Complaints

Ulcerative colitis and regional enteritis are collectively referred to as inflammatory bowel disease (IBD). It is well known that some children with these diseases have arthritis that typically takes the form of a spondyloarthropathy and which may become evident before the IBD. Studies have demonstrated that many individuals with spondyloarthropathy have an unusual appearance to their gastrointestinal mucosa (lining). Exactly how this relates to developing arthritis is uncertain. Children with...

Enthesitisassociated Arthritis

The term spondyloarthropathy does not refer to a specific disease. Meaning arthritis involving the back, it describes a pattern of inflammation that may occur in children with a variety of underlying conditions. For many years, children with spondyloarthropathies were considered to have JA, but now these children are described as having enthesitis-associated arthritis. Although enthes-itis-associated arthritis is considered a subtype of juvenile arthritis, it is important to recognize that this...

Differential Diagnosis Of Lyme Disease

Lyme disease is a typical infection-associated or reactive arthritis. As a result, it can be confused with other infection-associated types of arthritis. The key differences in children with arthritis due to Lyme disease are the absence of a recent infection (most children develop infection-associated arthritis ten to fourteen days following a recognized illness) and the presence of a positive Lyme titer. Systemic lupus erythematosus and other forms of collagen vascular disease may also begin...

Specific Conditions

In wryneck, also called torticollis, the child holds the head to one side because of problems with the sternocleidomastoid muscle, at the front of the neck. This muscle is sometimes injured at birth and becomes shortened as a result of the injury. Children with this problem may develop neck pain as they get older and their muscles try to compensate. Wryneck in older children is usually due to an injury to a neck muscle, such as from carrying a heavy backpack on one side. Neck muscle injury is...

Testing for a Knee Flexion Contracture

Have your child sit on the floor with legs together and outstretched. A normal child can put the back of his or her knee flat on the floor so you cannot even slip a piece of paper underneath it. If you can see a space under the knee or slip your fingers under it, there is a flexion contracture. Children who continually favor the leg that hurts will eventually develop a weakening (atrophy) of the muscles in that leg. As with flexion contracture, physical therapy can help prevent this problem. An...

Treatment Of Kawasaki Disease

Once the diagnosis of KD is established, the antibiotics can be stopped and appropriate anti-inflammatory therapy started. Intravenous IgG is usually given right away because it very quickly stops the inflammation associated with KD. The early administration of IV IgG (within ten days of the onset of symptoms) has been shown to dramatically reduce the risk of developing coronary artery aneurysms. If physicians are unsure of the diagnosis but want to treat with IgG, they should save a tube of...

Heart Involvement in SLE

Mild heart involvement is common in children with SLE but does not usually become significant. Pericarditis (involvement of the pericardium, the fibrous sac containing the heart) may cause chest pain that may worsen with deep breaths or changing position, such as leaning forward. Pericarditis can be detected easily with an echocardiogram. Children with chest pain must also be evaluated for pulmonary emboli (see Lung Involvement in SLE, below). Minor thickening of the pericardium is often found...

Linear Scleroderma en Coup de Sabre and Parry Romberg Syndrome

Linear scleroderma en coup de sabre is a particular form of linear scleroderma that may not truly be related to the other forms. Children with linear sclero-derma en coup de sabre have an area of thickened abnormal skin involving one side of the forehead and extending along the scalp toward the back. They usually do not have significant underlying problems. Parry-Romberg syndrome is a gradually progressive facial hemiatrophy. In a full-fledged case, there is significant deformity, with one...

American College of Rheumatology Criteria for a Diagnosis of Definite SLE

Malar rash a red rash over the cheeks (often crossing over the nose) 2. Discoid rash a scaly red rash (uncommon in children) 3. Photosensitivity burns easily in sun, rashes and sensitivity to light 4. Mucosal ulcers sores in the mouth or nose 5. Serositis inflammation of the lining of the chest or abdomen, producing pain 6. Arthritis pain swelling or limitation of motion of a joint 7. Renal involvement abnormalities on the urine tests or blood tests 8. Neurologic involvement problems with...

Psoriatic Arthritis

Psoriatic arthritis is another spondyloarthropathy that requires special attention. Pediatric rheumatologists continue to debate exactly who belongs in this group, since a child does not have to have psoriasis to have psoriatic arthritis, and children might have another form of arthritis and coincidentally have psoriasis. It is called psoriatic arthritis because over the course of as much as ten to fifteen years, many children who have this type of arthritis will develop psoriasis. Whether they...

Laboratory Tests

Lab test results must be viewed as part of the total picture of the patient, along with a good history and physical examination. Many rheumatic diseases are associated with abnormal laboratory tests, but there are diseases in which all the tests are normal. Conversely, many children are found to have mild laboratory abnormalities but do not have rheumatic disease. It is also important to remember that laboratory tests are not always accurate. Always recheck a result that does not make sense, or...

Linear Scleroderma

Linear scleroderma differs from morphea in that the areas of involved skin form linear bands instead of irregular ovals. Its cause remains unknown. A typical case of linear scleroderma in a child presents as a tight band of skin on the top of one foot extending up onto the leg. It may also begin on the hand and arm. These areas appear pinkish at first and don't hurt. Later they become pale and harden. A small area of involvement may be of little concern, but if a large area is involved,...

Gold Shots

Gold sodium thioglucose and gold sodium thiomalate (brand names Myochrysine and Solganol, also known as gold shots) were the standard of therapy for difficult arthritis in adults and children when I began my career. For many children, they were dramatically effective, bringing a slow but steady resolution of the arthritis. The major difficulty with gold shots is that they require painful intramuscular injections. The injections are given weekly until the arthritis is well under control and then...

Synovial Fluid Aspiration

Synovial fluid aspiration, or the removal of fluid from an inflamed joint, is often done in the physician's office. However, sometimes it is done in the radiology department because physicians want to use X-ray guidance or ultrasound to make sure the needle is in the right place. Synovial fluid aspiration is normally done for the purpose of analyzing the fluid to look for evidence of infection, bleeding, or tumors. In children, the test is done most often to exclude the possibility of...

Specific Knee Conditions

Osgood-Schlatter disease is the result of inflammation of the patellar tendon where it attaches to the lower leg. As children grow, it takes time for the tendons (tissues that attach muscle to bone) to become firmly attached to the bone. During periods of rapid development, such as from nine to fifteen years of age, children's muscles often strengthen more rapidly than the tendon-bone attachment does. Running and kicking, such as while playing sports, leads to repeated pulling on the tendon...

Kidney Involvement in SLE

Kidney (renal) involvement is one of the most worrisome aspects of SLE. However, there are varying degrees of kidney involvement, from the very mild to the very severe. Approximately two-thirds of children with SLE will have at least mild kidney involvement at the time they are diagnosed. Most but not all children with significant kidney involvement have evident abnormalities on a urinanalysis when they are first brought to the doctor. In a child with obvious SLE, the physicians may elect to...

Treatment Of Lyme Disease

Optimal treatment for Lyme disease is dependent on the age of the child, the manifestations of the disease, and whether the child has any allergies to drugs. Young children are typically treated with amoxicillin, while children over the age of ten are typically treated with doxycycline. Doxycycline is not used in younger children because it will become incorporated in the enamel of developing teeth and may cause a permanent grayish stain. Some physicians feel it is acceptable to use doxycycline...

Complications Of Kawasaki Disease

Once the diagnosis of KD has been properly established, the major concern is whether the child has any cardiac involvement. Early in the illness, a small number of children develop inflammation of the muscles of the heart (pancarditis). Some children develop a coronary artery aneurysm (a bulge in the wall of an artery near the heart). The risk is that the bulge may fill with clotted blood, blocking blood flow and causing a heart attack. Fortunately, this is rare. The second major concern is...

Hand Wrist and Finger Pain

Finger injuries are extremely common in children of all ages. Obvious fractures are easily recognized and quickly diagnosed by appropriate X-ray examination. FIG 3-11 The muscles of the shoulder and the rotator cuff. Injuries often result from the muscles enlarging with athletic activity to the point where they are irritated as they pass between the bones. FIG 3-11 The muscles of the shoulder and the rotator cuff. Injuries often result from the muscles enlarging with athletic activity to the...

Chemistry Panel

The chemistry panel, also called the metabolic panel or serum multichannel automated chemistry (SMAC), consists of a variety of tests that document primarily the function of the liver and kidneys. In some hospitals, the test includes electrolytes and a lipid profile, but there is some variation between laboratories in the list of tests included. Serum glucose refers to the amount of sugar in the blood. The level may be elevated or decreased in diabetics but is usually normal in children with...

Midfoot Pain

A number of different conditions may cause pain in the middle of the foot. Again, acute injuries are obvious and easily recognized with appropriate X-rays. The most common serious cause of chronic foot pain in active children is a stress fracture of the metatarsals. Stress fractures are overuse injuries found in many different sports, ranging from football and soccer to dance and gymnastics, and can occur in other parts of the body as well. They are typically treated with casting and rest....

Muscle Enzymes Creatine Kinase and Aldolase

Creatine kinase (CK) is an enzyme produced by skeletal muscles, the heart muscle, and the brain. Although it may be elevated in adults who have recently suffered a heart attack, the most frequent cause of elevations in childhood is muscle inflammation. This may occur in children with dermatomyositis, scleroderma, or mixed connective tissue disease. Sometimes the CK is elevated with extensive exercise, but in these children the level goes back to normal after two weeks' rest. The level of CK is...

Treatment for Pauciarticular Onset Arthritis

Treatment for pauciarticular-onset arthritis usually consists of nonsteroidal anti-inflammatory drugs (NSAIDs). These drugs are discussed in detail in Chapter 20. I often use diclofenac for children with pauciarticular-onset disease that does not respond adequately to other NSAIDs. Naproxen, celecoxib, nabumetone, and diclofenac have the advantage of being given less frequently than ibuprofen. For children who have true pauciarticular arthritis, it is rare for additional medications to be...

Common variable hypogammaglobulinemia This is a condition in which children with immature immune systems do not have

Children from three to seven years of age who limp whenever they have a viral infection often have low immunoglobulin levels. On evaluation they often have a very mild degree of periarticular pain and no other obvious findings. The complaints typically disappear in a day or a few days, when the infection has resolved. However, the limp or other joint pains may recur with subsequent infections. I have seen a number of children with six, seven, or even eight such episodes. Routine...

Urinalysis

Examination of a urine specimen (urinalysis) is the easiest way to determine whether the kidneys are inflamed or damaged. When damaged, the kidneys can leak red or white blood cells or protein. A typical urinalysis report will describe the specific gravity, which reflects how well the kidney is concentrating the urine. This must be evaluated with reference to whether someone has been drinking a lot or is dehydrated. If a person is dehydrated, the urine should be concentrated and have a high...

Sclerodermatomyositis

Sclerodermatomyositis is an overlap disorder in which there is a band of tight skin that appears to be linear scleroderma, but also the muscle weakness, elevated muscle enzymes, and heliotropic rash (a rash in areas exposed to sun, often the face and eyelids) typical of dermatomyositis (see Chapter 14). The simultaneous occurrence of manifestations of two separate diseases in these children is unexplained. Laboratory abnormalities found in children with sclerodermatomyositis include a positive...

Elbow Pain

Nursemaid's elbow is one of the more common causes of distress in young children. Parents usually notice that a young child (two to three years is the peak age group) is holding the arm bent and not using it. It is most often the left arm, but either may be involved. Typically, the injury occurs when a parent or sibling tugs hard on the arm as the child is leaning away. It can also happen if you pick the child up by the arm (this should be avoided). The excessive stress on the elbow causes the...

Specialized Tests

The antinuclear antibody (ANA) test determines whether serum from the child's blood reacts with various types of material in the nuclei of cells. ANA testing used to be very significant in diagnosing children with rheumatic disease. The main problem with the test was that the results were difficult to compare between different laboratories. Each lab used its own materials for running the test and did its own calibrations. In the early 1980s it was decided that a standardized test would be...

Dermatomyositis and Polymyositis

Dermatomyositis in childhood is characterized by weakness of the proximal muscles those muscles closest to the trunk and rash. In most cases the disease begins slowly, with the gradual onset of progressive weakness. However, a small percentage of cases begin with dramatic fever, rash, elevated muscle enzymes, and profound weakness. Dermatomyositis may begin in any age group, sometimes affecting very young children and at other times teenagers. The dermato-myositis that occurs in adults appears...