EpistemisMorning joint stiffness and pain in children over six weeks
Specialty: Pediatrics.
Why it occurs
- Juvenile Idiopathic Arthritis or JIA (heterogeneous group of autoimmune-based inflammatory joint diseases that begin before the age of 16, last at least 6 weeks and have no known cause; divided into oligoarticular, polyarticular and systemic subtypes)
- Post-infectious reactive synovitis or post-streptococcal arthritis (joint inflammation secondary to a previous bacterial or viral infection, usually self-limited but which can persist for several weeks)
- Pediatric Systemic Lupus Erythematosus or systemic vasculitis (autoimmune diseases that present with polyarthritis, malar erythema, kidney involvement and positive immunological markers)
- Subacute or chronic infectious arthritis (joint tuberculosis or Lyme disease due to Borrelia burgdorferi with persistent joint involvement)
- Functional joint pain or joint hypermobility syndrome (pain after exertion without real inflammation or persistent morning stiffness).
Initial workup
Complete general analysis: complete blood count (leukocytosis, thrombocytosis and anemia of chronic disorders are common in JIA), elevated erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). Determination of Rheumatoid Factor (RF), anti-cyclic citrullinated peptide antibodies (anti-CCP) and antinuclear antibodies (ANA, whose positivity in oligoarticular JIA confers a high risk of anterior uveitis). Plain x-ray of the affected joint (to rule out destructive bone lesions or tumors). High-resolution joint ultrasound with power Doppler (highly sensitive study of choice to confirm the presence of active synovitis, increased synovial blood flow and joint effusion). Slit lamp examination by pediatric ophthalmologist.
red flags
Presence of high fever in daily peaks (typically predominantly nocturnal, which descends rapidly associated with an evanescent maculopapular rash of salmon pink color, characteristic of systemic JIA); painful ocular involvement with red eye, photophobia or decreased visual acuity (suspicion of chronic anterior uveitis associated with JIA, frequently asymptomatic in the initial stages, requiring slit lamp screening); Persistent, progressively worsening lameness with signs of periarticular muscle atrophy; associated generalized lymphadenopathy, hepatosplenomegaly or serositis; severe limitation for the child's daily activities or delay in body weight growth.
Standard management
- Naproxen — non-steroidal anti-inflammatory drug of initial choice for the control of pain and joint inflammation in JIA; dose of 10 to 20 mg/kg/day orally divided into two doses with food) or Ibuprofen (dose of 30 to 40 mg/kg/day divided into 3 or 4 doses
- Methotrexate — disease-modifying drug or non-biological DMARD, indicated in polyarticular or refractory forms; dose of 10 to 15 mg/m2 orally or subcutaneously once a week, administered together with folic acid to reduce toxicity
- Intra-articular infiltration with triamcinolone hexacetonide — indicated in oligoarticular forms to induce rapid remission of the affected joint, performed in the operating room or under sedation by a specialist
- Biological drugs such as Etanercept or Adalimumab (TNF-alpha antagonists, indicated in refractoriness under strict rheumatological indication).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Pediatrics
- Listed causes
- 5
- Treatment options
- 4