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in this brief lecture we're going to
discuss the swollen joint in children
and in particularly the swollen joint
where it is essentially a transient
autoimmune condition this would be
either reactive arthritis or transient
synovitis this is an important lecture
because these two entities appear quite
commonly in children but they're
basically benign conditions I'm going to
go through them and explain the
differences between them now so reactive
arthritis at one point was also called
Reiter's syndrome is an autoimmune
attack on a joint typically after an
infection and usually it's more common
in GU or GI infections so the classic GU
infection that can result in a reactive
arthritis is chlamydia in adolescence
with chlamydia they can after the
infection starts then later develop an
autoimmune attack on their joints from a
GI standpoint there are some bugs that
are implicated more likely in an
autoimmune attack or a a reactive
arthritis
these include Yersinia and t'rul it Iike
Salmonella enteritis Shigella and
Campylobacter in other words the
bacterial pathogens other than E coli
that are most likely to cause this
problem there is also group a strep
which perhaps we will consider as a
different issue group a strep reactive
arthritis is a part of rheumatic fever
and we'll discuss rheumatic fever in
another lecture ok so reactive arthritis
typically is reactive that means first
you have the infection you make the
antibodies against that bug and those
antibodies through freakish occurrence
also attack your joints later on down
the line so this usually happens 1 to 4
weeks after the first infection it has
acute onset and it may be migratory
involving multiple joints there's a
classic phrase for chlamydia can't see
P can't climb a tree what that is
basically pointing out is these patients
can get eye involvement can't pee means
they're having the urethritis of
chlamydia and can't climb a tree means
their knees are swollen so that's a
classic thing for what we previously
called writer syndrome but now we're
just calling reactive arthritis so for
reactive arthritis the diagnosis is
really usually made clinically if
there's still something there you could
test for the causative disease for
example certainly with chlamydia a urine
chlamydia test is positive and unless
that patient has been treated that test
will continue to be positive in fact
it'll be positive in a substantial
number of cases where they have been
treated and they might need to be
treated again but in patients who've
just had say Campylobacter the
Campylobacter is long gone usually by
the time they're developing the reactive
arthritis so testing isn't possible so
most of the time we don't bother with
testing up to 80% of patients who have
reactive arthritis are HLA b27 but
knowing someone is HLA b27 probably
isn't particularly beneficial if they
were to go on to develops a ankylosing
spondylitis we would be testing them
anyway so it's unclear that knowing
their HLA type is particularly helpful
we do like to rule out other potential
causes that are more significant than
reactive arthritis for example through
history and physical exam we can
probably rule out lupus or an infected
joint or the other things that are more
significant and require more aggressive
therapy reactive arthritis is managed
typically through containing the
inflammation and the good news is these
children usually get better reasonably
well and have a great prognosis we
usually start off with treating with
NSAIDs that's the most important
therapeutic air we often we use
long-acting NSAIDs like twice a day
Naprosyn
or even once day meloxicam as a way of
controlling their inflammation without
having to take medicines every six hours
like you would with
Pro Fionn the goal is to sustain the
inflammation as much as it is to control
the pain injected steroids can
absolutely be done either systemically
or intra-articular Li if this is a very
severe reactive arthritis if there were
multiple joints involved I might go with
the systemic steroids first children
with rheumatic fever will go on to
penicillin prophylaxis but we'll discuss
that more in the rheumatic fever lecture
so let's switch gears now and talk about
a disease which is very similar to
reactive arthritis but is
distinguishable because it happens
during or just immediately after the
infection as opposed to one or four
weeks later and that is the key point
the user member high impact on the test
reactive arthritis have one to four
weeks after an infection transient
synovitis happens either during or just
after the infection also the infection
is usually in transient synovitis of
viral syndrome it's usually an upper
respiratory infection or a URI typically
the age of a child who has to having
transient synovitis is there between 2
and 12 years of age and typically this
will affect one maybe two joints and
usually the hips first choice then the
knee then something else this is usually
mono articular inflammation it's usually
a child showing up with a swollen knee
and that's it and oh yeah
they had a cold yesterday the problem is
usually mild they may not be able to
bear weight but will transiently be sick
but then often be better in only one or
two days and it may be completely
resolved in three to four days because
this is such a short-lived phenomenon we
usually just treat with NSAIDs we may do
a couple days of Naprosyn
or ibuprofen as needed remember
transient synovitis is transient it's an
inflammation of the joint it's during
the virus and this is incredibly common
it's impossible to pry
for a year as a pediatrician without
seeing a case so that's my summary of
these two conditions thanks for your
attention
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