Presentations
- Acutely unwell
- Decreased joint range of motion
- Fever
- Functional impairment
- Joint pain
- Joint swelling
- Limp
- Rash
- Stiffness, such as morning stiffness or with inactivity
Conditions
- Arthritis in the context of infection:
- mycobacterium-related
- post-infectious, including transient synovitis
- post-streptococcal, including acute rheumatic fever
- septic arthritis, acute – with or without osteomyelitis
- Juvenile idiopathic arthritis (JIA):
- enthesitis-related arthritis
- oligoarthritis, including extended or persistent disease
- polyarthritis:
- rheumatoid factor negative
- rheumatoid factor positive
- psoriatic
- systemic–onset
- unclassified
- JIA-associated medical emergencies:
- macrophage activation syndrome (MAS) / secondary hemophagocytic lymphohistiocytosis (HLH)
- systemic onset JIA pericarditis / cardiac tamponade
- JIA-associated uveitis
- Non-JIA causes of inflammatory arthritis:
- associated with other rheumatic conditions
- chromosomal syndrome-associated, such as:
- DiGeorge / 22Q syndrome
- Down syndrome
- Turner syndrome
- coeliac disease-associated
- immune deficiency mediated
- inflammatory bowel disease-associated
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Conditions
- Adult-onset inflammatory arthritis:
- adult-onset Still disease
- axial spondyloarthritis:
- non-radiographic
- radiographic
- crystal-induced, such as gout
- osteoarthritis
- psoriatic arthritis
- reactive arthritis
- rheumatoid arthritis:
- seronegative
- seropositive
- Conditions that mimic JIA
For each presentation and condition, Advanced Trainees will know how to:
Synthesise
- recognise the clinical presentation
- identify relevant epidemiology, prevalence, pathophysiology, and clinical science
- take a comprehensive clinical history
- conduct an appropriate examination
- establish a differential diagnosis
- plan and arrange appropriate investigations
- consider the impact of illness and disease on patients and their quality of life when developing a management plan
Manage
- provide evidence-based management
- prescribe therapies tailored to patients’ needs and conditions
- recognise potential complications of disease and its management, and initiate preventative strategies
- involve multidisciplinary teams
Consider other factors
- identify individual and social factors and the impact of these on diagnosis and management
Epidemiology
- Age of onset for different JIA subtypes
- Annual incidence and prevalence
- Genetic factors associated with JIA
- Geographic variability in JIA subtypes
- Male to female ratio for different JIA subtypes
Pathophysiology
- Principles of autoinflammation and autoimmunity
Treatments
- Considerations for medications used in the treatment of JIA:
- drug interactions
- duration and discontinuation
- mode of action
- route of administration
- safety monitoring
- side effect profiles
- Corticosteroids:
- intra-articular
- intravenous
- oral
- Disease-modifying antirheumatic drugs (DMARDs):
- biologic DMARDs (bDMARDs), such as inhibitors of:
- B-cells
- co-stimulatory inhibition
- interleukin-1
- interleukin-6
- interleukin-12/23
- interleukin-17
- tumour-necrosis factor α
- conventional DMARDs (cDMARDs), such as:
- hydroxychloroquine
- leflunomide
- methotrexate
- sulfasalazine
- small molecule targeted synthetic DMARDs (tsDMARDs):
- Janus kinase (JAK) inhibitors
- Non-steroidal anti-inflammatory drugs (NSAIDs)
- Treatments for macrophage activation syndrome
Clinical assessment tools
- JIA:
- damage scores
- disease activity scores
- outcome measures
Investigations
- Baseline investigations looking for inflammation
- Infection screening as relevant, such as antistreptolysin O titre
- Monitoring blood tests for patients on treatment
- Pre-immunosuppression screening, such as latent tuberculosis screening
- Role of different imaging modalities:
- in diagnosis of arthritis, and consideration of differentials
- in surveillance of disease activity and assessing damage over time
- Specific immune testing in inflammatory arthritis, such as:
- anticyclic citrinullated peptide
- antinuclear antibody
- human leukocyte antigen (HLA) B27
- rheumatoid factor
- Testing for macrophage activation syndrome
- Work up for differentials of chronic inflammatory uveitis
Physical examination
- Comprehensive physical examination for a child with suspected inflammatory arthritis of the musculoskeletal system and other relevant systems, such as:
- abdominal
- cardiac
- ear, nose, and throat
- respiratory
- skin
- Screening examinations:
- paediatric gait, arms, legs, and spine (pGALS)
- paediatric regional examination of the musculoskeletal system (pREMS)
Procedures
- Intra-articular steroid injections
Specific considerations
- Function-related outcomes
- JIA:
- cardiovascular outcomes
- extra-articular manifestitations
- mortality rates in systemic-onset
- multidisciplinary teams and their importance in the management of JIA, including:
- occupational therapy
- physiotherapy
- specialist nurse
- Management of chronic immunosuppression:
- Potential for secondary pain sensitisation in patients with inflammatory arthritis
- Screening for and management of chronic uveitis
