reactive arthritis 02.19.2014

8/12/2019 Reactive Arthritis 02.19.2014

1/18

Tyson Jones, MD, PGY2

2/19/14

Morning Report


2/18

HPI T.H. is a 2 year old previously

healthy male

Fever to 103, NB/NB emesis x2, and limp x 1 day.

Diarrhea x 3 days, approx 2

weeks ago. Complaining of pain with lifting

legs up for diaper changes.

Taken to PCP the next day withfever of 104F despite motrin

and tylenol alternating Q3hr. Admitted to OSH x 4 days,

then transferred to PCH.


3/18

PAST MEDICAL HISTORY: Term birth, no complicationsat birth. No chronic medical conditions. Has had 2 earinfections treated with antibiotics, but none in the past 4

months. Otherwise healthy. PAST SURGICAL HISTORY: No surgeries

IMMUNIZATIONS: Up to date including the flu shot.

MEDICATIONS: None regularly. Has been taking tylenoland motrin alternating Q3hr with this illness.

ALLERGIES: none

DIET: normal for age

FAMILY HISTORY: PGF with T2DM, otherwise negativefor cancer, recurrent infection, arthritis or immunologic

diseases. SOCIAL HISTORY: Lives with parents and older sisters

ages 9, 7, and 5y. No pets in the home, no recent travel,no exposures to farm or exotic animals.


4/18

REVIEW OF SYSTEMS +fever +complaints of pain in genital region vs hip

+vomiting

+??Limp

+diarrhea 2 weeks ago

- coryza/rhinorrhea

- rash

- cough - swelling/erythema

- no known trauma


5/18

PHYSICAL EXAM

T 38.6. HR 140. BP 113/55. RR 34. SaO2 98% on Room Air.

WEIGHT - 11.5 Kg, (8th%ile) HEIGHT - 86.5 cm, (10th%ile)GENERAL: Very irritable with exam during exam, minimallycooperativeHEAD: normocephalic, atraumatic.EYES: normal red reflex and pupillary reflexes bilaterally,

extraocular movements intact, conjugate gaze, no conjunctivalinjection.EARS: Normal tympanic membranes, no erythema.NOSE: no discharge or obstruction.OROPHARYNX: moist mucus membranes, no exudate, nopharyngeal erythema.

NECK: supple without lymphadenopathy or tenderness topalpation. Normal ROM.


6/18

PHYSICAL EXAM continuedCARDIOVASCULAR: tachycardic, normal rhythm, normal S1/S2, nomurmur, no gallop, normal pulses.

LUNGS: clear to auscultation bilaterally, no retractions.

ABDOMEN: non-tender, Difficult exam due to upset patient.

EXTREMITIES: all extremities warm and well perfused. No cyanosis, or

edema including no joint effusion noted.

BACK: no abnormalities noted, though difficult to assessGENITOURINARY: normal Male external genitalia.

NEUROLOGIC: Fussy with exam, consolable with mom, moves all

extremities equally in the bed without gross deficit, patellar tendon reflexes

normal.

SKIN: no rash

MUSCULOSKELTAL: passive ROM intact, though he does exhibit slight

guarding of left knee and hip, no erythema surrounding hip, knee, or

ankle joints. No joint effusion noted. Normal muscle strength. On fourth

exam of the day: Walks with stiff left leg and slightly inturned left foot.


7/18

DDx

2 yo M with vomiting, diarrhea, fever, and limp x 4days


8/18

Bone Conditions:

Benign neoplasm

Osteoblastoma

Osteoid OsteomaCongenital condition

Club foot

DDH

Developmental Condition

Legg-Calve-Perthes

diseaseSCFE

Infection

Osteomyelitis

Limb length discrepancy

Malignant Neoplasm

Ewing Sarcoma

LeukemiaOsteosarcoma

Osteonecrosis

Sickle Cell Disease

Overuse injury

Stress Fracture

Trauma

Toddlers Fracture

Intra-abdominal Conditions

Appendicitis

Neuroblastoma

Psoas-Abscess

Intra-Articular Conditions

Congenital conditions

Discoid lateral meniscus

Hemarthrosis

HemophiliaTrauma

Infection

Gonorrhea

Lyme Disease

Septic Arthritis

Inflammation

Acute rheumatic feverJuvenile Rheumatoid

Arthritis

Reactive Arthritis

SLE

Transient Synovitis

Neuromuscular conditions

Cerebral Palsy

Meningitis

Muscular DystrophyMyelomeningocele

Soft-Tissue conditions

Infection

CellulitisPyomyositis or viral

myositis

Soft tissue abscess

Chondromalacia patellae

Jumpers knee

Osgood-Schlatter disease

Sever disease

Spinal Conditions

Diskitis

Spinal Cord Tumors

Vertebral Osteomyelitis

BROAD DIFFERENTIAL FOR CHILD WITH A LIMP:


9/18


10/18


11/18

Labs:Pertinent OSH Labs:

CBC: WBC 18.2 (Band 5, Seg 52, Lymph 35), Hgb 11.6, Hct 35.4, Plts281

BMP: Normal

Blood culture: NG

VRP: Coronavirus OC43+

PCH labs:

WBC: 24.0->14.0->13.8->18.2-

>10.5

CRP: 4.08->2.72->9.18->4.4

ESR: 11->17.0

UA: SG 1.020, pH 6, cloudy, trace

protein, neg nitrite, neg LE

Urine micro (clean catch): few

bacteria

Repeat UA: normal

D dimer 377

Ferritin 141

CK 52

CMP: normal

ASO


12/18

Imaging

OSH: Pelvic Xraynormal OSH: Pelvic and Knee USnormal

Bone Scan: Normal bone scan. No evidence of osteomyelitis.SPECT: Normal bone scan SPECT of the pelvis and femurs. Noevidence of osteomyelitis

CT abdomen and pelvis : Normal CT of the abdomen andpelvis. Normal appendix.

MRI Pelvis: No sign of joint effusion/synovitis, osteomyelitis, orpyomyositis.

MRI L Leg: Very small area of abnormal signal andenhancement in the lateral anterior thigh musculature. No otherabnormality.

Renal US: Right: Normal. Left: Normal.

Abdominal US: No ileocolic intussusception. Small amount ofright lower quadrant free fluid.


13/18

DIAGNOSIS: Reactive Arthritis


14/18

REACTIVE ARTHRITIS

A form of non-septic

arthritis developing after

an extra-articular infection

Arthritogenic bacteria: GI: Salmonella, Shigella,

Yersinia, Campylobacter

GU: Chlamydia,

Ureaplasma


15/18

Clinical Manifestations Several stages involved:

Clinical infection precedes the appearance of arthritisand/or enthesitis by 1 to 4 weeks

Active period of weeks to months Sustained remission or recurrent episodes which may

evolve to enthesistis related arthritis, especially inpatients that are positive for HLA B27Acute arthritis and/or enthesitis usually seen (may see

tenosynovitis, bursitis, dactylitis) Patients may continue to have fever, weight loss, fatigue

and muscle weakness Painless, shallow mucosal ulcers are common Urethritis and cervicitis are rare Conjuctivitis occurs in about two thirds of children at

onset


16/18

Laboratory Studies

Mild decrease in hemoglobin and leukocytosiswith neutrophilia

Elevated inflammatory markers (platelets,

immunoglobulins, ESR and CRP)

Autoantibodies (RF and ANA) are usually absent

but reactive arthritis most frequently occurs in

HLA-B27 positive individuals

Synovial fluid is sterile Cultures (blood, urine, stool) obtained at the time

of infection may be positive


17/18

Treatment:

NSAIDs Meloxicam 2.25mg PO qday x 1-2 months.

No clear evidence that antibiotics during the

inflammatory phase alter the course of the

disease

Rarely, corticosteroids (oral or intra-articular) may

be required


18/18

References

1. Carter JD, Hudson AP. Reactive arthritis: clinicalaspects and medical management. Rheum Dis

Clin North Am 2009; 35(1):21-44.

2. Rihl M, Klos A, Khler L, et al. Infection and

musculoskeletal conditions: Reactive arthritis.Best Pract Res Clin Rheumatol 2006;

20(6):1119-37.

reactive arthritis 02.19.2014

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