kathy bailey consultant paediatric rheumatologist coventry and warwickshire
TRANSCRIPT
Kathy BaileyConsultant Paediatric Rheumatologist
Coventry and Warwickshire
Common
History and examination essential
Missed diagnosis permanent disability
Simple problems require confident
diagnosis
Will become part of curriculum!
Limp stiffness swelling pain restriction of movement
change in activities
not using limb colour change in limb
fever rash unwell
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
◦ Acute or chronic
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
◦ Acute or chronic
EXAMINATION◦ objective signs
HISTORY!!!◦ Inflammatory◦ mechanical◦ non-organic/psychosomatic
◦ Acute or chronic
EXAMINATION◦ objective signs
TESTS◦ ???
Age of child Duration Symptoms Impact on activities Joints affected Family History Antecedents
◦ infection/trauma/◦ illness
Age of child Duration Symptoms Impact on activities Joints affected Family History Antecedents
◦ infection/trauma/◦ illness
Associated features:◦ Constitutional◦ Fever◦ Rash◦ Muscle weakness◦ Eyes◦ Weight loss◦ GI◦ bruising◦ LN/mucusitis ....etc
Height and weight Temp/pulse/BP General observations Rash Systems examination
Urinalysis
www.arc.org.uk/arthinfo/emedia.asp
LOOKgait
swelling
deformity
rash/colour changes
FEELheat
swelling
tenderness
MOVErestriction
+/- pain
muscle strength
Inflammatory Mechanical Psychosomatic
Pain +/- + +++
Stiffness ++ +/- +
Swelling +++ +/- +/-
Sleep disturbance
+/- - ++
Instability +/- ++ +/-
Physical signs
++ + +/-
(or ++++)
InflammatoryInflammatory MechanicalMechanical IdiopathicIdiopathic
InfectionInfection
ReactiveReactive
Post StrepPost Strep
JIAJIA
Connective Connective tissue diseasestissue diseases
- SLE- SLE
- JDMS- JDMS
- Scleroderma- Scleroderma
- Vasculitis- Vasculitis
HypermobilityHypermobility
OsteochondrosesOsteochondroses
- osgood-schlatter- osgood-schlatter
- Scheuermann’s- Scheuermann’s
- Perthes- Perthes
Chondromalacia Chondromalacia patellapatella
Osteochondritis Osteochondritis dissecansdissecans
Slipped upper Slipped upper femoral epiphysisfemoral epiphysis
Pain Pain amplification amplification syndromessyndromes
- Localised- Localised
- Generalised- Generalised
Growing painsGrowing pains
Acute
Fever Localised tenderness
hot Painful to move Raised inflammatory markers
Fever Localised tenderness
hot Painful to move Raised inflammatory markers
JOINT ASPIRATION
Site %
Knee 39 Hip 25 Ankle 14 Elbow 12
Organisms
Staph Aureus
Tuberculosis
Salmonella in sickle cell disease
•May be history of recent infection
•Single or multiple joints
•No systemic features
•Resolves by 6 weeks
•Important to consider alternative diagnoses
Reactive Vasculitis (small vessel)
Palpable Purpura Arthralgia/
Arthritis Abdominal pain Nephritis Headaches
1% of patients referred to paediatric rheumatology have underlying malignancy
Acute Lymphoblastic Leukaemia◦ Bone pain and arthralgia in 20-40%◦ Suspect from history, exam, or blood count◦ Bone Marrow aspirate
Acute Lymphoblastic Leukaemia
Neuroblastoma◦ Commonest solid tumour under infants◦ Bone pain from secondary spread◦ Urinary excretion of catecholamine metabolites
(VMA)
Acute Lymphoblastic Leukaemia
Neuroblastoma
Primary Bone tumour◦ Osteoid osteoma – benign◦ osteosarcoma
Features to raise concern:◦ Bone pain (night time)◦ Weight loss◦ Night sweats or fevers
◦ Abnormal bloods
◦ Xray changes
5 of following1. Fever >5 days; unresponsive to Abx2. Non purulent conjunctivitis3. lymphadenopathy >1.5cm4. Rash - polymorphous5. mucosal changes6. extremities
early - swelling/palmar erythema late – peeling
OR 4 plus coronary artery aneurysms
Prevent late sequel of coronary artery aneurysms
◦ Intravenous IVIG
◦ Aspirin – initially high, anti inflammatory then low dose, anti platelet
Chronic
JIA Juvenile Idiopathic Arthritis
JRA Juvenile Rheumatoid Arthritis
JCA Juvenile Chronic Arthritis
JIA Juvenile Idiopathic Arthritis
JRA Juvenile Rheumatoid Arthritis
JCA Juvenile Chronic Arthritis
JIA commonest rheumatic condition in childhood◦ 30 – 150 per 100,000
10 years follow up◦ 1/3 achieve remission◦ 30% have severe functional limitations
Fantini et al, ACR 1996
Disease of childhood onset ◦ under 16 years
Persistence of arthritis ◦ 1 or more joints ◦ 6 or more weeks◦ Exclusion of other diagnoses
Defined by clinical features in first 6 months
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints
Persistent Extended
Girls >boys Younger age Best prognosis
Girls >boys Younger age Best prognosis
Associated with uveitis
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints
RF positive RF negative
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints◦ Psoriatic Arthritis
Arthritis AND psoriasisOR Arthritis plus 2 of:
Nail pitting Dactylitis First degree relative with confirmed psoriasis
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints◦ Polyarthritis 5 or more joints◦ Psoriatic Arthritis◦ Enthesitis Related Arthritis
Arthritis AND enthesitisOR Sacroiliac pain and HLA B27
Defined by clinical features in first 6 months◦ Oligoarthritis 1-4 joints
Persistent Extended
◦ Polyarthritis 5 or more joints RF positive RF negative
◦ Psoriatic Arthritis◦ Enthesitis Related Arthritis◦ Systemic Arthritis
Daily fever for at least 2 weeks duration (quotidian for 3 days)
Plus one or more of:◦ Evanescent rash◦ Generalized lymphadenopathy◦ Hepatosplenomegaly◦ Serositis
Arthritis EXCLUSION OF OTHER DIAGNOSES
Poor indicators Polyarticular onset and course Rheumatoid factor positive girls Systemic disease with persistent features Delay in starting effective treatment
Good indicators Oligoarticular disease
Goals◦ Disease remission◦ Symptomatic improvement
Stiffness Pain Joint range of movement
◦ Prevent joint damage◦ Normal growth and development◦ Education and normal adolesence◦ Prevent eye damage from Uveitis
Multidisciplinary team
◦ Paediatric rheumatologist
◦ Nurse specialist
◦ Occupational Therapist
◦ Physiotherapist
◦ Social worker
◦ Ophthalmologist
◦ Podiatrist
Anti inflammatory drugs◦ NSAIDs◦ Glucocorticoids
“Disease modifying drugs”◦ Methotrexate
◦ Etanercept◦ New biologic agents for recalcitrant disease
Avascular necrosis of the femoral head usually 2-10 (peak 4-6) yrs. 3-5 boys:girls Bilateral 30 %
Imaging:
Asymmetry in femoral heads
Consider MRI or Nuclear medicine if clinical suspicion is high
10-13 years old Overweight boys 25% bilateral within 18/12
Slip of femoral head through growth plate (posteriorly and inferiorly)
Imaging:
AP and (frog) lateral films needed CT/ MRI in cases of difficulty
Klein line should intersect femoral head
Inappropriate history
Physical signs don’t match story
Other concerning features
Concerns raised by others
Chondromalacia patella Adolescent girls Painful knees - kneeling
- going up stairs
Osgood-Schlatter disease Adolescent boys Pain and swelling at tibial tuberosity Increased by exercise
Osgood-Schlatter disease Adolescent boys Pain and swelling at tibial tuberosity Increased by exercise
Tenderness +/- swelling of tibial tuberosity Pain on resisted extension of knee
Clinical diagnosis
DO NOT XRAY
Very common
May be generalised or localised
Frequently responsible for musculoskeletal pain
Common cause of lower limb pain
If symptomatic – correct with good footware and insoles
25-40% of children! 3-5 years and 8-12 years Typical history
Wake during night with pain Eased with massage May be worse after active day No daytime symptoms
No abnormal physical signs
No identifiable inflammatory or mechanical condition
Chronic pain Impact on daily activities
Average age 9 – 12 years Girls > boys Disease of the developed world
Localised idiopathic pain eg RSD
CFS/ME
Fibromyalgia
Diffuse idiopathic pain
History History History Examination Examination Examination
Investigations: targeted
Blood Count◦ ? Appropriate to clinical features
Inflammatory markers◦ Usually mirror clinical features◦ Not always raised in inflammatory conditions
Blood and synovial fluid cultures ANA/Rh Factor
◦ Not helpful in making a diagnosis Imaging
◦ Need to use best modality and ask the right question
Musculoskeletal complaints are common in childhood
Serious pathology leads to long term disability if not appropriately managed
Diagnosis is dependant on good history and examination