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

JUVENILE IDIOPATHIC ARTHRITIS CASE REPORT Full name: Trần Phương T Gender : female Age : 11 Date of birth: 12/10/2003 Date of admission: 11/10/2013 Chief complain • • • • Fever recurrent Fatigue, anorexia, worried pain, and swelling multiple joints movements restricted due to pain PROGRESS On 8/2012: • 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, knee hips: swollen, pain • Warmth +, tenderness in the joint , movements restricted due to pain • Local hospital diagnosis: Arthritis • Treatment: Ibrafen 30 mg/kg/ day* W, no respond PROGRESS • • • • • • • Treated with some traditional medicines for year 11/2013 admission, diagnosis: JIA , high active, DAS-CRP 120; cortisol : 20 Mmol/mml Treatment: methylpred mg/day 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 1st , prednisolon 10 mg/day, methotrexate 12,5 mg/week , plaquenil, salazopirin, CRP 20,6 5/2014: tocilizumab 2nd, pred mg/day, methotrexate 10 mg/week , plaquenil, salazopirin, CRP 20 6/2014: tocilizumab 3rd, prednisolon mg/day, MTX 10 mg/week , plaquenil, salazopirin, CRP 12,5 • • • • • • • months before admission: the patient presented with fever of 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 • Myalgia • Fatigue, anorexia, weigh loss • No rash, • No anemia, blleeding from gums or any other mucosal bleeds • No hepatospleenomegaly , lymphadenopathy • No seizures, altered sensorium HISTORY • Past history: - Nil significant, - patient was treated by private practitioner, but fever and joints pain tend to recur • Family: no h/o arthritis, or others autoimmune diseases ON ADMISSION On examination: • Pt conscious, orrient • Febrile , temp 39o C • pallor (+), no icterus, no cyanosis, no clubbing • No rash, No blleeding from gums or any other mucosal bleeds • No hepatospleenomegaly , lymphadenopathy • No seizures, altered sensorium • Pulse: regular, BP: 110.70 mmhg • T1, T2 heard, no murmurs Both lung sound norrmal 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 RBC 4,2 T/L Normal HB 92 G/L low Hct 0,42 Normal WBC 33 G/L High Neut 82,7 % High PLT 633 G/L High CRP 120 High ESR 1h: 110mm 2h: 120 mm High LABORATORY EXAMINATION TEST PROCEDURE RESULT High/Low/Normal Urea 4,6 mmol/l Normal Creatinine 73 μmol/l Normal Glucose 5,7 mmol/l Normal Got 14 U/L Normal Gpt 20 U/l Normal RF 42 UI/,l High Anti CCP 5,2 High Cortisol 20 mmol/l low LABORATORY EXAMINATION TEST PROCEDURE RESULTS Anti HIV NEGATIVE HbsAg NEGATIVE Anti HCV NEGATIVE Anti HAV NEGATIVE PCR CMV NEGATIVE X quang tim phổi NEGATIVE Quantiferon chẩn đoán lao NEGATIVE PCR 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 DIAGNOSIS • 11 years old, girrl with: prolonged fever months: low grade fever, more in the evenings • Anemia • Poly arrthritis: swollen, warm +, movement restricted • Anemia, BC, CRP, ESR elevate high • RF (+), Anti CCP (+) DIFERENTIAL DIAGNOSIS: - Septic arthritis - Hemathrosis - Juvenile idiopathic arthritis - SLE - Trauma - Tuberculosis - Other arthritis DIAGNOSIS: POLY JIA RF (+), high active TREATMENT - Solumedrone: mg/kg/day IV * 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 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 month - Hb: 102, WBC: 15 G/L , PLT 630 G/L - CRP: 50 mg/l - ESR: 75/110 mm/h - Echo both of knee: fluid mm, ankles: mm Diagnosis: JIA polyarthritis RF (+)/ High active disease FOLLOW UP TREATMENT - outpatient • • • • • • Prednisolon: mg/kg/ngày MTX: 15mg/m2 da/ tuần Hydroxychloroquine salazopirine Axit folic Vitamin D - canxi -> Re examination after months Follow up 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 months • • • • • • • Steroid injection: both of knees CS tapering: 0,5/kg/day MTX: 12mg/ m2 / week Plaquenil: 5mg/kg/day Sulfasalazine: 50 mg/kg/day Axit folic Vitamin D- canxi -> follow up months Follow up at 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 Treatment • 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 , plaquenil, salazopirin, CRP 20,6 • On 5/2014: no fever, the sign of sinovitis (knee, wrist, ankle) improved well • CBC: 12 G/L, CRP: 20 mg/l, ESR: 50/60 mm/h • TOCILIZUMAB nd: 10 mg/kg Follow up • On 6/2014: No fever, no pain, but ankles still swelling CRP: 20,9 mg/L -> tocilizumab 3rd, -> CRP: 12,5 mg/L Continue treatment: prednisolon mg/ngày , MTX 10 mg/tuần, , Plaquenil salazopirin, SUMMARY The girl , 11 years old, Diagnosis JIA after 12 months, high active disease , no respond with DMARDs Treatment : tocilizumab : tapering CS After 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 ... or others autoimmune diseases ON ADMISSION On examination: • Pt conscious, orrient • Febrile , temp 3 9o C • pallor (+), no icterus, no cyanosis, no clubbing • No rash, No blleeding from gums or... High LABORATORY EXAMINATION TEST PROCEDURE RESULT High/Low/Normal Urea 4, 6 mmol/l Normal Creatinine 73 μmol/l Normal Glucose 5,7 mmol/l Normal Got 14 U/L Normal Gpt 20 U/l Normal RF 42 UI/,l... chẩn ? ?o? ?n lao NEGATIVE PCR lao NEGATIVE Laboratory examination • Peripheral smear: normocytic norrmochromic anemia, no immature cells seen • Bone marrow: norrmal study, no blast seen • Abdominal