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Regression in Activities

Meena is a 3 year old girl who attends the GP with a history of reluctance to walk. This has been going on for 8 weeks or so. Mum says that Meena used to walk to nursery, but they now have to carry her as she complains of pains in her knees. She has stopped going down stairs in the mornings, and wants to be carried. She cries when her parents dress her at breakfast time. Nursery report that she is less active and is not keen on going outside during playtimes. She occasionally complains of pains in her knees, but has no other pain. Mum has not noticed any redness or swelling.

She has had no recent infections, apart from a mild cold which lasted a few days, and there is no history of recurrent temperatures or rashes. Meena is normally fit and well, and has had all of her immunisations as scheduled.

The local doctor performs an examination, and notes a swollen left knee, with reduced range of movement. She notes that Meena's right ankle seems quite stiff, although she is not sure if it is swollen.

She speaks to the on-call paediatrician, who recommends referral to the paediatric outpatient unit. Meena is seen on the paediatric unit. She has normal observations, and is afebrile with a temperature of 36.8. She is found to have an effusion at her left knee, and at her right ankle and right subtalar joint. She has blood tests done (complete blood count, acute phase, autoantibodies), which were normal, and normal x-rays. She is referred to the paediatric rheumatology clinic, and seen in the next available clinic slot. The rheumatology team note the history of pain for 8 weeks, and exclusion of other conditions based on results from the outpatient attendance.

A diagnosis of Juvenile Idiopathic Arthritis is made, and Meena is listed for intra-articular steroid injections under general anaesthetic to her affected joints. She is referred to the ophthalmologists to have her eyes screened for anterior uveitis. A physiotherapy review is arranged to follow her joint injections.

Morning stiffness, behaviour change and regression of achieved developmental milestones (e.g. walking down the stairs).

Symptoms of pain and stiffness that are worse in the mornings or after periods of rest, with variability in symptoms throughout the day.

Musculoskeletal examination such as pGALS and systemic examination (looking for pallor, lymphadenopathy and abdominal organomegaly) should be performed. Blood tests are not always necessary, and if there is concern about the diagnosis (or the child is young and there are concerns about taking blood tests) then referral is strongly recommended as soon as possible.

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