“The Limping Child”

Pediatric Rheumatology Case

Thomas, 2 year old male

o 4 months history of limping with left knee

swelling
o Associated with morning stiffness
o No fever or rash
o No history of trauma or antecedent infection
Musculoskeletal Examination

• Limping gait
• Swelling of the left
knee with warmth
(no erythema/tenderness)
• Unable to fully flex or
extend the left knee
Laboratory Tests Findings

CBC ESR 20 mm/hr

Hgb 12
Hct 0.38 Rheumatoid factor (-)
WBC 8,600
polys 45% ANA (+) 1:640 titer
lymphs 47%
monos 8% ASO titer <200
Platelets 250,000
 QUESTION #1
Give the salient features of the
patient.
Salient Features

A 2 year old male with chronic (> 6 weeks)

monoarthritis (inflammation of the left
knee) with morning stiffness.
 QUESTION #2
What is the most likely diagnosis of
the patient?
JUVENILE RHEUMATOID ARTHRITIS
PAUCIARTICULAR TYPE
ACR Criteria for JRA

o Age of onset < 16 years of age

o Persistent arthritis in at least one joint for
> 6 weeks
o Exclusion of other diagnoses
Types of JRA

• PAUCIARTICULAR ( < 5 joints)

• POLYARTICULAR (>/= 5 joints)
• SYSTEMIC (1 or more joints + fever/rash)
 QUESTION #3
Give the differential diagnosis of the
patient.
Septic Arthritis
• Usually presents as monoarthritis
• Large joints of the lower extremity
(most common sites of infection)
• Accompanied by systemic signs of illness
(e.g. Fever, headaches, chills, vomiting)
• Very severe joint pain with red, hot,
swollen joint on examination
Reactive Arthritis

• Occurs after a history of infection

• Affects both large and small joints
• +/- systemic symptoms of illness
• Affected joints are swollen +/-
warmth/tenderness, (-) erytheaa
• Self-limiting course (rarely lasting for > 6 weeks)
• Good response with NSAIDs
Acute Rheumatic Fever
• Occurs following a Grp A Streptococcal infection
• Peak age 6-15 years old
• Jones criteria

MAJOR MINOR
-Carditis -Fever
-Arthritis -Arthralgia
-Sydenham’s chorea -Elevated ESR/CRP
-Erythema marginatum -Prolonged PR interval
-Subcutaneous nodules
Supporting evidence of antecedent Group A 
                   Streptococcal infection
Acute Rheumatic Fever
• Arthritis of RF affects primarily large
joints
• Migratory in nature
(joint symptom resolving spontaneously
within hours, only to reappear to another
joint)
• Very severe joint pain (may cause
pseudoparalysis)
• Joint symptom very responsive to Aspirin
Juvenile
Spondyloarthropathy
• Common in adolescent males
• Usually presents as chronic asymmetric
arthritis
• Large joints are commonly affected
• (+) axial involvement (back pain is a
common symptom)
• Associated with HLA-B27
Hemarthroses
• Bleeding inside the joint
• Occurs following an injury
• Spontaneous bleeding in patients with
coagulation disorder (e.g. Hemophilia)
• Affected joint is warm, very painful,
swollen with limited range of motion.
 QUESTION #4
What is the implication of a positive ANA in
a patient with JRA?
ANA in JRA

ANA positivity is a knowm

risk factor for the
occurrence of chronic
uveitis.

Regular ophthalmologic
evaluation is advised until
7 years from the onset of
disease.
 QUESTION #5

Is Rheumatoid Factor specific for JRA?

Rheumatoid Factor

• Not specific for JRA

• Can be positive in certain infections and
malignancies
• Only 10-15% of JRA patients are positive
for Rheumatoid factor
JRA patients with (+) RF have a more aggressive disease
         with poorer overall functional outcome.
 QUESTION #6
What is the most appropriate treatment
for this child?
Treatment plan
• Medications: NSAIDs (e.g. Ibuprofen,
Naproxen)
• Intraarticular steroid injection
• Physical therapy for stretching and range of
motion exercises
• Regular ophthalmologic evaluation

NO ROLE FOR DMARDs IN PAUCIARTICULAR JRA