Rheumatoid Arthritis Child

Three phase bone scan (left) and MIP whole body PET-CT with F18-FDG, showing increased uptake in shoulders, elbows, hips and knees.

Thorax blood pool Bone Scan F18-FDG PET (MIP)

Boy, 10-year-old that presented with headache, fever and joint pain. Laboratory showed inflammatory abnormalities and normal neck CT. Echo showed small adenopathies.
Evaluated by ENT: normal neck and nasofibroscopy. Infectology: Respiratory film array (-), Blood cultures (4): negative, Urine culture (-). IgG Bartonella (-), Normal bone scintigraphy, Normal echocardiogram. Normal chest xray. PCR for CMV and Parbovirus (-).
Evaluated by rheumatology. It was found normal Immunoglobulins (slight increase of IgA) and Complement c3 - c4. Ac anti ENA: negative; ANCA (-); Total CK: normal; Rheumatoid factor 19.4 (slightly elevated), Dimer D 7627 (increased +++), Fibrinogen 678, TTPK 46, Ferritin 371 ng / ml. Due to severe polyarthralgia and persistence of high inflammatory parameters (PCR: 153 - 143 - 238 - 331 mg / l), PET-CT was performed and suggestive of inflammatory joint pathology, with predominant involvement of the left knee. No metabolic lesions suggestive of malignant tumor activity were observed.
Immunomodulatory therapy with Gammaglobulin metilprednisolone + tocilizumab (Acmo antil il 6). Later he received 2 doses of Tocilizumab, and also metilprednisolone 16-12 mg V.O. Excelent response was noted.

References:

1 Shimizu M, Ikawa Y, Mizuta M, Takakura M, Inoue N, Nishimura R, Yachie A. FDG. PET in macrophage activation syndrome associated with systemic juvenile idiopathic arthritis. Pediatr Int. 2017 Apr;59(4):509-511.

2 Kanetaka T, Mori M, Nishimura K, Nozawa T, Kikuchi M, Sakurai N, Hara R, Yamazaki K, Yokota S. Characteristics of FDG-PET findings in the diagnosis of systemic juvenile idiopathic arthritis. Mod Rheumatol. 2016;26(3):362-7.

3 Ikegawa T, Yamazaki K, Nishimura K, Kanetaka T, Kikuchi M, Nozawa T, Hara R, Sato T, Sakurai N, Yokota S. A case of severe systemic juvenile idiopathic arthritis introduced tocilizumab in early phase of the disease]. Gakkai Kaishi. 2014;37(3):176-82.

4 Tateishi U, Imagawa T, Kanezawa N, Okabe T, Shizukuishi K, Inoue T, Yokota S.PET assessment of disease activity in children with juvenile idiopathic arthritis. Pediatr Radiol. 2010 Nov;40(11):1781-8.

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