Peh, WCG

HKU Scholars Hub

Title Radiological conference. Juvenile rheumatoid arthritisAuthor(s) Peh, WCGCitation Hong Kong Practitioner, 1997, v. 18 n. 9, p. 483-485Issued Date 1997URL http://hdl.handle.net/10722/44652Rights Creative Commons: Attribution 3.0 Hong Kong LicenseRADIOLOGICAL CONFERENCEClinical History:An 8-year-old boy presented with multiple joint pains, which started at the ase of about 1 -2 years. Both wrists weresymmetrically and severely affected.Figure 1: Posteroanterior radiograph (left hand) Figure 2: Posteroanterior radiograph (right hand)What is the diagnosis?a) Juvenile rheumatoid arthritis.b) Leukaemia.c) Juvenile dermatomyositis.d) Haemophilia.e) Tuberculous arthritis.This radiology case was prepared by: Dr. Wilfred C.G. Peh, Associate Professor,Department of Diagnostic Radiology,The University of Hong Kong,Queen Mary Hospital.483Radiological ConferenceRADIOLOGICAL CONFERENCEAnswer:a) Juvenile rheumatoid arthritis.Radiological findingsThe posteroanterior wrist radiographs (Figures 1- 3)show fragmentation, irregularity and deformity of all thecarpal bones. Similar changes affecting the distal radialand ulnar epiphyses are demonstrated. There is mildperiarticular osteoporosis. Both hands are symmetricallyinvolved.Figure3: This figure is identical to Figure 2 withaddition of arrows. Irregular fragmentationof the carpal bones (open arrows) and distalforearm epiphyses (arrows) are presentDiscussionIn children presenting with painful joint symptoms, theinitial role of imaging is to determine whether the problemis indeed due to a real joint disease or not. Conditionswhich may mimic joint disease include leukaemia andjuvenile dermatomyositis. The term juvenile chronicarthritis (JCA), besides encompassing the disease juvenilerheumatoid arthritis (JRA), also includes other paediatricconnective tissue diseases, juvenile ankylosing spondylitisand juvenile psoriatic arthritis.JRA is relatively common, having a prevalence of 21 to70 per 100,000 population, and may affect children asyoung as 1 to 2 years of age. The 3 main clinical subgroups,namely: systemic onset, polyarticular onset and pauci- ormono-articular onset, account for about 70% of cases. Bonyerosions, joint space narrowing and bony ankylosis arelate radiographic features of JRA. In young children wherethe bone ends are still cartilaginous, the radiographic cluesfor the detection of joint disease may be subtle and areeasily missed if one is unaware of them. These signsinclude growth disturbances due to per iar t icularhyperaemia, typically giving a bulbous appearance to thedistal ends of the proximal phalanges; periarticularperiostitis; per iart icular soft tissue swelling,- andperiarticular osteopaenia.The limitation of using plain radiographs to evaluatejoint disease in children is the non-visualization ofcartilage, the position of which is indirectly implied fromthe relatively large space between the ossified bone ends.In such circumstances, considerable cartilage destructionoften occurs before any bony erosion is radiographicallyapparent. Magnetic resonance imaging (MRI) providesdirect demonstration of the cartilage and surrounding softtissues in a multiplanar manner. This imaging technique isvery promising in the detection, diagnosis and monitoringof disease activity in patients with JRA.LeukaemiaClinically, patients with leukaemia may present withpainful joints. The most important radiographic featureof leukaemia is a lucent band in the metaphysis of theinvolved bone. If present symmetrically in a child over 2years of age, this sign is considered pathognomonic. Othersigns of leukaemia include periosteal reaction, metaphysealdestruction and pathological fractures. None of theseradiographic features were present in this case.Juvenile dermatomyositisAlthough the joints are usually normal or only minimallyaffected in juvenile dermatomyositis, muscle involvementoften results in multiple joint pain. Muscle or soft tissuecalcification represent late changes of this disorder. MRI484Hong Kong Practitioner 18 (9) September 1996is the most sensitive means of detectins early muscularinvolvement and is useful in guidins the selection of themost appropriate biopsy site. The radiographic changesin this case are not compatible with those of juveniledermatomyositis.HaemophiliaThe joint changes in haemophilia are due to repeatedepisodes of intra-articular bleeding. Large joints such as theknee, elbow, ankle, hip and shoulder are most commonlyaffected. Intra-osseous bleeds may produce lucentdefects. There may also be periarticular osteoporosisand coarsened trabecula. Sometimes, dense soft tissueswelling due to deposition of haemosiderin in thickenedsynovium may be seen periarticularly. In this case, theclinical history, sites of involvement and radiographicappearances exclude the diagnosis of haemophilia.Tuberculous arthritisTuberculous arthritis maybe associated with pulmonarytuberculosis. The frequently involved peripheral joints arethe hips, knees, hands and feet. The disease process isusually of an insiduous onset, with the joint space beingunaffected till late in the disease course. Periarticularosteopaenia often precedes destructive changes. Erosionsare typically present at the peripheral non-contact pointsof the joints. Tuberculous arthritis is classically mono-art icular, and can be excluded in this case whereinvolvement is bilateral and symmetrical. •ReferencesPoznanski AK. Radiologic approach to joint disease in children. In: ResnickD, Pettersson H (eds). Skeletal Radiology London: Merit Communications.1992; pp 455-481.Chapman S, Nakielny R. Aids to Radiologic Differential Diagnosis. 3rd ed.London: Bailliere Tindall. 1995; pp 552-553.SUPPOSITORIESFOR CHILDRENQUICK RELIEVE FOR CHILDRENEach suppository contains:100 mg PARACETAMOL + 100 mg PROPYPHENAZONE(No Phenacetin, no Aspirin)RELIEVE PAIN RAPIDLYACT AGAINST INFLAMMATIONDOSAGEfrom 1 to 4 years of age: Vz to 1 suppository 2 times daily,after 4 years of age up to 3 suppositories daily, dependingupon weight.Samples upon request. 20% Bonus for Trial order.• CALMING AND SOOTHING• DECREASE FEVER FASTMERCK Gesellschaft mbH, Wien Austria,division OVCMUSole Agents: J>«« Hing Pharmaceuticat Co.,Room 1012, Block. 3, Nan Fung Industrial City,18 Tin Hau Road, Tuen Mun, N.T., Hong Kong.Tel: 24558138 Fax: 2455 8008485

Radiological conference. Juvenile rheumatoid arthritis

http://hub.hku.hk/bitstream/10722/44652/1/24868.pdf

Radiological conference. Juvenile rheumatoid arthritis

Abstract

Similar works

Full text

Available Versions

HKU Scholars Hub