Mimics of JIA July 2017 GP refresher A/Prof Chris Scott Getting to - - PowerPoint PPT Presentation

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Mimics of JIA July 2017 GP refresher A/Prof Chris Scott Getting to - - PowerPoint PPT Presentation

Sep 14, 2022 463 likes •1.07k views

Mimics of JIA July 2017 GP refresher A/Prof Chris Scott Getting to know you How many of you have seen children with Juvenile Idiopathic arthritis? How many of you routinely examine the MSK system? How many of you are confident in

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Mimics of JIA

July 2017 GP refresher A/Prof Chris Scott

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Getting to know you…

How many of you have seen children with Juvenile Idiopathic arthritis? How many of you routinely examine the MSK system? How many of you are confident in examining the joints of children? How many of you had dedicated teaching on JIA in med school?

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Introduction

  • In a prospective study from The Royal Hospital for Sick

Children, Edinburgh, every 58th child presented with an acute atraumatic limp.

  • A survey of adolescents in British Columbia revealed

that musculoskeletal complaints were perceived as the 2nd most common health concern after acne. Juvenile Arthritis is the most common cause of musculoskeletal disability in children.

  • Musculoskeletal pain can be the presenting feature of

many different conditions, including life threatening conditions

Fischer SU..1999 Foster & Cabral, 2006

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Is JIA common

  • How many of you agree

with this statement – IDDM is more prevalent than JIA in children? – Septic arthritis is more common than JIA Septic arthritis: 1/300

JIA: 1/250

IDDM: 1/300

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Scenario

  • A six year old Caucasian girl pain and stiffness
  • f the right knee for 3 months.
  • She is completely well apart from her knee

complaints

  • She walks into the consulting room.
  • Pain never wakes her at night
  • She has no fever or other complaints
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Examination of the knee

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Course

  • Her mantoux and quantiferon is done and is

negtive

  • She responds well to initial NSAIDs
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  • Which of these is most likely?
  • a. Juvenile Idiopathic Arthiritis
  • b. Tuberculosis
  • c. Malignancy
  • d. Trauma
  • e. Pigmented Villonodular Synovitis
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Course

  • On further examination you see this:
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JIA

  • Diagnosed with JIA
  • Sent to ophthalmologist for eye screening
  • Uveitis confirmed
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JIA

Chronic Arthritis <16yr No

  • ther

cause >6wks

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JRA vs JCA

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Oligoarticular <4 joints ANA Uveitis Enthesitis Related hlab27 Psoriatic Polyarthritis RF negative Polyarthritis RF positive Systemic JIA Extended >5 6 months

JIA ‘subtypes’

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Presenting Features

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Scenario

  • 4 year old boy
  • Parents email with the following story

– Joint pain all over – Especially bad in legs and feet – Seen by a local doctor – Suspected reactive arthritis – Discharged on ibuprofen

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Course

  • Pain still present at 4 weeks. Now unable to

walk

  • Very painful back,hips, pelvis and knees
  • Being carried around
  • Parents very concerned as child is miserable

and losing weight

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Course

  • Pain is present all the time
  • Wakes him some nights
  • Has lost a lot of weight
  • On examination hips tender to

movement

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Results

  • FBC: Pancytopenia
  • LDH: 2000
  • Xray:
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Comments on the Xray?

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Neuroblastoma

Diagnosis?

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Scenario

  • An adolescent boy presents with hip pain and

knee pain

  • On examination her knee is normal but his hip

is tender to movement in all planes, and markedly limited, especially on internal rotation

  • His HLAB27 is positive but his ESR is normal
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Scenario

  • 4 year old girl with hip pain- 5 weeks, ongoing

– Pain at all times of the day and night – Unsure of morning stiffness- pain always present – No weight loss – Low grade fever on and off – No family history of psoriasis – No TB contacts and TB workup negative

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On examination

  • Right hip tender to flexion and extension
  • Less painful with internal and external

rotation

  • No other swollen joints
  • Eye exam normal
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FBC

  • Hb: 10,4, Platelets 205, WCC: 2.1
  • ESR 70
  • Smear is normal
  • Xray hip normal
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Results

  • Hip USS shows no effusion
  • CXR normal
  • Mantoux negative
  • ANA positive
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Next step:

  • Trial of Brufen
  • Zero response
  • Pain wakes her at night and not able to

weight bear

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Bone Marrow

  • Acute Lymphoblastic Leukemia
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Scenario

  • A colleague refers a patient with pain in

multiple joints

  • He is concerned that she may have

polyarthritis but admits to not being very good with joint examination

  • You walk into the waiting room to call the

patient…

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Scenario

  • Boy of 6yrs with family history of TB in the family
  • 2/12 history of painful knee after a fall. Seen by
  • rtho: arthroscopy
  • Biopsy: Chronic inflammation suggestive of JIA
  • Synovial fluid appears bloody- referred to

rheumatology

  • On examination knee swollen and very tender.
  • Fixed flexion contracture.
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Final diagnosis: Haemophillia

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Complete non-weight bearing Any attempt to move the limb causes extreme distress Constant severe pain Night pain and waking Fever Immunocompromised child

  • due to primary disease or medications

RED FLAGS

Night pain Severe and non-remitting pain Pallor, bruising, anaemia, thrombocytopenia Lymphadenopathy Hepatosplenomegaly Systemic symptoms

  • lethargy, weight loss, night sweats, fever

Back pain in the unwell child Delay in seeking medical attention Changeable history inconsistent with pattern of injury or developmental stage of the child Repeated presentations Un-witnessed injury Complete non-weight bearing with occult fracture Joint swelling lasting > 6 weeks Stiffness / slowness in the mornings Joint pain may not be verbalised in the very young child and may manifest as being grumpy, clumsy or avoiding activities Regression of achieved milestones Leg length discrepancy and muscle wasting suggest chronicity (many months)

SEPSIS MALIGNANCY NON ACCIDENTAL INJURY JUVENILE IDIOPATHIC ARTHRITIS

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Irritable hip / transient synovitis

  • Often diagnosis of exclusion
  • Preceding viral infection common but child usually

relatively well with a painless limp

  • Examination findings – restricted hip rotation only

usually (look at ALL joints)

  • USS may show small effusion around hip joint
  • If afebrile can usually be discharged with planned

follow-up / open access in meantime

Right hip with effusion Normal left hip

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Growing Pains?

  • Benign Nocturnal Musculoskeletal

pains of childhood

  • Never in the day
  • Always recovered by the morning
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A free online interactive information resource for clinicians

For further information www.pmmonline.org or email pmm@ncl.ac.uk

www.pmmonline.org

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The End…