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Toronto Notes 2019
Rheumatology
Pediatrics P83
Rheumatology
Growing Pains
Epidemiology
• age2-12yr,M=F
Clinical Presentation
• diagnosisofexclusion
• intermittent,non-articularpaininchildhoodwithnormalphysicalexamfindings
• painatnight,oftenbilateralandlimitedtothecalf,shin,orthigh;typicallyshort-lived • relievedbyheat,massage,mildanalgesics
• childiswell,asymptomaticduringtheday,nofunctionallimitation
• possiblefamilyhistoryofgrowingpains
Management
• labinvestigationsnotnecessaryiftypicalpresentation;reassuranceandsupportivemanagement
Juvenile Idiopathic Arthritis
• aheterogenousgroupofconditionscharacterizedbypersistentarthritisinchildren<16yr
• diagnosis:arthritisin≥1joint(s);duration≥6wk;onsetage<16yrold;exclusionofothercausesof
arthritis; classification defined by features/number of joints affected in the first 6 mo of onset
Systemic Arthritis (Still’s Disease)
• onsetatanyage,M=F
• onceortwicedailyfeverspikes(>38.5oC)≥2d/wkwithtemperaturereturningbelowbaseline;children
usually acutely unwell during fever episodes
• extra-articularfeatures:erythematous“salmon-coloured”maculopapularrash,lymphadenopathy,
hepatosplenomegaly, leukocytosis, thrombocytosis, anemia, serositis
• arthritismayoccurweekstomonthslater
• highESR,CRP,WBC,plateletcount
Oligoarticular Arthritis (1-4 joints)
• mostcommontypeofJIA
■ onset early childhood (<5 years of age), F>M
• persistent:affectsnomorethan4jointsduringthediseasecourse
• extended:affectsmorethan4jointsafterthefirst6mo
• typicallyaffectslargejoints:kneemostcommon,elbows,wrists;hipinvolvementunusual
• ANApositive~60-80%,RFnegative
• screeningeyeexamsforasymptomaticanterioruveitis(occursin~30%)
• complications:kneeflexioncontracture,quadricepsatrophy,leg-lengthdiscrepancy,growth
disturbances, uveitis
Polyarticular Arthritis (5 or more joints)
• ANApositivein50%,uveitisin10% • RFnegative(usuallynegative)
■ onset: 2-4 yr and 6-12 yr, F>M
■ symmetrical involvement of large and small joints of hands and feet, TMJ, cervical spine • RFpositive
■ onset: late childhood/early adolescence, F>M
■ similar to the aggressive form of adult rheumatoid arthritis
■ severe, rapidly destructive, symmetrical arthritis of large and small joints ■ may have rheumatoid nodules at pressure points (elbows, knees)
■ unremitting disease, persists into adulthood
Enthesitis-Related Arthritis
• onset:latechildhood/adolescence,M>F
• arthritisand/orenthesitis(inflammationatthesitewheretendonsorligamentsattachtothebone) • weightbearingjoints,especiallyhipandintertarsaljoints
• riskofdevelopingankylosingspondylitisinadulthood
Psoriatic Arthritis
• onset:2-4yrand9-11yr,F>M
• arthritisandpsoriasisORarthritisandatleasttwoof:
■ dactylitis, nail pitting or other abnormalities, or family history of psoriasis in a 1st degree relative ■ asymmetric or symmetric small or large joint involvement