PEDIATRIC RHEUMATOLOGY UPDATE
A NEWS LETTER FROM
THE DIVISION OF
HOSPITAL FOR SPECIAL SURGERY
This page is provided by Thomas J. A. Lehman MD
Delivering the best care - with great care
Dr. Lehman is the author of many textbook chapters and articles on
the care of children and young adults with SLE and other rheumatic
diseases. He practices in
"funny" blood tests?
What do you say when parents or an adolescent complain about cold hands?
Do you worry about children who always seem to have mottled skin?
We all know you have to evaluate children with prolonged clotting studies, but what do you do if you notice the PT or PTT is unusually short?
Can these things possibly be related to each other? If they are, should you care??
Recognizing that many of the complaints highlighted are often benign is one of the biggest challenges in writing a newsletter. At the same time I see children with serious conditions who clearly had all the associated findings which should have made their doctors suspicious but went undiagnosed for a long time. The trick is to know what questions to ask in order to quickly decide whether the complaint needs to be pursued further.
Anticardiolipin antibodies (ACLs) have now been recognized to be a major cause of childhood strokes and other bleeding problems - both excessive clotting and excessive bleeding. When questioned many of these children have a long history of cold hands, and livedo reticularis. Some children are detected when they have abnormal clotting times when tested before routine surgery. Either too short, or too long. Others are discovered when they complain of 'heavy periods' and are discovered to have profound menorrhagia. When VDRL testing was routine, many children with ACLs were discovered because of false positive VDRL or RPR tests.
With more widespread testing we now know that ACLs may be the cause of stroke, chorea, cardiac vegetations, unexplained emboli or excessive bleeding. Most often these problems first appear in adolescence, but they can occur in younger children. You certainly aren't going to screen every child, but chronically cold hands and mottled skin are the most frequent associated symptoms. When they are present we should ask about other findings and consider further testing.
Birth control pills increase the risk of problems in girls who are ACL positive. This makes teenage girls the most important group to consider. They probably aren't asking their pediatricians for birth control pills, but you may learn that the patient is on them, or be asked for advice. A teenage girl with cold hands, who was put on birth control pills because she had extremely heavy periods, ought to be worked up for ACLs. Many won't be positive, but we need to be careful.
The routine work-up for ACLs is easy. You want to test for anticardiolipin or antiphospholipid antibodies, and you want to check the PT and PTT. Unfortunately not all laboratories are equal when it comes to these tests. All of these tests could be normal in your lab and the patient might still have problems. Any one of the tests being abnormal warrants further investigation. There's a lot of discussion about how best to do the tests and how to interpret them and respond. We'll be glad to help you out with that part. If you have a suspicious patient we can have specialized tests performed by outstanding experts in the field of ACLs here at the Hospital for Special Surgery.
The Division of Pediatric Rheumatology at HSS continues to grow. We’re adding faculty, and we’ve received grants to expand both our teaching programs and our research into the causes and care of childhood rheumatic disease. Thank you for your continued support!
If you have patients who
don’t want to come into NYC we can see them at the
Dr. Lehman is
the author of many textbook chapters and articles on the care of children and
young adults with rheumatic diseases including SLE, JRA, dermatomyositis,
“Dr. Tom Lehman’s experience and compassion are evident on every page of this book, and they help guide the reader—child, parent, and healthcare professional alike – through the world of childhood arthritis. This book is an absolute gem written with a single goal in mind: improve the lives of kids with arthritis.” -- Jack Klippel, M.D. President and CEO of the Arthritis Foundation
“Dr. Lehman has given parents and families of children with
arthritis the first book that speaks to the parent and child as equals. His book explains the illnesses, the
medications, the lab tests, and the disease course in simple, understandable
lay language and givens them valuable insight into how a pediatric
rheumatologist thinks. Bravo!”-- Charles Spencer, M.D.,
Professor of Clinical Pediatrics,
It’s not just
A guide to childhood muscle, bone, and joint pain,
rheumatic diseases and the latest treatments
It has always been a frustration trying to answer the many questions I have received from people over the web. I can’t take the time and give them the detail I would like to. I have to take care of my patients. This book is a distillation of my experience answering questions for parents and health professionals over 25 years of practice. If you want to know about the diseases, the tests, the medications, or how to be sure you are getting the best care– If you are the family member of a child with joint pains, this book will give you the answers. If you are a general physician, a pediatrician, or a nurse who cares for children with these diseases it will answer many of the questions families ask you, and you can recommend it to them. It will also answer many of your questions about what shots to give, what precautions to take, and the other questions families, pediatricians, and other health care providers have asked me over the years.
is the author of many textbook chapters and articles on the care of children
and young adults with SLE. He practices
Click here for The Lupus Foundation web page
The Arthritis Foundation also works with children with lupus.
This site provided by Thomas J. A. Lehman MD
Chief, Division of Pediatric Rheumatology
The Hospital for Special Surgery
535 E 70 St,
212-606-1151, fax 212-606-1938, e-mail firstname.lastname@example.org
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