Juvenile rheumatoid arthritis in children: Still's syndrome - features of the clinical course, modern approaches to therapy

general information

Arthritis is accompanied by pain in the affected joints and is dangerous due to its complications. In some cases, the disease leads to the development of joint deformities or the formation of contractures. In the future, this may reduce the patient’s ability to work and cause disability.

According to statistics, 1 child in 1000 suffers from arthritis. Boys experience joint damage 2-3 times less often than girls. Pathology can occur in children from 0 to 18 years of age. However, patients under the age of 5-6 years are most often affected.

Regardless of their origin, arthritis is capable of triggering autoimmune processes in the body, which are characterized by a systemic nature. The pathogenetic links of the disease, in addition to the joints, begin to affect the skin, muscles and internal organs.

Skin syndrome in rheumatic diseases in children

Rheumatic diseases (RD) occupy one of the prominent places in the structure of childhood morbidity. According to consolidated reporting data from the Ministry of Health of the Russian Federation, the prevalence of rheumatic diseases is 5.7 per 100,000 children.

Rheumatic diseases of childhood are presented in the domestic working classification of the Republic of Belarus (1988-1998). These are rheumatic fever (rheumatism), diffuse connective tissue diseases, juvenile arthritis, systemic vasculitis, and other diseases of the joints, bones and soft tissues.

Among the clinical manifestations of a number of RBs, skin changes occupy an important place, the correct assessment and interpretation of which plays an important role in the differential diagnostic search and contributes to reliable and timely recognition of the disease.

This article highlights the features of skin syndrome in some rheumatic diseases of childhood observed by the authors.

Rheumatic fever

Rheumatic fever (rheumatism) is considered as a systemic disease of connective tissue with a predominant localization of the process in the cardiovascular system, developing in connection with acute infection with group A β-hemolytic streptococcus in predisposed individuals, mainly in children and adolescents 7-15 years old.

Diagnostic criteria include polyarthritis, cardiac involvement, chorea, erythema annulare, and rheumatic nodules.

Among the skin manifestations, ring-shaped erythema (annular rash) is observed in 7-10% of children, is usually not accompanied by subjective complaints, does not rise above the skin level, disappears with pressure, is predominantly localized on the skin of the torso, less often on the arms and legs. Ring-shaped erythema, as a rule, is noted at the onset of the disease; when activity subsides, it disappears, but it can also persist for a number of months.

Rheumatic nodules have been very rare in recent years, mainly in children with recurrent rheumatism. These are round, dense, painless formations varying in size from a few millimeters to 1–2 cm. The predominant localization is at the sites of tendon attachment, over bone surfaces and protrusions, in the area of ​​the knee, elbow, metacarpophalangeal joints, in the occipital region and the area of ​​the Achilles tendons. The number of nodules varies from one to several. They persist from 7-10 days to two weeks and less often - up to one month.

Neither erythema annulare nor rheumatoid nodules require special local treatment.

Juvenile rheumatoid arthritis (JRA)

From a modern point of view, JRA is considered as an independent nosological form of unknown etiology, characterized by complex autoimmune processes of pathogenesis, the presence of a large cascade of inflammatory and immunological processes developing on a genetically altered background and accompanied by systemic disorganization of connective tissue with the predominant involvement of joints in the pathological process and the progressive course of the disease.

The most serious variant in terms of the nature of clinical manifestations, course and prognosis is the systemic variant of JRA, which is divided into two forms: Still's disease and Wissler-Fanconi subsepsis.

Still's disease

It occurs, as a rule, in young children, usually begins acutely, is accompanied by hectic fever, a pronounced reaction from the reticuloendothelial system (lymphadenopathy, hepatolienal syndrome), involvement of internal organs in the pathological process (polyserositis), joint damage, and significant changes in laboratory parameters.

A classic sign of the systemic variant is the presence of skin changes in the form of a non-fixed erythematous rash, which is pink, maculopapular, less often pinpoint skin elements located on the chest, abdomen, arms, legs. They disappear with light pressure, are not accompanied by subjective manifestations and significantly intensify with fever and at the height of the activity of the pathological process. The rash often persists for a long time and may appear during exacerbation of the disease.

In 5-10% of children with the polyarticular form of JRA, the appearance of rheumatoid nodules is noted. Nodules of a dense-elastic consistency are usually mobile, not fused with the underlying tissues, the skin over them is sometimes erythematous. The nodules may disappear spontaneously or persist for a long time. Their appearance is considered an unfavorable prognostic sign.

Wissler-Fanconi subsepsis

It is an acute inflammatory condition, the characteristic features of which should be considered hectic fever, persistent rashes, arthralgia or unstable arthritis, hepato- and/or splenomegaly, lymphadenopathy, as well as high leukocytosis with a shift to the left, increased ESR and anemia in the blood. The disease picture resembles sepsis and Still's disease.

A characteristic manifestation of the disease is the presence of a rash, which is characterized by great diversity and polymorphism, often located on the torso and limbs. A typical sign of a rash is the Koebner phenomenon, i.e. the appearance or intensification of a rash in response to mechanical irritation of the skin. The rash is usually not accompanied by subjective complaints. A special variant of skin changes is characterized by a “linear nature”, and more often the stripes are located obliquely or horizontally, localized mainly on the torso and thighs, resembling stretch marks. A hemorrhagic rash is extremely rare.

A distinctive feature of the rash should be considered its stability. The rash worsens significantly as the temperature rises.

Systemic lupus erythematosus (SLE)

A multisystem autoimmune disease that develops on the basis of a genetically determined imperfection of immunoregulatory processes, which results in damage to many organs and systems. The main signs of SLE are skin changes, nonerosive arthritis, nephritis, encephalopathy, pleurisy or pericarditis, cytopenia (leukopenia and thrombocytopenia), and a positive test for ANA in the blood. There are more than 20 types of skin manifestations in SLE: from erythematous to severe bullous rashes. Most often (in 1/3-1/2 children), especially at the onset of the disease, erythema occurs above the zygomatic protrusions and in the area of ​​the bridge of the nose, resembling a “butterfly”. It is characterized by symmetry and is usually not accompanied by any subjective sensations; worsens with excitement and solar insolation. Erythematous rashes are often located on open parts of the body in places not protected from the sun (face, upper chest), less often over large joints, mainly elbows and knees. Sometimes discoid lesions appear, leaving behind cicatricial atrophy. In the acute period, lupus cheilitis occurs (damage to the red border of the lips). Various vascular changes may also be observed: telangiectasia, palmar, plantar, digital capillaritis, hemorrhagic rashes, as manifestations of vasculitis (petechiae, purpura); livedo reticularis on the skin of the lower, less often the upper limbs and torso. Lupus enanthema or aphthous stomatitis occurs in 1/3 of children.

Scleroderma

In general, the disease is distinguished by clinical polymorphism. The most characteristic is the formation of scleroderma lesions of plaque or stripe shape, localized in various areas, most often on the limbs and torso. The lesions may be hypo/hyperpigmented, with a yellowish or reddish tint. Many children have a fairly pronounced thickening of the skin, which in some of them is combined with thickening of the subcutaneous soft tissues. Most patients have no subjective sensations, but itching and pain may occur. Over time, the lesions undergo a distinct transformation with the formation of residual changes in the form of atrophy and/or skin dyschromia.

In addition to plaque or strip-like skin lesions, rarer varieties are identified: “saber strike” type, Pasini-Pierini atrophoderma, white spot disease, bullous hemorrhagic, etc.

Children with systemic scleroderma have a more pronounced range of signs from the skin and subcutaneous soft tissues, and their relatively greater nonspecificity.

Dermatomyositis. Polymyositis

This is a severe progressive systemic disease of the muscles, skin and microvasculature with less distinct damage to internal organs, often complicated by calcification and purulent infection. The clinical picture includes fever, progressive muscle weakness, up to complete immobility, intense muscle pain, increasing muscular and general dystrophy.

Dermatitis is a pathognomonic sign for the disease, occurs in 3/4 of children with juvenile dermatomyositis, and most often appears within a few weeks of the onset of muscle symptoms. The most typical early skin changes can be considered erythematous spots with a violet tint, primarily in the periorbital (symptom of “glasses”) and perinasal areas, on the eyelids and ears, rashes in the area of ​​the extensor surfaces of the small joints of the hands (Gottron’s papules), equivalents of which are also noted over other joints. Skin symptoms also include erythema with swelling of the periungual ridges, vasculitic spots, livedo reticularis, and ulcerative-necrotic changes. Alopecia and dystrophic changes in the nails may develop. The vascular component is represented by palmar capillaritis, livedo reticularis, and telangiectasia.

Systemic vasculitis

Systemic vasculitis (SV) is a group of diseases characterized by primary destructive and proliferative damage to the walls of blood vessels of various sizes, leading to secondary changes in organs and tissues. Existing classifications of SV take into account the caliber of affected vessels, the nature of inflammation, histological data, and immunological features of the process. Skin phenomena are included in various activity assessment schemes. These include: petechiae/ecchymoses, livedo reticularis, skin necrosis, ulcers, erythema nodosum, nodules along the vessels.

The most significant diseases from the group of systemic vasculitis in terms of the frequency of skin involvement are hemorrhagic vasculitis and polyarteritis nodosa.

Hemorrhagic vasculitis

The most common systemic vasculitis in children, characterized by damage to small vessels with changes primarily in the skin, intestines, and kidneys. Main manifestations: non-thrombocytopenic purpura, arthritis and arthralgia, abdominal pain, gastrointestinal bleeding and glomerulonephritis. In almost half of the cases, a recurrent nature of the process is noted. The prognosis is often favorable.

Almost all patients experience skin changes. Characterized by a symmetrical petechial rash and/or palpable purpura, localized mainly distally on the lower extremities, worsening after the child is in an upright position and observed for several days. These changes are so characteristic that they occupy one of the leading positions among other diagnostic criteria. Along with this, there are erythematous, papular and vesicular elements.

Polyarteritis nodosa

It is a necrotizing vasculitis of peripheral and central arteries of medium and small caliber. Juvenile polyarteritis nodosa is characterized by necrotization of the skin with underlying soft tissues and mucous membranes with the development of polymorphic clinical symptoms. Changes can affect any organ and develop against the background of fairly pronounced general symptoms of the disease (fever and cachexia). In addition, weight loss, skin changes, abdominal and musculoskeletal pain, and involvement of the central nervous system are noted.

Skin changes are observed in more than half of patients and are often one of the first symptoms of the disease. The most typical are painful subcutaneous nodules along the vessels, livedo (reticular or tree-like). Livedo, which occurs in most patients, can persist during periods of remission, becoming more pronounced during exacerbation. Every third patient develops thromboangiitis syndrome with the rapid formation of necrosis of the skin and mucous membranes, gangrene of the distal extremities. Papulo-petechial rashes, vesicles, and bullae may also be observed. The significance of skin changes in the diagnosis of the condition is emphasized by the presence of skin symptoms in the diagnostic criteria of the disease.

Lyme disease

It is a multisystem disease caused by the spirochete Borrelia burgdorferi, which is transmitted by ixodid ticks. Skin changes are represented primarily by tick-borne erythema migrans at the site of the tick bite. Erythema is a red spot growing along the periphery with a diameter of at least 5 cm, homogeneously colored or ring-shaped with clearing in the center. In a third of cases, erythema may be accompanied by itching and pain. Erythema may disappear spontaneously, but progression and chronicity of the process and the appearance of secondary skin erythema are possible. Quite rarely, the appearance of urticarial elements, erythema nodosum, a single benign lymphocytoma of the skin and, in adults, chronic atrophic acrodermatitis are also observed. Other clinical signs include influenza-like syndrome, enlarged regional lymph nodes, manifestations of the nervous system (damage to the facial and other cranial nerves and radiculopathy), heart (atrioventricular block), arthralgia, arthritis, and sometimes eye damage.

Skin changes occur in Kawasaki disease, mixed connective tissue disease, periodic disease and other rare diseases falling under the rheumatological rubric.

Treatment

Treatment of skin changes in most rheumatic diseases comes down to relieving the main symptoms of the disease. One of the leading places in the spectrum of antirheumatic drugs is occupied by glucocorticosteroids. The most intensive method of administering steroids is pulse therapy, in which the dose of the administered drug reaches 20–30 mg/kg per day. The course is three days, repeated administration is indicated if necessary. Doses prescribed orally vary depending on the nosological form and the degree of activity of the process from 1-2 mg/kg (calculated for prednisolone) to 0.5–0.7 mg/kg per day. A dose of 0.1–0.3 mg/kg per day can be considered maintenance. GCS are often prescribed in combination with NSAIDs in standard doses. Among the basic drugs that complement GCS, the drug of choice today (especially for JRA) is methotrexate (calculated dose 10 mg/m2 per week). Azathioprine (1.5 mg/kg per day), cyclosporine A (sandimmune) (3.5-5 mg/kg per day), cyclophosphamide, sulfasalazine, gold preparations, quinoline drugs, and their combinations are also used. A certain role in the treatment of rheumatic diseases is given to immunoglobulin therapy, which is carried out in courses of several cycles of intravenous administration at the rate of 0.4-0.5 g/kg per administration. Recently, there has been a search for new effective and safe drugs, such as necrosis factor inhibitors (Remicade, etanercept, etc.), mycophenolate mofetil, leflunomide, etc.

Local therapy is also used. Applications of DMSO, solcoseryl, indovazin, dollit cream, madecassol, heparin and other local remedies are prescribed. Physiotherapeutic procedures, including spa therapy, also play an important role. In many cases, the treatment complex includes antifibrotic drugs (penicillamine, as well as madecassol, colchicine, enzymes, etc.), glucocorticosteroids, and agents affecting the microcirculation system (pentoxifylline, nicoshpan, etc.). The need to use immunosuppressants (methotrexate, azathioprine, etc.), quinoline derivatives (plaquenil), and systemic enzyme therapy is discussed.

In dermatomyositis, sunscreens, anti-inflammatory and antipruritic drugs, and steroid ointments play a role in the treatment of skin changes. Quinoline derivatives are effective against dermatological manifestations of the disease. If skin changes are resistant, along with the use of GCS and plaquenil, dapsone, mycophenolate mofetil (allows you to gradually reduce the dose of GCS), tacrolimus (topical use for erythematous, edematous changes) can be added to the treatment complex.

Thus, skin changes, often an integral part of a complex picture of disorders throughout the body, occupy a significant place in the practice of pediatricians and pediatric rheumatologists. It is the skin syndrome, first detected at an appointment with a dermatologist or first contact doctor, that should alert you to the possible development of one of the rheumatological diseases.

D. L. Alekseev, Candidate of Medical Sciences N. N. Kuzmina, Doctor of Medical Sciences, Professor S. O. Salugina, Candidate of Medical Sciences Institute of Rheumatology RAMS, Moscow

Classification: types of arthritis in children

There are a large number of different types of arthritis in children, each of which differs in its main features, course and prognosis.

• Juvenile rheumatoid arthritis (JRA). An autoimmune disease that often causes joint deformation and subsequent disability in adulthood.
• Rheumatoid arthritis. The disease is a consequence of the negative effects of streptococci. In addition to the joints, the cardiovascular system is often involved in the pathological process.
• Juvenile ankylosing spondylitis (Bechterew's disease). A rarer form of arthritis, accompanied by damage to the spine with the gradual development of its deformation.
• Reactive arthritis. A group of pathologies that are characterized by damage to the joints against the background of the activity of bacteria and viruses that multiply primarily in the gastrointestinal tract or urinary system of the patient.
• Infectious arthritis. They occur against the background of exposure to pathological microorganisms: bacteria, viruses, fungi, parasites.

The disease can be acute or chronic. The task of parents and doctors is to timely identify pathology and prevent its transition to a latent state. this approach reduces the risk of complications.

Therapy for JRA

Treatment of juvenile rheumatoid arthritis diagnosed in children involves restricting physical activity. The patient is not recommended to run, jump, play sports or engage in martial arts. Parents should monitor their babies and prevent them from being in the sun. The diet is changing - doctors insist on reducing the amount of salt, proteins, carbohydrates and animal fats. The diet is based on dishes high in vegetable fats. It is acceptable to consume low-fat fermented milk products, vegetables and fruits.

The basis of drug therapy for JRA is anti-inflammatory drugs and pathogenetic drugs. If necessary, the doctor may prescribe a course of glucocorticosteroids (orally, locally or intra-articularly). Massage sessions and physical therapy exercises become an important component of treatment. Physiotherapy procedures are indicated for patients - phonophoresis, ozokerite applications, laser therapy.

Symptoms of arthritis in children

The main clinical symptom of all types of arthritis in children is pain in the affected joint.
Its characteristics may differ depending on the cause of the disease and the individual characteristics of the body. However, each disease has its own characteristics, such as its favorite location, intensity of pain, presence of joint deformities, etc. The table shows the differential diagnosis of articular syndrome in various arthritis. This will help parents navigate the variety of symptoms and, without missing anything, contact a pediatric rheumatologist in a timely manner.

In addition to articular syndrome, childhood arthritis may be accompanied by other symptoms:

• classic symptoms of inflammation - redness, swelling, decreased functional activity, increased local skin temperature over the lesion;
• fever up to 38-39oC;
• muscle pain;
• morning stiffness – the need to work out the affected joints after waking up;
• enlargement of nearby lymph nodes.

Decreased joint function can be manifested by lameness, inability to hold a pen, pencil, or perform household activities.

Symptoms

In the early stages, the disease is most often relatively mild, so patients do not immediately seek medical help. Symptoms of autoimmune arthritis develop gradually, and the development of a full clinical picture of the disease takes several years. Most often, at the very beginning of the onset of the disease in adults, small joints are affected, especially the hands, and in children, on the contrary, large joints are affected. During this period, the patient has only general symptoms. These include:

• weakness;
• malaise;
• loss of appetite;
• weight loss;
• low-grade fever.

The main signs of illness are:

• Morning soreness and joint stiffness for an hour or longer.
• Painful sensations and swelling.
• Characterized by symmetrical damage to the joints of the right and left sides.
• Limitation of functions due to swelling of the joints.

As autoimmune arthritis develops, the following characteristic signs occur:

• Typical deformation of the hands and feet.
• The occurrence of muscle destruction.
• Disintegration of damaged joints, compression of fibers.

In the final stages of the disease, the following are possible:

• The appearance of rheumatoid nodules that do not cause pain.
• Enlarged lymph nodes.
• Inflammation of blood vessels.
• Pathological processes in the kidneys and lungs.
• Heart problems.
• Osteoporosis.
• Gastrointestinal diseases.
• Neuropathy.
• Eye lesions.

Autoimmune disease (arthritis) leads to damage to all organs and damage to small joints of the limbs. Due to the fact that a person may not experience typical joint pain for a long period of time, he comes to see a doctor when significant changes have already occurred in the cartilage and joints, which greatly complicates treatment.

Causes of arthritis in children

Arthritis in children can be a consequence of the influence of both internal and external factors. Most often, the disease develops against the background of the following situations:

• Past viral or bacterial infections. Inflammatory processes in the digestive tract or urinary system are especially dangerous.
• Autoimmune disorders. Juvenile rheumatoid arthritis is a consequence of improper functioning of the immune system, when aggressive immune cells are formed against one's own tissues.
• Injuries and surgical interventions in violation of the rules of asepsis and antisepsis. Bruises, open fractures, and hematomas increase the risk of developing inflammation in the joint.
• Genetic predisposition. Predetermines reduced resistance of connective tissue to adverse external influences (connective tissue dysplasia is especially dangerous).
• Mechanical damage to intra-articular tissues due to obesity, too intense sports and the child lifting excessive weights.

The health of the children of the Southern Urals is our concern!

Severe joint diseases are not only the prerogative of adults and the elderly. These serious illnesses can also affect a child. In Chelyabinsk, sick children with joint pathologies are provided with qualified medical care at the Chelyabinsk Regional Children's Clinical Hospital in the department of cardiology and rheumatology. The head of the department, a doctor of the highest category, Natalya Kolyadina, talks about the main tasks and problems of treating childhood arthritis.

— Natalya Alexandrovna, why does the department deal with two such different specialties as cardiology and rheumatology? — Indeed, in adults, cardiology and rheumatology are two completely independent departments in the hospital. For children - they are united. Now society is trying to come to the concept of a “family doctor,” but doctors are still afraid of this, because a huge responsibility will fall on their shoulders and they will need extensive and systematic knowledge in all specialties. I always tell my doctors in the department that first of all, we must be pediatricians and know everything about childhood diseases, and only then study a specific specialty in more depth and detail, in particular, cardiology and rheumatology. — What diseases are treated in your department? — Our department treats children of different ages from three months to 18 years. Doctors in our department work with children who may have heart rhythm disturbances, heart failure, heart defects, arterial hypertension, as well as severe pathology of joints and connective tissue. In total, our department has 15 rheumatology beds and 25 cardiology beds. But the most difficult of all our little patients are children suffering from rheumatoid arthritis. This is a very complex disease with subsequent disability. Currently, about 500 children with rheumatoid arthritis have been recorded in the Chelyabinsk region. — What is rheumatoid arthritis? “This is a serious joint disease that can occur at any age, including children. Sometimes the eyes are also affected, and the child can become completely blind. There are also very severe cases when all internal organs suffer. Like most such diseases, it is autoimmune in nature. The body produces autoantibodies against its own tissues, which lead to joint damage. — What are the first signs of the disease? — A high temperature rises, chills begin, a rash occurs, lymph nodes become enlarged, a blood test indicates an inflammatory process in the body. These are signs of the onset of many diseases, and doctors often cannot immediately determine the cause of the ailment. The doctor must be a true professional in order to correctly and clearly diagnose the child. As for parents, it is important not to miss the moment of the onset of the disease in the child. If, along with the signs of a cold or after it, the baby complains of pain in the legs or arms and the joints look swollen, then you should immediately consult a rheumatologist. The sooner treatment begins, the more optimistic the prognosis of the disease will be. — Why does a child begin to suffer from such a serious and seemingly “adult” disease? — The exact cause of the disease has not yet been established. If there are any disorders or mutations in the genes, then some kind of push is enough for it to develop into a serious illness, such as oncology, diabetes mellitus or rheumatoid arthritis. For example, in my practice there have been cases when a mother or father leaves the family, and for the child this is extremely stressful. Against the background of this stress, the disease begins to develop. Trauma, hypothermia, infection, and heredity can also be a provoking factor. — Is this disease inherited? - Yes. There is a genetic predisposition to such diseases, for example, carriage of the so-called histocompatibility antigens. — Is it possible to find out about a tendency to such diseases even before the birth of a child? - No. This disease cannot be determined in utero. — At what age do children most often get sick? - The ages are very different. There are even the smallest children under one year old. Moreover, the earlier a child falls ill, the more severe the disease. — What methods are used to treat such children now? — Treatment of rheumatoid arthritis in children is carried out comprehensively. During the acute period - in a hospital, during the period of remission - on an outpatient basis and in a sanatorium. Treatment requires a lot of effort. In complex diagnostic cases of diseases and ineffective therapy in the department, patients are sent to the federal centers of Moscow. Our leading specialists also constantly undergo improvement cycles and master new treatment methods. Recently I was at the congress of the rheumatology school in Moscow and gave a presentation to my colleagues. It turned out that our department operates at a fairly high level. Previously, children were treated mainly with hormonal drugs. Now we prescribe hormones less often. Currently, long-term therapy with cytostatics is used for juvenile rheumatoid arthritis. In practice, these methods are sometimes ineffective. For the last two years, together with the Department of Childhood Diseases No. 2 of Chelny State Medical Academy and the chief freelance pediatric cardiologist and rheumatologist Galina Glazyrina, we have been introducing high-tech treatment methods. New medications have appeared, so-called “biological agents,” which are now approved for use in children. If previously they could only be prescribed in Moscow, now we have been trained in biological therapy, have a license and can independently prescribe and carry out treatment with these drugs. Today, 11 children receive such medications from us. But they are very expensive, and we do not yet have financing mechanisms, because they are not included in the preferential lists of additional drug coverage. — Do there be deaths in children? “Our mortality rate is now very low. But if a child does not receive the necessary treatment, he may remain deeply disabled for life. Children in this case can live a long time, but their self-care function is significantly impaired. — Is it possible to completely recover from rheumatoid arthritis? — Modern medicine does not know how to completely cure rheumatoid arthritis, but with careful treatment and unquestioning adherence to all doctor’s recommendations, long-term remission and a satisfactory quality of life can be achieved. New treatment methods help to quickly relieve the acute process in the joints, and significantly improve the child’s condition, so that many of the children can attend regular school, and later continue their education at universities and start their own family. But parents of a sick child will have to be patient and prepare for the fact that the fight against a serious illness will be long and difficult. Children stay in our department for a very long time. There are often complications. Sometimes mothers or fathers cannot withstand such stress and abandon the child. This is additional stress for children. The child may fall into severe depression. Some parents simply do not understand how important it is to take treatment correctly and on time and do not take it seriously. But most simply do not have enough money for expensive medications. — How much do the drugs cost? - It depends on the severity of the disease. On average, you need from 600 thousand to one million rubles per year per child. — Does anyone help finance the treatment of such children? “Unfortunately, people simply do not know about this serious disease. Many people are now helping cancer patients. This is, of course, necessary and important. But it is very difficult to see children suffering from rheumatoid arthritis. At the same time, we know how to help them, we know how to do it, but we do not have such capabilities. If there are ways to raise such children, then it would be a sin not to treat them. Of course, sometimes they help us. Last year, Governor Mikhail Yurevich allocated 300 thousand rubles to one girl to purchase medicine. After the treatment, she literally came back to life and felt much better. Sometimes charities help. Also in this half-year, our hospital allocated three million 700 thousand rubles for treatment with high-tech methods to children suffering from rheumatoid arthritis. But this, of course, is not enough. We are currently treating 11 children, and at least 20 more patients need treatment. We are always grateful to those who help us. Children and their parents are ready to accept any help. If it becomes possible to buy medicine for children, they will be able to live a full life, and together we can make them happy. Those who want to help sick children can contact directly the department of cardiology and rheumatology in the second building on the fifth floor of the Chelyabinsk Regional Children's Clinical Hospital or by phone - the secretary of the chief physician or 260-89-90 - the head of the department, Natalya Aleksandrovna Kolyadina.

Olga Melchakova, Uralpress news agency

Expert opinion

Rheumatologists emphasize that arthritis in children is a very insidious disease that can lead to disability of the child. Persistent joint deformities can remain for life and thereby reduce the patient’s ability to work. That is why you need to contact a rheumatologist in time for specialized help aimed exactly at the target. Early initiation of therapy helps reduce the risk of complications. In addition, the duration of treatment in the initial stages of the disease is significantly shorter than in advanced cases.

Prognosis and prevention

JRA belongs to the group of lifelong diagnoses. Timely therapy and regular visits to a rheumatologist will help achieve stable remission without reducing the quality of life and severe restrictions in joint mobility. The risk of pathology transitioning to the acute stage is significant. An optimistic prognosis is formed with the early onset of the disease. Late manifestations of JRA are characterized by a continuously recurring course. The patient suffers from limited mobility of the limbs and becomes disabled.

Preventive measures involve parental supervision of young children to prevent excessive insolation or hypothermia. Children should limit contact with carriers of viral and bacterial infections.

Diagnosis of arthritis in children

Establishing a diagnosis of arthritis begins at the initial consultation stage. The doctor assesses the child’s general condition and details the complaints, conducts an examination and evaluates the functional activity of the affected joints.

To determine the cause of the disease, a rheumatologist prescribes laboratory and instrumental examination methods.

• General and biochemical blood test. The severity of the inflammatory process in the body is assessed.
• Blood test for inflammatory markers - antistreptolysin O, fibrinogen, C-reactive protein.
• Blood test for HLA-B27. This marker indicates ankylosing spondylitis.
• A blood test for citrullinated vimentin (MCV) is a marker of rheumatoid arthritis.
• Ultrasound of affected joints. The doctor evaluates the volume of synovial fluid, the size of the joint cavity, and the condition of the cartilage surfaces.
• X-ray of the affected joints. This study is necessary to assess the extent of bone tissue damage.
• MRI of joints. Indicated in difficult clinical cases.

Another effective diagnostic method is arthroscopy. This is an invasive endoscopic procedure that involves inserting a thin probe with a video camera at the end into the joint cavity. With its help, the doctor examines the pathological area from the inside. The main disadvantage of this procedure is its invasiveness. Therefore, arthroscopy is prescribed as a last resort when non-invasive examination methods cannot help in establishing an objective diagnosis.

If symptoms of damage to other organs and systems are detected, the child is examined by related specialists - a cardiologist, an orthopedist, an infectious disease specialist, an ophthalmologist.

Reactive arthritis

What is reactive arthritis?

Reactive arthritis is an inflammatory non-purulent joint disease that develops after an acute intestinal or genitourinary infection.

How common is reactive arthritis?

Among rheumatic diseases, reactive arthritis is the most common disease. Its prevalence is 86.9 people per 100 thousand children. Teenage boys and young men are most often affected.

Why does reactive arthritis occur?

One of the most common causes of reactive arthritis is chlamydial infection. In childhood, chlamydial arthritis accounts for up to 80%. Children and adults can become infected with chlamydia through contact with people who are carriers of the infection, as well as from animals (cats, dogs), and birds. Infection occurs through airborne droplets, airborne dust, sexual contact, household contact, and also during the passage of the fetus through the infected birth canal of the mother.

The second most common causative agents of reactive arthritis are intestinal microorganisms. The causative agents of intestinal reactive arthritis include Yersinia, Salmonella, Shigella, and Campylobacter.

How does reactive arthritis manifest?

Usually, when questioning the patient, you can find out that 1-3 weeks before the onset of joint manifestations, the patient suffered from an acute respiratory infection, an intestinal disorder, or urinary disorders (pain, increased frequency of urination). Reactive arthritis itself begins acutely, the temperature rises, and the general condition worsens. Large joints of the lower extremities are affected - knees, ankles, heels, metatarsophalangeal and interphalangeal joints, and less commonly, hand joints.

Most often, the joints of the lower extremities become inflamed, especially the toes, where swelling also develops, spreading to the entire finger, and a bluish or purple-bluish coloration of the skin (the finger becomes like a sausage or radish). In addition to arthritis, the development of enthesopathies is characteristic - inflammation of the tendons at the places of their attachment to the bones, especially often in the heel area. Some patients may experience pain in the spine. In many cases, reactive arthritis is short-lived (from several days to several weeks) and goes away with treatment, but in some patients it can become chronic.

In Reiter's disease, a typical form of reactive arthritis, along with articular manifestations, there are signs of urethritis and eye damage (conjunctivitis and more severe forms).

Options for eye damage in Reiter's disease can be the following: conjunctivitis (inflammation of the conjunctiva of the eye) - most often not purulent, with a light discharge, quickly passing; recurrent iridocyclitis (inflammation of the iris and ciliary body) is a type of uveitis with a favorable course; panuveitis (inflammation of all layers of the choroid - iris, ciliary body, choroid) with retinal detachment, up to loss of vision.

Uveitis is characterized by redness of the eyes, photophobia, lacrimation, transient decrease or blurred vision, changes in eye color, changes in the shape and size of the pupil.

Extra-articular manifestations are characterized by damage to the skin, most often in the form of a rash, mucous membranes of the oral cavity (stomatitis), heart, peripheral nervous system (neuritis); skin (curatoderma).

Is reactive arthritis dangerous?

The prognosis for life and long-term functional ability is generally favorable.

Unfavorable prognosis factors for reactive arthritis are considered to be: frequent exacerbations of articular syndrome, hereditary predisposition to rheumatic diseases, carriage of the HLA-B27 antigen, ineffectiveness of anti-inflammatory and antibacterial therapy.

Deaths with reactive arthritis are rare; the main reason is the development of complications, in particular heart damage (carditis, myocarditis).

To reduce the risk of complications and prevent the transition of the acute course of reactive arthritis to chronic, timely and adequate treatment of the infectious process of the inflammatory process is necessary, which requires constant monitoring by a rheumatologist.

How is reactive arthritis diagnosed?

The diagnosis of Reiter's disease or reactive arthritis is made on the basis of data on a previous infection, analysis of the characteristics of the clinical picture, data from laboratory and instrumental examination methods and results for the presence of the pathogen.

What treatments are there for reactive arthritis?

The goal of treatment for reactive arthritis is to eliminate the infectious agent, cure or achieve stable clinical and laboratory remission.

Treatment of a patient with reactive arthritis should be carried out in a specialized hospital. Treatment of reactive arthritis is conservative and includes the use of antibacterial drugs, non-steroidal anti-inflammatory drugs, and glucocorticoids as indicated. During the period of subsidence of acute inflammatory phenomena, exercise therapy and massage are indicated.

One of the main methods of treatment is the prescription of antibacterial drugs. Since chlamydia is a microorganism with a special type of life activity, the choice of antibacterial drugs is limited. These antibiotics include macrolides, tetracyclines and fluoroquinolones.

However, tetracyclines and fluoroquinolones are quite toxic and have side effects that limit their use in pediatric practice. In this regard, macrolides are most often used to treat chlamydia in children. In children over 8 years of age, tetracyclines can be used.

Antibiotic therapy is more effective in the acute stage of Reiter's syndrome.

In case of protracted and chronic course of reactive arthritis, antibiotic therapy is not effective enough.

In patients with chronic reactive arthritis, the immune system functions inadequately, pathological reactions predominate over protective ones. Given these features, various immunomodulatory agents are used to treat chronic chlamydial arthritis. However, their use should be extremely careful, only as prescribed by a doctor.

For the treatment of reactive arthritis of chlamydial etiology in children, treatment regimens using Taktivin, glucosaminylmuramyl dipeptide, and N-hydroxy poly-1,4-ethylenepiperazine have also been developed. The administration of immunomodulators stimulates the body's protective properties and increases overall resistance.

Prescribing antibiotics and immunomodulators does not solve the general problem of treating reactive arthritis. Since the disappearance of chlamydia from the genitourinary organs does not mean a complete cure. The components (antigens) of microorganisms persist longer than the pathogen itself. Control studies are required one, two, three months after the end of treatment. If necessary, repeated courses of antibiotics and immunomodulators are possible. Only a doctor can decide whether a repeat course is necessary.

Antibacterial therapy is advisable for all children with reactive arthritis in whom antibodies to coliform bacteria are detected in diagnostic titers or intestinal bacteria are cultured during bacteriological examination of stool. The drugs of choice are aminoglycosides.

In addition to therapy aimed at eliminating the infection, symptomatic therapy is prescribed.

Non-steroidal anti-inflammatory drugs. Prescribed to reduce pain in all patients. The drugs are prescribed for the acute period. The dose of the drug is calculated depending on the age and weight of the patient.

Steroid anti-inflammatory drugs. Glucocorticosteroids have the most powerful and rapid anti-inflammatory effect. They are the drugs of choice when it is necessary to quickly stop disease activity, pain, and developing complications. The main route of administration of glucocorticoids for reactive arthritis is intra-articular.

Immunosuppressive drugs. In case of continuous exacerbation of articular syndrome, the presence of enthesopathies, limited mobility of the spine (the child does not reach more than 15 cm with his fingertips to the floor), inflammatory changes in blood tests and the ineffectiveness of standard therapy, the prescription of immunosuppressive drugs is indicated. The drug of choice is Sulfasalazine. Prescribed and canceled only by a doctor. Treatment is carried out for a long time (years), under the control of general and biochemical blood tests to prevent the development of side effects.

Primary prevention has not been developed. The main focus is to prevent the development of the disease:

• Healthy lifestyle
• Sanitation of foci of infection.
• Maintaining personal hygiene rules
• Treatment of parents for chlamydia
• Immunogenetic counseling and identification of parents of HLA-B27 antigen carriers
• Family planning

Secondary prevention – prevention of relapse of the disease

• Healthy lifestyle
• Maintaining personal hygiene rules
• Seeing a doctor earlier
• Following the recommendations of a rheumatologist
• Do not self-medicate

Treatment of arthritis in children

Arthritis in children is a pathology that requires complex treatment, which depends on the type of disease, its cause and stage of development, the severity of the main symptoms and signs. In addition to relieving pain, the doctor is faced with the task of normalizing the function of the patient’s immune system and preventing the disease from becoming chronic in cases where this is possible. For this purpose, predominantly conservative treatment methods are used.

Conservative treatment

Regardless of the type of arthritis, conservative therapy is aimed at solving the following problems:

• elimination of pain and inflammation in affected joints;
• removal from the body of waste products of microorganisms that cause the disease;
• optimization of immune system function;
• restoration of function of the affected joint;
• preventing the development of contractures and deformities.

Achieving these goals with medications alone is not always possible. Therefore, rheumatologists use an integrated approach.

• Anti-inflammatory drugs. These include both conventional non-steroidal anti-inflammatory drugs and hormones. Sometimes patients are prescribed “heavy artillery” drugs—cytostatics. However, in pediatrics they try to avoid them due to side effects.
• Physiotherapy. The emphasis is on local anti-inflammatory and restorative procedures - UHF, magnetic therapy, ultrasound.
• Massage and exercise therapy.
• Balneotherapy, sanatorium-resort treatment.

The complex effect on the affected joints in particular and the body as a whole contributes to the activation of internal protective mechanisms and, consequently, faster recovery of the joints. With timely consultation with a doctor, it is possible to cope with the disease and prevent the development of complications.

Surgery

Surgeries for arthritis in pediatric practice are performed extremely rarely. They are indicated only for organic deformation of joints and persistent contractures.

Surgery

Experts resort to surgical intervention for arthritis only when all methods of conservative therapy have been tried. During surgical intervention, the use of two techniques is of greatest importance:

• synovectomy – removal of the articular synovial membrane;
• complete joint replacement with an endoprosthesis.

The decision to replace a joint is made by an orthopedist together with a rheumatologist. The operation is performed when the joint is very deformed and has lost its ability to move. And the most important thing is the patient’s desire to undergo surgery. In this case, the postoperative period is much more successful. An artificial prosthesis can last from 5 to 15 years. The patient needs to take care of the new joint and limit its mobility.

Chronic disease of joint tissues, which subsequently affects cartilage and bone structures, is a very serious illness. In the absence of proper therapy, it constantly progresses and leads to disability. Only comprehensive treatment and patient compliance with all doctor’s recommendations leads to remission.

Don't delay your visit to the doctor. Self-medication, as well as unauthorized withdrawal of medications, is unacceptable for this disease. They will result in deterioration of health and progression of the disease.

You can make an appointment at the Canon clinic on the website or by phone +7

Prevention of arthritis in children

Prevention of arthritis involves eliminating provoking factors. Of course, no one can change their own DNA yet. However, you can treat a sore throat in time, avoid contact with people sick with ARVI, rationalize physical activity, avoiding unbearable overexertion.

If you have relatives with arthritis in your family, it is recommended to visit a rheumatologist at least once a year and undergo a basic set of tests to identify preclinical changes. This will allow you to start therapy on time if pathology is diagnosed.

Questions

• Which doctor treats arthritis in children?
  A pediatric rheumatologist diagnoses and treats arthritis.
• Do arthritis always cause deformities?
  Persistent deformities are characteristic of juvenile rheumatoid arthritis and ankylosing spondylitis. However, they do not always occur. The basis for preventing deformation is timely consultation with a doctor and targeted treatment.
• Is it possible to cure arthritis with folk remedies?
  Traditional medicine is not a scientifically proven form of treatment. This means that it is not possible to predict the effect of certain medicinal plants on the child’s body. Using traditional medicine methods, precious time is lost, and the pathological process can take an aggressive course. To effectively combat arthritis, the use of medications aimed at interrupting the vicious circle of changes in the body is required. Traditional medicine can act as an auxiliary therapy, but not a basic one, and only after consultation with your doctor.
• Is it always necessary to take “hormones” for arthritis in children?
  Hormonal therapy is prescribed to children only with certain forms of arthritis if there are absolute indications.

Children's arthritis. Causes, treatment, prevention.

The first symptoms of a health problem are pain and swelling in the knee. Their causes are bacteria, viruses, genetic and autoimmune diseases. In this case, the body temperature may not increase. Therefore, parents often do not pay attention to complaints and are in no hurry to take their child to the doctor.

However, advanced stages of the disease are more difficult to diagnose, and the prognosis becomes less favorable.

Types of arthritis

There are several types of childhood arthritis:

• Arthritis of the hip joint.

Caused by viruses, bacteria, fungus, parasites. In rare cases, this condition is caused by Lyme disease. The infection enters the joint cavity along with blood and lymph. This usually occurs after an injury. Treatment should be started immediately. Otherwise, the little patient’s condition will rapidly deteriorate.

• Ankylosing spondylitis.

Or juvenile ankylosing spondylitis. This is a chronic disease that affects the sacroiliac joints, spinal joints and paravertebral soft tissues. This disease is characterized by complaints of pain in the back and lower back, as well as stiffness of movement. However, the same disease can also affect the joints. Mainly elbows, knees and ankles.

• Juvenile rheumatoid form

This is a chronic disease that affects the joints. Develops in children under 16 years of age. When it appears, an inflammatory process is observed, and the disease itself progresses quickly and, if it starts, can affect not only the joints, but also spread to the internal organs. As a result, this disease takes on a systemic form.

• Reactive arthritis.

Appears after extra-articular infectious diseases. Reactive arthritis is an inflammation, the focus of which is located in the bone joints. The disease can be either postenterocolitic, that is, occur after an intestinal infection, or urogenital, that is, sexually transmitted.

• Rheumatoid arthritis.

Develops after an infection, such as a sore throat or pharyngitis. At the onset of the disease, a high temperature is noted, as well as symptoms of intoxication - weakness, headache, chills. At the first signs of illness, the child should be immediately taken to the doctor and treatment should begin as soon as possible.

Causes of arthritis in children

There are several reasons for the appearance of this disease in a child. This:

• Osteomyelitis.

A purulent-necrotic process that occurs in the bones, bone marrow and surrounding soft tissues. Osteomyelitis is caused by pyogenic bacteria and microbacteria. They enter the body in two ways: through the bloodstream and after injury.

• Osteosarcoma.

A tumor arising from bone tissue. This pathology is extremely rare. It is characterized by an aggressive course and extremely rapid growth. Its cells can produce bone tissue, but it does not calcify, that is, it does not harden. With this disease, the bones of the lower jaw and pelvis are affected, and in rare cases the spine is affected. Osteosarcoma typically affects older people, but cases have been reported in children.

• Vegetovascular disorders.

This disorder is accompanied by pain in all joints.

• Degenerative changes.

Degenerative changes in the musculoskeletal system (MSA) appear as a result of increased physical activity and during heavy sports, for example, weightlifting.

• Hemophilia.

This is a hereditary blood disease that disrupts the blood clotting factor. With this pathology, hemorrhage into the joint cavity is observed.

• Bacterial.

The causative agents of arthritis are streptococci, staphylococci and tuberculosis. Streptococcal infection is the causative agent of rheumatism.

• Autoimmune arthritis.

Caused by disruption of the cells of the immune system. This type of pathogen provokes infection with juvenile rheumatoid arthritis.

• Viral.

Viruses cause reactive arthritis. These include all types of herpes, rubella, enteroviruses, measles, hepatitis and influenza. The disease can go into an acute phase and become more complicated after the illness.

treatment of arthritis in children

To determine the type of disease, a number of studies are carried out. Diagnostics includes biochemical and serological studies. In addition, doctors determine the tolerability of certain medications.

To treat childhood arthritis, complex therapy is carried out, divided into several stages. It includes both modern and conservative methods.

For relapses and acute phases, a gentle motor regimen is indicated. Wearing bondages is also recommended. In acute cases, fixation with plaster or orthosis.

Drug therapy uses antibiotics and muscle relaxants, as well as non-steroidal anti-inflammatory drugs. In addition to them, doctors also use glucocorticosteroids and immunosuppressive therapy.

Massage and physiotherapy (magnetic therapy, laser therapy, ultraviolet irradiation, UHF therapy, ultrasound) are recommended as auxiliary means. For acute conditions, painkillers creams and ointments are used.

In case of deterioration, surgical operations are resorted to.

Prevention of arthritis in children

The most reliable prevention of arthritis is complete and timely treatment of infectious diseases.
You cannot leave a child untreated just because his condition has improved. Rheumatologists also recommend strengthening the child’s immunity by hardening and using complexes of vitamins and microelements. Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Sources

• Rheumatology: Clinical guidelines / ed. Academician RAMS E.L. Nasonova. – 2nd ed., rev. and additional - M.: GEOTAR-Media, 2010. - 752 p.
• Assier E., Boissier M.-C., Dayer J.-M. Interleukin-6: from identification of the cytokine to development of targeted treatments. Joint Bone Spine 2010;77(6):532–6.
• Nam JL, Winthrop KL, van Vollenhoven RF et al. Current evidence for the management of rheumatoid arthritis with biological disease-modifying antirheumatic drugs: a systemic literature rewires informing the EULAR recommendations for the management of RA.