Joint Swelling

Question 1

Causes of Monoarthritis

Answer 1

1. Trauma - Haemarthrosis
2. Infection
   • Pyogenic, TB
   • Viral infection
   • Lyme disease

3. Inflammatory condition
• Rheumatic fever
• JIA
• SLE
• HSP
• Crohn's disease
• UC

4. Blood disease
   • Haemophilia
   • Sickle cell disease
5. Malignancy
   • Leukaemia
   • Neuroblastoma

Question 2

Causes of Migratory /Flitting Polyarthritis

Answer 2

1. Rheumatoid arthritis
2. Rhematic fever
3. Reiter’s disease
4. HSP
5. SLE
6. Septicaemia e.g. Chronic gonococcal infection, Hepatitis, meningococcaemia, Infectious Mononucleosis
7. Serum sickness
8. Enteropathic arthropathy
9. Psoriasis
10. Immunodeficiency

Question 3

Examination of a case of monoarthritis

Answer 3

1. 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

2. 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)
3. Examine other joints for inflammatory changes including the neck and temporal mandibular joint
4. Examine other systems
   •CVS – murmur
   • Abdo – orgnomegaly, fistula
   • Lymphadenopathy

Question 4

History taking for JIA

Answer 4

1. 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

2. HPC - Triggers, no of hospitalizations and sequence of joint involvement and Cx and their Mx
3. Social Hx - disease impact on child, siblings, family, financial, social support
4. FH - Arthritis, autoimmune conditions, IBD, Psoriasis, enthesitis, uveitis

Question 5

Inx for JIA

Answer 5

1. 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)
2. 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

Question 6

Mx for JIA

Answer 6

Goals:
• Stop inflammation
• analgesia
• Maintain joint function
• Prevent deformities
• Tx of Cx an extra articular manifestations
• Optimal nutrition
• Rehabilitation
• psychosocial health
• Education

1. Local corticosteroid injections
2. NSAIDs to reduce pain and stiffness, S/E - Anorexia and abdo pain
3. 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

5. Pain and stiffness
   • Pain- paracetamol and ice packs or hot packs
   • Morning Stiffness - warm bath/ shower or hot packs - use long acting nocturnal NSAIDs
6. Maintain joint functions
   • PT - passive movements and gentle exercises
   • Footwear
   • Splints
   • Hydrotherapy
   • OT - UL movements, fine motor movements

Question 7

Medications and side effects

Answer 7

• 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

Question 8

Cx and Rx

Answer 8

1. 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