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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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