What Does a Pediatric Rheumatologist Do?

Juvenile rheumatoid arthritis (JRA) is a common connective tissue disease in children. It is characterized by chronic arthritis and the involvement of multiple systems throughout the body. It is also the leading cause of disability and blindness in children.

Younger children tend to have persistent irregular fever first. Its systemic symptoms are more significant than joint symptoms, and older children or adult patients are more limited to joint symptoms. The clinical manifestations of this disease are quite different and can be divided into different types, so there are many names, such as Still's disease, juvenile chronic arthritis (JCA), juvenile arthritis (JA) and so on.

Causes of pediatric rheumatoid disease

The cause is unknown. It is generally believed that the etiology of this disease may be related to the following two factors, namely, the susceptibility and exogenous nature of immune inheritance, which are caused by the stimulation of environmental factors.

Clinical manifestations of pediatric rheumatoid disease

Fever

Most of them occur slowly, and a few of them appear suddenly. They can be irregular low fever, continuous high fever or intermittent high fever. Fever resolves itself after several weeks to months, but it is easy to happen repeatedly.

Rash

During the fever, about 1/5 of the children develop rashes, which vary in form, most of which are small maculopapular rashes, and a small number of erythematous erythema centers appearing as a ring-shaped erythema, which can spread throughout the body with occasional itching. The rash often disappears quickly, but can reappear with fever.

3. Joint swelling and pain

This is the main symptom, which usually occurs weeks or months after the fever. It usually invades the knee and ankle joints in the beginning, and can develop into the wrist, elbow, shoulder, and cervical joints. Most of them are bilaterally symmetrical, and some children are migratory. In addition, some children may be accompanied by anemia, pericarditis, myocarditis, pleurisy, pneumonia, and so on.

Pediatric rheumatism examination

1. Determination of rheumatoid factor

Rheumatoid factor is an autoimmune antibody generated by the body against its own denatured IgG. These antibodies also include immunoglobulins such as IgA, IgM, and IgG. At present, the measurement methods used in clinical practice are to measure IgG rheumatoid factor, and the IgG and IgA rheumatoid factors in the serum of some rheumatoid arthritis patients cannot be measured by the current method. Its rheumatoid factor remains negative. The titer of rheumatoid factor has a certain correlation with the progress and cure of the disease. Therefore, rheumatoid factor will be used clinically as an important indicator for clinical observation of treatment effect. But rheumatoid factor is not a specific serological diagnosis of rheumatoid arthritis.

2. Erythrocyte sedimentation rate (ESR)

Erythrocyte sedimentation rate is also called ESR. The rapid increase in erythrocyte sedimentation is due to the increase in large asymmetric molecules in the plasma, such as fibrinogen and oral globulin, which accelerate the sedimentation of red blood cells. It is a more reliable method for testing the degree of rheumatism and arthritis.

3.C-reactive protein (CRlP)

c-reactive protein is mostly elevated.

4. Determination of serum immunoglobulin

Immunoglobulins are a group of serum globulins with similar antibody activity and tuberculosis. Can be divided into IgG, IgA, IgM, IgD, IgE five categories. During acute and chronic inflammation, various globulins are increased. Quantitative determination of IgG, IgA, IgM is helpful for diagnosis and efficacy analysis.

5. Antinuclear antibodies

A few cases were positive for antinuclear antibodies.

6. Joint synovial fluid inspection

The white blood cell count can reach 5-8 × 109 / L, and complement is normal or decreased.

7. X-ray of the joint

Early manifestations are swelling of soft tissues near the joints, osteoporosis, and periostitis.

8. CT, MRI, high-resolution ultrasound and radionuclide scanning.

Diagnosis of pediatric rheumatism

The diagnosis of this disease is mainly based on clinical manifestations. Those with systemic symptoms or arthritis symptoms that last for more than 6 weeks, who can exclude other diseases, should be considered as the disease.

Differential diagnosis of pediatric rheumatoid disease

Early cases should be distinguished from acute purulent infections, osteomyelitis, sepsis, septic arthritis, tuberculosis, leukemia and malignant tumors, traumatic arthritis, viral arthritis, and should also be distinguished from rheumatic fever, systemic lupus erythematosus, etc Identification of collagenous diseases.

Pediatric rheumatism treatment

The purpose of treatment is to reduce symptoms, maintain joint function and prevent joint deformities. Due to the long course of treatment, treatment needs to be performed for a long time, which requires close cooperation between children and parents.

General treatment

Comprehensive treatment should be adopted early. Pay attention to rest and proper nutrition. With physical therapy, a warm water bath should be used in the acute phase, because warm water treatment can reduce pain. For physical therapy, exercise should be done step by step, first passively, then actively. Avoid excessive fatigue and aggravate joint pain.

2. Drug treatment

(1) Non-steroidal anti-inflammatory drugs Aspirin is the first choice. If the treatment is ineffective or intolerable, switch to other non-steroidal anti-inflammatory drugs (toxidine, naproxen, ibuprofen, indomethacin, diclofenac sodium). The course of treatment is long, and it must be maintained for at least six months after the symptoms are controlled.

(2) Anti-rheumatic drugs for relieving the condition The effects of this class of drugs are slow, and they usually take months to six months to take effect, and they are relatively toxic. Therefore, they are only suitable for those who have not been controlled by non-steroid drugs for a long time and have joint bone damage Children. Gold preparation, penicillamine, hydroxychloroquine, sulfasalazine.

(3) Adrenal corticosteroids must strictly grasp the indications: 1) Multi-joint type add small doses of prednisone to non-steroidal anti-inflammatory drugs and disease-relieving anti-rheumatic drugs for severely ill children. 2) If the systemic fever and joints are not controlled by a sufficient amount of non-steroidal anti-inflammatory drugs, prednisone may be added. 3) Hormonal systemic therapy is generally not recommended for oligoarticular types. 4) Those with mild iris ciliary body inflammation can use pupil dilatation and hormone eye drops. For patients with severely impaired vision, in addition to topical injection of hormones, prednisone should be taken orally daily, followed by daily administration.

(4) Immunosuppressants Patients with severe systemic symptoms and progressive arthritis have no effect on aspirin and other non-steroidal anti-inflammatory drugs. Immunosuppressants such as cyclophosphamide, azathioprine, methotrexate, Cyclosporine A.

(5) Other drugs In recent years, intravenous injection of gamma globulin has been used to treat juvenile rheumatoid arthritis and has achieved certain results.

3 Corrective surgery

To reduce the risk of adhesive tenosynovitis and dorsi carpal tendon rupture, tendonectomy can be performed. Synovectomy can be performed in patients with synovial hypertrophy, joint pain, and limited joint mobility. For children with severe hip and knee involvement, joint replacement can be performed after the puberty of bone growth stops in late adolescence.