PEDIATRIC RHEUMATOLOGY OVERVIEW DR. PREETI NAGNUR MEHTA CONSULTANT RHEUMATOLOGIST SUCHAK HOSPITAL & ELITE HOSPITAL, MALAD QQ PUROHIT HOSPITAL, BORIVALI WOCKHARDT HOSPITAL, MIRA ROAD JASLOK HOSPITAL, PEDDAR ROAD

INTRODUCTION  Arthritis is common in Rheumatic diseases  More than 100 causes of arthritis in children  But not all rheumatic diseases are associated with arthritis

MUSCULOSKELETAL SYMPTOMS Very Common Joint pain and backpain May sound non-specific May be ignored Frequent change of doctors Diagnosis may be missed or delayed Need to pick up Red Flag signs

WHAT IS ARTHRITIS?  Swelling within the joint  Fluid or Bony Swelling  Inflammatory or Degenerative

APPROACH TO ARTHRITIS 1. Is it Articular 2. Is it Acute or Chronic? 3. Is Inflammation present? 4. How many/which joints are involved? 5. What are the RED FLAGS? 6. Extra-articular manifestations

ARTICULAR VS PERIARTICULAR FINDING ArticularPeriarticular PAINDiffuse, Deep Tenderness Point RANGE OF MOTION Active + Passive in all planes Active Motion in few planes SWELLINGCommonUncommon

FOUR FINGER TECHNIQUE FOR PIP

TWO FINGER TECHNIQUE FOR M CP

ACUTE OR CHRONIC Acute Chronic < 6 weeks > 3 months May be self limitedWill need treatment Post traumatic (Hemarthrosis) Post Viral (Rubella, Parvo) Infection - Bacterial Transient or Toxic synovitis Reactive arthritis Onset of systemic inflammatory disease – HSP, Kawasaki, Rheumatic fever Serum Sickness Juvenile Idiopathic Arthritis Juvenile Spondyloarthropathy Juvenile Psoriatic Arthritis Infection – TB Other systemic inflammatory diseases – SLE, Dermatomyositis, Vasculitis

INFLAMMATION?  Early morning stiffness > 30 mins  Redness, swelling and warmth  High inflammatory markers  Anemia of chronic disease  High platelets

HOW MANY JOINTS?  Monoarthritis  Oligoarthritis  Polyarthritis

SYMMETRICAL VS ASYMMETRICAL  Symmetrical – same group of joints on both sides  Classical in RA  Axial spine symmetrical in SpA  Asymmetrical in Psoriatic arthritis

RED FLAG SIGNS  Constitutional symtoms – Fever, weight loss, loss of appetite  Radiological erosions at baseline  Extra-articular manifestations  Fracture  Infection

Other Causes of Joint Pain: Mimics of Arthirits  Mechanical Causes – Patellofemoral syndrome Hypermobility syndrome  Malignancies and Metastasis  Endocrine abnormalities  Inherited bony dysplasias  Chronic pain syndromes  Psychogenic causes

ACUTE RHEUMATIC SYNDROMES  Reactive Arthritis  Transient / Toxic Synovitis  Henoch Schonlein Purpura  Kawasaki Disease  Acute Rheumatic Fever

REACTIVE ARTHRITIS (REITER SYNDROME)  Arthritis and other extra-articular features following infections  Extra-articular features – Conjunctivitis or Uveitis not common Urethritis in children Rash (keratoderma Blenorrhagica) In Children  Classical triggers : Enteric (Salmonella, Shigella, Yersinia) Non-gonococcal urethritis Other infections – Varicella, Parvovirus, Group A Streptococcus

TRANSIENT SYNOVITIS  Acute hip synovitis in toddlers – early school age  Often follows onset of upper respiratory tract infection  Usually unilateral leg or hip pain  May have low grade fever  Labs usually normal  Pain and limitation of movements of affected hip  Self limited. Resolves within a few days to weeks.