A 4 yo WF brought in by mother for L knee swelling, limp, and decreased activity starting 7 weeks ago.

Physical Exam

  • Afebrile
  • Well-appearing
  • Left knee swelling with small effusion
  • Other joints unremarkable

Diagnostic Workup

  • CBC and CMP unremarkable
  • Normal inflammatory markers
  • ANA positive, RF negative
  • Plain radiographs of L knee normal
Diagnosis

Treatment

  • Start weekly methotrexate
  • Low threshold to add TNF inhibition if incomplete response to methotrexate

Referral

  • Refer for an eye exam to screen for uveitis

A 12 yo F presents with joint pain in R knee and L hand for 2 months.

Physical Exam

  • Afebrile
  • Well-appearing
  • R knee swelling with small effusion
  • L hand with 3rd digit dactylitis
  • Nail pitting on both hands
  • DIPs of bilateral hands swollen, tender

Diagnostic Workup

  • CBC and CMP unremarkable
  • Normal inflammatory markers
  • Mildly elevated inflammatory markers
  • RF negative
Diagnosis

Treatment

  • Start weekly methotrexate
  • Short course of oral steroids for symptom control
  • Low threshold to add TNF inhibition if incomplete response to methotrexate

Referral

  • Refer for an eye exam to screen for uveitis