Pediatric emergency medicine trisk 2994 2994
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Iridocyclitis. Iridocyclitis (inflammation of the iris and ciliary body) occurs in
approximately 10% to 20% of all children with JIA. This can be of acute or chronic
onset. The chronic type of iridocyclitis occurs primarily in young children with
oligoarticular JIA, especially girls with oligoarthritis and a positive ANA. In contrast,
acute iridocyclitis occurs most often in older boys with oligoarticular disease.
Acute iridocyclitis is characterized by sudden onset of redness, tearing, pain, and
photophobia, and urgent management may be required to preserve vision. Immediate
consultation with an ophthalmologist is essential. The usual emergent treatment
includes topical corticosteroids and mydriatics.
Flare of a Single Joint in a Patient with JIA. In a patient known to have JIA and
receiving anti-inflammatory medication, acute swelling with pain and limitation of
range of movement of a single joint raises a common management problem. Potential
causes of such an acute monoarthritis include a flare of JIA versus septic arthritis or
Lyme arthritis, and careful attention to physical examination and historical features are
essential to avoid misdiagnosis.
Physical findings characteristic of infection of a joint are fever, extreme pain,
tenderness, erythema, and warmth over the joint. The affected joints of JIA, while often
swollen, warm, and stiff, are rarely red. With infection, there is usually pronounced
splinting of an infected joint due to pain; the slightest movement may cause muscle
spasm. In contrast, some range of motion is usually possible even with severely
inflamed joints of JIA. If the patient is taking an immunosuppressive medication,
physical findings of inflammation and/or infection may be masked.
If infection cannot be excluded with confidence, joint fluid must be aspirated, and
the fluid sent for cell count, Gram stain, and culture. Synovial fluid is bacteriostatic and
some fastidious organisms, such as Kingella , may be particularly difficult to culture, so
joint fluid samples should be inoculated into blood culture bottles to optimize
sensitivity. If there is any doubt about the diagnosis, it is best to also obtain a blood
culture (which increases diagnostic yield, as the organisms causing septic arthritis are
generally spread hematogenously) and then to initiate treatment for septic arthritis.
For the acute swelling and pain in a single joint caused by a JIA flare, resting the
involved extremity for 2 to 3 days may be adequate. After infection has been excluded,
injection of the joint with a topical steroid preparation such as triamcinolone
hexacetonide (1 mg/kg, maximum 40 to 60 mg) may provide rapid and sustained relief.
If multiple joints are involved during a flare, treatment with systemic agents from
NSAIDs to corticosteroids may be necessary, as may escalation of the baseline antiarthritis regimen for severe or persistently active arthritis.
Ruptured Popliteal Cyst. There are six bursae around the knee joint. Of these, the
gastrocnemius semimembranosus bursa is the one that most often communicates with
the synovial space. Consequently, in the presence of effusion in the knee joint, fluid
