Dear Colleagues;

Greetings! The new team that has taken over the Rheumatology Chapter of the IAP. We

have taken some time to settle down and hope that we can now regularly communicate

with you. A few points that I would like to emphasize are

1. We would like to go green and thus confirm that all further newsletters will be

electronic as this will conserve paper, help you to file the newsletters if you like

and will be significantly low cost.

2. If you would like to be in touch with the RCIAP please ensure that you e mail your

id and your telephone number to Dr. Rashna Dass , Secretary at

rashnadass@gmail.com or to me, Dr. Sujata Sawhney at

drsujatasawhney@gmail.com

3. NO FURTHER PAPER COMMUNICATION WILL BE DONE SO WE URGE YOU TO

PLEASE RESPOND AND HELP TO MAKE THE CHAPTER VIBRANT AND ACTIVE

4. Our newsletters will be thematic and the first one helps Paediatricians to decide

when a patient should be referred to a Paediatric Rheumatologist.

5. Your suggestions are welcome and we will be delighted to take questions/cases/

pictures that you may want to share with us

6. Once again may I request for your cooperation and help us to take the chapter

forward.

7. This news letter:

� Helps you to understand why a child with arthritis needs to be

seen by a Paediatric Rheumatologist and also decide when a

Pediatric Rheumatologist should be involved in the care of such

children

� Gives you details about the forth coming conference at Nagpur

� Gives you details about the short term course on Paediatric

Rheumatology on offer at Mumbai

Happy Reading

Dr Sujata Sawhney

Dr Rashna Dass

(Editorial Board)

1. Importance of early diagnosis of juvenile idiopathic arthritis

(JIA)

Joint pains in children are a

common problem faced by clinicians all over

the world. About 10-20 % of school going

children have some form of musculoskeletal

pain. Rheumatic fever accounts for about

100-150 cases per one million cases and

Juvenile idiopathic arthritis (JIA) for about

16-150 cases per million cases. Practising

Paediatricians are more tuned to think of

tuberculosis, acute bacterial infections,

acute rheumatic fever or growing pains as a

common differential diagnosis of joint pain

in children, particularly in our country with a

huge burden of infectious diseases. Thus JIA

may not even figure in the initial diagnosis

of a child with joint pain.

Rheumatic diseases, and in

particular JIA form an important cause of

lifetime childhood disability which may be

articular or extra-articular in nature. Some

of the more serious complications

associated with JIA are as follows:

1. Articular and peri-articular:

a. Joint deformity

b. Hypoplasia of the temporo-

mandibular joints leading to

restricted mouth opening

c. Ankylosis and narrowing of cervical

spine & joint subluxation and risk

of paraparesis / paraplegia

d. Hip joint erosions and need for

total hip replacement in the

adolescent period

e. Growth failure – short stature

f. Disproportionate growth of limbs-

leg length discrepancy

g. Sacroiliiatis

h. Disuse atrophy

i. Coxa valga deformity

2. Extra-articular:

a. Chronic silent uveitis and

subsequent irreversible blindness

b. Aortic regurgitation

c. Pulmonary fibrosis

d. Vasculitis

e. Carpal tunnel syndrome

f. Sgoren’s syndrome

g. Felty’s sundrome

h. Polyserositis

i. Fulminant hepatic failure

j. Laryngeal stricture secondary to

cricoarytenoid arthritis

k. Amylodosis

l. Macrophage activation

syndrome

A frequent misconception has been that

most of the childhood arthritis would

disappear by childhood. This has been

proved otherwise by various studies

wherein it was demonstrated that most

cases of JIA still had some form of active

disease even after 10 years of follow up. It

was found that 30-70% of cases of

pauciarticular onset, 40-50%of polyarticular

onset and 25-58% of systemic onset still had

active disease at or near puberty. The longer

the follow up, the worse was the functional

state.

Prognosis after proper treatment in

individual subtypes are fairly distinct.

Overall, eighty percent of those with

pauciarticular disease will remain without

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major difficulty at the end of 15 years.

Fifteen percent of the pauciarticular JIA

develop a polyarticular course with severe

joint deformity. But silent uveitis remains a

major problem in this subtype. In the

seronegative polyarticular variety only

about 10-15% have functional disability at

the end of 10-15 years. In contrast the sero-

positive poyarticular variety has a more

severe course in spite of adequate therapy

and a majority continue to have active

disease at 15 years of follow up. Of those

with systemic onset JIA, 50% will remit

without recurrence. Four percent of the

children with systemic onset JIA die from

infection or amyloidosis.

Thus, one can see that the above

statistics bring forth the following

important points to mind while treating

children with JIA:

1. Proper diagnosis and early

aggressive intervention can

minimize both short term and long

term morbidity associated with

these conditions

2. Preserve normal physical, social

and emotional growth and

development

3. Achieve remission of disease

4. Laboratory findings may be minimal

and hence an examination by a

skilled worker is a must.

One must also remember that

Paediatric Rheumatologists are

specially trained for:

1. Differential diagnosis in children

and adolescents

2. Efficient use of diagnostic tests

3. Selection of most appropriate

therapy

4. Monitoring for long term

effectiveness of therapy and

appearance of side effects

associated with therapy

5. Achieve favourable outcomes

6. Coordination for multi-specialty

care

7. Deal with the social and

psychological aspects of

chronically ill children and their

families which need support.

Most of the Paediatric

rheumatologists in India are located at

centres where facilities for diagnosis and

multi-specialty care are available. Such care

and expertise may not be available to many

of us practising in the different parts of this

vast country. Therefore we must put in

efforts to involve a Paediatric

Rheumatologist at an early stage for better

and holistic management of such

disadvantaged children. By doing so we will

also be able to establish a good follow up

system for the affected children.

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2. Guidelines for early referral of arthritis cases to a Paediatric

Rheumatologist (Adapted from the ACR guidelines 1997):

Children and adolescents with the

following joint diseases may benefit from

early referral to a Paediatric

Rheumatologist:

1. Patients with unclear diagnoses:

a. Prolonged fever

b. Loss of function:

i. Inability to attend school

ii. Regression in physical skills

c. Normal laboratory findings

but local or generalized pain

and / or swelling

d. Abnormal laboratory findings

but symptoms and / or

examination do not fit the

clinical criteria for a specific

rheumatic disease

e. Complaints not consistent

with laboratory findings or

physical examination

f. Unexplained physical findings

such as rash, fever, anemia,

weakness, weight loss, fatigue

or anorexia along with

arthritis

g. Unexplained musculoskeletal

pain

h. Suspicion of an associated

autoimmune diseases

2. Diagnostic evaluation and long

term management of:

a. Juvenile idiopathic arthritis

b. Spondyloarthropathies:

i. Ankylosing spondylitis

ii. Reiter’s syndrome

iii. Psoraitic arthritis

iv. Arthritis associated with

inflammatory bowel

disease

v. Lyme disease with arthritis

vi. Chronic recurrent

multifocal osteomyelitis

vii. Post-infectious arthritis

viii. Relapsing polychondritis

3. Confirmation of diagnosis and

formulation / participation in a

treatment plan:

a. Apophysitis

b. Reactive arthritis

c. Osteochondroses

d. Growing pains

e. Iritis / Uveitis

f. Acute Rheumatic fever

g. Erythromelalgia

h. Raynaud’s disease

i. Reflex sympathetic dystrophy

j. Cold induced injury

k. Pain syndromes

l. Osteoporosis

m. Over use syndromes;

hypermobility syndromes

4. Diagnostic or treatment

evaluation, provide for proper

physiotherapy regimens

5. Provide second opinion or

confirmatory evaluation when

requested in certain cases where

primary physicians request expert

opinion for families requiring

subspecialty input to cope with

disease process, accept treatment

plan, allay anxiety and provide

education.

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VII NATIONAL CONFERENCE OF PEDIATRIC RHEUMATOLOGY

7TH AND 8TH NOVEMBER 2009

NAGPUR, INDIA

Hosted by

Indian Academy of Pediatrics, Nagpur Branch and IAP Rheumatology

Chapter

Highlights:

� Eminent International and National Faculty

� Arthritis for Primary Pediatrician

� Standard Treatment Protocols

� Newer Diagnostic and Therapeutic Options � Clinical Challenges in Pediatric Rheumatology

� Interactive Practice Oriented Sessions

For Further Details Contact:

Dr.Nandini Babhulkar, Sushrut Hospital & Research Centre, Ramdaspeth,

Nagpur-440010, M.S, India

E mail: nandinisush@yahoo.com

Mobile: 9730111000.

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Indian Academy of Pediatrics (Rheumatology Chapter) announces

“REACH AND TEACH”

A 40 hour intensive course in pediatric rheumatology

17-21st

September 09

Principal Sponsor and Host: Hargobind Foundation (www.hargobind.com)

Co host: Pediatric Rheumatology Unit, Jaslok Hospital and Research Center, Mumbai.

WHAT: The chapter envisages training about twenty physicians (pediatricians and adult rheumatologists)

strongly desirous of pursuing/developing the sub specialty of pediatric rheumatology in Tier 1 cities.

HOW: This will be done through a 5 day program (8 hours a day) of lectures / case discussions/ panel

discussions/ slide shows/ and videos with emphasis on practical day to day problems in clinical practice.

WHERE: At the Jaslok hospital and Research Center, Mumbai.

BY WHOM: A multidisciplinary faculty comprising of invited international and national experts in pediatric

rheumatology, ophthalmology, orthopedics, radiology, pathology and physiotherapy.

EVALUATION AND CREDIT: Candidates attending the course will undertake a pre and post test. They will

receive certificates at the end of the course.

COST: Rs 10000 for members of the Rheumatology Chapter (proof needed) and Rs 12500 for non members.

Candidates are expected to make their own travel and lodging arrangements in Mumbai. Two full scholarships

and two half scholarships are available for candidates needing financial aid. The course fee includes pre

course material, course instruction, breakfast and lunches on day of instruction and a banquet dinner. The

costs have been subsidized owing to an educational grant from Hargobind Foundation.

HOW TO APPLY AND CRITERIA FOR SELECTION: Doctors desirous of attending the course will write a 250

word statement of purpose and optionally have at least two colleague pediatricians support their cause. They

would attach a brief resume highlighting any achievements or activities in pediatric rheumatology. Attach a

demand draft for the appropriate amount stating- Jaslok Hospital and Research Center. Those applying for a

scholarship may attach an added plea/justification for the same (confidentiality assured).All correspondence

by email except drafts which may be mailed to address below.

LAST DATE FOR APPLICATION: 1st

June 2009 (Since the Newsletter is going out late due to unavoidable

reasons, as a special concession only the RCIAP Members may apply for this Course upto 10th

June, 2009.)

LAST DATE FOR WITHDRAWAL: 1st July 2009 (no refunds after this date). Candidates not selected or those

who choose to withdraw will have their drafts returned after this date.

CONTACT DETAILS: Course Coordinator Dr Raju Khubchandani .

Associates: Dr Chetna Khemani, Dr. Vijay Viswanathan and Dr. Rachana Hasija

Contact email: reachandteach09@yahoo.co.in

Drafts to be mailed to: Dr. Raju Khubchandani, 31, Kailas Darshan, Nana Chowk, Mumbai -400007

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LIFE MEMBERSHIP FORM OF “RHEUMATOLOGY CHAPTER OF IAP”

(Only for Life Members of Central IAP)

1. Membership No. of Central IAP:……………………………………………………………………………

2. Name:….………………..…………..…………..…………..…………..…………..…………..………………….

3. Corresponding Address: …………..…………..…………..…………..…………..…………..…………..

…………..…………..…………..…………..…………..…………..…………..…………..…………..……………

4. Permanent Address: …………..…………..…………..…………..…………..…………..………………..

…………..…………..…………..…………..…………..…………..…………..…………..…………..……………

5. Phone No.(s): …………..…………..………….. Mobile(s): …………..…………..…………………..

6. Email (COMPULSORY): …………..…………..…………..……………...…………..…………..…………

7. Professional Attachment: …………..…………..…………..…………..…………..…………………….

8. Academic Qualification: …………..…………..…………..…………..…………..…………..…………..

9. Date of Birth: …………..…………..…………..…………..…………..…………..…………..………………

Date: Signature:

Present fees of Life Membership is Rs. 1000/-. To be paid in DD in favour of

“Pediatric Rheumatology Chapter of IAP”, payable at Shillong