Rheumatology: JIA, Spondylarthropathies, Lyme Flashcards
Approach to child with joint pain – Key Points (7)
- Distinguish b/w arthralgia and arthritis
- Localized to progressive
- History of trauma
- Presence or absence of systemic symptoms
- History of stiffness & time day
- History of sexual activity
- Pain with movement, restriction of movement
Arthralgia vs. Arthritis
Arthralgia– refers to pain in the joints
*Will not be warm or have an effusion
Arthritis – involves clinical signs of inflammation such as palpable joint swelling, warmth and/or erythema and decreased mobility
*Warm with effusion
Painful Joints: General (6)
- Migratory Arthritis: inflammation that resolves in one joint as it appears in the next
- Classically seen in RF and GC arthritis
- Joint pain from JRA tends not to migrate as much as have an additive pattern
- Ensure you are not missing trauma or cancer
* Need history of stiffness and time day, history of sexual activity, and whether there is pain with movement or restricted movements - Morning pain → arthritis
* Gets better as day goes on but worsens if prolonged sitting or lying down - Overuse injuries and ischemia → hurts at end of day
Common Causes of MS Pain in Children: Non-Inflammatory Trauma (6) vs. Structural (4)
Trauma:
i. Contusion
ii. Sprains, strains
iii. Fractures
iv. Subluxations
v. Overuse syndrome
vi. Abuse
Structural
i. SCFE
ii. Avascular Necrosis
iii. Patellofemoral disorders
iv. Joint hyper mobility
Common Causes of MS Pain in Children: Inflammatory (7)
- Osteomyelitis
- Septic arthritis
- Post infectious reactive arthritis
- Viral Arthritis (toxic synovitis)
- Cellulitis
- Diskitis
- Lyme disease
Common Causes of MS Pain in Children: Rheumatologic (7)
- JRA
- Sondyl arthropathies
3 Systemic vasculitis:
- SLE
- Kawasaki
- Henoch-schonelein purpura
- Serum sickness
Common Causes of MS Pain in Children: Systemic diseases (3)
- Hematologic/oncologic disorders (leukemia, sickle cell, local tumor)
- Metabolic disorders
- Inflammatory bowel disease
JIA Diagnostic criteria (5)
- Arthritis lasting six weeks or more in a child younger than 16 years
American College of Rheumatology criteria for JRA:
- Age < 16 years old
- Arthritis in at least one joint for six consecutive weeks.
- Exclusion of other causes of arthritis
- Arthritis requires the presence of swelling or effusion or two of the following: warmth, pain on motion, and limited ROM.
JIA Common Findings (5)
- Swollen/stiff/painful/erythematous joints
- Morning stiffness
- Limp
- Decreased activity level secondary to pain
- Pain alone is not enough!
JIA Complications (4)
- Joint damage
- Bony deformities
- Joint laxity
- Iritis
* Can lead to blindness
* From prolonged uveitis – can be silent until it shows up and then damage has already been caused
* If ANA positive, child must see optho every 3 months to avoid iritis
JIA Subgroups (3)
- Systemic onset JIA
* Bimodal fevers – very bad → gets better → bad again - Pauciarticular JIA
- Polyarticular JIA
JIA Systemic Onset (15)
- Affects 10-20%
- Slight male dominance
- High spiking fevers
- Arthritis within 6 months after onset of fever.
- Arthralgia and arthritis worsen with temperature elevation.
- Salmon pink macular lesions
- Lymphadenopathy, hepatosplenomegaly
- Chronic iritis does not occur with these patients.
- Pleuritis and pericarditis in 50% of cases
- Increased WBC
- Increased platelets
- Decreased hemoglobin/hematocrit
- Increased ESR and CRP
* Lupus patients will always have a high ESR - ANA usually negative
* If ANA positive → increased risk of uveitis - Rh Factor usually negative
Outcomes of systemic JIA (2)
- ½ of children with SoJIA recover completely
2. ½ go on to have chronic disease
Pharm Treatments for JIA (6)
NSAIDS
- Indicin
- Naprosen
- Prednisone
Immunosuppression
- Anakinra
- Rilonacept
- Cyclosporine
Pauciarticular JIA/Oligoarticular JIA (2)
- Largest group of JIA (50%)
2. Affects 4 or fewer joints
JIA Labs (4)
- CBC- high inflammatory markers- plt ct
- ESR, CRP
- Lyme to r/o other causes***
- ANA
i. Helps determine risk of uveitis
ii. ANA + at higher risk of uveitis
iii. Must see ophthalmologist every 3 months
Polyarticular Arthritis (4)
- Arthritis in 5 or more joints
- Girls greater than boys 3:1
- Symmetric involvement of small joints
- Usually involves the temporomandibular joint and cervical spine
* Poly is more likely to involve TMJ and cervical
* Can also cause micrognathia
JIA Lab Results (7)
- CBC: Anemia, high platelet count
- RF (Rheumatoid factor)/CCP
+ = Adult type
- = Most children are negative
* If a child has arthritis and they are RF+ then they are more likely to act as an adult rheumatoid arthritis patient
*Poly JIA and more likely to have it for life, more destructive - ESR: Inflammatory marker
- CRP: Early inflammatory marker
- Lyme: Must r/o
- Ophthalmology: To evaluate for iritis (Every 6 months)
* Anyone who is Rf + or has polyarhtirits must go to optho every 3 months - Can get false positive mono titers
Treatment goals for JIA (3)
- Control inflammation
- Maintain joint ROM and muscle strength Decrease chronic joint pain
- Assure normal physical and psychosocial functioning
NSAIDs for JIA (3)
- First line treatment
- 4 – 6 weeks are needed to see full response
- Examples: Ibuprofen, naproxen, tolmetin, voltaren
Steroids for JIA (3)
- Intra–articular steroid injections suppress arthritis rapidly without systemic treatment
- Steroid injections are beneficial when oral meds are not tolerated
- Effects are felt within 24-48 hours and last for 3- 9 months
Second Line Agents for JIA (2)
- Added to drug regimen depending on disease activity
- TNF Alpha inhibitors:
i. Methotrexate
ii. Sulfasalazine
iii. Entanercept
iv. Remicade
v. Orencia
* vi. Anikinra; Good for systemic, but very expensive
* vii. Rituximab; saved for children who are Rf+ and difficult to treat
Key to JIA (4)
- Follow up and monitoring
- 1/3rd grow out of it
- 1/3rd have waxing and waning course
- 1/3rd will continue to have it t/o childhood onto adulthood
Spondyloathropathies (3)
- Group of arthritides characterized by negative titers for RF and ANA
- Positive titers for HLA-B27
- Affect mainly boys in early adolescence
Spondyloathropathies Types (4)
- Ankylosing spondylitis: Males, SI joints and spine, symmetrical, HLA-B27+ve
- Psoriatic arthritis: Symmetric polyarthritis/asymmetric oligoarthritis, psoriasis +nt, DIP involved
- Reactive arthritis: Antecedent GI/GU infection, asymmetric oligoarthritis
- Enteropathic arthritis: With IBD, axial/peripheral oligo-arthritis
Diseases included in Spondylarthropathies (5)
- Seronegative enthesopathy-arthropathy
- Ankylosing spondylitis
- Juvenile psoriatric arthritis
- Reiters syndrome
- Arthritis associated w/ Inflammatory Bowel Disease
Lyme Disease as Joint Pain differential (2)
- Tick-borne condition, transmitted via deer ticks in eastern and upper mid-west
- In the US 94% of cases are from: NY, NJ, Conn, Penn, Rhode Island, Mass, Wisconsin, Minnesota, California
Lyme disease manifestations (9)
- Erythema migrans: 3-32 days after bite
- Inflammation spread outward from macular central lesion in annular pattern w/ central clearing
- Large lesion > 5 cm in diameter are more specific for the diagnosis
- Concurrent w/ rash: sub-acute febrile illness, malaise, headache, mild stiff neck, myalgia and arthralgia
- Lyme Arthritis– most characteristic early disseminated manifestation in children
- Tends to attack large joints (knees)
- Is usually asymmetric
- Episodes are brief and recurrent
- If untreated may progress to chronic
Less common lyme manifestations (6)
- Bell’s Palsy
- Aseptic meningitis
- Conjunctivitis
- Myocarditis
- Pericarditis
- Heart Block (usually 1st degree)
Lyme Diagnosis (6)
- Erythema migrans- with + history of exposure = diagnosis
- Early in disease may not be able to culture it out
- Early disseminated and late disease- serologic testing
- Borderline false + are common
- Most reliable is enzyme linked Assay (Elisa)
- Confirmation is western blot
Lyme Treatment (5)
i. Amoxicillin
ii. Penicillin
iii. Ceftriaxone
iv. Doxycycline
v. Erythromycin
