QUICK RECALL

Question 1

Multiple types =
o Stills disease (systemic JIA)
o Polyarticular JIA
o Oligoarticular JIA (Pauci-articular JIA)
o Juvenile Ankylosing Spondylitis
o SLE
o Lyme Disease

these are examples of?

Answer 1

JIA

Question 2

• Features
  o Inflammation – lymph glands, spleen, pericarditis, pleuritis, joints
  o Extreme fatigue, high spiking fevers, salmon colored rash that comes and goes
  o Arthritis – FOR AT LEAST 6 WEEKS
  o Poor appetite, nausea, weight loss
• Precise cause not yet known
• Lab Tests
  o Elevated = WBCs, ESR, CRP, Ferritin
  o Decreased = RBCs
  o Negative = RF (rheumatoid factor), ANA (for SLE)
• Treatment – NSAIDS, DMARDs, Immunosuppressant’s

Answer 2

Systemic JIA (Stills Disease)

Question 3

• Features
  o Affects small joints (hands and feet) but can involve large joints; usually symmetrical
  o Affects > 4 joints w/ pain lasting > 6 weeks
  o To meet diagnosis criteria it needs have ^ to occur w/in the first 6 months of illness
  o Begins before 16 yrs old and may have history of chronic anterior uveitis
• Signs
  o Limp, joint swelling, fever, light pink rash, and it MAY involve heart, liver, spleen, and lymph
  nodes (different than still which does and is more systemic)

- Labs
o RF (-) form = 5 or more joints in first 6 months
o RF (+) form = 5 or more joints in first 6 moths ß (+) form is much more aggressive 
o Elevated = ESR, CRP, Ferritin, WBCs
o Decreased = RBCs

• Treatment – NSAIDS, DMARDS

Answer 3

Polyarticular JIA

Question 4

• MOST common form of JIA (F>M)
• Peak incidence is 2nd and 3rd yrs of life
• Features
  o Morning stiffness, mild discomfort, limp, swelling and warmth of affected joints
  § Leg length discrepancy most common
  § At risk for chronic anterior uveitis
  o Fewer than 4 joints are affected for the entire course
• Labs
  o Positive ANA, elevated WBC w/o signs of infection, hypoalbuminemia w/o proteinuria
  o Xray – soft tissue swelling w/in joints, if chronic then bone erosion
• Treatment – NSIADS and DMARDS but has good prognosis and will remit on its own

Answer 4

Oligoarticular JIA (Pauci-articular JIA)

Question 5

• Features
  o Enthesopathy and arthritis of large joints in the lower extremities
  o Ankylosing tarsitis of the ankle is common
• Duration
  o Long term
• Cause is unknown
• Diagnostic Criteria
  o MUST HAVE 2 of the following
  § Persistent sacroiliac tenderness &/or inflammatory lumbosacral pain
  § Positive HLA-B27; Negative RF and ANA
  § Acute symptomatic anterior uveitis
  § 1st degree relative w/ a history of AS, ERA, sacroilitis with IBD, reactive arthritis, or acute
  anterior uveitis

Answer 5

Juvenile Ankylosing Spondylitis

Question 6

• Most common in females, African Americans, Asians, Hispanics and those w/ 1st degree relative w/ SLE
• Peak onset in early teens and rare <5 yrs
• Features
  o Aberrant B cell formation and increased production of specific and non-specific autoantibodies
  w/ immune complex formation and deposition
  § Fever, malar rash, photosensitivity, arthritis (small joints of hands and feet)
• Diagnosis
  o 4 or more criteria, 1 clinical, and 1 laboratory OR biopsy proven lupus nephritis w/ a (+) ANA
  o MD Please Offer All RNs A Holiday Immediately
  § Malar rash, discoid rash, photosensitivity, oral ulcerations, arthritis, renal issues,
  neurologic issues, serositis, ANA +, hematologic abnormalities, immune autoantibodies
• Treatment - No permeant cure, goal is to reduce symptoms

Answer 6

SLE

Question 7

• Features
  o Erythema migrans in early disease and in early disseminated disease there is multiple erythema
  migrans w/ cranial nerve palsies, and carditis
  o Late disease à arthritis, polyneuropathy, encephalopathy
• Labs
  o Positive Lyme ELISA test confirmed by positive western blot
• Treatment - Doxycycline or amoxicillin

Answer 7

Lyme Disease

Question 8

• Features
  o Defined as arthritis w/ psoriasis or arthritis w/ 2 of the following
  § Dactylitis, nail abnormalities, family history of psoriasis in 1st degree relative
  o Presentation
  § Asymmetric arthritis affecting both large and small joints
  § Psoriasis on extensor surfaces

Answer 8

Psoriatic Arthritis

Question 9

• Features
  o Bone or joint infection confined to the synovium of a joint affects the hip, knee, ankle
  § May present w/ clinical signs of bacteremia (fever, high WBC, ESR, CRP)
  § Usually joint effusion
  o Most common in childhood, boys > girls
  o Staph is the most common cause
• Radiographic Evaluation
  o Infections of peripheral joints are readily diagnosed by arthrocentesis

Answer 9

Septic Arthritis

Question 10

• Result of infection
• Most common in the 1st decade of life due the rich metaphyseal blood supply
  o Location is in the metaphysis
• Causes
  o S. Aureus most common cause in all children
  o Group B Strep most common in neonates
  o Pseudomans most common in direct puncture
  o TB most common to have extrapulmonary involvement
  o Salmonella most common in sickle cell patients
• Pathophysiology
  o Spread through bone occurs via haversian and Volkmann canal systems
  o Purulence develops in conjunction w/ osteoblast necrosis, osteoclast activation, the release of
  inflammatory mediators, and blood vessel thrombosis
  § Subperiosteal abscess develops when the purulence breaks through the metaphyseal cortex
• History
  o Limb pain, recent local infection, immunizations
• PE
  o Edematous, warm, swollen, tender limb, evaluate for point tenderness
• Radiographs
  o AP and Lateral and will see new periosteal bone formation 5-7 days later w/ osteolysis 10-14
  days later
• CT and MRI – MRI will show marrow edema
• Labs
  o CRP will be elevated in 6 hrs and will be elevated in 98% of cases = MOST sensitive to monitor
  therapeutic response (tells you your treatment is working if going down)
  o ESR is elevated
  o Bone Aspiration = definitive diagnosis
• Treatment
  o Empric Antibodies for IV 4-6 weeks
  o Can do surgery if it is out of control
• Complications
  o DVT (Risk factors = CRP > 6, surgical treatment, >8 yrs of age)
  o MRSA, Meningitis, Chronic OM, Septic arthritis, Growth disturbances of limb if growth plate
  involvement, Pathologic factors
• Clinical Features Suggestive of Bone Infection
  o Constitutional symptoms
  o Less than 14 days of signs and symptoms
  o Focal symptoms and signs of inflammation in a previously healthy child
  o Limitation in function
  o Elevated ESR and CRP

Answer 10

Pediatric Hematogenous Osteomyelitis

Question 11

• Intraosseous abscess related to a focus of subacute pyogenic OM
  o Most common form of the subacute OM
• S. aureus is the most common cause
• M>F
• Location
  o Predilection for metaphysis
  § Occurs w/ unfused epiphyseal plates (but rarely traverses them)
  o Proximal/distal tibial metaphysis
• Radiographic Features
  o Lytic lesion in oval configuration oriented along the long axis of bone
  o Surrounded by thick rim of sclerotic bone
  o MRI
  § Penumbra sign – differentiates subacute OM from other bone lesions
  • Rim lining of an abscess cavity w/ higher signal intensity

Answer 11

Brodies Abscess