Transcript Paediatric Case Presentation

Paediatric Case
Presentation
Natasha Quader ST1
September 2008
Patient CD



8 year old girl
Normally fit and well
PC – Pyrexia
- Lethargy
- Groin and hip pain
History of Presenting Complaint

7/52 ago had pyrexia for 1 week followed by a cough → viral URTI

Intermittent pyrexia - mainly nocturnal spikes

C/o hip and groin pain.
- Present on waking up in the morning
- Pain waking her up during sleeping
- Developed difficulty in walking, pain on weight bearing

Increasingly lethargic – sleeping during the day and missing school

Generally unwell, ↓ appetite, irritable and crying
PMH

PMH
- Laryngomalacia during infancy
- RTA in Feb ’07 – back injury resolved

SH – no recent travel abroad

Immunisations up-to-date

DxH – nil, NKDA

FH – Maternal grandmother with RA
Examination 1










Alert, communicating
PR – 80 regular
Temp – 38 °C
RR-18

Abdomen
Bilateral cervical
lymphadenopathy
Throat – NAD
Ears – wax bilaterally
No rashes
HS I + II + O
Chest: Clear
Inguinal
lymphadenopathy
Lower
abdominal
tenderness
Examination 2
CNS
MSK
 CN – NAD. PEARL
 No hip/knee joint
 Lower limbs bilaterally
swelling
- tone normal
 Tenderness over AIS
- power 4/5
and crest bilaterally
- reflexes symmetrical
 Hips - ↓ active ROM
 Co-ordination – intact
 Romberg’s negative
 Antalgic gait
 Slight waddling and holding R.
inguinal region
Positive Examination Findings

Pyrexic

Lower abdominal tenderness

Bilateral inguinal lymphadenopathy

Bilateral hip tenderness and restricted ROM

Antalgic gait
Differential Diagnosis






Septic hip
Infection – viral, bacterial, Lyme disease
Juvenile arthritis
Malignancy – leukaemia, neuroblastoma
Perthes
Transient irritable hip
Infection Screen







MSU – NAD
Blood cultures – no growth
EBV Igm – negative
Toxopl Igm – negative
ASOT – normal
Rubella Igm – negative
Parovirus Igm – negative
Bilateral Hip X-ray
Imaging


USS abdo and hips – no fluid in hip joints
MRI abdo/pelvis - No evidence of avascular
necrosis
Blood Test Results
Initial
GP
Hb
WCC
Plt
7 weeks
later
8 weeks
In -patient
9.9
6.3
418
9.7
5.5
354
9.7
4.2
338
98
9
90
13
105
9 weeks
Inpatient
10.2
6.1
516
Neut
Lymp
CRP
ESR
104
10 weeks
OPA
14 weeks
OPA
10.2
6.1
516
2.20
2.70
11.1
4.9
295
<1
104
<1
14
Follow Up


Follow up 10/7 after discharged from Hospital
Symptoms much improved
- no complaints of hip pain on weight bearing
- no pain during sleep
- no pyrexia for 5/7
- analgesia reduced from QDS to ON
- generally more mobile, active and cheerful
Follow up Results


On examination
- discomfort on extreme range of full
abduction of R. hip
- Tearful on jumping on 2 feet
Repeat bloods: ESR remains high – 104
Anti nuclear antibody positive

Referral → Rheumatologist
→ Ophthalmologist
Juvenile Arthritis
Is a group of conditions
in which there is chronic arthritis
lasting more than 6 weeks,
presenting
before 16 years of age
Classifications

Systemic illness (Still’s disease)
- 20%

Rh factor negative polyarticular
- 25%

Rh factor positive polyarticular
- 5%


Pauciarticular arthritis assoc with ANA
& chronic uveitis - 30-35%
Pauciarticular arthritis assoc with spondylitis
and HLA B27 - 10-15%
Aetiology



Autoimmune disease in which the cause of arthritis is
largely unknown
A possible viral aetiology has been considered for a
variety of arthritis conditions and clustering of
patient’s following viral epidemics
Viral infections that have noted include mumps,
rubella and Parvovirus B19
Pauciarticular Arthritis



Female > Male
Involvement of up to 4 or fewer joints – typically
larger joints such as the knee
3 subtypes:
1) The early onset form (< 5 years of age), involves
most frequently knee joints
2) The late onset form ( > 9 years of age) most
frequently involves hips with/without sacroilitis
3) Develops at any age with an asymmetrical
oligoarthritis, dactylitis and psoriatic manifestation
Pauciarticular Arthritis 2



Is a large association with Anti Nuclear
Antibodies between 40-75%
Frequently associated with chronic anterior
uveitis (can be asymptomatic or asso pain,
light sensitivity and redness)
Regular opthalmological screening is indicated
Complications




Chronic anterior uveitis – if poorly controlled may
result in permanent eye damage, including blindness
Flexion contactures of the joint – joint held in the
most comfortable position, thereby minimising intraarticular pressure. Chronic disease can lead to joint
destruction and need for joint replacement
Growth failure – anorexia, chronic disease and
steroid therapy
Amyloidosis – rare complication causing proteinuria
and renal failure
Management 1

Multidisciplinary approach is required for
optimal Rx: - relieve pain
- preserve joint function
- maintain normal growth and
psycho – social development

Physiotherapist & Occupational Therapists
- strengthen muscles & keep joints flexible
- encourage normal limb development
- maintain function and prevent deformities
- develop exercise programs
Management 2

Paediatricians, Rheumatologist and Nurses
- educating child and family
- medical management

Counsellor
– for the child and their family to reduce anxiety
and share management of disease
Medical Management

NSAIDS – aspirin, ibuprofen, diclofenac

DMARDS (Disease modifying anti rheumatic drugs)
- under rheumatologist’s supervision
- hydroxychloroquine, penicillamine, methotrexate

Intra-articular corticosteroid injections

Corticosteroids

– severe systemic involvement &/or for eyes Rx
TNF alpha blockers
– block the immune protein TNF (inflammatory agent in
arthritis)
Prognosis

Symptoms usually go away after a few years

There are usually no further recurrences

Some children may have longer lasting
involvement
References




Laura Quarte et al. Juvenile idiopathic arthritis: An update on
clinical and therapeutic approaches. Ann Ital Med Int 2005; 20:
211-217
Juvenile Rheumatoid Arthritis
http://www.emedicine.com/ped/topic1749.htm
Juvenile Rheumatoid Arthritis
http://www.emedicinehealth.com/juvenile_rheumatoid_arthritis
/article_em.htm
Arthritis in children
http://www.medicinenet.com/juvenile_arthritis/article.htm