Diseases » Juvenile Rheumatoid Arthritis » Diagnosis

Diagnosis of Juvenile Rheumatoid Arthritis

Juvenile Rheumatoid Arthritis Diagnosis: Book Excerpts

• Differential Diagnosis - Arthritis – Single Joint
• Diagnosis - Psoriatic arthritis
• Diagnosis - Juvenile rheumatoid arthritis
• Diagnosis - Rheumatoid arthritis
• Diagnosis - Septic arthritis
• Differential Overview - Polyarticular Arthritis
• Differential Overview - Acute Monoarticular Arthritis
• Diagnosis - Psoriatic arthritis
• Diagnosis - Juvenile rheumatoid arthritis
• Diagnosis - Rheumatoid arthritis

Tests and diagnosis discussion for Juvenile Rheumatoid Arthritis:

Doctors usually suspect JRA, along with several other possible conditions, when they see children with persistent joint pain or swelling, unexplained skin rashes and fever, or swelling of lymph nodes or inflammation of internal organs. A diagnosis of JRA also is considered in children with an unexplained limp or excessive clumsiness.

No one test can be used to diagnose JRA. A doctor diagnoses JRA by carefully examining the patient and considering the patient's medical history, the results of laboratory tests, and x rays that help rule out other conditions.

• Symptoms--One important consideration in diagnosing JRA is the length of time that symptoms have been present. Joint swelling or pain must last for at least 6 weeks for the doctor to consider a diagnosis of JRA. Because this factor is so important, it may be useful to keep a record of the symptoms, when they first appeared, and when they are worse or better.
  
  
• Laboratory tests--Laboratory tests, usually blood tests, cannot by themselves provide the doctor with a clear diagnosis. But these tests can be used to help rule out other conditions and to help classify the type of JRA that a patient has. Blood may be taken to test for RF and ANA, and to determine the erythrocyte sedimentation rate (ESR).
  
  
  • ANA is found in the blood more often than RF, and both are found in only a small portion of JRA patients. The RF test helps the doctor tell the difference among the three types of JRA.
    
    
  • ESR is a test that measures how quickly red blood cells fall to the bottom of a test tube. Some people with rheumatic disease have an elevated ESR or "sed rate" (cells fall quickly to the bottom of the test tube), showing that there is inflammation in the body. Not all children with active joint inflammation have an elevated ESR.
  
  
• X rays--X rays are needed if the doctor suspects injury to the bone or unusual bone development. Early in the disease, some x rays can show cartilage damage. In general, x rays are more useful later in the disease, when bones may be affected.
  
  
• Other diseases--Because there are many causes of joint pain and swelling, the doctor must rule out other conditions before diagnosing JRA. These include physical injury, bacterial or viral infection, Lyme disease, inflammatory bowel disease, lupus, dermatomyositis, and some forms of cancer. The doctor may use additional laboratory tests to help rule out these and other possible conditions.

(Source: excerpt from Questions and Answers About Juvenile Rheumatoid Arthritis: NIAMS)

Diagnostic Tests for Juvenile Rheumatoid Arthritis: Online Medical Books

16 MEDICAL BOOKS ONLINE! Review excerpts from medical books online, free, without registration, for more information about diagnostis of Juvenile Rheumatoid Arthritis.

Arthritis – Single Joint: Differential Diagnosis
(In A Page: Pediatric Signs and Symptoms)

• Septic arthritis
  –Rapid diagnosis critical: Untreated septic arthritis causes irreversible joint and bone destruction
  –Usually presents hyperacutely with very tender, swollen, warm, red joint with severely restricted range of motion
  –Usual pathogens: Haemophilus influenzae type b, Staphylococcus aureus, group B strep in neonates, and Neisseria gonorrhoeae in adolescents; fungal and mycobacterial arthritis are seen rarely, may have chronic course

• Lyme arthritis
  –Second most common manifestation of Lyme disease (after erythema migrans)
  –Monoarthritis of a knee occurs in about two-thirds of children with Lyme disease
• Reactive arthritis
  –Probably the most common etiology of childhood rheumatic diseases
  –Transient sterile arthritis following a bacterial GI infection
  –Usually full resolution, but a few children have a chronic course
• Trauma, overuse, fracture
  –Often acute onset with significant pain
• Malignancy such as leukemia, neuroblastoma and osteogenic sarcoma
• Pauciarticular juvenile rheumatoid arthritis (JRA)
• Spondyloarthropathies (SpA)
• Congenital hip dysplasia
• Slipped capital femoral epiphysis (SCFE)
  –Most common adolescent hip disorder
  –Separation of the femoral growth plate
  –More common in obese males
• Spontaneous osteonecrosis of the joint
  –Mostly in hip (Legg-Calvé-Perthes disease), shoulder, and knee
  –More common in males
• Internal structural abnormality
  –Discoid meniscus, osteochondritis dissecans, synovial chondromatosis
• Hemarthrosis due to trauma, bleeding disorder such as hemophilia, or benign tumors such as hemangiomas and pigmented villonodular synovitis
• Periodic fever syndromes such as familial Mediterranean fever

Workup and Diagnosis

• History
  –Acute or chronic
  –Mechanical (pain worsens with activities, improves with rest, and usually involves weight-bearing joints)
  –Inflammatory (waxing and waning, symptoms unrelated to use, morning stiffness)
  –History of trauma
  –Night-time symptoms
  –Attempted treatments
  –Systemic symptoms: Fever, rash, pain, fatigue
  –Past medical history: Birth history, existing medical conditions, surgeries, broken bones, growth and development, medications
  –Unusual exposures such as tick bites

• Physical exam
  –Vital signs, including growth parameters
  –Musculoskeletal exam for swelling, tenderness, warmth, redness, range of motion, asymmetry
  –Muscle strength and neurologic exam (tone, sensory and reflexes)
  –Lympadenopathy, organomegaly, rash, systemic symptoms
• Radiologic evaluation may include X-ray, US, MRI, and bone scan to evaluate for fracture, infection, tenosynovitis, or internal derangements
• Lab investigation may include CBC, ESR, CRP, examination of synovial fluid, viral titers (parvovirus), Lyme titers, RF, and ANA

» READ BOOK EXCERPT ONLINE »

Source: In A Page: Pediatric Signs and Symptoms, 2007

Psoriatic arthritis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Inflammatory arthritis in a patient with psoriatic skin lesions suggests psoriatic arthritis.

CONFIRMING DIAGNOSIS X-rays confirm joint involvement and show:

❑ erosion of terminal phalangeal tufts

❑ “whittling” of the distal end of the terminal phalanges

❑ “pencil-in-cup” deformity of the distal interphalangeal joints

❑ relative absence of osteoporosis

❑ sacroiliitis

❑ atypical spondylitis with syndesmophyte formation. Hyperostosis and paravertebral ossification result, which may lead to vertebral fusion.

Blood studies indicate negative rheumatoid factor and elevated erythrocyte sedimentation rate and uric acid levels.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Juvenile rheumatoid arthritis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Persistent joint pain and the rash and fever clearly point to JRA. Laboratory tests are useful for ruling out other inflammatory or even malignant diseases that can mimic JRA. Disease activity and response to therapy can also be monitored through laboratory results.

❑ Complete blood count shows decreased hemoglobin levels, neutrophilia, and thrombocytosis.

❑ Erythrocyte sedimentation rate and C-reactive protein, haptoglobin, immunoglobulin, and C3 complement levels may be elevated.

❑ ANA test may be positive in patients who have pauciarticular JRA with chronic iridocyclitis.

❑ RF is present in 15% of JRA cases, compared with 85% of rheumatoid arthritis cases.

❑ Positive HLA-B27 antigens may forecast later development of ankylosing spondylitis.

❑ X-rays in early stages reveal changes, including soft-tissue swelling, effusion, and periostitis in affected joints. Later, osteoporosis and accelerated bone growth may appear, followed by subchondral erosions, joint space narrowing, bone destruction, and fusion.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Rheumatoid arthritis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

Typical clinical features suggest this disorder, but a definitive diagnosis is based on laboratory and other test results:

❑ X-rays — in early stages, show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; finally, cartilage and bone destruction and erosion, subluxations, and deformities

❑ rheumatoid factor test — positive in 75% to 80% of patients as indicated by a titer of 1:160 or higher

❑ synovial fluid analysis — reveals increased volume and turbidity but decreased viscosity and complement (C3 and C4) levels; white blood cell count usually exceeds 10,000/µl

❑ erythrocyte sedimentation rate — elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation commonly parallels disease activity)

❑ complete blood count — usually reveals moderate anemia and slight leukocytosis.

A C-reactive protein test can help monitor response to therapy.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Septic arthritis: Diagnosis
(Professional Guide to Diseases (Eighth Edition))

CONFIRMING DIAGNOSIS Identifying the causative organism in a Gram stain or culture of synovial fluid or a biopsy of synovial membrane confirms septic arthritis. When synovial fluid culture is negative, positive blood culture may confirm the diagnosis.

Joint fluid analysis shows gross pus or watery, cloudy fluid of decreased viscosity, usually with 50,000/µl or more white cells, primarily neutrophils. Synovial fluid glucose is usually more than 40 mg/dl. (See Other types of arthritis, page 584.)

Other diagnostic measures include the following:

❑ X-rays can show typical changes as early as 1 week after initial infection — distention of joint capsules, for example, followed by narrowing of joint space (indicating cartilage damage) and erosions of bone (joint destruction).

❑ White blood cell count may be elevated, with many polymorphonuclear cells; erythrocyte sedimentation rate is increased.

» READ BOOK EXCERPT ONLINE »

Source: Professional Guide to Diseases (Eighth Edition), 2005

Polyarticular Arthritis: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Osteoarthritis

❑ Rheumatoid arthritis

❑ Lyme arthritis

❑ Systemic lupus erythematosus

❑ Psoriatic arthritis

❑ Polyarticular gout

❑ Viral arthritis

❑ Scleroderma

❑ Reiter syndrome

❑ Inflammatory bowel disease

❑ Gonococcal arthritis

❑ Ankylosing spondylitis

❑ Systemic vasculitis

❑ Sarcoidosis

❑ Pseudogout (CPPD)

❑ Acute rheumatic fever

❑ Still disease

Diagnostic Approach

Ascertain that the pain is articular; that is, it is exacerbated by the function of the joint. Detecting synovitis limits the differential to inflammatory arthridites and systemic rheumatic diseases. Findings of synovitis include palpable soft tissue bogginess around a joint, warmth over a joint, or effusion. Involvement of the wrists, elbows, or metacarpophalangeal joints implies inflammatory disease rather than osteoarthritis. Morning stiffness persisting for as long as 1 to 2 hours, relieved by NSAIDs, is typical for inflammatory arthritis, as is a history of a red joint.

Differentiating features include the following: Erythema nodosum: sarcoidosis, inflammatory bowel disease-related arthritis, or Behçet disease. Rash: lupus, Still disease, vasculitis, dermatomyositis, endocarditis, disseminated gonorrhea, or Behçet disease. Fever greater than 40˚C: Still disease, bacterial arthritis, or lupus. Fever preceding arthritis: viral arthritis, Lyme, reactive arthritis, Still
desease, or bacterial endocarditis. Spiking fever: bacterial infection or Still
disease. Splenomegaly: rheumatoid arthritis and lupus. Raynaud: scleroderma, mixed connective tissue disease, or lupus. Oral ulcers: lupus, Behçet disease, or viral arthritis. Dry eyes and mouth: Sjögren syndrome, mixed connective tissue
disease, or lupus. Ocular findings: lupus, Behçet disease, sarcoidosis, or reactive arthritis. Migratory arthritis: gonococcemia, rheumatic fever, meningococcemia, viral arthritis, lupus, acute leukemia, or Whipple disease. Episodic recurrences: Lyme, crystal-induced arthritis, inflammatory bowel disease, Still disease, or lupus. Morning stiffness: rheumatoid arthritis, polymyalgia rheumatica, Still
disease, or viral arthritis. Symmetric small-joint synovitis: rheumatoid arthritis, lupus, or viral arthritis.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Acute Monoarticular Arthritis: Differential Overview
(Field Guide to Bedside Diagnosis)

❑ Injury

❑ Gout

❑ Osteoarthritis

❑ Lyme disease

❑ Gonococcal arthritis

❑ Seronegative spondyloarthropathy

❑ Septic arthritis

❑ Pseudogout

❑ Septic bursitis

❑ Avascular necrosis

Diagnostic Approach

Ascertain that arthritis (joint inflammation) is present by eliciting pain on joint motion. A hot, swollen joint with constitutional symptoms such as fever, weight loss, and malaise suggests infection. The skin may hold clues to psoriasis, systemic lupus, viral exanthems, Lyme disease, and others. Erythema nodosum occurs with sarcoidosis or inflammatory bowel disease. Urethritis suggests gonorrhea or Reiter syndrome. A monoarticular presentation of a polyarticular disease may be rarely seen in rheumatoid arthritis, Reiter syndrome, ankylosing spondylitis, psoriatic arthritis, inflammatory bowel disease, and sarcoidosis.

» READ BOOK EXCERPT ONLINE »

Source: Field Guide to Bedside Diagnosis, 2007

Psoriatic arthritis: Diagnosis
(Handbook of Diseases)

Inflammatory arthritis in a patient with psoriatic skin lesions suggests psoriatic arthritis. X-rays confirm joint involvement and show:

❑ marginal erosion at interphalangeal joints with areas of thin, “fluffy” new bone formation

❑ “whittling” of the distal end of the terminal phalanges

❑ “pencil-in-cup” deformity of the distal interphalangeal joints

❑ relative absence of osteoporosis

❑ sacroiliitis

❑ atypical spondylitis with syndesmophyte formation, resulting in hyperostosis and paravertebral ossification, which may lead to vertebral fusion.

Blood studies indicate negative rheumatoid factor and elevated erythrocyte sedimentation rate and uric acid levels.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Juvenile rheumatoid arthritis: Diagnosis
(Handbook of Diseases)

Persistent joint pain, rash, and fever clearly point to JRA. Laboratory tests are useful for ruling out other inflammatory or even malignant diseases that can mimic JRA and for monitoring disease activity and response to therapy.

❑ Complete blood count shows decreased hemoglobin levels, neutrophilia, and thrombocytosis.

❑ Erythrocyte sedimentation rate, complement (C)-reactive protein, haptoglobin, immunoglobulin, and C3 levels may be elevated.

❑ Test results may be positive for ANAs in patients who have pauciarticular JRA with chronic iridocyclitis.

❑ RF is present in 15% of patients with JRA, as compared with 85% of patients with RA.

❑ Positive HLA-B27 test may forecast later development of ankylosing spondylitis.

❑ Early X-ray changes include soft-tissue swelling, effusion, and periostitis in affected joints. Later, osteoporosis and accelerated bone growth may appear, followed by subchondral erosions, joint space narrowing, bone destruction, and fusion.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

Rheumatoid arthritis: Diagnosis
(Handbook of Diseases)

Typical signs and symptoms suggest RA, with a firm diagnosis supported by laboratory and other test results:

❑ X-raysin early stages show bone demineralization and soft-tissue swelling; later, loss of cartilage and narrowing of joint spaces; and finally, cartilage and bone destruction and erosion, subluxations, and deformities.

❑ RF is positive in 75% to 80% of patients, as indicated by a titer of 1:160 or higher.

❑ Synovial fluid analysisshows increased volume and turbidity but decreased viscosity and elevated white blood cell counts (often greater than 10,000/µl).

❑ Serum protein electrophoresis may show elevated serum globulin levels.

❑ Erythrocyte sedimentation rate and C-reactive protein are elevated in 85% to 90% of patients (may be useful to monitor response to therapy because elevation typically parallels disease activity).

❑ Complete blood count usually shows moderate anemia, slight leukocytosis, and thrombocytosis.

» READ BOOK EXCERPT ONLINE »

Source: Handbook of Diseases, 2003

 » Next page: Signs of Juvenile Rheumatoid Arthritis

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