1. common rheumatologic diagnoses
Dustin Fleck, MD
pediatric rheumatology

2. pediatric rheumatology
autoimmune and autoinflammatory conditions
can affect all organs
primarily affects: connective tissues (muscle, joints, tendons)

3. rheum clinic diagnoses

4. juvenile idiopathic arthritis (JIA)
JIA v. JRA?

5. JRA EULAR criteria (1977) pauciarticular polyarticular systemic
***JRA has been clinically used term since the 1940s

6. JCA EULAR criteria (1978) pauciarticular polyarticular systemic
juvenile rheumatoid arthritis (JRA)
juvenile psoriatic arthritis
juvenile ankylosing arthritis

7. JIA ILAR criteria (1997) oligoarticular systemic polyarticular
extended
oligoarticular
persistent
systemic
seronegative
polyarticular
JIA
seropositive
enthesis related arthritis
psoriatic arthritis
other

8. arthritis defined as joint effusion alone limited range of motionor
(2 of 3)
limited range of motion
tenderness or pain on motion
increased warmth of joint

9. juvenile idiopathic arthritis (JIA)
>6 weeks
<16 years of age
exclude other diagnoses

10. juvenile idiopathic arthritis
6 months to 16 years of age
1 in 250-1,000 children affected
females > males (2:1)

12. after 6 months: still less than 5
oligoarticular jia
less than 5 joints
after 6 months: still less than 5
after 6 months: 5 or more
persistent oligo JIA
extended oligo JIA

13. polyarticular jia involving more than 4 joints in 1st 6 months
+ RF/CCP
-RF/CCP
seropositive poly JIA
seronegative Poly JIA

14. prognosis
persistent oligo> seronegative poly > extended oligo > seropositive poly

15. enthesitis related arthritis
ERA,
spondyloarthropathy
juvenile ankylosing apondylitis
age: (males 4:1)

16. enthesitis related arthritis

17. juvenile ankylosing spondylitis

18. juvenile ankylosing spondylitis

19. juvenile psoriatic arthritis

20. juvenile psoriatic arthritis

21. juvenile psoriatic arthritis

22. juvenile psoriatic arthritis+
2 of the following
dactylitis
nail pits
1st degree relative with psoriasis
arthritis +
psoriasis or

23. making the diagnosis
physical exam
exclusion

24. physical exam

25. physical exam

26. does lab work confirm the diagnosis of JIA?
the workup
does lab work confirm the diagnosis of JIA?

27. anti-nuclear antibody (ANA)
Figure 1: antibody binding of proliferating cell nuclear antigen (PCNA) in the systemic lupus erythematous serum. Image downloaded from Biomedical Central. Arthritis Research and Therapy. Tan, Eng. 12:104 (2014)

28. anti-nuclear antibody (ANA)
30%
of healthy children will have a positive ANA on laboratory screen

29. anti-nuclear antibody (ANA)
9,782
children would have a positive ANA on laboratory screening in Dayton, Ohio

30. anti-nuclear antibody (ANA)
Anti-DsDNA
Anti-Sm
Anti-SSA
Anti-SSB
Anti-Scl70
Anti-Jo
Anti-RNP
Anti Ribosomal
Anti- Chromatin
ANA

32. what role does ANA play in JIA?

33. uveitis

34. uveitis
Positive ANA + 6 years or younger = High risk

35. rheumatoid factor

36. rheumatoid factor tissue damage complement activation
inflammatory cytokines
tissue damage

37. rheumatoid factor positivity
Rheumatoid arthritis
80%

38. Bacterial endocarditis
Healthy 70 year old
Rheumatoid arthritis
80%
Multiple Vaccines
15%
Coxsackie B virus
15%
Bacterial endocarditis
40%
EBV and CMV infections
20%

39. Bacterial endocarditis
jra 5%
Healthy 70 year old
Rheumatoid arthritis
80%
Multiple Vaccines
15%
Coxsackie B virus
15%
Bacterial endocarditis
40%
EBV and CMV infections
20%

40. anti-cyclic citrullinated peptide antibody
antiperinuclear factor (1964)
antikeratin antibodies (1979)
anti-sa antibodies

41. RF v. CCP sensitivity specificity RF -> 84.8% CCP -> 74%

42. RF v. CCP RF -> extra-articular manifestation
CCP -> articular damage/erosion

43. Treatment NSAIDS DMARDS Other Biologics TNF alpha inhibitors
RF + triple therapy
NSAID
methotrexate
hydroxychloroquine
NSAIDS
Intra-articular corticosteroid injection
DMARDS
Ankylosing spondylitis
TNF alpha inhibitors
Other Biologics

44. take home points JIA is a common chronic disease in children
JIA is a clinical diagnosis made off physical exam
laboratory studies are for risk/sub-categorization