Case Report
Rare presentation of polyarticular juvenile idiopathic arthritis and the role of the radiograph in initial diagnosis
Scottish Medical Journal 2014, Vol. 59(3) e6–e7 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014542386 scm.sagepub.com
MA Khan1, M Thyagiarajan2, M Laugharne3 and J Clinch1
Abstract Background: Polyarticular disease affects one-third of all juvenile idiopathic arthritides. It affects girls twice as much as boys. It usually involves peripheral joints throughout the course of disease. It is unusual for cervical spine involvement to be the presenting symptoms of RF negative polyarthritis. Clinical case: This is the case of RF-negative polyarticular juvenile idiopathic arthritis that was reported with six-week history of neck pain, torticollis and left knee effusion. The case was sent to the radiology department from primary care. Despite the fact that the symptoms occurred quite recently, on initial radiograph significant cervical spine inflammation and damage were revealed. Conclusion: This case highlights the importance of early recognition of neck involvement in juvenile idiopathic arthritis as well as significance of close liaison between radiology and paediatric rheumatology. It also highlights the possible role of cervical spine imaging in all children with juvenile idiopathic arthritis.
Keywords Juvenile idiopathic arthritis, cervical spine, paediatrics, radiology
An 11-year-old girl came to a local emergency department (ED) with a 4-month history of neck pain. On arrival, she also had left knee swelling and effusion from last 6 weeks. She had plain radiograph taken of her left knee and neck (cervical spine) (Figures 1 and 2, respectively). When her radiographs were reported by the radiologist, the clinical details were connected to the findings on radiographs. An initial diagnosis of arthritis was suggested and a referral sent to rheumatology services. The findings of arthritis were confirmed with magnetic resonance imaging (MRI) of cervical spine (Figure 3). Clinically, her history was ordinary. Her neck had severe restriction in extensions as well as in lateral rotation to the left and right. On further investigation, she was confirmed as anti-nuclear antibody positive. She was treated with pulsed methyl prednisolone and was also started on subcutaneous methotrexate. Her presentation was quite unique as among children with rheumatoid factor (RF)-negative polyarthritis; knees, wrists and ankles are the most commonly
affected joints both at initial occurrence and also throughout the disease course.1 Cervical spine involvement is not commonly recognised early in the course of RF-negative polyarthritis either clinically or radiographically.2 This case highlights that neck pain in children without any history of trauma or any other illness should be taken seriously and investigated properly. Torticollis is commonly seen in primary care; it is important that juvenile idiopathic arthritis (JIA) with cervical spine inflammation as a presenting factor should be included in the differential diagnosis list.
1
Department of Paediatric Rheumatology, Bristol Children’s Hospital, UK Department of Paediatric Radiology, Bristol Children’s Hospital, UK 3 Department of Radiology, Royal United Hospital Bath NHS Trust, UK 2
Corresponding author: JG Clinch, Consultant Paediatric Rheumatologist, Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8AE, UK. Email: [email protected]
Downloaded from scm.sagepub.com at FUDAN UNIV LIB on May 8, 2015
Khan et al.
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Figure 1. The large joint effusion in the supra-patellar pouch of left knee.
Figure 3. T1 post-gadolinium fat saturated sagittal image showing thickened and enhancing synovium (pannus) between the anterior arch of C1 and the odontoid peg.
Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References
Figure 2. Lateral cervical spine X-ray showing increased distance between the anterior arches of C1 and the odontoid peg (11 mm).
1. Cassidy JT, Ross EP, Ronald ML, et al. Textbook of pediatric rheumatology: expert consult. Philadelphia: Saunders, 2010. 2. Oen K, Reed M and Malleson PN. Radiologic outcome and its relationship to functional disability in juvenile rheumatoid. J Rheumatol 2003; 30: 832–840.
The possibility of rheumatological disease should always be considered in any child with significant neck pain and restriction of movement, and careful evaluation and proper investigation can give crucial clues to the diagnosis.
Downloaded from scm.sagepub.com at FUDAN UNIV LIB on May 8, 2015
Rare presentation of polyarticular juvenile idiopathic arthritis and the role of the radiograph in initial diagnosis
Scottish Medical Journal 2014, Vol. 59(3) e6–e7 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0036933014542386 scm.sagepub.com
MA Khan1, M Thyagiarajan2, M Laugharne3 and J Clinch1
Abstract Background: Polyarticular disease affects one-third of all juvenile idiopathic arthritides. It affects girls twice as much as boys. It usually involves peripheral joints throughout the course of disease. It is unusual for cervical spine involvement to be the presenting symptoms of RF negative polyarthritis. Clinical case: This is the case of RF-negative polyarticular juvenile idiopathic arthritis that was reported with six-week history of neck pain, torticollis and left knee effusion. The case was sent to the radiology department from primary care. Despite the fact that the symptoms occurred quite recently, on initial radiograph significant cervical spine inflammation and damage were revealed. Conclusion: This case highlights the importance of early recognition of neck involvement in juvenile idiopathic arthritis as well as significance of close liaison between radiology and paediatric rheumatology. It also highlights the possible role of cervical spine imaging in all children with juvenile idiopathic arthritis.
Keywords Juvenile idiopathic arthritis, cervical spine, paediatrics, radiology
An 11-year-old girl came to a local emergency department (ED) with a 4-month history of neck pain. On arrival, she also had left knee swelling and effusion from last 6 weeks. She had plain radiograph taken of her left knee and neck (cervical spine) (Figures 1 and 2, respectively). When her radiographs were reported by the radiologist, the clinical details were connected to the findings on radiographs. An initial diagnosis of arthritis was suggested and a referral sent to rheumatology services. The findings of arthritis were confirmed with magnetic resonance imaging (MRI) of cervical spine (Figure 3). Clinically, her history was ordinary. Her neck had severe restriction in extensions as well as in lateral rotation to the left and right. On further investigation, she was confirmed as anti-nuclear antibody positive. She was treated with pulsed methyl prednisolone and was also started on subcutaneous methotrexate. Her presentation was quite unique as among children with rheumatoid factor (RF)-negative polyarthritis; knees, wrists and ankles are the most commonly
affected joints both at initial occurrence and also throughout the disease course.1 Cervical spine involvement is not commonly recognised early in the course of RF-negative polyarthritis either clinically or radiographically.2 This case highlights that neck pain in children without any history of trauma or any other illness should be taken seriously and investigated properly. Torticollis is commonly seen in primary care; it is important that juvenile idiopathic arthritis (JIA) with cervical spine inflammation as a presenting factor should be included in the differential diagnosis list.
1
Department of Paediatric Rheumatology, Bristol Children’s Hospital, UK Department of Paediatric Radiology, Bristol Children’s Hospital, UK 3 Department of Radiology, Royal United Hospital Bath NHS Trust, UK 2
Corresponding author: JG Clinch, Consultant Paediatric Rheumatologist, Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Upper Maudlin Street, Bristol, BS2 8AE, UK. Email: [email protected]
Downloaded from scm.sagepub.com at FUDAN UNIV LIB on May 8, 2015
Khan et al.
e7
Figure 1. The large joint effusion in the supra-patellar pouch of left knee.
Figure 3. T1 post-gadolinium fat saturated sagittal image showing thickened and enhancing synovium (pannus) between the anterior arch of C1 and the odontoid peg.
Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References
Figure 2. Lateral cervical spine X-ray showing increased distance between the anterior arches of C1 and the odontoid peg (11 mm).
1. Cassidy JT, Ross EP, Ronald ML, et al. Textbook of pediatric rheumatology: expert consult. Philadelphia: Saunders, 2010. 2. Oen K, Reed M and Malleson PN. Radiologic outcome and its relationship to functional disability in juvenile rheumatoid. J Rheumatol 2003; 30: 832–840.
The possibility of rheumatological disease should always be considered in any child with significant neck pain and restriction of movement, and careful evaluation and proper investigation can give crucial clues to the diagnosis.
Downloaded from scm.sagepub.com at FUDAN UNIV LIB on May 8, 2015
