The heart in juvenile rheumatoid arthritis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor: Cafer Zorkun, M.D., Ph.D. [2]

Overview

Juvenile Idiopathic Arthritis (formerly known as Juvenile Rheumatoid Arthritis) (JIA), as defined by the American Rheumatism Association (ARA), is the presence of arthritis (chronic, seronegative, and peripheral) before age 16 years, of at least 3 months duration, when other causes have been excluded. Chest pain, chest discomfort and dyspnea may found in polyarticular and systemic onset forms. [1] [2]

Cardiac involvements are usually subclinical with early diastolic dysfunction followed by latent onset of symptoms with increasing systolic dysfunction and heart failure which is a late finding. Abnormal diastolic function of the left ventricle has also been reported in juvenile idiopathic arthritis [3] [4] [5] [6]

When occurs, cardiac involvement is the second major cause of mortality in Juvenile Idiopathic Arthritis.[7]

Cardiac involvement occurs in about 4.7% of all cases [8] and includes pericarditis, aortitis, coronary vasculitis, valvulitis (endocarditis), conduction system involvement, pulmonary hypertension and myocarditis.

Cardiac involvements may be seen due to disease progression and applied medical treatment. It has been shown that the cause of abnormal diastolic parameters may be multiple and may be a cumulative effect of several factors such as pericarditis with or without pericardial effusion, hypertension,[9] left ventricular hypertrophy, therapy with cardiotoxic agents such as cyclosporine, gold salts[10] d-penicillamine [11] chloroquine [12] [13] and hydroxychloroquine, hypertension due to steroid therapy, secondary amyloidosis[14] and vascular stiffness from vasculitis.

Classification of Juvenile Idiopathic Arthritis

1- Oligoarticular (pauciarticular) onset of Juvenile Idiopathic Arthritis (JIA)

40-60% of all cases

A. More frequently occurs in girls (girls/boys = 5/1)

B. Peak age of onset is at age 2 years.

C. Four or fewer joints are involved during the first 6 months of the disease (often asymmetric involvement).

Oligoarticular onset commonly involves the knees and, less frequently, the ankles and wrists.

The arthritis may be evanescent, rarely destructive, and radiologically insignificant.

D. Approximately 75% of these patients test positive for antinuclear antibody.

E. This mode of onset rarely is associated with systemic signs. A high risk for uveitis exists. [15]

2. Polyarticular onset of juvenile idiopathic arthritis

20-40% of all cases

A. More frequently occurs in girls (girls/boys=3/1).

B. Peak age of onset is at age 3 years.

C. It involves 5 or more joints during the first 6 months of the disease.

Polyarticular onset juvenile idiopathic arthritis commonly involves the small joints of the hand and, less frequently, the larger joints of the knee, ankle, or wrist.

Asymmetric arthritis may be acute or chronic and may be destructive in 15% of patients.

D. Immunoglobulin M form of rheumatoid factor is present in 10% of children with this juvenile idiopathic arthritis subgroup. It is associated with subcutaneous nodules, erosions, and a poor prognosis.

Approximately 40% of these patients test positive for antinuclear antibody.

E. Systemic symptoms, including anorexia, anemia, and growth retardation are moderate. An intermediate risk for uveitis exists. [16]

3. Systemic onset of juvenile idiopathic arthritis

10-20% of all cases.

A. Equal frequency in boys and girls and can appear at any age.

B. Symmetric polyarthritis is present and may be destructive in 25% of patients.

C. Hands, wrists, feet, ankles, elbows, knees, hips, shoulders, cervical spine, and jaw may be involved.

D. Antinuclear antibody is positive in only 10% of the patients.

E. Systemic onset is associated with fever (high in evening and normal in morning), macular rash, leukocytosis, lymphadenopathy, and hepatomegaly. Serositis and cardiac involvement may also occur with pericardial (pericarditis) [17] and myocardial involvement (myocarditis)[18] [19]

Pleural pleuritic and splenic involvement splenomegaly, and abdominal pain less commonly are observed. A low risk for uveitis exists.

Although it is not common; aortic (cusp thickening) and mitral valve involvement (mild mitral insufficiency) may be found in polyarticular formation of juvenile idiopathic arthritis[20]. Following the valve involvement, an atrial flutter can be a manifestation.

Pericarditis in a 12 years old boy with juvenile idiopathic arthritis

Diagnosis of Cardiac Involvement

Electrocardiography

Non specific T wave changes (bi-phasic or negative T vawes) may be observed. [21] Pericarditis can develop secondary to JIA. When occurs, all characteristics ECG changes of pericarditis can be seen.[22]

Echocardiography

Pericardial effusion can be recognized quite accurately by echocardiographic examination even in latent stages. In some cases, left ventricular diastolic diameter may be reduced. [23] [24]

Treatment

The medical therapy, is designed to reduce pain and the single most useful agent is that of the non-steroidal anti-inflammatory drug. Commonly used varieties include - Aspirin 75 - 90mg/kg/day.

Higher doses are tolerated in the younger. The dose should be given 4 times a day, with meals.

Occasionally, elevation of liver enzymes may develop in some children. Overt manifestation of liver disease are extremely uncommon. A potential association between Aspirin and Reye's syndrome with encephalopathy has been identified often with viral illnesses. These children should be immunized for influenza and possibly also to chicken pox.

Prognosis

Cardiac functions should be evaluated by annually performed echocardiographic examinations in all patients during follow-up period. The prognosis in pericarditis seems to be good if patients do not develop cardiac tamponade or constrictive pericarditis. [25] [26]

References

  1. Bernstein B, Takahashi M, Hanson V. Cardiac involvement in juvenile rheumatoid arthritis. J Pediatr 1974;85:313-7.
  2. Gupta MR, Cardiac function in juvenile rheumatoid arthritis J Postgrad Med December 2004 Vol 50 Issue 4, 266-67
  3. Levendoglu F, Temizhan A, Ugurlu H, Ozdemir A, Yazici M. Ventricular function abnormalities in active rheumatoid arthritis: a Doppler echocardiographic study. Rheumatol Int 2004; 24:141-6. Epub 2003 Jun 19
  4. Bharti BB, Kumar S, Kapoor A, Agarwal A, Mishra R, Sinha N. Assessment of left ventricular systolic and diastolic function in juvenile rheumatoid arthritis. J Postgrad Med 2004;50:262-7
  5. Oguz D, Ocal B, Ertan U, Narin H, Karademir S, Senocak F. Left ventricular diastolic functions in juvenile rheumatoid arthritis. Pediatr Cardiol 2000; 21:374-7.
  6. Huppertz H, Voigt I, Muller-Scholden J, Sandhage K. Cardiac manifestations in patients with HLA B27-associated juvenile arthritis. Pediatr Cardiol 2000; 21:141-7.
  7. Hull RG. Outcome in juvenile arthritis. Br J Rheumatol 1988;27:66-71
  8. Svantesson H, Bjorkhem G, Elborgh R. Cardiac involvement in juvenile rheumatoid arthritis. A follow-up study. Acta Paediatr Scand 1983;72:345-50.
  9. Yamamoto T, Abe T, Mastuya M, Kobayashi K, Akaike J, Ikeda Y, et al. A case with juvenile rheumatoid arthritis who developed cerebral vasculitis and venovascular hypertension. Ryumachi 2000;40:818-23.
  10. Qasim FJ, Thiru S, Gillespie K. Gold and D-penicillamine induce vasculitis and upregulate mRNA for IL-4 in the Brown Norway rat: support for a role for Th2 cell activity. Clin Exp Immunol 1997;108:438-45.
  11. 1Qasim FJ, Thiru S, Gillespie K. Gold and D-penicillamine induce vasculitis and upregulate mRNA for IL-4 in the Brown Norway rat: support for a role for Th2 cell activity. Clin Exp Immunol 1997;108:438-45.
  12. Iglesias Cubero G, Rodriguez Reguero JJ, Rojo Ortega JM. Restrictive cardiomyopathy caused by chloroquine. Br Heart J 1993;69:451-2
  13. Ratliff NB, Estes ML, McMahon JT, Myles JL. Chloroquine-induced cardiomyopathy. Arch Pathol Lab Med 1988;112:578.
  14. Husby G. Amyloidosis and rheumatoid arthritis. Clin Exp Rheumatol 1985;3:173-80.
  15. Uveitis and Juvenile Idiopathic Arthritis
  16. Uveitis and Juvenile Idiopathic Arthritis
  17. Lietman PS, Bywaters EG. Pericarditis in juvenile rheumatoid arthritis. Pediatrics 1963; 32:855-60.
  18. Miller JJ 3rd, French JW. Myocarditis in juvenile rheumatoid arthritis. Am J Dis Child 1977;131:205-9.
  19. Uveitis and Juvenile Idiopathic Arthritis
  20. Ozer S, Alehan D, Ozme S, Bakkaloglu A, Söylemezoglu O. Mitral and aortic insufficiency in polyarticular juvenile rheumatoid arthritis Pediatr Cardiol 1994; 15: 151-153.
  21. Cindas A, Gokce-Kutsal Y, Tokgozoglu L, Karanfil. A QT dispersion and cardiac involvement in patients with rheumatoid arthritis. Scand J Rheumatol 2002;31:22-6.
  22. Pediatric Cardiology Handbook, Johnson WH Moller JH 2001 ISBN 0781728789 Retrieved from Google Books
  23. Pediatric Cardiology Handbook, Johnson WH Moller JH 2001 ISBN 0781728789 Retrieved from Google Books
  24. Levendoglu F, Temizhan A, Ugurlu H, Ozdemir A, Yazici M. Ventricular function abnormalities in active rheumatoid arthritis: a Doppler echocardiographic study. Rheumatol Int 2004; 24:141-6. Epub 2003 Jun 19
  25. Svantesson H, Bjorkhem G, Elborgh R. Cardiac involvement in juvenile rheumatoid arthritis. A follow-up study. Acta Paediatr Scand 1983; 72: 345-50.
  26. Hull RG. Outcome in juvenile arthritis. Br J Rheumatol 1988;27:66-71

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