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This patient had good control of his symptoms for 1 year but now has a prolonged flare, probably denoting worsen-ing disease (not just a temporary flare). In addition to physical findings and measurement of acute-phase reac-tants such as sedimentation rate or C-reactive protein, it would be wise to get hand and feet radiographs to docu-ment whether he has developed joint damage. Assuming such damage is found, the appropriate approach would be either a combination of nonbiologic DMARDs (eg, adding sulfasalazine and hydroxychloroquine) or adding a biologic medication, usually a TNF inhibitor. Follow-up should be every 1–3 months to gauge response and toxicity. Adverse events requiring caution are an increased risk of infection, possible appearance of lymphoma and rare liver function test or hematologic abnormalities. Importantly, close follow-up should ensue, including changing medications every 3–6 months until full disease control is achieved.
Roger K. Long, MD, & Hakan Cakmak, MD
A 4-year-old boy (height 90 cm, –3 standard deviations [SD]; weight 14.5 kg, approximately 15th percentile) presents with short stature. Review of the past history and growth chart demonstrates normal birth weight and birth length, but a progressive decrease in height per-centiles relative to age-matched normal ranges starting at 6 months of age, and orthostasis with febrile illnesses. Physical examination demonstrates short stature and mild generalized obesity. Genital examination reveals descended but small testes and a phallic length of –2 SD. Laboratory evaluations demonstrate growth hormone (GH) deficiency and a delayed bone age of 18 months. The patient is started on replacement with recombinant human GH at a dose of 40 mcg/kg per day subcutaneously. After 1 year of treatment, his height velocity has increased from 5 cm/y to 11 cm/y. How does GH stimulate growth in children? What other hormone deficiencies are sug-gested by the patient’s history and physical examination? What other hormone replacements is this patient likely to require?