When a patient suspected with juvenile idiopathic arthritis turns out to be diagnosed with an infectious disease - a review of Lyme arthritis in children

Case 326: Intra-Articular Osteoid Osteoma

HISTORY

A 15-year-old male patient presented with a 3-week history of inner left thigh pain provoked by activity and experienced occasionally at rest. The patient denied nighttime pain, fever, or chills. Laboratory investigation revealed the following normal values: hemoglobin level of 15.6 g/dL (normal range, 13-16 g/dL), platelet count of 240 × 103/µL (normal range, 140-440 × 103/µL), and total leukocyte count of 7100 cells/µL (normal range, 4500-11 000 cells/µL). The percentage of neutrophils was considered low at 44% (normal range, 54%-62%), and the percentage of eosinophils was slightly high at 3.7% (normal range, 0%-3%). An anteroposterior radiograph of the left hip is shown. Physical therapy was initiated, with no improvement after 2 weeks of therapy. The patient was referred to an orthopedist for further evaluation. At physical examination, the patient endorsed marked left hip pain with hip flexion to 90°, limited internal and external rotation (5° and 15°, respectively), and antalgic gait favoring the left leg. Hip MRI and further serologic analysis were requested for further evaluation. Although the serologic testing was performed at an outside laboratory, the physician reported positive immunoglobulin-G Lyme titers, normal C-reactive protein level, and normal erythrocyte sedimentation rate. Pelvic CT was requested. The patient was prescribed a course of doxycycline (100 mg twice daily for 28 days), with reported resolution of symptoms 2 weeks after initiation of treatment. Three weeks later, the patient presented to our department with recurrent left hip pain, which was similar in severity compared with the initial presentation. A second MRI examination of the left hip was performed 4 months after the initial presentation.

Chronic limping in childhood, what else other than juvenile idiopathic arthritis: a case series

BACKGROUND

Limping is a common clinical symptom in childhood; different clinical conditions may lead to limping and the diagnosis of the underlying cause may often be a challenge for the pediatrician.

CASE PRESENTATION

We describe the clinical manifestations, radiological pictures and disease course of other causes of limping in childhood, through a case series of seven cases and a brief discussion of each disease.

CONCLUSIONS

although trauma is the most common cause of acute limping, when there is no history of traumatic events and the limping has a chronic course, Juvenile Idiopathic Arthritis is usually the most likely clinical diagnosis. However, other some rare conditions should be taken into account if JIA is not confirmed or if it presents with atypical clinical picture.

Bilateral Knee Lyme Arthritis in Children: A Report of 3 Cases

CASES

Three patients presented with bilateral knee pain, effusion, decreased range of motion, and difficulty ambulating. Synovial analysis demonstrated leukocytosis in bilateral knees with positive serum enzyme-linked immunosorbent assay. All cases were managed with antibiotics and anti-inflammatories. One patient developed chronic Lyme arthritis and underwent arthroscopic synovectomy.

CONCLUSION

Bilateral knee arthritis is a possible presentation of Lyme disease in children. Accurate diagnosis and treatment with antibiotics and anti-inflammatories can lead to satisfactory outcomes. Arthroscopic synovectomy may be indicated if conservative treatment fails.

The Impact of Operative Intervention in Pediatric Lyme Arthritis

BACKGROUND

Lyme arthritis often presents as acute monoarticular arthritis challenging to distinguish from septic arthritis. Typical management for Lyme arthritis entails antibiotic therapy, while septic arthritis usually warrants operative debridement. During the period when Western Pennsylvania transitioned to a Lyme-endemic region, many children underwent operative intervention who were ultimately diagnosed with Lyme arthritis due to diagnostic ambiguity. We examined the impact of the operative intervention on pediatric Lyme arthritis outcomes.

METHODS

We conducted a retrospective cohort study of patients admitted to a tertiary care children's hospital who were diagnosed with Lyme arthritis from 2008 to 2018 using chart review. Inclusion criteria were positive Lyme serology by Centers for Disease Control and Prevention (CDC) definition, clinical arthritis, and negative bacterial cultures. We recorded clinical presentation, laboratory data, details of hospitalization, costs, and outcomes after therapy to compare the impact of antibiotics alone (nonoperative group) versus antibiotics plus operative debridement (operative group).

RESULTS

A total of 149 patients met the inclusion criteria. Overall, 47 (32%) patients underwent orthopaedic intervention. Operative management was associated with increased length (3.17 vs. 1.40 d) and cost ($27,850 vs. $10,716) of admission. The clinical resolution was documented in 57/58 patients (98%) in the nonoperative group and 41/42 patients (98%) in the operative group. The median duration to resolution was 21 days for both groups.

CONCLUSIONS

Operative management of pediatric patients with Lyme arthritis is associated with increased resource utilization and costs while being similarly efficacious to nonoperative management. As the US Lyme epidemic expands, improved diagnosis and management of acute undifferentiated arthritis may prevent unneeded operative intervention.

LEVEL OF EVIDENCE

Level III-retrospective cohort study.

The effect of Qianliekang tablets on the clinical efficacy, immune function, and inflammatory factor levels in the prostatic fluid of elderly chronic prostatitis patients

PURPOSE

To study the effect of Qianliekang tablets on the clinical efficacy, immune function, and inflammatory factor levels in the prostatic fluid of elderly chronic prostatitis (CP) patients.

METHODS

106 elderly CP patients admitted to our hospital between June 2018 and June 2020 were recruited as the study cohort and randomly divided into a regular group and an observation group. The regular group was administered tamsulosin hydrochloride, and the observation group was administered a combination of tamsulosin hydrochloride and Qianliekang tablets. After a course of treatment, the clinical efficacy, the changes in the patients' symptoms, the function scores, the prostate ultrasound indicators, the changes in the T lymphocyte subsets, and the inflammatory factor expression levels in the prostatic fluid before and after the treatment were measured and compared in the two groups. The occurrence of adverse effects during the treatment was statistically analyzed.

RESULTS

The overall effectiveness rate in the observation group was superior to the overall effectiveness rate in the regular group (94.34% vs. 75.47%, P < 0.05). There were no significant differences in the patient clinical data before the treatment in the two groups (P > 0.05). After the treatment, the CD₄ ⁺/CD₈ ⁺ immune function indicators, the prostatic fluid inflammatory factor levels, the symptom function scores, and the prostate ultrasound indicators in the observation group were better than they were in the regular group (all P < 0.05). No significant differences were found in the incidence of adverse effects between the two groups (P > 0.05).

CONCLUSION

Qianliekang tablets can improve the curative effect in elderly CP patients, enhance their immune function, and reduce the inflammatory factor expression levels in their prostatic fluid.

Lyme Arthritis in Children on the Uptick in Western New York Area

Objective:

This study explores a suspected increasing incidence of Lyme arthritis in the Western New York pediatric population. In addition, we aim to describe a clinical picture of Lyme arthritis and the clinical features that distinguish it from other forms of arthritis.

Methods:

Patients diagnosed with Lyme arthritis between January 2014 and September 2018 were identified using International Classification of Diseases—10th Revision (ICD 10) codes for Lyme disease and Lyme arthritis. Patients were included in the study if they (1) exhibited arthritis, (2) tested positive for Lyme antibodies, and (3) exhibited a positive Western blot.

Results:

A total of 22 patients were included in the study. There was a general trend toward an increasing number of cases of Lyme arthritis over the 45-month observation period. We identified 1 case in each 2014 and 2015, 4 cases in 2016, 7 in 2017, and 9 in the first 9 months of 2018. In total, 17 patients had arthritis as their only symptom at the time of diagnosis and 10 patients had a rash or a history that prompted suspicion of Lyme disease. The knee was the most frequent joint (86.4% of patients), and patients typically had 2 or fewer joints affected (86.4% of patients).

Conclusions:

A significant increase (P = .02) in Lyme arthritis cases was observed at Oishei Children’s Hospital of Buffalo. Lyme arthritis may clinically present similarly to other forms of arthritis, such as oligoarticular juvenile idiopathic arthritis, so health care providers should be aware of distinguishing clinical features, which include rapid onset of swelling and patient age. Because the geographic area of endemic Lyme disease is expanding, all health care providers need to be aware of Lyme arthritis as a possible diagnosis.