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Chronic synovitis


Juvenile chronic arthritis is a general term for non-infective chronic inflammatory joint disease in children, much of which is clinically and aetiologically distinct from adult disease. There are several different types. Classification is constantly changing and the term juvenile idiopathic arthritis has also been suggested. This is likely to need changing again when causes are established, which may be fairly soon! Growth retardation and bony ankylosis are important features of childhood arthritis. Hypoplasia of the jaw leads to a typical facial pattern. Synovitis may also lead to excessive epiphyseal growth with limb length inequality.


Subclassification of Chronic synovitis - JUVENILE CHRONIC ARTHRITIS

1. A systemic illness with a fleeting migratory erythematous macular rash, splenomegaly, serositis, fever and joint pain (Still's Disease). Synovitis may only be a minor feature. This syndrome has similarities to lupus and adult rheumatoid but no specific autoantibodies are recognised. The distribution of lesions suggests that it is mediated by small immune complexes, but the nature of the antigen is unknown.


2. A widespread (polyarticular) synovitis, without systemic features. This may be chronic and destructive. Some older children have a positive rheumatoid factor and overlap with adult rheumatoid arthritis. Uveitis may occur.


3. A chronic synovitis of few joints (pauciarticular), commoner in girls and associated with antinuclear antibodies and chronic uveitis. Eye damage is insidious and often silent. Synechiae may develop, with secondary glaucoma. Ophthalmic screening is essential. Joint disease often settles, but overgrowth of epiphyses is a characteristic of involved joints in this group and leads to limb length discrepancy. A subgroup develop more widespread joint disease later (extended pauciarticular). Antinuclear antibodies in this syndrome include specific antibodies to the oncoprotein DEK which appears to be involved in the control of leucocyte proliferation.


4. A chronic synovitis of one or a few joints, usually including a knee, in HLA-B27 positive children who may go on to develop Spondylitis in adult life. Most are adolescent boys. Acute anterior uveitis is associated.


5. Synovitis associated with psoriasis which is similar to the adult patterns but which tends to lead to widespread ankylosis of both spine and peripheral joints in older children.

6. The combination of allergic purpura and joint synovitis was described by Schönlein and the association with abdominal pain by Henoch. Henoch-Shönlein purpura is almost certainly a post-infective immune complex vasculitis. The mechanism remains unclear but may involve a disturbance of interactions involving IgA and complement. Microvascular damage in other organs occurs, the major problem being renal damage (20-30%). 10-15% of renal cases go on to renal failure.


The three forms of juvenile idiopathic arthritis seen most characteristically in young children; systemic, polyarticular and pauciarticular, appear to be aetiologically distinct from adult syndromes. What is not clear is whether they overlap or whether they are discrete. All three syndromes show varying associations with MHC Class I and Class II allotypes, changing with age, some of which are shared between syndromes.


Treatment of juvenile chronic arthritis tends to be by analogy with adult disease. Methotrexate is widely used to suppress synovitis. The efficacy of other slow acting agentsis in doubt.

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Modified 3-11-04
Information compiled from the National Institutes of Health


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