Septic arthritis in children

Irreversible neurological manifestations in undiagnosed disseminated gonococcal infection

Neisseria gonorrhoeae causes a common sexually transmitted infection with manifestations ranging from asymptomatic to urethritis and pelvic inflammatory disease to disseminated infections including septic arthritis. Serious complications may arise in unrecognised or inappropriately treated infections.We report a young, healthy woman who developed fever and joint pain and was diagnosed with an inflammatory arthritis. After starting immune suppressing treatments, she experienced right wrist drop and progressive muscle atrophy, joint contractures and sensory loss. Electrodiagnostic studies showed patchy, mixed neurogenic and myopathic features. Areas of muscle oedema on extremity MRI led to a right brachioradialis biopsy, which showed only nonspecific changes. Other testing, including lumbar puncture and MRI of the brain/spine was noncontributory. Additional history revealed unprotected intercourse with a new partner prior to symptom onset. Urine gonorrhoeae PCR was positive, and right shoulder arthrocentesis confirmed septic arthritis. After intravenous antibiotic treatment with ceftriaxone, she demonstrated slow, incomplete symptomatic improvement.

A Systematic Approach to Diagnosing Arthritis Based on Radiological Imaging

:

Radiology plays key roles in diagnosis of arthritis. We herein suggest an algorithmic approach to diagnosing arthritis. First, the number of joint involvements is reviewed. Monoarticular arthritis includes septic arthritis, pigmented villonodular synovitis, and synovial chondromatosis. Second, polyarticular arthritis can be categorized by its characteristics: erosive, productive and mixed. Erosive disease includes rheumatoid arthritis, hemophilia, and amyloidosis while productive disease includes osteoarthritis, and hemochromatosis. Third, mixed diseases are subcategorized by symmetricity. Ankylosing spondylitis and inflammatory bowel disease related arthritis affect joints symmetrically while psoriatic arthritis, reactive arthritis, and crystalline arthropathy are asymmetric. Adjacent soft tissue density, periostitis, and bone density are ancillary findings that can be used as additional differential diagnostic clues. The final step in identifying the type of arthritis is to check whether the location is a site frequently affected by one particular disease over another. This systematic approach would be helpful for radiologist to diagnose arthritis.

Clinical and epidemiological differences between septic arthritis of the knee and hip caused by oxacillin-sensitive and -resistant s. aureus

OBJECTIVE

To establish the risk factors for joint infection by oxacillin-resistant Staphylococcus aureus (MRSA) using clinical and epidemiological data.

METHODS

All septic arthritis cases of the knee and hip diagnosed and treated in our institution from 2006 to 2012 were evaluated retrospectively. Only patients with cultures identified as microbial agents were included in the study. The clinical and epidemiological characteristics of the patients were analyzed, seeking the differences between populations affected by MRSA and oxacillin-sensitive Staphylococcus aureus (MSSA).

RESULTS

S. aureus was isolated in thirty-five patients (46.0%) in our total sample, 25 in the knee and 10 in the hip. Of these 35 patients, 22 presented with MSSA and 13 presented with MRSA. Provenance from a health service-related environment, as described by the Centers for Disease Control and Prevention, was the only variable associated with oxacillin-resistant strains of this bacterium (p = 0.001).

CONCLUSION

Provenance from a health service-related environment was associated with a higher incidence of MRSA-related septic arthritis, suggesting that this agent should be considered in the initial choice of antibiotic treatment. Previous surgeries of the knee or affected limb and the absence of leukocytes might also be related to infection with this agent.

Epidemiology of septic arthritis of the knee at Hospital das Clínicas, Universidade de São Paulo

Background

Septic arthritis is an infrequent disease although very important due to the possibility of disastrous outcomes if treatment is not adequately established. Adequate information concerning the epidemiology of septic arthritis is still lacking due to the uncommon nature of the disease as well as the struggle to establish a correct case-definition.

Objective

To epidemiologically characterize the population seen at Hospital das Clínicas, University of São Paulo with a diagnosis of septic arthritis between 2006 and 2011.

Methods

Sixty-one patients diagnosed with septic arthritis of the knee between 2006 and 2011 were retrospectively evaluated. The patients’ clinical and epidemiological characteristics, the microorganisms that caused the infection and the patients’ treatment and evolution were analyzed.

Results

Septic arthritis of the knee was more common among men, with distribution across a variety of age ranges. Most diagnoses were made through positive synovial fluid cultures. The most prevalent clinical comorbidities were systemic arterial hypertension and diabetes mellitus, and the most commonly reported joint disease was osteoarthritis. Staphylococcus aureus was the prevailing pathogen. Fever was present in 36% of the cases. All patients presented elevation in inflammatory tests. Gram staining was positive in only 50.8% of the synovial fluid samples analyzed. Six patients presented complications and unfavorable evolution of their condition.

Conclusion

S. aureus is still the most common pathogen in acute knee infections in our environment. Gram staining, absence of fever and normal leukocyte count cannot be used to rule out septic arthritis.

Hip septic arthritis in children: assessment of treatment using needle aspiration/irrigation

INTRODUCTION

This retrospective series evaluated the surgical treatment of hip arthritis in children by needle aspiration-irrigation alone.

PATIENTS AND METHODS

Forty-three cases of septic hip arthritis were treated by needle aspiration-irrigation under general anesthesia associated with intravenous then oral administration of antibiotics. Clinical and biological criteria at admission, during hospitalization and at final follow-up were studied to identify any criteria carrying a predictive value for unsuccessful needle aspiration-irrigation.

RESULTS

Thirty-eight hips had a favorable outcome in this series, while secondary open arthrotomy was required in five hips for further irrigation. Common criteria found in the group requiring open arthrotomy were a diagnosis delay of at least 6 days between initial clinical symptoms and treatment as well as markedly abnormal biological results at admission. A threshold for the predictive value of certain variables was identified including C-reactive protein above 100, white polynuclear blood count above 15000, and sedimentation rate above 25 in the first hour and 50 in the second hour.

DISCUSSION

Treatment modalities for septic arthritis of the hip remain controversial in children and various techniques have been shown to be effective in the literature. Needle aspiration-drainage, the least invasive of these, has been shown to have good results, even in the hip, even though this is a deep, tight, joint which is known to be difficult to drain. Prognostic criteria are difficult to identify, however all authors agree that delayed treatment makes evacuation of intra-articular debris especially difficult.

CONCLUSION

Needle aspiration-irrigation is effective in septic arthritis of the hip, as long as basic principles are followed. Delayed treatment and certain biological criteria should be taken into account when selecting a treatment, since negative predictive criteria identified in this series were present in the five hips requiring secondary arthrotomy.

An unusual case of gonococcal arthritis of the finger

Gonococcal arthritis is the most common acute septic arthritis in sexually active young adults. It is caused by the gram-negative diplococcus Neisseria gonorrhoeae. In 0.5-3% an untreated mucosal infection disseminates throughout the system and affects mostly big joints like the knee, elbows, and ankles. N. gonorrhoeae is a fragile microorganism which is difficult to culture. Penicillin resistance has developed worldwide in recent years, therefore, patients should be treated by a third generation Cephalosporin. In this article, we describe the unexpected finding of septic arthritis in the proximal interphalangeal joint of a 50-year-old patient. The septic arthritis was caused by N. gonorrhoeae.

Prospective evaluation of a shortened regimen of treatment for acute osteomyelitis and septic arthritis in children

BACKGROUND

We present the findings of a prospective, bi-center study to establish the appropriate duration of antibiotic therapy for acute, uncomplicated bone and joint infections in children. Historically, patients have been treated with prolonged courses of intravenous and oral therapy. Our hypothesis was that children could be safely treated with 3 days of high-dose intravenous therapy followed by 3 weeks of oral therapy.

METHODS

We prospectively collected data from children presenting to Birmingham Children's Hospital and The Royal Children's Hospital, Melbourne who fitted our diagnostic criteria for septic arthritis and osteomyelitis over a 52-month period. Inclusion criteria for entry into the database were children <or=16 years of age who had no underlying disease or medical therapy predisposing to infection, and who had symptoms for less than 14 days before presentation. They were all started on intravenous antibiotics and a predetermined treatment algorithm was followed. All patients with septic arthritis also underwent joint washout. The patients were converted to oral antibiotics once they improved clinically and hematologically. Regular outpatient follow-up continued for 1 year with blood tests and x-rays.

RESULTS

Our database included 70 consecutive, eligible children aged 2 weeks to 14 years. Staphylococci were the only organisms isolated in cases of osteomyelitis, whereas Streptococcal infection was more prevalent in patients with septic arthritis. Using our treatment protocol, we found that 59% of children could be converted to oral therapy after 3 days of intravenous therapy and 86% after 5 days. The median duration of inpatient stay was 5 days. We established that 3 weeks of oral therapy was appropriate for those patients who received 5 days or less intravenous treatment. We have identified temperature and C-reactive protein as the best quantitative means of monitoring response to therapy. All patients were clinically, hematologically, and radiologically normal before discharge 1 year post-presentation.

CONCLUSIONS

We have found that a shortened course of intravenous and oral antibiotic therapy is effective in the management of acute uncomplicated bone and joint sepsis in children.

Is musculoskeletal history and examination so different in paediatrics?

Musculoskeletal (MSK) complaints in children and adolescents are common. The differential diagnosis is broad and based predominantly on clinical assessment. The skills both for eliciting history and for examination require understanding of the child/young person's specific emotional and cognitive developmental stage; interpretation of the findings requires knowledge of normal (and abnormal) motor and musculoskeletal growth and development. We specifically describe the different approach, unique skills and knowledge required by all clinicians who assess children and adolescents with MSK complaints; children and adolescents are not 'just little adults'. We emphasize the importance of clinical competence in ensuring that patients with juvenile idiopathic arthritis are diagnosed early and referral to specialist centres is not delayed with consequential suboptimal management and outcome. There is evidence that physician clinical skills in MSK assessment are inadequate, probably as a result of systemic deficiencies in the education process. Current and proposed solutions are discussed.

Septic arthritis in a patient with juvenile rheumatoid arthritis

The acute flare of joint inflammation in the child with known juvenile rheumatoid arthritis causes concern primarily regarding the need for additional or modified medical treatment. Acute joint inflammation in an otherwise healthy child creates concern regarding the existence of joint infection. In the early phase of disease, the clinical findings and symptoms of an inflamed joint attributable to juvenile rheumatoid arthritis or infection may be similar and difficult to differentiate from the other. Juvenile rheumatoid arthritis usually is well controlled by medical interventions, however, the initiation of specific treatment is more urgent in children with joint sepsis. The following case report is presented to emphasize the difficulty in evaluation of patients with known juvenile rheumatoid arthritis and coexistent septic arthritis, and to discuss the methods used to differentiate between the two conditions.

Treatment of postoperative anterior cruciate ligament infections with graft removal and early reimplantation

BACKGROUND

Septic arthritis after arthroscopic anterior cruciate ligament reconstruction is rare, and the most appropriate treatment is unclear. Current recommendations are that, if the graft is removed, reimplantation should be delayed for 6 to 9 months.

HYPOTHESIS

Early removal of the graft with appropriate infection management followed by early reimplantation can lead to good results.

STUDY DESIGN

Uncontrolled retrospective review.

METHODS

Records of all patients who developed postoperative infection after anterior cruciate ligament reconstruction were reviewed. Four patients had early graft removal and appropriate infection management including 6 weeks of intravenous antibiotics followed by anterior cruciate ligament graft reimplantation within 6 weeks of completion of antibiotic therapy.

RESULTS

Follow-up at an average of 21 months (range, 14 to 31) showed that the patients treated with early reimplantation had full symmetric knee range of motion and no effusion. The average modified Lysholm score was 92.5. Radiographs demonstrated no joint-space narrowing or osteophyte formation. The 30-pound KT-1000 arthrometer side-to-side difference averaged 3 mm.

CONCLUSION

Graft removal after confirmed anterior cruciate ligament graft infection and intravenous antibiotic administration followed by early graft reimplantation can give excellent results.

A swollen joint: why all the fuss?

Acute arthritis may be a potential medical emergency. An infected joint causes rapid cartilaginous destruction and risk of future osteoarthritis. Prompt attention to the historical clues and potential causative organisms ensures appropriate therapy. Numerous microbes have been identified as the causative agent in septic arthritis, and various populations have distinct susceptibilities to these specific organisms. One broad classification of septic arthritis is differentiating gonococcal and nongonococcal organisms. This classification is important, as not only do the organisms differ, but the age of the patient and the portal of entry also differ. Aspiration of synovial fluid is paramount for proper diagnosis and management of septic arthritis. In addition, the timely administration of properly chosen antibiotic agents is essential for reducing morbidity and mortality.

Imaging of musculoskeletal infections

Imaging studies play a critical role in the diagnosis and management of musculoskeletal infections in children. Conventional radiography is usually the first imaging study performed with other imaging modalities as needed. Ultrasound is helpful in detecting joint effusions and fluid collections in the soft tissue and subperiosteal regions, and may guide localization for aspiration or drainage. CT can demonstrate osseous and soft tissue abnormalities and is ideal for detecting gas in soft tissues. Nuclear scintigraphy and MR imaging are valuable because of their high sensitivity. Scintigraphy is particularly useful in identifying multifocal involvement, which is an important consideration in neonatal osteomyelitis and CRMO. MR imaging provides accurate information on both the soft tissues and bones and is our imaging study of choice for evaluating the local extent of musculoskeletal infections.