Juvenile rheumatoid arthritis.

The early diagnosis of JRA rests on the recognition of three distinct modes of onset that are important in preventing deformity, blindness, and even death. Systemic onset is characterized by typical systemic manifestations, particularly high spiking fever and the rheumatoid rash, polyarticular onset is noted by arthritis of more than four joints, and pauciarticular onset is distinguished by involvement of four joints or less, most often a knee initially. In JRA, fundamental to the heart of successful management is patient and parental education regarding both the nature of the disease and goals of therapy. Whereas the NSAIDs are adequate for the control of active disease in most patients, two key issues must be resolved. First, it is important to recognize that the choice of drug for the individual patient is frequently a matter of trial and error. Second, it is critical to prescribe antiinflammatory quantities of a given drug. The slow-acting (remittive) agents, such as intramuscular or oral gold, are reserved for patients with prolonged active polyarthritis, which affects 15 per cent of all patients with JRA. There are several drawbacks to the use of remittive agents. They must be tried for several months, often in the presence of rapidly developing joint limitation and erosions on radiograph, before their effectiveness can be determined. Also, when using these drugs, one must often follow a meticulously graduated dosage regimen, while carefully monitoring the patient for toxic and potentially lethal side effects. It follows, therefore, to never use these agents unless you are familiar with their administration and potential toxicity and to seek help from a specialist.