Approach to a child with arthritis by dr praman kushwah

1. APPROACH TO A CHILD WITH
ARTHRITIS
By
Dr Praman Kushwah
Guide Dr Himanshu Dua

2. “When an arthritis patient walked in the front
door
I wanted to walk out the back one”
—Sir William Osler
(1849–1919)

3. We will be approaching as
• Definations
• Classification – acute &chronic
• Causes
• History taking – focus on questionaire
• Examination
• Investigations
• Common disorders we come accross

4. ARTHRITIS
Swelling or effusion or the presence of 2 or more of
following signs : limitation of range of movement
,tenderness or pain on motion ,increased heat .
ARTHRALGIA
Joint pain without any signs of inflamation.
• Monoarthritis : only one joint involved
• Oligoarthritis : 1-4 joints during 1st 6 months of
disease
• Polyarthritis : >5 joints during 1st 6 months of disease

5. Questionaire
• ? Onset of symptom
• ? Age /Gender
• ? Progression of symptoms/Recurrence
• ? Sick/ nonsick
• ? Trauma
• ? Family history
• ? Associated symptoms – Fever, rash, bleeding,
ocular symptoms ,blood transfusions ,any
deformity ,weight loss, glands

6. MONOARTHRITIS

7. Arthritis in childhood is common with
monoarthritis being more common than
polyarthritis.
• Acute monoarthritis (< 2 weeks)
• Chronic monoarthritis (> 6 weeks)

8. ACUTE MONOARTHRITIS

9. CAUSES
1. Septic arthritis
2. Reactive arthritis including the initial
presentation of acute rheumatic fever and
post infectious arthritides
3. Hemarthrosis
4. Traumatic joint effusion
5. Bone tumours and acute leukemia
6. Juvenile arthritis (systemic onset or enthesitis
related subcategories)

11. APPROACH
A good history is pivotal
The key points to focus upon are :
1. child ‘well’ or ‘sick’?
2. history of trauma?
3. Features suggestive of infection, either localised
or systemic?
4. family history of bleeding diathesis?
5. nature of the onset?

12. 6.Any Constitutional features?
1. Fever,
2. sore throat
3. weight loss
4. loss of appetite
5. diarrhoea
6. urethral discharge,
7. history of sexual activity
8. history suggestive of uveitis (painful red eye)
9. rash

13. 7. What is the nature of pain and/or stiffness?
– Night pain  osteomas or malignancies.
– early morning stiffness improvement with
gentle mobility  inflammatory arthritis.
– Pain more in the evenings ,worsens after movement or
with exercise  mechanical pain.
8. Is there a history of medications being taken
– steroids  avascular necrosis
– retinoids  monoarthritis
– anticonvulsants  articular manifestation of lupus
– Chelation therapies  arthropathy

14. Examination
General Examination Pallor,rashes, palpable purpura,
peeling of the skin, thickening of the
skin, conjunctivitis, icterus,
lymphadenopathy, nail
pitting,pigmentation, psoriasis, oral
ulcers, nodules
systemic examination Tachycardia / murmurs, presence of chest
infection, or hepatosplenomegaly
musculoskeletal
system
swelling, redness and soft tissue involvement

15. Investigations
Laboratory investigations: Radiological evaluation
A. CBC,ESR, CRP
B. Coagulation studies
C. Blood culture
D. Viral titers
E. Anti streptolysin O titre: ASO titre
F. Throat swab
G. Tuberculin test
X- ray-
wide joint Space
features of injury
features of osteochondritis ,avascular
necrosis , Deposits in joints
Malignancy
Ultrasound - effusion and for diagnostic
aspiration
MRI - show features of synovitis ,effusion
,bone Edema ,osteomyelitis , tumor
Echocardiography: assist in diagnosis of
child with suspected Acute Rheumatic fever

16. The Common Causes

17. Pyogenic Arthritis
1. True clinical emergency
2. Common infecting organism is staphylococcus aureus,
streptococcus species, pseudomonas aeruginosa,
pneumococci, neisseria meningitidis gonococcus,
escherichia coli, klebsiella and enterobacter species
3. Onset of fever, malaise and signs such as erythema, local
heat and significant pain at affected joint are all suggestive of
a septic joint
4. Diagnostic is monoarthritis with regional lymphadenopathy .
5. Delay in treatment can result in disastrous complications
6. Total recommended antibiotic course is for at least 6 weeks.

18. Transient Synovitis of the Hip
1. In young toddlers and up to 8 years
2. Well child with a history of mild upper respiratory infection
in the recent
3. Diagnosis of exclusion and a septic hip is an important
differential where the child is toxic, febrile and has a
significant pain
4. Settles with simple analgesia in 24–48 h, needs rest

19. Reactive Arthritis
1. Infection with enteric organisms (shigella, salmonella and
campylobacter)
2. Very painful, usually relatively short-lived
3. Presence of HLA-B27 in the patient and a family history of
spondyloarthropathy appear to increase the risk
4. Arthritis,urethritis and acute conjunctivitis are well
described to occur together. (Reiter’s syndrome)

20. Post Streptococcal reactive
arthritis (PSRA) and acute Rheumatic fever
(ARF).
1. Usually present with multiple joint involvement
2. Pattern of joint disease is fleeting in ARF and usually not
involved for more than a wk
3. diagnosis of ARF is established mainly on clinical grounds
major criteria include (1) carditis, (2) polyarthritis, (3) chorea,(4) erythema
marginatum, and (5) subcutaneous nodules. The minor criteria include (1) arthralgia
(counted only when arthritis is not present), (2) fever, (3) elevated acute phase reactants,
and (4) an electrocardiogram showing prolonged PR interval
4. PSRA resolves over 6–8 weeks and has a less dramatic
response to nsaids as compared to ARF
5. PSRA tends to occur sooner after a streptococcal infection
than the arthritis of ARF (7–10 vs 10–28 days).
6. Articular outlook for both forms is excellent

21. Arthritis as Part of Systemic Illness
Systemic infections Systemic vasculitic illnesses
1. Leptospirosis,
2. Brucellosis,
3. Mycoplasma,
4. Hepatitis B &C,
5. Enteroviral
6. Arboviral infections such as
chikungunya
1. Kawasaki disease and
henoch schnolein purpura
2. Monoarticular presentation
is described though less
typical
3. Children have large joint
involvement of the lower
limbs with angioedema over
the hands and feet.

22. Malignancy
1. Diffuse hematological malignancy (leukemia, lymphoma)
2. localised osseous malignancy (osteosarcoma/ Ewing's) can
present as joint pain
3. red flag signs are that the child is usually sick and may have
bone pain, night pain and/or back pain.
4. features that point to the diagnosis of a malignancy are
pallor, hepatosplenomegaly, lymphadenopathy and bony
tenderness
5. X-rays may show periosteal reactions and other features of
bony malignancy

23. Hemarthrosis
• Especially a male infant who has significant bruising after
trivial trauma, large hematomas after vaccination or
spontaneous large articular swellings that begin abruptly and
are very painful
• Recurrent hemarthrosis can damage the joint and lead to
chronic arthropathy needing synovectomy and/or joint
replacement in the long term.
• Prophylactic aggressive factor replacement therapy
• Instillation of corticosteroid, to prevent the development of
chronic changes in the effected joint

24. CHRONIC MONOARTHRITIS

25. Causes
1. Juvenile arthritis (systemic onset
oligoarticular ,and the ERA subcategories.)
2. Chronic hemarthrosis
3. Malignancies/bone tumors
4. Infections such as tuberculosis
5. Miscellaneous disorders e.g., Sarcoidosis,
pigmented villonodular synovitis.

26. APPROACH
• Distinguish between the sick and well child
• Identify for presence of other pointers of chronic disease.
• Some conditions can present as either as acute or chronic
monoarthritis
– hemarthrosis
– subcategories of jia
– children with malignancies.

27. Sick child Well child
1. Partially treated septic arthritis
2. TB
3. Other infection-lyme disease,
brucellosis
4. Vasculitis
5. Sarcoidosis
6. Collagen vascular disease-eg SLE
7. Malignancy
8. Arthritis associated with other chronic
diseases- IBD, celiac disease
1. OJIA( oligoarticular JIA)
2. Enthesitis related arthritis
3. Psoriatic arthritis
4. Pigmented villo-nodular synovitis
5. Mechanical injury/foreign body e.g.
Plant thorn synovitis

28. HISTORY
1. Morning stiffness
2. Night pains
3. Restriction of activities
4. Recent sore throat,
5. Gastroenteritis,
6. Red and painful eyes,
7. Chronic skin disease such as psoriasis
8. Significant trauma
9. History of tuberculosis (tb) or contact
10. Recent travel to an area endemic for lyme disease,
brucellosis or A history of tick bite

29. EXAMINATION
1. Skin examination
2. Formal ophthalmology evaluation by slit lamp for uveitis
3. Musculoskeletal examination

30. Investigations
Laboratory investigations: Radiology
1. Mantoux test
2. chest X -ray for TB
3. ASLO titre
4. Lyme/Brucella serology
5. Bone marrow aspirate for
infection
6. Bone marrow biopsy for
malignancy
7. ANA screen
1. Joint space narrowing
2. Brodie’s abscess is characteristic of
osteoarticular TB
3. Bone Scan is useful in picking up
partially treated septic arthritis,
juxta- articular osteomyelitis

31. The Common Causes

32. Osteoarticular TB
• By direct invasion into a joint
• Or as a reactive arthritis termed poncet’s disease (usually a
polyarticular disease)where the tubercular infection is at a
distant site
• Significant pain as a result of muscle spasm around the
involved joint
• Contact history with TB is frequently obtained
• Definitive diagnosis is by synovial fluid culture of
mycobacterium TB (low yield) or PCR for mycobacteriumtb
(low sensitivity, high specificity)

33. Oligoarticular JIA (OJIA)
• monoarticular presentation diagnosis of exclusion
• joint should be involved for more than 6 weeks
• characteristic morning stiffness and mild pain
• Baseline tests are usually normal MRI will show
synovitis and effusion
• NSAIDS and Intra-articular steroids , aggressive
approach with DMARDs needed.
• articular prognosis is usually excellent

34. Pigmented Villonodular
Synovitis(PVNS)
• Rare cause of chronic monoarthritis
• Benign synovial hypertrophic condition
• Girls more than boys
• Painless recurrent large joint effusion with no systemic signs
and normal inflammatory markers
• MRI is diagnostic ,it shows hemosiderin deposits
• T/t intra-articular steroids, later surgical or radioactive
synovectomy.

35. POLYARTHRITIS

36. • Caused directly by an infectious agent or
indirectly by immune mechanisms,
• May be a component of a systemic disease
process or may be idiopathic

37. Viral Parvovirus B19, Enteroviruses, Adenoviruses, Mumps, Rubella, Varicella
zoster virus, Hepatitis B, Coxsackie virus, Cytomegalovirus, EBV, HIV.
Bacterial Staphylococcal and streptococcal infections, Neisseria gonorrhae,
Hemophilus influenzae; Bacterial endocarditis.
Other Infections Tuberculosis, Leptospirosis, Fungal infections, Brucellosis
Parainfectious /
Reactive
HIV, Group A streptococcal infections, Salmonella, Shigella, Yersinia,
Campylobacter, Mycoplasma, Chlamydia
Rheumatological Juvenile idiopathic arthritis (JIA), Systemic lupus erythematosus (SLE),
Juvenile dermatomyositis (JDMS), Behcet syndrome
Systemic
Vasculitides
Henoch-Schonlein purpura (HSP), Kawasaki disease (KD), Polyarteritis
nodosa (PAN), Wegener’s granulomatosis
Spondyloarthropa
thies
Juvenile ankylosing spondylitis (JAS), Psoriatic arthritis
Enteropathic arthritis
Miscellaneous Sarcoidosis, Drug/serum sickness reactions
CAUSES

38. HISTORY
• patient demographics, disease chronology, inflammatory
nature, progression, distribution of joint involvement and
extra-articular manifestations
• arthritis persisting for more than 6 weeks usually rules out an
infective pathology
• Age At the onset
Early childhood Mid-childhood Late childhood
1. Polyarticular JIA
(RF negative),
2. Kawasaki disease
3. Henoch schonlein
purpura (HSP)
1. Juvenile psoriatic
arthritis
2. Juvenile
dermatomyositis
3. Polyarteritis nodosa
1. Juvenile ankylosing
spondylitis (JAS)
2. SLE
3. Polyarticular JIA
(RF positive)
• Gout and crystal deposition disease are extremely uncommon in
childrens

39. • Sex
Boys Girls
1. Vasculitides like KD and PAN
2. spondyloarthropathies like
inflammatory bowel disease and JAS
1. Many rheumatological disorders (e.g.
SLE, Polyarticular JIA)
•Onset of Disease
Acute Subacute or chronic
1. Septic arthritis
2. Arthritis associated with KD/HSP
1. Polyaticular JIA
2. Sarcoidosis
•Past History
reactive arthritis  recent diarrhea, acute conjunctivitis,
urethritis, and fever with or without
rash
systemic onset JIA  pyrexia of unknown origin and give
history of having received multiple
courses of antimicrobials.

40. EXAMINATION
1. Common patterns of Articular Involvement
Small Joints Large joints Small and large joints
1. Viral arthritis
2. SLE
1. JAS
2. Reactive arthritis
1. Polyarticular JIA
2. Psoriatic arthritis
(asymmetrical)
2. Topography and distribution
Disease Symmetry Axial involvement
Viral arthritis Symmetrical NO
Polyarticular JIA Symmetrical / asymmetrical NO
JAS asymmetrical YES
Psoriatic arthritis Usually asymmetrical YES/NO
SLE Symmetrical NO
Reactive arthritis asymmetrical YES/NO

41. 3. Is any particular joint involved
– acute dactylitis or distal interphalangeal involvement 
psoriatic arthritis
– Enthesitis  juvenile spondyloarthropathies
4. Is there a joint deformity
– Deforming arthritis  polyarticular JIA
– non-deforming arthritis a/w SLE and IBD

42. Physical signs to be looked for
System Involved Physical Finding Diagnoses
1.Ophthalmologic 1. Uveitis
2. Conjunctival injection
without exudate
1. JIA
2. KD
2.Dermatologic 1. Malar rash, alopecia
Oral ulcers
2. Heliotrope rash,
Gottron papules
3. Polymorphous rash,
perineal desquamation,
edema, and erythema
of hands
4. Evanescent
salmoncolored rash
5. Palpable purpura
6. Nail pitting or
onycholysis
1. SLE
2. JDM
3. KD
4. SJIA
5. HSP, SLE
6. JIA (psoriatic)

43. 3. Neurologic 1. Seizures, psychosis, mood
disorder, decline in school
performance
2. Stroke
3. Proximal muscle Weakness
1. SLE
2. SLE, vasculitis
3. JDM, MCTD
4. Cardiovascular 1. New heart murmur
2. Pericarditis
3. Raynaud phenomenon
1. ARF, IE
2. SJIA, SLE, ARF
3. SLE, MCTD,scleroderma
5. Respiratory tract 1. Pleuritis
2. Acute or chronic sinusitis,
Pulmonary nodules, or
hemorrhage
3. Interstitial lung disease
1. SJIA, SLE
2. GPA
3. SLE or scleroderma
6. Gastrointestinal/
Genitourinary tract
1. Weight loss or poor
growth
2. Diarrhea/hematochezia,co
licky abdominal pain
3. History of gastroenteritis
4. History of urethritis or
cervicitis
1. IBD, malignancy, SLE
2. IBD, HSP
3. Reactive arthritis
4. Reactive arthritis,
gonococcal arthritis

44. INVESTIGATIONS
Investigation Abnormality detected Comments
Markers of
inflammation
↑ ESR,
↑ CRP,
↑ Globulins,
thrombocytosis
ESR and CRP elevation usually indicate
activity (ESR may not always be elevated)
Hemogram Normocytic
normochromic anemia,
leucocytosis ,
thrombocytosis,
Eosinophilia,
haemolytic anemia(DCT+)
SLE may have leucopenia and
thrombocytopenia at presentation
Urine routine Urinary sediment,
sterile pyuria,
hematuria
proteinuria
Sterile pyuria seen in JIA and KD(not be
mistaken for UTI)

45. Synovial fluid
analysis/Biopsy
JIA can have a markedly
PMN response (not be
mistaken for septic
arthritis)
1. Indicated if diagnostic problem;
2. Gram stain,
3. pyogenic and mycobacterial
cultures Biopsy under
arthroscopy
Specific
investigations
1. RF,
2. anti CCP antibodies
3. HLA B27,
4. ANA
5. ANCA
1. Polyarticular disease can be RF
+/−, ANA usually positive in SLE,
2. HLA B27 for Juvenile
spondyloarthropathies and
reactive arthritis,
3. ANCA for systemic vasculitides
Other
investigations
1. KFT,
2. LFT,
3. X-ray,
4. ASO titres,
5. Throat swab,
6. HIV,
7. Viral serologies,
8. ECHO
1. Baseline metabolic profile in all
patients
2. other investigations are disease
specific

46. TREATMENT
Common causes of
polyarthritis
Specific therapy Comments
Infectious/
Parainfectious
1. Viral infections - self
limiting;
2. antimicrobials for bacterial
infections;
3. NSAIDs in reactive arthritis
Patients with Rheumatic fever require
long term penicillin prophylaxis
Rheumatological
disorders
1. NSAIDs
2. steroids and
immunosuppressive therapy
depending on the specific
disorder
Physiotherapy and occupational
therapy as important as drug therapy
Systemic Vasculitis 1. Immunoglobulin in KD
2. NSAIDs/steroids in HSP and
other vasculitis
1. Immunoglobulin therapy in KD can
prevent long term morbidity
2. prompt administration of steroids
in lupus can be life saving
Miscellaneous Supportive and definitive
treatment depending on
aetiology
Disease may evolve in time in any
category and patients need follow up

47. The Common Causes

48. Rheumatic Diseases
• Systemic JIA (SJIA)
• Criteria for the Classification of Juvenile Rheumatoid
Arthritis
• Age at onset: <16 yr
• Duration of disease: ≥6 wk
• Onset type defined by type of articular involvement in the 1st 6 mo

49. • Systemic
– Arthritis in ≥1 joint with, or preceded by, fever of at least 2 wk in
duration that is documented to be daily (“quotidian”*) for at least
3 days and
– accompanied by ≥1 of the following
» 1. Evanescent (nonfixed) erythematous rash
» 2. Generalized lymph node enlargement
» 3. Hepatomegaly or splenomegaly or both
» 4. Serositis
• Oligoarthritis
• Polyarthritis (RF-negative)
• Polyarthritis (RF- positive)
International League of Associations for Rheumatology
Classification of Juvenile Idiopathic Arthritis (JIA)

50. • Psoriatic arthritis
– Arthritis and psoriasis, or arthritis and at least 2
of the following:
• 1. Dactylitis
• 2. Nail pitting and onycholysis
• 3. Psoriasis in a 1st-degree relative

51. • SLE
– in adolescence with low-grade fevers
– constitutional symptoms of anorexia, weight loss,
malar rashes, and painfulpolyarthritis affecting
both the large and small joints
– ANA titer is strongly positive
– nephritis, cytopenias, hypocomplementemia, anti-
dsDNA,and other autoantibodies differentiates
SLE

53. • systemic sclerosis and idiopathic inflammatory
myositis
– mild nonpainful arthritiS
Juvenile
dermatomyositis
Systemic sclerosis Mctd
1. Weakness
2. Heliotrope rashes,
3. Gottron papules
1. Sclerotic skin
changes
2. Raynaud
phenomenon
3. Skin and gum
telangiectasias,
4. Respiratory
symptoms,
5. GI tract dysmotility
1. Raynaud
phenomenon,
2. Myositis,
3. Polyarthritis
4. Sclerodactyly
5. Positive ANA titer
6. High titers of anti-rnp
autoantibodies.

54. VASCULITIDES
KAWASAKI HSP
Palpable purpura
Age ≤20 yr at onset
Bowel angina
Wall granulocytes
on biopsy

55. Viral pathogens
• Parvovirus B19 (most widely)
– causes fifth disease/erythema infectiosum
– self-limited exanthem
– diagnosis is made if circulating IgM antibodies to
parvovirus
– Treatment is supportive with NSAIDs

56. • Rubella vaccine
– Symptoms usually 2 weeks after vaccination
– Symmetric, migratory, and additive arthritis
typically resolve within 2 to 4 weeks
• Several herpesviruses /hepatitis B and C/HIV

57. Other Important Diagnostic
Considerations
• IBD
– 2 patterns of joint disease
– first pattern is involvement of the lower extremity
joints, especially the ankles and knees
– peripheral arthritis tends to parallel the activity of the
GI tract inflammation
– second pattern is of axial involvement and is often
associated with HLA-B27 and little relation to the GI
disease
– Medical management is aimed at optimizing control
of the GI tract inflammation

58. • Malignancy
– Infiltration of the bone or synovium can mimic
polyarthritis
– ALL can cause polyarthritis as a result of leukemic
infiltration into the synovium
– Laboratory evaluation may show moderate to
severe anemia or an elevation of the ESR, with a
normal or low platelet count; a low WBC count; or
high lactate dehydrogenase or uric acid levels.

59. Therapeutics for Childhood Rheumatic
diseases
CLASSIFICATION THERAPEUTIC INDICATIONS
NSAIDs Etodolac
Ibuprofen
Naproxen
Celecoxib
Meloxicam
JIA
Spondyloarythropathy
Serositis
Cutaneous vasculitis
Uveitis
DMARDs Methotrexate
Leflunomide
HCQ
Sulfasalazine
JIA
Uveitis
SLE
APLA syndrome
TNF alfa antagonist Adalimumab
Etanarcept
Infliximab
JIA
Spondyloarthropathy
Psoriatic arthritis
Uveitis
Sarcoidosis
Modulate T cell activation Abatacept JIA

60. CLASSIFICATION THERAPEUTIC INDICATIONS
Anti CD 20 antibody rituximab SLE
Interlukin 1 antagonist Anakinra
canakinumab
Systemic JIA
Interlukin 6 antagonist tocilizumab Systemic JIA
Intravenous
immunoglobulins
IVIG Kawasaki
Juvenile dermatomyositis
SLE
glucocorticoids Prednisone
Methylprednisolone
Intraarticular
Prednisolone ophtalmic
suspension
SLE
Juvenile dermatomyositis
Vasculitis
JIA
Sarcoidosis
uveitis
immunosuppresive Mycophenolate mofetil SLE
uveitis
cytotoxic cyclophosphamide SLE
Vasculitis
Juvenile dermatomyositis

61. pGALS
• A recently developed and validated tool is the
pGALS ( pediatric Gait, Arms, Legs, Spine),
which is a simple screening examination that
can be performed in a few minutes.

65. References
1. Textbook of pediatric rheumatology / [edited by] James T. Cassidy ... [et
al.]. — 6th ed.
2. Nelson Textbook of Pediatric 20th ed
3. Approach to Polyarthritis /Surjit Singh & Sonia Mehra