1. Paediatric Case Presentation
Natasha Quader ST1
September 2008

2. Patient CD 8 year old girl Normally fit and well PC – Pyrexia
- Lethargy
- Groin and hip pain

3. History of Presenting Complaint
7/52 ago had pyrexia for 1 week followed by a cough → viral URTI
Intermittent pyrexia - mainly nocturnal spikes
C/o hip and groin pain.
- Present on waking up in the morning
- Pain waking her up during sleeping
- Developed difficulty in walking, pain on weight bearing
Increasingly lethargic – sleeping during the day and missing school
Generally unwell, ↓ appetite, irritable and crying

4. PMH PMH - Laryngomalacia during infancy
- RTA in Feb ’07 – back injury resolved
SH – no recent travel abroad
Immunisations up-to-date
DxH – nil, NKDA
FH – Maternal grandmother with RA

5. Examination 1 Abdomen Alert, communicating PR – 80 regular
Temp – 38 °C
RR-18
Bilateral cervical lymphadenopathy
Throat – NAD
Ears – wax bilaterally
No rashes
HS I + II + O
Chest: Clear
Abdomen x x x x x
Lower abdominal tenderness
Inguinal lymphadenopathy

6. Examination 2 CNS CN – NAD. PEARL Lower limbs bilaterally
- tone normal
- power 4/5
- reflexes symmetrical
Co-ordination – intact
Romberg’s negative
Antalgic gait
Slight waddling and holding R. inguinal region
MSK
No hip/knee joint swelling
Tenderness over AIS and crest bilaterally
Hips - ↓ active ROM

7. Positive Examination Findings
Pyrexic
Lower abdominal tenderness
Bilateral inguinal lymphadenopathy
Bilateral hip tenderness and restricted ROM
Antalgic gait

8. Differential Diagnosis
Septic hip
Infection – viral, bacterial, Lyme disease
Juvenile arthritis
Malignancy – leukaemia, neuroblastoma
Perthes
Transient irritable hip

9. Infection Screen MSU – NAD Blood cultures – no growth
EBV Igm – negative
Toxopl Igm – negative
ASOT – normal
Rubella Igm – negative
Parovirus Igm – negative

10. Bilateral Hip X-ray

11. Imaging USS abdo and hips – no fluid in hip joints
MRI abdo/pelvis - No evidence of avascular necrosis

12. Blood Test Results
Initial GP
7 weeks
later
8 weeks
In -patient
9 weeks
In-patient
10 weeks
OPA
14 weeks Hb
9.9
9.7
10.2
11.1
WCC
6.3
5.5
4.2
6.1
4.9
Plt
418
354
338
516
295
Neut
2.20
Lymp
2.70
CRP 9 13
<1
ESR 98 90
105
104 14

13. Follow Up Follow up 10/7 after discharged from Hospital
Symptoms much improved
- no complaints of hip pain on weight bearing
- no pain during sleep
- no pyrexia for 5/7
- analgesia reduced from QDS to ON
- generally more mobile, active and cheerful

14. Follow up Results On examination
- discomfort on extreme range of full abduction of R. hip
- Tearful on jumping on 2 feet
Repeat bloods: ESR remains high – 104
Anti nuclear antibody positive
Referral → Rheumatologist
→ Ophthalmologist

15. Juvenile Arthritis Is a group of conditions
in which there is chronic arthritis
lasting more than 6 weeks,
presenting
before 16 years of age

16. Classifications Systemic illness (Still’s disease) - 20%
Rh factor negative polyarticular %
Rh factor positive polyarticular %
Pauciarticular arthritis assoc with ANA
& chronic uveitis %
Pauciarticular arthritis assoc with spondylitis and HLA B %

17. Aetiology
Autoimmune disease in which the cause of arthritis is largely unknown
A possible viral aetiology has been considered for a variety of arthritis conditions and clustering of patient’s following viral epidemics
Viral infections that have noted include mumps, rubella and Parvovirus B19
Systemic form is asso with HLA DR4
Oligoarhritis HLA DR5

18. Pauciarticular Arthritis
Female > Male
Involvement of up to 4 or fewer joints – typically larger joints such as the knee
3 subtypes:
1) The early onset form (< 5 years of age), involves most frequently knee joints
2) The late onset form ( > 9 years of age) most frequently involves hips with/without sacroilitis
3) Develops at any age with an asymmetrical
oligoarthritis, dactylitis and psoriatic manifestation
1) Asso with chronic ant uveilitis and ANA

19. Pauciarticular Arthritis 2
Is a large association with Anti Nuclear Antibodies between 40-75%
Frequently associated with chronic anterior uveitis (can be asymptomatic or asso pain, light sensitivity and redness)
Regular opthalmological screening is indicated

20. Complications
Chronic anterior uveitis – if poorly controlled may result in permanent eye damage, including blindness
Flexion contactures of the joint – joint held in the most comfortable position, thereby minimising intra-articular pressure. Chronic disease can lead to joint destruction and need for joint replacement
Growth failure – anorexia, chronic disease and steroid therapy
Amyloidosis – rare complication causing proteinuria and renal failure

21. Management 1
Multidisciplinary approach is required for optimal Rx: - relieve pain
- preserve joint function
- maintain normal growth and
psycho – social development
Physiotherapist & Occupational Therapists
- strengthen muscles & keep joints flexible
- encourage normal limb development
- maintain function and prevent deformities
- develop exercise programs

22. Management 2 Paediatricians, Rheumatologist and Nurses
- educating child and family
- medical management
Counsellor
– for the child and their family to reduce anxiety and share management of disease

23. Medical Management NSAIDS – aspirin, ibuprofen, diclofenac
DMARDS (Disease modifying anti rheumatic drugs)
- under rheumatologist’s supervision
- hydroxychloroquine, penicillamine, methotrexate
Intra-articular corticosteroid injections
Corticosteroids
– severe systemic involvement &/or for eyes Rx
TNF alpha blockers
– block the immune protein TNF (inflammatory agent in arthritis)
Intial Rx NSAIDS to reduce inflammation in affected joints and avoid long term damage to joints.
Second choice drugs - DMARDS – slow acting - anti rheumatic drugs to induce disease remission or to sloe its evolution
Steroids injected into some joints to rapidly help improvement, after first drainage off any fluid in that joint that may be restricting movement.
Prednisolone – s-e – inhibtion of structural growth and premature appearance of osteoporosis

24. Prognosis Symptoms usually go away after a few years
There are usually no further recurrences
Some children may have longer lasting involvement

25. References
Laura Quarte et al. Juvenile idiopathic arthritis: An update on clinical and therapeutic approaches. Ann Ital Med Int 2005; 20:
Juvenile Rheumatoid Arthritis
Juvenile Rheumatoid Arthritis
Arthritis in children