1. Case Presentation Audie C. Florida, M.D.

2. CC: Right ankle Swelling Came in ER for evaluation. 11-year-old w/m right ankle pain x 2 days no injury that he can recall. not twist or turn his ankle wrong. swelling medial side. Mom noticed some redness around it and a little bit swollen. no fevers or chills at home.

3. Social History 1 brother and sister Live with dad who has custody Mother is LPN

4. Family History Father has “stiff back” evensince he was a teenager and is unable to bend his back forward. Patient’s father has not received medical care due to financial reason. seen by specialist at children’s hospital was thought that he has likely Alkylosing spondylitis Maternal Grandmother with arthritis as a child and hip replacement at age 10 Negative for SLE, Psoriasis, IBD, Sarcoidosis

5. PMHX Immunization UTD No Surgeries Hospitalization – Rotavirus at 5 yo admitted for a few dayafl

6. Xray 9/06 Localized soft tissue swelling over the medial aspect of the ankle. No acute bone injury is seen.

7. ER Dx and Management. DIAGNOSIS: Cellulitis right ankle. Keflex 250 QID x 7 day

8. FMC visit 9/06 ER f/u DIAGNOSIS: Cellulitis right ankle. Continue Keflex 4 more days Ibuprofen

9. FMC visit 10/06 Right malleolus swelling continue Ibuprofen reassured that the swelling may take some time to be totally resolved Ice may be used after activity for symptom relief. Pes Cavus- arch supports in his shoes

10. FMC visit 1/07 B/l ankle and foot swelling of unknown etiology- Juvenile Rheumatoid Arthritis cannot be ruled out. Advised the mother to take Ibuprofen. Labs ordered:ESR,ANA, CBC, Chem 7, Uric Acid, TSH, Free T4, X-ray b/l foot and ankle joints Chronic Constipation- resolved

11. FMC visit 1/07 Joint stiffness, decreased range of motion, joint swelling, no fever, no weight loss Feels pain with walking throughout the day and it is worst at the end of the day. No bowel habit change

12. Lab 1/25 Uric Acid – 2.8L ESR –67 H CBC – WNL TSH/Free T4 WNL ANA- negative

13. Xray 1/25 Probable pes planus. Otherwise negative right foot. Negative left foot

14. FMC visit 2/07 Fractured Tarsal Coalition b/l foot - Tarsal coalition is probably congenital and fracture during baseball play 4 months ago. ordered immobilizing splint for the right foot. MRI ordered Advised to take NSAID for pain. Referred to Dr. Gunnlaugson

15. MRI foot 2/07 – right ankle/foot IMPRESSION: There is a fibrous coalition of the calcaneus and navicular. An ankle joint effusion is present. There is a longitudinal split tear of the peroneus longus tendon below the lateral malleolus. No other tendon abnormality is present. There is no ligament abnormality or osteochondral defect.

16. MRI 2/07 right anke/foot 1. Incomplete cuboid stress fracture. 2. Longitudinal (grade-2) intrasubstance tears of the distal peroneus longus tendon and tenosynovitis. 3. Tibialis posterior tenosynovitis and peritonitis. 4. Fibrous calcaneonavicular tarsal coalition.

17. MRI 2/07 left ankle Bone contusion involving the base of the first metatarsal and medial cuneiform. 2. Non-displaced fracture of the mid aspect of the cuboid bone. 3. Tenosynovitis and partial tear of the distal peroneal longus tendon. 4. Fibrous coalition at calcaneonavicular joint.

18. MRI 2/07 left ankle/foot IMPRESSION: 1. Fibrous coalition between the calcaneonavicular bones. 2. Non-displaced fracture of the cuboid bone. 3. Tenosynovitis and partial tear of the peroneus longus tendon.

19. Referral Referred patient to Dr. Gunnlaugson Dr. Gunnlaugson referred the patient to Children’s Hospital Orthopaedic unit for Tarsal Coalition fracture. Children’s Hospital Orthopaedic referred patient to Rheumatology

20. ROS ROS Negative Fatigue, weight loss, night sweats or fever, no rashes, photosensitivity, easy bleeding or bruising, poor wound healing, alopecia, mouth ulder, vision change, dry eyes, dry mouth, headaches, memory loss, change personality, chest pain, shortness of breath, abdominal pain, hematochezia, melena, diarrhea, vomiting, dysphagia, dysphonia, dysuria, hematuria, numbness/Tingling, Raynaud’s phenomenon, cold or heat

21. Labs 7/07 ESR 21(previously 50 3/07) CRP 0.22(previously 5.33 3/07) H/H – 13.8/38.6 WBC – 6.4 LFF = WNL CR =0.7 Rheumatoid factor <20(3/07) TSH\Free T4 WNL HLA B27 +

22. Physical examination Physical Examination Ear: Normal Eye: Normal Oropharynx: no mucosal Ulder Neck: Supple, no mass No Lympadenopathy Normal Arterial pulses Heart Regular rate and rhythm, no murmur Respiration – normal Lung – Clear to auscultation bilaterally

23. Physical Examination Left ankle <25% LOM, subtalar LOM < 25% Axial skeleton – more straight without curvature Normal Muscle mass, normal muscle strenth, proximally and distally in upper and lower extremities.

24. Diagnosis 12yo w/m with HLA- B27 positive enthesitis related JRA. Responded well to PO Steroid and Enbrel 2x/weeks. Dx: Juvenile Spondyloarthropathy

25. Rheumatology Diagnosis and Management Oral Prednisone 20mg BID Intraarticular injection fo steroid b/l ankles Enbrel ol6ml SQ 2x weekly Zantac 75mg BID

26. Interval history Interval History: Diagnosed with Subtalar Arthritis 3/07, Intraarticular injection b/l ankles and right subtalar joint result in decreased degree of swelling, pain and morning stiffness. Had Enbrel Injection for 15 weeks. Patient full participating in activities in the Gym without complaints. No GI complaints. Patient is taking Indocin 50mg daily

27. Additional studies MRI SI joints –4/07 normal PT home exercise No Baseline Opthalmology exam

28. JRA 3 major types of JRA are: Pauciarticular which affects 4 or fewer jointsPauciarticular Polyarticular JRA which affects 5 or more jointsPolyarticular JRA Systemic onset JRA which affects at least one joint but causes inflammation of internal organs as well.Systemic onset JRA

29. Spondyloarthropathies group of conditions characterized by the classic clinical triad of Arthritis Enthesitis (inflammation and tenderness at sites of tendon insertion Human leukocyte antigen B27 (HLA- B27)

30. The most common spondyloarthropathies ankylosing spondylitis reactive arthritis (Reiter syndrome) psoriatic arthritis arthritides of inflammatory bowel disease.

34. Thank you