Juvenile Rheumatoid Arthritis

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Juvenile rheumatoid arthritis is one of the most common pediatric rheumatic disorders and a major cause of chronic disability and occasional crippling deformity. The clinical manifestations include synovitis of the peripheral joints with effusion and periarticular soft-tissue swelling. Onset is before 16 years of age, and overall prevalence is estimated tobe 113/100,000

Preventive Rheumatoid Arthritis

Fig. 10.47A, B Insufficiency fractures and avascular bone necrosis in rheumatoid arthritis treated with corti-costeroids. A Anteroposterior radiograph of the right hip in a 34-year-old woman with rheumatoid arthritis shows peripheral sclerosis and central irregularity, suggesting microfractures and necrosis (arrowheads). Note that the volume of the femoral head is somewhat reduced. B Anterior pinhole scan reveals spotty "hot" areas in the periphery (arrows) and a "cold" area in the center of the femoral head, respectively denoting insufficiency fractures and avascular necrosis. Increased tracer uptake is also seen in the acetabulum with degenerative change (arrowheads)

Fig. 10.47A, B Insufficiency fractures and avascular bone necrosis in rheumatoid arthritis treated with corti-costeroids. A Anteroposterior radiograph of the right hip in a 34-year-old woman with rheumatoid arthritis shows peripheral sclerosis and central irregularity, suggesting microfractures and necrosis (arrowheads). Note that the volume of the femoral head is somewhat reduced. B Anterior pinhole scan reveals spotty "hot" areas in the periphery (arrows) and a "cold" area in the center of the femoral head, respectively denoting insufficiency fractures and avascular necrosis. Increased tracer uptake is also seen in the acetabulum with degenerative change (arrowheads)

Fig. 10.48A, B Juvenile rheumatoid arthritis. A Antero-posterior radiograph of the right knee in a 14-year-old girl shows marked periarticular soft-tissue swelling and enlargement of the distal femoral and proximal tibial epiphyses with articular widening (arrows). B Anterior pinhole scan reveals increased tracer uptake showing enlarged articular bones (arrowheads) with intensified phy-seal activity (arrows) caused by hypervascularity

Arthritis Bone Scan

Fig. 10.49 Value of whole-body bone scintigraphy in the diagnosis of juvenile rheumatoid arthritis. Anterior whole-body bone scan in an 18-year-old female with polyarthritis clearly shows prominent symmetrical multiarticular tracer uptake (arrows)

(Miller and Cassidy 2004). Pathology is characterized by villous hypertrophy and hyperplasia with hyperemia and edema of subsynovial tissues. Pannus, an inflammatory exudate that covers the inner synovial lining, is a stigma of early rheumatoid arthritis. It gradually erodes the articular cartilages, invades contiguous bones, and finally results in ankylosis. Diagnosis is based on exclusions as well as on objective arthritis, classic intermittent fever, and rash.

Radiographic features include soft-tissue swelling and osteopenia and enlargement of the distal femoral and proximal tibial epiphyses with articular widening or narrowing (Fig. 10.48A). Cervical involvement is a heralding sign in 2% of patients (Ansell and Kent 1977). Detailed description on the scintigra-phic features of juvenile rheumatoid arthritis is scanty (Jones et al. 1988). According to our limited experience, juvenile rheumatoid arthritis appears to be another excellent indication for bone scintigraphy reinforced with pinhole scintigraphy. Indeed, pinhole scintigraphy provides useful information on synovitis, erosion, and enlarged periarticular bones that are caused by hypervascularity (Fig. 10.48B). In addition, as in rheumatoid arthritis in adults, whole-body scanning is extremely valuable in juvenile rheumatoid arthritis for the holistic survey of mono-pauci-, or polyarticular involvement as well as bone contracture and deformity that may occur in the late stage (Fig. 10.49).

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