Case Studies

 Case 10.7 Juvenile chronic arthritis

A 2-year-old girl was taken to her GP because she was unwilling to walk. Her GP found her right knee to be swollen and tender and referred her to an orthopaedic surgeon who was concerned that she may have septic arthritis, although she was systemically well. An X-ray was normal. Synovial fluid was aspirated under general anaesthetic, but was sterile on culture. The pain settled somewhat, although the knee was still swollen on examination. Two months later her left ankle also became swollen and painful. Blood tests show a raised erythrocyte sedimentation rate at 40mm/h, a negative test for rheumatoid factor and a low titre (1/40) homogenous antinuclear antibody (ANA). DNA antibodies were not detected. Serum immunoglobulins were normal. A diagnosis of pauciarticular juvenile chronic arthritis was made and she was treated with ibuprofen with a good response. However, three months later the knee was still swollen and she was given an intra-articular steroid injection with complete resolution of the synovitis. Her vision seemed normal but ophthalmological screening revealed a severe chronic anterior uveitis which was treated with topical steroids. At the age of four her joint disease was in complete remission, but her uveitis remained intermittently active. She remains under long-term ophthalmological follow-up.