Juvenile idiopathic arthritis case report

JUVENILE IDIOPATHIC ARTHRITIS CASE REPORTFull name: Trần Phương TGender : femaleAge : 11 Date of birth: 12/10/2003Date of admission: 11/10/2013Chief complainFever recurrentFatigue, anorexia, worried pain, and swelling multiple jointsmovements restricted due to painPROGRESSOn 8/2012: 2 months before admissionfever, more in the evenings, Fatigue, anorexiaNo cough, no dyspnea, no chest pain, no pain abdomenThe metacarpal and interphalangeal joints , wrists, knees, hips: swollen, painWarmth +, tenderness in the joint , movements restricted due to painLocal hospital diagnosis: ArthritisTreatment: Ibrafen 30 mg/kg/ day* 2 W, no respond Treated with some traditional medicines for 1 year11/2013 admission, diagnosis: JIA , high active, DAS-CRP 120; cortisol : 20 Mmol/mml. Treatment: methylpred 2 mg/day 1 week -> no fever, -> oral prednisolon 1mg/kg/day; methotrexate: 15 mg/m2 /week . CRP: 6512/2013 : prednisolon 1mg/kg/day MTX 15mg/week, plaquenil, salazopirin, CRP 50 mg/L .4/2014: tocilizumab 1st , prednisolon 10 mg/day, methotrexate 12,5 mg/week , plaquenil, salazopirin, . CRP 20,6.5/2014: tocilizumab 2nd, pred 5 mg/day, methotrexate 10 mg/week , plaquenil, salazopirin, CRP 20 .96/2014: tocilizumab 3rd, prednisolon 5 mg/day, MTX 10 mg/week , plaquenil, salazopirin, . CRP 12,5.PROGRESS2 months before admission: the patient presented with fever of 2 monthsFever low grade, with no rigos , more in the eveningsNo cough, expectorations, dyspnea, chest pain, palpitationsNo weight loss, night sweatsNo dysuria, henaturia, pain abdomenNo loose stools , abdominal pain, constipationOn examination of joints:The metacarpal and interphalangeal joints , wrists, knees, hips: swollen, painWarmth +, tenderness in the joint line +, movements restricted due to painMyalgiaFatigue, anorexia, weigh lossNo rash, No anemia, blleeding from gums or any other mucosal bleedsNo hepatospleenomegaly , lymphadenopathyNo seizures, altered sensorium HISTORYPast history:- Nil significant, - patient was treated by private practitioner, but fever and joints pain tend to recurFamily: no h/o arthritis, or others autoimmune diseasesON ADMISSIONOn examination:Pt conscious, orrientFebrile , temp 39o C pallor (+), no icterus, no cyanosis, no clubbingNo rash, No blleeding from gums or any other mucosal bleedsNo hepatospleenomegaly , lymphadenopathyNo seizures, altered sensorium Pulse: regular, BP: 110.70 mmhgT1, T2 heard, no murmurs. Both lung sound norrmal JIA CASEExamination of joins: The metacarpal and interphalangeal joints , wrists, knees, hips: swollen, painWarmth +, tenderness in the joint line +, movements restricted due to painMyalgiaOther joints appeared norrmalLaboratory examinationTest procedureRESULT High/Low/NormalRBC4,2 T/LNormalHB92 G/LlowHct0,42NormalWBC 33 G/LHighNeut82,7 %HighPLT633 G/LHighCRP120 HighESR1h: 110mm2h: 120 mmHigh LABORATORY EXAMINATIONTEST PROCEDURERESULT High/Low/NormalUrea4,6 mmol/lNormalCreatinine73 μmol/lNormalGlucose5,7 mmol/lNormalGot14 U/LNormalGpt20 U/lNormalRF42 UI/,lHighAnti CCP5,2HighCortisol20 mmol/llowLABORATORY EXAMINATIONTEST PROCEDURERESULTS Anti HIVNEGATIVEHbsAgNEGATIVEAnti HCVNEGATIVEAnti HAVNEGATIVEPCR CMVNEGATIVEX quang tim phổiNEGATIVEQuantiferon chẩn đoán laoNEGATIVEPCR laoNEGATIVELaboratory examinationPeripheral smear: normocytic norrmochromic anemia, no immature cells seen Bone marrow: norrmal study, no blast seenAbdominal echo: no mass, no abdominentCoagulation: PT, APTT : norrmalHIV, HbsAg, anti HCV(-), mantoux (-)Blood , urine culture:no organism grownFactor RF(+) , ANA, ds DNA (-)Aspiration from joint – fluid +, yellow, no pus, culture : no orrganism , 100 cells Chest X- RAY: normal, Joint Xray: normal DIAGNOSIS 11 years old, girrl with: prolonged fever 2 months: low grade fever, more in the eveningsAnemiaPoly arrthritis: swollen, warm +, movement restrictedAnemia, BC, CRP, ESR elevate high RF (+), Anti CCP (+)DIFERENTIAL DIAGNOSIS:- Septic arthritis- Hemathrosis- Juvenile idiopathic arthritis- SLE- Trauma- TuberculosisOther arthritis DIAGNOSIS: POLY JIA RF (+), high active.  TREATMENT- Solumedrone: 1 mg/kg/day IV * 7 days-> fever decrease, still pain swollen joints but improvedPrednisolon: 1mg/kg/dayMTX 15 mg/m2 / week Axit folicVitamin D- Canxi-> follow up after 1 month : -> Decrease fever, arthritis responsed well Follow up after 1monthNo feverjoints: still pain, swollen but improvedStill knees pain, restricted movement, both of wrists and ankless still swollenAll small joints in both hand: no swollen, no pain.other signs: normalFollow up after 1 month- Hb: 102, WBC: 15 G/L , PLT 630 G/L- CRP: 50 mg/lESR: 75/110 mm/hEcho both of knee: fluid 6 mm, ankles: 4 mmDiagnosis: JIA polyarthritis RF (+)/ High active disease .FOLLOW UP TREATMENT - outpatientPrednisolon: 1 mg/kg/ngàyMTX: 15mg/m2 da/ tuầnHydroxychloroquine salazopirineAxit folicVitamin D - canxi-> Re examination after 3 monthsFollow up 3 months laterNo fever, still swollen knees, restricted movement, both of wrists and ankless still swollenAll small joints in both hand: no swollen, no pain.CRP 30 mg/l, Esr: > 50mm/hDiagnosis: polyarthritis RF(+)/ high active disease TREATMENT AFTER 3 monthsSteroid injection: both of kneesCS tapering: 0,5/kg/dayMTX: 12mg/ m2 / weekPlaquenil: 5mg/kg/daySulfasalazine: 50 mg/kg/dayAxit folicVitamin D- canxi-> follow up 3 monthsFollow up at 6 monthsFever sometime, more in the eveningsWrist, ankle, knee: still pain, decrease swollen, restricted Hb: 110g/l; CBC: 16G/L; plt: 430 G/L CRP: 30 mg/l, ESR: 95/110mm/hCORTISON: 120 MMOL/L-> transfer : Biologic DMARD -> Screening TB, hepatitis B and C, HIV, according to the processTreatment4/2014: 22 kg4/2014: tocilizumab 1ST: 10 mg/kg, -> no fever; swollen, pain joints: decreasedPred 15 mg/day, methotrexate 12,5 mg/week , plaquenil, salazopirin, . CRP 20,6.On 5/2014: no fever, the sign of sinovitis (knee, wrist, ankle) improved wellCBC: 12 G/L, CRP: 20 mg/l, ESR: 50/60 mm/hTOCILIZUMAB 2 nd: 10 mg/kgFollow up On 6/2014:No fever, no pain, but ankles still swellingCRP: 20,9 mg/L-> tocilizumab 3rd, -> CRP: 12,5 mg/L. Continue treatment: prednisolon 5 mg/ngày , MTX 10 mg/tuần, ,Plaquenilsalazopirin, .SUMMARY The girl , 11 years old, Diagnosis JIA after 12 months, high active disease , no respond with DMARDs Treatment : tocilizumab : tapering CSAfter 3 months of treatment: + failure of thượng thận: respond + Giảm liều corticoid 5mg/ngày, + MTX : decrease dose of MTX: from 15mg/week ->10mg/week .Thank you for your attention !