Rheumatology - Referral Guidelines

Caring for children with rheumatic and inflammatory diseases, our physicians are skilled in diagnosis, treatment, and longterm monitoring of therapeutic effectiveness and coordination of care. With three full-time pediatric rheumatologists, our team treats 1,500 outpatient visitors and 200 inpatients each year. We offer a multidisciplinary approach to patient care and collaborate closely with Nephrology, Orthopedic Surgery, Ophthalmology, Pain Medicine, and Physical and Occupational Therapy.

Rheumatic diseases are an important cause of disability in childhood. Proper diagnosis and early aggressive intervention can minimize both short and long term morbidity of these conditions. The goals of treatment of childhood rheumatologic diseases are to control disease activity, preserve normal physical, social and emotional growth and development, minimize chronic disability and deformity, and achieve remission of disease.

When to refer a patient to Rheumatology:

  • Dermatomyositis /Muscle Weakness:
    • Pre-Referral Workup:
      • Skin rashes (eyelids, knuckles, knees, elbows)
      • Photosensitivity
      • Weakness (proximal muscles)
      • Swallowing difficulties
      • Fatigue
      • Nail fold erythema
      • Calcium nodules
      • Suggested labs: CBC w/diff, CMP, CK, LDH, Aldolase,
      • ESR, CRP, ANA w/titer, TB skin test
    • When to Refer:
      • Abnormal labs
      • Muscle weakness (severe weakness or abdominal pain can be a medical emergency)
      • Swallowing problems
  • Fever of Unknown Origin /Periodic Fever Syndromes:
    • Pre-Referral Workup:
      • Fever pattern and duration
      • Associated symptoms (e.g., rashes, weight loss)
      • Diary or calendar of fevers episodes
      • Ethnicity and family history
      • Infections ruled out
      • Clear sinuses and chest X-rays
      • Labs: CBC w/diff, ANA w/titer, ESR, CRP, AST, LDH,
      • Blood cultures, TB skin test, stool for occult blood
    • When to Refer:
      • Persistent fevers over 2 weeks with source
      • Mouth sores
      • Swollen joints
      • Abnormal labs (e.g., high ESR)
  • Generalized Arthralgia:
    • Pre-Referral Workup:
      • Check for presence of: joint swelling, hypermobility, flat feet, sleep disorder, mood disorder
    • When to Refer:
      • If patient has persistent joint swelling, persistent limp or joint contracture, not attributable to an orthopaedic problem
      • If there is a specific source of pain, i.e. arthritis or myositis or there is lab evidence of inflammation (elevated ESR), refer to Pain Medicine and/or PT for Fibromyalgia
  • Possible SLE Evidence of multisystem disease – may present as arthritis, chronic ITP, hemolytic anemia, or renal disease:
    • Pre-Referral Workup:
      • Rashes (malar, discoid), photosensitivity, hair loss, fatigue, fevers, Raynaud’s, mouth ulcers, swollen, joints, bruising, bleeding, edema
      • Family history of autoimmune disease
      • Suggested labs: CBC w/diff, ESR, CRP, CMP, ANA w/titer, ENA, Anti-dsDNA, C3, C4, UA, TB skin test
    • When to Refer:
      • Strongly positive ANA and other abnormal labs
      • Low ANA with absence of clinical or other lab findings is unlikely to be SLE
  • Raynaud’s:
    • Pre-Referral Workup:
      • Triphasic color change (white, purple, and red) in response to cold or stress
      • Primary more common in adolescent females
      • Evidence of other organ involvement (secondary)
      • Digital ulcers
      • Labs: CBC w/diff, CMP, ESR, ANA w/titer, UA
    • When to Refer:
      • Severe symptoms or frequent episodes
      • Digital ulcerations
      • Signs of other autoimmune disease
      • Abnormal labs
  • Scleroderma Syndromes:
    • Pre-Referral Workup:
      • Skin changes (thickening, tightening, sclerodactyly)
      • Multisystem disease in generalized form (e.g.,esophageal dysmotility, calcinosis, pulmonaryhypertension, renal involvement)
      • Labs: CBC w/diff, CMP, ESR, ANA w/titer, UA, TB, skin test, chest x-ray
    • When to Refer:
      • Suspected scleroderma of any type
      • Skin tightening

Read further guidelines on referring to Rheumatology.

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