Approach To Acute Arthritis in Kids: Allyson Mcdonough, MD Baylor Scott & White Health Department of Rheumatology

Approach to Acute Arthritis in
Kids
Allyson McDonough, MD
Baylor Scott & White Health
Department of Rheumatology
Disclosures
Abbivie
STRIVE - JIA Registry
Eli Lilly
Illuminate SLE clinical trial
What we will talk about
Arthritis Overview
Clinical Evaluation
Differential Diagnosis
Diagnostic Evaluation
Treatment & Referral Pearls
Arthritis in Children
YES fever/sick NO
single many single many

Septic arthritis JIA, SLE, JDM
Lyme?
acute chronic acute chronic
JIA, SLE, JDM Trauma Oligo JIA
Toxic synovitis Lyme
migratory non-migratory Oligo JIA TB
Lyme Vasculitis Hemophilia Fungal
Rheumatic Fever Tumor Lyme Tumor
GC
Sickle cell
Arthritis
Greek arthron = joint

-algia = pain
-itis = inflammation
Incidence 5-10 per 100 000 children
aged 16 years or younger
Arthritis
Swelling or effusion
OR two or more:
Limited range of motion
Tenderness or pain on
motion
Increased heat
Underlying Etiology
1) Trauma / Mechanical
2) Acute bacterial infection
3) Subacute bacterial infection
4) Inflammatory
Reactive to infection Gray
Not infection related Area
5) Malignancy
HPI: Investigate The 5 Ws
W Prompt Pearl
Who age & gender clue to cause
pain, palliation,
What describe joints
provoking
onset and timing of migratory or non-

When symptoms migratory
Where which joints size, symmetry
pt or familys suggested trauma can

Why cause be a
Review of Systems
Systemic: fevers, weight loss
Skin: rashes, sun sensitivity, wounds, hair loss
HEENT: preceding URI, sore throat, mouth
ulcers, conjunctivitis
Chest: pleuritis, chest pain (serositis)
GI: diarrhea
MSK: morning stiffness, back pain,
heel pain
History and Physical
PMH especially history of joint problems
Family history of autoimmune disease,
arthritis
Social history: travel, exposures
Examine all systems and perform a
complete joint exam!!
Trauma / Mechanical
Soft tissue injury
Ligament sprain or tear
Meniscal tear
Chondromalacia, osteochondritis dissecans,
patellofemoral syndrome
Fracture or stress fracture
Hips: Perthes, SCFE
Hemarthrosis
Acute Bacterial Infection
Septic joint or bursa
Osteomyelitis with infected joint or with
sympathetic effusion
Important characteristics:
Extreme pain
Very warm, sometimes red
Refusal to bear weight or walk
Must tap joint
Subacute Bacterial Infection
Lyme late sign, acute, intermittent, mono (knee) or
oligo, not so painful
TB indolent, oligo
Primary syphilis bone invasion
Secondary syphilis symmetric knees
Brucellosis hip or knee monarthritis, SI
Salmonella sicklers
Bartonella long bone osteo
Inflammatory Arthritis
Reactive arthritis
Acute rheumatic fever
Other bacterial reactive arthritis
Viral reactive arthritis
Immunization associated arthritis (Rubella)
Systemic inflammatory condition
SLE
Dermatomyositis
Vasculitis
Juvenile idiopathic arthritis
Reactive Arthritis
Classic reactive arthritis
Gonococcal, Chlamydia
migratory or additive
tenosynovitis
Enteric bacterial infections
Yersinia
Salmonella
Shigella
Camphylobacter
TB reactive arthritis (polyarthritis)
Post-streptococcal arthritis
Systemic Infectious Disease
Viral reactive arthritis
Toxic (transient) synovitis of hip
Acutely painful arthritis
Post URI
High inflammatory markers
Aseptic tap
Nonspecific transient arthritis
Post-viral
Serum sickness-like reactions due to immune
complexes
Parvo, mycoplasma, EBV, many others
Hepatitis prodrome
Systemic Inflammatory Conditions
Vasculitis
Henoch Schonlein purpura
Migratory para-arthritis, painful
Kawasaki
Swollen hands and feet
Serum sickness (antibiotics)
Systemic connective tissue diseases
Lupus
Dermatomyositis
Juvenile Idiopathic Arthritis
Arthritis for at least 6 weeks
Diagnosis of exclusion
Onset type defined by type

of disease in first 6 months
Subtype % of JIA Age Sex Symm Joints
Any - all,
Systemic Some All ages F=M S or A
severe
Poly RF+ least Adolescent F>>M S All, severe
Preschool &
Poly RF- many F>>M S Any
Elementary
Oligo
most Preschool F>>>M A Knee, uveitis
ANA+ or -
Preschool &
Psoriatic few Late F>M A Any, dactylitis
Elementary
ERA/
few Boys > 8 M>>F S or A Axial, hips
HLA-B27
Systemic JIA
Polyarticular arthritis
Large & small joints, usually symmetric
10% no joint involvement at presentation
Evanescent rash
Salmon colored macules or patches
Trunk, proximal extremities, axilla, groin
Appears with fever
Spiking quotidian fever that breaks
HSM, lymphadenopathy, serositis
Can progress to life threatening
MAS (macrophage activation syndrome)
Malignancy
Suspect if:
constitutionally unwell, pain out of proportion
bone tenderness rather than tenderness
limited to the joint line
profound anemia or cytopenia
if platelets are normal with high esr
High LDH
Leukemia
Neuroblastoma
Bone tumors
Diagnostic
Investigations
Joint Aspiration
Must do when cannot bear weight, extremely
painful joint with fever
Most common: knee & hip
Synovial fluid analysis
Signs of infection: WBCs >50 or 100,000, low glucose,
high protein
Positive findings cannot definitively distinguish septic
from non-infectious
Gram stain and culture can be negative in 30-40% of
infected joints
Imaging
X-rays
Ultrasound
MRI
Bone scan
Labs
Infectious workup
CBC: anemia, leukocytosis, thrombocytosis
Elevated ESR, CRP, ferritin
Elevated LFTs
Signs of DIC: prolonged coags, D-dimers, low
fibrinogen
UA
proteinuria/hematuria
ANA and RF
Positive ANA/RF: not diagnostic for any
rheumatic condition
Negative ANA/RF: does not rule out any
rheumatic condition
ANA confers risk for uveitis in oligoarthritis
Rheumatoid factor in setting of chronic polyarticular
arthritis confers risk for erosive arthritis
Arthralgias
Arthralgia = joint pain without inflammation
Growing Pains
Psychogenic rheumatism
Conversion disorder
Malingering
Depression, Anxiety
Reflex neurovascular dystrophy
Reflex sympathetic dystrophy
Complex regional pain syndrome
Juvenile Fibromyalgia
Benign joint hypermobility
Hereditary connective tissue disease
Erlos Danlos
Marfans
Cystic Fibrosis
Treatment & Referral
Pearls
Arthritis in Children
YES fever/sick NO
single many single many

Septic arthritis JIA, SLE, JDM
Lyme?
acute chronic acute chronic
JIA, SLE, JDM Trauma Oligo JIA
Toxic synovitis Lyme
migratory non-migratory Lyme TB
Lyme Vasculitis Oligo JIA Fungal
Rheumatic Fever Tumor Hemophilia Tumor
GC
Sickle cell
Initial Management of Arthritis
Evaluate for infection, consider malignancy, get
imaging & basic labs
Symptomatic treatment: NSAIDs
Ibuprofen 10 mg/kg/dose 3-4 times daily
Naprosyn 10 mg/kg/dose twice daily
Ice & heat
Avoid steroids
No need to limit activity unless orthopedic concerns
Send to ER if concerned about septic joint
Consider ortho consult if trauma
Refer to rheumatology
symptoms > 4 weeks
no identifiable non-rheum cause
Initial management of chronic non-
arthritis joint pain
Physical therapy
NSAIDs, Acetaminophen avoid narcotics
If concern for depression/anxiety or parental factors
refer to counseling/psychiatry
Work on adequate sleep duration and quality
Address mechanical factors
Flat feet podiatry, shoe inserts
Obese weight management
Hypermobility bracing, strengthening, avoid
high impact activities, consider
genetics consult
Urgent vs Non-urgent
5 y/o girl with high fever, 13 y/o with depression &
evanescent rash, joint pain. insomnia complains of
Strep screen and other several year history of
infectious work up neg. 10/10 joint pain, sitting
WBC, PLT, ESR, CRP calmly & smiling. ANA
elevated 1:40, all other labs
14 y/o AAF with malar rash, normal. Mother who is a
arthralgias, fevers, fatigue. nurse with pmhx of
Low wbc, hgb, plt. UA shows fibromyalgia is frantic and
trace protein & blood. ANA demands to know whats
+ 1:2560 wrong with her daughter.
Semi-Urgent vs Non-urgent
14 y/o male with back pain worst in 12 y/o with pmhx chronic
the morning, improves with constipation c/o exercise induced
ibuprofen and exercise. Father has arthralgias, frequent ankle sprains
psoriasis. and clumsiness, occasional mild
knee swelling after vigorous exercise
3 y/o female with asymptomatic and had to quit gymnastics.
swelling of the left knee. She will
occasionally limp in the morning but 10 y/o obese male with knee and
does not complain of pain or exhibit ankle pain. Exam reveals flat feet
any physical limitation. Mom and mild valgus knee deformity
notices she squints when lights are
turned on. She was diagnosed with
pink eye a few months ago.
Send to pedi-ophtho urgently
References
Approach to the Child with Joint Pain, but Normal
Physical Examination, Michelle Miller, MD
Approach to Acute Limb Pain in Childhood, Shirley M.L.
Tse, MD, Ronald M. Laxer, MD
Arthritis in Children and Adolescents, Janice John, DO,
MS, MPH, Latha Chandran, MD, MPH. Pediatrics in
Review
Its Not Just Growing Pains, Thomas Lehman, MD
American College of Rheumatology Image Bank
Acknowledgments
Megan Curran, MD
Ann and Robert H. Lurie Childrens Hospital of
Chicago
Baylor Scott & White Department of Pediatrics
Baylor Scott & White CME Office
Loren McDonough

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Approach to Acute Arthritis in

single many single many

Greek arthron = joint

onset and timing of migratory or non-

Where which joints size, symmetry

pt or familys suggested trauma can

Arthritis for at least 6 weeks

Onset type defined by type

Poly RF+ least Adolescent F>>M S All, severe

single many single many

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