1. Approach to a child with
arthritis
Dr.Singaram.A

2. Arthritis vs Arthralgia
• Arthralgia – symptom; pain in the joint
• Arthritis – sign; intra-articular swelling or
2 or more of:
 Limitation of range of motion;
 Tenderness or pain on motion
 Increased temperature or erythema

3. Differential diagnosis of childhood
joint pain or swelling
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Avascular necrosis and epiphyseal disorders
Reactive and postinfectious arthritis
Trauma: Accidental and nonaccidental
Hematologic
Rheumatological
Infection
Tumor
Idiopathic pain syndromes
Systemic diseases

4. Tender points - Fibromyalgia

5. Types of Joint Pain
History
Inflammatory
Mechanical
Sinister
Onset
Insiduous
Sudden
Insiduous
Course
Fluctuant
Persistent
Persistent
Relation to time
More in morning More in evening
No relation
Relation to
activity
Improves
worsens
Worsens
Example
JIA
SCFE
Malignancy

6. Arthritis – Basic Approach
• Onset : Acute (< 6 weeks) or chronic
• No. of joints involved
• Type of joints
• Associated systemic features
• Precipitating factors

7. Some important clues…
• Inflammed/infected joint assumes a
characteristic posture
• Wasting of muscles in chronic joint involvement
• Referred pain
• Swollen joints and enlarged lymph nodes

8. Review of systems
Gottron's papules
Evanescent pink macular rash
HSP
Lower extremity purpuric lesions
Oligoarthritis or psoriatic JIA
Asymptomatic chronic anterior
uveitis
Enthesitis related arthritis
Acute symptomatic uveitis (pain,
redness)
Kawasaki disease
Conjunctival injection without
discharge
Sjogren's syndrome
Oral
Malar rash and hair loss
Systemic JIA
Ophthalmologic
SLE
Dermatomyositis
Dermatologic
Dry eyes with keratitis
SLE
Painless oral ulcers on palate
Behcet Disease
Large extremely painful oral ulcers

9. Review of systems
Pericarditis
Raynaud phenomenon
Takayasu arteritis
Absent pulses
IBD, SLE, or vasculitis
Weight loss or poor growth
IBD
Diarrhea and abdominal pain
Reactive arthritis
Preceding infectious
gastroenteritis
HSP
Genitourinary
New heart murmur
SLE or scleroderma
Gastrointestinal
ARF or endocarditis
SLE, systemic JIA, or ARF
Cardiovascular
Intermittent colicky abdominal pain
Gonococcal arthritis
Pustular urethritis or cervicitis
Reactive arthritis
Non-gonococcal urethritis
Behcet disease or IBD
Large painful genital ulcerations

10. Review of systems
Hemolytic anemia
Pancytopenia
Bleeding disorders
Neurologic
SLE or hemoglobinopathy
(eg, SCD)
SLE
Hematologic
Hemarthrosis
SLE
Seizures and psychosis
SLE or fibromyalgia
Difficulty concentrating
SLE, vasculitis, or
hypercoagulability
Stroke
Vasculitis
Asymmetric polyneuropathy
Dermatomyositis and
polymyositis
Proximal muscle weakness

11. Common clinical presentations
• Acute monoarthritis
- Sick child (+/- fever)
- Well child (+/- trauma)
• Chronic monoarthritis
- Sick child
- Well child
• Polyarthritis
- Acute
- Chronic

12. Acute monoarthritis
Sick Child
Fever
Yes
Septic arthritis
Reactive arthritis
Kawasaki disease
Malignancy
SOJIA
No
Partially treated sepsis
Malignancy
Connective tissue
disorders

13. Acute monoarthritis
Well
child
Significant
trauma
Yes
No
Fractures
Bleeding disorders
Mechanical
derangements
Neoplasm
JIA

14. Synovial fluid analysis
• Hemorrhagic – Hemarthrosis, PVS
• 1500 – 50,000 cells/ cu.mmInflammatory/reactive arthritis
• >50,000 cells/ cu.mm – septic arthritis

15. Chronic monoarthritis
Chronic monoarthritis
Sick child
Well child
Partially treated
Oligoarticular JIA
Septic arthritis
Reactive arthritis
Enthesitis related/psoriatic
arthritis
Systemic onset JIA
Mechanical
SLE

16. Acute polyarthritis
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Acute rheumatic fever
Infective endocarditis
Viral arthritis
Lyme disease
Kawasaki disease
HSP
PSRA

17. Chronic polyarthritis
• Systemic onset/ Polyarticular JIA
• SLE
• Juvenile Dermatomyositis
• SLE/ PAN
• Other inflammatory arthritis

18. Systemic onset JIA
Pauciarticular onset
JIA
50
Polyarticular onset
JIA
30 to 40
F>M
peaks 2 to 5, 10 to 14
years
any, rare to start in hip
Percent of JIA patients
10 to 15
Sex
Age
F=M
any <17 years
Joints
any
Fever, rash,
lymphadenopathy,
hepatosplenomegaly
Uveitis
yes
F>M
peak 2 to 3 years, rare
>10
large joints, but rarely
hips
no
rare
20 percent, esp ANA +
less frequent
Laboratory abnormalities
- Leukocytosis
marked
- Anemia
marked
- Elevated ESR
marked
- ANA
absent
no
no
mild
low titer common
- Rheumatoid factor
rare
absent
Destructive arthritis
Disease modifying
drugs
>50 percent
commonly used
rare
rarely used
no
mild
mild
low titer common in
younger
10 to 20 percent in
those >10 years
>50 percent
commonly used
no