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HIGH-YIELD FACTS

  • Nonsteroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, immunosuppressants, and biologic agents ameliorate the underlying inflammatory process of systemic lupus erythematosus (SLE).

  • Admit patients with suspected acute rheumatic fever (ARF). Administer penicillin to eradicate any residual carriage of group A β-hemolytic Streptococcus (GAβHS).

  • Enthesitis-related arthritis is a rheumatic disorder that can present in later childhood or adolescence. It is characterized by involvement of the sacroiliac (SI) joints and lumbar spine, but patients may also have peripheral arthritis.

  • Treat reactive arthritis with anti-inflammatory agents; the role of antibiotic treatment is unclear unless Chlamydia trachomatis is the inciting infection.

  • In juvenile idiopathic arthritis (JIA), polyarticular disease involves more than four joints and rheumatoid factor may be present or absent. Pauciarticular JIA involves four or fewer joints (most commonly leg joints but rarely hip involvement). Intermittent spiking fever may be the initial manifestation of systemic onset JIA.

TRANSIENT SYNOVITIS

Transient synovitis, also known as toxic synovitis, is the most common cause of hip pain in childhood. It is a self-limited condition caused by a nonpyogenic inflammatory response of the synovium. Its peak incidence is between 3 and 6 years of age and it affects boys more commonly than girls, with a slight predilection for the right hip. Less than 5% of cases are bilateral. Pain may be referred to the medial aspect of the thigh or knee. An association with active or recent infection, trauma, or allergic hypersensitivity is suspected. Many children with transient synovitis have or recently have had an upper respiratory illness.

Affected patients either refuse to walk or walk with a limp. The leg is held in flexion with slight abduction and external rotation. Passive movement is usually pain-free; however, there may be pain and a slightly decreased range of motion with extreme internal rotation or abduction. Low-grade fever and malaise may be present. The diagnosis of transient synovitis is one of exclusion, as laboratory values may be normal or may reveal mild elevations in the white blood cell (WBC) count and erythrocyte sedimentation rate (ESR). Clinical decision rules have been developed to help differentiate transient synovitis from septic arthritis based on the presence or absence of fever, the ability to bear weight, WBC counts, and inflammatory markers (ESR and C-reactive protein [CRP]) (Chapter 109). In the absence of fever and without elevated WBC and ESR, septic joint is unlikely, and the diagnosis of transient synovitis can be made without obtaining joint fluid. Kingella kingae septic arthritis, however, can present with minimal clinical abnormalities and may be mistaken for transient synovitis,1 so it is imperative that you provide these patients with close follow-up. Anteroposterior (AP) and “frog-leg” lateral radiographs of the pelvis tend to be normal in transient synovitis; other findings consistent with transient synovitis include medial joint space widening, an accentuated pericapsular shadow, and Waldenström sign, which is lateral displacement of the femoral epiphysis with surface flattening secondary to effusion. ...

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