360
CHAPTER 11
|
Juvenile Idiopathic Arthritis
A
B
FIGURE 11-9.
The cervical spine in a child with polyarticular JIA.
A.
At 6 years of age, there are no radiographic abnormali-
ties.
B.
At 21 years of age there is ankylosis of C2–C5.
FIGURE 11-10.
CT scan of SI joints in a child with JAS showing
erosions and sclerosis of the SI joints. (Courtesy of D. Ruben Burgos-
Vargas.)
ERA. It is especially important in boys above the age of 6,
where there is a family history of HLA-B27–associated illness,
or SI joint or spinal inflammatory pain.
Synovial Fluid Analysis.
Arthrocentesis with synovial
fluid analysis and culture should be performed in all children
with an acute arthritis accompanied by fever or in children for
whom the diagnosis is unclear. In JIA, synovial fluid is type
II, or inflammatory. The appearance is typically yellow and
cloudy with decreased viscosity. Leukocyte counts are generally
between 15 and 20,000 cells/mm
3
; however, they may range
as high as 100,000 cells/mm
3
(130–132). There is typically a
neutrophil predominance (130).
Synovial Biopsy.
A synovial biopsy should be performed
if the diagnosis remains unclear after laboratories, imaging, and
synovial fluid analysis. Biopsy is particularly helpful if a diag-
nosis of tuberculosis, PVNS, or sarcoidosis is being considered.
TREATMENT RECOMMENDATIONS
Medications.
The fundamental purpose of pharmaco-
logic therapy is to achieve pain control, decrease inflammation,
prevent joint destruction, and to maintain remission. The
medications used are individualized for each patient, depend-
ing on their subtype of arthritis, degree of inflammation, and
previous pharmacologic response.
Nonsteroidal Anti-Inflammatory Drugs.
NSAIDs are
the initial therapeutic intervention in many children with JIA.
NSAIDs provide both analgesia and anti-inflammatory effects.
NSAIDs affect the biosynthesis of prostaglandins by direct inhibi-
tion of cyclo-oxygenase (COX) (133). There are two isoforms
