JIA is classified into three broad categories: systemic, polyarthritis, and oligoarthritis . Oligoarthritis is prevalent in females, with negative RF and positive ANA results being pathognomonic . Oligoarthritis has a relatively good prognosis compared with the other categories. Our patient was diagnosed with oligoarticular JIA when she was 12 years old; however, no definitive diagnosis was made when her symptoms first appeared at 2 years old. The diagnosis of JIA is made based on the child’s symptoms and the results of physical and blood examinations. It is recognized that a definite diagnosis is difficult as there is no single, definitive laboratory test for JIA. Joint effusion and numerous rice bodies were observed in the knees of our patient during her first operation. Rice body formation is not a frequently observed pathology and diseases accompanied by rice body formation in the affected joints include soft tissue tumors, such as synovial chondromatosis, or chronic arthritis (septic, tuberculous, or systemic). The existence of rice bodies is not considered to be typical of JIA. However, we think from our experience that JIA should be taken into consideration during differential diagnosis when rice bodies are identified [6, 7]. We performed arthroscopic synovectomy for diagnosis at 2 years of age. Since the pathological findings for the rice bodies showed acidophilic tissues and no definite diagnosis was made, biopsy at 2 years of age might not have been helpful for the diagnosis of JIA. However, soft tissue tumors and tuberculous arthritis could be ruled out.
The general approach to treating JIA includes nonsteroidal anti-inflammatory drugs and multiple intra-articular injection of steroids as first-line therapy, and the second option is MTX or a biological product. If these are not sufficient, synovectomy might be an effective treatment option for mono-articular JIA. The surgical treatment for JIA remains controversial. Adamec et al. reported that surgical treatment should be evaluated in cooperation with a rheumatologist after administration of an appropriate conservative therapy for at least 6 months. Dell'Era et al. reported the outcomes of 31 knee synovectomies (six cases of oligoarthritis, 20 of polyarthritis, and five of psoriatic arthritis) in 19 children with JIA. The best results were observed in the group with oligoarthritis. They concluded that the aim of arthroscopic synovectomy was to enhance nonsurgical therapy. In our patient, no definite diagnosis was made before the second operation, although knee swelling was prolonged and repeated knee aspiration was required. Arthroscopic knee synovectomy was helpful in reducing her symptoms and in making a diagnosis of atypical recurrent JIA, which leaded to treatment with the appropriate medication. Typically, surgical intervention is not recommended until erosions are radiologically manifested. However, we think that arthroscopic synovectomy is one of the options of treatment and prevention of bone erosions for JIA. Toledo et al. described the following: that arthroscopy made it possible to remove synovial tissue mechanically during the subacute phase of mono-articular JIA, might prevent pannus formation, and may lead to complete remission of arthritis. Medication for JIA also remains controversial. She received MTX medication due to recurrence of knee arthritis. There has been no recurrent knee arthritis, and no side effects.
The recurrence of symptoms, even in oligoarthritis, is not uncommon, with the relapse rate after synovectomy reported to be 36 to 67% [4, 9]. In addition, the mean period free from recurrence was only 1.69 years . Thus, surgical treatment alone may not be sufficient for the treatment of JIA.
This patient was diagnosed as oligoarticular JIA and was treated with arthroscopic synovectomy of both knees at the age of 2 years. After a 10-year asymptomatic period, arthritis recurred in one knee without any cause. Children who suffer prolonged joint swelling are at risk of JIA. Even if the symptoms heal and no definite diagnosis is made at the first treatment, informed consent is needed to make the patients understand the future risk of recurrent arthritis after even lengthy asymptomatic periods.