Arthritis 2

Arthritis 2

reactive arthritis
1. commonest arthritis in childhood
2. presentation
  1. transient joint swelling (< 6 weeks)
    1. ankle or knees
  2. follows (rarely accompanies) evidence of extra-articular infection
  3. low grade fever
3. causes
  1. pathogens
    1. bacteria
      1. enteric (often cause in kids)
        Salmonella
        Campylobacter
        Shigella
        Yersinia
      2. STI (in teens)
        chlamydia
        gonococcus
      3. Mycoplasma
      4. Borrelia burgdorferi (Lyme disease)
    2. viral
  2. rare in developing countries
    1. rheumatic fever
    2. post-streptococcal
4. Ix
  1. acute phase reactants normal/mildly elevated
  2. X-ray normal
juvenile idiopathic arthritis (JIA)
1. commonest chronic inflammatory joint disease in kids & teens in UK
2. = persistent joint swelling ( > 6 weeks duration)
  1. presenting before 16 years old
    1. in absence of infection or any other defined cause
3. in 95% JIA is clinically & immunologically different from adult rheumatoid arthritis
4. prevalence = 1 in 1000 children
5. 7 different subtypes
6. clinical classification
  1. based on no of joints affected in 1st 6 months
    1. polyarthritis
      1. > 4 joints
    2. oligoarthritis
      1. up to & including 4 joints
    3. systemic
      1. w/ fever & rash
  2. other subtypes
    1. psoriatic arthritis
    2. enthesitis
  3. presence of rheumatoid factor
  4. presence of HLA B27 tissue type
7. clinical features
  1. hx
    1. gelling (stiffness after periods of rest e.g. long car rides)
    2. morning joint stiffness & pain
  2. presentation in young child
    1. intermittent limp
    2. deterioration in behviour or mood
    3. avoidance of prev enjoyed activities
  3. intially there may be only minimal evidence of joint swelling
    1. but subseq swelling of joint presents, due to
      1. fluid within joint
      2. inflammation
      3. (if chronic)
        thickening of synovium
        swelling of periarticular soft tissues
  4. long term if uncontrolled
    1. -> bone expansion from overgrrowth
      1. in knee
        leg lengthening
        valgus deformity
      2. hands
        discrepancy in digit length
      3. wrist
        advancement of bone age
  5. if systemic features present consider
    1. sepsis
    2. malignancy
8. complications
  1. chronic anterior uveitis
    1. common
    2. asymptomatic
    3. can-> severe visual imp
    4. screening w/ slit lamp indicated
      1. esp for kids w/ oligoarticular disease
  2. flexure contractures of joints
    1. occur when joint held in most comfortable position
      1. so intra-articular Pa minimsed
    2. chronic untreated diseae->
      1. joint destruction
        needing joint replacement
  3. growth failure
    1. generalised, from
      1. anorexia
      2. chronic disease
      3. systemic corticosteroid therapy
    2. localised overgrowth
      1. leg length discrepancy
        due to prolonged ative knee synovitis
    3. undergrowth
      1. micrognathia
        seen in longstanding or suboptimally treated arthritis
        due to premature fusion of epiphysis
  4. constitutional probs
    1. anaemia of chronic disease
    2. delayed puberty
  5. osteoporosis
    1. multifactorial aetiology
      1. diet
      2. weight bearing
      3. delayed menarche
    2. reduce risk
      1. dietary supplements
        Ca2+
        vit D
    3. minimise oral corticosteroid use
      1. & bisphosphonates sometimes
  6. amyloidosis
    1. very rare
    2. ->
      1. proteinuria
      2. renal failure
    3. high mortality
9. Mx
  1. induce remission as much as possible
  2. manage in specialist paeds rheumatology MDT
    1. education & support
    2. physical therapy
      1. maintain joint function
    3. links to dentistry, ophthal, orthopaed
  3. encourage participation in all except contact sports
  4. medical
    1. NSAIDs
      1. don't modify disease
      2. help relieve sx during flares
    2. joint injections under ultrasound guidance
      1. effective
      2. 1st line for oligoarticular JIA
      3. used as bridging agent (multiple injections) for polyarticular disease
        when starting methotrexate
      4. often needs sedation or inhaled anaesthesia (Entonox)
    3. methotrexate
      1. early use reduces joint damage
      2. effective in about 70% o f polyarthritis
      3. weekly dose (tablet, liq, injection)
      4. reg monitoring
        abnormal liver function
        bone marrow suppression
      5. nausea common
    4. systemic corticosteroids
      1. avoid if possible
      2. pulsed iv methlypred
        induction agent for severe polyarthritis
      3. life saving for severe sys arthritis
    5. cytokine modulators
      1. useful in severe disease refrac to methotrexate
        anti-TNF alpha, IL-1, CTLA-4 or IL-6
      2. T cell depletion + autologous haematopoetic stem cell rescue
        for refractory disease
      3. costly , given under strict national guidance w/ registries for long term surveillance
10. prognosis
  1. min 1 in 3 kids will have ongoing active disease into adulthood
    1. w/ sig morbidity from prev inflammation
      1. joint damage
        need joint replacement surgery
      2. visual impairment from uveitis
      3. fractures from osteoporosis
      4. psychosocial
septic arthritis
1. serious infection of the joint space
  1. -> bone destruction
2. commonest in kids < 2 years old
3. route
  1. from haematogenous spread
  2. follows a puncture wound or infected skin lesions e.g. chicken pox
  3. in young kids
    1. from adj osteomyelitis into joints where capsule inserts below epiphyseal growth plate
4. presentation
  1. joint
    1. red
    2. warm
    3. acutely tender
    4. reduced range of movement
  2. acutely unwell febrile child
  3. infants
    1. hold limb still (pseudoparesis, pseudoparalysis)
      1. cry if limb moved
    2. hip joint covered by subcut fat
      1. so hard to diag SA
  4. joint effusion
  5. initial presentation
    1. limp or pain referred to knee
5. usually only 1 joint affected
  1. hip of concern in infants & young kids
6. causative pathogen
  1. beyond neonatal period
    1. S. aureus
      1. usually only 1 joint affected
  2. H. influenzae
    1. unimmunised kids
    2. affects multiple sites
7. predisposing illness
  1. immunodeficiency
  2. sickle cell disease
8. coexistent in 15% of osteomyelitis
9. Ix
  1. raised WCC
  2. raised acute phase reactants
  3. blood cultures
  4. ultrasound deep joints e.g. hip
    1. exclude effusion
  5. X-ray
    1. exclude trauma
    2. in SA
      1. initially normal
        w/ widening of joint space
        soft tissue swelling
  6. bone scan
  7. MRI
    1. may show adj osteomyelitis
  8. aspiration of joint space under US guidance
    1. definitive ix
    2. do stat, unless this will delay Abx significantly
  9. washing out of joint or surgical drainage
    1. if resolution no rapid
    2. for deep seated joint e.g. hip
  10. joint initially immobilised in functional position
    1. but subseq mobilised to prevent permanent deformity
Henoch-Schonlein purpura
1. commonest vasculitis of childhood
2. purpuric rash over lower legs & buttocks
3. assoc w/ arthritis of ankles & knees
4. abdo pain
5. haematuria
6. proteinuria
systemic lupus erythematosus
1. rare in children
2. present in teen females
  1. malaise
  2. arthralgia
  3. malar rash (often photosensitive)
3. serious complications
  1. organ involvement
    1. kidneys
    2. lungs
    3. CNS
juvenile dermatomyositis
1. rare
2. insidious onset
  1. malaise
  2. progressive weakness
    1. difficulty climbing stairs
  3. facial rash
    1. erythema over bridge of nose
    2. violaceous (heliotropic) discoloration of eyelids
  4. skin over metacarpal & PIP joints hypertrophic & pink
  5. dilated & tortuous nailfold capillaries
  6. muscle pain
  7. arthritis in 30%
3. resp failure & aspiration pneumonia

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	Created by v.djabatey about 10 years ago