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Regression of Activities

Katie is a 3 year old girl who attends her family doctor (general practitioner - GP) with a history of reluctance to walk. This has been going on for 8 weeks or so. Her mother says that Katie used to walk to daycare/nursery, but they now have to carry her as she complains of pains in her knees. She has stopped going down stairs in the mornings, and always wants to be carried. She cries when her parents dress her. The staff at the nursery/daycare report that she is less active and is not keen on going outside during playtime. She occasionally complains of pains in her knees. Her mother has not noticed any redness or swelling.

Katie has had no recent infections, apart from a mild cold which lasted a few days, and there is no history of recurrent fevers or rashes. Katie is normally fit and well, and has had all of her immunisations as scheduled.

The GP performs an examination, and notes a swollen left knee, with reduced range of movement. She notes that Katie’s right ankle seems quite stiff, although she is not sure if it is swollen.

The GP speaks to the on-call paediatrician, who recommends referral to the paediatric outpatient unit. Katie is seen on the outpatient unit. She looks well and is afebrile. Katie has effusions of her left knee, right ankle and a stiff right subtalar joint. She has blood tests (full blood count, inflammatory markers, autoantibodies), which are normal and normal x-rays. She is referred to the paediatric rheumatology clinic. The rheumatology team note the history of pain for 8 weeks and exclude other conditions based on results from the outpatient attendance.

A diagnosis of Juvenile Idiopathic Arthritis is made, and Katie is booked for intra-articular steroid injections of her affected joints under general anaesthetic. She is referred to the ophthalmologist to have her eyes screened for anterior uveitis. A physiotherapy review is arranged to follow her joint injections.


What are the key points in the history?

Morning stiffness, behavioural change and regression of achieved developmental milestones (e.g., walking down the stairs).

What features suggest an inflammatory component?

Symptoms of pain and stiffness that are worse in the mornings and after periods of rest, limited joint range of motion, and the presence of swelling/effusions.

What examination would be appropriate for the GP to perform?

Musculoskeletal examination such as pGALS and systemic examination (looking for pallor, lymphadenopathy and abdominal organomegaly) should be performed.

Blood tests are not always diagnostic for JIA (may be completely normal) and if there is concern about the diagnosis (or the child is young and there are concerns about doing blood tests), then referral is strongly recommended as soon as possible.

Blood tests are indicated more so to rule out other diagnoses, e.g., malignancy or infection, rather than to make the diagnosis of JIA.