More Related Content
Similar to APPROACH TO A CHILD WITH ARTHRITIS-1.pptx (20)
More from EnohLena (7)
Recently uploaded (20)
APPROACH TO A CHILD WITH ARTHRITIS-1.pptx
- 1. APPROACH TO A CHILD WITH ARTHRITIS PRESENTATION BY SIMH ANDREA DANIELLE LEVEL 600 MEDICINE
- 2. OUTLINE Introduction History taking and physical examination Investigations Imaging Management Conclusion
- 3. Introduction Musculoskeletal and joint diseases appear to be increasing and continue to be a growing childhood health problem. Musculoskeletal pain in children is common, affecting mainly school children. Various local and systemic, acute and chronic, benign and malignant conditions are associated with musculoskeletal pain.
- 4. Introduction Arthritis is common in childhood. The pattern, presentation and duration of arthritis help differentiate between various diagnoses. These patients frequently create a diagnostic dilemma because of extremely wide range of differentials. The most important aspects of diagnosis are comprehensive history taking and detailed clinical examination. Relevant laboratory findings can then help in facilitating diagnosis.
- 7. History taking Clinical information in patient including disease chronology, inflammatory nature, progression, distribution of joint involvement and extra-articular manifestations help narrow down diagnostic possibilities. Important aspects are to be emphasized in the history 1. Age: this usually gives idea about the diagnosis Early childhood -Polyarticular juvenile idiopathic arthritis(rheumatoid factor negative) -Kawasaki disease -Henoch Schonlein purpura -Systemic onset JIA(can occur at all ages)
- 8. History taking Middle childhood -Psoriatic arthritis -Juvenile dermatitis(mean age 7 years, but with bimodal distribution with peaks at 2-5 years and 12-13 years) -Polyarteritis nodosa Late childhood -Enthesitis related arthritis -Systemic lupus erythematosus -Polyarticular JIA(rheumatoid factor positive)
- 9. History taking 2. Sex: many rheumatologic diseases have a preference for girls such as systemic lupus eruthematosus, polyarticular JIA, psoriatic arthritis, juvenile dermatomyositis and oligoarticular JIA. In males, the vasculitis(granulomatous and non-granulomatous) are more common like Henoch Schonlein purpura, Kawasaki disease, polyarteritis nodosa; enthesitis related arthritis and inflammatory bowel disease. Systemic onset JIA has equal distribution in both sexes
- 10. History taking 3. Onset of disease and duration: -Acute onset(<6 weeks): septic arthritis, Lyme disease, and arthritis associated with Kawasaki disease and Henoch Schonlein purpura. -Subacute or chronic onset(>6 weeks): examples given in box 26-1 PAIN Characteristic of pain in arthritis is extremely important. The site, number of joints involved, severity, duration, pattern and association of warmth, discoloration and/or loss of function. Morning stiffness is suggestive of inflammatory pain. Night pain could suggest an underlying malignancy.
- 11. History taking Personal and family history: bleeding disorders or family history of human leukocyte antigen-B27 associated diseases Review of systems: fever or other constitutional symptoms(weight loss, night sweats, anorexia) as well as extra articular features like diarrhoea, ocular symptoms, rash, headache, hematuria/proteinuria) Precipitating factors: trauma, infection(bacterial,viral,fungal), drug exposure
- 12. Physical examination ARTICULAR INVOLVEMENT Examination involves determining which joints are involved at that time and evolution of joint involvement, that is, joint involvement pattern. The doctor has to evaluate; 1. Is involvement articular or extra-articular? Articular disorders are characterised by pain, swelling(due to synovitis, joint effusion, deformity), joint tenderness, limitation of active and passive movements. Pain only on active movement and point tenderness reflect extra-articular involvement.
- 13. Physical examination 2. Is involvement inflammatory or not? Morning stiffness, gelling(pain after a period of inactivity), systemic manifestations and elevated acute phase reactants are suggestive of inflammatory pain. Mechanical pain on the other hand is present during movement and relieved by rest. They do not have positive laboratory findings. 3. How many joints are affected? Mono-single joint, oligo-4 or less joints and poly-5 or more joints. Acute monoarthritis can be seen in infective arthritis, septic arthritis, reactive arthritis. Chronic monoarthritis include tuberculous, reactive arthritis in a n ill child. Acute polyarthritis is a feature of rheumatic fever or viral arthritis. Various forms of JIA present with chronic polyarthritis.
- 14. Physical examination 4. Axial and/or peripheral joint involvement? Joint involvement can be axial: spine, sacroiliac joint, sternoclavicular or manubriosternal joint; peripheral that is joints of the extremities. Axial involvement is seen in ERA, ankylosing spondylitis, rarely in SLE. Diseases of peripheral joints include juvenile idiopathic arthritis, juvenile dermatomyositis. 5. Is the involvement additive, migratory or intermittent? Additive means new joint involvement over and above an already involved joint like in rheumatoid arthritis. Migrating involvement is seen in rheumatic fever and intermittent joint involvement is seen in SLE.
- 15. Physical examination 6. Is involvement symmetric or asymetric?
- 17. Physical examination The musculoskeletal examination should include a review of all the joints and examination of gait with focus on affected joints. Redness, warmth, swelling should be reviewed using the contralateral side for comparism. Passive and active motion should be observed. A detailed general examination should be done including vital signs and growth parameters. Emphasis can be laid on assessing if there are rashes, purpura, peeling of the skin, nail pitting, oral or nasal ulcers to aid in diagnosis making.
- 19. Investigations Laboratory investigations by themselves have little role in diagnosis. None can confirm a diagnosis and absence of a disease marker does not exclude disease. Hematology: it usually indicates presence of inflammation. Normocytic normochromic anemia is found in inflammatory processes and severity can refelect severity of disease. Leucocytosis is a commom finding but leucopenia suggests SLE. Thrombocytosis areassociated with inflammatory arthropathies. Thrombocytopenia should alert possibility of SLE or leukemia
- 20. Investigations Acute phase reactants: Erythrocyte sedimentation rate and C- reactive proteins are used to assess degree of inflammation. CRP rises quickly(within 24hrs) and falls rapidly on resolution of inflammation. Note that in SLE, CRP is usually normal. ESR is also elevated. Urine analysis: Significant changes can occur in a patient with arthritis but it is essential in a suspected case of SLE(lupus nehritis) Autoantibodies(serology): Useful markers of autoimmune antibodies. Rheumatoid factor, antinuclear antibodies and anti- double stranded DNA are usually tested
- 21. Imaging X-ray of involved joint: can show widening of joint space or joint space narrowing, decreased bone density, erosions and additional bone deposition. CT scan of involved joint: it is more sensitive than X-ray as it detects changes in the bone more rapidly Ultrasonography: preferred to visualize joint effusion Magnetic resonance imaging
- 22. Management Management can be classified into medical and surgical and non- pharmacologic Medical management is symptomatic. For arthritis, NSAIDs are usually prescribed as they have analgesic and anti-inflammatory properties. For severe inflammation, corticosteroids are given such as methyl prednisolone(15-30mg/kg IV 6 hourly for 2-3days), prednisone(0,05-2mg/kg 12 hourly) and triamcinolone. If fever, antipyretics are given. If an etiology is found, it should be treated.
- 23. Management Surgery can be done in cases of trauma and if the disease causes limb length discrepancy Non-pharmacological measures such as physiotherapy aids in rehabilitation
- 24. Conclusion Arthritis in a child could be self-limiting or be indicative of a more serious condition which could increase morbidity and mortality. Despite a wide range of differentials, a good history and clinical evaluation of the patient is important to get a correct diagnosis. Serious or life-threatening conditions should be identified and treated promptly by medical or surgical management.
- 25. References : Netter's Pediatrics Approach to a child with arthritis: Bangladesh health 2014 Medscape