She was elegant on her toes executing a perfect relevé when she suddenly collapsed seemingly in excruciating pain clutching her ankle. Hobbling off the floor, Sarah*, a 13-year-old gymnast who loved hitting the balance beam, soon found herself struggling to walk normally after her ankle was swollen and painful.
A doctor examined her and found that there was ligament strain and prescribed some anti-inflammatory drugs. But when she did not find much relief, put her on a course of antibiotics. When the pain only worsened her parents sought orthopaedic care.
"Initially, I thought it might be a strained ligament or infection, but with prior history of rest and medications received, her symptoms should have subsided," says Dr Sachit Malhan, specialist orthopaedics surgeon at Harley International Medical Clinic. After X-rays, MRI and a detailed blood test was done, the results that came back were concerning: The inflammation levels in her body were five times higher than normal. Taking into account a few other factors evident from the scan, with another course of medication and splintage, she was sent home, and reviewed after another week before she was diagnosed with juvenile idiopathic arthritis.
She was prescribed a course of medications for JIA and over a period of a couple of months, Sarah found immense relief. She was also recommended to consult an occupational therapist as she wanted to pursue gymnastics.
"By introducing her to an occupational therapist, she was slowly reintegrated into her gymnastics classes. Six months later her mother called me to tell me she was doing well," says Dr Sachit, who has more than 10 years of experience in this field.
So, what is juvenile idiopathic arthritis? What are the symptoms? Which section of the population is more at risk of acquiring this condition?
Excerpts from an interview with Dr Sachit:
What is juvenile idiopathic arthritis (JIA)?
JIA is a autoimmune disease that occurs in children below the age of 18. Idiopathic means the causes are hypothesized or not known and under evaluation. Arthritis means joint problems or joint inflammation. It is an auto-immune disease that can be classified into three main types:
• Oligoarticular, where less than five joints are affected. Knee affection is most common.
• Polyarticular, where more than five joints are affected and may involve smaller joints like fingers, wrist, toes.
• Systemic, where a patient exhibits systemic symptoms involving among others, fever, moderate-large sized, salmon-coloured pink rashes, eye inflammation (uveitis). The liver and spleen may also be affected (usually enlargement).
Both oligoarticular and polyarticular conditions are more common in females making up 80 per cent of the cases. The systemic variant makes up to 20 per cent cases, and is more common in males.
Close to 300,000 children in the US are affected by JIA and the number of patients in the UAE too is quite significant.
What are the causes of JIA?
Some experts believe JIA is an autoimmune disease which has been postulated, may be due to some viruses, which may attack the child’s immune system and destabilizes it.
The white blood cells from immune system fighting the virus, falsely, start recognising the synovial membrane (producing synovial fluid inside the joints, which lubricates and nourishes the joints and reduces friction) in the child’s joints, as the enemy and attacks it. This is called synovitis in the initial stages where most of the children present pain and swelling. But if it continues, over a prolonged duration, the cartilage may get damaged, and the joint will get eroded. If this cartilage is significantly damaged, it may lead to various complications of joint pains and growth-related disturbances. With a rise in Covid-19 and variant cases, we did observe an increase in incidence of JIA, but it will require further studies to establish a direct link.
How is it diagnosed?
Usually joint problems in children can be caused by injuries/trauma or infections. Children could also be suffering from swelling which could be because of neoplasia-like growths or cancer. JIA is only diagnosed after ruling out all the above, so it is typically a disease of exclusion.
Early diagnosis is crucial for best treatment. If symptoms persist for more than ‘six’ weeks, experts should explore the possibility of the child having JIA.
No single test can diagnose JIA, but various tests together can help doctors make a diagnosis, categorization of JIA, treatment formulation, prognosis and prevention of future complication. Blood tests, radiological intervention, invasive interventions may be required for diagnosis.
How can parents spot signs of arthritis in their kids and what are the symptoms?
The most common presentation is a ‘painful morning limp’ that gets better by afternoon. A child should typically be active and fresh when they wake up but if they are limping around, it may be a sign. The limping usually gets better by afternoon because joint swelling in this condition improves by then. In polyarticular, finger, hand or wrist involvement may lead to difficulties in studies or art. Eye problems like Uveitis, can also develop, in some affected children. Late presentations may be with Joint contractures, fixed deformities or growth-related disturbances.
How can it be treated?
This typically requires a multidisciplinary approach, which means more than one doctor or discipline is involved in treating the child. The treatment administered can be medication, surgical or supportive.
The specialists involved could be a paediatric rheumatologist to administer medication, or orthopaedic surgeon for treatment of deformities or growth disturbances, ophthalmologist to tackle eye condition, dermatologist to tackle skin conditions. The child may also require assistance of physiotherapist or occupational therapist, to ensure the child revisits the physical activities they loved doing.
In the medical approach, patients with pain and swelling will be given anti-inflammatory drugs.
When it comes to the supportive method of treatment, physiotherapy or assistive occupational therapy may be needed for reinstating as normal as possible level of movements, so child may return to their studies or favourite activities as soon as possible. To maintain joints in a functional position, they may need help of orthotics (special shoes, steel bars shoes etc).
Surgical approach may be needed for joint contractures or growth disturbances.
What do parents need to watch out for in their children post-treatment?
There are two especially important parts of remission after the treatment.
One is watchfulness. If an affected child has been administered medication, is in remission and is back at school, the question hangs, as to whether symptoms of JIA will return? The answer is yes, there is a possibility it may return. Symptoms can reappear even after the age of 20.
But should you be afraid of this? No. Your child should lead a normal life. If it reoccurs just remember to check for infection or trauma and if symptoms persists for two or three weeks. By then you should start thinking about whether it could be JIA. If it persists for six weeks, it is definite.
Second part you need to pay close attention to is mental well-being. We have to remember children are sensitive and in such situations might need psychological care. Parents should not hesitate in seeking these kinds of services for their children. Not only can professionals help the child, but parents can too, by keeping their child’s morale up.
What is the difference between JIA and adult rheumatoid arthritis (RA)?
The age group affected is the first difference. Other differences: RA is single entity whereas JIA has various distinct sub-types; many patients with JIA find that symptoms subside as they age, while adults usually have life-long RA with possibility of exacerbation later in life but usually they remain in remission 50-70 per cent of times. JIA may affect a child’s bone or cause joint-related growth disturbances, whereas RA does not affect growth as the disease impacts adults. Rheumatoid factor is more common in adults (80 per cent) whereas it is less than 50 per cent in JIA.
What is the role of diet in managing this condition?
Usually, a light balanced diet containing proteins is preferred in the acute phase, so a child can digest easily. Later in JIA or remission, the child is allowed to eat normal diet, just like other family members.
* Name changed for privacy reasons