Approach arthritis in childhood


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Approach arthritis in childhood

  1. 1. Approach to a child with arthritis Dr.Singaram.A
  2. 2. Arthritis vs Arthralgia • Arthralgia – symptom; pain in the joint • Arthritis – sign; intra-articular swelling or 2 or more of:  Limitation of range of motion;  Tenderness or pain on motion  Increased temperature or erythema
  3. 3. Differential diagnosis of childhood joint pain or swelling • • • • • • • • • Avascular necrosis and epiphyseal disorders Reactive and postinfectious arthritis Trauma: Accidental and nonaccidental Hematologic Rheumatological Infection Tumor Idiopathic pain syndromes Systemic diseases
  4. 4. Tender points - Fibromyalgia
  5. 5. Types of Joint Pain History Inflammatory Mechanical Sinister Onset Insiduous Sudden Insiduous Course Fluctuant Persistent Persistent Relation to time More in morning More in evening No relation Relation to activity Improves worsens Worsens Example JIA SCFE Malignancy
  6. 6. Arthritis – Basic Approach • Onset : Acute (< 6 weeks) or chronic • No. of joints involved • Type of joints • Associated systemic features • Precipitating factors
  7. 7. Some important clues… • Inflammed/infected joint assumes a characteristic posture • Wasting of muscles in chronic joint involvement • Referred pain • Swollen joints and enlarged lymph nodes
  8. 8. Review of systems Gottron's papules Evanescent pink macular rash HSP Lower extremity purpuric lesions Oligoarthritis or psoriatic JIA Asymptomatic chronic anterior uveitis Enthesitis related arthritis Acute symptomatic uveitis (pain, redness) Kawasaki disease Conjunctival injection without discharge Sjogren's syndrome Oral Malar rash and hair loss Systemic JIA Ophthalmologic SLE Dermatomyositis Dermatologic Dry eyes with keratitis SLE Painless oral ulcers on palate Behcet Disease Large extremely painful oral ulcers
  9. 9. Review of systems Pericarditis Raynaud phenomenon Takayasu arteritis Absent pulses IBD, SLE, or vasculitis Weight loss or poor growth IBD Diarrhea and abdominal pain Reactive arthritis Preceding infectious gastroenteritis HSP Genitourinary New heart murmur SLE or scleroderma Gastrointestinal ARF or endocarditis SLE, systemic JIA, or ARF Cardiovascular Intermittent colicky abdominal pain Gonococcal arthritis Pustular urethritis or cervicitis Reactive arthritis Non-gonococcal urethritis Behcet disease or IBD Large painful genital ulcerations
  10. 10. Review of systems Hemolytic anemia Pancytopenia Bleeding disorders Neurologic SLE or hemoglobinopathy (eg, SCD) SLE Hematologic Hemarthrosis SLE Seizures and psychosis SLE or fibromyalgia Difficulty concentrating SLE, vasculitis, or hypercoagulability Stroke Vasculitis Asymmetric polyneuropathy Dermatomyositis and polymyositis Proximal muscle weakness
  11. 11. Common clinical presentations • Acute monoarthritis - Sick child (+/- fever) - Well child (+/- trauma) • Chronic monoarthritis - Sick child - Well child • Polyarthritis - Acute - Chronic
  12. 12. Acute monoarthritis Sick Child Fever Yes Septic arthritis Reactive arthritis Kawasaki disease Malignancy SOJIA No Partially treated sepsis Malignancy Connective tissue disorders
  13. 13. Acute monoarthritis Well child Significant trauma Yes No Fractures Bleeding disorders Mechanical derangements Neoplasm JIA
  14. 14. Synovial fluid analysis • Hemorrhagic – Hemarthrosis, PVS • 1500 – 50,000 cells/ cu.mmInflammatory/reactive arthritis • >50,000 cells/ – septic arthritis
  15. 15. Chronic monoarthritis Chronic monoarthritis Sick child Well child Partially treated Oligoarticular JIA Septic arthritis Reactive arthritis Enthesitis related/psoriatic arthritis Systemic onset JIA Mechanical SLE
  16. 16. Acute polyarthritis • • • • • • • Acute rheumatic fever Infective endocarditis Viral arthritis Lyme disease Kawasaki disease HSP PSRA
  17. 17. Chronic polyarthritis • Systemic onset/ Polyarticular JIA • SLE • Juvenile Dermatomyositis • SLE/ PAN • Other inflammatory arthritis
  18. 18. Systemic onset JIA Pauciarticular onset JIA 50 Polyarticular onset JIA 30 to 40 F>M peaks 2 to 5, 10 to 14 years any, rare to start in hip Percent of JIA patients 10 to 15 Sex Age F=M any <17 years Joints any Fever, rash, lymphadenopathy, hepatosplenomegaly Uveitis yes F>M peak 2 to 3 years, rare >10 large joints, but rarely hips no rare 20 percent, esp ANA + less frequent Laboratory abnormalities - Leukocytosis marked - Anemia marked - Elevated ESR marked - ANA absent no no mild low titer common - Rheumatoid factor rare absent Destructive arthritis Disease modifying drugs >50 percent commonly used rare rarely used no mild mild low titer common in younger 10 to 20 percent in those >10 years >50 percent commonly used no