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Paediatrics: Rheumatoid factor-positive polyarthritis

A chronic symmetrical infl ammatory polyarthritis (>5 joints) with positive RF on two occasions at least 3mths apart.

Rheumatoid factor-positive polyarthritis

 

A chronic symmetrical infl ammatory polyarthritis (>5 joints) with positive RF on two occasions at least 3mths apart. Typically affects teenage girls, though any age possible. Similar to adult rheumatoid arthritis, but gener-ally a more aggressive disease.

 

 

ARA criteria for diagnosis of rheumatoid arthritis1

•   Morning stiffness: >1hr at peak illness

 

•   Arthritis in at least 3 joints: witnessed by a physician

 

•   Hand arthritis: wrists, MCPs, or PIPs

 

•   Symmetrical arthritis

 

•   Rheumatoid nodules

 

•   Rheumatoid factor-positive

 

•   Erosions on X-ray

 

All symptoms need to be present for at least 6wks. Four or more crite-ria need to be fulfilled for diagnosis of rheumatoid arthritis (RA). These are primarily classification criteria (90% sensitivity and specificity).

 

Clinical features

 

•   History of early morning and immobility stiffness.

 

•   Symmetrical arthritis affecting large and small joints associated with rheumatoid nodules. Wrists and PIPs affected early. Hip involvement can be aggressive and lead to early hip replacement.

•   Tenosynovitis common around fingers and ankles.

•   Systemic features: low grade fever (differential diagnosis systemic JIA); hepatosplenomegaly; lymphadenopathy; serositis (pericarditis and pleurisy).

•   Eyes: uveitis rare; dry eyes relatively common (10–35%); episcleritis can lead to a painful red eye.

 

Investigations

 

•   FBC; CRP; LFTs; RF; ANA.

 

•   Renal function and urinalysis.

 

•   X-rays of affected joints and CXR.

 

Management

 

•   Monitor disease activity and aim for good control of arthritis.

 

•   Regular meticulous assessment for tender and swollen joints, muscle wasting, joint damage, and loss of joint function.

•   Monitor growth development and nutritional status.

•   Exercise: range of joint motion and aerobic activity.

•   Psychosocial development can be severely affected and needs addressing.

 

Treatment

 

• Start treatment as soon as possible.

 

• NSAIDs provide relief from pain, stiffness, and swelling.

 

• All children will need disease-modifying antirheumatic drug (DMARDs): MTX is the least toxic and most well established—orally or SC. Others include hydroxychloroquine, sulfasalazine, azathioprine, ciclosporin, and gold. These have been used in combination with MTX or alone.

 

• Steroids: intra-articular steroids to settle synovitis in individual joints; oral steroids as adjunct to DMARDs; pulsed IV steroids for flare of disease. Aim to minimize total steroid load.

 

• Biologic agents: Anti-TNF agents (etenercept, infliximab, adalimimab) have been shown to reduce joint erosions and may prevent progression to secondary arthritis

 

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Paediatrics: Bones and joints


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