UW Ped MSK cases 1 dalis Flashcards
(1) A 5-year-old girl is brought to the clinic with joint pain and rash. Last week, the patient developed pain in her knees. The pain resolved after a few days, but now her ankles and wrists are tender. She has also developed a nonpruritic, pink rash on her back. The patient had previously been healthy except for a sore throat a few weeks ago that resolved on its own. Temp. 38.3 C (101 F), pulse 85/min, RR 20/min. Cardiac examination is normal. The lungs are clear to auscultation. The wrists and ankles are stiff and tender to manipulation. Multiple large, well-demarcated, erythematous, nonpruritic patches with a slightly raised outline are present on the trunk and proximal limbs. Laboratory results are as follows: Leu 6,500; Neutrophils 56%, Lymphocytes 33, Hb 12.5 g/dL
Platelets 380,000/mm3, CRP 32
ESR 62 mm/h. Which of the following is the most likely diagnosis in this patient?
ACUTE RHEUMATIC FEVER
(1) ACUTE RHEUMATIC FEVER vs JIA?
Systemic juvenile idiopathic arthritis is diagnosed when arthritis is present for >6 weeks.
Systemic symptoms, including fever and rash, can be seen in children with systemic juvenile idiopathic arthritis, but the arthritis is usually not migratory, as in this patient.
(1) ACUTE RHEUMATIC FEVER.
Diagnosis is based on clinical or laboratory evidence of a preceding group A streptococcal infection along with 2 major, or 1 major plus 2 minor, Jones criteria.
JONES = major
Minor: fever, arthralgias, elevated ESR, prolonged PR interval
(1) ACUTE RHEUMATIC FEVER. late cardiac sequele?
mitral regurgitation/stenosis
(2) ) A 14-year-old girl is brought to the clinic for leg pain. She first noticed achiness in the ankles 3 months ago after starting a daily walking routine on a local trail to improve her health. The aches tend to be worse in the morning but improve over the day. The pain spread to the knees, elbows, and wrists over the past month. Prior to this, the patient had been sedentary and spent most of her time indoors watching television. In addition to the walking routine, she has transitioned to a plant-based diet. The patient feels tired most days despite sleeping 9 hours a night. Her weight has improved from the 95th percentile to the 90th percentile over the past 3 months, and her height is stable at the 75th percentile. Temp. 37.3 C, pulse is 80/min, RR 16/min. Cardiopulmonary examination is normal. Bilateral ankles, knees, elbows, and wrists have mild swelling and tenderness to palpation. Which of the following medications is most appropriate for this patient’s condition? Dx?
Dx = JIA
Tx answer = naproxen
(2) JIA.
Juvenile idiopathic arthritis (JIA), a chronic autoinflammatory condition, is the most common cause of arthritis in children. Polyarticular JIA, as seen in this patient, involves ≥5 joints within 6 months of disease onset and is most commonly diagnosed in toddler and adolescent girls (ie, bimodal distribution).
JIA gali buti systemic, polyarticular, oligoarticular
(2) JIA - systemic CP?
Arthritis in >= 1 joint for >=6 weeks
Quotidian fever for >=2 weeks
Evanescent rash
Hepatosplenomegaly
Lymphadenopathy
(2) JIA - polyarticular CP?
Arthritis >= 5 joints
May be complicated by uveitis
(2) JIA - oligoarticular CP?
Arthritis < 5 joints
May be complicated by uveitis
(2) JIA = labiau paplite tarp mergaiciu
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(3) A 4-year-old boy is brought to the emergency department for evaluation of persistent fevers. About 6 weeks ago, the patient developed rhinorrhea, cough, and body aches after returning from a family trip to Costa Rica. Although the other symptoms resolved, he still has intermittent fevers and aches. The fevers tend to spike in the evenings and are accompanied by a pink, nonpruritic rash. Both features completely resolve by morning. The patient has continued to attend preschool because he feels well during the day. However, he has had a fever and rash every evening for the last 5 days. The patient takes no medications. Temperature is 39.1 C (102.4 F). He appears tired. The oropharynx and bilateral tympanic membranes are normal. Cardiac examination shows tachycardia without murmurs. There are several pink macules at the waist and bilateral axillae. The spleen is palpable 3 cm below the costal margin. There is swelling of both knees and tenderness with deep palpation. Laboratory results are as follows:
Hemoglobin 10.6 g/dL
Platelets 600,000/mm3
Leukocytes 17,000/mm3
Neutrophils 80%
Eosinophils 1%
Lymphocytes 19%
Which of the following is the most likely diagnosis in this patient?
SYSTEMIC JUVENILE IDIOPATHIC ARTHRITIS
(3) Systemic JIA can present any time during childhood and is characterized by:
* Arthritis in ≥1 joint for ≥6 weeks: Commonly affected joints include the hips, knees, and hands. Patients may have arthralgias (as in this patient) prior to the onset of arthritis.
* Fever for ≥2 weeks: Fever occurs in a quotidian pattern in which high temperatures spike once daily (often in the evening) followed by spontaneous return to normothermia. An evanescent pink rash often accompanies the fever, as seen in this patient.
hemo: leukocytosis, elevated inflammatory markers, thrombocytosis, and hyperferritinemia. Anemia due to chronic inflammation and iron deficiency is also seen.
(3) fever in JIA vs fever in acute rheumatic fever?
rheumatic fever: fever is typically persistent rather than quotidian
JIA: Fever occurs in a quotidian pattern in which high temperatures spike once daily (often in the evening) followed by spontaneous return to normothermia
(3) JIA vs Dengue fever?
Dengue virus is present in Costa Rica and can cause acute fever, rash, and joint pain. Leukopenia is typical, and bruising or bleeding often occurs due to thrombocytopenia. In addition, this child’s prolonged symptoms make dengue virus unlikely.
(3) JIA vs Malaria?
Malaria presents with intermittent fever, fatigue, joint pain, hepatosplenomegaly, and anemia. However, fevers are not associated with rash, and risk of malaria is very low in Costa Rica
(3) JIA vs SLE?
(SLE) can cause chronic fever, rash, joint swelling, lymphadenopathy, and hepatosplenomegaly. However, malar rash is typical, and SLE is unusual in children age <5.
(3) JIA vs Parvovirus 19?
Parvovirus B19 infection is an acute illness that presents with fever and rash (eg, “slapped cheeks,” lacy truncal rash). Joint involvement can occur but is more common in adult women and resolves within 3 weeks.
(4) A 3-year-old girl is brought to the clinic for evaluation of right knee swelling. Her mother first noticed the swelling and a limp 2 months ago but attributed them to roughhousing with her brother. Typically, the limping was present in the mornings and resolved by midday. However, while bathing the patient last night, her mother noticed that the right knee was more swollen than usual. The knee is not painful, and the patient has had no fever or rashes. Temperature is 37.5 C (99.5 F). She can bear weight on both legs but has a noticeable limp. The right knee is swollen and slightly warm. The overlying skin appears normal and intact. There is no tenderness to palpation. Peripheral pulses are normal. Sensation is intact. This patient is at greatest risk for which of the following complications?
UVEITIS
Dx = Oligoarticular JIA
Ophthalmologic screening examinations are performed regularly because untreated uveitis is often asymptomatic and can lead to irreversible vision loss.
(4) Oligoarticular JIA, the most common form, is characterized by involvement of ≤4 joints (ie, <5 joints) within the first 6 months of disease onset.
A limp that is worse in the morning in a toddler girl (age <5), such as this patient, is a typical presentation of oligoarticular JIA. Joint swelling is present, but pain may be minimal. The large joints (eg, knees, ankles) are most commonly affected; however, hip involvement is rare. Systemic symptoms (eg, fever, rash) do not occur.
case buvo pamineta ,,typically, the limping was present in the mornings and resolved by midday”.
(5) An 11-year-old girl is brought to the emergency department due to right shoulder pain. The patient first noticed the pain 4 days ago after softball practice. She has been placing cold compresses over the shoulder and taking acetaminophen with initial improvement, but the pain has awakened her from sleep the last 2 nights. Today she is unable to lift her right arm to brush her teeth. Four months ago, the patient was diagnosed with polyarticular juvenile idiopathic arthritis involving the wrists, knees, and ankles. She is taking methotrexate, and her symptoms had been gradually improving after dose adjustments. Temperature is 38.5 C (101.3 F). The patient holds her right arm at her side, and she resists attempts to move the shoulder due to pain. The overlying skin is warm. Bilateral wrists, knees, and ankles are mildly edematous. The shoulder joint is aspirated, and synovial fluid analysis reveals leukocyte count of 55,000 cells/mm3, with 80% polymorphonuclear cells and 20% lymphocytes. Which of the following is the best next step in management of this patient? Dx?
Dx = pediatric septic arthritis
Tx = start IV abs
Juvenile idiopathic arthritis (JIA) is a risk factor for septic arthritis because underlying joint inflammation predisposes to bacterial seeding.
Usmle love confuse JIA with septic arthritis
(5) septic arthritis. Elevated synovial leukocyte count >50,000/mm3 with a neutrophil predominance (polymorphonuclear cells >80%-90%) is highly suggestive of infection, and identification of bacteria in the synovial fluid is diagnostic.
JIA flare is typically <50,000/mm3
(6) A 2-month-old boy + persistent crying. Last evening, he began crying after his mother lifted his legs to change his diaper. Overnight, the patient was intermittently fussy and refused to breastfeed, and he has been difficult to console this morning. He was born at term via cesarean delivery due to breech presentation and was discharged on day 2 of life. Temperature is 38.5 C (101.3 F). Cardiopulmonary examination is normal. The liver edge is 1.5 cm below the costal margin. Bilateral testicles are present and nontender. The right hip is held flexed, abducted, and externally rotated. The patient cries with palpation of the upper right thigh and resists movement of that hip. The left hip has full range of motion. Laboratory results are as follows:
Complete blood count
Hemoglobin 9.8 g/dL
Platelets 250,000/mm3
Leukocytes 20,000/mm3
Neutrophils 80%
Lymphocytes 20%
Which of the following is the most likely diagnosis in this patient?
SEPTIC ARTHRITIS
Mx = joint aspiration, antibitotics
In infants, symptoms may be nonspecific, including fever, inconsolability, and poor feeding, as in this patient. Subtle signs of joint involvement (most commonly knee and hip) in infants include lack of movement of the affected side (pseudoparalysis) and excessive fussiness during diaper changes or repositioning, as seen in this patient. Infants often lie with the affected hip flexed, abducted, and externally rotated to maximize joint space and comfort. Physical examination may reveal pain with active or passive motion, as well as asymmetric swelling.
(7) A 2-year-old girl is brought to the clinic for evaluation of left knee pain and fever. The knee pain began 2 months ago. At the time of onset, the patient and several other children at day care had cough and rhinorrhea, but only the patient developed joint pain. Movement is limited by pain in the morning but seems to improve in the afternoon. For the past month, she has had a daily fever and an erythematous macular rash over her chest around bedtime. Temperature is 36.1 C (97 F), blood pressure is 90/60 mm Hg, and pulse is 114/min. Physical examination shows swelling, erythema, and warmth of the left knee, with pain elicited on passive and active movement of the left hip. The patient can walk but has a slight limp. Laboratory results are as follows:
Hemoglobin 10 g/dL
Platelets 520,000/mm3
Leukocytes 21,000/mm3
Erythrocyte sedimentation rate 100 mm/hr
Which of the following is the most likely diagnosis in this patient?
Systemic JIA
(8) A 16-year-old girl is brought to the office due to pain in multiple joints. The pain has primarily been in her left knee and hip, right shoulder, and both wrist and hand joints. The patient says the pain seemed to be in one joint and would improve after a day or 2 before moving to a different joint. She also notes that she had 2 days of fever and malaise a week ago, but these have since resolved. Physical examination shows tenderness and pain on movement of the bilateral wrists and left fingers. There is mild swelling and tenderness of the left knee with no erythema. Several 3- to 4-mm, nontender pustules with a surrounding erythematous rim are present on the left lower extremity. Left knee arthrocentesis yields clear synovial fluid with a leukocyte count of 30,000/mm3. Synovial fluid culture is negative. Which of the following historical factors is most likely associated with this patient’s presentation?
UNPROTECTED SEXUAL INTERCOURSE
(8) gonococal synovial fluid findings?
DGI is marked by synovial fluid leukocyte count <50,000/mm3 (in contrast to most other forms of bacterial arthritis)
Synovial fluid culture is usually negative because N gonorrhoeae is a fastidious intracellular organism that does not grow well on standard media.
(8) gonococal Tx?
Treatment with intravenous ceftriaxone is curative in most cases.
(9) A 2-year-old boy is seen in the emergency department for refusal to walk. His family returned 3 days ago from a weekend camping trip in Arizona. The parents do not recall the boy having any injuries, but he did have a cough and runny nose just before the trip. Since returning home, the parents have noticed the patient limping mildly when running. After day care yesterday, his left knee began hurting. The parents placed a cold compress on the knee last evening, which helped. This morning, the patient refused to walk and cried when the parents took him out of bed. He has no chronic medical conditions and takes no medications. Immunizations are up to date. Temperature is 38.3 C (101 F). The skin over the left knee is warm and edematous. There are no abrasions. The patient resists all attempts at passive range of motion. The knee is aspirated, and synovial fluid reveals a leukocyte count of 53,000/mm3; the joint aspiration specimen is sent for culture. The patient is admitted to receive intravenous vancomycin. After 2 days, he continues to have fever and refuses to walk. Which of the following is the most appropriate to add to this patient’s regimen?
CEFTRIAXONE (covers gram -)
vanco was given => no response => suspect gram negative infection
(10)A 16-year-old boy is brought to the office due to right knee swelling. He first noticed it after soccer practice a few days ago but does not recall injuring the knee. The joint feels stiff and is not painful. The patient spent the summer at a soccer camp in Maine. He is sexually active with his girlfriend and uses condoms. Vital signs are normal. The patient can bear weight and has a grossly normal gait. Examination of the right knee shows palpable warmth and a large effusion. It is minimally tender to palpation. Range-of-motion testing shows decreased flexion of the right knee compared with the left. All other joints are normal. Plain radiographs reveal no bony deformity. Aspiration yields yellow, translucent fluid with a leukocyte count of 15,000/mm3 (50% neutrophils) and no organisms on Gram stain. Which of the following is the most likely cause of this patient’s knee swelling?
BORRELIA BURGDORFERI INFECTION
(10) This patient developed acute monoarticular arthritis after a trip to a Lyme disease–endemic area (eg, Maine). Given some of his clinical and microbiologic findings, Lyme arthritis, the hallmark of late Lyme disease, should be considered. Lyme disease is caused by Borrelia burgdorferi, a spirochete transmitted by the deer tick, Ixodes scapularis. Because the nymph form of the tick is quite small, patients often do not recall the inciting bite. Although most patients come to clinical attention shortly after transmission with early manifestations (eg, erythema migrans, fever, fatigue), these symptoms may go unrecognized or not occur.
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(10) Lyme arthritis is the presenting manifestation of Lyme disease in approximately 30% of cases. It typically causes acute monoarticular arthritis of the knee, but asymmetric oligoarticular arthritis can occur. Involved joints usually have large effusions but are minimally painful. Systemic symptoms are typically absent. Synovial fluid analysis typically reveals a leukocyte count of 10,000-25,000/mm3 with negative Gram stain and culture. Detection of Lyme antibodies in the serum (enzyme-linked immunosorbent assay and Western blot testing) helps confirm the diagnosis. Oral doxycycline is the first-line treatment.
(10) Reactive arthritis presents 1-4 weeks after an enteric or Chlamydia trachomatis infection. Asymmetric oligoarthritis (rather than monoarthritis) occurs, typically with extraarticular manifestations such as urethritis and eye involvement (eg, conjunctivitis, uveitis).
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(11) A 6-year-old boy is brought to the office by his mother due to fever, pruritic rash, and joint pain. The rash began 2 days ago and has spread to his trunk and arms. The patient has also had pain in the wrists and ankles. He was diagnosed with streptococcal pharyngitis 9 days ago and is on his second to last day of oral penicillin. Temperature is 38.8 C (101.8 F). Physical examination shows an uncomfortable-appearing boy with a diffuse rash on the arms and back. There are palpable lymph nodes in the cervical, axillary, and inguinal regions. The wrists and ankles are tender to palpation but are not swollen or erythematous. The remainder of the physical examination is normal. Which of the following is the most likely diagnosis?
SERUM SICKNESS-LIKE REACTION (zymejau acute rheumatic fever)
This boy took penicillin for several days and then developed symptoms (eg, fever, urticaria, arthralgia) of serum sickness–like reaction (SSLR).
(11) Although the presentation of SSLR closely resembles serum sickness (SS), the underlying cause differs. SS, classically triggered by?
Foreign proteins in antivenom, antitoxin, monoclonal antibody.
Due high-titer immune complex (IC) generation, IC tissue deposition, and excessive classical complement cascade activation.
(11) SSLR is not associated with ICs or complement activation; although the exact etiology is unclear, cases may reflect drug-related hapten formation or direct lymphocyte cytotoxicity triggered by exposure to beta-lactam (eg, cefaclor, penicillins) or sulfa (eg, trimethoprim-sulfamethoxazole) drugs.
Trigers: medications, particularly cefaclor, penicillin, TMP-SMX
(11) Both SS and SSLR have same presentation?
Fever
Urticarial rash: intensely pruritic plaques that spare the mucous membranes and typically persist for >24 hours
Arthralgia: polyarticular joint pain that worsens with movement and palpation. Signs of arthritis (eg, overlying erythema, warmth, edema) are not typically present but may occasionally occur
(11) Manifestations typically begin within 5-14 days of medication initiation and resolve spontaneously with medication discontinuation. BOTH, SS and SSLR
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