Arthritis Basics
Signs and Symptoms
Diagnosis
Treatment
Arthritis Basics
The word "arthritis" means inflammation of a joint (or
joints). Inflammation of a joint results in accumulation of inflammatory
fluid inside the joint or in thickening of the lining of the joint (called
the synovium), which in turn leads to swelling of the joint. If there is
no swelling, at least two of the following three symptoms have to be present:
pain or tenderness on movement of a joint, limitation of range of movement,
and heat.
Although inflammation of a joint causes pain, pain in
the joint is not always caused by inflammation. Therefore, just because
a child has pain in a joint, it does not necessarily indicate arthritis,
although arthritis is one of the major and most important causes of joint
pain.
Arthritis may affect one or many joints. When it affects
one joint, it’s called monarticular arthritis. When it affects several
joints, it’s called polyarticular arthritis. When it occurs abruptly
and with severe pain, heat, and an inability to move, it’s called acute
arthritis, and it often makes a physician suspect infection with bacteria
(septic arthritis).
Arthritis may also come on gradually over several weeks,
and last for weeks or months; this is called chronic arthritis.
The causes of chronic arthritis are different from the causes of acute
arthritis.
Signs and Symptoms
Below are some common symptoms of arthritis in children:
-Pain in joints
-Swelling of
joints
-Limping
-Inability to
move the joint
-Holding the
affected limb in one position
-Heat over the
joint
-Stiffness of
joints
-Irritability
( in infants)
-Crying on handling
(in infants)
Associated signs and symptoms, such as fever rash, sores
in the mouth, redness and watering of the eyes, if present, may help the
physician determine the exact diagnosis of what disease condition is responsible
for the arthritis.
Diagnosis
As already pointed out, pain in a joint alone is not an
indication of arthritis. The mistake of identifying a symptom (pain in
a joint) with a disease (arthritis) leads to unnecessary tests, overdiagnosis,
inappropriate treatment, and unnecessary parental anxiety. Based on a child’s
medical history and a careful physical examination, the physician has to:
(1) diagnose whether or not arthritis is the cause of the child’s symptom-complex,
and then (2) consider which of several diseases is causing the arthritis.
There are several causes of arthritis. As already discussed,
septic arthritis is caused by infection with bacteria. Many viral infections
can cause acute cases of arthritis. Arthritis of rheumatic fever is often
acute, affects many joints, and moves from one joint to another. Lyme disease
can cause arthritis and is often intermittent. Rheumatoid arthritis in
children is called Juvenile Rheumatoid Arthritis, is chronic, and is different
in many ways from arthritis seen in adults.
Some common causes of arthritis in children include:
Acute
-Injury (trauma)
-Infection-related
arthritis: (Septic arthritis, Viral arthritis, Lyme disease)
-Immune related
arthritis:(Rheumatic fever, Serum Sickness, Kawasaki disease)
Chronic
-Juvenile Rheumatoid
Arthritis
-Systemic Lupus
Erythematosus
-Psoriasis-related
Some conditions associated with pain in the joints or
with aches and pains may look like arthritis -- but the actual problem
may be something else, with some of the conditions being benign while others
are serious. The following is a list of conditions that can "mimic" arthritis
that the physician must be aware of when examining a child:
-Acute
leukemia
-Neuroblastoma
-Hypermobility
of joints
-Hypothyroidism
-Perthe’s Disease
-Slipped Capital
Femoral Epiphysis
It is also important to remember that as part of normal
growth, children often complain of pain in their arms and legs without
suffering any limitation of normal activities (so called "growing pains").
And both children and adults with depression often complain of pain in
various parts of the body.
These aches and pains may be generalized, or they may
be localized, such as in the muscles, bones, or joints. In the medical
literature, joint pain alone without inflammation is called arthralgia,
a condition that requires proper attention, since several diseases are
associated with it. A partial list of diseases associated with arthralgia
is as follows:
-Excess physical
activity
-Growing pains
-Acute viral
diseases (e.g., flu)
-Chronic diseases
(e.g., diabetes, thyroid disease)
-Bone diseases
(tumors)
-Neurological
diseases (e.g., Guillain-Barre syndrome)
-Generalized
malignancy (leukemia)
-Psychosocial
problems ( school avoidance, family stress)
-Childhood depression
-Reactions to
medications
-Substance abuse
-Lack of sleep
-Chronic Fatigue
Syndrome
-Fibromyalgia
syndrome
Given that it’s impossible to do tests to exclude every
one of these conditions, it becom`s clear why the physician has to evaluate
each child’s medical history, perform a careful physical examination, and
think about the best possible explanation before ordering appropriate laboratory
tests and/or imaging studies (plain x-rays, a CT scan, or an MRI).
It is important to remember that laboratory tests cannot
differentiate between health and disease. The history and physical examination
help the physician decide whether a given disease is -- or might -- be
present. The tests are performed to confirm the presence of a suspected
disease. Additional tests may then be performed to define the disease and
also to exclude any conditions that can mimic the suspected disease.
Even after these steps have been taken, there are two
frequent problems in the diagnosis of rheumatic diseases: 1. Rheumatic
diseases (which include rheumatic fever, rheumatoid arthritis, and systemic
lupus erythematosus) are like "first cousins" -- they strongly resemble
each other, but with minor but crucial variations. 2. Since many of these
diseases evolve over months and years, a physician may initially label
a child as having one disease (e.g., juvenile rheumatoid arthritis) and
later change the diagnosis to another one (e.g., psoriasis-related arthritis).
Treatment
Treatment of arthritis will depend on what the physician
has determined to be the actual cause of the arthritis. If the cause is
a bacterium, such as staphylococcus or the organism that causes Lyme disease,
the treatment will be an appropriate antibiotic. If the cause is rheumatic
fever, the child will need penicillin to eradicate the streptococcal infection
and a nonsteroidal anti-inflammatory drug (NSAID) to treat the arthritis.
Rheumatoid arthritis will require treatment with one of
the nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen (marketed
as Advil, Motrin, etc.), and naprosyn (marketed as Aleve). If these do
not work the physician may suggest adding other drugs such as methotrexate
or a newer biological agent called "Enbrel."
For children with rheumatoid arthritis, a physical therapy
program is often needed to maintain the range of movement, relieve pain
and stiffness, and maintain and improve function.
If there is infection of a joint, an orthopedic surgeon
may be brought in (in addition to treatment with antibiotics) to remove
as much of the fluid as possible. This is especially necessary if the infected
joint is the hip. The child will be placed in a splint until the infection
subsides and the pain brought under control. The child will require physical
therapy throughout the period of treatment.
If the joint swelling and pain are due to leukemia, the
child will be referred to an oncologist (a physician who specializes in
leukemia and cancers), whereas a child with slipped capital femoral epiphysis
should be cared for by an orthopedic surgeon.
In summary, treatment will be quite different for the
many different conditions causing arthritis. That’s why proper diagnosis
is so critical before any treatment can be planned.
