Clinical Trial Details
— Status: Not yet recruiting
Administrative data
| NCT number |
NCT04326582 |
| Other study ID # |
Arthiritis in children |
| Secondary ID |
|
| Status |
Not yet recruiting |
| Phase |
|
| First received |
|
| Last updated |
|
| Start date |
April 1, 2020 |
| Est. completion date |
May 1, 2021 |
Study information
| Verified date |
March 2020 |
| Source |
Assiut University |
| Contact |
Mohamed Masoud |
| Phone |
01060196515 |
| Email |
mohamedmasoudabnob[@]yahoo.com |
| Is FDA regulated |
No |
| Health authority |
|
| Study type |
Observational
|
Clinical Trial Summary
- To define prevalence of different types of arthritis in patients attending Assiut
University Children Hospital (AUCH)
- To define prognosis of these different types
- To evaluate management of arthritis in Assiut University Children Hospital, in
comparison to international guidelines
Description:
Arthritis is defined as inflammation of the joint, Patients have symptoms of joint pain,
stiffness, swelling, redness, warmth and decreased range of motion of the affected joints.
Arthritis may be caused by transient synovitis, juvenile idiopathic arthritis ( JIA),
reactive arthritis, viral arthritis and other inflammatory diseases; septic arthritis also
occurs as a complication of bacteraemia in children. The overall incidence of arthritis and
its causes are not well documented in children, and have even been reported to be unknown.Two
population-based studies have described the incidence of different diagnoses of arthritis in
childhood. Both of these studies were performed in Northern Europe and reported that
transient synovitis is the most common cause.
The outcome and treatment of arthritis depend on its etiology. Children with transient
synovitis do not need any surgical procedures and are treated symptomatically at home.
However, children with septic arthritis require early diagnosis and hospital treatment,
including surgical joint drainage and intravenous antibiotics so that septicaemia and joint
damage can be avoided.
JIA is one of the more common chronic diseases of childhood with a prevalence of
approximately 1 per 1,000 .
Criteria and classification Three groups have developed sets of criteria to classify children
with arthritis: The American College of Rheumatology (ACR), The European League Against
Rheumatism (EULAR), and The International League of Associations for Rheumatology (ILAR).
- THE ILAR classification of JIA includes the following categories:
- systemic-onset JIA
- persistent or extended oligoarthritis
- Rheumatoid factor (RF)-positive polyarthritis
- RF-negative polyarthritis
- Psoriatic JIA
- Undifferentiated(disease does not meet criteria for any of the other subgroups, or it
meets more than 1 criterion)
- Septic arthritis was defined as arthritis associated with bacteria isolated from
blood or synovial fluid.
- Arthritis that did not retrospectively fulfil criteria for septic arthritis, JIA or
other well-established diagnoses (haemarthrosis, Kawasaki disease, malignant
disease, Gaucher disease, systemic lupus erythematosus, villo-nodular synovitis,
dermatomyositis and chronic recurrent multifocal osteitis) was classified as
'arthritis without any definitive diagnosis.
- Although acute monoarthritis (as for instance septic arthritis) is usually considered to
be a medical emergency, it is not often realized that patients with polyarthritis also
need to be evaluated promptly to ensure timely management. Delays in diagnosis and/or
treatment may result in significant morbidity, as for example in rheumatic fever and
Kawasaki disease. It cannot be overemphasized enough that the most important clues to
underlying etiology in a patient with polyarticular disease are found not in the
investigations but in the clinical history and physical examination. Some investigations
(e.g. radiographs of joints) are commonly done but may have little or no role in the
initial assessment of the patient. Polyarticular joint disease has multi-factorial
etiology. It may present acutely as in self limiting viral illnesses or it can be the
beginning of a chronic sinister disease. The underlying etiological process can be
infectious or post infectious, a rheumatological disease or a manifestation of systemic
disease. The disease may evolve over days or sometimes weeks, thereby making the
diagnosis difficult at the time of presentation. Viral infections (for e.g. Parvovirus
B19) are often associated with a self-limiting symmetrical arthritis of small joints.
Septic polyarthritis caused by direct invasion of the joint by microbes can occur in
disseminated staphylococcal and streptococcal infections, gram negative sepsis or bacterial
endocarditis. Reactive arthritis, a sterile arthritis mediated by immune mechanisms, is
usually seen after genitourinary (Chlamydia) or gastrointestinal (salmonella, shigella,
yersinia or campylobacter) infections. It is said that arthritis persisting for more than 6
weeks usually rules out an infective pathology.
Clues from the history and examination:
- Arthritis present for at least 6 weeks before diagnosis (mandatory for diagnosis of
JIA).
- Either insidious or abrupt disease onset, often with morning stiffness and arthralgia
during the day, joint pain or abnormal joint use, history of school absences or limited
ability to participate in physical education classes, spiking fever occurring once or
twice each day at about the same time of day all are history findings in children with
JIA.
- "How has their general health been?" - Asking about red flags? The presence of systemic
symptoms should raise concerns about multisystem illness (e.g. JSLE or inflammatory
bowel syndromes and further serious pathology such as malignancy, bacterial infection or
trauma (including non-accidental injury; NAI) must be excluded before diagnosing JIA. It
is therefore essential to check for the presence of 'red flags Musculoskeletal red flags
Night time wakening with pain Bone pain Fever Anorexia Weight loss Malaise Features
suggestive of non-accidental injury
"Did anything precede their symptoms?" - Distinguishing reactive and traumatic causes
Typically, reactive arthritis occurs around 7-10 days after the acute illness and
spontaneously remits within 2-3 weeks of onset; gastrointestinal infections may cause a
reactive arthritis but in the older patient sexually acquired infection needs to be
sensitively explored. Falls in children are common and may be a 'red herring' as children
with arthritis are often more prone to falling. It is important to explore further for
inconsistency or discrepancy between circumstance and degree of injury, which should raise
suspicion about NAI.
"What are they like in the morning?"- Mechanical versus inflammatory features.
Joint swelling is a prominent symptom of inflammatory conditions such as JIA, but can be
subtle and often missed by parents (as well as health care professionals). To be diagnostic
of JIA, joint swelling needs to persist for several weeks (by definition, more than 6 weeks)
and other conditions excluded. Morning stiffness may manifest itself through functional
change (i.e. difficulty dressing or managing the stairs: "my child walks like an old man") or
through a noticeable change in behaviour; parents often mention that their child is
particularly miserable in the morning. Prolonged inactivity may precipitate stiffness known
as 'gelling', and the child may describe difficulty getting up after sitting for a sustained
length of time e.g.
following long car journeys.
"What can they no longer do?" - Developmental milestones
A history of regression of achieved motor milestones is often present with inflammatory joint
disease and can manifest as the child becoming 'clumsy' or withdrawing from activity (e.g. no
longer walking independently). Regression of a previously attained motor milestone suggests
an acquired condition whereas delay alone might suggest a congenital or inherited condition
(such as development dysplasia of the hip (DDH) or muscular dystrophy)
- Identifying the cause of polyarthritis may initially look difficult to the uninitiated.
However, clinical clues in patient demographics, disease chronology, inflammatory nature,
progression, distribution of joint involvement and extra-articular manifestations help narrow
the diagnostic possibilities.
Age At the onset of the disease may give clues to the diagnosis. Polyarticular JIA
(rheumatoid factor negative), Kawasaki disease (KD) and Henoch Schonlein purpura (HSP)
usually present in early childhood. In mid-childhood, juvenile psoriatic arthritis, Juvenile
Dermatomyositis (JDMS) and Polyarteritis Nodosa (PAN) have their peak frequencies. Juvenile
ankylosing spondylitis (JAS) and SLE typically present in late childhood or early
adolescence. Rheumatoid factor positive polyarticular JIA, mimicking the clinical profile of
adult RA, usually presents only after the age of 10years.Disorders like gout and crystal
deposition disease are extremely uncommon in children.
Sex While many rheumatological disorders (e.g. SLE, polyarticular JIA) have a predilection
for girls, there are others (e.g. vasculitides like KD and PAN; Spondyloarthropathies like
inflammatory bowel disease and JAS) which are more common in boys.
Onset of Disease and Duration While some arthritides may have an acute onset (e.g. septic
arthritis and arthritis associated with KD/HSP) others may have a subacute or chronic
insidious course as typically seen in polyarticular chronic insidious course as typically
seen in polyarticular JIA or sarcoidosis. Polyarthritis of less than 6 weeks duration is seen
in self limiting viral arthritides, rheumatic fever or reactive arthritis. It may sometimes
be prudent not to give a label in the first few weeks of the illness when the disease process
is still evolving.
Family History Although Mendelian inheritance is not usually seen in inflammatory
polyarthritis, familial clustering of cases can be seen in ankylosing spondylitis,
inflammatory bowel disease and psoriatic arthritis. The latter condition is especially
intriguing because clinical manifestations of psoriasis can be subtle and very variable
amongst the family members.
