[Neonatal infections of the bones and joints]

Osteomyelitis and Thrombosis in a Newborn with Group A Streptococcus Infection

Neonatal osteomyelitis (OM), although exceptionally rare, has been linked to detrimental sequel, as diagnosis in the early stages is challenging and any delay in treatment can lead to disturbance in skeletal growth. In pediatric OM the most commonly grown bacteria is Staphylococcus aureus followed by group A Streptococcus (GAS). Notwithstanding, sepsis-induced coagulopathy is a well-known entity in children and adults, still sepsis-associated thrombosis is sparsely observed. we present a case of a newborn with GAS associated OM and thrombosis. A term neonate on the 11th day of life was referred to our NICU due to right (R) lower limb edema, cyanosis and core temperature up to 39 °C. Late onset sepsis was suspected and started on vancomycin and amikacin. A colour Doppler scan showed thrombosis of the R common femoral vein. The neonate started on iv unfractionated heparin. Ampicillin was added given positive for GAS blood culture. An MRI on the 5th day of admission, showed evidence of thrombosis resolution. On the 14th day of admission, a bone Tc99 scan showed evidence of OM of R femur. Antibiotic treatment switched to amoxicillin per os. The management was restricted to anticoagulant therapy with low molecular weight heparin for 3 months and antibiotic therapy for 6 months without surgery intervention and the patient recovered and discharged at 42 days of age. Early diagnosis and treatment of neonatal osteomyelitis can prevent bone destruction. Sepsis-associated thrombosis is barely observed during osteomyelitis, yet it should be considered as an emerged case requiring prompt treatment.

Pseudo paralysis of the shoulder and increased C-reactive protein are predictive factors for septic shoulder in children superior to other clinical symptoms: a retrospective case series of 25 patients

PURPOSE

The aim of the study was to evaluate predictable parameters with the highest sensitivity used in the diagnosis of children septic shoulder arthritis.

METHODS

All children treated in our paediatric orthopaedic hospital between 2000 and 2017 with intraoperative verified septic arthritis of the shoulder were included in this retrospective study. Diagnostic procedures e.g. ultrasound, MRI, radiograph or blood samples as well as typical clinical symptoms were evaluated as predictable parameters for septic shoulder arthritis in paediatric patients. Descriptive statistics as well as sensitivity analysis were performed.

RESULTS

In all, 25 children, 20 boys and five girls, aged from eight days to 15 years, were included for further statistical analysis. All parameters included were tested for sensitivity with binomial confidence intervals (Cis) of 95%. Predictive parameters with highest sensitivity were pseudo paralysis (100%, CI 0.86 to 1.00) and C-reactive protein (CRP) (96%, CI 0.79 to 0.99) superior to temperature (52%, CI 0.3 to 0.73), white blood count (11%, CI 0.01 to 0.34), radiograph (21%, CI 0.04 to 0.50), ultrasound (71%, CI 0.47 to 0.88) or MRI (100%, CI 0.78 to 1.00).

CONCLUSION

The diagnosis of a septic arthritis of the shoulder in children can be challenging for the clinician and especially for the resident doctor. Clinical symptoms such as pseudo paralysis and increased CRP level must be considered as predictive markers not to delay further diagnostics and treatment.

LEVEL OF EVIDENCE

IV.