Juvenile idiopathic arthritis (JIA), also known as juvenile arthritis and formerly known as juvenile rheumatoid arthritis (JRA), is the most common chronic rheumatic disease of childhood, affecting approximately 3.8 to 400 out of 100,000 children. Juvenile refers to disease onset before 16 years of age, while idiopathic refers to a condition with no defined cause, and arthritis is inflammation within the joint. JIA is an autoimmune, noninfective, inflammatory joint disease, the cause of which remains poorly understood. It is characterised by chronic joint inflammation. JIA is a subset of childhood arthritis, but unlike other, more transient forms of childhood arthritis, JIA is a lifelong condition with relapse of disease after treatment discontinuation being common. JIA has clinical and pathologic correlates to adult inflammatory and auto-immune arthritis, with the diseases believed to exist on a continuum from childhood to adulthood. There are six biologically and clinically distinct forms of JIA: oligoarticular JIA, rheumatoid factor negative polyarticular JIA, rheumatoid factor positive polyarticular JIA, enthesitis-related arthritis, psoriatic JIA and systemic JIA. A definitive diagnostic test for JIA is lacking: diagnosis is made clinically by a combination of laboratory and clinical factors. Cancer and other auto-immune or inflammatory conditions are usually considered. The prognosis for children with JIA has improved dramatically over recent decades, particularly with the introduction of biological therapies and a shift towards more aggressive treatment strategies. JIA treatment aims for normal physical and psychosocial functioning, which is an achievable goal for some children with this condition.
Signs and symptoms Arthritis entails inflammation within the joint, and presents as swelling, pain, stiffness and restricted joint movement. Symptoms of JIA vary. This is because JIA has several subtypes, which differ according to the number of affected joints, severity of disease, age of onset, prognosis and presence or absence of inflammation in other parts of the body. The key clinical feature in JIA is persistent swelling of the affected joints. Any joint can be affected, but large joints such as the knee and ankle are most commonly involved. Involvement of small joints of the hands and feet is more likely when many joints are affected ('polyarthritis'). Swollen joints may also feel warmer to touch. Swelling may be difficult to detect clinically, especially for joints such as those of the spine, sacroiliac joints, shoulder, hip, and jaw. Joint pain is an important symptom, although some children experience minimal or no pain with their arthritis. In these children, the first sign of arthritis may be limping, especially in the morning. Swelling and pain usually result in limited movement of the affected joints, for example a knee held bent causing a limp, or being unable to make a full fist. Limited movement may reduce a child's ability to fully participate in activities and undertake usual tasks such as those used for self-care. In some JIA subtypes, more non-specific symptoms of being unwell may be present, such as lethargy, fatigue and poor appetite. Children with systemic JIA usually present with fever and a classic rash and may become quite ill. Late effects of arthritis can include joint contractures (stiff, bent joints with loss of movement) due to joint damage; limb length discrepancies and muscle wasting with muscle weakness.
Extra-articular JIA is associated with inflammation in the front of the eye (acute or chronic anterior uveitis), which affects about one in six children with JIA. Eye involvement occurs most commonly in girls, those with only a few joints involved (oligoarthritis), those with rheumatoid factor negative polyarticular JIA, and those with a positive anti-nuclear antibody (ANA). Girls younger than six years old are at greatest risk of anterior uveitis. 90% of chronic anterior uveitis occurs within 4 years of JIA diagnosis. Acute anterior uveitis is seen in 11-13% of JIA and is more commonly associated with the enthesitis related arthritis subtype. It presents with light sensitivity, redness of the eyes and eye pain. Regular eye exams are required for children affected by acute or chronic anterior uveitis related to JIA. Children with the Systemic JIA subtype often experience extra-articular manifestations including fever, rash, enlarged lymph nodes, enlarged liver or spleen, serositis and anemia.
Complications JIA is a chronic disorder, which if neglected, can lead to serious complications. However, with regular follow-up and modern treatments, complications have reduced and outcomes improved. If inflammation is not treated, it can damage the joint, the cartilage and the bone. With the advent of modern therapies, these complications of JIA have become much less common. Children with JIA may have a reduced overall rate of growth, especially if the disease involves many joints or other body systems. This may be due to a combination of the disease itself, as well as its treatments, particularly corticosteroid use. Paradoxically, limbs where a large joint (such as the knee) is inflamed may have increased growth in the short term, leading to limb-length discrepancy (i.e. one arm or leg is slightly longer than the other). This is due to increased blood supply to the bony growth plates surrounding the inflamed joints. Bone density and bone strength may be reduced through a combination of inflammation, corticosteroid use and reduced physical activity levels. Uveitis, if left untreated, can result in scarring, glaucoma, cataracts, and even blindness. Regular monitoring allows for early detection and treatment. Steroid eye drops are usually the first line treatment for anterior uveitis. However, other treatments – many of which also treat arthritis (e.g. methotrexate, biologics) – may be required to keep the inflammation under control, and to minimise steroid use over the longer term. Long term steroid use can contribute to the development of cataracts. Macrophage activation syndrome (MAS) is a severe, potentially life-threatening complication that can occur in patients with the systemic subtype of JIA. MAS involves uncontrolled activation of the immune system, which can present with a sepsis-like picture of fever, rash, enlarged liver and spleen, enlarged lymph nodes and cardiorespiratory compromise.
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