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7 Articles in this Series
Introduction
Addressing Arthralgia in Children
An ACR/ARHP Preview
Axial Spondylitis: Mimics, Progression, the Need for MRI, and New Management Recommendations
How Rheumatic Diseases Can Hurt Sexual Health
Tanezumab for Hip and Knee OA; Cosentyx for Ankylosing Spondylitis; and Upadacitinib for RA
Treating Chronic Musculoskeletal Pain in Older Adults
Uncovered Inflammatory Pathways of Osteoarthritis Call for New Targets

Addressing Arthralgia in Children

Persistent joint pain, with or without other symptoms, in pediatric patients may require long-term monitoring for proper diagnosis. An ACR/ARHP 2018 Meeting Highlight with Michael Miller, MD.

 

Michael Miller, MD, a professor of pediatrics at the Feinberg School of Medicine at Northwestern University, spoke about arthralgia, or joint pain, in the pediatric population at the Chicago-based 2018 ACR/ARHP annual meeting. Dr. Miller also practices pediatric rheumatology at the Ann & Robert H. Lurie Children’s Hospital of Chicago. He used a few case examples to illustrate how clinicians may assess for arthralgia in children, including how to diagnose potentially more serious diseases.

“When a pain clinic receives a pediatric referral for arthralgia, knowing how to move forward may be challenging,” he said. “Often, children with joint pain have normal physical exams on their first visit. The key is understanding that children take longer to develop manifestation of diseases, so repeated exams will be necessary during follow-up visits.”

Screening for MSK Pain Syndromes in the Pediatric Population

Even when a child with joint pain has a normal initial physical exam, conditions such as Juvenile Idiopathic Arthritis (JIA) or malignancies may be diagnosable on subsequent visits. Monitoring to rule out other diagnoses is therefore crucial, Dr. Miller noted.

One of the most common causes of arthralgia in children is hyperextensibility arthralgia (often associated, for unknown reasons, with a low titer positive ANA blood test). Most patients do well with reassurance and physical therapy. Over time, it is important, however, to watch for the development of subclinical enthesitis or arthritis, he noted.

In addition, Dr. Miller pointed out that one important way to help distinguish children with organic causes of arthralgia from those whose joint pain is mostly related to psychological problems: most children with organic based arthralgia, depressed about missing school, make every effort to attend. In contrast, in Dr. Miller’s experience, children with musculoskeletal (MSK) pain syndromes tend to be anxious about returning to school, and they often have multiple school absences. In all cases, however, diseases causing arthralgia will need to be considered by appropriate history, physical findings, and laboratory results, including:

  • Juvenile Idiopathic Arthritis
  • Lupus (SLE)
  • Mixed connective tissue disease (MCTD)
  • Scleroderma

Dr. Miler shared the case of a 5-year-old with wrist pain but no swelling or loss of motion. He was anemic with blood test results that also showed neutropenia and lymphocytosis. As neutropenia and lymphocytosis are atypical for rheumatic diseases, children who present with joint pain in cases such as this may need to undergo a bone marrow test, he advised. In this case, the child was found to have leukemia.

Infection-based Joint Pain

“We also see kids with joint pain following a resolved infection,” said Dr. Miller. This could result from post-infectious arthritis (usually less than 6 weeks of pain); or reactive arthritis (often following a bacterial infection such as Lyme disease, enteritis or a UTI). A small number of these patients will develop chronic arthritis, which may be difficult to distinguish from JIA whose onset is accelerated by infection.

Juvenile Idiopathic Arthritis (JIA)

Dr. Miller reminded the audience that JIA is a diagnosis of exclusion. Systemic onset JIA may present with persistent fevers, salmon pink or evanescent rash on the trunk and extremities, and hepatosplenomegaly or adenopathy. A delay before synovitis develops is typical. Common types of JIA are:

  • Oligoarticular: affecting four or fewer joints
  • Polyarticular: usually affecting at least five joints

Enthesitis/Childhood Spondyloarthritis

He added that persistent pain over the heels/soles of feet may be an early sign of a subset of JIA affecting primarily ligaments and tendons (enthesitis); psoriatic arthritis or sports-related injuries should also be considered. Enthesitis-related arthritis may take months or years to manifest. Conditions that may mimic enthesitis include psoriatic and polyarticular arthritis.

Child with knee joint pain (Source: 123RF)Joint pain in children could stem from a number of MSK conditions.

Tests to Order

When assessing a child with arthralgia, with or without arthritis, first-line differential diagnostic tests may include:

  • ESR (Dr. Miller noted that results are normal in as many as half of children with active synovitis)
  • CBC (which may identify acute lymphocytic leukemia)
  • ALT (to rule out any underlying liver disease)

For the child with arthralgia and additional symptoms

Small subsets of pediatric patients with lupus and JIA can develop interstitial lung disease, he warned, so clinicians need to be aware and cautious. Paying attention to fever, rash, adenopathy, pain in other areas, for instance, is crucial. In some cases, an extensive workup for infectious disease and rheumatic disease may be needed.

An echocardiogram may be useful in evaluating the child with a persistent non-specific rash, adenopathy, joint pain, and fever. Results may show coronary artery aneurysm, thickened mitral valve, or pericardial effusion, findings in Kawasaki Disease, subacute bacterial endocarditis, and systemic-onset JIA, respectively.

Back pain, Dr. Miller noted, is a unique symptom, with a broad differential.  Because back pain may be referred from one part of the spine to another, an MRI of the entire spine is useful in excluding such causes as:

  • Spondylolisthesis
  • Infections
  • Tethered cord
  • Syrinx
  • Chiara malformation
  • Tumor

One simple guideline, offered by Dr. Miller: admit children who cannot walk, for observation and evaluation. He has had patients admitted whose evaluation revealed causes including iliac osteomyelitis, neuroblastoma, and even sexual abuse.

For the child with arthralgia and weakness, Dr. Miller recommends ruling out juvenile dermatomyositis, muscular dystrophy, and malignancy. Asking questions about weakness can help identify proximal muscle weakness seen in dermatomyositis (eg, can the child get out of bed, change clothes, etc). Lab tests may include CPK. Normal results by themselves do not exclude inflammatory muscle disease, as they can be seen in children with chronic inflammatory muscle disease.

Overall, Dr. Miller shared a few personal clinical pearls about arthralgia, tests, and assessment:

  • Always look for additional symptoms
  • Review guidelines or differential diagnoses
  • Repeat physical exams
  • Use lab and imaging evaluations, including an echocardiogram with fever/rash/adenopathy
  • Consider leukemia – remember lymphocytosis and neutropenia are unusual in rheumatic diseases.

On Medication Management

Although his talk focused on assessment, not treatment, of arthralgia, Dr. Miller did offer some best practices based on his clinical experience. “If a child has a pain syndrome, we avoid medication as much as possible,” said Dr. Miller. Instead, his hospital team focuses on physical therapy and non-medical approaches, including relaxation techniques, guided imagery, and meditation. They avoid steroids and only trial NSAIDs for short periods. He also recommends referral to a pain clinic for any other necessary medication management.

 

On Communicating with Parents

Finally, Dr. Miller discussed challenges related to communicating with parents who are rightly concerned about their children’s problems, including missed school. He did offer some advice based on what he practices in his clinical setting:

  • Avoid telling a parent that “nothing is wrong” with their child and avoid suggesting that the child’s pain is a psychological issue. Instead, explain why you may not be able to make a diagnosis at this time.
  • Talk about the importance of follow-up and repeated exams. By monitoring for physical changes several times a year, you will be able to consider other diagnoses.
  • In addition, talk to parents about conditioning and recommend a program, such as that under the supervision of a physical therapist, so that any lack of activity due to arthralgia does not lead to deconditioning.

Lastly, Dr. Miller advised that it is important to recommend a psychologist or psychiatrist as any child with chronic pain is likely living with secondary stress as a result of dealing with their pain, especially if they are not making a lot of progress—whether they realize it or not. Many parents may not want to hear this, but it is still important that they do. Dr. Miller disclosed that some pediatric rheumatologists believe pediatric patients need to be seen more regularly by other types of specialists—beyond the rheumatologist’s scope of care and that this should be considered case by case.

 

Next summary: An ACR/ARHP Preview
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