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Elbow joint pain in a 6 year old girl

Q: My daughter, 6 years 4 months old, is complaining of pain in the right elbow joint since December 2001. Initially there was only pain but gradually there is restriction of movement of the joint. I have consulted an orthopedic doctor who advised certain tests the results of which are as follows: ESR 50 mm (Ist hour), C-reative protein & R. A. factor negative, differential blood count normal and hemoglobin is 9.6 gm/dL, Mantoux test negative. It was presumed to be Tuberculosis (TB). I took my daughter to Apollo Hospital, Hyderabad and additional tests were done: Adenosine deaminase (ADA)levels in serum 36 U/L, Tuberculosis IgG negative, Tuberculosis IgM positive. An MRI was also done. I was told to continue the anti-tuberculous treatment (Rinzide DT forte one tab daily and Banadon 1/2 tab daily). The ESR has come down to 16 mm and though the treatment has continued for six months, there is no relief in pain and the movement is still restricted. In May 2002 she complained of pain in the neck and both knee joints. The case was referred to a rheumatologist. Other tests showed: 1. R.F. negative, 2. ANA negative, 3. C.R.P negative. He prescribed the following medicines: 1.Alltrex-2.5 mg 2 tabs on every Saturday night, 2.Folic acid 5 mg 1 tab every 3rd day, 3.Brufen 200 mg 1 tab twice a day. The growth of my daughter is also not satisfactory and she weighs only 15 kg for the last one year. Mentally she is normal (stood first in her class consisting of 60 student in LKG & UKG). The place where I reside is slightly affected by fluorine in the drinking water. We moved to this place a year ago and since then my wife is also complaining of pain in both knees.

A:First of all we need to be clear on the diagnosis of your child. A provisional diagnosis of tuberculosis was made on the basis of a single joint pain (elbow) and the fact that her other investigations for rheumatoid arthritis were negative. You have mentioned that X-rays and MRI were done but you have not mentioned the exact report. It is important to know the findings on X-ray and MRI. Often in single joint arthritis it is very difficult to arrive at a definitive diagnosis and therefore, some times based on the clinical symptoms, anti-tuberculosis treatment may be started empirically. Now that she has pain in other joints, it seems to be something other than tuberculosis. There are several types of arthritis which can present like this where rheumatoid factor is negative. Even after complete investigations the final diagnosis may be different and it may be possible only to make a retrospective diagnosis. Having said that, she needs to have a very close examination of all her joints and other physical characteristics. This could give a clue to the nature of her arthritis. The treatment that has been started may not however, change significantly. Pain in any arthritis may persist even after the disease activity has come down (including tuberculosis). This is because once articular cartilage has eroded patient will have pain on movements of the joint. I would recommend a fresh review by a Rheumatologist. Growth in height may be less in some children with arthritis.

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