Approach to Polyarthritis

Approach to Polyarthritis in childrenDr. Hriday De, PGT, ICHObjectives To know the different causes of polyarthritis in paediatric age groupHow proper history taking helps in narrowing differentialsTo know details of physical examination important in rheumatologyImportance of extra-articular signs and symptoms

Definition Arthritis is defined by the presence of intra-articular swelling or 2 or more of the following findings on joint examination: Pain on motion, loss of motion, erythema, and heat.Polyarthritis :Inflammation of more than 4 joints on physical examination.Causes Infections Viral Parvovirus B19 Enteroviruses Adenoviruses Mumps, RubellaVaricella zosterHepatitis B Coxsackie virus Cytomegalovirus EBV, HIV BacterialStaphylococcal and streptococcal infectionsNeisseria gonorrhaeHemophilus influenzae Bacterial endocarditis Tuberculosis Leptospirosis BrucellosisParainfective/Reactive SalmonellaShigellaYersiniaCampylobacter MycoplasmaHIVGroup A streptococcal infectionsChlamydiaTBRheumatologicalJuvenile idiopathic arthritis (JIA)Systemic lupus erythematosus (SLE)Juvenile dermatomyositis (JDMS) Behcet syndromeJuvenile ankylosing spondylitis (JAS)Psoriatic arthritisEnteropathic arthritisSystemic vasculitis Henoch-Schonlein purpura (HSP) Kawasaki disease (KD) Polyarteritis nodosa (PAN) Wegeners granulomatosisOthers SarcoidosisMalignancy :ALL ,NeuroblastomaSickle cell anaemiaMetabolic disorders:Gauchers , Farber's disease,Diabetic cheiroarthopathyMucopolysaccharidoses:Morquios, Scheie

Mimics: Pseudo rheumatic dysplasia,Skeletal dysplasia,Spondyloepiphyseal dysplasia, Winchester SyndromeCase scenario

9 yr old female childRecurrent swelling and pain of b/l knee joint, ankle joint, wrist joint a/w fever subsided with an interval of 2 wks to 1 monthsh/o redness of eyesNo rashFit and well in-betweenTC 13000 N57L36 Plt 2.5lakhESR 82CRP43ANA,RA,AntiCCP,ASO, AntiDnase B all negativeEye check up normalCXR 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 jointsWhat 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 inflammationCardinal signs of inflammation: erythema, warmth, pain, and swelling. Fatigue, weight loss, or fever.Morning stiffness lasting > 1 hour = underlying inflammationStiffness after physical inactivity (gelling phenomenon).Age Early childhood :Oligoarticular JIAKawasaki diseaseHSPMid childhood:Juvenile psoriatic arthritisJuvenile Dermatomyositis (JDMS)Polyarteritis Nodosa (PAN)Late childhood:Juvenile ankylosing spondylitis (JAS) SLE Rheumatoid factor positive polyarticular JIAGender Most have female predilectionsKD, PAN, Spondyloarthropathies like inflammatory bowel disease and JAS which are more common in boysRF - RF+ HLA B27+ SYSTEMIC POLY PAuci SOLIGO HLA B27-

MOST COMMONFEMALEEARLY CHILDHOOD

FEMALEMALELATE CHILDHOODLATE CHILD HOODTHROUGH OUT CHILDHOODTHROUGH OUT CHILDHOODPolyPaSOnset Acute: ( 6wks)Poly JIAAnkylosing SpondylitisPsoriasis

YESNOInfectionsReactive arthritisReiters complexSystemic onset JIAKawasaki disease Polyarteritis nodosaMalignancyALLNeuroblastomaPolyarticular JIAEnthesitis related arthritisIBD associated arthritisPsoriatic arthritisSLEJuvenile DermatomyositisSclerodermaSickle cell dactylitisMucopolysaccharidosesHSPMetabolic disordersFever? Pattern recognition

Evolution of the joint involvementMigratory :Rheumatic fever Gonococcal arthritisAdditive:SLEJIA Psoriatic arthritisIntermittent :Reactive arthritis.Topography and distributionSymmetric: JIA SLE

Asymmetric : Reactive arthritisSeptic

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, and fever reactive arthritis

Pyrexia of unknown origin and multiple courses of antimicrobials systemic onset JIA

Family history: ankylosing spondylitis, inflammatory bowel disease and psoriatic arthritis Examination pGALS

Extra -articular involvementEye

K s in ra sjogr sle31

Oral cavity

Skin

Nails and hair

Systemic

Hemolytic anaemia in sle, lymphopenia in sle, ild in sle, pilmonary hge......pulmonary aneurysm in bechet, kidney,39Lab investigation

Case cont.WHAT we had missed?h/o intermittent cough Father was a TB pt, took ATD 2 yrs backOn further inv:MANTOUX + ve 20 x 20, sputum AFB (-)ve, synovial fluid for AFB (-) veCT chest ....Mediastinal and hilar nodes with central calcification

Diagnosis Poncets 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?Amoxicillin Cefalexin Ciprofloxacin Metronidazole Nitrofurantion

Q2. 1. AmoxicillinThis patient has Lyme disease. For skin disease first line therapy is either Amoxicillin (500mg tds po for 3 weeks), Doxycycline or Cefuroxime for 3 weeks48Question 2

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

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Lofgren's SyndromeReferences

Nelsons Textbook of PaediatricsJames T. Cassidy Textbook of paediatric rheumatologyIndian Journal of Paediatrics (2010) 77:10051010Medscape.comUptodate.com

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