Polyarticular arthritis in kids can be successfully treated

MANILA, Philippines - Rheumatoid arthritis (RA) is a disease that is most common in the elderly. It is a common assumption because most causes of joint damage are age-related, including wear-and-tear and joint degeneration.

However, it is important to note that just because most cases of arthritis occur in people aged 50 and above, arthritis is not limited to the younger age group. Young adults can get arthritis, too, as well as children, even to some as young as two years old up to 16 years old.

Arthritis in young children is known as juvenile idiopathic arthritis (JIA). It is a chronic disease that causes pain, stiffness, swelling, and limitation in the motion and function of multiple joints.

It is an autoimmune disease that develops because certain cells of the immune system do not work properly and they attack healthy joints.

JIA is typically classified into three different types: pauciarticular JIA, arthritis affecting four or fewer joints; systemic JIA, which along with joint swelling, is characterized by rash and fever; and polyarticular JIA, which means five or more joints are affected, and is the type of JIA most likened to RA in adults. 

A sudden pain

Micca Aguilar Delgado was a little girl like other little girls. She likes to sing, dance, and play badminton and enjoys spending time with family and friends. However, when she was nine years old something changed drastically. She began to experience a strange pain in her wrists. It started to hurt so much that her parents found the pain inhibiting her activities. The pain worsened and it spread to her knees.

“We did not know what went wrong,” said Mrs. Auralica Delgado, Micca’s mother. “The pain continued to get worse. My sister-in-law told us about arthritis in children and said we should take her to a doctor to get her checked.”

Through a referral, the Delgados found themselves at the UST Hospital clinic of pediatric rheumatologist Dr. Christine Bernal in May 2010.

“When I first saw Micca, she already had significant limitations on both wrists,” Bernal recalled. “I decided to do an X-ray and get blood tests. The results showed that Micca was positive for rheumatoid factor (RF). The numbers were very high. The CBC also showed slight anemia. There was also already joint space narrowing on both wrists but no erosions yet.”

Micca was diagnosed with polyarticular JIA. Only about 10-15 percent of children are RF-positive and it indicates a more aggressive form of JIA. The diagnosis came as a surprise to Mrs. Delgado who did not think this kind of disease could affect a child so young.

Bernal started the child on anti-inflammatory drug (NSAID) and methotrexate, a disease-modifying anti-rheumatic drug. Micca showed improvements and soon the NSAID was stopped.

A second attack

Bernal treated Micca for three months and saw improvements in her condition. However, after the initial checkup and treatment, Micca and her mother did not go back for the follow-up consultations.

Micca continued her methotrexate medication for a year, but unfortunately experienced nausea and vomiting while on the medicine. Because of the side effects, the child pleaded with her mother to stop the medication after the first year thinking she was already cured.

“We should have consulted with Dr. Bernal regularly,” Mrs. Delgado admitted. “Micca was doing well so we thought it would be okay to continue with her medicine. We stopped the methotrexate after a year and did not see any immediate problems.”

However, unknown to them, the disease would come back more aggressively. After a year of stopping the methotrexate, Micca had another attack, which was worse than the first bout. She experienced severe pain on her hands, wrists, knees, and ankles.

The pain got so bad she could no longer do simple tasks like getting up from bed, brushing her teeth, or taking a bath by herself. “Micca would wake up crying from the pain,” her mother recalled. “We knew we had to go back to see Dr. Bernal.”

Finding the right treatment

“When I saw Micca again in December 2012 she had severe stiffness and significant joint pain,” Bernal related. “Both wrists, knees, and ankles were already affected. The inflammatory markers were elevated and anemia was still present caused by chronic inflammation.”

Mrs. Delgado explained the side effects Micca experienced while on methotrexate so Bernal decided to switch Micca to methotrexate injections as opposed to the oral form. There was no vomiting and nausea, but the clinical response to the injections was not satisfactory.

Bernal then decided to try a biologic medication. She started Micca on tocilizumab infusions. The effect was immediate. After one month on the medication, there was a significant decrease in pain and inflammation as well as improvement in movement. Even better, Micca did not experience side effects.

“I wish that Micca had expressed her apprehensions over the initial form of medication with me,” Bernal said. “The non-compliance with treatment gave the JIA room to expand. Had I known she was experiencing nausea and vomiting we could have adjusted her medicine earlier and we could have prevented the flare.”

Bernal decided to continue the tocilizumab infusions and Micca continued to improve. She was able to get back the movement in her joints and even slowly return to her normal activities like playing, singing, and dancing. Her overall disposition improved.

Mrs. Delgado said, “We see our Micca coming back to us. She is not always crying or in pain. She’s more like the happy little girl we’ve always known.”

Kids get arthritis, too

Micca is just one of many children who are diagnosed with juvenile idiopathic arthritis every year. The cause of JIA is unknown and there are no warning signs or preventive measures. The most important thing is for parents to be aware of the disease. It can happen at any time.

Parents should look out for swelling in the joints, rashes that come and go, and even recurring high fevers. If their child is experiencing these symptoms it is better to have them checked right away.

“Untreated juvenile arthritis can lead to permanent joint damage, impaired skeletal maturation, and growth stunting,” Bernal said, “not to mention the physical pain and limited mobility.”

JIA is the most common cause of disability and chronic pain in children. There are treatments for juvenile arthritis and the sooner children are properly diagnosed the better and the sooner treatment can begin.

Fifty percent of children with JIA will have the disease burn out when they reach adulthood and those who detect it and treat it early have a better chance to achieve remission.