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Rheumatology 101
A Pediatrician’s Guide
Pediatric Staff and Alumni Day 2016 Dawn M. Wahezi, Yonit Sterba, Tamar Rubinstein
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Disclosures
- None
Rheumatology 101 A Pediatricians Guide Pediatric Staff and Alumni - - PowerPoint PPT Presentation
Rheumatology 101 A Pediatricians Guide Pediatric Staff and Alumni - - PowerPoint PPT Presentation
cham.org Rheumatology 101 A Pediatricians Guide Pediatric Staff and Alumni Day 2016 Dawn M. Wahezi, Yonit Sterba, Tamar Rubinstein cham.org Disclosures None cham.org Pick a Group Group 1 A child with a limp Group 2 ANA
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Pick a Group
- Group 1 – A child with a limp
- Group 2 – ANA – To test or not to test!
- Group 3 – Picture time! Who would you send to a Pediatric
Rheumatologist?
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Group 1
A child with a limp
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Group 1 - Case
2 yo white female is brought to your office because her mother says for the past 6 weeks, she has limped every morning for about 45 minutes. She does not have any current fever or rash, but her mother does report that she had a “cold” one month ago.
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Question 1
What findings in the history suggest that this is true arthritis? What would you like to know about her exam to help make this distinction?
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True arthritis
- Arthalgia vs arthritis
– Morning preponderance – Stiffness/limp > 30 minutes – Improves with activity
- Definitions
– Non-bony swelling OR – Two of the following:
- Pain
- Warmth
- Limited ROM
- +/- Erythema
- Signs of chronic disease
– Atrophy, leg length discrepancy
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Question 2
What is the differential diagnosis for monoarthritis in this child? What additional investigations would you like to do?
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Differential
- Acute onset < 6 weeks:
- Infectious
– Septic – Lyme – ARF/PRSA – Parvovirus
- Trauma
- Malignancy
- Hemophilia
- Chronic > 6 weeks:
- Rheumatologic
– JIA (oligo, PsA, ERA) – SLE – Sarcoidosis – Other
- Infectious
– Tuberculosis
- Malignancy
Initial work-up: CBC, ESR/CRP, Lyme, ASLO, Parvo IgG/IgM
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Question 3
You suspect that this patient may have JIA. What are the subtypes of JIA and which ones do you suspect in this patient?
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Juvenile Idiopathic Arthritis
- Categories:
- Oligoarthritis > 50%
– Persistent – Extended
- Polyarthritis ~20%
– Rheumatoid Factor Negative Rheumatoid Factor Positive
- Systemic Arthritis ~10%
- Enthesitis Related Arthritis (ERA)
~10%
- Psoriatic Arthritis (PsA) ~10%
- Undifferentiated Arthritis
- Definition:
- Arthritis of unknown etiology
- In a child < 16 years old
- Persists over 6 weeks
- Must rule out other causes
What percentage of polyarticular JIA patients will have a positive RF?
Only 15%!
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Joint distribution
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Question 4
What major comorbidity is associated with JIA and how does it manifest itself? What are risk factors for this comorbidity?
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Anterior Uveitis
- Acute uveitis
– Erythema, pain and photophobia – ERA
- Chronic uveitis
– Minimally symptomatic – Oligo JIA, PsA
- Complications:
– Cataracts – Glaucoma – Synechiea – Band Keratopathy
Risk Factors: ANA+, age < 7, female, early in dx (< 4 years)
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Group 2
ANA – To test or not to test!
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Group 2
What are the 3 major indications for screening a patient with an ANA?
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ANA testing - Indication # 1
- True arthritis > 6 weeks
– ANA determines uveitis risk in JIA – May be a presentation of SLE
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ANA testing – Indication # 2
- Raynaud phenomenon
– Primary vs Secondary – SLE, JDM, Scleroderma
- Abnormal nailbed capillaroscopy
highly suggestive of underlying rheumatologic disease
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Raynaud Phenomenon
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A RASH POINts MD
- Arthritis
- Renal disease
- ANA positive
- Serositis
- Hematologic disorder
- Photosensitivity
- Oral ulcers
- Immunologic disorder
- Neurologic symptoms
- Malar rash
- Discoid rash
ANA testing – Indication # 3
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What percentage of healthy patients can have a positive ANA?
20 to 30%!
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Positive ANA
- Immunoflorescence:
reported as a titer and staining pattern
– Serial dilutions of patient’s serum the higher the titer, the more dilutions needed to eliminate detection of antibody – Pattern of nuclear immunofluorescence suggests type of antibodies present in patients serum
Homogeneous Nucleolar Peripheral Speckled
anti-dsDNA, anti-histone anti-Smith, anti-RNP, anti-Ro (SSA), anti-La (SSB) anti-dsDNA
anti-centromere
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Group 3
Picture time! Who would you send to a Pediatric Rheumatologist?
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Who should see a pediatric rheumatologist?
A B C D E
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Gottron’s papules
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Who should see a pediatric rheumatologist?
A B C D E
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Mucocutaneous Manifestations of SLE
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Who should see a pediatric rheumatologist?
A
B C D
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Vasculitis
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Who should see a pediatric rheumatologist?
B C A
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Neonatal lupus
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