Intra-articular methylprednisolone acetate in the management of chronic arthritis in children king Hussein medical center experience

Intraarticular steroid injection in Juvenile Idiopathic arthritis [JIA] has been recently introduced into pediatric rheumatology practice. Much of the evidence supporting its use based on open, non-controlled studies. Patients and methods: We prospectively evaluated the impact of a single intraarticular injection of Methylprednisolone acetate on control of inflammatory arthritis of knee joints in a group of 24 children [30 joints] with Juvenile Idiopathic Arthritis who failed to respond satisfactory to Non-Steroidal Anti-inflammatory Drugs[NSAIDs] with or without slow acting anti-inflammatory drugs. Adverse effects were also evaluated. The study was carried out at the pediatric immunology clinic at King Hussein medical Center [KHMC] between December 1999 to June 2003. Patients aged between 1.5 to 10 years with a mean of 3.39 years. The median duration of follow-up was 24 months. We achieved a significant restoration of the extension function of most joints injected. The mean duration of effect was 18 months for oligoarthritis, and 24 months for juvenile psoriatic arthritis and enthesitis related arthritis compared with 6.75 months for other subtypes. All patients with oligoarthritis who were on oral steroid have discontinued this treatment. This effect was partial or not seen in other subtypes. Relapse rate was higher in patients with systemic- and polyarthritis subtypes. The favorable outcome did not correlate with age, sex or disease duration. The beneficial effect of the injections did not correlate with the presence of antinuclear antibodies [ANA] or ESR. Local adverse effects were few and self-limited with no evidence of systemic toxicity. Intraarticular injection of methylprednisolone acetate appears to be effective, rapid and not associated with significant adverse effects in oligoarthritis, Juvenile Psoriatic arthritis and Enthesitis related arthritis subtypes. On contrary it was found to be less effective in systemic and polyarthritis subtypes

Post-streptococcal reactive arthritis [PSRA]: Clinical features and risk of carditis

Post-streptococcal reactive arthritis [PSRA] is a poorly understood clinical syndrome in which oligoor polyarthritis occurs following a group Astreptococcal pharyngitis. There is lack of universally accepted guidelines for diagnosis and management of these patients. Long-term data regarding risk of carditis within this population are insufficient. To study the clinical features, risk of subsequent carditis and the need for prophylactic antibiotics in this population. Forty-five patients with the diagnosis of PSRA w e re identified at the pediatric immunology clinic in King Hussein Medical Center, Jordan between January 1999 and April 2003. They all had evidence of preceding streptococcal infection and joint disease at initial presentation. However, none fulfilled the updated revised Jones criteria for diagnosis of acute rheumatic fever [ARF]. Common viral causes of reactive arthritis were excluded and all patients had cardiac evaluation at presentation. Follow up was for a minimum of two years, focusing on clinical recurrences and the clinical and/or echocardiographic evidence of carditis. Forty patients, 21 male and 19 female, aged between six and 17 years with a mean age of 10 years were included in the follow up study. All patients had persistent arthritis lasting 2-6 weeks at presentation, which did not respond to conventional therapy with salicylates. Symmetrical polyarthritis of large joints was predominant. Small and axial joints were involved in 45% and 33% cases respectively. Cardiac evaluation at initial presentation was normal. They all had evidence of preceding group Astreptococcal infection. During follow up, four patients developed evidence of carditis with recurrence of arthritis. They were found to be noncompliant with prophylactic antimicrobials. Post-streptococcal reactive arthritis may be considered a separate entity from acute rheumatic fever. However, because of the risk of subsequent carditis in certain percentage of patients, we recommend long-term antimicrobials prophylaxis as advised for patients with acute rheumatic fever