JIA Poly articular.pptx..............case presentation

Case presentation of JIA

1. Welcome to clinical meeting Dr . Sazzadul Amin Resident Year-2 Neonatology Dr. Kripesh Ranjan Roy Resident Year-3 General Pediatrics

2. Particulars of patient Name : Sifat Age : 4 Years Sex : Male Address : Jhenaidah . Date of examination : 29.03.21 Date of admission :29.03.21 Informant : Mother

3. Presenting complaints Pain and swelling of multiple joints for 5 months.

4. History of present illness According to statement of informant mother, Sifat was reasonably well 5 months back. Then he developed pain and swelling of multiple joints, which initially involved the right wrist joint, followed by left wrist joint, both knee joints and both ankle joints. Joint involvement was additive in nature, non migratory and was associated with morning stiffness for more than 1 hour.

5. Pain was severe enough to hamper his daily activities. On query mother gave history of low grade irregular fever for same duration, highest recorded temperature was 101°F, not associated with chills and rigor. He had no history of rash, photosensitivity, oral ulcer, cough, respiratory distress, urinary complaints . .

6. For this illness he visited to several registered physician and was treated with syp . Naproxen, multivitamin and tab. Phenoxymethyl penicillin irregularly and in inadequate dose and duration. But as his condition did not improve, he got admitted into BSMMU for further evaluation and better management.

7. Birth history Antenatal : Uneventful Natal : At term , by NVD at home and average birth weight Postnatal : Nothing significant

8. Developmental history Age appropriate Past illness Nothing significant Immunization history Immunized as per EPI schedule

9. Feeding history He was on exclusive breast feeding up to six months of age, then complementary feeding was started and he is now on family diet.

10. Travelling history No significant travelling history. Family history He is the only issue of his non- consanguinous parents.

11. Socioeconomic history Belongs to lower socio-economic class Father is a farmer. Mother is a housewife. Live in tin-shed house. They use sanitary latrine and drink tube-well water.

12. Treatment History He was treated with Syp . Naproxen, Oral phenoxymethyl penicillin, Tab calcium and vitamin D irregulary and inadequate in dose and duration.

13. Physical examination

14. General examination Appearance- sick looking Pallor- mild Temp-98.6⁰ F Jaundice Cyanosis Edema Dehydration Clubbing Absent

15. General examination Lymph node- not palpable Skin survey : BCG mark –present. Ear, nose and throat: normal Back and spine: normal Bed side urine for albumin: nil

16. Vital signs: H/R : 100 beats /min R/R : 20 breaths/ min BP : 90/60mmHg ( both systolic and diastolic BP lies between 50 th and on 90 th centile)

17. Weight : 16 kg (lies at 50 th centile ) Height : 106 cm (75 th to 90 th centile ) Anthropometry

18. Systemic examination

19. Locomotor System Upper limb Look Feel Move Elbow joints Normal Normal Not restricted Wrist joint Swollen(both joints) Tenderness present grade 2/4 Restricted Shoulder joints Normal Normal Not restricted Small Joints of Hands N ormal Normal Not restricted

20. Lower limb Look Feel Move Hip joints Normal Normal Not restricted Knee joints Swollen(both joints) Temp raised Tenderness present Grade 2/4 Patellar tap - + ve , Flactuation test + ve Restriction on flexion Ankle joints Normal Tenderness present Grade 2/4 Restricted Small joints of feet Normal Normal Not restricted

21. Locomotor system: Examination of spine : Normal Temporomandibular Joints : Normal F/O Enthesitis : Absent Schober’s test : Negative Gait: Antalgic gait

22. Alimentary system examination Mouth & Oral cavity : healthy. Abdomen proper: Inspection Abdomen is not distended Umbilicus centrally placed & inverted Engorged vein/visible peristalsis – absent Hernial orifices – intact

23. Palpation: Soft, non tender Liver- not palpable , Spleen – not palpable Fluid thrill : Absent Percussion : Shifting dullness: absent Auscultation: Bowel sound : Present

24. Inspection Shape of the chest : normal R/R : 20 breaths/min Visible vein & Pulsation : absent Scar mark : absent Palpation Trachea : centrally placed Apex beat : left 5 th ICS, medial to mid- clavicular line Respiratory system examination

25. Percussion note Resonant all over the lung fields Auscultation Breath sound : vesicular Added sound : absent Vocal resonance : normal & symmetrical

26. Other systems examination were normal

27. Salient feature Sifat , a 4 years old immunized boy, got admitted with the complaints of pain and swelling of multiple joints of both upper and lower limbs involving both wrists, both knee joints and both ankles joints for last 5 months. Joint pain was additive, symmetrical, non migratory and was associated with morning stiffness. Pain was so severe that he could not perform his daily activities.

28. Sifat also had low grade irregular fever for same duration. He had no history of rash, photosensitivity, oral ulcer, cough, respiratory distress, urinary complaints. He was treated with syp naproxen, tab phenoxy methyl penicillin, tab calcium, vitamin D in irregular and inadequate dose and duration without any significant improvement.

29. On examination he was ill looking, mildly pale. Vital signs were within normal limit. Anthropometrically he was well thriving. On systemic examination he had features of arthritis on both wrists, both knee joints and both ankle joints. There was no organomegaly . Other systemic examination revealed normal findings.

30. Juvenile Idiopathic Arthiritis (Poly articular variety) Provisional diagnosis

31. Differential diagnosis Systemic JIA

32. Juvenile Idiopathic Arthiritis ( Polyarticular JIA) Points in favor: Age : less than 16 years History of multiple joints pain and swelling Duration of disease more than 6 weeks On exam: Features of arthritis present in 6 joints

33. Systemic JIA Points in favor : Age : less than 16 years History of multiple joints pain and swelling Duration of disease more than 6 weeks History of fever On exam : Features of arthritis present in 6 joints Point against: Fever not characteristic No rash No organomegaly , lymphadenopathy or serositis

34. Investigations

35. Investigations C omplete B lood C ount : Hb – 8.9 gm/dl ESR- 90 mm in 1 st hour TC- 13,000 / cumm DC- N -61 % , L -3 3 % Pl a t elet - 450 000/ cumm Urine R / M/E: Protein: Nil RBC: Nil Pus cell: 1-2/HPF

36. SGPT: 14 U/L Serum creatinine: 0.45 mg/dl Serum ferritin : 189 ngm /L (70-140 ng /ml) RF : <9.19 IU/ml (negative) Chest X-ray: normal study Eye evaluation- Normal

37. Final Diagnosis Polyarticular (RF – ve ) Juvenile Idiopathic Arthritis

38. Treatment Counseling Normal diet Syp . Naproxen – 15 mg/kg/day Tab. Calcium Tab. Folic acid

39. Treatment Specific Treatment : Inj . Me thotrexate - 15 mg/ m2 /dos e/week

40. Follow up on Day 2 of hospital Admission Subjective Objective Assessment Plan Pain and swelling of joints persisting Sifat was a lert Temp- 98.4° F Pulse- 90/min BP- 90/60 mm of hg Locomotor system exam: S.J-04 (Both knee,both wrists ) T.J - 06 (Both knees,wrists,ankles (Grade- 2/4) Fluctuation test and patellar tap positive ROM- present static Continue treatment, start MTX after getting all reports .

41. Follow up on Day 6 after addmission Subjective Objective Assessment Plan No new complain Alert, Mildly- pale Afebrile Pulse- 92 b/min BP- 90/60 mm of hg Locomotor system exam: SJ-2 (both knee) TJ -02 ( Both knee, grade1/4 ) ROM- 2 (both knee ) Improved Continue treatment and plan for discharge

42. Patient was discharged and advised to come for follow up after one month with base line investigations.