Pitfalls in the diagnosis and management of juvenile idiopathic arthritis: a retrospective case-note analysis

Abstract

<h3>Background</h3> Juvenile idiopathic arthritis (JIA) is the most common cause of persistent arthritis in children. It is defined as arthritis of unknown aetiology presenting before the 16th birthday, persisting for at least 6 weeks and where other known causes of arthritis have been excluded. JIA is no longer considered as a benign condition as long-term studies have shown that JIA may persist in to adulthood with disability. <h3>Aims/Methods</h3> In order to improve their services, the authors performed a retrospective case-note analysis of children younger than 16 years of age who were diagnosed with JIA over a 10-year period (2000–2008). A proforma was used to collect the information on the type of JIA, age of onset, age at diagnosis, source of referrals and past medical history. Evidence has shown that patients who receive treatment late may suffer from a more persisting inflammation and disability. Early use of disease-modifying antirheumatic drugs during the first 3 months of onset has been associated with an optimal control of the disease. <h3>Results</h3> 41 case notes were retrieved. 18 referred by the general practitioner (GP) and 13 via an orthopaedic surgeon. Delay in diagnosis was defined as 3 months from the start of the joint symptoms; that is joint swelling and pain. 21/41 were oligoarticular JIA of which seven were extended form, 13/41 polyarticular JIA, five with systemic onset and one with enthesitis related arthritis and one with arthritis associated with inflammatory bowel disease. Eight had a history of trauma before presentation and six had a recent infection. Delay in diagnosis was observed in 14 out of 41 cases (%36); two cases parents could not appreciate the significance of the symptoms, in 12 delayed diagnosis occurred by the professionals. Most delays by the professionals were from the orthopaedic surgeons (10 out of 12). Eight were under orthopaedic surgeon, referred by accident and emergency and GP with a history of a trivial injury before joint swelling. Two had previous history of tonsilitis with diagnosis of reactive arthritis, one case with hip pain and slight elevation of inflammatory markers treated conservatively with possible toxic synovitis. One child with finger joints swelling was under follow ups with no clear diagnosis. <h3>Conclusion</h3> The authors conclude from the clinical notes that trivial injury is relatively common in children. A detailed history indicating the severity of injury and a thorough examination as well as early referral to paediatrician could significantly reduce the rate of delayed diagnosis.