Seronegative Juvenile Idiopathic Arthritis-Pediatric Oncall

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Rakesh Kumar, Binay Ranjan, Manjul Vijay Department of Pediatrics, Katihar medical college, Katihar...

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Question
A 13 year old boy was being treated as seronegative Juvenile Idiopathic Arthritis for last 6 months. He had Diclofenac, Solu-Medrol and a bi-weekly course of oral methotraxate. There was pain in large joints but from history, no convincing data was obtained regarding joint swelling. Now he presented with extreme pain on moving lower limbs and trunk, bed ridden. He is mentally very clear, communicates well, despite his illness, comes 1st in the class. On Examination, ankles and legs remained flexed, afraid of truncal movement, no joints are swollen or tender. He feels extreme pain and screams on touch on lower back, but if the I sustain the pressure, pain goes away and no screaming is observed even on deep pressure. Lower limbs initially seem spastic, he cries on movement but these can be flexed very slowly. After a while, passive movement becomes easy and painless. Adductors were seen spastic, but on slow and sustained effort, these become soft. muscles of lower trunk and lower limbs are initially spastic but on manipulation, these become soft and pain goes away for a while. Ankle and knee jerks are HYPER exagerated, ankle and patellar clonus are present but planter response is flexor. Upper limbs also show hyper reflexia to lesser extent. He Cannot stand or walk. On attempt, he screams on moving legs, those seems spastic! He cannot bend his joints. Is there any suggestion on how to approach to diagnosis and a logical management plan?
Answer
Rule out a neurological problem and scurvy. Get an MRI of the spine if needed in view of brisk reflexes. Back to All Questions

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