When a little limp spells big trouble

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When a little limp spells big trouble

http://www.clevelandjewishnews.com/articles/2006/03/09/special/health2/special05\

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Early detection of juvenile arthritis is important for successful

treatment

Three years ago, a few months before she turned 3, Addie Peritt woke

up complaining of a stiff, swollen ankle. Usually a spunky, active child,

Addie refused to use her leg. So her parents took her to the emergency room,

where, although an X-ray didn't show a break, doctors put her leg in a cast

for four weeks. But at the end of that month, Addie's ankle had not

improved.

" It was scary. We didn't know what it was or whether she would ever

get better, " recalls her mother . " We weren't getting any answers. "

The Peritts consulted several specialists. One doctor, suspecting

juvenile arthritis, suggested they take Addie to a rheumatologist.

Pediatric rheumatologists are rare -there are only 250 in the entire

country. Luckily for Addie, who lives south of Akron, her referral in late

2003 came just when Philip Hashkes was due to arrive from Israel to head The

Cleveland Clinic's pediatric rheumatology department. Addie became one of

Dr. Hashkes's first patients.

Addie was diagnosed with juvenile idiopathic arthritis (JIA), a

condition of chronic joint inflammation in children under age 16. JIA was

previously called juvenile rheumatoid arthritis but was renamed to

differentiate it from adult arthritis.

Juvenile arthritis is as common as juvenile diabetes, says Hashkes.

" About one kid in 1,000 has it, but you don't hear about it as much. "

Symptoms of the disease show up without warning. Morning stiffness,

walking with a limp, swelling with or without pain, or joint soreness that

lasts longer than six weeks can indicate JIA. In younger children, parents

may notice regression of motor skills; for instance, a child who could climb

stairs before and now doesn't.

" JIA is often missed or ignored, but early diagnosis and aggressive

treatment are crucial, " says the doctor.

To help clinicians, Hashkes co-authored a system of evidence-based

guidelines for identification and treatment, which was published in The

Journal of the American Medical Association (Oct. 5, 2005). Hashkes examined

279 clinical studies on JIA to identify the most effective practices in

treating this little-known condition.

The best treatment is steroid injections, but these must be given

infrequently to avoid negative side effects. Addie received a steroid

injection in her ankle joint, and the swelling went down immediately. Soon

she was running for the first time in months.

For the few patients who don't respond to the steroids, there are new

biologic modifying medications, drugs that target the inflammation; Hashkes

has used these with success, he says.

In addition to soreness and pain-limited mobility, another risk from

JIA is slow or uneven bone growth. To avoid this outcome, Hashkes treats the

arthritic joint aggressively and monitors patients carefully for growth

discrepancies. Should a discrepancy develop, the patient would need to use a

shoe lift for the shorter leg.

Children with arthritis may also develop uveitis, an inflammation in

the eye. When Addie complained that her eyes hurt and the sun bothered her,

it was clear she had developed this secondary condition.

When caught early, uveitis can be treated.

Children with JIA may also suffer from arthritis and osteoarthritis as

adults, depending on the damage to the joint.

With early detection and modern treatments, successful results are

typical. In a best-case outcome, children with JIA can stop their

medications, and the disease goes into remission.

" We can't cure it, but we can have more successes, " explains Hashkes.

" We can significantly improve quality of life for these kids, " who 30 years

ago might have ended up in wheelchairs or needing joint replacement.

Addie just celebrated her 6th birthday, bowling with her 17 best

friends n her kindergarten class at Akron's Lippman Day School. JIA didn't

slow her down one bit as she aimed her ball and jumped with delight watching

the pins drop.