Pediatric Rheumatology Video Conference Permanente Medicine Today

Review:

On June 8, 2012, Dr. Charles Wibblesman hosted a Permanente Medicine Today video conference with Kaiser Oakland’s  Pediatric Rheumatologists,  Suhas Radhakrishna, MD and Elizabeth Shaw.

This video conference can be viewed here:  http://insidekp.kp.org/ncal/tpmgphysicianed/media/video/pediatric_rheumatology/index.html

Drs Radhakrishna and Shaw reviewed several highlights from a recent publication from the Pediatric Clinics of North America.  This thorough review of pediatric rheumatologic disorders has several chapters.  One of the more informative chapters is:  Laboratory Testing in Pediatric Rheumatology.  

The entire publication can be found here.

Drs Radhakrishna and Shaw presented a case-based video conference reviewing the presentation, work-up, indications for referral and treatments for rheumatologic disorders.

With all cases, they stressed that the evaluation of rheumatologic disorders begins and continues with a through history and physical examination.  Laboratory studies should include basic labs and under most circumstances, ANA and Rheumatoid Factor are not indicated with the initial evaluation.

Highlights:

Arthritis, which is defined as joint pain, swelling, warmth, limited movement or pain with movement, should be differentiated from Arthralgia, which is joint pain without signs of inflammation.

The differential diagnosis of a child presenting with arthritis should include: infection, post infectious arthritis (benign toxic synovitis), malignancy (leukemia, bone lesion), Juvenile Idiopathic Arthritis (JIA), non-accidental trauma, and hemarthrosis.

Initial laboratory evaluation of a child with mono-articular joint swelling should include:

·       CBC with differential

·       ESR

·       LDH

·       Uric Acid

·       Lyme titers

·       ALT

·       Lytes

·       BUN and creatinine. 

In addition, a urinalysis and radiographs (to rule out cyst, malignancy) should be obtained and a PPD should be placed.

ANA and RF are not useful lab studies during the initial work-up.  15% of the population will have a positive ANA and have no clinical signs of rheumatic disease.  In patients who are already diagnosed with JIA, a positive ANA is helpful as it is associated with increased risk of uveitis.

For patients with poly-articular symptoms, Rheumatologic Factor (RF) and CCP antibody should be ordered as well as the above mentioned labs.

Ophthalmology referral to evaluate for uveitis should be considered in patients with suspected JIA.

Treatment for Juvenile Arthritis can include NSAIDs such as Naprosyn 5 to 10 mg/ kg per dose, (500mg max per dose).  If naproxen is not working, a rheumatology specialist will consider steroid injection of the affected joint.  A single corticosteroid injection in a patient with mono-articular JIA could elicit years of dormancy.  Close follow-up is maintained as relapses can happen. 

Patients with poly-articular involvement need systemic treatment with immunosuppressants.

Editor’s Commentary:

This case-based videoconference offers the physician a methodical and strategic approach in evaluating rheumatologic disorders and other similar conditions.   If not already viewed, this videoconference is well worth the time to do so now.

The Oakland Pediatric Rheumatology eConsult page is rich with clinical pearls that help guide the primary care physician.  It offers synopses of clinical presentations and laboratory recommendations for pediatric rheumatologic disorders such as Dermatomysitis, Fever of Unknown Origin, Pain Syndrome, Periodic Fever, Raynauds, Scleroderma, SLE (Lupus), Vasculitis, and Juvenile Arthritis.   All pediatricians and family practice doctors are encouraged to review this eConsult site.http://insidekp.kp.org/ncal/tpmgphysicianed/media/video/pediatric_rheumatology/index.html