A 3-year-old girl is brought to the clinic for evaluation of right knee swelling. Her mother first noticed the swelling and a limp 2 months ago but attributed them to roughhousing with her brother. Typically, the limping was present in the mornings and resolved by midday. However, while bathing the patient last night, her mother noticed that the right knee was more swollen than usual. The knee is not painful, and the patient has had no fever or rashes. Temperature is 37.5 C (99.5 F). She can bear weight on both legs but has a noticeable limp. The right knee is swollen and slightly warm. The overlying skin appears normal and intact. There is no tenderness to palpation. Peripheral pulses are normal. Sensation is intact. This patient is at greatest risk for which of the following complications?

Question

A 3-year-old girl is brought to the clinic for evaluation of right knee swelling.  Her mother first noticed the swelling and a limp 2 months ago but attributed them to roughhousing with her brother.  Typically, the limping was present in the mornings and resolved by midday.  However, while bathing the patient last night, her mother noticed that the right knee was more swollen than usual.  The knee is not painful, and the patient has had no fever or rashes.  Temperature is 37.5 C (99.5 F).  She can bear weight on both legs but has a noticeable limp.  The right knee is swollen and slightly warm.  The overlying skin appears normal and intact.  There is no tenderness to palpation.  Peripheral pulses are normal.  Sensation is intact.  This patient is at greatest risk for which of the following complications?

Quizplus · Accepted Answer

11ec25c8_d73e_16e0_bc81_33b101d21a97_MD0003_00 This patient likely has juvenile idiopathic arthritis (JIA), a chronic autoinflammatory condition of childhood. Oligoarticular JIA, the most common form, is characterized by involvement of ≤4 joints (ie, <5 joints) within the first 6 months of disease onset. A limp that is worse in the morning in a toddler girl (age <5), such as this patient, is a typical presentation of oligoarticular JIA. Joint swelling is present, but pain may be minimal. The large joints (eg, knees, ankles) are most commonly affected; however, hip involvement is rare. Systemic symptoms (eg, fever, rash) do not occur. Uveitis (ie, intraocular inflammation) is a serious complication that develops in a minority of patients with oligoarticular JIA. Ophthalmologic screening examinations are performed regularly because untreated uveitis is often asymptomatic and can lead to irreversible vision loss. Although not present in all patients with oligoarticular JIA, antinuclear antibodies are a risk factor for uveitis. Additional laboratory findings (eg, leukocyte count, hemoglobin, erythrocyte sedimentation rate) are typically normal in oligoarticular JIA. Treatment is aimed at relieving inflammation and includes nonsteroidal anti-inflammatory drugs, intraarticular glucocorticoids, and disease-modifying antirheumatic drugs. (Choice A) Atrioventricular conduction block is a complication of Lyme disease, which typically presents as monoarthritis, most commonly of the knee. Erythema migrans and systemic findings (eg, fever, headache) often precede the joint abnormalities, and joint swelling does not resolve throughout the day. Erythema migrans (Choice B) Inflammatory bowel disease is associated with spondyloarthritis, which typically presents in adult men with chronic lower back pain due to axial (eg, sacroiliac) joint involvement. (Choice C) Intramuscular hemorrhage occurs with hemophilia, an X-linked recessive bleeding disorder that can cause acute joint pain and swelling due to hemarthrosis. Chronic arthritis in a young girl makes hemophilia and hemarthrosis unlikely. (Choice D) Pulmonary fibrosis is seen in association with rheumatoid arthritis, which most commonly presents with small joint (eg, hands, feet) arthritis in adult women. Pulmonary manifestations do not occur in oligoarticular JIA. Educational objective: The oligoarticular form of juvenile idiopathic arthritis (JIA), the most common subtype, is characterized by arthritis involving ≤4 joints. Patients are classically girls age <5. Regular ophthalmologic screening is indicated because uveitis is a serious potential complication of oligoarticular JIA that can cause irreversible vision loss if untreated. References: Juvenile idiopathic arthritis-associated uveitis. (http://www.ncbi.nlm.nih.gov/pubmed/27121190)

A 3-Year-Old Girl Is Brought to the Clinic for Evaluation