10 JIA case report, HOIJ NGHI o KHOA 29 4 2017

Chief complain• Fever recurrent • Fatigue, anorexia, worried • pain, and swelling multiple joints • movements restricted due to pain... On 8/2012: • 2 months before admission • fever, m

JUVENILE IDIOPATHIC ARTHRITIS CASE

Chief complain

• Fever recurrent

• Fatigue, anorexia, worried

• pain, and swelling multiple joints

• movements restricted due to pain

On 8/2012:

• 2 months before admission

• fever, more in the evenings, Fatigue, anorexia

• No cough, no dyspnea, no chest pain, no pain abdomen

• The metacarpal and interphalangeal joints , wrists,

knees, hips: swollen, pain

• Warmth +, tenderness in the joint , movements restricted due to pain

• Local hospital diagnosis: Arthritis

• Treatment: Ibrafen 30 mg/kg/ day* 2 W, no respond

• Treated with some traditional medicines for 1 year

• 11/2013 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: 65

• 12/2013 : prednisolon 1mg/kg/day MTX 15mg/week, plaquenil, salazopirin, CRP 50 mg/L

• 4/2014: tocilizumab 1 st , prednisolon 10 mg/day, methotrexate 12,5

mg/week , plaquenil, salazopirin, CRP 20,6.

• 5/2014: tocilizumab 2 nd , pred 5 mg/day, methotrexate 10 mg/week ,

plaquenil, salazopirin, CRP 20 9

• 6/2014: tocilizumab 3 rd , prednisolon 5 mg/day, MTX 10 mg/week , plaquenil, salazopirin, CRP 12,5.

PROGRESS

• 2 months before admission:

• the patient presented with fever of 2 months

• Fever low grade, with no rigos , more in the evenings

• No cough, expectorations, dyspnea, chest pain, palpitations

• No weight loss, night sweats

• No dysuria, henaturia, pain abdomen

• No loose stools , abdominal pain, constipation

On examination of joints:

• The metacarpal and interphalangeal joints , wrists, knees, hips: swollen, pain

• Warmth +, tenderness in the joint line +, movements restricted due to pain

ON ADMISSION

On examination:

• Pt conscious, orrient

• Febrile , temp 39 o C

• pallor (+), no icterus, no cyanosis, no clubbing

• No rash, No blleeding from gums or any other

JIA CASE

Examination of joins:

• The metacarpal and interphalangeal

joints , wrists, knees, hips: swollen, pain

• Warmth +, tenderness in the joint line +, movements restricted due to pain

• Myalgia

• Other joints appeared norrmal

LABORATORY EXAMINATION

TEST PROCEDURE RESULT High/Low/Normal

LABORATORY EXAMINATION

TEST PROCEDURE RESULTS

Quantiferon chẩn đoán lao NEGATIVE

Laboratory examination

• Peripheral smear: normocytic norrmochromic anemia,

no immature cells seen

• Bone marrow: norrmal study, no blast seen

• Abdominal echo: no mass, no abdominent

• Coagulation: PT, APTT : norrmal

• HIV, HbsAg, anti HCV(-), mantoux (-)

• Blood , urine culture:no organism grown

• Factor RF(+) , ANA, ds DNA (-)

• Aspiration from joint – fluid +, yellow, no pus, culture :

no orrganism , 100 cells

• Chest X- RAY: normal, Joint Xray: normal

• 11 years old, girrl with: prolonged fever 2 months: low grade fever, more in the evenings

• Anemia

• Poly arrthritis: swollen, warm +, movement restricted

• Anemia, BC, CRP, ESR elevate high

- Solumedrone: 1 mg/kg/day IV * 7 days

-> fever decrease, still pain swollen joints but improved

• Prednisolon: 1mg/kg/day

• MTX 15 mg/m2 / week

• Axit folic

• Vitamin D- Canxi

-> follow up after 1 month :

-> Decrease fever, arthritis responsed well

Follow up after 1month

• No fever

• joints: still pain, swollen but improved

• Still knees pain, restricted movement, both

of wrists and ankless still swollen

• All small joints in both hand: no swollen,

no pain

• other signs: normal

Follow up after 1 month

FOLLOW UP TREATMENT - outpatient

Follow up 3 months later

• No fever, still swollen knees, restricted

movement, both of wrists and ankless still swollen

• All small joints in both hand: no swollen, no pain

• CRP 30 mg/l, Esr: > 50mm/h

• Diagnosis: polyarthritis RF(+)/ high active disease

TREATMENT AFTER 3 months

• Steroid injection: both of knees

Follow up at 6 months

• Fever sometime, more in the evenings

• Wrist, ankle, knee: still pain, decrease swollen, restricted

• Hb: 110g/l; CBC: 16G/L; plt: 430 G/L CRP: 30 mg/l, ESR: 95/110mm/h

CORTISON: 120 MMOL/L

-> transfer : Biologic DMARD

-> Screening TB, hepatitis B and C, HIV, according to the process

• 4/2014: 22 kg

• 4/2014: tocilizumab 1ST: 10 mg/kg,

-> no fever; swollen, pain joints: decreased

• Pred 15 mg/day, methotrexate 12,5 mg/week ,

SUMMARY

The girl , 11 years old,

Diagnosis JIA after 12 months, high active disease , no respond with DMARDs

Treatment : tocilizumab : tapering CS

After 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 !