Arthritis in children

Asist.univ.Dr.Alexis Cochino

Definition. Causes.
inflammation of a joint/multiple joints due to:
Trauma Infection (septic/reactive arthritis) Autoimmunity Malignancy

Definition. Causes.
inflammation of a joint/multiple joints due to:
Trauma Infection (septic/reactive arthritis) Autoimmunity Malignancy

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)

JIA/JRA
chronic idiopathic arthritis>6 months synovial joints ~50% persistence at 10y Classification
1. Oligoarticular: <5 joints (~50%; F>M)
Persistent: <5 joints involved during the duration of followup. Extended: >4 joints involved during the duration of followup.

2.

Polyarticular: >4 joints (F>M)

RF+ RF-

3.

Systemic (fever, salmon-pink rash, lymphadenopathy, hepatosplenomegaly) (~10%; M>F) Psoriatic arthritis Entesitis related arthritis (inflammation at insertion of tendons, ligaments or fascia to bone; lower axial skeletal involvement; HLAB27 often present) Unclassified

4. 5.

6.

Septic arthritis/ osteomyelitis

Etiology:
< 2 mo: Staph, E.coli, group B Strep, GNR 2mo-5yo: Staph, H.flu B, Kingella, group A Strep, 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

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 Fever Arthralgia ESR or CRP WBC PR interval culture / rapid Strep atg ASO previous RF

Minor

Strep.A inf.prove

D+: 2M/1M+2m + Strep.inf.prove Heart valve destruction (mitral>>aortic>tricuspid) Joint deformity (repeated attacks)

Sequellae

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

Some numbers
Septic arthritis
1/5000 children

JIA
~5 prevalence of pediatric arthritis ~20 arthritis-related ambulatory care visits/1000 children/year ~1% of all hospitalizations ~ 1 death/million children/year

Presenting reason
Bone/joint signs:
Assymetry Limp Pain Joint effusion Function impairment (decreased ROM) Redness Fever Shivers Rashes Lymphadenopathy Hepatosplenomegaly

w or w/o systemic signs:

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 (initial ilness):

Diarrhea Dysuria, pollakiuria Abdominal pain

Developmental milestones Close relatives with same problem

Clinical evaluation
Temperature Rash, throat, lips, tongue Subcut. nodes Lymph nodes Liver, spleen

Clinical evaluation
Limbs symetry Gait Look for foreign body

Clinical evaluation
Joint(s):
Tender, red, hot, swollen ROM No. of aff. joints Preferred position

Clinical evaluation
looking for joint effusion/tenderness
patellar tap test
metacarpophalangeal joints

bulge test

Lab tests
Blood
CBC+diff. ESR, CRP LDH Hb ELFO Uric acid Serology
Borrelia Strep

Synovial fluid
Aspect, viscosity Cells Chemistry Crystals Cultures

Stools:
Blood, cultures

Urine:
Urinalyses Culture Rapid atg tests

Cultures PCR Autoantibodies

dsDNA ANA RF Ro, La

Pharyngeal swab
Culture Rapid Strep test

HLA-B27 AS(L)O Clotting (Fg, PT, aPTT)

Clinical consultations
ophtalmology: q3-6 months ( in any JIA, but esp. oligoarticular JIA with ANA+)

Clinical consultations
orthopedics surgery hemato/oncology cardiology (ECG prolonged PR interval; heart US valves, coronary aa.) neurology (headache, chorea, ataxia) metabolic disorders

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

Imagistic studies
MRI
Accurate, pain-free, no X rays Use: any arthritis Early signs:
Effusion Hyperemia Soft tissue swelling Bone/cartilage lesions

Time-consuming, expensive

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 acute settings

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

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 Overuse syndromes (in athletes)

Not-to-be-overlooked !!!
(or delayed!)
Developmental dysplasia (of the hip) Developmental
Slipped capital femoral epiphysis Aseptic bone necrosis (Legg-Calve-Perthes disease) Sprain, contusion Fractures Osgood-Schlatter disease (patellar tendon insertion into the tibial tubercle) Patellofemoral syndrome

Trauma

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 Overuse syndromes (in athletes)

Treatment
Trauma ortho social services Haemarthrosis:
FFP, clotting factor antibiotics surgery

Septic arthritis
emergency start of i.v. antibiotics (staph, strep, pneumo, H.flu, E.coli, pseudomonas, kingella) total 4-6 weeks (7-10 days parenteral) surgery

Sicklemia:
emergency fluids and analgesics hematology

Rheumatic fever antibiotics (Pen) + NSAIDs/CS

Malignancy oncology/hematology Developmental ortho

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)

Treatment algorithm for a child with chronic arthritis.

Hull R G Rheumatology 2001;40:1309-1312

British Society for Rheumatology

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

Hull R G Rheumatology 2001;40:1309-1312

British Society for Rheumatology

Treatment algorithm: systemic disease.

Hull R G Rheumatology 2001;40:1309-1312

British Society for Rheumatology