In this post, I link to and excerpt from the outstanding podcast and show notes of “Enthesitis-Related Arthritis (ERA)” From PedsCases. by Vivian Jan 25, 2020:
This podcast on an approach to enthesitis-related arthritis (ERA) covers classification, epidemiology, pathogenesis, clinical presentation, investigation and management. It was developed by Vivian Szeto, a medical student at the University of Alberta in Edmonton, Canada with Dr. Rumsey, a Pediatric Rheumatologist at the University of Alberta and Stollery Children’s Hospital in Edmonton, Canada.
- Septic Arthritis (Part 1)
- Juvenile Idiopathic Arthritis
- Evaluation of a Limp
- Acute Rheumatic Fever
- Henoch-Schlolein Purpura (HSP)
- Juvenile Dermatomyositis
- Systemic Lupus Erythematosus
- Physical Examination in a Patient with a Suspected Systemic Rheumatic Disease
Key Take Home Points
To summarize, here are some key take home points:
1) ERA is a type of juvenile idiopathic arthritis which involves inflammation and swelling of joints and entheses, typically of the lower extremities.
2) ERA is most commonly diagnosed in adolescent males.
3) Clinical presentation of ERA typically includes an insidious onset of oligoarticular arthritis (4 or less joints affected) and entheseal tenderness around the knee, hip, foot, and ankle.
4) A differential diagnosis would include: excessive running and jogging, which will mimic inflammatory enthesitis, fibromyalgia, or one or more apophysitis syndromes (Osgood Schlatter disease, Sinding-Larsen-Johansson syndrome and Sever’s disease).
5) Important aspects of an approach to these patients include: taking a thorough history, performing a thorough exam of all the joints and enthesis points (Look, Move, Feel), consideration of blood work (e.g. CBCd, ESR, CRP), and radiographic investigations (Xrays and/or MRI). Discussion with and early referral to a pediatric rheumatologist is highly recommended.
6) Management of ERA would include using a step-wise approach: non-pharmacologic treatment (physiotherapy, occupational therapy) for all, Non-Steroidal Anti-Inflammatory
Drugs (NSAIDs), disease modifying anti-rheumatic drugs (DMARDs), and finally
biologics. Potential glucocorticoid treatment can also be considered. There is a very limited role for surgical intervention in the management of ERA. Also, regular lab work, eye exams, and clinical appointments are key.
7) The prognosis of ERA is highly variable from child to child but tends to be worse than in other categories of JIA.