Professional Documents
Culture Documents
RCSI students
2013
Arthralgia Or Arthritis
Arthralgia : pain in the joint
Arthritis : Swelling or any 2 of
Warmnethness
Tenderness
Limited movements
Scenario 1
A 2 years old child ,c/o left knee swelling for 6 days
preceded by trauma while jumping in kindergarten.
Hx of fever and unable to bear on weight. X ray of
left knee show no fracture.
Scenario 2
A 18 month old girl ,c/o of right hip pain with limping
for 3 days that gradually improved. Hx of cold, fever,
coryza preceded the pain episode.
Scenario 3
4 years old boy, Hx of knees pain, intermittent,
mainly at night after playing all the day, relieved by
massage and pain killer. O/E healthy boy with normal
knees and normal lab results.
Scenario 4
Scenario 5
4 years old girl with Hx of right knee swelling and
low grade fever for 3 months, no Hx of trauma, skin
rash. O/E right knee swelling, little tender and other
system exam. Uneventful.
Impression??
Chronic arthritis, ?? JIA
Arthritis in children
Either
Inflammatory :
Infection: Septic arthritis, Osteomyelitis
Rheumatic disorders: SLE,JIA
Neoplastic disorders:
Could be;
1.
2.
Acute
Chronic
Arthritis in children
NON inflammatory:
1. Growing pain; peak age:4-5 years. poplitial fossa.
2. Hypermobility syndrome.
3. Reflex neurovascular dystrophy;
Hyperesthesia, mottled skin coloring and vascular instability.
Definition
Juvenile Idiopathic arthritis (JRA) is a chronic arthritis that persists for a
minimum of six consecutive weeks in one or more joints, commencing
before the age of 16 years and after active exclusion of other causes.
Classification(ILAR 2005)
By mode of onset during the first six months
A.
B.
C.
D.
E.
Classification (contd)
F. Enthesitis-related arthritis
G. Psoriatic arthritis
H. Others: arthritis of unknown cause that begins during
childhood and persists for at least 6 weeks.
Prognosis
Episodes of systemic
disease
Progressive arthritis
Poor growth
Vasculitis
Pauciarticular JRA
Pauci-JIA
Pauci-JIA
synovial cyst
Polyarticular JRA RF
Any age
More in Female
C/F
Polyarticular JRA RF -
Polyarticular JRA-RF +
Over 8 years of age
More in Female
Resemble RA in adult
C/F
- Peripheral arthritis
- Enthesopathies Planter Fascia,
Achilles tendon
- Acute Iritis
- Sacroiliac pain
- Axial disease
HLA associations: 50% - 75% HLAB27
Pathogenesis of JIA
Synovitis of JRA characterised by villus hypertrophy and
hyperplasia and hyperaemia and oedema of sub synovial tissue
Pannus formation.
Diagnosis
No one path gnomonic criteria of these diseases in
children
Diagnosis based on a history compatible with
inflammatory joints disease and a physical
examination that confirm presence of objective
arthritis.
Lab abnormality ( ESR, CRP, Low Hb) support the
diagnosis in absence of results suggest different Dx.
Lab Findings
CBC: low Hb, High WBC, High Plat,
ESR, CRP, Globulin, immunoglobulin.
High ferritin.
ANA in 40-85% of pauci JIA
ANA, homogenous or speckled, associated with increase risk of
developing uveitis
RF ,older children with poly JIA, portends a poor prognosis.
consecutive positive tests over a defined period.
Radiology Findings
Radiology Findings
Differential diagnosis
Systemic onset JIA:
Infection (EBV,CMV,TORCH)
Collagen vascular disease; SLE, others
Malignancies; ALL, others.
Other types of JIA;
CVD
Malignancies
Management of JRA
Team approach
Rheumatologist
Ophthalmologist
Physiotherapist
Psychologist
Treatment of JRA
Drugs
Physiotherapy
Occupational therapy
Treatment of JIA
5. Biological agents (anti
TNF,Anti-IL6,Anti-IL1)
4. Cortico-steroids,
Azathioprine, cyclosporine
3. Methotrexate
2. IA steroid, hydroxychloroquine
NSAID
Empirical
Aspirin, Naproxen, Ibuprofen
Try 3 NSAID for 2 month each
Monitor CBC, LFT, Urea, Creatinine
Intra-articular steroid.
Management of JRA
When we use corticosteroid for JIA
Overwhelming systemic illness
Bridge therapy,lower doses
Intra Articular injection for acute, or synovial cyst.
Ophthalmic use; uveitis
Slit lamp ophthalmic examination
Calcium intake
DMARDs (contd)
Sulphasalazine
Polyarticular JRA HLA B27 related diseases
Effective
Safe
Mechanism: adenosine release
Cyclosporine A
Refractory JRA
Mechansim:
Dose: 3.5 5mg/kg/day
Blocks IL2 gene
Inhibits T-cell activation
Monitor: blood pressure, urea, creatinine
Combination with MTX
Uveitis
Physiotherapy
Relief of pain
Ice/heat packs
Tens
Occupational Therapy
Hand Function
Hydrotherapy
Warm water
Support body/limbs
Assists joints movement
Resist movements
Education
Sharing management