Approach to Polyarthritis in children

Dr. Hriday De, PGT, ICH

Objectives

• To know the different causes of polyarthritis in paediatric age group

• How proper history taking helps in narrowing differentials

• To know details of physical examination important in rheumatology

• Importance of extra-articular signs and symptoms

Definition

• Arthritis is defined by the presence of intra-articular swelling or 2 or more of the followingfindings on joint examination:

Pain on motion, loss of motion, erythema, andheat.

• Polyarthritis :Inflammation of more than 4joints on physical examination.

Causes

Infections

Viral

• Parvovirus B19

• Enteroviruses

• Adenoviruses

• Mumps, Rubella

• Varicella zoster

• Hepatitis B

• Coxsackie virus

• Cytomegalovirus

• EBV, HIV

Bacterial

• Staphylococcal and streptococcal infections

• Neisseria gonorrhae

• Hemophilus influenzae

• Bacterial endocarditis

• Tuberculosis

• Leptospirosis

• Brucellosis

Parainfective/Reactive

• Salmonella

• Shigella

• Yersinia

• Campylobacter

• Mycoplasma

• HIV

• Group A streptococcal infections

• Chlamydia

• TB

Rheumatological

• Juvenile idiopathic arthritis (JIA)

• Systemic lupus erythematosus (SLE)

• Juvenile dermatomyositis (JDMS)

• Behcet syndrome

• Juvenile ankylosing spondylitis (JAS)

• Psoriatic arthritis

• Enteropathic arthritis

Systemic vasculitis

• Henoch-Schonlein purpura (HSP)

• Kawasaki disease (KD)

• Polyarteritis nodosa (PAN)

• Wegener’s granulomatosis

Others

• Sarcoidosis• Malignancy :ALL ,Neuroblastoma• Sickle cell anaemia• Metabolic disorders:Gaucher’s , Farber's

disease,Diabetic cheiroarthopathy• Mucopolysaccharidoses:Morquio’s, Scheie

Mimics: Pseudo rheumatic dysplasia,Skeletal dysplasia,Spondyloepiphyseal dysplasia,Winchester Syndrome

Case scenario

• 9 yr old female child• Recurrent swelling and pain

of b/l knee joint, ankle joint, wrist joint a/w fever

• subsided with an interval of2 wks to 1 months

• h/o redness of eyes• No rash• Fit and well in-between

• TC 13000 N57L36 Plt 2.5lakh

• ESR 82

• CRP43

• ANA,RA,AntiCCP,ASO, AntiDnase B all negative

• Eye check up normal

• CXR normal

WHAT NEXT ???

History

Questionnaire

• Is the pain severe enough to disturb the sleep of the child? • Is there any early morning stiffness? • Does the pain worsen after movement or does it get

worse with exercise?• Where did the pain start from?• Which joints are involved?• Upper limb joints/lower limb joints• What is order of involvement?• Whether arthritis is migratory or non migratory?• Is the joint involvement symmetrical or asymmetrical?• Is joint pain part of a systemic illness?

Does this patient have arthralgia or arthritis?

• Key = presence of inflammation

• Cardinal signs of inflammation: erythema, warmth, pain, and swelling.

• Fatigue, weight loss, or fever.

• Morning stiffness lasting > 1 hour = underlying inflammation

• Stiffness after physical inactivity (gelling phenomenon).

Age

• Early childhood :Oligoarticular JIAKawasaki diseaseHSP• Mid childhood:Juvenile psoriatic arthritisJuvenile Dermatomyositis (JDMS)Polyarteritis Nodosa (PAN)• Late childhood:Juvenile ankylosing spondylitis (JAS) SLE Rheumatoid factor positive polyarticular JIA

Gender

• Most have female predilections

• KD, PAN, Spondyloarthropathies like inflammatory bowel disease and JAS which are more common in boys

RF - RF+ HLA B27+ SYSTEMIC

POLY PAuci S

OLIGOHLA B27-

MOST COMMON

FEMALEEARLY

CHILDHOODFEMALE MALE

LATE CHILDHOOD

LATE CHILD HOOD

THROUGH OUT CHILDHOOD

THROUGH OUT CHILDHOOD

PolyPaS

Onset

• Acute: ( <2 wks)Septic arthritis Arthritis associated with KD/HSP Rheumatic fever• Sub acute: ( 2- 6 wks)Viral arthritisReactive arthritisSLE• Chronic: ( > 6wks)Poly JIAAnkylosing SpondylitisPsoriasis

YES NO

InfectionsReactive arthritisReiter’s complexSystemic onset JIAKawasaki disease Polyarteritis nodosaMalignancy•ALL•Neuroblastoma

Polyarticular JIAEnthesitis related arthritisIBD associated arthritisPsoriatic arthritisSLEJuvenile DermatomyositisSclerodermaSickle cell dactylitisMucopolysaccharidosesHSPMetabolic disorders

Fever?

Pattern recognition

Evolution of the joint involvement

• Migratory :Rheumatic fever Gonococcal arthritis• Additive:SLEJIA Psoriatic arthritis• Intermittent :Reactive arthritis.

Topography and distribution

• Symmetric:

JIA

SLE

• Asymmetric :

Reactive arthritis

Septic

Is any particular joint involved?

Is there a joint deformity?

• Deforming arthritis is typically seen in polyarticular JIA.

• SLE and inflammatory bowel disease is usually non-deforming

Others

• Past history:painful red eye with visual loss JAS

Recent diarrhoea, acute conjunctivitis, urethritis, andfever reactive arthritis

Pyrexia of unknown origin and multiple courses ofantimicrobials systemic onset JIA

• Family history: ankylosing spondylitis, inflammatorybowel disease and psoriatic arthritis

Examination

pGALS

Extra -articular involvement

Eye

Oral cavity

Skin

Nails and hair

Systemic

Lab investigation

Case cont.

WHAT we had missed?

• h/o intermittent cough

• Father was a TB pt, took ATD 2 yrs back

On further inv:

• MANTOUX + ve 20 x 20, sputum AFB (-)ve, synovial fluid for AFB (-) ve

• CT chest ....Mediastinal and hilar nodes with central calcification

Diagnosis

Poncet’s disease

(Tuberculous Rheumatism)

Evaluation of polyarthritis or polyarthralgia

http://www.uptodate.com/

Treatment

Question 1

A 15 year old female presented with fatigue, fever and arthritis of knees, wrists, elbow. She had noticed a rash on her left leg which had been getting worse. Two weeks ago she went camping in the Gorumara forest. On examination she had a left knee effusion. She had a 10cm diameter red macule on her left shin with central clearing. Joint aspirate No organisms, no crystals.

What is the most appropriate first line therapy?1. Amoxicillin 2. Cefalexin 3. Ciprofloxacin 4. Metronidazole 5. Nitrofurantion

Question 2

A 14-year-old female was admittedcomplaining of pain and swelling in bothknees, elbows, and ankles for 1 monthElevated ESR, CRP, normal autoantibody profileMantoux, sputum negative.

???????

Lofgren's Syndrome

References

• Nelson’s Textbook of Paediatrics

• James T. Cassidy Textbook of paediatric rheumatology

• Indian Journal of Paediatrics (2010) 77:1005–1010

• Medscape.com

• Uptodate.com

and special thanks to my teachers

THANK YOU