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Approach to a child with
arthritis
Dr.Singaram.A
Arthritis vs Arthralgia
• Arthralgia – symptom; pain in the joint
• Arthritis – sign; intra-articular swelling or
2 or mor...
Differential diagnosis of childhood
joint pain or swelling
•
•
•
•
•
•
•
•
•

Avascular necrosis and epiphyseal disorders
...
Tender points - Fibromyalgia
Types of Joint Pain
History

Inflammatory

Mechanical

Sinister

Onset

Insiduous

Sudden

Insiduous

Course

Fluctuant

P...
Arthritis – Basic Approach
• Onset : Acute (< 6 weeks) or chronic
• No. of joints involved

• Type of joints
• Associated ...
Some important clues…
• Inflammed/infected joint assumes a
characteristic posture
• Wasting of muscles in chronic joint in...
Review of systems
Gottron's papules
Evanescent pink macular rash

HSP

Lower extremity purpuric lesions

Oligoarthritis or...
Review of systems
Pericarditis
Raynaud phenomenon

Takayasu arteritis

Absent pulses

IBD, SLE, or vasculitis

Weight loss...
Review of systems
Hemolytic anemia

Pancytopenia

Bleeding disorders

Neurologic

SLE or hemoglobinopathy
(eg, SCD)
SLE

H...
Common clinical presentations
• Acute monoarthritis
- Sick child (+/- fever)
- Well child (+/- trauma)

• Chronic monoarth...
Acute monoarthritis
Sick Child

Fever

Yes
Septic arthritis
Reactive arthritis
Kawasaki disease
Malignancy
SOJIA

No
Parti...
Acute monoarthritis
Well
child
Significant
trauma

Yes

No

Fractures

Bleeding disorders

Mechanical
derangements

Neopla...
Synovial fluid analysis
• Hemorrhagic – Hemarthrosis, PVS
• 1500 – 50,000 cells/ cu.mmInflammatory/reactive arthritis
• >5...
Chronic monoarthritis
Chronic monoarthritis

Sick child

Well child

Partially treated

Oligoarticular JIA

Septic arthrit...
Acute polyarthritis
•
•
•
•
•
•
•

Acute rheumatic fever
Infective endocarditis
Viral arthritis
Lyme disease
Kawasaki dise...
Chronic polyarthritis
• Systemic onset/ Polyarticular JIA
• SLE
• Juvenile Dermatomyositis
• SLE/ PAN
• Other inflammatory...
Systemic onset JIA

Pauciarticular onset
JIA
50

Polyarticular onset
JIA
30 to 40
F>M
peaks 2 to 5, 10 to 14
years
any, ra...
Approach arthritis in childhood
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Approach arthritis in childhood Slide 1 Approach arthritis in childhood Slide 2 Approach arthritis in childhood Slide 3 Approach arthritis in childhood Slide 4 Approach arthritis in childhood Slide 5 Approach arthritis in childhood Slide 6 Approach arthritis in childhood Slide 7 Approach arthritis in childhood Slide 8 Approach arthritis in childhood Slide 9 Approach arthritis in childhood Slide 10 Approach arthritis in childhood Slide 11 Approach arthritis in childhood Slide 12 Approach arthritis in childhood Slide 13 Approach arthritis in childhood Slide 14 Approach arthritis in childhood Slide 15 Approach arthritis in childhood Slide 16 Approach arthritis in childhood Slide 17 Approach arthritis in childhood Slide 18 Approach arthritis in childhood Slide 19
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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/ cu.mm – 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
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