15. Paediatric Rheumatology Flashcards
What are the Benign Symptoms of Paediatric Rheumatology?
- Worse with Activity / Better with Rest
- Worse at the end of the day
- If night pain is relieved with simple Analgesia
What are the Benign Signs of Paediatric Rheumatology?
- No Joint Swelling
- No Bony Tenderness
- Normal Strength
- Normal Height / Weight Growth
What are the Red Flag Symptoms of Paediatric Rheumatology, suggestive of a Serious Condition?
- Fever
- Malaise / Lethargy
- Morning Joint Stiffness / Pain
- Night Pain Refractory to Simple Analgesia and Symptomatic during the Daytime
What are the Red Flag Signs of Paediatric Rheumatology, suggestive of a Serious Condition?
- Joint Swelling
- Bony Tenderness to Palpation
- Muscle Weakness
- Fall in Height / Weight Growth Curve
What are the Blood Investigation Findings associated with Paediatric Rheumatology Disease?
- Raised White Blood Cells and Neutrophils
- ESR Elevated - 48 hours after the Inflammation
- CRP Elevated - 6 hours after the Inflammation
- Blood Film - Normal Film does not Exclude Malignancy
- Blood Cultures - 46-80% Osteomyelitis
What are the Investigation Findings associated with Paediatric Rheumatology Disease?
- Plain X-Ray - May be normal early
- Ultrasound - Sensitive in detecting Joint Effusions
- MRI - Sensitive in detecting Early Osteomyelitis / Perthe’s / Inflammatory Disease / Malignancy
- Bone Scan - Sensitive in detecting Early Osteomyelitis
- CT - Useful to Detect Early Bone Changes / Tumours
What is the Epidemiology of Juvenile Idiopathic Arthritis?
- Female>Male - 3:1
- Aetiology is Unknown
- Chronic Inflammation
- Activated T-Cells and Macrophages involved
What are the Different Classifications of Juvenile Idiopathic Arthritis?
- Oligoarticular Juvenile Idiopathic Arthritis - 1-4 Joints:
- a) Persistent
- b) Extended - More than 4 Joints after 6 Months
- Polyarthritis - 5+ Joints in the first 6 Months:
- a) Rheumatoid Factor Negative
- b) Rheumatoid Factor Positive
- Psoriatic Arthritis
- Systemic Onset Arthritis
- Enthesitis Related Arthritis
- Undifferentiated
How does Juvenile Idiopathic Arthritis present?
- Joint Pain / Swelling
- Stiffness - Early Morning / Relieved by Movement
- Abnormal Gait / Movements / Posture / Limp
- Babies / Infants Crying / Irritability
- Regression of Milestones in Infants
- Fever / Rash
- Lymphadenopathy
- Hepatomegaly / Splenomegaly
- Serositis
What is the Medical Differential Diagnosis for Juvenile Idiopathic Arthritis?
- Septic Arthritis
- Reactive Arthritis
- Rheumatic Fever
- Associated with Inflammatory Bowel Disease
- Connective Tissue Disorder - SLE / Hypermobility / Growing Pain
What is the Surgical Differential Diagnosis for Juvenile Idiopathic Arthritis?
- Perthe’s Disease
- Slipped Upper Femoral Epiphysis
- Congenital Hip Dysplasia
- Fracture
- Trauma
- Referred Pain
What is the Malignant Differential Diagnosis for Juvenile Idiopathic Arthritis?
- Leukaemia
- Neuroblastoma
- Primary Bone Tumour
What are the investigations for Juvenile Idiopathic Arthritis?
- Anti-Nuclear Antibodies (ANA)
- HLA-B27
- Inflammatory Markers
- Rheumatoid Factor
- X-Ray / MRI
- MSK Examination of All Joints - not just symptomatic
Note - No Specific Test and Results are often Normal / Negative. This is to Exclude a Differential Diagnosis
What is the Management of Juvenile Idiopathic Arthritis?
- Encourage Normal Activity
- Drug Treatment
- Regular Ophthalmology Review for Uveitis
- Physiotherapy - Including Hydrotherapy
- Occupational Therapy
- Psychology
Note - Do Not Advise Rest / Splints / Crutches …
What is the Drug Treatment of Juvenile Idiopathic Arthritis?
- NSAID’s
- Intraarticular Joint Steroid Injection
- Oral / I.V. Methylprednisolone - Systemically
- DMARD - Methotrexate / Biologics
What are the Poor Prognosis Factors for Juvenile Idiopathic Arthritis?
- Active Disease at 6 Months
- Polyarticular Onset and Course
- Extended Oligoarticular
- Female
- Rheumatoid Factor Positive
- ANA Positive
- Persistent Raised Inflammatory Markers
What are the Complications of Juvenile Idiopathic Arthritis?
- Altered Growth of Limbs
- Scoliosis
- Short Stature
- Joint Damage / Destruction
- Blindness - Untreated Uveitis
- Psychological Effects of Chronic Disease
- Loss of Schooling
What are the Features of Septic Arthritis / Osteomyelitis?
- Fever
- Systemic Upset
- Severe Limitation of Joint Movement
Note - Beware of Subtle Presentation
What Investigations should be done for Septic Arthritis / Osteomyelitis?
- Bloods - FBC / CRP / ESR
- Ultrasound Guided Joint Aspiration
- X-Ray may show signs of Osteomyelitis
What is the Management of Septic Arthritis / Osteomyelitis?
- Urgent Orthopaedic Input
2. May need Washout and I.V. Antibiotics
What are the Features of Trauma?
- History of Trauma
2. Signs of Injury
What Investigations should be done for Trauma?
X-Ray / CT Scan
What is the Management of Trauma?
- Inpatient / Outpatient
2. Management is dependent on the Type / Cause of the Injury
What are the Features of Irritable Hip?
Systemically Well
What Investigations should be done for Irritable Hip?
Bloods - FBC / CRP / ESR
What is the Management of Irritable Hip?
- Advise Regular Analgesia for 48 hours
2. Review in 7-10 days
What are the Features of Henoch-Schoenlein Purpura?
- Purpuric Rash
- Abdominal Pain
- Haematuria
What Investigations should be done for Henoch-Schoelein Purpura?
- Urine Dipstick and Microscopy
2. Blood Pressure
What is the Management of Henon-Schoelein Purpura?
Paediatric Referral and Follow Up
What are the Features of Haemarthrosis?
If Spontaneous / After Minor Injury consider Haemophilia
What Investigations should be done for Haemarthrosis?
Coagulation Studies
What is the Management of Haemarthrosis?
Paediatric Referral if Clotting Screen Normal
What are the Features of Rheumatic Fever?
- Carditis
- Erythema Marginatum
- Migrating Polyarthritis
- Subcutaneous Nodules
- Chorea
What Investigations should be done for Rheumatic Fever?
- ECG / Echo
- Bloods - FBC / CRP / ESR / U&E
- ASOT (Antistreptolysin O Titer)
- DNase B (Looking for Group A Strep Antibodies)
What is the Management of Rheumatic Fever?
Refer to Paediatrics
What are the Features of Serum Sickness?
- History of Medication use
2. Rash
What Investigations should be done for Serum Sickness?
- Bloods - FBC / CRP / ESR / U&E
- ASOT (Antistreptolysin O Titer)
- DNase B (Looking for Group A Strep Antibodies)
What is the Management of Serum Sickness?
Follow up in 7-10 days
What are the Features of Reactive Arthritis?
- History of Recent Viral illness
2. Well Child
What Investigations should be done for Reactive Arthritis?
Exclude Septic Arthritis
What is the Management of Reactive Arthritis?
Follow up in 7-10 days
