Clinical History for Pediatric Polyarthritis
When evaluating a child with polyarthritis (>4 joints involved), obtain a detailed temporal pattern of joint involvement, assess for systemic features, and identify risk factors for severe disease to distinguish between juvenile idiopathic arthritis subtypes, acute rheumatic fever, and other inflammatory conditions. 1, 2
Essential Temporal and Pattern History
Joint Involvement Timeline
- Document the exact sequence and timing of joint involvement using a calendar or body diagram to distinguish additive (joints remain symptomatic as new ones are affected) versus migratory patterns (symptoms move from joint to joint with resolution in previously affected areas) 3
- Determine disease chronology: Acute onset (<6 weeks) suggests infection, reactive arthritis, or acute rheumatic fever, while chronic presentation (≥6 weeks) is required for JIA diagnosis 1, 2
- Identify if symptoms are progressive or episodic: Persistent joint involvement characterizes polyarticular JIA, whereas migratory polyarthritis lasting approximately 4 weeks total suggests acute rheumatic fever 4, 3
Critical Pitfall
NSAIDs may mask the migratory pattern of acute rheumatic fever—obtain detailed pre-treatment medication history including over-the-counter medications 4, 3
Inflammatory Features Assessment
Morning Stiffness and Pain Pattern
- Duration of morning stiffness: >1 hour suggests inflammatory arthritis (JIA, systemic vasculitis), while <1 hour indicates noninflammatory conditions like osteoarthritis 4, 5
- Pain characteristics: Inflammatory arthritis worsens with rest and improves with activity; noninflammatory pain worsens with activity 5, 6
- Functional impact: Document if the child is bedridden or has severe functional disability, which indicates aggressive disease requiring urgent intervention 7
Joint-Specific Symptoms
- Identify swelling, warmth, and tenderness in each affected joint—these inflammatory features distinguish true arthritis from arthralgias 8, 5
- Document limitation of range of motion and pain on passive movement 4
- Map symmetric versus asymmetric distribution: Symmetric involvement suggests worse prognosis in JIA and is characteristic of RF-positive polyarthritis 1, 2
High-Risk Joint Involvement
Specifically ask about involvement of prognostically important joints 1, 2:
- Cervical spine (neck pain, limited rotation)
- Wrists (bilateral involvement predicts erosive disease)
- Hips (pain with walking, limping)
- Temporomandibular joints (jaw pain with chewing, limited mouth opening—predicts micrognathia development)
Systemic Features and Extra-Articular Manifestations
Fever Pattern
- Quotidian (daily spiking) fever for ≥2 weeks with return to baseline between spikes characterizes systemic-onset JIA 1, 2
- Fever duration and pattern: Acute rheumatic fever presents with fever during the first 6 weeks, while systemic JIA requires documentation of fever pattern 4, 1
Rash Characteristics
- Evanescent salmon-colored rash appearing with fever spikes suggests systemic JIA 1, 2
- Erythematous-violaceous lesions or subcutaneous nodules on extensor surfaces raise concern for systemic vasculitis (polyarteritis nodosa) 7
- Psoriatic skin changes or nail pitting (dactylitis, onycholysis) indicate psoriatic arthritis 1
Constitutional Symptoms
- Weight loss, malaise, anorexia: Suggest systemic inflammatory disease (systemic JIA, vasculitis) 1, 7
- Fatigue severity: Profound fatigue indicates active systemic inflammation 5, 6
Organ System Review
- Cardiac symptoms: Chest pain, palpitations, or dyspnea may indicate carditis in acute rheumatic fever (present in 25-50% of cases, often subclinical) 4, 3
- Ocular symptoms: Eye redness, pain, or photophobia—though uveitis in JIA is typically asymptomatic, requiring scheduled screening 4
- Serositis: Pleuritic chest pain or abdominal pain suggests systemic JIA with serositis 1, 2
- Neurologic symptoms: Involuntary movements, emotional lability, or muscle weakness may indicate Sydenham chorea in acute rheumatic fever 4
Infectious and Triggering Events
Recent Infections
- Streptococcal pharyngitis within 1-5 weeks: Critical for diagnosing acute rheumatic fever and can trigger systemic vasculitis 4, 3, 7
- Viral prodrome: Rubella, parvovirus B19, EBV, or other viral infections can cause acute polyarthritis lasting <3 months 4, 6
- Gastrointestinal or genitourinary infections 1-6 weeks prior: Suggests reactive arthritis 1
Medication History
- Document all medications taken before symptom onset, including NSAIDs, antibiotics, and over-the-counter drugs that may mask symptoms or cause serum sickness 4, 3, 6
Age and Demographics
Age at Onset
- Peak age 1-5 years: Oligoarticular JIA with highest uveitis risk 4
- Onset <16 years: Required for JIA diagnosis 1, 2
- Male onset >6 years with lower extremity arthritis: Suggests enthesitis-related arthritis 1
Family History
- First-degree relatives with psoriasis, inflammatory bowel disease, or HLA-B27-associated diseases (ankylosing spondylitis, reactive arthritis, anterior uveitis) 1, 2
- Family history of autoimmune diseases: SLE, rheumatoid arthritis, or other connective tissue diseases 6
Poor Prognostic Indicators to Document
Identify features predicting severe disease course requiring aggressive treatment 1, 2:
- RF or anti-CCP antibody positivity (if known from prior testing)
- Symmetric polyarthritis
- High-risk joint involvement (cervical spine, wrist, hip, TMJ)
- Early functional disability
- Elevated inflammatory markers (ESR, CRP)
- Delayed diagnosis (>6 months from symptom onset)
Differential Diagnosis Considerations
Red Flags Requiring Urgent Evaluation
- Severe systemic symptoms with polyarthritis: Consider systemic vasculitis, malignancy (leukemia, lymphoma), or septic arthritis 4, 1
- Migratory polyarthritis with cardiac symptoms: Acute rheumatic fever requires immediate echocardiogram 4, 3
- Unilateral joint involvement with fever: Septic arthritis until proven otherwise 1