PAINLESS JUVENILE RHEUMATOID ARTHRITIS

Juvenile rheumatoid arthritis (JRA) is a chronic inflammatory disease affecting an unknown number of children throughout the world. Synonymous with the entity ‘arthritis’ is the word ‘pain’ in the minds of many parents and physicians. Control and relief of pain are the major goals in the treatment of arthritis. A variety of neurological syndromes associated with rheumatoid diseases and JRA are known [1]. The presentation of this case is to highlight the rarity of isolated cranial nerve palsy in JRA and to stress the importance of painless JRA. CASE REPORT A 11-year-old male child was admitted with acute onset of ptosis and outward deviation of left eye. No other positive relevant history was elicited from parents. Apart from this the child had been having recurrent attacks of painless bilateral knee swelling for last three years. During each episode, both knee joints used to get swollen up. Child denied history of associated pain, fever, skin rash, involvement of other joints, or visual problems. Throughout the three year period, child was never incapacitated and had been attending school regularly. He had not had the benefit of formal investigations. He had been receiving nonspecific analgesics at irregular intervals and on SOS basis as prescribed by family physician. Clinically he was a well nourished child with normal anthropometry. Vital parameters were normal. Central nervous system examination revealed normal higher functions. Third cranial nerve palsy on left side, i.e. ptosis, divergent strabismus, and a non-reactive dilated pupil were present (Fig 1). Other cranial nerves were normal. There was no motor or sensory deficit. Fundoscopy and slit lamp examination was normal. Examination of joints revealed bilateral effusion and synovial membrane thickening of both knee joints. There was no other evidence of inflammation. Joint mobility was mildly restricted. Open in a separate window Fig. 1 Swelling of both knee joints and ptosis of left eye in the patient.