Initial Evaluation of A Child with Arthritis-An Algorithmic Approach

R.P. K h u b c h a n d a n i a n d S u s a n D ' S o u z a Jaslok Hospital and Research Center and Breach Candy Hospital and Research Center, Mumbai, India.

Abstract. Arthritis is one of the less common, yet challenging problems that may confront a pediatrician. The potential pathology is diverse ranging from the benign with a good prognosis to the serious and ultimately fatal. From a spot diagnosis to conditions that evolve over time, few other conditions challenge and stimulate the clinical acumen. Several diagnoses can be made clinically with the laboratory investigations providing additional support. An approach through which the clinician seeks answers through a logical sequence of questions is presented to help shortlist the possible diagnosis. [Indian J Pediatr 2002; 69(10) : 875-880]

Key words : Childhood arthritis; Clinical approach

Rheumatology forms a very small part of a general pediatrician's practice. A report from the Royal Children's Hospital in Melbourne found that 1.6% of the children attending its emergency/ambulatory department did so for a non-traumatic muscle or joint problem? Arthritis is likely to be even less common, yet managing the child with arthritis is a challenging and rewarding experience. The reasons for this are as follows : 1. While several systemic diseases present with arthritis as a lead s y m p t o m (e.g. leukaemia), m a n y rheumatologic diseases m a y have significant extraarticular manifestations (e.g. systemic onset juvenile idiopathic arthritis). 2. It is imperative to identify those musculoskeletal emergencies whose early recognition, is likely to influence management options and eventual outcome (e.g. acute bacterial arthritis). 3. Since several rheumatological conditions evolve over time (e.g. lupus, juvenile idiopathic arthritis-JIA), it is not always possible to give a diagnostic label to the child at first presentation. Instead several diagnoses are established on follow-up. 4. Pattern recognition forms an important component of an approach to the arthritides (e.g. the 3-year-old girl with involvement of two large joints over 6 weeks and little else on clinical examination is invariably a case of oligoarticular JIA). Keeping these principles in mind, this article proposes an algorithmic approach to a child with arthritis through a series of sequential questions.
Reprint requests : Dr. R.P.Khubchandani,ConsultantPediatrician, Jaslok Hospital and ResearchCenter/BreachCandy Hospital and Research Center, 31 Kailas Darshan, Kennedy Bridge, Mumbai 400007. Fax : 022-3898362;E-mail : rajukay@hotmail.com Indian Journal of Pediatrics, Volume 69--October, 2002

ANATOMIC LOCALISATION
Is the Involvement Articular or Non-articular? Musculoskeletal pain, besides headache and abdominal pain is recognized as one of the three commonest forms of recurrent pain in childhood.2With an estimated frequency of 15,000/100,000 (15%) in children, it contrasts with the incidence of JIA at 0.015~ a thousand fold difference. Not all musculoskeletal pains necessarily indicate arthritis. 3 On the other hand the absence of pain does not preclude arthritis as is exemplified by the typical case of oligoarticular JIA where the child may present with a barely discernible limp? Articular structures include the synovium, synovial fluid, articular cartilage, intraarticular ligaments, joint capsule and juxtaarticular bone. Non-articular structures on the other hand include the supportive extra-articular ligaments, tendons, bursae, muscle, fascia, bone, nerve and overlying skin. Pain, joint line tenderness and limitation of range of motion on both active and passive movement characterize articular disorders. There may be associated swelling due to synovial thickening, joint effusion or bony enlargement. The presence of instability, locking, crepitus or deformities also signify articular involvement. Hyperpigmentation over the dorsum of the digits is sometimes associated with long-standing arthritis. Nonarticular involvement on the other hand is suggested by the presence of physical findings remote from the joint capsule. These disorders are characterized by pain on active and not on passive movement and that too in certain planes or directions only. They may have associated focal or point tenderness and seldom demonstrate instability, crepitus or deformity,s

875

R.P. Khubchandani and S. D'Souza P A T H O L O G I C A L PROCESS

Is the I n v o l v e m e n t Inflammatory or N o n - i n f l a m m a t o r y ?

While i n f l a m m a t o r y d i s o r d e r s c o u l d be d u e to an infectious, immune mediated or idiopathic process, noninflammatory disorders are usually mechanical in origin. The c a r d i n a l signs of i n f l a m m a t i o n are w a r m t h , erythema, persistent swelling (effusion) and tenderness. Pain m a y occur t h r o u g h the entire r a n g e of motion. Presence of protracted morning stiffness, gelling (stiffness after a period of inactivity) and systemic s y m p t o m s like fever, fatigue and weight loss also signify inflammatory pathology. There may be waxing and waning of disease activity unrelated to patterns of use. Laboratory evidence includes elevated acute phase reactants (e.g. ESR/CRP) and t h r o m b o c y t o s i s . This question is h o w e v e r m o s t reliably a n s w e r e d b y a r t h r o c e n t e s i s . I n f l a m m a t o r y synovial fluid contains more than 2 0 0 0 / c u m m of leucocytes. As a rough guideline effusions containing more than 100,000/cu m m of leucocytes are considered septic. 6 A l t h o u g h it m a y be difficult, it is vital to d e c i d e whether limited joint range of m o v e m e n t and persistent deformity indicate old, b u r n t out, inactive arthritis or whether there is ongoing inflammation present. Intraarticular effusion should p r o b a b l y always be taken to indicate active inflammation. The next m o s t sensitive indicator of active arthritis is pain at the end of range of joint movement. Pain that occurs only after physical activity, improves with rest and worsens as the day progresses is suggestive of mechanical disease. 7 N o n - i n f l a m m a t o r y d i s o r d e r s usually lack swelling, warmth and systemic features and

more often involve the knee and ankle. When present, the swelling is usually transient. Examination m a y reveal clicking, crepitus or locking and painful restriction in c e r t a i n p l a n e s only. L a b o r a t o r y i n v e s t i g a t i o n s are invariably normal. ETIOLOGY
What is the Cause?

Table 1A and 1B, present an o v e r v i e w of the c o m m o n causes of articular disease in children. CHRONOLOGY
Is the I n v o l v e m e n t Over Hours, Days, W e e k s or Months?

(Table lc) It is important to identify and refer acute arthritides that m a y require i m m e d i a t e i n t e r v e n t i o n a n d / o r u n u s u a l therapeutic options. Examples are replacement therapy for hemophilia or antibiotic therapy for certain bacterial infections. The latter, if untreated can destroy cartilage in as little as 1-2 days. 11WIG therapy for Kawasaki disease is another case in point. In s e v e r a l o t h e r s i t u a t i o n s e s t a b l i s h i n g a p r e c i s e diagnosis is not a pre-requisite to commence basic treatm e n t m e a s u r e s . Variations m a y occur and the s a m e disorder m a y have a sudden onset in some patients and be g r a d u a l in others (e.g. arthritis of sarcoidosis m a y evolve from 5 days-4months). Clinical clues pointing t o w a r d s c h r o n i c i t y are the p r e s e n c e of d e f o r m i t y , contractures and muscle wasting

TABLE1A. Common Causes of Articular Involvement in Children 89

Infectious agents/Post-infectious Drugs

Bacteria - Staphylococcal, H. influenzae, Post-streptococcal, Infective endocarditis (IE) Viral - parvovirus B19, hepatitis (B/C), Rubella. Lyme's arthritis Acute rheumatic fever (ARF) Indolent infections - TB, fungal, brucella. Connective tissue disorders (CTD) Systemio lupus erythematosus (SLE) Mixed connective tissue disease (MCTD) Poly/dermatomyositis (P/DMS) Scleroderma (SD)
Systemic Vasculitis

Pyrazinamide, vaccines, quinolones, amphotericin B.

Non-inflammatory

Trauma (fracture, internal derangement, hemarthrosis Avutsion fractures, Hypermobility, Slipped Capital Femoral Epiphysis (SCFE), Legg-Calve-Perth6's (LCP), Toxic synovitis, Foreign- body synovitis, Osteochondromatoses, Reflex neurovascular dystrophy
Hematological

Sickle cell disease (SCD) Coagulation disorders

Neoplastic disorders

Kawasaki disease (KD) Henoch- Sch6nlein purpura (HSP) Polyarteritis nodosa (PAN) Wegener's granulomatosis Beh~et's syndrome (BS) Hypersensitivity vasculitis
Idiopathic disorders

Malignant- leukemia, lymphoma, neuroblastoma, bone tumors. Benign- osteoid osteoma, pigmented villonodular synovitis.
Miscellaneous:

JIA - Durban classification (see Table 1B)

Immune deficiency disorders Sarcoidosis Mucopolysaccaroidosis Wilson's disease

876

Indian Journal of Pediatrics, Volume 69--October, 2002

Initial Evaluation of a Child with Arthritis-An Algorithmic Approach

TABLE15. Juvenile Idiopathic Arthritis (JIA)- Durban Classification TM#

1) Systemic arthritis Defined as arthritis with or preceded by daily fever of at least 2 weeks duration, that is documented to be quotidian (SOJIA) for at least three days, and accompanied by one or more of the following: evanescent, non-fixed erythematous rash, generalized lymphadenopathy, serositis and hepatomegaly or splenomegaly. 2) Oligoarthritis Persistent- affects no more than 4 joints throughout the disease course extended- affects a cumulative total of 5 joints (OJIA) or more after the first 6 months of disease. 3) Polyarthritis Rheumatoid Factor negative Arthritis affecting 5 or more joints during the first 6 months of disease RF being negative. (PRF-ve-JIA) 4) Polyarthritis Rheumatoid Factor positive Arthritis affecting 5 or more joints during the first 6 months of disease, associated with (PRF+ve-JIA) positive RF tests on 2 occasions at least 3 months apart. 5) Psoriatic arthritis Defined as arthritis and psoriasis or arthritis and at least 2 of the following: dactylitis nail abnormalities and family history of psoriasis in at least one first degree relative confirmed by a dermatologist. 6) Enthesitis Related Defined as enthesitis with arthritis or arthritis/enthesitis with at least 2 of the following: sacroiliac joint tenderness, Arthritis (ERA) presence of HLA-B27, family history in at least one first or second-degree relative of medically confirmed HLA-B27 associated disease. 7) Other arthritis Defined as arthritis of unknown cause that persists for at least 6 weeks but that either a) doesn't fulfill criteria for any of the other categories b)fulfills criteria for more than one of the other categories. # The International League of Associations for Rheumatology (ILAR), met in Durban in 1997 and discarded the confusing terms juvenile rheumatoid and juvenile chronic arthritis (JRA/JCA). They adopted the term JIA to indicate diseases of childhood onset characterized primarily by arthritis persisting for at least 6 weeks, and having no known current cause.

TABLE1C. Chronology

I
HOURS --to

-ACUTE (< 6 weeks) DAYS

to

[-- CHRONIC (> 6 weeks) WEEKS to

I MONTHS

I
Bacterial arthritis Trauma Coagulopathies

I
Infections:(viraL post viral post-vaccinial) Acute rheumatic fever, CTD Vasculitis Drugs Neoplasia Non-inflammatory (Mechanical) Miscellaneous Onset of JL~

I
JIA Indolent infections:(TB, fungus, brucella) Rare miscellaneous disorders

D E S C R I P T I O N OF J O I N T I N V O L V E M E N T What are the A d j e c t i v e s Q u a l i f y i n g the I n v o l v e d Joint?

Involved Joint-is the involved joint characteristic of a

particular disorder?
The site of the i n v o l v e d joint m a y be characteristic of a p a r t i c u l a r d i s o r d e r e.g. d i s t a l i n t e r p h a l a n g e a l joint involvement in p s o r i a t i c arthritis, bilateral t e m p o r o m a n d i b u l a r joint i n v o l v e m e n t in PRF-ve JIA or lower limb joint involvement in reactive arthritis.

Topography- is there involvement of the axial or peripheral

skeleton?
Axial s t r u c t u r e s i n c l u d e , a p a r t the spine, centrally l o c a t e d joints s u c h as the sacroiliac, s t e r n o c l a v i c u l a r , m a n u b r i o s t e r n a l , s h o u l d e r a n d hip joints. While s o m e rheumatic conditions rarely affect the axial segments (e.g. SLE, systemic vasculitis), a combined pattern is often seen in others (e.g. spondyloarthropathies, JIA-polyarticular/ systemic)& Axial disease and sacroilitis in juvenile ankylosing spondylitis (JAS) m a y occasionally develop as late as 5-10 years after the onset of s y m p t o m s ) 3

S e q u e n c e - is the involvement additive, migratory or intermittent?

A n a d d i t i v e p a t t e r n is seen in reactive arthritis. In this t y p e t h e r e is i n v o l v e m e n t of o t h e r j o i n t s w h i l e the p r e v i o u s joints still r e m a i n s y m p t o m a t i c . In m i g r a t o r y arthritis, the p a t h o l o g y ceases in one joint and starts in a n o t h e r p r e v i o u s l y n o r m a l joint. This pattern is seen in acute rheumatic fever. In the intermittent pattern, as seen in l u p u s , t h e r e is c o m p l e t e r e m i s s i o n of s i g n s a n d s y m p t o m s followed b y recurrence in the same or other joints. There is no evidence of active or residual disease d u r i n g the interim p e r i o d & 877

Number - is it oligoarticular or polyarticular?

O l i g o a r t i c u l a r i n v o l v e m e n t refers to n o t m o r e t h a n 4 involved joints while polyarticular to >5 involved joints. This onset pertains to articular involvement observed in the first 6 m o n t h s of disease.

Indian Journal of Pediatrics, Volume 69 October, 2002

R.P. Khubchandani and S. D'Souza

Distribution-

is the i n v o l v e m e n t s y m m e t r i c or asymmetric? (Table 2) TABLE Causes of Symmetric and Asymmetric Arthritis 2. Symmetric Asymmetric

InflammatoD' JIA (systemic,polyarficular) JIA (oligoarficular SLE, MCTD, Sarcoid ERA) Infectious Viral, Lyme's. Bacterial arthritis, IE This feature of the articular involvement has obvious limitations; every patient with a symmetricdisorder may have initial asymmetric phase.12

Deformity -

is the arthritis deforming or nondeforming?

Joint deformities indicate an aggressive or long-standing pathologic process. These may result from malaligrunent of articular structures, damage to periarticular structures, soft tissue contractures or associated ankylosis or fibrosis. 5 Joint destruction with deformity occurs relatively early in PRF+ve JIA and it is now considered that aggressive treatment should be introduced early to induce disease remission. 14Limb length discrepancy is a characteristic feature of OJIA, though it may be seen in other forms also. H y p e r v a s c u l a r i t y in the i n f l a m e d joint leads to overgrowth of the joint and consequently a longer limb on the affected side? Knee arthritis beginning before the age of about 9 years usually results in lengthening of the affected leg, but after this age, premature fusion of the epiphysis may result in a shorter affected leg. On the contrary nondeforming arthritis is usually seen in lupus or with inflammatory bowel disease (IBD). Other features - is there associated enthesitis ? Enthesitis is inflammation at the attachment of tendons, ligaments, fascia or joint c a p s u l e to bone. 7 Sites of e n t h e s e s in c h i l d r e n i n c l u d e the calcaneus, tibial tuberosity, metatarsal heads, ischial tuberosity, patella and iliac crest. 15 While e n t h e s i t i s is an i m p o r t a n t c o m p o n e n t in the diagnosis of ERA, it is relatively u n c o m m o n in o t h e r f o r m s of c h r o n i c a r t h r i t i s or connective tissue disorders. SYSTEMIC INVOLVEMENT Are There Extra-Articular Features and Do T h e y Dominate the Clinical Picture? M a n y i n f l a m m a t o r y arthritides m a y h a v e systemic f e a t u r e s and several s y s t e m i c diseases h a v e musculoskeletal manifestations. 7 Extra-articular features m a y dominate the clinical picture in conditions like connective tissue disorders, vasculitis, IBD, malignancies and SOJIA. Table 3 lists the systemic features that should be looked for in a child presenting with arthritis. PATIENT PROFILE Is the Presentation Age or Gender Specific? Is There Significant Family History? Consideration of the age of the child at the onset of
878

symptoms may aid in diagnosis. In early childhood (I-4 yrs.), OJIA, juvenile psoriatic arthritis, Kawasaki disease and septic arthritis are most frequent. In mid childhood (7-11 yrs.), polyarticular JIA, DMS, HSP and PAN have their peak frequencies. By late childhood and teenage years, JAS and SLE show a m a r k e d increase and rare vasculitis syndromes like Wegener's granulomatosis may also o c c u r Y Certain rheumatic conditions like gout, calcium pyrophosphate deposition disease, polymyalgia rheumatica and primary osteoarthritis almost never occur in childhood. The most striking differential sex ratios are seen in the p r e d o m i n a n c e of JAS in boys and SLE in girls. While SOJIA occurs with equal frequency in both sexes, OJIA is m o r e c o m m o n in y o u n g girls. In general, the s p o n d y l o a r t h r o p a t h i e s a n d v a s c u l i t i d e s are m o r e common in b o y s . 17 Significant family history m a y be obtained in AS, psoriasis, hemophilia, IBD etc. A positive family history of rheumatoid arthritis may be seen in 25% of patients with PRF+ve-JIA. PATTERN RECOGNITION D o the C l u s t e r of Features Elicited from A b o v e Questions Point to a Recognizable Disease Pattern? An e x p e r i e n c e d p h y s i c i a n m a y m a k e c e r t a i n preconsultative intuitive observations, which may aid the diagnosis. This process of evaluation begins as the patient walks into the clinic. Pattern recognition, by using the knowledge of the age / sex of the child coupled with the nature and m o d e of joint i n v o l v e m e n t m a y help the p h y s i c i a n m a k e i n f o r m e d guesses a b o u t the likely diagnosis of a specific rheumatic disease. For example : 9 A pattern of scattered, asymmetric large and small oligoarticular / limited polyarthritis (especially distal i n t e r p h a l a n g e a l joints) suggests juvenile psoriatic arthritis. 9 O n s e t of p o l y a r t h r i t i s in a t e e n a g e girl s h o u l d suggest the possibility of SLE or polyarticular JIA. 17 9 The presence of inflammatory tarsal involvement and enthesopathy may be a distinguishing feature b e t w e e n JAS and JIA in the absence of axial disease. TM 9 Isolated hip involvement, may be caused by toxic synovitis, LCP, Slipped capital femoral epiphysis or less likely b y c h r o n i c i n f l a m m a t o r y a r t h r i t i s probably AS. 17 9 An older child or young adolescent male with low back pain m a y have AS b u t mechanical causes, infection or malignancy are more likely. 17 PITFALLS If c o n s i d e r i n g the d i a g n o s i s of J u v e n i l e i d i o p a t h i c arthitis look for possible "red herrings'(Table 4)
Indian Journal of Pediatrics, Volume 69--October, 2002

Initial Evaluation of a Child with Arthritis-An Algorithmic Approach

9 TABLE3. Extra-Artlcular Features that May be Associated wath Arthn" ~ i S 716 9

Where?
Eye

What? Non-purulent conjunctivitis Uveitis (acute anterior, painful, red eye) Uveitis (insidious anterior, presents as visual loss) Uveitis (posterior) Painful cracked, bleeding lips and strawberry tongue. Mouth ulcer methotrexate. Red gums at tooth line Alopecia/hair loss Psoriasis Periorbital rash (heliotrope) Malar rash (photosensitive) Raynaud's phenomenon Nail pitting, onycholysis Nail fold infarct Subcutaneous calcinosis Digit infarction Gottron's papules Periungal desquamation Erythema marginatum Subcutaneous nodules Urticaria

why? KD ERA OJIA Sarcoidosis KD SLE, BS, ERA, DMS, DMS SLE Psoriatic arthritis DMS SLE DMS, SD Psoriatic Arthritis CTD DMS, SD PAN DMS KD SOJIA, SLE, KD, Parvovirus Macular rash rubella, ARF ARF, PRF+ve-JIA CTD : Systemic vasculitides Vasculitides HSP, SLE Sarcoid, IBD, TB, Systemic vasculitides, CTD

Mouth

Head and neck

Skin
Hands

Trunk and arms

Lower limbs and Feet

Livido reticularis Purpura Erythema nodosum Wasting/contractures Tender swollen Proximal muscle weakness Lymphadenopathy Petechiae Pallor Dysphagia Abdomir~al pain Diarrhoea Malabsorbtion Hepatic dysfunction Organomegaly Upper airway disease Pleural effusion/p]euritis Pericarditis Myocarditis Valvular disease Hypertension Urethritis Genital ulcers Proteinuria Renal failure/Hematuria Fits, coma, psychosis Chorea Neuropathies Headache

Muscles

JIA
DMS DMS OJIA, SLE, Malignancy, TB, KD SLE, Malignancy SOJIA, SLE, Malignancy, SCD DMS, SD PAN, SLE Reactive arthritis, IBD SD Wilson's, SLE, hepatitis (B/C), SCD OJIA, SLE, malignancy, SCD Wegener's granulomatosis SLE, SOJIA, ARF SLE, SOJIA, ARF Polymyositis, ARF,SOJIA, Amyloidosis ARF, JAS, SLE, APS, Hype~obility PAN, SLE Reiter's, Reactive arthritis BS SLE, drug, amyloidosis SLE, NSAIDS, Amyloidosis, systemic vasculitides SLE SLE, ARF PAN SLE

Haematological

Gastrointestinal

Respiratory

Cardiovascular

Genitourinary

Neurological

Indian Journal of Pediatrics, Volume 69 October, 2002

879

R.P. Khubchandani and S. D'Souza

TABLE4. Features Alerting to Alternative Diagnoses
Oligoarticular JIA 9 9 9 9 9 9 9 9 Male More than 4 yrs at onset Sick looking child Significant systemic signs Isolated hip involvement2~ Dactylitis Markedly elevated ESR RF positive 9 9 9 9 9 9 9 Polyarticular JIA Male Younger age group Dominant extra-articular features Marked fever Isolated large joint involvement Asymmetric joint involvement Markedly elevated ESR 9 9 9 9 9 9 9 9 9 9 9 Systemic JIA19 Monoarthritis Hard hepatosplenomegaly/nodes Bony tenderness Persistent diarrhoea Significant weight loss Pain out of keeping with degree of synovitis Child looks ill during afebrile episodes Leucopenia/thrombocytopenia ANA/RF positive Persistent rash Renal involvement

IMPACT What is the Impact of the D i s e a s e on the Child With H i s Family?

Considering that several arthritides may run a prolonged a n d / o r p a i n f u l c o u r s e a n d t r e a t m e n t o f f e r e d c o u l d b e as d e m a n d i n g as the d i s e a s e itself. It is i m p o r t a n t to o b t a i n a n i d e a of the effect the s y m p t o m s are h a v i n g o n the child a n d his family. M i s s i n g school, a v o i d a n c e of sports, p e e r p r e s s u r e a n d the difficult p e r i o d of a d o l e s c e n c e n e e d to be c o n s i d e r e d . P a i n a n d l o s s of f u n c t i o n (i.e. i n a b i l i t y to m o v e n o r m a l l y ) m a y c a u s e a d i s a b i l i t y (i.e. u n a b l e to c a r r y o u t c e r t a i n activities). D i s a b i l i t y in t u r n m a y b e a v a r i a b l e c a u s e of h a n d i c a p . (i.e. i m p a c t o n g e n e r a l life). A s a n e x a m p l e arthritis of a f e w s m a l l h a n d s of the h a n d m a y r e s u l t in difficult m o v e m e n t ( f u n c t i o n a l loss). "This m i g h t m a k e it d i f f i c u l t to d o u p shirt b u t t o n s or p l a y t h e p i a n o (disability). While most people would bypass the d i s a b i l i t y w e r e the p e r s o n a p r o f e s s i o n a l p i a n i s t h o w e v e r , the consequences would be even more telling and the h a n d i c a p e n o r m o u s . S i m i l a r l y f a m i l y i s s u e s s u c h as u n d e r s t a n d i n g a n d a c c e p t a n c e of t h e d i a g n o s i s , l o n g t e r m financial b u r d e n of t r e a t m e n t a n d the l o o m i n g threat of p r o l o n g e d d i s a b i l i t y also n e e d to b e a d d r e s s e d .

REFERENCES
1. Allen R. Differential diagnosis of arthritis in childhood. Badlieres Clin Pediatr 1993; 1 : 665-694. 2. Apley J. Limb pains with no organic disease. Clin in Rheum Disease 1976; 2 : 487-491. 3. Sills JA. Non-inflammatory musculoskeletal disorders in childhood. Arch Dis Child 1997; 77 : 71-75. 4. Sherry DD, Bohnsach J, Salmonsa K, Wallace LA, Melins E. Painless juvenile rheumatoid arthritis. J Pediatr 1990; 116 : 921923. 5. Cush JJ, Lipsky PE. Approach to articular and musculoskeletal disorders. Braunwald E, Fauci AS, Kasper DL, Hauser SL, Longo DL, Jameson JL, eds. Harrison's Principles of Internal

Medicine. Vol 2. 15t" edn. McGraw-Hill 2001; 1979-1986. 6. Baker DG, Schumacher HR. Acute monoarthritis. N Engl J Med 1993; 329 : 1013-1020. 7. Southwood TR, Malleson PN. The clinical history and physical examination. Baillieres Clin Pediatr 1993; 1: .637-664. 8. Brewer EJ. Pitfalls in the diagnosis of juvenile rheumatoid arthritis. Pediatr Clin North Am. 1986; 33: 1015-1032. 9. White PH. Juvenile Chronic Arthritis. In Kippel JH, Dieppe PA, eds. Rheumatology. 2na edn. Mosby International 1998; 5: 18.1-19.1. 10. Petty RE, Southwood TR, Baum J, Bhettay E, Glass DN, Manners Pet al. Revision of the proposed classification criteria for juvenile idiopathic arthritis. Durban 1997. Journal of Rheumatology 1998; 10 : 1991-1994. 11. Riegels- Nelsen P, Frimodt-Moler N, Jensen JS. Rabbit model of septic arthritis. Acta Orthop Scand 1987 : 58 : 14-19. 12. Hubscher O. Pattern recognition in arthritis In Kippel JH, Dieppe PA, eds. Rheumatology. 2nd edn. Mosby International 1998; 2: 3.1-3.6. 13. Burgos-Vargas R. Spondyloarthropathies and psoriatic arthritis in children. Curr Opin Rheumatol 1993; 5: 634-643. 14. Sathanathan R, David J. The adolescent with rheumatic disease. Arch Dis Child 1997; 77 : 355-358. 15. Rosenberg AM, Petty RE. A s y n d r o m e of seronegative enthesopathy and arthropathy in children. Arthritis Rheum 7982; 25 : 1041-1047. 16. Griffiths ID. Extra- articular features of rheumatic diseases. In Maddison PJ, Isenberg DA, Woo P, Glass DN, eds. Oxford Textbook ofRheumatology Vol 1.2 na edn. Oxford University Press. 1998; 169-179. 17. Petty RE. Children and adolescents. In Maddison PJ, Isenberg DA, Woo P, Glass DN, eds. Oxford Textbook of Rheumatology Vol 1.2 nd edn. Oxford University Press. 1998; 9-22. 18. Burgos VR, Vazquez MJ. The early clinical recognition of juvenile onset ankylosing spondylitis and its differentiation from juvenile rheumatoid arthritis. Arthritis Rheum 1995; 38: 835-844. 19. Laxer RM, Schneider R. Systemic-onset juvenile chronic arthritis. In Maddison PJ, Isenberg DA, Woo P, Glass DN, eds. Oxford textbook of Rheumatology. Vol 1. 2 "d edn. Oxford University Press. 1998; 1114-1131. 20. Ansell BM. Joint manifestations in children with juvenile chronic arthritis. Arthritis Rheum 1997; 20: 204-206.

880

Indian Journal of Pediatrics, Volume 69---October, 2002