Paediatric Case Presentation Natasha Quader ST1 September 2008.
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Transcript of Paediatric Case Presentation Natasha Quader ST1 September 2008.
Paediatric Case Paediatric Case PresentationPresentation
Natasha Quader Natasha Quader ST1ST1
September 2008September 2008
Patient CDPatient CD
8 year old girl8 year old girl Normally fit and wellNormally fit and well
PC – PyrexiaPC – Pyrexia
- Lethargy- Lethargy
- Groin and hip pain- Groin and hip pain
History of Presenting History of Presenting ComplaintComplaint
7/52 ago had pyrexia for 1 week followed by a cough → viral 7/52 ago had pyrexia for 1 week followed by a cough → viral URTI URTI
Intermittent pyrexia - mainly nocturnal spikesIntermittent pyrexia - mainly nocturnal spikes
C/o hip and groin pain. C/o hip and groin pain. - Present on waking up in the morning- Present on waking up in the morning - Pain waking her up during sleeping- Pain waking her up during sleeping - Developed difficulty in walking, pain on weight bearing- Developed difficulty in walking, pain on weight bearing
Increasingly lethargic – sleeping during the day and missing Increasingly lethargic – sleeping during the day and missing school school
Generally unwell, Generally unwell, ↓ appetite, ↓ appetite, irritable and cryingirritable and crying
PMHPMH
PMH PMH - Laryngomalacia during infancy- Laryngomalacia during infancy - RTA in Feb ’07 – back injury resolved- RTA in Feb ’07 – back injury resolved
SH – no recent travel abroadSH – no recent travel abroad
Immunisations up-to-dateImmunisations up-to-date
DxH – nil, NKDADxH – nil, NKDA
FH – Maternal grandmother with RAFH – Maternal grandmother with RA
Examination 1Examination 1 Alert, communicatingAlert, communicating PR – 80 regularPR – 80 regular Temp – Temp – 38 38 °C°C RR-18RR-18
Bilateral cervical Bilateral cervical lymphadenopathylymphadenopathy
Throat – NADThroat – NAD Ears – wax bilaterallyEars – wax bilaterally No rashesNo rashes
HS I + II + OHS I + II + O Chest: ClearChest: Clear
AbdomenAbdomen
Inguinal lymphadenopathy
Lower abdominal tenderness
Examination 2Examination 2CNSCNS CN – NAD. PEARLCN – NAD. PEARL Lower limbs bilaterallyLower limbs bilaterally - tone normal- tone normal - power 4/5 - power 4/5 - reflexes symmetrical- reflexes symmetrical Co-ordination – intactCo-ordination – intact Romberg’s negativeRomberg’s negative Antalgic gaitAntalgic gait Slight waddling and holding R. Slight waddling and holding R.
inguinal regioninguinal region
MSKMSK No hip/knee joint No hip/knee joint
swellingswelling Tenderness over AIS Tenderness over AIS
and crest bilaterally and crest bilaterally Hips - Hips - ↓ active ROM↓ active ROM
Positive Examination Positive Examination FindingsFindings
PyrexicPyrexic
Lower abdominal tendernessLower abdominal tenderness
Bilateral inguinal lymphadenopathyBilateral inguinal lymphadenopathy
Bilateral hip tenderness and restricted Bilateral hip tenderness and restricted ROMROM
Antalgic gaitAntalgic gait
Differential DiagnosisDifferential Diagnosis
Septic hipSeptic hip Infection – viral, bacterial, Lyme diseaseInfection – viral, bacterial, Lyme disease Juvenile arthritisJuvenile arthritis Malignancy – leukaemia, neuroblastomaMalignancy – leukaemia, neuroblastoma PerthesPerthes Transient irritable hipTransient irritable hip
Infection ScreenInfection Screen MSU – NADMSU – NAD Blood cultures – no growthBlood cultures – no growth
EBV Igm – negativeEBV Igm – negative Toxopl Igm – negativeToxopl Igm – negative ASOT – normalASOT – normal Rubella Igm – negativeRubella Igm – negative Parovirus Igm – negativeParovirus Igm – negative
Bilateral Hip X-rayBilateral Hip X-ray
ImagingImaging
USS abdo and hips – no fluid in hip jointsUSS abdo and hips – no fluid in hip joints
MRI abdo/pelvis - No evidence of avascular MRI abdo/pelvis - No evidence of avascular necrosisnecrosis
Blood Test ResultsBlood Test ResultsInitialInitial
GPGP7 weeks7 weeks
laterlater
8 weeks8 weeks
In -patientIn -patient9 weeks9 weeks
In-In-patientpatient
10 weeks10 weeks
OPAOPA14 weeks14 weeks
OPAOPA
HbHb 9.99.9 9.79.7 9.79.7 10.210.2 10.210.2 11.111.1WCCWCC 6.36.3 5.55.5 4.24.2 6.16.1 6.16.1 4.94.9PltPlt 418418 354354 338338 516516 516516 295295NeutNeut 2.202.20LympLymp 2.702.70
CRPCRP 99 1313 <1<1 <1<1ESRESR 9898 9090 105105 104104 104104 1414
Follow UpFollow Up
Follow up 10/7 after discharged from HospitalFollow up 10/7 after discharged from Hospital
Symptoms much improvedSymptoms much improved
- no complaints of hip pain on weight bearing- no complaints of hip pain on weight bearing
- no pain during sleep- no pain during sleep
- no pyrexia for 5/7- no pyrexia for 5/7
- analgesia reduced from QDS to ON- analgesia reduced from QDS to ON
- generally more mobile, active and cheerful- generally more mobile, active and cheerful
Follow up ResultsFollow up Results On examinationOn examination - discomfort on extreme range of full - discomfort on extreme range of full
abduction of R. hipabduction of R. hip - Tearful on jumping on 2 feet- Tearful on jumping on 2 feet
Repeat bloods: ESR remains high – 104Repeat bloods: ESR remains high – 104 Anti nuclear antibody positiveAnti nuclear antibody positive
Referral → RheumatologistReferral → Rheumatologist → → OphthalmologistOphthalmologist
Juvenile ArthritisJuvenile Arthritis
Is a group of conditions Is a group of conditions
in which there is chronic arthritis in which there is chronic arthritis
lasting lasting more than 6 weeksmore than 6 weeks, ,
presenting presenting
before 16 years of agebefore 16 years of age
ClassificationsClassifications
Systemic illness (Still’s disease) - 20%Systemic illness (Still’s disease) - 20%
Rh factor negative polyarticular - 25%Rh factor negative polyarticular - 25%
Rh factor positive polyarticular - 5%Rh factor positive polyarticular - 5%
Pauciarticular arthritis assoc with ANAPauciarticular arthritis assoc with ANA & chronic uveitis - 30-35%& chronic uveitis - 30-35%
Pauciarticular arthritis assoc with Pauciarticular arthritis assoc with spondylitis and HLA B27 - 10-15%spondylitis and HLA B27 - 10-15%
AetiologyAetiology
Autoimmune disease in which the cause of Autoimmune disease in which the cause of arthritis is largely unknownarthritis is largely unknown
A possible viral aetiology has been considered for A possible viral aetiology has been considered for a variety of arthritis conditions and clustering of a variety of arthritis conditions and clustering of patient’s following viral epidemics patient’s following viral epidemics
Viral infections that have noted include mumps, Viral infections that have noted include mumps, rubella and Parvovirus B19rubella and Parvovirus B19
Pauciarticular ArthritisPauciarticular Arthritis Female > MaleFemale > Male Involvement of up to 4 or fewer joints – typically larger joints Involvement of up to 4 or fewer joints – typically larger joints
such as the kneesuch as the knee
3 subtypes:3 subtypes: 1) The early onset form (< 5 years of age), involves most 1) The early onset form (< 5 years of age), involves most
frequently knee joints frequently knee joints
2) The late onset form ( > 9 years of age) most frequently 2) The late onset form ( > 9 years of age) most frequently involves hips with/without sacroilitisinvolves hips with/without sacroilitis
3) Develops at any age with an asymmetrical 3) Develops at any age with an asymmetrical
oligoarthritis, dactylitis and psoriatic manifestationoligoarthritis, dactylitis and psoriatic manifestation
Is a large association with Anti Nuclear Is a large association with Anti Nuclear Antibodies between 40-75%Antibodies between 40-75%
Frequently associated with chronic anterior Frequently associated with chronic anterior uveitis (can be uveitis (can be asymptomaticasymptomatic or asso pain, or asso pain, light sensitivity and redness)light sensitivity and redness)
Regular opthalmological screening is Regular opthalmological screening is indicatedindicated
Pauciarticular Arthritis 2Pauciarticular Arthritis 2
ComplicationsComplications Chronic anterior uveitisChronic anterior uveitis – if poorly controlled may – if poorly controlled may
result in permanent eye damage, including blindnessresult in permanent eye damage, including blindness
Flexion contactures of the jointFlexion contactures of the joint – joint held in the – joint held in the most comfortable position, thereby minimising intra-most comfortable position, thereby minimising intra-articular pressure. Chronic disease can lead to joint articular pressure. Chronic disease can lead to joint destruction and need for joint replacementdestruction and need for joint replacement
Growth failureGrowth failure – anorexia, chronic disease and – anorexia, chronic disease and steroid therapysteroid therapy
AmyloidosisAmyloidosis – rare complication causing proteinuria – rare complication causing proteinuria and renal failureand renal failure
Management 1Management 1 Multidisciplinary approach is required for Multidisciplinary approach is required for
optimal Rx: optimal Rx: - relieve pain- relieve pain - preserve joint function- preserve joint function - maintain normal growth and- maintain normal growth and psycho – social developmentpsycho – social development
Physiotherapist & Occupational TherapistsPhysiotherapist & Occupational Therapists - strengthen muscles & keep joints flexible - strengthen muscles & keep joints flexible - encourage normal limb development- encourage normal limb development - maintain function and prevent deformities- maintain function and prevent deformities - develop exercise programs- develop exercise programs
Management 2Management 2
Paediatricians, Rheumatologist and NursesPaediatricians, Rheumatologist and Nurses
- educating child and family- educating child and family
- medical management- medical management
CounsellorCounsellor
– – for the child and their family to reduce for the child and their family to reduce anxiety and share management of diseaseanxiety and share management of disease
Medical ManagementMedical Management
NSAIDS – aspirin, ibuprofen, diclofenacNSAIDS – aspirin, ibuprofen, diclofenac
DMARDS (Disease modifying anti rheumatic DMARDS (Disease modifying anti rheumatic drugs)drugs)
- under rheumatologist’s supervision- under rheumatologist’s supervision - hydroxychloroquine, penicillamine, methotrexate- hydroxychloroquine, penicillamine, methotrexate
Intra-articular corticosteroid injectionsIntra-articular corticosteroid injections
Corticosteroids Corticosteroids – – severe systemic involvement &/or for eyes Rxsevere systemic involvement &/or for eyes Rx TNF alpha blockers TNF alpha blockers – – block the immune protein TNF (inflammatory agent in block the immune protein TNF (inflammatory agent in
arthritis)arthritis)
PrognosisPrognosis
Symptoms usually go away after a few Symptoms usually go away after a few yearsyears
There are usually no further recurrencesThere are usually no further recurrences
Some children may have longer lasting Some children may have longer lasting involvementinvolvement
ReferencesReferences Laura Quarte et al. Juvenile idiopathic arthritis: An update Laura Quarte et al. Juvenile idiopathic arthritis: An update
on clinical and therapeutic approaches. Ann Ital Med Int on clinical and therapeutic approaches. Ann Ital Med Int 2005; 20: 211-2172005; 20: 211-217
Juvenile Rheumatoid Arthritis Juvenile Rheumatoid Arthritis http://www.emedicine.com/ped/topic1749.htmhttp://www.emedicine.com/ped/topic1749.htm
Juvenile Rheumatoid Arthritis Juvenile Rheumatoid Arthritis http://www.emedicinehealth.com/juvenile_rheumatoihttp://www.emedicinehealth.com/juvenile_rheumatoid_arthritis/article_em.htmd_arthritis/article_em.htm
Arthritis in childrenArthritis in children
http://www.medicinenet.com/juvenile_arthritis/article.htmhttp://www.medicinenet.com/juvenile_arthritis/article.htm