Pediatric Rheumatology Referral Guidelines

Proper diagnosis and early aggressive intervention of rheumatic diseases 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.

Our physicians are skilled in diagnosis, treatment and long-term monitoring of therapeutic effectiveness and coordination of care for children with rheumatic diseases.

Valley Children’s experienced pediatric rheumatology team treats one of the largest populations with periodic fever syndromes in the country. We offer a multidisciplinary approach to patient care and
collaborate closely with Nephrology, Orthopaedic Surgery, and Physical and Occupational Therapy.

Refer to Rheumatology

Refer to the Rheumatology Department at Valley Children's online through CareLink or our referral portal, or refer via fax.

Refer a patient

Rheumatology Office Numbers

Contact Pediatric Rheumatology via phone (559-353-6450) or fax (559-353-7214).

Contact a Physician Liaison

Physicians can reach a physician liaison for help with referrals or other questions by calling 559-353-7229.

*Laboratory workup should be as complete as possible in local labs, otherwise, send results of what is available.

Call Rheumatologist to discuss any ill patients for possible referral or clinical uncertainty.

Download these rheumatology referral guidelines as a PDF

Condition	Pre-Referral Work-up	When to Refer
Dermatomyositis / Muscle Weakness	Skin rashes (eyelids, knuckles, knees, elbows) Photosensitivity Weakness (proximal muscles), swallowing difficulties, fatigue Nail folds Erythema Calcium nodules Suggested labs: CBC with diff, CK, LDH, Aldolase, AST, ALT, ESR, CRP	Abnormal labs Muscle weakness (severe weakness or abdomina pain can be a medical emergency) Swallowing problems
Fever of Unknown Origin	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 with diff, ANA, ESR, CRP, AST, LDH, blood cultures Suggested workup: TB skin test, stool for occult blood	Persistent fevers over 2 weeks with no identifiable source Mouth sores Swollen joints Abnormal labs (e.g., high ESR)
Possible SLE Evidence of multisystem disease may present as arthritis, chronic ITP, hemolytic anemia, or renal disease	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 with Diff, CMP, ESR, CRP, ANA, ENA (Smith / RNP), AntidsDNA, C3, C4, UA, urine protein/creatine ratio	Strongly positive ANA and other abnormal labs Low ANA (1:40, 1:80) with absence of clinical or other lab findings is unlikely to be SLE (Of note: ANA 1:40 is negative)
Raynaud’s	Triphasic color change (white, purple, red) in response to cold or stress. Primary more common in adolescent females Evidence of other organ involvement (secondary) Digital ulcers Nail fold vessel changes Labs: CBC, Diff, Plts, ANA, Antiphospholipid antibodies, UA	Severe symptoms or frequent episodes, digital ulcerations, signs of other autoimmune disease Abnormal labs
Scleroderma Syndromes	Multisystem disease in generalized form (e.g., dysphagia, dyspnea, renal involvement) Skin changes (thickening, tightening)	Suspected scleroderma of any type Skin tightening
Swollen Joint, Painful Joints (Juvenile Arthritis)	Call Rheumatologist if concern about systemic arthritis, unexplained fevers, prolonged fevers, morning stiffness, rash, decreased appetite, low energy and activity level, response to NSAIDS Family history of Ankylosing Spondylitis, Psoriasis or IBD Swollen joints, tenderness and decreased range of motion Suggested labs: CBC, diff, Plts, ANA, ESR, RF, CRP, UA, ASO, DNAse B	Swollen joints, stiffness in the morning for longer than 6 weeks Contractures Refusal to ambulate Missing school due to stiffness or pain
Vasculitis Multisystem Involvement	History of rashes (nonblanching purpura), ulcerations, abdominal pain, chronic epistaxis, hemoptysis, chronic sinusitis, hematuria, arthritis, stroke, seizure Hypertension Nasal ulcers Suggested labs: CBC, ESR, CRP, UA, Creat, ANCA	Complicated HSP or prolonged Suspected vasculitis: Wegener’s, Takayasu’s, Polyarteritis Abnormal abdominal, lung, CNS or joint exam

Condition

Pre-Referral Work-up

When to Refer

Dermatomyositis / Muscle Weakness

Skin rashes (eyelids, knuckles, knees, elbows)

Photosensitivity

Weakness (proximal muscles), swallowing difficulties, fatigue

Nail folds

Erythema

Calcium nodules

Suggested labs: CBC with diff, CK, LDH, Aldolase, AST, ALT, ESR, CRP

Abnormal labs

Muscle weakness (severe weakness or abdomina pain can be a medical emergency)

Swallowing problems

Fever of Unknown Origin

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 with diff, ANA, ESR, CRP, AST, LDH, blood cultures

Suggested workup: TB skin test, stool for occult blood

Persistent fevers over 2 weeks with no identifiable source

Mouth sores

Swollen joints

Abnormal labs (e.g., high ESR)

Possible SLE

Evidence of multisystem disease may present as arthritis, chronic ITP, hemolytic anemia, or renal disease

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 with Diff, CMP, ESR, CRP, ANA, ENA (Smith / RNP), AntidsDNA, C3, C4, UA, urine protein/creatine ratio

Strongly positive ANA and other abnormal labs

Low ANA (1:40, 1:80) with absence of clinical or other lab findings is unlikely to be SLE

(Of note: ANA 1:40 is negative)

Raynaud’s

Triphasic color change (white, purple, red) in response to cold or stress.

Primary more common in adolescent females

Evidence of other organ involvement (secondary)

Digital ulcers

Nail fold vessel changes

Labs: CBC, Diff, Plts, ANA, Antiphospholipid antibodies, UA

Severe symptoms or frequent episodes, digital ulcerations, signs of other autoimmune disease

Abnormal labs

Scleroderma Syndromes

Multisystem disease in generalized form (e.g., dysphagia, dyspnea, renal
involvement)

Skin changes (thickening, tightening)

Suspected scleroderma of any type

Skin tightening

Swollen Joint, Painful Joints (Juvenile Arthritis)

Call Rheumatologist if concern about systemic arthritis, unexplained fevers, prolonged fevers, morning stiffness, rash, decreased appetite, low
energy and activity level, response to NSAIDS

Family history of Ankylosing Spondylitis, Psoriasis or IBD

Swollen joints, tenderness and decreased range of motion

Suggested labs: CBC, diff, Plts, ANA, ESR, RF, CRP, UA, ASO, DNAse B

Swollen joints, stiffness in the morning for longer than 6 weeks

Contractures

Refusal to ambulate

Missing school due to stiffness or pain

Vasculitis
Multisystem Involvement

History of rashes (nonblanching purpura), ulcerations, abdominal pain, chronic epistaxis, hemoptysis, chronic sinusitis, hematuria, arthritis, stroke, seizure

Hypertension

Nasal ulcers

Suggested labs: CBC, ESR, CRP, UA, Creat, ANCA

Complicated HSP or prolonged

Suspected vasculitis: Wegener’s, Takayasu’s,
Polyarteritis

Abnormal abdominal, lung, CNS or joint exam