Ward Round - a boy with multiple joint swellings

Abstract

IK is a 10-year-old HIV non-reactive boy who was referred to Queen Elizabeth Central Hospital (QECH) General Paediatric Clinic in early October 2007 with complaints of several months of multiple joint swellings and loss of range of movement. We could not identify any obvious trigger for the joint problems. There were no associated systemic features such as fever, lethargy, malaise or rash.He was a thin, rather despondent looking child with tender, boggy, non-erythematous but mildly warm swelling of both ankles (figure 1), knees (figure 2), elbows and wrists as well as several proximal interphalangeal (PIP) joints bilaterally (figure 3). All of these joints were tender and had a reduced range of movement, and he found it difficult and painful to walk. There was no rash or fever, no obvious eye changes, no lymphadenopathy and a normal abdominal examination.He had been managed at a nearby hospital for the previous month with prednisolone 5mg twice daily and regular ibuprofen (200mg tds) for a presumed inflammatory process, as well as flucloxacillin for a potential infective component. There had not been much change in his symptoms over this time.IK's family, including his parents, two brothers and a sister, all live in Nsanje where his father works as a computer software installer. The other family members were all well and IK himself had not suffered from any other significant medical conditions in the past.