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Approach to Polyarthritis in children
Dr. Hriday De, PGT, ICH
Objectives
• To know the different causes of polyarthritis in paediatric age group
• How proper history taking helps in narrowing differentials
• To know details of physical examination important in rheumatology
• Importance of extra-articular signs and symptoms
Definition
• Arthritis is defined by the presence of intra-articular swelling or 2 or more of the followingfindings on joint examination:
Pain on motion, loss of motion, erythema, andheat.
• Polyarthritis :Inflammation of more than 4joints on physical examination.
Causes
Infections
Viral
• Parvovirus B19
• Enteroviruses
• Adenoviruses
• Mumps, Rubella
• Varicella zoster
• Hepatitis B
• Coxsackie virus
• Cytomegalovirus
• EBV, HIV
Bacterial
• Staphylococcal and streptococcal infections
• Neisseria gonorrhae
• Hemophilus influenzae
• Bacterial endocarditis
• Tuberculosis
• Leptospirosis
• Brucellosis
Parainfective/Reactive
• Salmonella
• Shigella
• Yersinia
• Campylobacter
• Mycoplasma
• HIV
• Group A streptococcal infections
• Chlamydia
• TB
Rheumatological
• Juvenile idiopathic arthritis (JIA)
• Systemic lupus erythematosus (SLE)
• Juvenile dermatomyositis (JDMS)
• Behcet syndrome
• Juvenile ankylosing spondylitis (JAS)
• Psoriatic arthritis
• Enteropathic arthritis
Systemic vasculitis
• Henoch-Schonlein purpura (HSP)
• Kawasaki disease (KD)
• Polyarteritis nodosa (PAN)
• Wegener’s granulomatosis
Others
• Sarcoidosis• Malignancy :ALL ,Neuroblastoma• Sickle cell anaemia• Metabolic disorders:Gaucher’s , Farber's
disease,Diabetic cheiroarthopathy• Mucopolysaccharidoses:Morquio’s, Scheie
Mimics: Pseudo rheumatic dysplasia,Skeletal dysplasia,Spondyloepiphyseal dysplasia,Winchester Syndrome
Case scenario
• 9 yr old female child• Recurrent swelling and pain
of b/l knee joint, ankle joint, wrist joint a/w fever
• subsided with an interval of2 wks to 1 months
• h/o redness of eyes• No rash• Fit and well in-between
• TC 13000 N57L36 Plt 2.5lakh
• ESR 82
• CRP43
• ANA,RA,AntiCCP,ASO, AntiDnase B all negative
• Eye check up normal
• CXR normal
WHAT NEXT ???
History
Questionnaire
• Is the pain severe enough to disturb the sleep of the child? • Is there any early morning stiffness? • Does the pain worsen after movement or does it get
worse with exercise?• Where did the pain start from?• Which joints are involved?• Upper limb joints/lower limb joints• What is order of involvement?• Whether arthritis is migratory or non migratory?• Is the joint involvement symmetrical or asymmetrical?• Is joint pain part of a systemic illness?
Does this patient have arthralgia or arthritis?
• Key = presence of inflammation
• Cardinal signs of inflammation: erythema, warmth, pain, and swelling.
• Fatigue, weight loss, or fever.
• Morning stiffness lasting > 1 hour = underlying inflammation
• Stiffness after physical inactivity (gelling phenomenon).
Age
• Early childhood :Oligoarticular JIAKawasaki diseaseHSP• Mid childhood:Juvenile psoriatic arthritisJuvenile Dermatomyositis (JDMS)Polyarteritis Nodosa (PAN)• Late childhood:Juvenile ankylosing spondylitis (JAS) SLE Rheumatoid factor positive polyarticular JIA
Gender
• Most have female predilections
• KD, PAN, Spondyloarthropathies like inflammatory bowel disease and JAS which are more common in boys
RF - RF+ HLA B27+ SYSTEMIC
POLY PAuci S
OLIGOHLA B27-
MOST COMMON
FEMALEEARLY
CHILDHOODFEMALE MALE
LATE CHILDHOOD
LATE CHILD HOOD
THROUGH OUT CHILDHOOD
THROUGH OUT CHILDHOOD
PolyPaS
Onset
• Acute: ( <2 wks)Septic arthritis Arthritis associated with KD/HSP Rheumatic fever• Sub acute: ( 2- 6 wks)Viral arthritisReactive arthritisSLE• Chronic: ( > 6wks)Poly JIAAnkylosing SpondylitisPsoriasis
YES NO
InfectionsReactive arthritisReiter’s complexSystemic onset JIAKawasaki disease Polyarteritis nodosaMalignancy•ALL•Neuroblastoma
Polyarticular JIAEnthesitis related arthritisIBD associated arthritisPsoriatic arthritisSLEJuvenile DermatomyositisSclerodermaSickle cell dactylitisMucopolysaccharidosesHSPMetabolic disorders
Fever?
Pattern recognition
Evolution of the joint involvement
• Migratory :Rheumatic fever Gonococcal arthritis• Additive:SLEJIA Psoriatic arthritis• Intermittent :Reactive arthritis.
Topography and distribution
• Symmetric:
JIA
SLE
• Asymmetric :
Reactive arthritis
Septic
Is any particular joint involved?
Is there a joint deformity?
• Deforming arthritis is typically seen in polyarticular JIA.
• SLE and inflammatory bowel disease is usually non-deforming
Others
• Past history:painful red eye with visual loss JAS
Recent diarrhoea, acute conjunctivitis, urethritis, andfever reactive arthritis
Pyrexia of unknown origin and multiple courses ofantimicrobials systemic onset JIA
• Family history: ankylosing spondylitis, inflammatorybowel disease and psoriatic arthritis
Examination
pGALS
Extra -articular involvement
Eye
Oral cavity
Skin
Nails and hair
Systemic
Lab investigation
Case cont.
WHAT we had missed?
• h/o intermittent cough
• Father was a TB pt, took ATD 2 yrs back
On further inv:
• MANTOUX + ve 20 x 20, sputum AFB (-)ve, synovial fluid for AFB (-) ve
• CT chest ....Mediastinal and hilar nodes with central calcification
Diagnosis
Poncet’s disease
(Tuberculous Rheumatism)
Evaluation of polyarthritis or polyarthralgia
http://www.uptodate.com/
Treatment
Question 1
A 15 year old female presented with fatigue, fever and arthritis of knees, wrists, elbow. She had noticed a rash on her left leg which had been getting worse. Two weeks ago she went camping in the Gorumara forest. On examination she had a left knee effusion. She had a 10cm diameter red macule on her left shin with central clearing. Joint aspirate No organisms, no crystals.
What is the most appropriate first line therapy?1. Amoxicillin 2. Cefalexin 3. Ciprofloxacin 4. Metronidazole 5. Nitrofurantion
Question 2
A 14-year-old female was admittedcomplaining of pain and swelling in bothknees, elbows, and ankles for 1 monthElevated ESR, CRP, normal autoantibody profileMantoux, sputum negative.
???????
Lofgren's Syndrome
References
• Nelson’s Textbook of Paediatrics
• James T. Cassidy Textbook of paediatric rheumatology
• Indian Journal of Paediatrics (2010) 77:1005–1010
• Medscape.com
• Uptodate.com
and special thanks to my teachers
THANK YOU
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