Working Diagnosis:
Juvenile Idiopathic Arthritis, Psoriatic Subtype

Treatment:
The patient was started on adalimumab, methotrexate, and prednisolone. A biologic medication was initiated for multi-compartmental inflammatory arthritis and significant tenosynovitis in the right wrist. Prednisolone was initiated for immediate relief of pain with a plan to taper off once the other medications started working.
The patient was subsequently referred to ophthalmology to evaluate for eye inflammation.

Outcome:
At three months, overall improvement in joint pain and swelling was noted but the patient still experienced recurring psoriasis, morning stiffness, and intermittent limping. He will likely have chronic arthritis for life, given his presentation and positive HLA-B27 antigen. The patient was given no long-term sport or activity restrictions. Instead, he was strongly encouraged to pursue regular physical activity and sports to keep joints mobile. He was advised to refrain from high exposure activity during the COVID-19 pandemic due to his immunocompromised status.

Author's Comments:
Juvenile idiopathic arthritis is a clinical diagnosis, but labs and imaging can help guide treatment and predict outcome. Patients with rheumatologic diseases may first be seen by sports medicine physicians. Initial workup may include CBC, ESR, CRP, x-ray and MRI. HLA-B27 should be included to help predict clinical course if there is clinical concern for spondyloarthropathy, psoriasis, or inflammatory bowel disease. One should screen for tuberculosis if anticipating starting immunomodulatory treatments. Caution is advised when obtaining an ANA or rheumatoid factor as they are non-specific and often do not change management. Lastly, physical activity is strongly encouraged

Editor's Comments:
This case reminds sports medicine physicians to perform a detailed history and comprehensive physical examination. Be on the lookout for physical examination findings that may indicate a systemic process, such as changes in hair or nails, skin findings, multiple sites of pain, tenderness, or swelling, weight changes, fevers, or malaise. This patient had chronic, multifocal pain and no history of trauma, making fracture, soft tissue tear, or other acute injury process unlikely. Additionally, he had skin and nail findings and had a personal history of eczema and psoriasis and a strong family history of auto-immune diagnoses.
As the author states, laboratory studies may be helpful in narrowing the differential diagnosis and/or directing clinical management but choose wisely. A CBC can be useful in evaluating for signs of infection as well as changes related to anemia or thrombocytopenia, which may point towards a systemic process. In JIA, rheumatoid factor and ANA have been shown to be nonspecific and do not alter the treatment plan even when positive; hence they are not routinely recommended labs in children. HLA-B27 can be helpful in determining prognosis in rheumatologic conditions.

References:
Petty RE, Southwood TR, Manners P, et al. International league of associations for rheumatology classification of juvenile idiopathic arthritis: Second revision, Edmonton, 2001. Journal of rheumatology. 2004;31(2):390-92. https://www.ncbi.nlm.nih.gov/pubmed/14760812.

Nigrovic PA, Sundel RP. Juvenile psoriatic arthritis. In: Textbook of pediatric rheumatology. Seventh Edition ed.; 2016:256-267.e5. https://www.clinicalkey.es/playcontent/3-s2.0-B978032324145800020X. 10.1016/B978-0-323-24145-8.00020-X.

Sudoł-Szopińska I, Matuszewska G, Gietka P, Płaza M, Walentowska-Janowicz M. Imaging of juvenile idiopathic arthritis. part I: Clinical classifications and radiographs. Journal of ultrasonography. 2016;16(66):225-236. https://www.ncbi.nlm.nih.gov/pubmed/27679726. doi: 10.15557/JoU.2016.0023.

Colbert RA. The classification challenge of pediatric spondylarthritis. The Rheumatologist. 2010. https://www.the-rheumatologist.org/article/the-classification-challenge-of-pediatric-spondylarthritis/.

Nigrovic PA. Psoriatic juvenile idiopathic arthritis: Pathogenesis, clinical manifestations, and diagnosis. UpToDate Website. https://www.uptodate.com/contents/psoriatic-juvenile-idiopathic-arthritis-pathogenesis-clinical-manifestations-and-diagnosis?source=history_widget. Updated 2019.

Ringold S. Spondyloarthritis in children. UpToDate Website. https://www.uptodate.com/contents/spondyloarthritis-in-children?source=history_widget. Updated 2018.

Sarwark J, Labella C. PEDIATRIC ORTHOPAEDICS AND SPORTS INJURIES : A quick reference guide. 2nd ed. American Academy of Pediatrics; 2014. http://www.r2library.com/resource/title/9781581108477.

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