Arthritis – Multiple Joints
Arthritis – Multiple Joints: Excerpt from In A Page: Pediatric Signs and Symptoms
Clinical history and physical examination is a fundamental diagnostic tool in polyarthritis. Laboratory findings of inflammation include anemia, elevated ESR, CRP, and thrombocytosis. Normal or low platelet count, elevated LDH and uric acid levels raise the possibility of a malignancy. Establishment of methotrexate therapy in arthritis of many rheumatologic conditions has started a new era in treatment of childhood arthritides, and newer treatments under investigation may enable the prevention of long-term disability.
Differential Diagnosis
- Infectious
–Reactive arthritis (postenteric or genital including Reiter syndrome, postviral, poststreptococcal)
–Acute rheumatic fever (ARF): Migratory, painful; usually affects large joints; diagnosis is based on Jones criteria, which includes five major (arthritis, carditis, Sydenham chorea, erythema marginatum, subcutaneous nodules) and several minor (fever, arthralgia, elevated ESR or CRP, prolonged P-R interval) manifestations
–Lyme disease: Arthritis is monoarticular or oligoarticular, is rarely symmetric, and is the second most common manifestation of Lyme disease after erythema migrans
–SBE-related arthritis
–Septic polyarthritis (unusual)
- Rheumatic
–Polyarticular JRA: Arthritis in five or more joints in first 6 months of disease, insidious onset, symmetric involvement, may be RF+ (erosive, similar to adult RA) or RF-
–Systemic-onset JRA: Presents with severe systemic involvement (fever, rash, serositis), which may precede the arthritis, usually oligoarticular
–Juvenile ankylosing spondylitis (JAS): Initially affects lower extremity joints; later affects axial skeleton, also affects tendons
–Psoriatic arthritis
–Arthritis of IBD: Usually more transient than JRA
–SLE: May present only with arthritis, may be misdiagnosed as JRA
–Other connective tissue diseases (scleroderma)
–Vasculitis (HSP, Kawasaki disease)
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Malignancy such as leukemia
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Other systemic disorders: Serum sickness, sarcoidosis, Behçet disease, Ehler-Danlos syndrome, mucopolysaccharidoses, Noonan syndrome, Turner syndrome
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Medications (minocyline, carbamazapine)
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Sickle cell disease
Workup and Diagnosis
- History
–Acute or chronic; persistent or intermittent; degree of pain, night-time symptoms
–Systemic symptoms such as fever, weight loss, rash, and fatigue
–Mouth and/or genital ulcers, abdominal pain, vomiting, diarrhea, bloody stools
–Past medical history: Birth history, existing medical conditions, surgeries, broken bones, growth and development, any recent URI, genital infection or strep infection, unusual exposures such as tick bites
- Physical exam
–Vital signs including growth parameters
–Musculoskeletal exam for swelling, tenderness, warmth, redness over the joints, range of motion of the joints; asymmetry, muscle strength
–Lympadenopathy, organomegaly, rash, dysmorphic features, presence of bone pain and neurologic exam (tone, sensory, and reflexes)
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Labs: CBC, ESR or CRP, RF and ANA; Lyme titers, lupus panel, complement (C3, C4) levels; viral titers (HCV, EBV, parvovirus), LDH, U/A, LFTs
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Radiology: CXR, X-ray of involved joints, US, MRI, and bone scan to rule out infection, malignancy, and to confirm effusion and tenosynovitis
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Studies: ECG, echocardiogram, angiogram, UGI/SBF, endoscopy when clinically indicated
Treatment
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Even though unlikely, if septic arthritis (such as with Neisseria gonorrhoeae) is a possibility, antibiotic treatment should be started immediately
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Appropriate treatment of malignancy
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NSAIDs for JRA and spondyloarthropathies as an initial therapy; disease-modifying antirheumatic drugs (DMARDs) such as sulfasalazine and methotrexate, and biologics (e.g., TNF blockers) are added depending on clinical response
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Specific treatments of other mixed connective tissue diseases depending on their severity
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Corrective and/or supportive medical/surgical interventions
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Supportive therapy such as PT and OT to increase range of motion and strength; insoles to correct leg length discrepancy
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Psychosocial support especially with chronic diseases
Book Source Details
- Book Title: In A Page: Pediatric Signs and Symptoms
- Author(s): Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
- Year of Publication: 2007
- Copyright Details: In A Page: Pediatric Signs and Symptoms, Copyright © 2007 Lippincott Williams & Wilkins.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: In A Page: Pediatric Signs and Symptoms
Authors: Jonathan E. Teitelbaum, Kathleen O. Deantonis, Scott Kahan
Publisher: Lippincott Williams & Wilkins
Copyright: 2007
ISBN: 1-4051-0427-9
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