Arthritis in Children_students

8/13/2019 Arthritis in Children_students

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Arthritis in children

Asist.univ.Dr.Alexis Cochino


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Definition. Causes.

inflammation of a joint/multiple joints due to:

Trauma

Infection (septic/reactive arthritis)

Autoimmunity

Malignancy


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Definition. Causes.

inflammation of a joint/multiple joints due to:

Trauma

Infection (septic/reactive arthritis)

Autoimmunity

Malignancy


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Causes

Developmental dysplasia (of the hip

Other developmental conditions

Trauma (abused child!) Infections

osteomyelitis, septic arthritis

reactive arthritis, Lyme

JIA Other connective tissue disorders (SLE, Kawasakys)

Clotting disorders

Malignancy

Referred pain

Sickle cell crisis

Overuse syndromes (in athletes)


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JIA/JRA chronic idiopathic arthritis>6 months

synovial joints

~50% persistence at 10y

Classification

1. Oligoarticular: M) Persistent: 4 joints involved during theduration of followup.

2. Polyarticular: >4 joints (F>M) RF+

RF-

3. Systemic (fever, salmon-pink rash,lymphadenopathy, hepatosplenomegaly)(~10%; M>F)

4. Psoriatic arthritis

5. Entesitis related arthritis (inflammation atinsertion of tendons, ligaments or fascia tobone; lower axial skeletal involvement;

HLAB27 often present)

6. Unclassified


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Septic arthritis/ osteomyelitis

Etiology: < 2 mo: Staph, E.coli, group B Strep, GNR

2mo-5yo: Staph, H.flu B, Kingella, group AStrep, Pneumo

adolescents: Staph, group A Strep, N.gonorrhoeae, Salmonella

Foreign body: Staph, Pseudomonas

Rare: Mycobact., fungi or anaerobes

Blood-born, penetrating injury

Clinic: red, TENDER, ROM, swollen; may lack in

younger/hip

Systemic signs (fever, chills, malaise)

Septic shock

Diagnosis Clinic+lab test (may be

normal)+US/MRI/bone scans

XR normal until late (50% focal bone mass);

periosteal detachement earlier


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Rheumatic

fever previously common (mid 1900s)

post Strep A infection (pharyngeal/skin)

Diagnosis criteria (modified Jones criteria, 1992)

Major Polyarthritis

Carditis

Subcutaneous nodules

Erythema marginatum

Sydenham's chorea

Minor

Fever Arthralgia

ESR or CRP

WBC

PR interval

Strep.A inf.prove culture / rapid Strep atg

ASO previous RF

D+: 2M/1M+2m + Strep.inf.prove

Sequellae Heart valve destruction (mitral>>aortic>tricuspid)

Joint deformity (repeated attacks)

http://www.youtube.com/watch?v=HOalYWvVLU8&feature=related


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Some numbers

Septic arthritis 1/5000 children

JIA

~5 prevalence of pediatric arthritis

~20 arthritis-related ambulatory carevisits/1000 children/year

~1% of all hospitalizations

~ 1 death/million children/year


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Presenting reason

Bone/joint signs: Assymetry

Limp

Pain

Joint effusion

Function impairment (decreased ROM) Redness

w or w/o systemic signs: Fever

Shivers Rashes

Lymphadenopathy

Hepatosplenomegaly


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History

Age, sex Onset

First time/recurrent

Mono/poly articular Symptoms pattern

Recent trauma/infection

Systemic symptoms: e.g. fever, weight loss,

shivers, sweats

Associated signs (initialilness):

Diarrhea

Dysuria, pollakiuria

Abdominal pain

Developmental

milestones

Close relatives withsame problem


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Clinical evaluation Temperature Rash, throat, lips, tongue

Subcut. nodes

Lymph nodes

Liver, spleen


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Clinical evaluation

Limbs symetry Gait

Look for foreign body


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Clinical evaluation

Joint(s):

Tender, red, hot, swollen ROM

No. of aff. joints

Preferred position


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Clinical evaluation looking for joint effusion/tenderness

bulge testpatellar tap test

metacarpophalangeal joints


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Lab tests Blood

CBC+diff.

ESR, CRP

LDH

Hb ELFO Uric acid

Serology Borrelia

Strep

Cultures

PCR

Autoantibodies dsDNA

ANA RF

Ro, La

HLA-B27

AS(L)O

Clotting (Fg, PT, aPTT)

Synovial fluid Aspect, viscosity

Cells

Chemistry

Crystals

Cultures

Stools: Blood, cultures

Urine: Urinalyses

Culture

Rapid atg tests

Pharyngeal swab

Culture Rapid Strep test


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Clinical consultations

ophtalmology: q3-6 months

( in any JIA, but esp. oligoarticularJIA with ANA+)


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Clinical consultations

orthopedics

surgery

hemato/oncology

cardiology (ECG prolonged PR interval; heart

US valves, coronary aa.)

neurology (headache, chorea, ataxia)

metabolic disorders


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Imagistic studies Ultrasound

Fast, mobile, pain-free, no X rays

Use in:

Septic/reactive/AI/hemorrhagic Early signs:

Effusion

Hyperemia

Soft tissue swelling

disadv.:

Operator-dependent Low resolution


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Imagistic studies

MRI Accurate, pain-free, noX rays

Use: any arthritis

Early signs: Effusion

Hyperemia

Soft tissue swelling

Bone/cartilage lesions

Time-consuming,expensive


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Imagistic studies

XR: Fast, largely available

Use: Chronic diss.

Trauma

Developmental Mind special incidences

Disadv.: Radiation

Low resolution

Late signs Low sensitiv. for masses

No use in some acutesettings


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Imagistic studies

Bone scans Use: Prolonged evolution w/o

localisation sympt/signs

Paget, tumors, early

osteomyelitis/avascular

necrosis

Disadv.:

Low availability

Expensive

Radiation

Very low resolution


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Differentials

Developmental dysplasia (of the hip); risk factors: first child, female, breech position, family history

Developmental Slipped capital femoral epiphysis (M>F)

Aseptic bone necrosis (Legg-Calve-Perthes disease; 3-10 yo; M>F)

Trauma (abused child!) Sprain, contusion

Fractures

Osgood-Schlatter disease (patellar tendon insertion into the tibial tubercle)

Patellofemoral syndrome Infections (osteomyelitis, septic arthritis)

Infection-related arthritis (RF, Lyme)

JIA

Other connective tissue disorders (SLE, Kawasakys)

Haemarthrosis Malignancy (leukemia, sarcoma, neuroblastoma)

Referred pain (from inflam.process, e.g.appendicitis, psoas abscess)

Sickle cell crisis



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Not-to-be-overlooked !!!(or delayed!)

Developmental dysplasia (of the hip)

Developmental Slipped capital femoral epiphysis

Aseptic bone necrosis (Legg-Calve-Perthes disease)

Trauma Sprain, contusion

Fractures

Osgood-Schlatter disease (patellar tendon insertion into the tibial tubercle) Patellofemoral syndrome

Infections (osteomyelitis, septic arthritis)

Infection-related arthritis (RF, Lyme)

JIA

Other connective tissue disorders (SLE)

Malignancy (leukemia, sarcoma, neuroblastoma)

Referred pain (from inflam.process)

Sickle cell crisis



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Treatment

Trauma ortho social services

Haemarthrosis: FFP, clotting factor

antibiotics

surgery

Sicklemia: emergency fluids and analgesics

hematology

Malignancy oncology/hematology

Septic arthritis

emergency start of i.v. antibiotics(staph, strep, pneumo, H.flu, E.coli,

pseudomonas, kingella)

total 4-6 weeks (7-10 daysparenteral)

surgery

Rheumatic fever antibiotics(Pen) + NSAIDs/CS

Developmental ortho


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Treatment of JIA

Kynesitherapy

Early arthritis concept Every drug used: the lowest efficient dose!!

NSAIDs: Ibuprofen, naproxen, diclofenac

With meals!!! Attn: AEs (gastric, renal, cardiac, skin, lung)

CS: p.o., i.v., puls therapy

AEs (metabolic, CV, bone, eyes, gastric)

DMARDs: Metothrexat, leflunomide, antimalarials, sulfasalazine

AEs: liver, blood, eyes, skin

Biologics Monoclonal antibodies (TNFa, Il-6, Il-1, CTLA-4)

AEs: infections (TB especially; prior TB screening MANDATORY)


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Treatment algorithm for a child with chronic arthritis.

Hull R G Rheumatology 2001;40:1309-1312

British Society for Rheumatology


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Treatment algorithm: multiple joints involved. *, Consider second opinion/reconsiderdiagnosis.




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Treatment algorithm: systemic disease.



Arthritis in Children_students

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