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Joint Pain in Childhood

  • The history and physical examination are key to establish the correct diagnosis of joint pain in childhood and according to that, the Doctor will ask for laboratory and radiologic examination for final diagnosis and appropriate treatment.
  • It’s important to know the nature of pain, duration, frequency, stiffness,  severity. The timing , how many joints are involved and family history of rheumatoid disease, and if there is any other symptoms such as fever, weight loss, fatigue, gastrointestinal symptoms (diarrhea, blood in stool), signs of previous urinary tract infection, tonsillitis, skin rash and any symptoms of inflammation (redness, effusion, warmth) or just joint pain without signs of inflammation, and any precipitating factor such as trauma, infection and immunization.
  • Physical examination includes range of movement of joints, inflammation signs and systemic examination for skin and chest, heart, abdomen, bones and muscles to detect any systemic disease that can cause joint pain or inflammation.

NO INFLAMMATION JOINT PAIN CAN BE:

  1. Growing pain: occurs in young child (4-5 years). The pain might be in the popliteal fossa and its relieve by gentle massage and reassurance. Pain during the day is not a growing pain.
  2. Psychologic Pain: vague joint pain, fatigue, psychological distress, physical examination and laboratory test within the normal.
  3. Periarticular cause: fracture, osteomyelitis, neoplastic disorder such as Leukemia, Neuroblastoma, and Lymphoma associated with infiltration of the bone marrow. 

ACUTE ARTICULAR INFLAMMATION: 

  1. Infections: Staphylococci, streptococci are frequent cause of septic arthritis in childhood. This arthritis present with a single inflamed joint with fever and elevated WBC and ESR.
  2. Reactive arthritis: accompanied by bacterial or viral infection, its polyarticular. The patient has infection and the following morning, he awakes and unable to walk with decrease range of motion, low grade fever without significant elevation of WBC and ESR.
  3. Poststreptococcal reactive arthritis: Child with arthritis and elevated ESR after streptococcal infection.
  4. Acute onset of collagen vascular disease and rheumatic fever: Henoch-schonlein purpura

CHRONIC ARTICULAR INFLAMMATION:

  1. Infection such as Tuberculosis.
  2. Collagen Vascular disease:
  • Juvenile Rheumatoid Arthritis (3 TYPES)
  1. Pauciarticular onset JRA: Involve 4 or less joints. Some patient have (ANA) positive and they are at risk for complicating eye disease (IRIDOCYCLITIS). Some patients with HL AB27 are most likely to have spondyloarthropy in future.
  2. Polyarticular onset: more than 5 joints involvement in the first 6 months. Some patients have RF positive.
  3. Systemic JRA: high fever, rash, variable joint involvement, many children with systemic JRA do well ,others develope significant internal organ involvement or progresse to chronic destructive arthritis.
  • Spondyloarthropathy: The hallmark is asymmetric large joint arthritis associated with limited lumbar flexion and tenosynovitis; (ANA) and RF are negative. Psoriaform arthritis is considered spondyloarthropathy but with positive (ANA) and irridocyclitis.
  • Ankylosing spondylitis: occurs in HLAB27 positive males with radiologic sarcoilitis.
  • Reiter’s syndrome: combination of arthritis, urethritis and conjunctivitis.
  • Psoriatic arthritis: with typical skin lesion and asymmetric dactylitis (sausage digits).
  • Inflammatory bowel disease: the arthritis accompanying inflammatory bowel disease or maybe the initial manifestation. So any child with arthritis who develops chronic or recurrent abdominal pain should be evaluated for presence of ulcerative colitis or regional enteritis.
  • Dermatomyositis: acute inflammatory condition of skin and muscle. The patient has proximal muscle weakness with heliotrope rash and elevated CPK and SGOT and aldolase. The diagnosis is made by muscle biopsy.
  • Systemic lupus erythematosus: characteristic molar rash, fever, failure to thrive, arthralgia, malaise, hematuria or thrombocytopenia, anemia, and leukocytosis, (C3, C4) are low, (ANA) positive, antibodies to ds DNA positive.
  • Henoch-schonlein purpura, purpuric rash with abdominal pain, arthritis and maybe renal involvement.
  • Benign hypermobile joint syndrome
  • Immunization associated arthritis after rubella immunization.
  • Arthritis associated with immunoglobulin deficiency
  • Arthritis associated with cystic fibrosis.
  • Arthritis associated with Marfan and Ehlers syndrome.

INVESTIGATIONS: Plan XRAY, MRI, ultrasound.

LAB TEST: CBC, ESR, ANA, RF, C3-C4 antibodies, ds DNA, HLA B27, Calcium, Phosphorus, Vitamin D, CPK, Aldolase, urine, stool analysis, ECG, Cardio echogram for criteria of rheumatic fever.

The treatment may vary according to the diagnosis.

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