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Juvenile rheumatoid arthritis & Non-gonococcal acute infectious arthritis

Rheumatoid arthritis occurring in children below 14 years of age constitutes Juvenile Rheumatoid arthritis and is part of the disease process which goes ultimately into the adult from of disease.

It may appear at any age in childhood but most cases are seen between 1-5 years of age, girls being affected more than the boys.

There is involvement of one or more joints in Juvenile rheumatoid arthritis with swelling, tenderness pain and limitation of movement. Systemic toxicity in the form of high fever, lymphadenopathy and hepatosplenomegaly is marked. Growth is affected.

About 10% of children develop continuous spiking fever and toxemia weeks before any joint involvement appears. Joint involvement is variable, it mostly being polyarticular while in some there is monoarticular involvement to start with which eventually becomes polyarticular.

The joint involvement in this form of entity is just like in adults.

Laboratory investigations of Juvenile rheumatoid arthritis are of little help. There is leucocytosis with raised ESR and C-reactive proteins. Rheumatoid factor is rarely demonstrable.

Generally it is self limiting disease but in one third of the cases disease continues into adulthood. Some children may develop deformities and disability after subsidence of acute stage. Children with juvenile rheumatoid arthritis if not treated properly may develop complications like renal failure and cardiopulmonary failure. Inter current infections are also very common.

Treatment

It is on the same lines as adult form of rheumatoid arthritis. Care should be taken to differentiate this form of disease from rheumatic fever which is quite common at this age.

Infectious arthritis

It is not a very uncommon condition and its early recognition is important. A number of organisms are known to be responsible for causing acute arthritis and these range from gram positive cocci (staphylococcus aureus) Pneumococci, streptococci, gonococci, gram negative bacilli to various viral infections.

Septic arthritis results from direct hematogenous involvement of the synorial membrane which is a highly vascular tissue. Conditions which predispose to it are extremes of age, immune compromised states, cancer, diabetes, phagocytic cell dysfunction and chronic alcoholism.

A common feature is a minor injury to the joint. It may be as a result of arthroscopy or intraarticular injection of steroids or prosthetic implants. An extra articular focus of infection may be present in a few cases.

Organisms reach the joint either by hematogenous or lymphatic spread or due to spread from a focus in the bone. Hosts immune defense plays an important role in the development of disease.

Non-gonococcal acute infectious arthritis

It presents acutely with painful swelling of a large joint generally the knee. It is soon followed by involvement of other joints like hip, shoulder, ankle, wrist etc. It is usually either a child or young adult who manifests with the disease.

There are constitutional symptoms like fever, malaise and ill health. There may be evidence of a primary source of infection. Of the various organisms staphylococcus aureas is the commonest followed by streptococci and gram negative bacilli.

But multiple organism infection is equally common. The joint is swollen, painful and there is restriction of movements. Diagnosis is made by aspiration of synovial fluid which may be purulent depending on the infecting organism. A grams stain shall show the presence of organism.

Culture of the fluid is important to confirm the diagnosis. Besides this the presence of leucocytosis, raised ESR and C-reactive proteins are important tests. Blood culture may be positive in about 50% of patients.

X-ray of the joint will show soft tissue swelling with progressive loss of joint space. Bony destruction is present in late stages. Further tests like MRI and radionucleide bone scanning may be required to assess the extent of disease. A case of septic arthritis may have to be differentiated from a case of acute gout, reactive and rheumatoid arthritis.

Treatment consists of immobilization of the joint and antibiotics (Intravenous clindamycin 300 mg 6 hly I Inj. Cefotaxime Ilg 12 hrly / Inj Cefoperazone SOD 1—2 g/12 hrly). It is preferable to give antibiotics either through intramuscular or intravenous route as they will pass into the joint. Intravenous route is preferred for first two weeks and as the condition improves, these are switched on to oral antibiotics to be given for 6 weeks.

Aspiration of the synovial fluid is done by needle daily until no fluid is aspirated. If infection is allowed to persist in the joint, it shall delay the recovery. Sometimes if the aspiration by needle is not successful and pockets of pus and debris get collected in the joint, surgical drainage may be done.

Prognosis of a case of septic arthritis shall depend on the etiological organism and its response to treatment. With extensive treatment, complete recovery takes place within a few days.

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