare differences between groups where appropriate. Multivariate logistic regression analyses were used to identify predictors for clinical parameters.

RESULTS

Two hundred eighty-seven JIA patients with 60.6% males of predominantly Chinese descent were included in the study. The median onset age was 9 years (IQR 5.3-12.6), and the median follow-up duration was 30.1 months (IQR 9.1-61.7). Enthesitis-related arthritis (ERA, 32.8%) followed by persistent oligoarthritis (31.0%) was the most common. Elbow or ankle involvement predicted oligoarthritis extension (OR 15.8 (95% CI: 2.3-108.3, p = 0.005), 8.1 (95% CI: 1.5-45.3, p = 0.017)). JIA-associated uveitis was rare (2.8%) which paralleled the less common positive-ANA rate. Majority of our ERA patients had HLA-B27 (79.8%), together with older age predicted sacroiliitis (OR 4.7 (95% CI: 2.0-11.1, p < 0.05), OR 1.2 (95% CI: 1.1-1.3, p = 0.002)). TMJ involvement was under-reported. Methotrexate remained the most common DMARD used, but 36% of patients required biologics for which ERA and polyarthritis were the majority. Joint damage was rare.

CONCLUSION

This study highlights geographical and ethnic differences in JIA epidemiology. Compared with reports elsewhere, our JIA population had many unique findings and good functional outcomes requiring regional study validation. Key points • ERA is the most prominent JIA subtype in Singapore with high prevalence of HLA-B27. • JIA-associated uveitis is rare in SEA and is not associated with ANA or JIA-subtypes. • Elbow and/or ankle involvement at presentation is associated with oligoarthritis extension in our JIA cohort.

The Pattern of Juvenile Idiopathic Arthritis in a Single Tertiary Center in Saudi Arabia

Introduction. Juvenile Idiopathic Arthritis (JIA) is the most common chronic arthritis in children. Our aim is to describe demographic, clinical, and laboratory characteristics and treatment of JIA patients followed up in Pediatric Rheumatology clinic in a tertiary center in Saudi Arabia. Methods. Medical records of all patients who are followed up between January 2007 and January 2015 were retrospectively reviewed. Data were collected about demographic, clinical, and laboratory features and treatment. Results. Total patients were 82, males were 31 (37.8%), and mean age of JIA onset was 7.1 ± 3.6 yr. Mean follow-up duration was 2.67±1.6 yr. Systemic onset JIA (SoJIA) was the commonest (36.5%), followed by polyarticular in 29.2% and oligoarticular in 28%. Large and small joints are involved in 76 (92%) and 30 (36.6%), respectively. Main extra-articular feature was fever in 34 (41.4%). Uveitis was diagnosed in 7 (8.5%) and in 5 (21.7%) of oligoarticular JIA. Anemia was found in 49 (59.7%), high ESR in 45 (54.8%), and leukocytosis and thrombocytosis in 33 (40.2%). Positive ANA was found in 30 (36.5%) mainly in oligoarticular subtype as 12 (52%) patients (out of 23) had this positive test. 9 patients (10.9%) required NSAIDs only, 6 patients (7.3%) required NSAIDs and intra-articular steroids only, and 19 (23%) required NSAIDs, methotrexate, steroids, and biologics. Conclusion. SoJIA is the most common JIA subtype in our study. A population based rather than a single center study will give more details about JIA characteristics in Saudi Arabia

A retrospective study on 158 Thai patients with juvenile idiopathic arthritis followed in a single center over a 15-year period

AIM

To determine the outcomes of juvenile idiopathic arthritis (JIA) in Thai children.

METHODS

A retrospective cohort study. All JIA patients in a rheumatology clinic, Ramathibodi Hospital, between July 1997 and December 2012 were enrolled. The patient data were reviewed from medical records. At the most recent follow-up visit, patient outcomes were assessed in three aspects: disease status, functional outcomes and structural damage.

RESULTS

Of 168 patients, 158 (94.0%) were assessed in disease status and functional outcomes, with 114 patients (67.9%) assessed in three aspects over 4 years of disease. The most common JIA category was systemic JIA (SJIA) (33.8%), followed by enthesitis-related arthritis (ERA) (24.8%), oligoarthritis (18.5%), rheumatoid factor (RF)-negative polyarthritis (15.3%), RF-positive polyarthritis (7.6%) and one undifferentiated arthritis. SJIA had the highest remission rate due to early diagnosis and prompt treatment compared to other categories, whereas RF-positive polyarthritis carried the worst prognosis in three aspects, followed by ERA. Moreover, ERA patients had the highest failure rate in conventional therapy, half of whom had combined treatment with biologic agents and presence of human leukocyte antigen (HLA)-B27 was a predictor for biologic treatment in ERA patients. In addition, disease duration > 2 years or failure of conventional therapy was a predictor of structural bone damage.

CONCLUSIONS

SJIA had the highest remission rate, whereas RF-positive polyarthritis had the worst outcome in three aspects. Prolonged disease duration or failure of conventional therapy was a predictor of structural bone damage, while HLA-B27 was a predictor for biologic treatment in ERA patients.

Common presentations of pediatric rheumatologic diseases: a generalist's guide

PURPOSE OF REVIEW

To present a case-based approach of three common scenarios which often present to the primary care physician. The approach to these cases and the differential diagnosis are discussed for these common rheumatologic diseases.

RECENT FINDINGS

Numerous healthy children and adolescents are referred to pediatric rheumatologists for the evaluation of suspected rheumatologic diseases. Often, general rheumatologic laboratory tests are sent which are not necessarily specific to the clinical situation. There is a high false-positive rate associated with many of these tests and undue anxiety and referrals result from these. Directed laboratory studies based on history and exam findings are more prudent and useful in the evaluation of these children. Routine antinuclear antibody testing, for example, is not recommended without supportive symptoms or signs.

SUMMARY

A practical approach for primary care physicians is described for the evaluation of patients suspected of having some of the more common pediatric rheumatologic symptoms and diseases.