Synovitis In Children Research Articles

Use of MRI prior to corticosteroid injections of wrist joints in children with JIA

Purpose The use of intra-articular corticosteroids in children with juvenile idiopathic arthritis (JIA) is an accepted therapeutic option as their use has been found to be safe and proven to facilitate rapid resolution of signs and symptoms of inflammation. An increasing number of studies have described improved sensitivity of magnetic resonance imaging (MRI) compared with conventional radiography in detection of early synovitis, tendinopathy, bone edema, and bone erosions. The purpose of this study was to document joints within the wrist and carpus with active synovitis in children with JIA using MRI and to explore how MRI localization of affected joints prior to intra-articular corticosteroid injection affects outcomes.

Advances and challenges in imaging in juvenile idiopathic arthritis

Imaging assessments of the joints of children with juvenile idiopathic arthritis (JIA) are challenging, owing to the unique features of the growing skeleton. Traditionally, imaging studies in childhood arthritis have been based on conventional radiography. However, in the past few years, interest in the use of MRI and ultrasonography has increased. As a result, imaging has become a main area of clinical and research investigation in paediatric rheumatology. The chief advance in the field of conventional radiography has been the development and validation of paediatric scoring systems for the assessment of radiographic progression. Several studies have shown that MRI provides a precise quantification of synovitis in children with JIA. Furthermore, a high frequency of bone marrow oedema and bone erosions has been found early in the disease course. Ultrasonography has been proven to be superior to clinical examination in detecting synovitis, tenosynovitis and enthesitis. A high frequency of subclinical synovitis has been demonstrated in patients with JIA who have clinically inactive disease using both MRI and ultrasonography. However, more information from healthy children is needed to enable differentiation of the bone and cartilage abnormalities that reflect damage from those that are part of normal development using MRI or ultrasonography. This Review provides a summary of the current information on conventional radiography, ultrasonography and MRI in JIA and highlights the advantages and limitations of each imaging modality.

The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children

Clinical prediction algorithms are used to differentiate transient synovitis from septic arthritis. These algorithms typically include the erythrocyte sedimentation rate (ESR), although in clinical practice measurement of the C-reactive protein (CRP) has largely replaced the ESR. We evaluated the use of CRP in a predictive algorithm. The records of 311 children with an effusion of the hip, which was confirmed on ultrasound, were reviewed (mean age 5.3 years (0.2 to 15.1)). Of these, 269 resolved without intervention and without long-term sequelae and were considered to have had transient synovitis. The remaining 42 underwent arthrotomy because of suspicion of septic arthritis. Infection was confirmed in 29 (18 had micro-organisms isolated and 11 had a high synovial fluid white cell count). In the remaining 13 no evidence of infection was found and they were also considered to have had transient synovitis. In total 29 hips were categorised as septic arthritis and 282 as transient synovitis. The temperature, weight-bearing status, peripheral white blood cell count and CRP was reviewed in each patient. A CRP > 20 mg/l was the strongest independent risk factor for septic arthritis (odds ratio 81.9, p < 0.001). A multivariable prediction model revealed that only two determinants (weight-bearing status and CRP > 20 mg/l) were independent in differentiating septic arthritis from transient synovitis. Individuals with neither predictor had a < 1% probability of septic arthritis, but those with both had a 74% probability of septic arthritis. A two-variable algorithm can therefore quantify the risk of septic arthritis, and is an excellent negative predictor.

Sonographic measurement of transient synovitis in children: diagnostic value of joint effusion

In an evaluation of the diagnostic criteria for ultrasonography (US) of transient synovitis in children, in a prospective study, 34 consecutive children with a painful hip underwent US. The ultrasonographic joint space (UJS) and the effusion space were measured in both hips, and the width of the UJS thickness in the asymptomatic hips was compared with that in the symptomatic hips. US showed the presence of a joint effusion in 31 of the 34 children and a bilateral effusion in 3. The US diagnostic criterion for hip effusion consists of a UJS thickness difference >2.0mm between asymptomatic and symptomatic hips. However, we found that 8 of the 31 UJS measurements compared between symptomatic hips and asymptomatic hips exhibited differences of <2mm. We suggest that effusion space measurements are possible for accurate visualization of synovitis, rather than the recording of differences in UJS measurements between hips.

Haemophilic arthropathy: the usefulness of intra-articular oxytetracycline (synoviorthesis) in the treatment of chronic synovitis in children

Synoviorthesis is already widely used in the treatment of chronic haemophilic synovitis. The aim of this study was evaluate the effectiveness of oxytetracicline synoviorthesis on the frequency of haemarthrosis in haemophilic children with chronic synovitis and its impact on joint function. Between January 2001 and October 2006, we performed 34 synoviorthesis in 28 paediatric patients (6-16 years old) with diagnosis of haemophilic arthropathy stage I-II. At each joint were administered five doses of oxytetracycline for five consecutive weeks at doses of 100 mg in elbow and ankle and 250 mg in the knee. The frequency of haemarthrosis and range of joint mobility were evaluated before and after of treatment. The results were analysed with Student t-test and descriptive statistics. Thirty-four joints were treated, including 20 knees (58.8%), eight elbows (23.5%) and six ankles (17.6%). Median follow-up was 46.3 months (range 12-71 months). The frequency of haemarthrosis was recorded before treatment 47.3 year(-1) (range 12-96, P < 0.0001) and decreased to 3.5 year(-1) (range 0-15, P = 0.0119) after treatment. The range of joint motion in flexion-extension before treatment was 84.9°, while after this was 97.5° (P = 0.0119). The synoviorthesis with oxytetracycline has shown a favourable effect in the treatment of chronic haemophilic synovitis in reducing the frequency of haemarthrosis and improvement was observed consistently in the range of motion.

PET assessment of disease activity in children with juvenile idiopathic arthritis

The degree of 18-fluorodeoxyglucose (FDG) uptake is previously reported to correlate with physical examination and laboratory tests for evaluating disease activity in patients with rheumatoid arthritis. The clinical validity of (18)F-FDG positron emission tomography (PET) has not been evaluated in juvenile idiopathic arthritis (JIA). To assess the relationship between (18)F-FDG PET uptake and disease activity in children with JIA. A total of 560 joints in 28 children (mean age, 5.4 years; range, 1-16 years) with JIA who had undergone whole-body (18)F-FDG PET before treatment were retrospectively assessed clinically, biochemically and radiographically. PET images were assessed independently by two readers. We investigated the relationships between the degree of synovial (18)F-FDG uptake and radiographic and clinical symptoms and laboratory findings. Joint tenderness and swelling had a positive association with abnormal (18)F-FDG uptake in the joint [odds ratio (OR) 5.37, 7.12, respectively]. The standardized uptake value (SUV) max correlated with the neutrophil count, plasma C-reactive protein (CRP), erythrocyte sedimentation rate (ESR) and matrix metalloproteinase (MMP) 3. Joint erosion (OR, 6.17), soft-tissue swelling (OR, 3.77), major joints involvement (OR, 3.50), tenderness (OR, 5.22), and CRP concentration in plasma (OR, 1.81) were positively associated with SUVmax. The degree of (18)F-FDG uptake may be associated with the severity of synovitis in children with JIA.

Comparison of clinical versus ultrasound‐determined synovitis in juvenile idiopathic arthritis

To compare clinical evaluation and ultrasonography (US) in the assessment of joint synovitis in children with juvenile idiopathic arthritis (JIA). Thirty-two patients underwent clinical evaluation of 52 joints by 2 pediatric rheumatologists. Joints were assessed for swelling, tenderness/pain on motion, and restricted motion. The same joints were scanned independently by an experienced sonographer for synovial hyperplasia, joint effusion, and power Doppler (PD) signal. In total, 1,664 joints were assessed both clinically and with US. On clinical examination, 98 joints (5.9%) were swollen, 59 joints (3.5%) were tender, and 40 joints (2.4%) had restricted motion. On US evaluation, 125 joints (7.5%) had synovial hyperplasia, 153 joints (9.2%) had joint effusion, and 53 joints (3.2%) had PD signal. A total of 104 (6.3%) and 167 (10%) joints had clinical and US synovitis, respectively. Of the 1,560 clinically normal joints, 86 (5.5%) had subclinical synovitis (i.e., had synovitis on US). US led to classifying 5 patients as having polyarthritis who were classified as having oligoarthritis or were found to have no synovitis on clinical evaluation. US variables were moderately correlated with clinical measures of joint swelling, but poorly correlated with those of joint tenderness/pain on motion and restricted motion. Overall, correlations were lower for PD signal than for synovial hyperplasia and joint effusion. We found that subclinical synovitis as detected by US is common in children with JIA. This finding may have important implications for patient classification and may affect the choice of the optimal therapeutic strategy in individual patients.

Persistent synovitis in children with Lyme arthritis: two unusual cases. An immunogenetic approach

We report on two patients with a persistent Lyme arthritis. In addition both had a peculiar disease history. The first patient had oligoarticular juvenile idiopathic arthritis in remission. Five months after an infected tick bite, she developed a relapse of arthritis in the same knee. We considered Lyme borreliosis as the possible trigger for this reactivation. The disease history of the second patient was that of a classical non-responder. After extensive antibiotic treatment osteolytic lesions became visible. MRI images suggested an erosive arthropathy and arthroscopy was used to investigate possible erosive arthritis. Studies on collected material made us consider the following hypothesis. Despite demonstration of a spirochete fragment in a synovial biopsy, the patient recovered without additional antibiotic treatment. delay of antibiotic treatment after appearance of erythema migrans may cause systemic spread of the antigen and predispose to Lyme arthritis. If intra-articular steroids are considered when spontaneous resolution of Lyme arthritis does not occur, magnetic resonance imaging of the affected joint, prior to administration, may provide additional information. The success of synovectomy may be related to removal of undegraded antigenic material which may prolong the inflammation.

Significance of Laboratory and Radiologic Findings for Differentiating Between Septic Arthritis and Transient Synovitis of the Hip

Although significant differences exist in the methods of treatment and prognoses of septic coxitis and transient synovitis in children complaining of acute hip pain, similar symptoms are present in these two diseases at the early stages, and differential diagnosis is difficult. To differentiate between these two diseases, the authors evaluated the clinical, serologic, and radiologic findings and tried to determine factors that could be used as diagnostic criteria. The authors performed a retrospective study by evaluating medical records, plain hip radiographs, and clinical findings in 97 patients with transient synovitis and 27 patients with septic arthritis. Univariate analysis showed significant differences in body temperature, serum WBC count, and ESR and CRP levels of the two patient groups. Plain radiographs showed a displacement or blurring of periarticular fat pads in all patients with acute septic arthritis, and multivariate regression analysis showed that body temperature >37 degrees C, ESR >20 mm/h, CRP >1 mg/dL, WBC >11,000/mL, and an increased hip joint space of >2 mm were independent multivariate predictors of acute septic arthritis. The authors conclude that the independent multivariate predictors are effective indices for the differential diagnosis of acute septic coxitis and transient synovitis.

The rational use of a local scoring system to differentiate between septic arthritis &amp; transient synovitis in children

In order to study the specificity and the sensitivity of a locally produced scoring system to differentiate between septic arthritis and transient synovitis at initial presentation, the records of 33 cases of irritable hip, 24 males and nine females, in the Pediatric departments of King Hussein Medical Center and Prince Rashid Military Hospital, Jordan, were reviewed retrospectively. Septic arthritis was diagnosed in nine patients all of whom scored nine or above; none were missed with false low scores. The sensitivity and specificity for this local scoring system were calculated to be 100% and 91.66% respectively. The positive predictive value was 81.81%.Conclusion: There is a significant overlap in the temperature; erythrocyte sedimentation rate and WBC count in children with toxic synovitis and septic arthritis of the hip. We found our local scoring system useful in predicting the patients at high or moderate risk of septic arthritis thus avoiding unnecessary invasive investigations and unjustified prolonged admissions and antimicrobial treatment.

Juvenile rheumatoid arthritis.

1. Jane G. Schaller, MD* 1. 2. *David and Leona Karp Professor of Pediatrics; Chair, Department of Pediatrics, Tufts University School of Medicine, Boston, MA. 1. There are several recognizable subgroups of juvenile rheumatoid arthritis (JRA): systemic-onset, polyarticular, pauciarticular, and late childhood onset. 2. Rheumatoid factor usually is negative in JRA. 3. Systemic-onset JRA is characterized by high intermittent fevers and other extra-articular manifestations: lymphadenopathy, rash, pleuritis, and pericarditis. 4. Iridocyclitis is absent in acute-onset disease but common in patients who have pauciarticular disease. 5. Nonsteroidal anti-inflammatory drugs (NSAIDs) remain the front-line and important agents in the therapy of patients who have JRA. 6. Controlled studies show that d-penicillamine, hydroxychloroquine, and oral gold are no more effective than placebo in the treatment of JRA. Juvenile rheumatoid arthritis (JRA) is a term used to describe the condition of chronic synovitis in children of which there are several distinct subgroups. Chronic synovitis in children was first described well in the English literature in 1897 by George Frederick Still, an English pediatrician and pathologist, who reported on 23 children who had chronic arthritis and came to his attention while he was training at the Hospital for Sick Children, Great Ormond Street. Still postulated that several separate conditions were responsible for chronic arthritis in children. Little subsequent work in this area was pursued until the late 1940s. Most modern observers have come to agree with Still that chronic arthritis in children encompasses several distinct disease subgroups (Table 1⇓ ). The relationship of JRA to adult rheumatoid arthritis was uncertain for many years. Now it seems clear that the classic adult-type rheumatoid arthritis does occur in children but is quite rare, the JRA subgroups seronegative 1 polyarthritis and systemic-onset disease also occur in adults but not frequently, the pauciarthritis of early childhood has not been recognized in adults, and the pauciarthritis of older children usually is classified as spondyloarthropathy in adults. The nomenclature for chronic childhood arthritis remains confusing (Table 2⇓), but …

Intracapsular pressure in hip synovitis in children

Scintimetry and intracapsular pressure recordings were performed in 10 painful hips in children. Maximum intracapsular pressures were recorded with the hip in extension or in 90 degrees of flexion. Minimum pressures were recorded with the hip in semiflexion. Extremely high pressures were recorded in extension/maximum internal rotation. In 3 cases the pressure exceeded the estimated systolic blood pressure. There was a close correlation between the volume of aspirated fluid and intracapsular pressure. In a case of septic arthritis, ischemia in the epiphysis was noted scintigraphically. This ischemia was reversed following decompression by aspiration.

Juvenile rheumatoid arthritis.

1. Jane G. Schaller, MD* 1. 2. *David and Leona Karp Professor of Pediatrics; Chair, Department of Pediatrics, Tufts University School of Medicine, Boston, MA. 1. There are several recognizable subgroups of juvenile rheumatoid arthritis (JRA): systemic-onset, polyarticular, pauciarticular, and late childhood onset. 2. Rheumatoid factor usually is negative in JRA. 3. Systemic-onset JRA is characterized by high intermittent fevers and other extra-articular manifestations: lymphadenopathy, rash, pleuritis, and pericarditis. 4. Iridocyclitis is absent in acute-onset disease but common in patients who have pauciarticular disease. 5. Nonsteroidal anti-inflammatory drugs (NSAIDs) remain the front-line and important agents in the therapy of patients who have JRA. 6. Controlled studies show that d-penicillamine, hydroxychloroquine, and oral gold are no more effective than placebo in the treatment of JRA. Juvenile rheumatoid arthritis (JRA) is a term used to describe the condition of chronic synovitis in children of which there are several distinct subgroups. Chronic synovitis in children was first described well in the English literature in 1897 by George Frederick Still, an English pediatrician and pathologist, who reported on 23 children who had chronic arthritis and came to his attention while he was training at the Hospital for Sick Children, Great Ormond Street. Still postulated that several separate conditions were responsible for chronic arthritis in children. Little subsequent work in this area was pursued until the late 1940s. Most modern observers have come to agree with Still that chronic arthritis in children encompasses several distinct disease subgroups (Table 1⇓ ). The relationship of JRA to adult rheumatoid arthritis was uncertain for many years. Now it seems clear that the classic adult-type rheumatoid arthritis does occur in children but is quite rare, the JRA subgroups seronegative 1 polyarthritis and systemic-onset disease also occur in adults but not frequently, the pauciarthritis of early childhood has not been recognized in adults, and the pauciarthritis of older children usually is classified as spondyloarthropathy in adults. The nomenclature for chronic childhood arthritis remains confusing (Table 2⇓), but …

Juvenile Rheumatoid Arthritis

Juvenile rheumatoid arthritis is the condition of chronic synovitis in children. This Condition was first well described in the English literature by George Frederick Still,1 an English pediatrician and pathologist, who in 1897 described 22 children with chronic arthritis who had come to his attention while he was still in training at the Hospital for Sick Children, Great Ormond Street. Still postulated that several distinct conditions were responsible for chronic arthritis in children. After Still, unfortunately, little work was done in the field of pediatric rheumatology until recent years. Most modern observers have come to agree with Still that chronic arthritis in children encompasses several distinct disease subgroups.2-5 The relationship of juvenile rheumatoid arthritis to adult rheumatoid arthritis remains uncertain; some of the subgroups described in children are not recognized in adults, whereas classic adult-type rheumatoid arthritis occurs in children, but accounts for only a small percentage of total patients.4 The nomenclature for chronic childhood arthritis is quite confusing at the present time (Table 1). The term juvenile rheumatoid arthritis (JRA) has been retained in the United States to describe all children with chronic arthritis, whereas the term juvenile chronic arthritis is becoming more widely used in Europe. The term Still disease, although according due honor to an important person, is confusing and should probably be discarded.