Joint Swelling Flashcards
Causes of Monoarthritis
- Trauma - Haemarthrosis
- Infection
• Pyogenic, TB
• Viral infection
• Lyme disease
3. Inflammatory condition • Rheumatic fever • JIA • SLE • HSP • Crohn's disease • UC
- Blood disease
• Haemophilia
• Sickle cell disease - Malignancy
• Leukaemia
• Neuroblastoma
Causes of Migratory /Flitting Polyarthritis
- Rheumatoid arthritis
- Rhematic fever
- Reiter’s disease
- HSP
- SLE
- Septicaemia e.g. Chronic gonococcal infection, Hepatitis, meningococcaemia, Infectious Mononucleosis
- Serum sickness
- Enteropathic arthropathy
- Psoriasis
- Immunodeficiency
Examination of a case of monoarthritis
- Examine the LL:
• Ask child to move of self first
• Ask for pain before touching pt
• Always compare 2 sides
• Look: For joint swelling, Erythema, for superficial bruises, scars, subcutaneous swelling, posture of limb and presence of contracture, wasting of muscle around the diseased joint or deformity.
- Feel:
- • for Hotness - means local inflammation
- • for tenderness
- • for effusion (patella tap, fluctuation)
- • for synovial thickening
- • for muscle wasting - Knee (Quadraceps) and Ankle (Gastrosoleus)
- Move - Active movements first then passive movement
- • test the joint’s function -eg. UL - comb & grip ; LL - walk and stand
- Examine:
• Face - rash (malar, Heliotrope - eye lids, Psoriasis, , ? Cushingnoid
• Eye - Uveitis, Pallor
• Hand - Clubbin, vasculitic rash
• Skin - Rash, bleeding sign, subcutaneous nodule (Rh nodule - firm & painless) - Examine other joints for inflammatory changes including the neck and temporal mandibular joint
- Examine other systems
•CVS – murmur
• Abdo – orgnomegaly, fistula
• Lymphadenopathy
History taking for JIA
- General
• Constitutional Sx - sleep, wt, appetite, fever
- Joint Sx - early morning stiffness, nocturnal pain, swelling, limitations
- Level of functioning - ADLs - eating (pain on mastication), poor dental hygiene, dressing, writing, walking, school, sports and activities
- Skin rashes (salmon rash, malar etc..)
- Chest Sx (pleuritic pain, pericarditis)
- Bowel problems - Diarrhoea (IBD)
- Eye problems
- Neurological - seizures / drowsiness (SLE/JIA), personality change and headache (SLE)
- Growth concerns - short stature, delayed puberty
- Nutritional issues - S/Es from drugs e.g. MTX - loss of appetite, hepatotoxicity and leukopenia)
- Risk of osteopenia (Bone mineral density between 1 and 2.5SD below the mean for age and sex) and osteoporosis - > 2.5 SD below) - ask whether on vit D /Ca supplements
• Drugs S/Es - Steroids, NSAIDs and MTX, compliance, why change of meds
- HPC - Triggers, no of hospitalizations and sequence of joint involvement and Cx and their Mx
- Social Hx - disease impact on child, siblings, family, financial, social support
- FH - Arthritis, autoimmune conditions, IBD, Psoriasis, enthesitis, uveitis
Inx for JIA
- Blood tests
• CBC - normochromic normocytic anaemia, leucocytosis, thrombocytosis
• ESR/CRP
• Serology - IgM RF, CCP, ANA (mainly in oligoarthritis type)
• Immunology - All immunoglobulins types , C3, C4
• HLA typing -B27, DR4 (polyarthritis/ RF +ve) - Imaging
• Plain x ray - exclude septic joint, tumour, trauma, might see soft tissue swelling, joint space narrowing, periarticular osteoporosis, joint erosions
- USG to look for effusions, synovitis and guide intra-articular therapy
- MRI
Mx for JIA
Goals: • Stop inflammation • analgesia • Maintain joint function • Prevent deformities • Tx of Cx an extra articular manifestations • Optimal nutrition • Rehabilitation • psychosocial health • Education
- Local corticosteroid injections
- NSAIDs to reduce pain and stiffness, S/E - Anorexia and abdo pain
- DMARDs - reduce the rate of adverse structural outcomes - joint erosions.
- Sequence of drugs to use
- • If active synovitis - always use intra-articular or systemic (IV or Po) steroids to achieve rapid remission)
- • If Oligoarthritis - use NSAIDs, if failed then MTX
- • if polyarthritis type - need to start MTX and steroids tgt
- • For life threatening systemic arthritis - use pulse corticosteroids) and MTX tgt, if failed then Leflunamide, if failed again then biologics
4. Monitor Disease activity • Clinical disease - fever, no of joints, worsening function • ESR • MRI/ X ray • Degree of anaemia
- Pain and stiffness
• Pain- paracetamol and ice packs or hot packs
• Morning Stiffness - warm bath/ shower or hot packs - use long acting nocturnal NSAIDs - Maintain joint functions
• PT - passive movements and gentle exercises
• Footwear
• Splints
• Hydrotherapy
• OT - UL movements, fine motor movements
Medications and side effects
• MTX
- low dose, once a week (Po or S/C), need folate supplement
• S/Es - loss of appetite, nausea, oral ulcers, Raised LFTs, neutropenia, thrombocytopenia, Agranulocytosis (rare). Need monthly blood tests to check LFTs and BM involvement
• Leflunomide
- flavourable to MTX in terms of efficacy and fewer s/e s (but currently being studied for JIA)
• S/Es - diarrhoea, raised LFTs and mucocutaneous abnormalities, teratogenic effects (requires contraception 2 years after use)
• Sulphazalazine (SSZ)
- Esp good for Enthesitis related Arthritis
- S/Es - Hypersensitivity rxns, hepatotoxity and BM toxicitiy
• Corticosteroids
- Systemic use is required for rapid control of disease activity esp in systemic arthritis, uveitis.
- For MAS, pericardial and pleural effusions (Use pulsatile IV steroids + maintainence agent Cyclosporine)
- Should be taken in the morning to minimise the impact on growth
• Biological agents
- TNF-alpha inhibitors (Entanercept, Infliximab and Adalimumab)
- IL-1 inhibitor (Anakira)
- IL-6 inhibitor (Tocilizumab)
- Anti CD 20 (Rituximab)
- T cell proliferation inhibitor (Abatacept)
Entanercept - for Rx resistant and polyarthritic type (S/Es - URTI, rhinitis, headache and rash and injection site rxn)
- All TNF agents can lead to reactivation of latent TB so requires Tuberculin test and chest X-ray to screen first. If +ve then start isoniazid 1 month before the Rx.
• S/Es for all - immunosuppression so live vaccines should be avoided.
N.B. VCZ should be given 3 months before starting the Rx
Cx and Rx
- Anterior Uveitis
• Increased risk in males, oligo type - Rx with steroid eye drops and mydriatics. MTX and Biologics useful
• ERA and Psoriatic type more associated with acute painful uveitis rather then the chronic one
• 1/3 still have active disease in adulthood
• RF positive pts have worse prognosis
