CASE REPORT
Pediatrics Sciences Journal (PedSci.
Volume 6.
Number 2: 59-63 P-ISSN: 2722-0427.
E-ISSN: 2722-1474
Published by Pediatrics Sciences Journal A case of oligoarthritis juvenile idiopathic arthritis in a 3-year-old male child: challenges in early diagnosis and management Heksa Trisnawati1*.
Farhan Ardiyanta Setyagisna1.
Muhammad Reva Aditya2.
Wisnu Barlianto3.
Desy Wulandari3
ABSTRACT
Bachelor Study Program of Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia Master Program in Biomedical Science.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia Allergy-Immunology Division.
Pediatric Department.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia *Corresponding email:
Heksa Trisnawati.
Bachelor Study Program of Medicine.
Faculty of Medicine.
Universitas Brawijaya.
Malang.
Indonesia.
heksatrisnawati@student.
Received: 2025-08-30 Accepted: 2025-10-25 Published: 2025-11-28 Introduction: Juvenile Idiopathic Arthritis (JIA) is the most common chronic rheumatic disease in children, characterized by persistent joint inflammation.
However, early diagnosis is often challenging due to heterogeneous clinical manifestations.
Among its subtypes, oligoarthritis is the most common, involving up to four joints within six months of symptom onset.
This case is distinctive due to its very early onset at the age of 3 years, prolonged diagnostic delay despite multiple healthcare visits, and diagnostic challenges related to nonspecific initial symptoms.
Delayed diagnosis can result in joint deformity, growth retardation, and long-term disability, highlighting the importance of early recognition and timely management.
Case Presentation: A 3-year-old male child presented with progressive joint pain, morning stiffness, and recurrent joint swelling that was initially associated with a history of trauma.
Symptoms had been present since the age of 1.
5 years, leading to a significant delay in definitive diagnosis.
Based on clinical evaluation, imaging findings, and laboratory investigations, a diagnosis of oligoarticular Juvenile Idiopathic Arthritis was established according to the International League of Associations for Rheumatology (ILAR) criteria.
The diagnostic process was further complicated by trauma-associated symptom onset and involvement of the temporomandibular joint (TMJ), which underscores the need for heightened clinical suspicion.
The patient received multidisciplinary management, including pharmacological therapy, physical rehabilitation, and nutritional support.
Conclusion: This case illustrates the complexity of diagnosing and managing oligoarticular JIA in pediatric patients, particularly in cases with very early onset, delayed diagnosis, and TMJ involvement.
A comprehensive multidisciplinary approach, along with increased clinical awareness and early diagnosis, is essential to control inflammation, preserve joint function, and prevent long-term complications in children with JIA.
Keywords: Early Diagnosis.
Juvenile Idiopathic Arthritis.
Multidisciplinary Management.
Oligoarthritis.
Temporomandibular.
Cite This Article: Trisnawati.
Setyagisna.
Aditya.
Barlianto.
Wulandari.
A case of oligoarthritis juvenile idiopathic arthritis in a 3-year-old male child: challenges in early diagnosis and management.
Pediatrics Sciences Journal 6.
: 59-63.
DOI: 10.
51559/pedscij.
INTRODUCTION
Juvenile Idiopathic Arthritis (JIA) is the most common chronic rheumatic disease in children, marked by persistent joint inflammation and 1 Despite its prevalence.
JIA often remains underdiagnosed due to its varied presentation, which can mimic other conditions.
2 Among its subtypes, oligoarthritis stands out as the most frequent, typically affecting up to four joints within six months of onset.
3 If not detected early, this condition can lead to joint deformities, growth disturbances, and long-term disability.
2,4,5
Globally, the prevalence of JIA varies widely, ranging from 3.
8 to 400 per 000 children.
This variability may be attributed to differences in geographic regions, population characteristics, and diagnostic criteria.
6 However, reliable data on its prevalence in Indonesia remains Cases like this emphasize the need for greater awareness among healthcare providers regarding the distinctive clinical patterns of JIA, especially in young children, where symptoms can be subtle or resemble other conditions.
Delayed diagnosis can have profound effects on a childAos physical growth, psychosocial development, and overall quality of 6,7 In this case, we present a 3-yearold child with progressive joint pain and stiffness, in whom symptom onset coincided with a history of trauma.
What makes this case unique is the complex progression of symptoms, including recurrent swelling and morning stiffness in multiple joints, which began as early as 5 years of age.
Despite receiving care at multiple healthcare facilities, the definitive diagnosis of Oligoarthritis JIA was only established after an extensive diagnostic workup, emphasizing the challenges in diagnosing JIA in low-resource settings.
This case report highlights the diagnostic journey, clinical presentation, and multidisciplinary management of a young patient with JIA.
By sharing this case, we aim to enhance awareness and improve early recognition of JIA among clinicians, ultimately contributing to better outcomes for children facing similar Open access:
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CASE REPORT
CASE PRESENTATION
A 3-year-and-2-month-old child was referred to Saiful Anwar Malang Hospital (RSSA) due to complaints of difficulty walking since May 2024.
The complaint was recorded 2 weeks after the patient fell while cycling.
However, the parents stated that the patient had a history of pain and swelling in both knees.
In addition, the patient also experiences difficulty bending both wrists since the patient was 1.
5 years Initially, the patient only complained about the right wrist, but over time both wrists became difficult to bend.
Until now, the patientAos complaints are still felt, accompanied by joint stiffness every morning for about 30 minutes.
In medical history, in May 2024, the patient was treated at Persada Hospital Malang in the Pediatric Neurology Clinic after falling off a bicycle.
Then, the patient was referred to the Orthopedic Department to address walking difficulties.
In November 2024, the patient was referred to the Medical Rehabilitation Department of RSSA by an orthopedic specialist who had treated the patient at Persada Malang Hospital, and stimulation was performed using Shortwave Diathermy (SWD) on the hamstring muscles and stretching.
was said that the complaints improved temporarily, but in December 2024, pain in both knees and both ankles reappeared, so the patient was referred to RSSA.
During the physical examination of the patientAos extremities, inspection revealed that the right and left knees appeared red.
On palpation examination, tenderness was found in both the right and left knees.
In the assessment of Range of Motion (ROM), it was found that both knees experienced limitations in both active and passive examinations.
In the Paediatric Gait.
Arms.
Legs, and Spine (PGALS) examination, the patient has limitations in several assessments, specifically in the Arm, including elbow flexion, shoulder abduction, and external rotation of the In addition to the arm, elbow limitations are also indicated by the patientAos inability to perform hip internal rotation and hip flexion.
The patient also has limitations in the movement of the temporomandibular joint.
Here are the attached results of the supporting examinations for this patient.
Figure 1.
Lumbosacral X-Ray .
/12/.
Within normal limits Figure 2.
X-Ray of the Right and Left Knee .
/12/.
showing soft tissue swelling with widened joint space and irregularity of the medial femoral joint surface.
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CASE REPORT
Table 1.
Laboratory result
24/12/2024
Laboratory Haemoglobin (HGB) .
/dL) Eritrosit (RBC) x10A Hematokrit (%) Leukosit x 10^3 Thrombosit .
cL) Neutrofil (%) Limfosit
LDH (U/L)
Ferritin .
g/m.
Figure 3.
Figure 4.
X-Ray Wrist Right and Left .
/01/.
Within normal limits USG Genu .
/01/2.
Synovitis with irregularity of the medial condyle cortex of the bilateral femur.
which consist of lumbosacral x-ray, rightleft knee x-ray, right-left wrist, as well as the complete laboratory results of the Figure 3 demonstrates anteroposterior radiographs of the right and left wrists, showing post-therapeutic changes.
Figure 4 presents ultrasonographic evaluation of the knee, illustrating the musculoskeletal soft tissue and joint structures following The laboratory findings in this patient are consistent with oligoarticular Juvenile Idiopathic Arthritis.
Complete blood count showed hemoglobin, leukocyte, and platelet levels within normal ranges, indicating the absence of significant anemia, infection, or systemic inflammation, which is typical in oligoarticular JIA compared to systemic The differential count revealed without marked neutrophilia, further Result Rheumatoid factor total (IU/m.
ANA test (AU/mL) 00 .
Phospor .
g/dL) Vitamin D 25-OH .
g/ 32,40 supporting a non-infectious inflammatory Normal ferritin and LDH levels help exclude macrophage activation syndrome and other hyperinflammatory Negative rheumatoid factor and antinuclear antibody results are also in accordance with oligoarticular JIA, which is commonly seronegative.
Overall, these laboratory findings are important in oligoarticular JIA as they help exclude infectious, malignant, and systemic inflammatory conditions, while supporting the diagnosis in conjunction with clinical presentation and imaging findings rather than serving as definitive diagnostic markers.
The weight of this patient is 13 kg.
The patient was given treatment in the form of Holiday-Segar fluid 1150 ml per day adjusted to the patientAos needs.
Administered IV Methylprednisolone 2x15 mg .
mg/kg/da.
IV neurotropic 1 ampule per day.
IV Ranitidine 2x15 mg .
mg/kg/da.
is also administered if the patient complains of pain and is fussy.
Oral methotrexate was initiated as a diseasemodifying antirheumatic drug (DMARD) and administered once weekly at a dose of 10Ae15 mg/mA.
Calcium carbonate 2x500 mg.
Vitamin C 1x100 mg, and also sodium phosphate 3x200 cc, along with a High Calorie High Protein diet 3 times A Published by Pediatrics Sciences Journal | Pediatrics Sciences Journal 2025.
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CASE REPORT
DISCUSSION
The patient in this case is a patient suffering from JIA.
Based on the International League of Associations for Rheumatology (ILAR) classification of subtypes of JIA, this patient is one with oligoarthritis, which is the most commonly encountered type according to reports worldwide.
2 Based on findings from 2020.
JIA is categorized as a chronic disease found in children under the age of 16, with the highest prevalence being in girls aged 1-3 years.
8 Here, we present a case of a boy who developed early symptoms at the age of 18 months, with symptom onset temporally associated with a history of patellar trauma.
JIA in the oligoarthritis type often affects the lower extremities, primarily the knee joint .
-50% of case.
, followed by complaints in the ankle.
9 JIA oligoarthritis in this patientAos condition is diagnosed based on anamnesis, physical examination, and additional examinations.
The onset found in this patient is under 16 years old and lasts longer than 6 weeks, thus meeting the ILAR criteria.
If a child is suspected of having JIA, then investigations related to a family history of autoimmune diseases and trauma history need to be further 10 In our case, the patient experienced swelling, redness, and limited ROM in both knee joints and fingers, indicating the oligoarticular subtype of JIA after ruling out other causes.
The correlation between the patientAos trauma history and the occurrence of autoimmune diseases is predicted to have a strong relationship and is supported by several Many studies shown that posttraumatic stress has a wide-ranging impact on immune function.
Other literature also supports the idea that stress plays a role in the initiation and exacerbation of autoimmune diseases.
11 Research conducted by Muhsen et al.
, showed that out of 3673 patients treated for RA, 60 of them were initiated by physical trauma.
Another study conducted by Al-Allaf et al.
, showed a significant relationship between a history of trauma 6 months before being diagnosed with RA and the common occurrence of sero-negativity in RA patients with a history of physical 13 The study aligns with the clinical condition of the patients in this research, which describes arthritis with seronegativity.
The clinical presentation of the patient, which includes knee joint pain and wrist pain, is also explained in this study as being caused by an inflammatory reaction involving key cytokines such as TNF.
IL-1, and IL-6, which promote inflammation in the synovium.
This inflammatory cascade also triggers leads to cartilage degradation and bone erosion mediated by osteoclast Observational data show that triggers causing tissue damage can induce and expose neoepitopes on connective tissue proteins, potentially leading to an autoimmune response that activates and stimulates arthritis.
A history of trauma from falling off a bicycle, as experienced by this patient needs to be excluded if the cause is a toddler fracture from the examination of definitive fracture signs until imaging is performed in the form of the right and left knees x-ray.
A history of trauma was carefully evaluated, as joint pain following injury may mimic inflammatory arthritis.
however, the persistence and progression of symptoms despite long-term conservative management, along with recurrent joint swelling and morning stiffness, were not consistent with trauma-related pathology.
In addition, we also need to exclude the possibility of the patient experiencing joint pain caused by Lyme Disease with a duration of weeks to months and caused by an infection due to Borrelia 14 However, the absence of epidemiological exposure, lack of systemic infectious symptoms, and the chronic progressive course made Lyme arthritis less likely.
Therefore, after excluding infectious and trauma-related causes, the clinical, laboratory, and imaging findings supported the diagnosis of oligoarticular Juvenile Idiopathic Arthritis.
In the initial diagnosis of JIA, a musculoskeletal assessment in children using pGALS is necessary.
In this patient, the patientAos gait showed limitations when asked to tiptoe or walk on their toes with heels raised.
Meanwhile, in the Arm, there are limitations in elbow flexion, shoulder abduction, and external rotation of the Legs also experience limitations in hip internal rotation and hip flexion.
Research shows that pGALS has a sensitivity of 97-100% and a specificity of 98-100% in detecting joint abnormalities in children with.
16 With pGALS, doctors can determine the severity of the disease and identify early joint involvement so that treatment can be initiated promptly to prevent long-term complications.
Then, pGALS can also be used for periodic evaluations by monitoring disease progression and response to therapy.
This is important for adjusting the treatment plan, including adjusting medication dosages and providing additional The temporomandibular joint (TMJ) in JIA is often overlooked in the initial evaluation, yet TMJ involvement in JIA has a significant impact on the childAos quality of Early detection of TMJ involvement in JIA can prevent more serious problems.
Delayed treatment of TMJ due to JIA can cause problems with the childAos facial Prolonged TMJ inflammation can disrupt normal jawbone growth, causing asymmetry and potentially leading to facial deformities such as retrognathism or malocclusion.
Additionally, limited movement in the TMJ affects the ability to chew and speak properly, which can impact overall quality of life and child Management of TMJ arthritis therapy in JIA requires a multidisciplinary approach, including rheumatology, dentistry, and 18 Controlling inflammation through pharmacological therapy, such as NSAIDs and DMARDs combined with physical therapy to improve range of motion, reduce stiffness, and the use of occlusal splints to reduce pressure on the TMJ can be effective.
Predicting relapses must identify potential triggers that can worsen the disease, such as infections, stress, or changes in physical activity levels.
Research shows that several biomarkers such as CRP and ESR correlate with the risk of relapse.
Additionally, symptoms that appear at a young age can increase the risk of recurrence.
20 By understanding the triggers and clinical predictors during routine evaluations, it will be possible to anticipate potential exacerbations and adjust treatment accordingly.
This case report has limitations, including the lack of long-term follow-up and its inability to establish causality between trauma and disease onset.
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CASE REPORT
CONCLUSION
REFERENCES