Management of Patients With Juvenile Idiopathic Arthritis in the Emergency Department

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Publication Date: March 2025 (Volume 22, Number 3)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAP Prescribed Credits, 4 AOA Category 2-B Credits. CME expires 03/01/2028.

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Peer Reviewers

Abstract

Juvenile idiopathic arthritis (JIA) is the most common pediatric rheumatic disease. Children may present to the emergency department during the initial presentation of JIA or due to disease-related complications. Differentiating JIA from emergent causes of joint pain, including severe infections and malignancies, can be challenging. This issue reviews the clinical presentation of JIA, provides guidance for differentiating JIA from conditions with similar presentations, and offers recommendations for management of JIA and JIA-related complications in the emergency department.

Case Presentations

An 18-month-old girl is brought into the ED for refusal to bear weight…

• The mother says that the child has been limping for the past week. The limping is worse when the girl first wakes up and improves as the day progresses. Her mother denies constitutional symptoms.
• On examination, you note bilateral swollen knees and ankles, with an inability to completely flex or extend at these joints. The girl’s vital signs and the rest of her physical examination are normal. Upon further questioning, the mother also tells you the girl has been eating less.
• Laboratory work in the ED reveals mildly elevated inflammatory markers. Imaging with joint ultrasound reveals effusions and synovial hyperemia.
• Should you be concerned for a joint infection? Should you consider other testing such as synovial fluid analysis or magnetic resonance imaging?

An anxious 12-year-old boy with known juvenile idiopathic arthritis who is on an anti-TNF agent presents with diffuse pain...

• The boy tells you that his left lower extremity pain is the most severe, and he has difficulty bearing weight. He denies any recent trauma, travel, or infections. He has not had any fevers.
• His vital signs and physical examination are largely unremarkable. The patient refuses examination of his left lower extremity and reports pain to light touch. You also notice some edema in his left lower extremity, with some blue discoloration.
• You order x-rays and laboratory studies, which are negative. The boy is given a dose of ketorolac and a dose of methylprednisolone, but neither medication helps his pain.
• The patient says the pain is severe, and he is requesting stronger pain medications. What is your next step in his management?

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