The Child With Joint Pain Diagnostic Clues Abraham Gedalia, M.D. Professor of Pediatrics Head, Division of Rheumatology Departments of Pediatrics, Louisiana State University Health Sciences Center and Children's Hospital of New Orleans New Orleans, LA Objectives: At the conclusion of this activity, the participants should be able to: 1. Discuss the approach to the child with joint pain or arthritis 2. Recognize the diagnostic clues of the different arthropathies 3. Develop strategy for the diagnosis

Both lower extremities showing elevated, diffuse purplish-colored scaly rash

12 year-old AAF presented with findings of deforming polyarthritis, rash and irtis. She was known to have JRA since the age of 2 years

Skin biopsy specimen revealing intradermal well-circumscribed, noncaseating epitheloid granulomata

A higher magnification showing a multinucleated giant cell of Langhans’ type Sarcoidosis

The Child With Joint Pain and/or Arthritis IMPORTANT DIAGNOSTIC CLUES Rashes Enthesitis Eye findings Radiologic findings

Enthesitis Ankylosing spondylitis

The Child With Joint Pain IMPORTANT DIAGNOSTIC CLUES Rashes Enthesitis Eye findings Radiologic findings

Conjunctiva Anterior Chamber Lens Choroid Retina Optic Nerve Sclera Ciliary Body Iris Pupil Cornea Vitreous Fovea

Iritis of juvenile rheumatoid arthritis

The Child With Joint Pain IMPORTANT DIAGNOSTIC CLUES Rashes Enthesitis Eye findings Radiologic findings

Radiologic findings in polyarticular JRA

A 7- year-old Caucasian girl presents with 6-month duration of pain in the right hip associated with morning stiffness and limp Work-up reveals normal CBC, ESR-36 mm/h; ANA & RF, and HLA-B27 are negative Plain film of both hips is normal A bone scan shows increased tracer activity in the right hip area Patient was diagnosed with JRA and treated with naproxen but continues to complain of persistent right hip pain.

Additional work-up including CT and MRI of the pelvis showed typical findings of Osteoid osteoma CT Scan MRI CT SCAN MRI

MRI of the R hip showed precisely The location of the tumor radio lucent nidus

Osteoid Oteoma 1. Osteoid osteoma is a common benign tumor of the bone that accounts for 2% to 3% of all primary bone neoplasms 2. Occurs in children and young adults, with age range of 5 and 20 years. Male > Female 3. The classical symptom is well-localized throbbing pain at night. Confusion can arise when the lesion is near a joint because it can mimic symptoms of arthritis or synovitis, thus leading to an incorrect diagnosis 4. The pain associated with osteoid osteoma is caused by the presence of abundant unmyelinated nerve fibers of the autonomic nervous system within the tumor nidus 5. Treatment is surgical, with en bloc excision of the tumor under Ct guidance