Review for the Primary Care Physician
Differential Diagnosis of Arthritis in Children
Arthritis is not a rare condition in childhood, and over one
hundred different conditions may produce signs and symptoms of arthritis in childhood.
Joint inflammation can arise from multiple causes, varying from a reaction to
minor infections, to injuries, and even to the presence of skeletal or systemic
malignancies. In all cases the basis for diagnosis is history, including family
and past medical history, and physical examination including all of the joints.
Laboratory tests such as erythrocyte sedimentation rate, complete blood count,
rheumatoid factor, and antinuclear antibodies, can be useful in selected
situations only. Other tests will be performed with the basis of a specific
clinical suspicion. Recognition of unusual syndromes is important; no child
should be labeled as having juvenile idiopathic arthritis (JIA) unless there is
a clear history of persistent joint (not soft tissue only) swelling, in
appropriate sites, and only if other causes of joint swelling have been
excluded. Bacterial infection should be suspected in a child with fever and a
single warm and painful swollen joint. In this situation synovial
fluid analysis and cultures should be immediately performed in order to
identify the nature of an underlying infection. Many different conditions can
mimic rheumatic diseases [1]; this review will focus on some of the more common
disorders seen by pediatric rheumatologists (Table 1).
TRAUMA
Parents or children themselves often refer to a trauma as
the cause of joint swelling, even though it is sometimes difficult to establish
the true relationship between the two events. In fact, the history of trauma
preceding the onset of arthritis is common, but is often a "red
herring", i.e., a complete coincidence. Therefore, a detailed history of
the traumatic event considering type, site, and degree of injury is recommended
when possible. Most children are physically active and often show bruises, cuts
or scratches on a routine physical examination. Moreover, adolescents are
particularly susceptible to develop traumatic lesions during competitive sport
activities. Hemarthrosis can occur after traumatic articular injury, even though considerable trauma is
required to produce a bloody synovial effusion.
Hemophilia and von Willebrand disease have to be
considered in the presence of recurrent intraarticular
bleeding, particularly if the traumatic event is absent or mild.
Computerized tomography and magnetic resonance imaging have
improved the diagnostic accuracy of articular
traumatic lesions [2].
INFECTIONS
Arthritis related to infection can be caused either by a
direct invasion of the infectious agent into the synovial
space (septic arthritis), or by different immunologic mechanisms triggered by
the infection from a different anatomical site (reactive or post-infectious
arthritis). Signs and symptoms of many rheumatologic disorders may unfold over
a prolonged period of time, and often diagnosis is delayed; however, it is
extremely important to rule out as soon as possible infectious causes of
arthritis. A delay in recognition and therapy can be associated with increased
morbidity and a poor joint or bone prognosis. If the onset of arthritis is acute,
especially in the presence of fever, infection should be immediately ruled out
with arthrocentesis (synovial
white cell count and culture) and laboratory testing (blood culture, complete
blood count, eryhtrocyte sedimentation rate,
C-reactive protein). Figure 1 provides a useful flow chart on how to proceed
with a child with a swollen joint.
Acute
Osteomyelitis
Fever and bone pain, associated with limp or avoidance of
use of the affected extremity, is the most common presentation of osteomyelitis. Fever is typically high (average 38-39 C°),
and a history of minor trauma within the previous 24-72 hours is not unusual.
Forty percent of cases of osteomyelitis in childhood
involve the femur or tibia. Pelvic osteomyelitis,
which can account up to 15% of cases, can involve the sacroiliac joints and may
present with pain in the hips, groin, buttock or abdomen. Point tenderness of
bone is often present and a good physical examination is essential [3].
Diagnosis can be difficult and is aided significantly by CT scans and MRI's.
Septic Arthritis
Septic arthritis occurs when a viable infectious agent is
present within the synovial space. The vast majority
of cases of septic arthritis occur in children. Large lower extremity joints
are typically involved (hips, knees and ankles). Onset is usually acute with
fever, pain and localized findings in the joint. Joint pain is usually severe,
and the infected joint and periarticular tissues are
swollen, warm, often with overlying erythematous
skin, and with restricted passive and active motion. Although most cases are monoarticular, approximately 5% involve more than one
joint. Haemophilus influenzae
type B is common in children younger than 2 years, while in older children the
organism that has been most commonly isolated is Staphylococcus aureus. Vaccination against H. influenzae
has decreased the incidence of this disorder in several countries.
In any child suspected of having a septic arthritis, blood
cultures and joint aspiration are mandatory. The synovial
fluid white blood count is often markedly elevated (> 5 x 109 /L)
in septic arthritis, although this is not a universal finding; moreover, synovial white count can be markedly elevated in reactive
or chronic arthritides as well. Synovial
fluid culture remains the gold standard technique to identify the causal agent,
but unfortunately results are negative in up to 20 % of cases. Evaluation by
polymerase chain reaction can sometimes be useful to identify bacterial
antigens in a culture- negative synovial fluid. In a
child with septic arthritis, intravenous antibiotics should be administered as
promptly as possible, even before the laboratory confirmation of the organism
involved or while awaiting the results of synovial
fluid cultures [3].
Tuberculous Arthritis
Typically, tuberculous arthritis
follows pulmonary tuberculosis as an indolent, persistent swelling of a single
joint, unresponsive to conventional therapy. This disorder has to be suspected
in epidemic situations or in recent immigrants from countries with endemic TB
problems. Synovial fluid cultures are often negative;
therefore the best diagnostic means is a synovial
membrane biopsy with culture [4].
REACTIVE AND POST-INFECTIOUS ARTHRITIS
By definition, infectious agents are not recoverable from
the synovial space in patients with reactive
arthritis. This kind of arthritis is the result of an immune response to
infection, usually in the respiratory, gastrointestinal or genitourinary
tracts. Reactive arthritides represent a very common
pediatric rheumatic disorder worldwide [5,6].
Viral arthritis
Arthralgias are common during
many viral syndromes, occurring more often than true arthritis secondary to
viral infections. These arthralgias are usually
migratory and self-limiting, without any residual joint disease. Only rarely
post-viral arthritis becomes chronic. Viral arthritis has been reported with a
number of viruses including Varicella-zoster,
Coxsackie, Epstein-Barr, Herpes simplex, parotitis,
rubella, hepatitis B, and Parvovirus B19. Although the general features are
common in all these cases, some display characteristic clinical findings [7].
Rubella.
Arthritis and arthralgias occur in
about a third of patients with wild-type rubella infection, and affect more
often adult females. Symptoms can also follow rubella vaccination. Rubella
arthritis usually begins about one week after the rash flare: the classic
presentation is a tenosynovitis of the wrists
associated with stiffness, pain and swelling of hands, wrists, knees and
ankles. In the pediatric age, typically the child is in a "catcher's
crouch" position. Symptoms usually resolve in a few days, but may recur.
Hepatitis
Seen in the prodromal phase of
illness, this arthritis most likely represents a serum-sickness type reaction
with rash (erythema multiforme).
This is usually seen in adolescents or young adults. The arthritis can be
severe and may precede the onset of jaundice. This syndrome has been reported
primarily with Hepatitis B infection and occasionally after the Hepatitis B
immunization.
Parvovirus B19 (Fifth's disease: Erythema
infectiosum)
Although this type of arthritis is most common in young
adult females, it has been reported that up to 5% of children with Parvovirus
B19 infection will develop arthritis. Typically, the onset of swelling occurs
soon after the development of rash, involving the small joints of the hands or
feet or a knee. Most cases are self-limited within a 2-4 week period, although
10% of adult women will have a prolonged course.
Acute Rheumatic fever
Acute rheumatic fever is a non-purulent complication of an
infection (usually of the upper repiratory tract)
caused by group A b -hemolytic Streptococcus pyogenes in a predisposed human host. It is a
connective tissue disease characterized by an inflammatory process that affects
several organs (mainly joints, heart, and brain) by cross-reactive antibody
formation and/or cell-mediated immune mechanisms.
Acute rheumatic fever peaks between 5 and 15 years of age,
with no major differences in incidence between females and males. Its prevalence
is very high in developing areas of the world, but a resurgence of this disease
in the last two decades has been observed in industrialized countries as well.
Although the modified Jones criteria [8] are essential for the diagnosis of
Acute Rheumatic Fever, these criteria are not very specific, being present in
other connective tissue diseases as well. In fact, children with juvenile
idiopathic arthritis, systemic lupus erythematosus,
or other rheumatic conditions may show arthritis, elevated erythrocyte
sedimentation rate, fever, chorea, or subcutaneous nodules. Moreover, recently
we have observed several children who did not have the classical clinical
presentation of streptococcal throat infection but then developed migratory
arthritis after a couple of weeks. No specific tests are available for the
definitive diagnosis of acute rheumatic fever; therefore, the diagnosis is
clinical, and the experienced physician should be able to interpret laboratory
results on the basis of clinical findings.
Fever, anorexia, malaise and pallor are systemic signs often
associated with rheumatic fever. Arthritis is the most common of the major
manifestations, but it is the most frequent cause of a misdiagnosis. The
arthritis in acute rheumatic fever affects primarily large joints (knees,
ankles, wrists, elbows); characteristically migratory, it rapidly responds to salicylates and other NSAIDs.
Joints are swollen, painful, warm, and with severely limited range of motion;
each single swollen joint usually heals within 1-3 days. Arthritis is
self-limited and non-deforming. More rarely, joint involvement can affect small
joints or cervical spine.
Carditis (myocarditis or more often endocarditis)
develops in about half of the patients, and is identified clinically as
appearance of a new heart murmur, or presence of an old murmur with new
features. The presence of echocardiographic
abnormalities in the absence of clinical findings should be evaluated
carefully, since the abnormalities might represent a falsely positive result or
a normal physiologic variant. Isolated pericarditis, that typically occurs in systemic lupus erythematosus
or systemic juvenile idiopathic arthritis, is rare in acute rheumatic
fever. Sydenham's chorea is a usually late
manifestation of rheumatic fever, characterized by purposeless movements;
evidence of streptococcal infection can lack due to the long latency period. Erythema marginatum and
subcutaneous nodules are uncommon, but, if present, simplify the diagnosis. The
presence of subcutaneous nodules is strictly linked to the presence of carditis.
Post-streptococcal reactive arthritis
Post Streptococcal Reactive Arthritis (PSReA)
is a form of arthritis that follows a documented infection by group A b -hemolytic Streptococcus, but lacks the required criteria
for the diagnosis of Acute Rheumatic Fever. PSReA is
characterized by arthritis involving one or more joints with symmetrical or
asymmetrical distribution, responding poorly to salicylates.
Unlike Acute Rheumatic Fever, it is often non-migratory and it can involve the
spine, small joints, and tendon sheaths. Despite the initial observation that carditis does not occur in PSReA,
several reports from different geographic areas describe pediatric PSReA patients who have subsequently developed carditis, especially mitral
insufficiency, when not placed on penicillin prophylaxis. Therefore, even
though this entity is considered by some authors to be separate from Acute
Rheumatic Fever, it has also been postulated that PSReA
may be a variant of it [9].
Arthritis following infection with enteric pathogens
Enteric pathogens, such as Salmonella, Shigella, Yersinia,
or Campylobacter, can cause infections that are followed by sterile
arthritis. Family history is often positive for spondyloarthropathy
and/or HLA-B27 positivity. Arthritis can be painful,
and usually has short duration. This arthritis problem was initially described
in adult men following venereal infections (Reiter's triad of arthritis, urethritis, conjunctivitis). In
childhood Reiter's syndrome is more commonly seen following an acute diarrheal episode, and tends to be an incomplete form.
Males are affected more frequently than females, and > 80% of
patients are HLA-B27 positive. The arthritis is usually pauciarticular
and involves lower extremity joints; fever and other systemic signs and
symptoms can also occur. In some patients this syndrome, that has been
considered benign and self-limited, may show a chronic course [10].
Transient synovitis of the
hip
This is a very common cause of limp in childhood, and can be
encountered very often in a pediatric practice. It is characterized by acute
onset of a limp and hip pain in an otherwise healthy child aged 3-10 years,
without a preceding history of trauma or injury. Hip pain, particularly in
younger children, can be absent, whereas a significantly limited range of
motion is present at physical examination. The patient has usually neither
fever nor other systemic signs, and diagnosis is often of exclusion. Laboratory
tests are not useful for diagnosis; when performed they will be normal or will
show a mild elevation of inflammatory parameters such as erythrocyte
sedimentation rate and white cell count [11]. A close follow-up is necessary
until resolution of signs and symptoms.
Lyme disease
Lyme disease is a systemic tick-borne
illness caused by the spirochete Borrelia burgdorferi. Lyme disease
occurs worldwide, with higher incidence in Eastern and
Serologic
testing can be unreliable, and unless the symptoms and signs are very
consistent, this diagnosis should be approached with caution, especially
outside of endemic areas. Detection of antibodies to B. burgdorferi
by ELISA is widely used clinically, but this testing is limited by
cross-reactivities with other organisms, high rates
of seropositive tests among asymptomatic subjects residing in endemic areas,
difficulty in distinguishing past from present infection, and lack of
standardization. Western immunoblot test of specimens
with equivocal or positive ELISA results can be useful diagnostically [12], but
the results should be interpreted in light of the number of positive bands, the
type of organism involved, and the signs and symptoms for which the test was
ordered. Living or recent travel in endemic areas, history of tick bites, and
detection of typical erythema migrans,
are all critical steps to an early diagnosis. Laboratory testing is best used
to confirm a diagnosis of Lyme disease which
has been suspected on clinical grounds.
MALIGNANCY
Systemic neoplasms must always be
considered in the evaluation of children with musculoskeletal pain, since
leukemia, lymphoma or neuroblastoma are often associated
to musculoskeletal signs and symptoms. Clinical features at onset can often
mimic juvenile idiopathic arthritis. Acute lymphatic leukemia is the most
common childhood systemic malignancy associated with musculoskeletal pain
and/or arthritis. Systemic symptoms are usually present, but hematological
abnormalities may take weeks or months to develop. Arthritis and/or arthralgia, involving one or more joints, may be present at
or near onset of disease, even as the sole finding, and is usually migratory.
In about 50% of patients, the correct diagnosis is delayed. Bone rather than articular pain or tenderness, pain that is accentuated
during the night sleeping or by weight bearing, local bony swelling in the
absence of trauma, and the presence of systemic
symptoms such as fever and weight loss are strongly suggestive of neoplasia. Mild depression of two cell lines of the CBC as
well as an elevated LDH are also worrisome.
In the presence of the above mentioned findings, a blood
smear and a bone marrow aspiration are mandatory. If the clinical suspicion is
high and bone marrow is negative, these tests may need to be repeated, and a
bone biopsy might be necessary. A plain radiograph of the affected area is
useful in the initial diagnostic evaluation: osteopenia,
cortical or periosteal lesions, osteolytic
reaction and metaphyseal bands can be present. It is
absolutely mandatory that the diagnosis of neoplasia
is ruled out before starting corticosteroid therapy in any child with
musculoskeletal signs and symptoms, since unnecessary treatment and delayed
diagnosis can be prognostically ominous in these
cases [13].
IMMUNE-MEDIATED ARTHRITIDES
Connective tissue diseases
Arthritis is present in almost all connective tissue
diseases, but with the exception of JIA the presence of typical signs and
symptoms associated with these diseases (i.e. malar
rash for systemic lupus erythematosus, fever for
The differential diagnosis of a child suspected of having a
systemic onset of JIA may be very difficult, especially at onset or early in
the course of the disease, when arthralgia or
arthritis may still be lacking. A helpful hint for the diagnosis is that the
child is really ill-appearing during the fever spikes, while surprisingly
well-appearing when the fever subsides. The presence of extra-articular features such as lymphadenopathy,
hepatosplenomegaly, and serositis
will help to establish the diagnosis.
Serum sickness like-reactions
These are immune complex-mediated diseases that follow
exposition to antigens such as drugs and/or microorganisms. They are very
common causes of arthritis in childhood. Rash (urticaria,
palpable nodules, purpura)
and systemic features such as fever and raised erythrocyte sedimentation rate
may accompany this kind of arthritis. These reactions commonly affect
transiently the ankles, wrists and knees. A relatively common but underdiagnosed example is represented by the arthritis that
occasionally follows the administration of cefaclor.
Henoch-Schonlein Purpura (HSP)
The arthritis of HSP typically involves the large lower
joints (knee, ankle); it is self-limited and benign. Recurrences are not
uncommon. Typical purpuric rash on flexor surface of
the legs, ankles and buttocks is pathognomonic, even
if sometimes it can be delayed. In fact, in some cases the joint symptomatology can occur before the rash is noted. The
onset of HSP may seldom occur with low-grade fever, subcutaneous edema and periarticular swelling of the hands and feet; in incomplete
cases (i.e. lacking a classic rash) the presence of abdominal pain and hematuria can assist in the diagnosis.
Inflammatory bowel disease
Inflammatory bowel disease (IBD, ulcerative colitis and Crohn's disease) has to be considered in a child with
arthritis associated with recurrent abdominal pain, weight loss, anorexia,
anemia, or delayed growth, even in the absence of previous diarrheal
episodes. The more common pattern of arthritis in patients with IBD is
inflammation affecting lower extremity joints, especially large joints. Pyoderma gangrenosum and erythema nodosum may sometimes
occur in IBD arthropathy, and are useful hints to
make the diagnosis [14]. Arthritis, particularly episodic joint problems, may
precede the bowel involvement by months to years.
Sarcoidosis
Sarcoidosis is a systemic granulomatous disorder of unknown cause that can also occur
in children. The classic appearance of sarcoid in the
early-onset form (patients presenting in the first 4-5 years of life) is
characterized at the onset by rash or arthritis without pulmonary involvement.
These children then often develop uveitis and other
various clinical manifestations, which can be multisystemic.
The arthritis of early-onset sarcoidosis is typically
a tenosynovitis, frequently with massive swelling of
wrists and ankles and sometimes knees and finger joints. Its clinical
appearance is usually distinctive from arthritis of juvenile idiopathic
arthritis, in that synovial hypertrophy in joints and
especially in tendon sheaths is typically accompanied by a relative lack of
pain, tenderness or restricted motion. With disease progression the arthritis
can become erosive with deformities and functional limitations. Laboratory
tests are often of little help. Serum calcium as well as lysozyme
and angiotensin-coverting enzyme levels are only occasionally
elevated. The chest radiograph is not useful for diagnosis in the very young
child as pulmonary involvement is frequently absent in early-onset sarcoid. The diagnosis of sarcoidosis
is best established on clinical grounds; histology will confirm clinical
suspicion by showing non-caseating granulomas in involved tissues (e.g. synovium
and skin) [15].
Foreign body
synovitis
Plant thorns or splinters of glass, wood, or metal can
dissect in from the skin to produce a chronic synovitis.
The patient typically presents with monoarticular
arthritis, often of several months duration. The original injury may have been
forgotten. Physical exam reveals an extremely boggy joint with hypertrophy of
soft tissues rather than the typical effusion. Joint taps are unrevealing since
the fluid is usually normal and the cultures are negative. Radiologic
imaging techniques can be helpful, but sometimes synovectomy
is necessary to establish the diagnosis [16].
NON INFLAMMATORY ARTHRITIDES
Storage diseases
Several metabolic disorders can mimic a rheumatic disease in
childhood. Storage diseases such as mucopolysaccharidoses
and mucolipidoses may present with articular swelling and stiffness. In Scheie
syndrome intelligence is normal and stature is preserved. It is characterized
by progressive stiffness of the joints, corneal clouding and carpal tunnel
syndrome. In Morquio syndrome children,
who also have normal intelligence, develop by 3 or 4 years of age stiff hands, valgus deformity of knees, severe dwarfism and other skeletal
abnormalities [17]. In mucolipidosis type
3 a progressive restriction of joint mobility becomes evident during the first
years of life [18]. In Gaucher's disease
polyarthralgia of large peripheral joints and widening
of the distal femur develops and in Farber's disease the child presents
in early infancy with swollen joints, subcutaneous nodules and a typical hoarse
cry [19]. Radiographic exams and specific enzyme analyses on plasma and
fibroblast cultures will be needed in these disorders to clarify the diagnosis
Skeletal abnormalities
Multiple epiphyseal dysplasia is one of the most
common skeletal dysplasia, inherited with an autosomal dominant trait. It presents in childhood with
pain and joint stiffness, leading to articular contractures
and occasionally scoliosis. Among epiphyseal dysplasias the late onset type shows most prominent
alterations. Affected children between 3 and 10 years of age exhibit severe
pain in knees, hips and fingers with progressive skeletal deformities and
contractures [20].Acro-osteolysis may at onset mimic
juvenile idiopathic arthritis, since affected joints are swollen and warm, but
carpal and tarsal bones are especially involved, and radiographs show
progressive bone lysis and destruction of the involved
joints [21].
Multicentric reticulohistiocytosis
is another disorder that can mimic
JIA. The affected child does have a symmetric polyarthritis,
but multiple osseous lesions with severe stiffness and contractures are
present, with histiocytic cutaneous
nodules [22].
Hypertrophic osteoarthropathy may be primary or secondary to heart or
lung disease (e.g., cystic fibrosis), inflammatory bowel disease and
malignancy. Clubbing of the fingers and toes with painful and sometimes swollen
joints are typically present. Radiographic findings are characteristic [23].
Patients with Chronic Recurrent Multifocal
Osteomyelitis (CRMO) experience insidious or
acute onset of articular pain, accompanied by fever
that mimics an osteomyelitis. The cause is unknown;
an infective cause has been suggested, but not proven. Bone scintigraphy
can demonstrate multiple areas of involvement not clinically evident. Cultures
are negative, and antibiotic therapy is ineffective since the disease runs its
course independently of medical treatment administered. Recurrent episodes of a
"sterile osteomyelitis" that occurs in
different anatomical sites may suggest the diagnosis [24].
Juvenile hyaline
fibromatosis is a very rare
hereditary syndrome, inherited with an autosomal
recessive trait. Characteristics features are multiple slowly growing
subcutaneous nodules, gingival hypertrophy, flexion contractures with joint
stiffness, and osteolytic lesions. A biopsy is needed
to confirm the diagnosis [25].
Miscellaneous
Growing pains this is a common pediatric condition, that is never
associated with arthritis but that is often considered in the differential
diagnosis of musculoskeletal pain in childhood. Pain, usually localized to the
lower extremities and often exacerbated by preceding exercise, typically occurs
during the night. The child is otherwise healthy, active, and physical exam is
normal. Frequently a family member had been diagnosed with this syndrome. Gentle
massage and heat with or without analgesics are usually effective, and
reassurance of the parents is very important [26].
Benign hypermobility syndrome
Orthopedic conditions
Osgood-Schlatter
disease is an
aseptic osteonecrosis of the anterior tibial apophysis. These patients
generally present with complaints of knee pain, and physical examination shows
point tenderness over the tibial tuberosity,
occasionally accompanied by soft tissue swelling. This syndrome, that may occur
bilaterally, is most common in active adolescent boys. Diagnosis is clinical;
radiographs, which can show tibial tuberosity alterations, are usually not necessary [28].
Legg-Calvé-Perthes
disease is an avascular necrosis of the femoral head of unknown etiology
that occurs in children (especially boys) aged 5-10 years. It can be bilateral
in 10-15% of cases, and presents itself with a limp and
varying degrees of hip pain. X-rays show progressive stages of bone
damage and regeneration, that can take years to
complete. MRI can detect abnormalities in early stages. Prognosis is highly
variable, and treatment options (conservative versus surgical) have to be
balanced in individual cases.
Slipped capital femoral epiphysis
is a hip disorder
that usually occurs in overweight adolescent boys after an injury. Chief
complains may be knee, thigh or groin pain. Physical examination reveals
limited range of motion in the hip. AP and frog-leg hip radiographs demonstrate
a posterior and downward slip of the femoral head. Early diagnosis is mandatory
since a prompt surgical intervention is required [29] to prevent permanent hip
damage.
Synovial hemangioma and pigmented villonodular
synovitis
may present with intermittent and recurrent
hemarthrosis, simulating monoarticular
JIA. They usually affect both females and males in the second decade of age,
and typically result in a sudden onset of painful swelling of knee. Aspiration
of synovial fluid at the onset of swelling yields
frank blood; Magnetic Resonance Imaging, and occasionally arthroscopy may be
needed to make the definitive diagnosis [30].
SUMMARY
Early diagnosis of juvenile idiopathic arthritis requires a
knowledge of JIA; How it presents, how it behaves, what physical findings such
as joint exam that are crucial, what lab tests are helpful. Also required is an
excellent awareness of the many conditions (infectious, malignant, orthopedic, metabolic) that can mimic JIA. It's useful to first get to
know JIA in its different syndromes of chronic arthritis and then to appreciate
the many above conditions that make up this challenging differential diagnostic
universe.
Rolando Cimaz,
MD; *
Pediatrics, Milano, and *
Corresponding author
Rolando Cimaz
Pediatrics
Via Commenda
9
20122 Milano
E-mail
Rolando.Cimaz@unimi.it
|
Table
1. Conditions that
most frequently mimic juvenile arthritis |
|
|
I. TRAUMA |
|
|
II. INFECTIONS |
|
|
|
|
|
|
VII. MISCELLANEOUS |
|
III. POST-INFECTIOUS ARTHRITIS |
|
|
|
|
|
|
|
|
|
|
IV. INFLAMMATORY BOWEL DISEASE |
|
|
(ulcerative colitis and Crohn's disease) |
|
|
V. ALLERGIC-IMMUNOLOGIC ARTHRITIS |
VIII. CONNECTIVE TISSUE DISEASES |
|
|
|
|
|
|
|
|
|
FIGURE 1. Flow chart for a child with a swollen joint
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