Letters to the Editor

Peritonitis and cervical early stages of the disease or as the single as presenting manifestations of joint implicated (6-9). In our patient, who presented with fever, neck stiffness and systemic juvenile idiopathic signs of peritoneal infl ammation, meningi- arthritis tis and peritonitis secondary to appendicitis were excluded. The associated evanescent Sirs, macular salmon-pink rash and cervical Early involvement of the cervical spine is spine involvement suggested sJIA. Diag- uncommon and peritonitis is a rare extra- nosis was confi rmed by the outcome with articular presentation in systemic-onset juv- a relapse. enile idiopathic arthritis (sJIA) (1-3). Over 21 years we observed 264 cases of We describe a previously healthy 4-year- JIA, of whom 3 had monoarticular C1-C2 old boy with C1-C2 arthritis and peritonitis involvement lasting for several months (2 presenting as the initial manifestations of previous to this case). sJIA. He was admitted following 2 days of We are not aware of any other published fever, lethargy, vomiting, abdominal pain cases of sJIA who presented with C1-C2 and neck stiffness. A blood count showed arthritis and peritonitis simultaneously . 20100 leucocytes/ml (74% neutrophils), the C-reactive protein was 2.8 mg/dl. Cerebral A. VAZ, MD spinal fl uid analysis excluded meningitis. C. VEIGA, MD Twelve hours post admission he appeared P. ESTANQUEIRO, MD clinically septic, developed abdominal M. SALGADO, MD signs suggestive of peritonitis and C-reac- Department of Pediatric Rheumatology, tive protein increased to 10 mg/dl. Antibiot- Fig. 1. Cervical MRI: arrows showing bilateral effu- Hospital Pediátrico de Coimbra, Portugal. ics (ampicilin, gentamicin and metronida- sion and enlargement of the apophyseal joints between Address correspondence to: zole) were started. Exploratory laparotomy C1 and C2 Dr. Ana Vaz, Avenida Bissaya Barreto, Hospital Pediátrico de Coimbra, Consulta de revealed a normal appendix, mild ascites Reumatologia, 3000-076 Coimbra, Portugal. (not analysed), and multiple lymph nodes peak of pyrexia (38ºC) until day 49, clini- E-mail: [email protected] with non-specifi c reactive hyperplasia on cal and laboratorial improvements were histology. Over the following days he main- evident, including normal mobilization of Competing interests: none declared. tained high fevers, generalized abdominal the neck after day 36. Therapy was gradu- References pain and neck stiffness. He initiated mu- ally tapered after 12 days of apyrexia and 1. JACOBS JERRY C: Juvenile . cousy and bloody diarrhoea. Mild hepat- acetylsalicylic acid was stopped 2 months In JACOBS JERRY C: Pediatric Rheumatology for osplenomegaly and axillary limphadenopa- later. Three months after presentation he the Practitioner. New York, Springer-Verlag; 1993: thy were noticed. Ultrasound showed mod- developed a morning right lower limb limp, 241-73. 2. CASSIDY J, PETTY R: Systemic Arthritis: In CAS- erate ascites and pleural effusion. Blood, from which he improved. At the seventh SIDY J, PETTY R, LAXER R, LINDSLEY C: Text- peritoneal and stool cultures were negative. month of disease (on 10 mg prednisone book of Pediatric Rheumatology. Philadelphia, El- Ceftriaxone was started and he was sent to on alternate days) he relapsed with fever, sevier Saunders. 2005: 291-303. our tertiary care centre. On day 13, a non- macular salmon-rash, right hip arthritis and 3. SCHALLER JG: Juvenile Rheumatoid Arthritis. itchy, evanescent and faint macular salmon- neck and hand tenderness. He presented Pediatr Rev 1997; 18: 337-49. 4. BHETTAY E, THOMSON AG: Peritonitis in Juvenile pink rash was observed, particularly in the leucocytosis (18730/ml, 94% neutrophils) Chronic Arthritis. A report of 2 cases. S Afr Med J legs. At this moment the haemoglobin was and a high ESR (81 mm/h). Methotrexate 1985; 68: 605-6. 8.9 g/dl, ferritin levels were raised (>15000 was started (15 mg/m2 once a week, orally) 5. POLLET SM, VOGT PJ, LEEK JC: Serous Peritonitis ng/ml; normal < 370) and erythrocyte sedi- and prednisone increased to 15 mg/day, re- in Adult Still’s Syndrome. J Rheumatol 11990;990; 117:7: mentation rate (ESR) was 47 mm/h. Anti- sulting in a good outcome. 98-100. 6. UZIEL Y, RATHAUS V, POMERANZ A, SOLAN H, nuclear antibodies and rheumatoid factor Remission was achieved two years after WOLACH B: Torticollis as the Sole Initial Present- were negative. Due to continued neck stiff- presentation. Prednisone and methotrexate ing Sign of Systemic Onset Juvenile Rheumatoid ness and decreased neck movements, cervi- were respectively stopped 2 months and 2 Arthritis. J Rheumatol 1998; 25: 166-8. cal bone radiography and bone scintigraphy years later. Five years following the initial 7. HENSINGER RN, DEVITO PD, RAGSDALE CG: were carried out, both normal, and cervical presentation he is symptom-free and leads Changes in the cervical spine in juvenile rheumatoid arthritis. J Bone Joint Surg AM 1986;1986; 668:8: 11986-98.986-98. MRI showed a small effusion and discrete a normal life. 8. ARABSHAHI B, BASKIN KM, RQ: Reactive arthri- enlargement of the two apophyseal joints Diffuse abdominal pain suggestive of se- tis of the temporomandibular joints and cervical between C1 and C2 (Fig. 1). Echocardiog- rositis is present in about 10% of children spine in a child. Pediatric Rheumatology 2007, 5: 4 raphy revealed mild pericardial thickening with sJIA (1), but reports in the medical doi:10.1186/1546-0096-5-4. and a small pericardial effusion with normal literature of peritoneal involvement are 9. SALMASO A, LURATI A, TERUZZI B et al.: Atlo-epistropheal involvement in oligoarthritis sub- cardiac function. On day 20, prednisone (2 rare (2, 4, 5). Although only a single joint set of Juvenile Idiopathic Arthritis (JIA): observa- mg/kg/day) and acetylsalicylic acid (80 may be affected, usually, multiple joints are tion of fi ve cases. Pediatric Rheumatology Online mg/kg/day) were started and antibiotics involved simultaneously in sJIA (2). Atlan- J 2005;2005; 3:3: 165-74.165-74. http://www.pedrheumonlinejour-http://www.pedrheumonlinejour- stopped. Despite maintaining an evening toaxial compromise is a rare fi nding at the nal.org/may-june05/pdf/atlo-epistropheal.pdf

974