Summary of "Session 1 e-Rheumatology"
Summary of “Session 1 e-Rheumatology”
This session is an introductory lecture on pediatric rheumatology aimed at general pediatricians, emphasizing the importance of recognizing rheumatological disorders early in clinical practice. The program is part of a 12-week e-masterclass series organized by the IAP Delhi chapter to enhance academic knowledge and clinical skills in pediatric subspecialties.
Main Ideas and Concepts
Program Introduction and Objectives
- The e-masterclass series covers various pediatric subspecialties, starting with pediatric rheumatology.
- Designed for office-based pediatricians to improve diagnosis and management of common and complex pediatric rheumatological conditions.
- Sessions include lectures followed by ample Q&A to encourage discussion.
Importance of Pediatric Rheumatology
- Pediatric rheumatology is an emerging specialty critical for diagnosing systemic diseases presenting with musculoskeletal symptoms.
- Many systemic diseases (connective tissue diseases, vasculitis, autoinflammatory syndromes) manifest with joint or musculoskeletal complaints.
- Pediatric rheumatology is described as a “last bastion” for clinicians, requiring careful history and examination.
Diagnostic Approach
- History is paramount:
- 85% of diagnosis comes from history, 10% from clinical examination, and 5% from laboratory tests.
- Detailed history should include growth, milestones, vaccination history, family history, and symptom pattern.
- Clinical examination skills, including joint assessment and use of tools like ultrasound (POCUS), are essential.
- Laboratory tests should be ordered judiciously with understanding of test limitations and pre-test probabilities.
- No single lab test can definitively rule in or out rheumatological disorders; clinical correlation is mandatory.
Common Clinical Presentations and Differential Diagnosis
- Joint pain and arthritis: Distinguish inflammatory vs non-inflammatory pain (e.g., juvenile arthritis vs hypermobility/growing pains).
- Fever of unknown origin (PUO): Rheumatological causes account for 20-25% of prolonged fevers.
- Connective tissue diseases (e.g., lupus) and vasculitis (e.g., Kawasaki disease, Henoch-Schonlein purpura) have varied presentations.
- Malignancies can mimic rheumatological diseases, especially leukemia presenting with joint pain.
- Importance of recognizing mimics and avoiding premature diagnosis or inappropriate treatment (e.g., steroids before diagnosis).
Specific Conditions Highlighted
- Acute rheumatic fever: Diagnostic criteria, common pitfalls (e.g., over-reliance on ASO titer).
- Juvenile idiopathic arthritis (JIA): Subtypes, clinical features, and treatment individualization.
- Systemic arthritis and macrophage activation syndrome: Clinical challenges and need for early recognition.
- Connective tissue diseases: Lupus as prototype, importance of correct ANA testing method (indirect immunofluorescence preferred over ELISA).
- Vasculitis: Large, medium, and small vessel vasculitis classification, clinical clues, and diagnostic approach.
- Autoinflammatory syndromes and rare conditions: Mentioned as upcoming topics.
Practical Tips and Take-Home Messages
- Always take a detailed history and perform a thorough clinical exam before ordering tests.
- Use imaging (e.g., ultrasound, MRI) as adjuncts but not replacements for clinical skills.
- Be cautious with laboratory interpretation; understand test limitations.
- Early diagnosis and treatment can prevent deformities and complications.
- Collaboration with specialists and repeated evaluation may be necessary.
- Avoid unnecessary or empirical treatments without clear diagnosis.
Q&A Highlights
- ANA testing: Indirect immunofluorescence on Hep-2 cells is gold standard; ELISA is less sensitive.
- Chickenpox arthritis: Usually self-limited; some may require hydroxychloroquine if persistent.
- Treatment of juvenile arthritis tailored by disease severity and prognosis.
- Kawasaki disease recurrence is very rare (<1%).
- COVID-19 pandemic has not significantly increased pediatric autoimmune arthritis but has led to increased tuberculosis due to steroid misuse.
- Common missed diagnoses include juvenile arthritis and vasculitis like Takayasu arteritis.
- Oral ulcers have diverse causes and require careful evaluation.
Methodology / Instructional Points
Approach to Pediatric Rheumatology Patient
- Take a detailed history focusing on symptom pattern, systemic involvement, family history, growth, and vaccination.
- Perform a thorough clinical examination emphasizing joint swelling, tenderness, range of motion, and extra-articular features.
- Differentiate inflammatory vs non-inflammatory joint pain using history and exam.
- Use imaging (ultrasound, MRI) to confirm joint inflammation or exclude mimics.
- Order laboratory tests selectively, understanding the sensitivity, specificity, and pre-test probability of each.
- Recognize common mimics (infections, malignancies, hematological disorders).
- Monitor for systemic features that suggest connective tissue diseases or vasculitis.
- Avoid premature empirical treatment that can mask diagnosis.
- Follow up and reassess frequently; rheumatologic diagnoses often evolve over time.
Laboratory Testing Principles
- ANA by indirect immunofluorescence is preferred for lupus screening.
- Rheumatoid factor has low sensitivity in children.
- No “rheumatology panel” exists; tests must be targeted.
- Understand the clinical context before interpreting lab results.
Management Principles
- Treatment tailored to disease subtype and severity.
- Use NSAIDs, steroids, DMARDs, or biologics as indicated.
- Early diagnosis and treatment prevent long-term disability.
Speakers / Sources Featured
- Dr. Pankaj G – President, IAP Delhi Chapter
- Dr. Prashant Subot – Vice President, Eastern Zone, IAP
- Dr. Kid Ahmedani – Executive Board Member, Jammu & Kashmir
- Dr. Shamina – Secretary, IAP Delhi Chapter
- Dr. Basar – Vice President, IAP Central
- Dr. Anu Mahui – Professor of Pediatrics, Kalavati Children’s Hospital and Lady Harding Medical College (Program Coordinator)
- Dr. Suata Sani – Senior Consultant, Pediatric Rheumatologist, Gangaram Hospital (Main Presenter)
- Dr. Dolly – Moderator/Panelist (responding to questions)
- Dr. Mukesh Verai – Executive Board Member, IAP Delhi
- Other Faculty and Participants – Various pediatricians and rheumatologists contributing during Q&A
Conclusion
The session provided a comprehensive introduction to pediatric rheumatology for general pediatricians, emphasizing clinical acumen, pattern recognition, and cautious use of investigations. It highlighted the complexity of diagnosis, the importance of considering mimics like malignancies and infections, and the critical role of early and accurate diagnosis to prevent morbidity. The interactive Q&A clarified practical issues and common clinical dilemmas, reinforcing the educational value of the program.
Category
Educational
