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Continuity Clinic Notebook:

 Chapter II. The Evaluation of the Sick Child

Chapter 2 Index

A. Evaluation by system

B. Other categories of illnesses:

1. Metabolic and Endocrine

2. Collagen-Vascular Illnesses

  

JRA: An Approach to Therapy

Diagnosis of JRA: Well-known presentations listed in textbooks:

  1. Systemic Onset: Fever (20% of cases): mostly boys, who have no iridocyclitis, can have any joints involved and have negative Rh factor, ANA; ultimately about 25% have severe arthritis.  95% have typical rash, 85% hepatosplenomegaly.
  2. Pauciarticular: (35-40% of cases): 80% girls; 30% have iridocyclitis, 90% have positive ANAs, HLA DR5, DRW6, DRW8; 20% get severe polyarthritis
  3. Pauciarticular II (10-15% of cases): 90% boys; 10-20% have iridocyclitis have negative ANAs with positive HLA B27. Spondyloarthropathy -? %
  4. Polyarticular I (20-25% of cases) 90% girls, rare iridocyclitis; 25% + ANAs Severe arthritis occurs in 10-15%.
  5. Polyarticular II (5-10% of cases); 100% + Rheumatoid Factor and 75% + ANA Severe arthritis occurs in > 50%.

Symptoms: Children with JRA tend to get fatigued very easily when symptomatic.  For instance, even in the Pauciarticular types, even when the joint is not swollen, there is evidence that when fatigue is most severe, the disease is most active.

Therapy of JRA:

  1. Reassurance: From the above table it would appear that about 20-25% of children presenting with whatever type of JRA will end up with chronic problems.  Of course if the child has the 5th variant listed above, then less able to reassure.
  2. Physical Management: Must preserve joint integrity: PT, OT, splints.
  3. 3 Levels of Drugs: Most pediatricians involved in the first level:

Level I.  NSAIDS:

Name of Medication Dosage (mg/kg/day)

Maximum Amount
1. Salicylate Preparation    
    ASA 60-100; achieve serum level 100  
2. Nonsalicylate meds    
   Tolmetin sodium (Tolectin)                 15-30 2000
   Naproxen (Naprosyn)                 10-20 750
   Naproxen liquid                 10-15 750
   Ibuprofen                 30-70 2400

Level II.  SAARDs: (Slow acting antirheumatic drugs): Included in this category: gold salts (now available in pill form), penicillamine (not effective in children), hydroxychloroquine (Plaquenil), and sulfasalazine (Azulfidine), Steroids are NOT indicated for arthritis.

Level III. Third-Line Agents: Methotrexate, Cytoxan, Imuran, Leukeran, Cyclosporin A.

Follow-Up of Children with Rheumatoid Arthritis: ESR, ESR, and ESR!

Remember there are 3 main goals in treatment of this disease:

  1. Preserve integrity of joints
  2. Help child have as normal a life as possible
  3. In pauciarticular variety, have opthalmologist check q 6 mo to prevent eye disease

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Department of Pediatrics  |  Medical College of Georgia
 Please email comments, suggestions or questions to:
John T.  Benjamin M.D.,  jbenj@mcg.edu

February 27, 2004