Clinical Case

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Clinical Case

Yanina S. Ameruso

General Children´s Hospital Dr. Pedro de Elizalde

Buenos Aires, Argentina

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Yanina S. Ameruso HGNPE – Bs.As.

Argentina Current Disease

February 2013: First visit.

 15 year old girl diagnosed in a neighboring country as JIA one year before.

 She was receiving low dose of methotrexate (5mg/week) and naproxen without clinical controls.

 She had a severe left knee synovitis since one week prior to the visit.

 Physical examination

 Left knee synovitis.

 Right Knee Overgrowth.

 Left Ankle Overgrowth with active and passive movements preserved.

 One centimeter of Length discrepancy of lower limbs.

 Both quadriceps muscle atrophy.

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Argentina

Current Disease

 Laboratory:

 Blood Count

 Acute Phase Reactants

 Renal Function

 Liver Function

 Viral Serologies Negatives.

 ANA and RF Negative.

 Intradermal Tuberculin Test Negative

 Chest x-Ray Normal.

 Left Knee X-Ray: Increased Joint Space and Soft Tissue. Bone Overgrowth.

What was the diagnosis?

Oligoarticular Juvenile Idiopathic Arthritis

ANA Negative

Normal

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 At our center, methotrexate and naproxen was initiated, at usual and therapeutic doses (20mg/week).

 During her evolution, she presented involvement of both knees and both ankles.

 Therapeutic arthrocentesis in the

knees was performed at three times.

(Feb-2013 / Jun-2013 / Jul-2014)

 She never presented uveitis or any ocular involvement.

 The patient remained in remission with medication for a year.

On 31^th October 2014 after 24 hs of fever, left ankle synovitis and left leg cellulitis

associated to skin injury, she was admitted.

Methotrexate was discontinued.

What are the differential diagnoses in which we should think at this time?

 Intercurrent Infectious Disease Secondary to Immunosuppression (soft tissue infection, osteomyelitis, etc)

 Reactivation of the underlying disease

What was the evolution of this

Patient?

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What additional studies would you ask for at this time?

 Laboratory: Normal. Negative blood cultures.

 Radiography: Not significant.

 Ultrasonography: Effusion of 6mm in left ankle joint.

 She began treatment with

Clindamycin 30 mg / kg / day.

 But…. On the fifth day of hospitalization, she presented clinical worsening, with:

1. Recurrence of fever

2. Increase joint fluid in her left ankle (effusion of 8mm)

3. Right hip arthralgia

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What would you do now?

Should you ask for another

studies?

Would you ask for an assessment

in another service?

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Work up

Blood Laboratory Test: Mild decrease in White Blood Cells and Platelets Count but within normal values.

Eritrosedimentation Increased. Negative Blood Cultures.

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Values/Date Oct-31-2014 Nov-5-2014

HB 13 12,9

WBC 8770 6570

NT 57 63

LT 47 36

PLT 195000 164000

ERS 20 50

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Left Tibia Nuclear Magnetic Resonance:

Stir - Weighted:

Tibia´s Bone Marrow Edema

T1-Weighted:

Soft Tissue Edema rounded Tibia

Infectious/Inflammatory Process

Argentina

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Bone Scans:

 Increased perfusion in left hip and left ankle.

 Involvement of the Right Head Femoral Avascular Necrosis.

 The Traumatology Service kept her follow up.

 She completed 14 days of Clindamycin treatment by

indication of Service of Infectious Diseases.

Hospital Discharge

Home

Argentina

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After Discharge

Biphenotypic Acute Leukemia was diagnosis

Date Physical

Examination Laboratory Comments 1st.

Control

Nov-17-14 Left Knee

Synovitis Normal Restarted MTX

2nd.

Control Dic-16-14 Right knee

Synovitis Leukopenia and

Neutropenia Acute

Phase Reactants Increased

Bone Marrow Aspiration

Argentina

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Muchas Gracias!

Thank You!

Obrigado!

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Questions for the Audience

 1-What additional exams should you request if a patient with JIA develops leukopenia and neutropenia after a month of an infectious intercurrence?

 2- In a child who presents a diagnosis of JIA, what are the clinical features or laboratory findings (at presentation) that can predict a diagnosis of Leukemia?

 3- What is the relationship between JIA/MTX and Cancer?

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