Selected causes of joint pain in

childhood Infection

 Bacterial osteomyelitis± septic arthritis

 Mycobacterium
 Post viral (rubella, EBV, hepatitis B etc)
 Lyme arthritis
Selected causes of joint pain in
childhood

Malignancy
 Leukemia
 Neuroblastoma
 Osteoid osteoma
Selected causes of joint pain in
childhood

Juvenile arthritis
 Systemic JA
 Pauciarticular JA
 Polyarticular JA
 Juvenile spondylitis
 Juvenile rheumatoid arthritis
Selected causes of joint pain in
childhood

Arthritis of other rheumatic diseases

 Juvenile psoriatic arthritis
 Dermatomyositis
 Systemic lupus erythematosus (SLE)
 Scleroderma
 Mixed connective tissue disease (MCTD)
 necrotizing vasculitis
 Reflex dystrophy
Selected causes of joint pain in
childhood

“Reactive” arthritis
 Reiter's syndrome
 Rheumatic fever
 Meningitis with H. Influenza:
meningococcus
Selected causes of joint pain in
childhood

 Henoch Schonlein Purpura

 Kawasaki's disease
Selected causes of joint pain in
childhood

Arthritis associated with chronic diseases

 Arthritis of inflammatory bowel disease
 Cystic fibrosis
 Sickle cell disease
 Hemophilia
 Thalassemia
Selected causes of joint pain in
childhood

Orthopedic causes
Hip
 slipped capital femoral epiphysis
 Legg-Calve-Perthes' disease
Knee
 synovial hemangioma
 discoid meniscus
Terminology / classification
of juvenile arthritis
Classic American classification
(refers to juvenile rheumatoid arthritis –JRA)
Systemic JRA
Pauciarticular JRA
Type I - ANA positive (young girls)
Type II- HLA B27- positive (older boys)
Polyarticular JRA
Rheumatoid factor-negative (younger children)
Rheumatoid factor-positive (older children)
Criteria for Classification of Juvenile
Arthritis

 Age of onset<16 years

 Arthritis in one or more joints defined as
swelling or effusion, or presence of two or
more of the following signs: limitation of
range of motion, tenderness or pain on
motion, and increased heat
 Duration of disease › 6 weeks

Cassidy & Petty 1990

Criteria for Classification of Juvenile
Arthritis

 Type of onset of disease during the first 6

months classified as:
 a. Polyarthritis: 5 or more joints
 b. Pauciarticular (oligoarthritis: 4 or
fewer joints)
 c. Systemic disease: arthritis with
intermittent fever
 Exclusion of other forms of juvenile arthritis

Cassidy & Petty 1990

Features of JA

Systemic Pauciarticular Polyarticular Juvenile Seropositive

JA JA JA spondylitis JA
• Median age at
onset (years) 5 2 3 10 12

• % of patients 10 40 20 20 10

• sex ratio M=F F>M F>M M>F F>M

• ANA No 60% 25% No 60%

• Rheumatoid factor No No No No 100%

• HLA association _ DR5 - B27 DR4

• Chronic uveitis No 30% 10% No No

• Prognosis of 30% sever 10% sever 20% sever mild but >75% sever
arthritis spondylitis
later
Non JA causes of MSK pain in Children

 Hypermobility Syndrome
 Pes Planus
 Genu recurvatum
 Patellar dislocation
 Chondromalacia Patella
 Osgood Schlatter disease
 Tenosynovitis
 Frostbite arthritis
 Reflex Sympathetic Dystrophy (RSD(
 Growing pain
 fibromyalgia
HLA Relationship in Children with JA

TYPE OF ONSET CLASS I CLASS II

Oligoarthritis (early onset =6 years) A2, B44,35,16, Dw7, DR4

Cw4

With uveitis Dw/DR5

Dw/DRw8
Dw6
DRw52,w62
DPw2

Without uveitis DR5,w8

ANA+ A2 DR5,w6,w8
DQw1

Polyarthritis B8,15 Dw14

RF+ Dw/DR4

Systemic disease B8,35 DR4

Dw7
ETIOLOGY
HLA
Environmental factors
infection
mycoplasma
parvo V
Rubella V
Klebsiela
Chlamydia
Reoviruses

Barometric pressure
Humidity (high)
pressure (low)

Diet

UV irradiation (juvenile dermatomyositis,

systemic lupus erythematosus – SLE (

Immune complex disease (heumatic fever, SLE, Henoch

Schonlein purpura)
Systemic Onset juvenile
arthritis
 fever 100%
 arthritis 100%
 rash 95%
 hepatosplenomegaly 85%
 lymphadenopathy 70%
 pericarditis 35%
 pleuritis 20%
 abdominal pain 10%
 muscle pain 5%
 uveitis <1%
Systemic Onset juvenile
arthritis

 fatigue
 anemia
 anorexia
 leukocytosis
 high acute phase reactants
Spondyloarthropathy
 low back pain and stiffness
 pauciarticular disease-small and large joints
 asymmetry in joint involvement
 painful arthritis
 enthesitis
 dactylitis
 sacroileitis
 limitation of chest expansion
 tenosynovitis
 uveitis
 reactive
arthritis IBD

Reiter's ankylosing
SEA
syndrome spondylitis
syndrome

Psoriatic
arthritis
 Comparison of juvenile
spondyloarthropathies

JRA JAS SEA

M:F 1:4 7:1 9:1
Average age of onset 5 >10 10
Average # joints 9 6 5
Fx Hx 30% 65% 65%
Back pain 2% 100% 45%
ANA +ve 30-80% 0% 0%
RF +ve 15% 0% 0%
HLA B27 15% 90% 72%