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Paediatric Rheumatology
Phil Riley
Consultant Paediatric Rheumatologist
Teaching
Introduction
Musculoskeletal pain common in
childhood
Wide range of diagnoses -benign to
malignant
JIA- early recognition and appropriate
treatment prevents damage
JIA- Multidisciplinary team
Differential Diagnosis
Inflammatory
Mechanical
Psychological
Differential DiagnosisInflammatory
Reactive
Infection
Inflammatory disease
Systemic disease
Malignancy
Irritable hip
Differential DiagnosisMechanical
Trauma-accidental and NAI
Hypermobility
Osteochondritides
Degenerative disorders
Haematological
Metabolic
Tumours- benign and malignant
DifferentialPsychogenic
Fibromyalgia
Functional illness
Reflex Sympathetic Dystrophy
Juvenile Idiopathic Arthritis
Unknown aetiology
Genetic predisposition
incidence 1 per 10,000
prevalence 1 per 1,000
Disease Course
50% still active after 25 years
X-ray Joint damage by 2.6 years
Increased mortality
Increased morbidity-Physical
-Growth
-Psychological
-Social
Classification of
Juvenile Arthritis
<16 years
>6 weeks arthritis
Subtypes classified for first 6 months
Subtypes
Oligoarthritis
-persistent
-extended
Polyarthritis (RF negative)
Polyarthritis (RF positive)
systemic
1-4
>=5
>=5
Investigations-JIA
ANA- Antinuclear antibody
Inflammatory markers- CRP,ESR
FBC- Anaemia of chronic disease
x-ray -loss of joint space, erosions and
carpal bone overcrowding
MRI- synovitis (gadolinium enhanced)
Uveitis
Chronic anterior uveitis
Often Asymptomatic
Young,female, oligoarthritis, positive
ANA (30%)
Polyarthritis (5%)
systemic(rare)
Slit lamp 3-6 monthly for 7 years
Subtypes
Systemic Arthritis
-Rash
-temp over 2 weeks
-with/without arthritis
-with/without serositis
-hepatosplenomegaly, lymphadenopathy
JIA
systemic rash
Systemic JIA
Quotidian fever
Systemic JIA
Macrophage Activation Syndrome(MAS)
-Bleeding, purpura, bruising
-Nodes,liver,spleen
-FBC,ESR
-PT,APTT, FDP
- Fibrinogen,clotting factors
Bone Marrow
IV steroids,Cyclosporin
Subtypes
Enthesitis-related arthritis
-HLA B27
Psoriatic Arthritis
Other
Treatment Options
NSAIDs
Steroids
Joint injections
Methotrexate
Sulphasalazine
Ciclosporin
TNF drugs
Autologous stem cell transplantation
Questions
Oligoarthritis
ANA pos
normal slightly raised ESR,CRP
NSAIDS
Joint injection
Ophthalmology referral
Rehab/MDT
Questions
Polyarthritis
ANA positive or negative
Rh factor positive or negative
very raised ESR,CRP
Steroids
Methotrexate
Eyes
Rehab/MDT
Questions
Systemic
Rash
Quotidian fever
NSAIDS
Steroids
Methotrexate
Macrophage Activation Syndrome
Treatment Concepts
Early
Monitoring
Multidisciplinary
Treatment continued
Physiotherapy
restore function
improve muscle strength
splints/serial casts
Occupational therapy
Psychology
Spotter
Butterfly Rash
Spotter
Buttterfly
Spotter
Raynaud’s
phenomenon
SLE- Diagnostic/ WHO
classification criteria(4 of 11)
Malar rash(butterfly)
Discoid lupus rash
Photosensitivity
Oral/nasal mucosal ulceration
Non-erosive arthritis
nephritis
-proteinuria/cellular casts
SLE-Diagnostic/WHO
classification(4 of 11)
Encephalopathy-seizures/psychosis
Pleuritis/pericarditis
Haematological
-lymphopaemia
-thrombocytopaenia
positive immunoserology
-anti ds-DNA
ANA positive
SLE- clinical features
Constitutional - fever/malaise/weight loss
Cutaneous
rash/photosensitivity/alopecia/mouth ulcers
Musculoskeletal
poly-arthritis/arthralgia
tenosynovitis
myopathy
avascular necrosis
SLE-Clinical features
Vascular
lupus crisis/Raynaud’s/livedo
Cardiac
pericarditis/myocarditis/endocarditis
Pulmonary
pleuritis/pneumonitis/haemorrhage
SLE-lab features
FBC- low platelets
- low lymphocytes
Inflammatory markers- high ESR,
normal CRP
ANA- very high ie >1:2560
DsDNA- high
C3,C4- low
Spotter
Neonatal lupus
Spotter
Neonatal Lupus
Neonatal lupus
Maternal autoantibody transmission
Cong heart block (Ro/La)
- 50%
Cutaneous neonatal lupus
- 37%
Hepatic/GI tract
- 8%
Haematologic
-6%
Neurologic and pulmonary -1%
Spotter
Heliotrope Rash
Spotter
Gottrons papules
Spotter
Calcinosis
Spotter
Capillaroscopy
Abnormal “bushy”
Thickening and
dropout
Definition of Juvenile
Dermatomyositis(JDM)
limb-girdle and anterior neck flexor
weakness
Muscle biopsy
Muscle enzyme increase
EMG
Dermatological features
JDM - clinical features
Proximal weakness
Vasculopathy
Heliotrope facial rash
Gottrons papules
Raised CK/LDH/AST/ALT
MR scan/muscle biopsy
Multi-organ occasionally
JDM - treatment
Steroids
pulse iv
oral tapering
Methotrexate
Cyclosporin/Immunoglobulin/Cyclophos
phamide/Anti TNF
Physio/Rehab
Spotter
en coup de sabre
Spotter
Sclerodactly
Scleroderma in children
Systemic sclerosis
limited cutaneous/CREST
diffuse
Localised
linear scleroderma (en coup de
sabre,morphoea)
Questions
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