Pediatric Rheumatology in Clinical Practice PDF
Preview Pediatric Rheumatology in Clinical Practice
Pediatric Rheumatology in Clinical Practice Pediatric Rheumatology in Clinical Practice Patricia Woo, Ronald M. Laxer, and David D. Sherry Patricia Woo, CBE, MBBS, PhD, FRCP, FMedSci Professor of Paediatric Rheumatology, Director of the Centre for Paediatric and Adolescent Rheumatology, University College London Great Ormond Street Hospital for Sick Children and University College Hospital, London, UK Ronald M. Laxer, MD, FRCPC Vice President, Clinical and Academic Affairs, The Hospital for Sick Children Professor of Pediatrics and Medicine, University of Toronto, Toronto, Ontario, Canada David D. Sherry, MD Director, Clinical Rheumatology, Attending, Pain Management, Departments of Rheumatology and Anesthesiology, The Children’s Hospital of Philadelphia Professor of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA British Library Cataloguing in Publication Data A catalogue record for this book is available from the British Library Library of Congress Control Number: 2006923490 ISBN-10: 1-84628-420-1 e-ISBN-10: 1-84628-421-X ISBN-13: 978-1-84628-420-5 e-ISBN-13: 978-1-84628-421-2 Printed on acid-free paper © Springer-Verlag London Limited 2007 Apart from any fair dealing for the purposes of research or private study, or criti- cism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc., in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 9 8 7 6 5 4 3 2 1 Springer Science+Business Media springer.com Preface Pediatric rheumatology is a relatively new speciality, with many fascinating conditions peculiar to young people. Many of these disorders are only rarely encountered by the generalist and so often present as diagnostic dilemmas. Our aim in producing this manual is to provide easily accessible and practical infor- mation in a pocket book. We aim to assist the pediatrician, the general practitioner, as well as rheumatologists with an interest in pediatric rheumatology, in the diagnosis and management of these diseases and problems. The emphasis has been placed on clinical presentation and how to arrive at a diagnosis, and an up-to-date management plan. Brief background information on the etiology is also provided. We sincerely hope that the infor- mation herein will help decrease the impact of these conditions on the children and their families by timely diagnosis and early intervention. Patricia Woo Ronald M. Laxer David D. Sherry Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . v Part I Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 1. General Presentation of Musculoskeletal Problems in Childhood . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 2. General Principles of Management . . . . . . . . . . . . . 16 Part II Inflammatory Rheumatologic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 3. Juvenile Idiopathic Arthritis (JIA) . . . . . . . . . . . . . . 23 4. Systemic Lupus Erythematosus (SLE) . . . . . . . . . . . 47 5. Juvenile Dermatomyositis . . . . . . . . . . . . . . . . . . . . 66 6. Scleroderma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 7. Overlap Syndromes . . . . . . . . . . . . . . . . . . . . . . . . . 90 8. Vasculitis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97 9. Lyme Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118 10. Autoinflammatory Syndromes . . . . . . . . . . . . . . . . . 123 11. Acute Rheumatic Fever and Post Streptococcal Arthritis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137 viii CONTENTS Part III Noninflammatory Rheumatologic Diseases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143 12. Noninflammatory Mechanical Pain Syndromes . . . . 145 13. Amplified Musculoskeletal Pain . . . . . . . . . . . . . . . . 155 14. Hereditary Conditions of Bone and Cartilage . . . . . . 166 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Part I Introduction Chapter 1 1 General Presentation of Musculoskeletal Problems in Childhood 1.1 INTRODUCTION The rheumatic diseases in children range from affecting a very iso- lated part of the body to including almost every organ and body system. The key to making a diagnosis usually rests in the patient’s history and physical examination. Paramount is the knowledge of what normal is, especially in the musculoskeletal examination. It is then, just a matter of recognizing the patterns of the various rheumatic diseases. Laboratory and imaging studies help sub- stantiate a diagnosis, and at times are essential, so determining the most efficacious use of these resources is vital. However, there exist children who defy our classification systems and will have features of several concurrent rheumatic diseases (overlap syn- dromes) or just part of a disease. It may take years before enough manifestations of their disease develop before a diagnosis can be definitively made (if ever). Additionally, some children will evolve from one diagnostic category into another so one needs to always be vigilant when caring for children with rheumatic illnesses. 1.2 RHEUMATOLOGIC HISTORY A typical rheumatologic history is on Table 1.1. Determining if a condition is inflammatory is generally the first step. Inflamma- tion is characterised by pain, warmth, redness, swelling, and limitation of function. Some inflammatory conditions only have one or two of these findings, and 25% of children with oligoarthritis report no pain. Morning stiffness and gelling (stiff- ness after being still such as in a car ride) are important indica- tors of inflammation. However, pain and loss of function is frequent in those without inflammation so the entire picture needs to be considered before arriving at a conclusion. 1.3 FAMILY HISTORY Many of the rheumatic diseases have a genetic basis so family history takes on an increased importance, including ethnic 4 PEDIATRIC RHEUMATOLOGY IN CLINICAL PRACTICE TABLE1.1. Rheumatologic History Present Illness Chief complaint? (could be pain, fever, rash, fatigue, dry mouth, or other rheumatic symptoms) Present medications and treatments? Recent past medications and treatments? (for this condition and for other conditions) Location of pain? Details of onset: Acute, gradual, traumatic? Duration of pain? Severity of pain: Getting better or worse? Quality of pain: Stabbing, burning, freezing, aching, spasms, crushing? Particular time of day that it is worse or better? Specifically, morning, evening, or nocturnal pain? Does it radiate, migrate, or is it episodic? It is hot or cold to the touch? Does it look different or swollen? Does it interfere with functioning? School attendance, chores, recreation, activities of daily living (dressing, eating, bathing, toileting)? Does anything make it better or worse? Medications, rubbing, ice, heat, activity, rest, distraction? Between 0 and 10, how much does it hurt? (or other pain scale such as Faces Scale). Right now, highest and lowest in the past week? Associated symptoms? Fever, rash, weight change, weakness, sleep disturbance, depression, anxiety, behavior change, cough, vision or hearing changes, headache, abdominal pain, diarrhea, dizziness, unable to concentrate? Past History Allergies Similar problem in the past? Immunization history, especially measles and hepatitis B Hospitalisations and surgeries Recent eye examination? Social History Any new life events? Divorce, moving, school changes, family member changes? Any change in grade in school and school performance? Living with whom? Travel outside the area? Where? Tick bite? Diarrhea? Family History Family members with rheumatic disease (SLE, arthritis, IBD, reactive arthritis, ankylosing spondylitis), psoriasis, back pain or spasms, even if family members know why they have back pain, heel spurs or heel pain, iritis, fibromyalgia, tuberculosis
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