staff conference
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SEPTEMBER 19, 2008 MARIA KARLA C. SAN PEDRO, MD. STAFF CONFERENCE. Objectives. Determine the approach to a child with joint swelling Be familiar with Relapsing Polychondritis as a differential diagnosis for joint swelling - PowerPoint PPT PresentationTRANSCRIPT
STAFF CONFERENCE
SEPTEMBER 19, 2008MARIA KARLA C. SAN PEDRO, MD
Objectives• Determine the approach to a child with joint swelling
• Be familiar with Relapsing Polychondritis as a differential diagnosis for joint swelling
• Differentiate Relapsing Polychondritis from other arthritides with systemic manifestations
• Know the diagnosis and management of Relapsing Polychondritis
Our Patient D.C., 6 /M From Meycauayan, Bulacan First admission on July 23, 2008 Chief complaint: right ear swelling
History of Present Illness 9 months PTA
Right ankle pain after tripping on the street, grade 4/10, associated with swelling, warmth, low grade fever; difficulty in ambulation
Given Paracetamol but with no reliefBrought to Philippine Orthopedic Center;
casting done; no relief
History of Present Illness 8 months PTA
Increase in severity of pain of right ankle, grade 7/10 accompanied with swelling of the nose, tender, warm
Brought to a local health center and given Cefalexin x 5 days with partial relief
7 months PTAFell from his bike; swelling of left ankle with
superficial abrasions
History of Present Illness 6 months 3 weeks PTA
Left knee swelling accompanied by difficulty in ambulation
Brought to a private doctor and given Cloxacillin x 7 days with temporary relief
History of Present Illness 6 months PTA
Persistence of difficulty in ambulation Brought to Philippine Orthopedic CenterA> Septic Arthritis of the left kneeUnderwent Incision and Drainage and arthrotomy
of the left knee and left ankle; purulent material on drainage of fluid
Given Oxacillin; Biopsy: granulomatous inflammation; started on Anti Koch’s; discharged apparently improved
History of Present Illness 3 months PTA
Brought to Philippine Orthopedic Center for swelling of both wrists and elbows accompanied by undocumented fever
Residual purulent material on the left knee and ankle; advised admission but opted to go home
History of Present Illness 1 month PTA
Increase in severity of symptomsBrought to Mary Johnston HospitalA> Juvenile Idiopathic ArthitisGiven Methotrexate
History of Present Illness 6 days PTA
Enlargement of the right ear with redness and itchiness associated with swelling and tenderness of both wrists, both elbows, left knee, and left ankle
Brought to a private doctor and referred to PGH Rheumatology
Review of Systems(+) Oral ulcers x 6
days(-) Genital ulcers(-) Dyspnea (-) Dysphagia(-) Epistaxis (-) Colds
(-) Blurring of vision(-) Vomiting(-) Raynaud’s
phenomenon(-) Weight loss(-) Oliguria,
Hematuria
Past Medical History Dengue Hemorrhagic Fever – 3 y/o Mumps – 5 y/o No previous Blood transfusions No previous operations
Family Medical History(+) Hypertension – paternal aunt(-) DM, PTB, BA, Kidney disease, Liver disease
Birth and Maternal History FT via SVD to a 29 year old G3P2 (2002) mother
at home c/o traditional birth attendant; mother with regular PNCU c/o LHC
Mother had frequent cough and colds during pregnancy; treated with Paracetamol with relief; no intake of teratogenic drugs, no exposure to radiation
At birth, patient had good cry and activity; no fetomaternal complications
Nutritional History Breastfed until 2 months old Shifted to formula feeding with Bonna at
2 months to 1 year old Complementary feeding at 6 months old No food preferences
Immunization History (+) BCG, OPV3, DPT3, Hepa B3, measles
Developmental History At par with age
Personal and Social History Youngest of 3 children Stopped schooling in kindergarten due
to illness Mother is a 35 year old housewife Father is a 53 year old construction
worker
Physical Examination Awake, alert, ambulatory with support,
NICRD BP 110/70, HR 110 bpm, RR 23 cpm, T
38oC Weight 15 kg, Height 109.5 cm, BMI 13,
WFA=71 (moderate PEM), HFA=95 (no stunting), WFH=83 (mild wasting)
Warm, moist skin, no active dermatoses
Physical Examination Pink palpebral conjunctivae,
anicteric sclerae (+) right auricular swelling,
(-) discharge, (-) tenderness (+) saddle nose deformity,
(-) discharge, (-) tenderness (-) oral ulcers, (-)
tonsillopharyngeal congestion trachea at midline, (-)
cervical lymphadenopathy
Physical Examination Equal chest expansion, (-) retractions, clear
breath sounds, (-) wheezes, (-) crackles Adynamic precordium, distinct heart sounds,
tachycardic, regular rhythm, (-) murmur, (-) heaves, (-) thrills
Flat, soft, normoactive bowel sounds, (-) tenderness, (-) organomegaly, LE edge not palpable, (-) masses
Grossly male, descended testes, (-) lesions, (-) discharge
Physical Examination Full and equal pulses (+) swelling and
tenderness of right elbow, bilateral wrists, left knee, left ankle, (+) superficial abrasion on left ankle, (+) linear scar over left ankle and left knee
(-) cyanosis, (-) jaundice
Physical ExaminationLeft knee: 0°-90°, Left ankle: dorsiflexion: 0° plantar flexion: 0°-
20° inversion: 0°-5° eversion: 0°Right ankle: full range
of motion
Physical ExaminationNeuro Exam General survey: Awake, coherent Cranial nerves: Pupils 2-3 mm EBRTL, brisk
corneals, (-) facial asymmetry, tongue midline, (+) gag reflex, good shoulder shrug
Sensory: 100% on all extremities Motor: 5/5 on all extremities DTRs: ++ on all extremities Cerebellar: Can do FTNT and APST with ease Meningeals: Supple neck, (-) nuchal rigidity Other reflexes: (-) Babinski
Initial Assessment
Possible Relapsing Polychondritis
Summary 6 year old male Admitted for swelling of the right ear Right ankle pain and swelling Swelling of the nose Swelling of the left ankle and left knee Progressive joint swelling of both wrists
and elbows
Arthritis
Arthritis Inflammation of a joint space associated
with joint swelling, pain, and limitation of motion
Results from infection, trauma, degenerative changes, or metabolic disturbances
Extra articular involvement with arthritis: Wegener’s Granulomatosis and Behcet’s Disease
Wegener’s Granulomatosis nasal/oral inflammation saddle nose deformity lung nodules/cavities microhematuria/red cell casts
Behcet’s Disease arthritis and arthralgia recurrent oral ulceration (3x per year) recurrent genital ulceration eye lesions skin lesions like erythema nodosum
Monoarticular Arthritis TB Arthritis responsive to Anti Koch’s
Septic Arthritis responsive to antibiotics acute onset
Polyarthritis
Gout excruciating, sudden,
unexpected, burning pain swelling, redness, warmth,
and stiffness involving ankle, heel, instep, knee, wrist, elbow, fingers, and spine
tophi affecting the big toe and helix of the ear
Osteochondroma involvement of cartilage involvement of bone enlarging mass weight loss
Juvenile Idiopathic Arthritis more than 6 weeks of pain,
swelling, and stiffness of joints involves metacarpophalangeal
joints, proximal interphalangeal joints wrists, and metatarsophalangyeal joints
involvement of cartilages such as the ears and nose
nonerosive and asymmetric
Relapsing Polychondritis
Definition Multisystemic disorder of unknown etiology
affecting young adults
Recurrent, progressive episodes of inflammation affecting the cartilaginous structures, resulting in tissue damage
Elastic cartilage of the ears and nose, hyaline cartilage of peripheral joints, fibrocartilage of the axial skeleton, and cartilage of the tracheobronchial tree
Diagnostic Criteria (3 or more) recurrent chondritis of both auricles
non erosive inflammatory polyarthritis
chondritis of nose cartilage
inflammation of ocular structures (keratitis, scleritis, episcleritis, uveitis)
chondritis of the respiratory tract (laryngeal and/or tracheal cartilages)
cochlear and/or vestibular damage causing sensorineural hearing loss, tinnitus and/or vertigo
Course in the Hospital
Rheumatologic Referred to Pediatric Rheumatology and
Orthopedics
Referred to Otorhinolaryngology for evaluation and anticipatory care for airway
Xrays: decreased joint space and osteochondral changes on the left knee and left ankle, no joint space, no osteochondral changes on the right ankle
Rheumatologic Diagnostic aspiration on the right ear
Neck STAPL: intact tracheobronchial airway and no obstruction
Rheumatologic Started on Prednisone 10 mg/tab (1.5 mkd) 1 tab
OD, Naproxen 275 mg/tab (20 mkd) ½ tab BID, Oxacillin (250) 750 mg/IV q6
2nd HD, (+) resolution of joint swelling and tenderness, afebrile, with good activity and appetite
P> Oxacillin shifted to Cloxacillin 250 mg/5 ml (120) 9 ml q6
Prednisone increased to 10 mg/5 ml (2 mkd) 5 ml TID
Cardiac Referred to Pediatric Cardiology for evaluation of
cardiovascular functioning
ECG: sinus tachycardia, no axis deviation, no chamber enlargement
2D Echo: fair LV systolic function, mild TR, LVE, no vegetation, minimal pericardial effusion
CK MB and Troponin I: positive
A> Possible Myocarditis vs Cardiomyopathy
Cardiac P> Started on Dobutamine (5 mcg/kg/min) at 5
cc/hr, Furosemide (1) 15 mg/IV OD, and Lanoxin (0.003) 0.25 mg/tab, 0.045 mg/pptab, 1 pptab q12
2nd HD, comfortable, not in acute distress with HR 90 bpm
Dobutamine discontinued, Lanoxin continued, and Furosemide was shifted to PO 20 mg/tab (0.75) ½ tab OD
Etiology Remains unknown
Loss of basophilic staining of the cartilage matrix with perichondral inflammation of the cartilage
Perivascular mononuclear and polymorphonuclear cell infiltrates
Chondrocytes become vacuolated, necrotic and replaced by fibrous tissue
Etiology Release of degradative enzymes
Immune mediated activation of chondrocytes and other inflammatory cells by cytokines including IL-1 and TNF-a
Autoimmunity
Prevalence 3.5 cases/million in the US (Doros, A.A,
October 2004)
4 cases seen in PGH
Peak age for disease onset is the 5th decade
Female preponderance with ratio of 3:1
Clinical Features Auricular chondritis
Joint pain with or without arthritis involving metacarpophalangeal, proximal interphalyngeal joints, wrists and knees
“Saddle nose” deformity
Scleritis, episcleritis, keratitis, and conjunctivitis
Clinical Features Hoarseness, non productive cough, dyspnea,
wheezing, and inspiratory stridor
Tenderness over thyroid cartilage and trachea
Aortic regurgitation and mitral regurgitation
Thoracic and abdominal aneurysm, myocarditis, pericarditis, silent myocardial infarction, paroxysmal atrial tachycardia, and 1st degree or even complete heart block
Clinical Features Mild mesangial proliferation, focal and
segmental necrotizing glomerulonephritis with crescents
Cranial nerve palsies, cerebral aneurysms and aseptic meningitis
Diagnostic Methods No specific diagnostic tools
Serum autoantibodies to collagen II and to 148 kDa noncollagenous cartilage matrix protein
Chest conventional radiographs, pulmonary function test, and chest CT tomography
Cartilage biopsy
Laboratory Findings Elevated ESR, CRP, anemia, leucocytosis, and
thrombocytosis
Serum antibodies to collagen II
Elevated urinary glycosaminoglycans levels
Serum 148 kDa noncollagenous matrix protein
(-) Rheumatoid factor, antinuclear antibodies or antineutrophil cytoplasmic antibodies
Management NSAIDs and Prednisone (1 mkday) Methotrexate Cyclophosphamide Anti CD4 monoclonal antibody Autologous stem cell transplantation Surgery: Tracheostomy
Prognosis Progressive disease
Intermittent or fluctuant inflammatory manifestations
Persistent symptoms between acute flares
Develops some degree of disability over the time
Overall survival rates were 74% at 5 years and 55% at 10 years
Updates on the Patient Swelling of ears and joints of other extremities Saddle nose deformity Cushingoid facies and hirsutism
Maintained on Prednisone, Lanoxin, Furosemide
2D Echo after 3-6 months Rehabilitation Hearing screen and Ophtha evaluation
Conclusion Correct and early diagnosis of polyarthritis are vital
Arthritis may be the initial clue to a serious systemic disease
Clinical diagnosis
Life threatening complications require awareness and recognition of disease
Long term follow up is necessary
Thank you!