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Donovan A, Quilty R, Joy BK, Seddigh S, Coatsworth H, Gauthier L, Comeau JL, Lang B, Leblanc J, Hatchette T, Stringer E. Retrospective validation of a rapid Lyme fluorescent immunoassay in differentiating Lyme arthritis from other musculoskeletal presentations in children in a Lyme-endemic region. Microbiol Spectr 2024; 12:e0359323. [PMID: 38682930 PMCID: PMC11237436 DOI: 10.1128/spectrum.03593-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 03/12/2024] [Indexed: 05/01/2024] Open
Abstract
Lyme arthritis can present similarly to other causes of joint pain and swelling including septic arthritis and other acute and chronic arthropathies of childhood. Septic arthritis, although rare, constitutes an orthopedic emergency and requires early surgical intervention to reduce the risk of permanent joint damage. Currently, results of standard serologic tests to diagnose Lyme disease take days to weeks, which is unhelpful in acute clinical decision-making. Thus, some children with Lyme arthritis are treated empirically for septic arthritis undergoing unnecessary invasive procedures and hospital admission while on inappropriate antibiotic therapy. We retrospectively validated the Quidel Sofia Lyme Fluorescent Immunoassay, a rapid serologic assay that can detect IgG and/or IgM antibodies to Borrelia burgdorferi in 10 minutes, in residual serum samples collected from 51 children who had Lyme arthritis and 55 children with musculoskeletal presentations who were Lyme negative. The sensitivity and specificity of the Sofia IgG to identify cases of Lyme arthritis in children were 100% (95% confidence interval [CI] of 93.0%-100%) and 96.4% (95% CI: 87.5%-99.6%), respectively. The positive likelihood ratio (LR) was 27.5 (95% CI 7-107), and the negative LR was 0.00 (95% LR 0.00-0.15). We propose that the Sofia IgG, a rapid method for identifying Lyme arthritis, may be useful in differentiating Lyme arthritis from other forms of arthritis. Used in conjunction with readily available clinical and laboratory variables, it could help to rapidly identify children who are at low risk of septic arthritis in Lyme-endemic regions. IMPORTANCE Lyme arthritis is a common manifestation of Lyme disease in children, with clinical features overlapping with other causes of acute and chronic joint pain/swelling in children. We have demonstrated that the Sofia IgG is a reliable test to rule in and rule out the diagnosis of Lyme arthritis in children with musculoskeletal presentations in a Lyme-endemic region. When used in conjunction with clinical and laboratory variables routinely considered when differentiating Lyme arthritis from other diagnoses, the Sofia IgG has the potential to fill an important gap in care, especially when acute decision-making is necessary. The Sofia IgG should be included in prospective research studies examining clinical prediction tools to identify children at low risk of septic arthritis.
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Affiliation(s)
| | - Rebecca Quilty
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Bryn K. Joy
- Dalhousie University, Halifax, Nova Scotia, Canada
| | - Shahriar Seddigh
- Division of Orthopedic Surgery, Nova Scotia Health, Halifax, Canada
| | - Heather Coatsworth
- National Microbiology Laboratory Branch, Public Health Agency of Canada, Winnipeg, Manitoba, Canada
| | - Luke Gauthier
- Division of Orthopedic Surgery, IWK Health, Halifax, Nova Scotia, Canada
| | - Jeannette L. Comeau
- Division of Pediatric Infectious Diseases, IWK Health, Halifax, Nova Scotia, Canada
| | - Bianca Lang
- Division of Pediatric Rheumatology, IWK Health, Halifax, Nova Scotia, Canada
| | - Jason Leblanc
- Department of Pathology and Laboratory Medicine, Nova Scotia Health, Halifax, Canada
| | - Todd Hatchette
- Department of Pathology and Laboratory Medicine, Nova Scotia Health, Halifax, Canada
| | - Elizabeth Stringer
- Division of Pediatric Rheumatology, IWK Health, Halifax, Nova Scotia, Canada
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Woods CR, Bradley JS, Chatterjee A, Kronman MP, Arnold SR, Robinson J, Copley LA, Arrieta AC, Fowler SL, Harrison C, Eppes SC, Creech CB, Stadler LP, Shah SS, Mazur LJ, Carrillo-Marquez MA, Allen CH, Lavergne V. Clinical Practice Guideline by the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA): 2023 Guideline on Diagnosis and Management of Acute Bacterial Arthritis in Pediatrics. J Pediatric Infect Dis Soc 2024; 13:1-59. [PMID: 37941444 DOI: 10.1093/jpids/piad089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/27/2023] [Indexed: 11/10/2023]
Abstract
This clinical practice guideline for the diagnosis and treatment of acute bacterial arthritis (ABA) in children was developed by a multidisciplinary panel representing the Pediatric Infectious Diseases Society (PIDS) and the Infectious Diseases Society of America (IDSA). This guideline is intended for use by healthcare professionals who care for children with ABA, including specialists in pediatric infectious diseases and orthopedics. The panel's recommendations for the diagnosis and treatment of ABA are based upon evidence derived from topic-specific systematic literature reviews. Summarized below are the recommendations for the diagnosis and treatment of ABA in children. The panel followed a systematic process used in the development of other IDSA and PIDS clinical practice guidelines, which included a standardized methodology for rating the certainty of the evidence and strength of recommendation using the GRADE approach (Grading of Recommendations Assessment, Development and Evaluation) (see Figure 1). A detailed description of background, methods, evidence summary and rationale that support each recommendation, and knowledge gaps can be found online in the full text.
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Affiliation(s)
- Charles R Woods
- Department of Pediatrics, University of Tennessee Health Sciences Center College of Medicine Chattanooga, Chattanooga, Tennessee
| | - John S Bradley
- Division of Infectious Diseases, Department of Pediatrics, University of California San Diego, School of Medicine, and Rady Children's Hospital, San Diego, California
| | - Archana Chatterjee
- Chicago Medical School, Rosalind Franklin University of Medicine and Science, North Chicago, Illinois
| | - Matthew P Kronman
- Division of Pediatric Infectious Diseases, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Sandra R Arnold
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Joan Robinson
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Lawson A Copley
- Departments of Orthopaedic Surgery and Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Antonio C Arrieta
- Division of Infectious Diseases, Children's Hospital of Orange County and University of California, Irvine, California
| | - Sandra L Fowler
- Division of Infectious Diseases, Department of Pediatrics, Medical University of South Carolina, Charleston, South Carolina, USA
| | | | | | - C Buddy Creech
- Division of Pediatric Infectious Diseases, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Laura P Stadler
- Department of Pediatrics, Division of Infectious Diseases, University of Kentucky, Lexington, Kentucky
| | - Samir S Shah
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Lynnette J Mazur
- Department of Pediatrics, University of Texas McGovern Medical School, Houston, Texas
| | - Maria A Carrillo-Marquez
- Division of Infectious Diseases, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Coburn H Allen
- Department of Pediatrics, University of Texas at Austin Dell Medical School, Austin, Texas
| | - Valéry Lavergne
- Department of Medical Microbiology and Infection Control, Vancouver General Hospital, Vancouver, British Columbia, Canada
- University of Montreal Research Center, Montreal, Quebec, Canada
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Abstract
PURPOSE OF REVIEW The aim of this article is to review the recent guidelines and literature regarding the diagnosis and the treatment of common pediatric musculoskeletal infections: septic arthritis, osteomyelitis, pyomyositis, and Lyme disease. RECENT FINDINGS In the last decade, a better understanding of the causative organisms of common bacterial infections, including Kingella , leads to prompt targeted antimicrobial coverage in all musculoskeletal infections. Prompt diagnosis and treatment continues to be the mainstay in the treatment of children with osteoarticular infections. Efforts to improve early detection have lead to improving rapid lab diagnostic testing; however, more advanced diagnostics such as arthrocentesis for septic arthritis and MRI for osteomyelitis and pyomyositis, remain the gold standard. Shorter and narrowed antibiotic courses, with appropriate transition to outpatient oral treatment provide effective infection clearance and reduction in complications of disease. SUMMARY Advances in diagnostics, including pathogen identification as well as imaging continues to improve our ability to diagnose and treat these infections, although still lack ability to provide definitive diagnosis without more invasive nor advanced techniques.
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Affiliation(s)
- Megan Hannon
- Division of Emergency Medicine
- Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, Massachusetts, USA
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4
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Gagliardi TA, Agarwalla A, Johnson PK, Leong J, DelBello DA. Bilateral Knee Lyme Arthritis in Children: A Report of 3 Cases. JBJS Case Connect 2023; 13:01709767-202306000-00026. [PMID: 37172117 DOI: 10.2106/jbjs.cc.22.00719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
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.
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Affiliation(s)
- Thomas A Gagliardi
- Department of Orthopedic Surgery, Westchester Medical Center, Valhalla, New York
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Ramadani A, Coulin B, De Marco G, Vazquez O, Tabard-Fougère A, Gavira N, Steiger CN, Dayer R, Ceroni D. Clinical and Biologic Characteristics of Kingella kingae -Induced Septic Arthritis of the Knee in Young Children. Pediatr Infect Dis J 2023; 42:195-198. [PMID: 36729984 PMCID: PMC9935552 DOI: 10.1097/inf.0000000000003797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/10/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND OBJECTIVES Septic arthritis of the knee is presumed to be the most frequent form of Kingella kingae -induced osteoarticular infection. This study aimed to report on the clinical course, biological parameters, and results of microbiological investigations among children with K. kingae -induced septic arthritis of the knee. It also assessed the modified Kocher-Caird criteria's ability to predict K. kingae -induced septic arthritis of the knee. METHODS The medical charts of 51 children below 4 years old with confirmed or highly probable K. kingae -induced arthritis of the knee were reviewed. Data were gathered on the five variables in the commonly-used Kocher-Caird prediction algorithm (body temperature, refusal to bear weight, leukocytosis, erythrocyte sedimentation rate, and C-reactive protein level). RESULTS Patients with K. kingae -induced arthritis of the knee usually presented with a mildly abnormal clinical picture and normal or near-normal serum levels of acute-phase reactants. Data on all five variables were available for all the children: 7 children had zero predictors; 8, 20, 12, and 4 children had 1, 2, 3, and 4 predictors, respectively; no children had 5 predictors. This gave an average of 1.96 predictive factors and a subsequent probability of ≤ 62.4% of infectious arthritis in this pediatric cohort. CONCLUSIONS Because the clinical features of K. kingae -induced arthritis of the knee overlap with many other conditions affecting this joint, the Kocher-Caird prediction algorithm is not sensitive enough to effectively detect K. kingae -induced septic arthritis of the knee. Excluding K. kingae -induced arthritis of the knee requires performing nucleic acid amplification assays on oropharyngeal swabs and joint fluid from those young children presenting with effusion of the knee, even in the absence of fever, leukocytosis, or a high Kocher-Caird score.
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Affiliation(s)
- Ardian Ramadani
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Benoit Coulin
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Giacomo De Marco
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Oscar Vazquez
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Anne Tabard-Fougère
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Nathaly Gavira
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Christina N. Steiger
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Romain Dayer
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
| | - Dimitri Ceroni
- Paediatric Orthopaedics Service, Geneva Children’s Hospital, Geneva University Hospitals, Switzerland
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6
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Jafari K, Woodward GA. Fever and Knee Effusion in the Pediatric Patient. Pediatr Emerg Care 2022; 38:555-561. [PMID: 36173430 DOI: 10.1097/pec.0000000000002839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT The pediatric patient with fever and knee effusion is always a cause for clinical concern. A thorough history and physical examination is required to guide appropriate diagnostic evaluation and management. Although pediatric knee effusions are common in the setting of trauma, the presence of fever should prompt consideration of infectious, rheumatologic, vasculitic, and malignant etiologies. This review covers the key components of the history, physical examination, diagnostic strategies, common etiologies, and initial management of the pediatric patient with fever and knee effusion.
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Affiliation(s)
- Kaileen Jafari
- From the Senior Fellow (PEM faculty as of February 2022), Division of Emergency Medicine, University of Washington Department of Pediatrics, Seattle Children's Hospital
| | - George A Woodward
- Chief, Division of Emergency Medicine, Professor, University of Washington Department of Pediatrics, Seattle Children's Hospital, Seattle, WA
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7
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Diagnostic Utility of Synovial Fluid Cell Counts and CRP in Pediatric Knee Arthritis: A 10-Year Monocentric, Retrospective Study. CHILDREN 2022; 9:children9091367. [PMID: 36138676 PMCID: PMC9498181 DOI: 10.3390/children9091367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/01/2022] [Accepted: 09/05/2022] [Indexed: 11/17/2022]
Abstract
Background: Orthopedic surgeons often use the intra-articular white blood counts (WBCs) and the percentage of polymorphonuclear cells (PMN) in the diagnosis of an acute swollen and painful knee joint in children. Today, there is no established threshold for the synovial WBC, and their differentiation, as indicative of native joint knee bacterial arthritis. We determine the sensitivity and specificity of synovial WBCs and PMN percentages in the prediction of a community-acquired, acute bacterial native joint septic arthritis (SA) in the pediatric population. Methods: A retrospective study on healthy children 0–16 years of age who underwent knee joint aspiration for a community-acquired, acute irritable knee effusion in our tertiary-care children’s hospital between May 2009 and April 2019 was conducted. We divided the study population into two groups according to the detection of bacterial arthritis in the synovial fluid (bacterial arthritis versus its absence) and compared the intra-articular leukocyte and C-reactive protein (CRP) levels. Results: Overall, we found a statistically significant difference regarding the total CRP (p = 0.017), leukocyte or PMN counts (p ≤ 0.001 in favor of a bacterial arthritis). In contrast, the percentage of the neutrophils was not determinant for the later confirmation of bacterial pathogens, and we were unable to establish diagnostically determining minimal thresholds of the intra-articular CRP and leukocyte levels. Conclusions: This pilot study suggests that either the leukocyte or PMN counts may be associated with a bacterial origin of knee arthritis in children. We plan a larger prospective interventional study in the future to confirm these findings including the investigation of other joint aspirate biomarkers.
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8
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Bisht RU, Burns JD, Smith CL, Kang P, Shrader MW, Belthur MV. The modified Kocher criteria for septic hip: Does it apply to the knee? J Child Orthop 2022; 16:233-237. [PMID: 35800650 PMCID: PMC9254023 DOI: 10.1177/18632521221106383] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2022] [Accepted: 05/11/2022] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Pediatric septic arthritis is a surgical emergency and timely diagnosis prevents serious complications. To differentiate between septic hip and transient synovitis, the predictive value of four original Kocher criteria (fever, inability to bear weight, elevated serum white blood cell count, and elevated erythrocyte sedimentation rate) plus Caird's addition of elevated C-reactive protein have been studied, termed the modified Kocher criteria. These criteria have not been tested extensively on septic knee. This study tested the utility of the modified Kocher criteria in predicting septic knee while validating it for septic hip. METHODS A retrospective chart review was conducted of pediatric patients evaluated at a single institution for irritable hip or knee between 2009 and 2018. Patients who underwent arthrocentesis were included and the modified Kocher criteria were applied to all. RESULTS One hundred fifty-five patients (96 hips and 59 knees) were identified. One hundred four (67.1%) patients had septic arthritis with 44/59 (74.6%) of knees and 60/96 (62.5%) of hips. The strongest predictors for septic hip and knee were elevated C-reactive protein (odds ratio = 26.9, p < 0.0001) and refusal to bear weight (odds ratio = 14.5, p < 0.0001), respectively. For hips, 5/5 criteria produced a 100% positive predictive value for septic arthritis. For knees, the combination of inability to bear weight and elevated C-reactive protein had a positive predictive value of 89.7%. CONCLUSION While all five of the modified Kocher criteria are not predictive of pediatric septic knee, the combination of two specific factors (inability to bear weight and elevated C-reactive protein) is strongly predictive. This study validates previous work that the modified Kocher criteria are predictive of septic hip. LEVEL OF EVIDENCE level III.
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Affiliation(s)
- Roy U Bisht
- The University of Arizona College of
Medicine – Phoenix, Phoenix, AZ, USA
| | - Jessica D Burns
- The University of Arizona College of
Medicine – Phoenix, Phoenix, AZ, USA
| | - Casey L Smith
- The University of Arizona College of
Medicine – Phoenix, Phoenix, AZ, USA
| | - Paul Kang
- Mel & Enid Zuckerman College of
Public Health, Phoenix, AZ, USA
| | - M Wade Shrader
- Department of Orthopedics,
Nemours/Alfred I. duPont Hospital for Children, Wilmington, DE, USA
| | - Mohan V Belthur
- The University of Arizona College of
Medicine – Phoenix, Phoenix, AZ, USA,Department of Orthopedics, Phoenix
Children’s Hospital, Phoenix, AZ, USA,Mohan V Belthur, Department of Orthopedics,
Phoenix Children’s Hospital, Main Building, Clinic B, 1919 E Thomas Road,
Phoenix, AZ 85016, USA.
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9
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A Clinical Prediction Rule for Bacterial Musculoskeletal Infections in Children with Monoarthritis in Lyme Endemic Regions. Ann Emerg Med 2022; 80:225-234. [DOI: 10.1016/j.annemergmed.2022.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/01/2022] [Accepted: 04/07/2022] [Indexed: 11/22/2022]
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10
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Donders CM, Spaans AJ, van Wering H, van Bergen CJA. Developments in diagnosis and treatment of paediatric septic arthritis. World J Orthop 2022; 13:122-130. [PMID: 35317401 PMCID: PMC8891656 DOI: 10.5312/wjo.v13.i2.122] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2021] [Revised: 08/08/2021] [Accepted: 01/20/2022] [Indexed: 02/06/2023] Open
Abstract
Acute septic arthritis in children is an orthopaedic emergency. A delay in diagnosis and inappropriate treatment can result in devastating damage to the joint with lifelong disability as a consequence. The clinical presentation can be a diagnostic challenge, especially in young children. A recent systematic review showed that joint tenderness and fever are important signals of septic arthritis. Ultrasound is helpful in detecting the presence of a joint effusion. Plain radiographs may show bone changes but magnetic resonance imaging is the most reliable imaging study for detecting concomitant osteomyelitis. The diagnosis of acute septic arthritis is highly suggestive when pus is aspirated from the joint, in case of a positive culture or a positive gram stain of the joint fluid, or if there is a white blood-cell count in the joint fluid of more than 50000/mm3. Staphylococcus aureus is the most commonly cultured organism. Recent systematic reviews have identified the most effective drainage techniques, including needle aspiration, arthroscopy and arthrotomy, depending on the affected joint. After the drainage procedure it is important to monitor the clinical and laboratory outcomes. Additional drainage procedures may be necessary in select cases.
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Affiliation(s)
- Cornelia M Donders
- Department of Orthopaedic Surgery, Meander Medical Centre, Amersfoort 3813 TZ, Netherlands
| | - Anne J Spaans
- Department of Orthopaedic Surgery, Sint Maartenskliniek, Nijmegen 6574 NA, Netherlands
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11
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Grant DS, Neville DN, Levas M, Balamuth F, Garro AC, Bennett JE, Thompson AD, Kharbanda AB, Lyons TW, Nigrovic LE. Validation of Septic Knee Monoarthritis Prediction Rule in a Lyme Disease Endemic Area. Pediatr Emerg Care 2022; 38:e881-e885. [PMID: 34160185 DOI: 10.1097/pec.0000000000002455] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE In Lyme disease endemic areas, Lyme and septic arthritis often present similarly. A published septic knee arthritis clinical prediction rule includes 2 high-risk predictors: absolute neutrophil count of 10,000 cells/mm3 or greater and erythrocyte sedimentation rate of 40 mm/h or greater. The objective of the study was to externally validate this prediction rule in a multicenter prospective cohort. METHODS We enrolled a prospective cohort of children with knee monoarthritis undergoing evaluation for Lyme disease at 1 of 8 Pedi Lyme Net emergency departments located in endemic areas. We defined a case of septic arthritis with a positive synovial fluid culture or a synovial fluid white blood cell count of 50,000 or greater per high powered field with a positive blood culture and Lyme arthritis with a positive or equivocal C6 EIA, followed by a positive supplemental immunoblot. Other children were classified as having inflammatory arthritis. We report the performance of the septic arthritis clinical prediction rule in our study population. RESULTS Of the 543 eligible children, 13 had septic arthritis (2.4%), 234 Lyme arthritis (43.1%), and 296 inflammatory arthritis (54.5%). Of the 457 children (84.2%) with available laboratory predictors, all children with septic arthritis were classified as high risk (sensitivity, 100%; 95% confidence interval [CI], 77.2%-100%; specificity, 68.1%; 95% CI, 63.6-73.3; negative predictive value, 278/278 [100%]; 95% CI, 98.6%-100%). Of the 303 low-risk children, 52 (17.2%) underwent diagnostic arthrocentesis. CONCLUSIONS The septic knee arthritis clinical prediction rule accurately distinguished between septic and Lyme arthritis in an endemic area. Clinical application may reduce unnecessary invasive diagnostic procedures.
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Affiliation(s)
| | - Desiree N Neville
- Division of Pediatric Emergency Medicine, Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Michael Levas
- Division of Pediatric Emergency Medicine, Children's Hospital of Wisconsin, Milwaukee, WI
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Aris C Garro
- Departments of Pediatrics and Emergency Medicine, Hasbro Children's Hospital, Providence, RI
| | - Jonathan E Bennett
- Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Wilmington, DE
| | - Amy D Thompson
- Division of Emergency Medicine, Nemours/A.I. duPont Hospital for Children, Wilmington, DE
| | | | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
| | - Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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12
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Thomas CS, Schiffman CJ, Faino A, Bompadre V, Schmale GA. Diagnostic Criteria for the Painful Swollen Pediatric Knee: Distinguishing Septic Arthritis From Aseptic Effusion in a Non-Lyme Endemic Area. Front Surg 2021; 8:740285. [PMID: 34790694 PMCID: PMC8591062 DOI: 10.3389/fsurg.2021.740285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 09/28/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: The child with a painful swollen knee must be worked-up for possible septic arthritis; the classic clinical prediction algorithms for septic arthritis of the hip may not be the best models to apply to the knee. Materials and methods: This was a retrospective case-control study of 17 years of children presenting to one hospital with a chief complaint of a painful swollen knee, to evaluate the appropriateness of applying a previously described clinical practice algorithm for the hip in differentiating between the septic and aseptic causes of the painful knee effusions. The diagnoses of true septic arthritis, presumed septic arthritis, and aseptic effusion were established, based upon the cultures of synovial fluid, blood cultures, synovial cell counts, and clinical course. Using a logistic regression model, the disease status was regressed on both the demographic and clinical variables. Results: In the study, 122 patients were included: 51 with true septic arthritis, 37 with presumed septic arthritis, and 34 with aseptic knee effusion. After applying a backward elimination, age <5 years and C-reactive protein (CRP) >2.0 mg/dl remained in the model, and predicted probabilities of having septic knee arthritis ranged from 15% for the lowest risk to 95% for the highest risk. Adding a knee aspiration including percent polymorphonucleocytes (%PMN) substantially improved the overall model performance, lowering the lowest risk to 11% while raising the highest risk to 96%. Conclusions: This predictive model suggests that the likelihood of pediatric septic arthritis of the knee is >90% when both "age <5 years" and "CRP > 2.0 mg/dl" are present in a child with a painful swollen knee, though, in the absence of these factors, the risk of septic arthritis remains over 15%. Aspiration of the knee for those patients would be the best next step.
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Affiliation(s)
- Claudia S Thomas
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, United States
| | - Corey J Schiffman
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, United States
| | - Anna Faino
- Seattle Children's Hospital, Seattle, WA, United States
| | - Viviana Bompadre
- Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, WA, United States
| | - Gregory A Schmale
- Department of Orthopaedics and Sports Medicine, University of Washington, Seattle, WA, United States.,Department of Orthopedics and Sports Medicine, Seattle Children's Hospital, Seattle, WA, United States
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13
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Tout AR, McClincy M, Anderson A, Nowalk A, Campfield BT. The Impact of Operative Intervention in Pediatric Lyme Arthritis. J Pediatr Orthop 2021; 41:e911-e916. [PMID: 34483307 DOI: 10.1097/bpo.0000000000001959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Andrew R Tout
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine
| | | | | | - Andrew Nowalk
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
| | - Brian T Campfield
- Division of Pediatric Infectious Diseases, Department of Pediatrics, University of Pittsburgh School of Medicine
- Department of Pediatrics, Richard K. Mellon Institute for Pediatric Research, University of Pittsburgh School of Medicine
- UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA
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14
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Lantos PM, Rumbaugh J, Bockenstedt LK, Falck-Ytter YT, Aguero-Rosenfeld ME, Auwaerter PG, Baldwin K, Bannuru RR, Belani KK, Bowie WR, Branda JA, Clifford DB, DiMario FJ, Halperin JJ, Krause PJ, Lavergne V, Liang MH, Meissner HC, Nigrovic LE, Nocton JJJ, Osani MC, Pruitt AA, Rips J, Rosenfeld LE, Savoy ML, Sood SK, Steere AC, Strle F, Sundel R, Tsao J, Vaysbrot EE, Wormser GP, Zemel LS. Clinical Practice Guidelines by the Infectious Diseases Society of America (IDSA), American Academy of Neurology (AAN), and American College of Rheumatology (ACR): 2020 Guidelines for the Prevention, Diagnosis and Treatment of Lyme Disease. Clin Infect Dis 2021; 72:e1-e48. [PMID: 33417672 DOI: 10.1093/cid/ciaa1215] [Citation(s) in RCA: 142] [Impact Index Per Article: 47.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Indexed: 12/13/2022] Open
Abstract
This evidence-based clinical practice guideline for the prevention, diagnosis, and treatment of Lyme disease was developed by a multidisciplinary panel representing the Infectious Diseases Society of America (IDSA), the American Academy of Neurology (AAN), and the American College of Rheumatology (ACR). The scope of this guideline includes prevention of Lyme disease, and the diagnosis and treatment of Lyme disease presenting as erythema migrans, Lyme disease complicated by neurologic, cardiac, and rheumatologic manifestations, Eurasian manifestations of Lyme disease, and Lyme disease complicated by coinfection with other tick-borne pathogens. This guideline does not include comprehensive recommendations for babesiosis and tick-borne rickettsial infections, which are published in separate guidelines. The target audience for this guideline includes primary care physicians and specialists caring for this condition such as infectious diseases specialists, emergency physicians, internists, pediatricians, family physicians, neurologists, rheumatologists, cardiologists and dermatologists in North America.
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Affiliation(s)
- Paul M Lantos
- Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Yngve T Falck-Ytter
- Case Western Reserve University, VA Northeast Ohio Healthcare System, Cleveland, Ohio, USA
| | | | - Paul G Auwaerter
- Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kelly Baldwin
- Geisinger Medical Center, Danville, Pennsylvania, USA
| | | | - Kiran K Belani
- Childrens Hospital and Clinical of Minnesota, Minneapolis, Minnesota, USA
| | - William R Bowie
- University of British Columbia, Vancouver, British Columbia, Canada
| | - John A Branda
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - David B Clifford
- Washington University School of Medicine, St. Louis, Missouri, USA
| | | | | | - Peter J Krause
- Yale School of Public Health, New Haven, Connecticut, USA
| | | | | | | | | | | | | | - Amy A Pruitt
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jane Rips
- Consumer Representative, Omaha, Nebraska, USA
| | | | | | | | - Allen C Steere
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Franc Strle
- University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Robert Sundel
- Boston Children's Hospital Boston, Massachusetts, USA
| | - Jean Tsao
- Michigan State University, East Lansing, Michigan, USA
| | | | | | - Lawrence S Zemel
- Connecticut Children's Medical Center, Hartford, Connecticut, USA
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15
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Swarup I, Meza BC, Weltsch D, Jina AA, Lawrence JT, Baldwin KD. Septic Arthritis of the Knee in Children: A Critical Analysis Review. JBJS Rev 2021; 8:e0069. [PMID: 32105243 DOI: 10.2106/jbjs.rvw.19.00069] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Septic arthritis of the knee is the most common type of septic arthritis in children, and it may result in irreversible joint damage.
» Staphylococcus aureus is the most common pathogen associated with septic arthritis, but other causative pathogens are possible in children with certain risk factors.
» The diagnosis of septic arthritis of the knee is based on history and physical examination, blood tests, and arthrocentesis.
» Empiric treatment with anti-staphylococcal penicillin or a first-generation cephalosporin is usually recommended but may be tailored according to local resistance patterns and clinical culture data.
» Open or arthroscopic surgical debridement including extensive lavage is effective in eradicating infection, and most patients do not require additional surgical intervention.
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Affiliation(s)
- Ishaan Swarup
- UCSF Benioff Children's Hospital, Oakland, California
| | - Blake C Meza
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Daniel Weltsch
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - John T Lawrence
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Keith D Baldwin
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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16
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Current Concepts in Pediatric Septic Arthritis. J Am Acad Orthop Surg 2021; 29:196-206. [PMID: 33273402 DOI: 10.5435/jaaos-d-20-00835] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 10/19/2020] [Indexed: 02/01/2023] Open
Abstract
Septic arthritis continues to present challenges regarding the clinical diagnosis, workup, and definitive management. Urgent management is essential, so treating surgeons must efficiently work through differential diagnoses, identify concomitant infections, and do a timely irrigation and débridement. The incidence of methicillin-resistant Staphylococcus aureus is increasing, typically resulting in a more rapid progression of symptoms with more severe clinical presentation. The diagnostic utility of MRI has resulted in improved detection of concomitant septic arthritis and osteomyelitis, although MRI must not substantially delay definitive management. Early diagnosis followed by urgent irrigation and débridement and antibiotic therapy are essential for satisfactory long-term outcomes. Antibiotics should not be administered until blood cultures and arthrocentesis fluid are obtained, except in rare cases of a septic or toxic patient. Once cultures are obtained, empiric antibiotic therapy should commence and provide coverage for the most likely pathogens, given the patient's age. Laboratory markers, especially C-reactive protein, should be followed until normalization and correlate with resolution of clinical symptoms. Definitive antibiotic selection should be shared with a pediatric infectious disease specialist, who can help guide the duration of treatment.
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17
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Tu J, Gowdie P, Cassar J, Craig S. Test characteristics of history, examination and investigations in the evaluation for septic arthritis in the child presenting with acute non-traumatic limp. A systematic review. BMJ Open 2020; 10:e038088. [PMID: 33380476 PMCID: PMC7780717 DOI: 10.1136/bmjopen-2020-038088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Septic arthritis is an uncommon but potentially significant diagnosis to be considered when a child presents to the emergency department (ED) with non-traumatic limp. Our objective was to determine the diagnostic accuracy of clinical findings (history and examination) and investigation results (pathology tests and imaging) for the diagnosis of septic arthritis among children presenting with acute non-traumatic limp to the ED. METHODS Systematic review of the literature published between 1966 and June 2019 on MEDLINE and EMBASE databases. Studies were included if they evaluated children presenting with lower limb complaints and evaluated diagnostic performance of items from history, physical examination, laboratory testing or radiological examination. Data were independently extracted by two authors, and quality assessment was performed using the Quality Assessment Tool for Diagnostic Accuracy Studies 2 tool. RESULTS 18 studies were identified, and included 2672 children (560 with a final diagnosis of septic arthritis). There was substantial heterogeneity in inclusion criteria, study setting, definitions of specific variables and the gold standard used to confirm septic arthritis. Clinical and investigation findings were reported using varying definitions and cut-offs, and applied to differing study populations. Spectrum bias and poor-to-moderate study design quality limit their applicability to the ED setting.Single studies suggest that the presence of joint tenderness (n=189; positive likelihood ratio 11.4 (95% CI 5.9 to 22.0); negative likelihood ratio 0.2 (95% CI 0.0 to 1.2)) and joint effusion on ultrasound (n=127; positive likelihood ratio 8.4 (95% CI 4.1 to 17.1); negative likelihood ratio 0.2 (95% CI 0.1 to 0.3)) appear to be useful. Two promising clinical risk prediction tools were identified, however, their performance was notably lower when tested in external validation studies. DISCUSSION Differentiating children with septic arthritis from non-emergent disorders of non-traumatic limp remains a key diagnostic challenge for emergency physicians. There is a need for prospectively derived and validated ED-based clinical risk prediction tools.
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Affiliation(s)
- Jacky Tu
- Monash Health, Melbourne, Victoria, Australia
- School of Clinical Sciences at Monash Health, Monash University, Melbourne, Victoria, Australia
| | - Peter Gowdie
- Department of Paediatrics and Department of Paediatric Rheumatology, Monash Children's Hospital, Melbourne, Victoria, Australia
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | | | - Simon Craig
- Department of Paediatrics, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
- Pediatric Emergency Department, Monash Medical Centre, Emergency Service, Monash Health, Melbourne, Victoria, Australia
- Emergency Research, Murdoch Children's Research Institute, Parkville, Victoria, Australia
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18
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Laliotis N, Chrysanthou C, Konstandinidis P, Giannakopoulou L. Diagnostic approach and arthroscopic treatment of septic arthritis of the knee, in an infant. Clin Case Rep 2020; 8:3389-3393. [PMID: 33363939 PMCID: PMC7752424 DOI: 10.1002/ccr3.3382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/18/2020] [Accepted: 08/30/2020] [Indexed: 11/12/2022] Open
Abstract
A 9-month-old baby presented with sudden inability to stand and unable to move his leg. Clinical examination showed edema and knee effusion. Blood tests and MRI confirmed septic knee arthritis without bone involvement. He was treated with arthroscopic lavage. He had a complete recovery and normal growth.
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19
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Septic Arthritis: An Evidence-Based Review of Diagnosis and Image-Guided Aspiration. AJR Am J Roentgenol 2020; 215:568-581. [PMID: 32783556 DOI: 10.2214/ajr.20.22773] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE. The purpose of this evidence-based review is to equip radiologists to discuss and interpret findings obtained with various imaging modalities, guide patient selection for percutaneous aspiration, and safely perform arthrocentesis to assess for infection in both native and prosthetic joints. CONCLUSION. Septic arthritis is an emergency that can lead to rapidly progressive, irreversible joint damage. Despite the urgency associated with this diagnosis, there remains a lack of consensus regarding many aspects of the management of native and periprosthetic joint infections.
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20
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Swarup I, LaValva S, Shah R, Sankar WN. Septic Arthritis of the Hip in Children: A Critical Analysis Review. JBJS Rev 2020; 8:e0103. [PMID: 32224630 DOI: 10.2106/jbjs.rvw.19.00103] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Septic arthritis of the hip is a common and potentially devastating condition in children. Septic arthritis is most commonly caused by Staphylococcus aureus, but other pathogens should be considered on the basis of patient age and presence of risk factors. Diagnosis of septic arthritis is based on history and physical examination, laboratory tests, radiographs, ultrasound, and arthrocentesis. Treatment comprises empiric antibiotics and joint debridement, and antibiotics are subsequently tailored on the basis of culture data, local resistance patterns, and clinical response. Late sequelae of septic arthritis include osteonecrosis, chondrolysis, growth disturbance, subluxation or dislocation, and progressive ankylosis. Surgical treatments to address these issues have been described.
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Affiliation(s)
- Ishaan Swarup
- UCSF Benioff Children's Hospital, Oakland, California
| | - Scott LaValva
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Ronit Shah
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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21
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Abstract
BACKGROUND The early diagnosis of pediatric septic arthritis is paramount to the prevention of long-term sequela. The purpose of this study is to investigate if the commonly used criteria developed by Kocher and colleagues for hip septic arthritis can be used for screening children with suspected septic knee. METHODS We retrospectively reviewed the charts of patients under the age of 19, between June 2002 to June 2017, who presented to a major tertiary-care children's hospital with septic knee. Diagnostic criteria included either a positive synovial culture from the knee, synovial white blood cell (WBC)>50,000 cells/mm, or synovial WBC count >25,000 cells/mm and clinical agreement of diagnosis from Infectious Disease and Orthopaedic colleagues. Collected data included the initial criteria described by Kocher and colleagues: history of fever, non-weight-bearing, erythrocyte sedimentation rate, and serum WBC as well as a recently modified criterion: C-reactive protein. Univariate analysis was used to determine the quality of these variables in ruling out septic knee. RESULTS One hundred four patient charts were found to meet our inclusion criteria demonstrating C-reactive protein>20 mg/L (75%), fever (65%), non-weight-bearing status (64%), erythrocyte sedimentation rate>40 mm/h (60%), and WBC>12,000 cells/mm (49%). With the 25 different combinations of these predictors adjusted for, in an escalating manner, 0 predictors suggested a sensitivity of 0.02, 1 predictor a sensitivity of 0.06, 2 predictors a sensitivity of 0.2, 3 predictors a sensitivity of 0.32, 4 predictors a sensitivity of 0.3, and 5 predictors a sensitivity of 0.11. CONCLUSIONS According to the Kocher criteria of the hip, at 3 or more criteria the probability of septic arthritis becomes 93% with a sensitivity of 0.84 provoking many physicians to use this cutoff in their assessment of hip pain. This study suggests that if these criteria were applied to the knee, 52% of septic knee cases could be missed. There is a need for further investigation of specific criteria of the knee as the markers of the hip septic arthritis are not necessarily applicable in the knee. LEVEL OF EVIDENCE Level III.
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22
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Nigrovic LE, Bennett JE, Balamuth F, Levas MN, Neville D, Lyons TW, Branda JA, Maulden AB, Lewander D, Garro A. Diagnostic Performance of C6 Enzyme Immunoassay for Lyme Arthritis. Pediatrics 2020; 145:peds.2019-0593. [PMID: 31836615 DOI: 10.1542/peds.2019-0593] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/26/2019] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES In Lyme disease endemic areas, initial management of children with arthritis can be challenging because diagnostic tests take several days to return results, leading to potentially unnecessary invasive procedures. Our objective was to examine the role of the C6 peptide enzyme immunoassay (EIA) test to guide initial management. METHODS We enrolled children with acute arthritis undergoing evaluation for Lyme disease presenting to a participating Pedi Lyme Net emergency department (2015-2019) and performed a C6 EIA test. We defined Lyme arthritis with a positive or equivocal C6 EIA test result followed by a positive supplemental immunoblot result and defined septic arthritis as a positive synovial fluid culture result or a positive blood culture result with synovial fluid pleocytosis. Otherwise, children were considered to have inflammatory arthritis. We report the sensitivity and specificity of the C6 EIA for the diagnosis of Lyme arthritis. RESULTS Of the 911 study patients, 211 children (23.2%) had Lyme arthritis, 11 (1.2%) had septic arthritis, and 689 (75.6%) had other inflammatory arthritis. A positive or equivocal C6 EIA result had a sensitivity of 100% (211 out of 211; 95% confidence interval [CI]: 98.2%-100%) and specificity of 94.2% (661 out of 700; 95% CI: 92.5%-95.9%) for Lyme arthritis. None of the 250 children with a positive or equivocal C6 EIA result had septic arthritis (0%; 95% CI: 0%-1.5%), although 75 children underwent diagnostic arthrocentesis and 27 underwent operative joint washout. CONCLUSIONS In Lyme disease endemic areas, a C6 EIA result could be used to guide initial clinical decision-making, without misclassifying children with septic arthritis.
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Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; .,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - Jonathan E Bennett
- Division of Emergency Medicine, Alfred I. Dupont Hospital for Children and Jefferson School of Medicine, Wilmington, Delaware
| | - Fran Balamuth
- Department of Pediatrics, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael N Levas
- Department of Pediatric Emergency Medicine, Children's Hospital of Wisconsin and Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Desiree Neville
- Division of Emergency Medicine, UPMC Children's Hospital of Pittsburgh and School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts.,Harvard Medical School, Harvard University, Boston, Massachusetts
| | - John A Branda
- Department of Pathology, Massachusetts General Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Alexandra B Maulden
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - David Lewander
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Aris Garro
- Department of Pediatrics and Emergency Medicine, Hasbro Children's Hospital and Alpert Medical School, Brown University, Providence, Rhode Island
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23
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Abstract
Septic arthritis in children is a surgical emergency, and prompt diagnosis and treatment are mandatory. If diagnosed quickly and treated correctly, the outcomes can be good. With delay in diagnosis and without proper treatment, outcomes often are quite devastating, with growth disturbance and joint destruction.
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24
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Abstract
Septic arthritis is an emergent condition caused by bacterial infection of a joint space. The most common etiology is hematogenous spread from bacteremia, but it can also occur from direct inoculation from bites, injection injuries, cellulitis, abscesses, or local trauma. Septic arthritis occurs most frequently in the lower extremities, with the hips and knees serving as the most common locations. The most sensitive findings include pain with motion of the joint, limited range of motion, tenderness of the joint, new joint swelling, and new effusion. Laboratory testing and imaging can support the diagnosis, but the criterion standard is diagnostic arthrocentesis. Treatment involves intravenous antibiotics and joint decompression.
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25
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Predicting Periarticular Infection in Children With Septic Arthritis of the Hip: Regionally Derived Criteria May Not Apply to All Populations. J Pediatr Orthop 2019; 39:268-274. [PMID: 30969258 DOI: 10.1097/bpo.0000000000000934] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND The management of septic arthritis of the hip in children can be complicated by the presence of additional coexisting periarticular infections (PAIs). Criteria predicting the presence of PAI have recently been proposed by Rosenfeld and colleagues with the goal of using magnetic resonance imaging (MRI) efficiently in the workup of septic arthritis. The purpose of this study was to determine the applicability of recently published predictive criteria for PAI (developed in the Southwestern United States using a variety of joints) to septic arthritis of the hip treated at a large Northeastern tertiary care center. METHODS We studied patients treated for septic arthritis of the hip with irrigation and debridement in a large Northeastern tertiary care center over a 10-year period. Laboratory and clinical variables related to presentation, treatment, and outcome were collected. Subjects with and without a perioperative MRI were compared with published criteria by Rosenfeld and colleagues. RESULTS Fifty-one subjects (53 hips) were identified with a mean age of 7.0 years (range, 1.2 to 19.3 y) and mean follow-up was 16 months (range, 2 to 85 mo). MRIs were obtained in 20 subjects (43%). Coexisting osteomyelitis was revealed in 7/20 of these studies (35% of MRIs); 4 of which showed coexisting intramuscular abscesses. Within our MRI cohort, the Rosenfeld criteria were found to have a sensitivity of 86%, a specificity of 54%, and a false-positive rate of 50% for the hip (compared with originally reported sensitivity of 90%, specificity of 67%, and false-positive rate of 33%). Overall, advanced imaging changed management in 5/51 patients (9%) by influencing the need for further treatment, whereas the remainder underwent isolated treatment of the septic hip joint with no adverse outcomes. One patient in the MRI cohort (without PAI) developed osteonecrosis of the femoral head. CONCLUSIONS We found lower sensitivity and specificity and higher false-positive rates for the Rosenfeld criteria in the hip for our geographically distinct population. Using the Rosenfeld criteria, MRIs would have been ordered unnecessarily in half of our series. Because of potential differences in regional microbiology and anatomic-specific factors, general predictive criteria for coexisting PAI based a single geographic region may be less generalizable to cases of hip sepsis in other geographic areas such as the Northeastern United States. LEVEL OF EVIDENCE Level 4-retrospective cohort study.
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26
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Ichikawa O, Glicksberg BS, Genes N, Kidd BA, Li L, Dudley JT. Lyme Disease Patient Trajectories Learned from Electronic Medical Data for Stratification of Disease Risk and Therapeutic Response. Sci Rep 2019; 9:4460. [PMID: 30872757 PMCID: PMC6418311 DOI: 10.1038/s41598-019-41128-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Accepted: 02/27/2019] [Indexed: 02/04/2023] Open
Abstract
Lyme disease (LD) is the most common tick-borne illness in the United States. Although appropriate antibiotic treatment is effective for most cases, up to 20% of patients develop post-treatment Lyme disease syndrome (PTLDS). There is an urgent need to improve clinical management of LD using precise understanding of disease and patient stratification. We applied machine-learning to electronic medical records to better characterize the heterogeneity of LD and developed predictive models for identifying medications that are associated with risks of subsequent comorbidities. For broad disease categories, we identified 3, 16, and 17 comorbidities within 2, 5, and 10 years of diagnosis, respectively. At a higher resolution of ICD-9 codes, we identified known associations with LD including chronic pain and cognitive disorders, as well as particular comorbidities on a timescale that matched PTLDS symptomology. We identified 7, 30, and 35 medications associated with risks of these comorbidities within 2, 5, and 10 years, respectively. For instance, the first-line antibiotic doxycycline exhibited a consistently protective association for typical symptoms of LD, including backache. Our approach and findings may suggest new hypotheses for more personalized treatments regimens for LD patients.
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Affiliation(s)
- Osamu Ichikawa
- Department of Genetics and Genomic Sciences, Institute for Next Generation Healthcare, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1498, New York, NY, 10029, USA.,Drug Research Division, Sumitomo Dainippon Pharma. Co. Ltd., 3-1-98 Kasugade-naka, Konohana-ku, Osaka, 554-0022, Japan
| | - Benjamin S Glicksberg
- Department of Genetics and Genomic Sciences, Institute for Next Generation Healthcare, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1498, New York, NY, 10029, USA.,Bakar Computational Health Science Institute, University of California, 550 16th St, San Francisco, California, 94158, USA
| | - Nicholas Genes
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, 1190 Fifth Avenue Box 1620, New York, NY, 10029, USA
| | - Brian A Kidd
- Department of Genetics and Genomic Sciences, Institute for Next Generation Healthcare, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1498, New York, NY, 10029, USA
| | - Li Li
- Department of Genetics and Genomic Sciences, Institute for Next Generation Healthcare, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1498, New York, NY, 10029, USA. .,Sema4, a Mount Sinai Venture, Stamford, Connecticut, 06902, USA.
| | - Joel T Dudley
- Department of Genetics and Genomic Sciences, Institute for Next Generation Healthcare, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place Box 1498, New York, NY, 10029, USA.
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27
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Yagupsky P. Microbiological Diagnosis of Skeletal System Infections in Children. Curr Pediatr Rev 2019; 15:154-163. [PMID: 30961502 DOI: 10.2174/1573396315666190408114653] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Revised: 03/23/2019] [Accepted: 03/26/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND If not timely diagnosed and adequately treated, skeletal system infections in children may result in severe and permanent disability. Prompt identification of the etiology of the disease and determination of its antibiotic susceptibility are crucial for the successful management of septic arthritis, osteomyelitis, and spondylodiscitis. However, the bacteriological diagnosis of these infections has been traditionally limited by the low yield of conventional cultures and, on average, one-third of cases of pediatric joint and bone infections remained unconfirmed. OBJECTIVE To review the medical literature to summarize the current approach diagnosing the pediatric skeletal system infections. METHODS The relevant publications for the last three decades were reviewed. RESULTS In recent years, the detection of skeletal system pathogens has been revolutionized by the use of improved laboratory methods, including seeding of synovial fluid and bone exudates into blood culture vials, and the development and implementation of sensitive nucleic acid amplification assays. These advances have resulted in the recognition of Kingella kingae as the predominant etiology of hematogenous infections of bones, joints, intervertebral discs and tendon sheaths in children aged 6-48 months, and reduced the fraction of culture-negative osteoarthritis. CONCLUSION As the exudate and tissue samples obtained from young children with skeletal system infections are frequently insufficient for a comprehensive laboratory workup, physicians should take in consideration the patient's age, predisposing medical conditions and possible exposure to zoonotic organisms, and use a judicious combination of Gram's stain, culture on blood culture vials, and molecular tests to maximize the microbiological diagnosis of these diseases.
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Affiliation(s)
- Pablo Yagupsky
- Clinical Microbiology Laboratory, Soroka University Medical Center, Ben-Gurion University of the Negev, Beer-Sheva 84101, Israel
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28
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Abstract
Lyme disease is the most common vector-borne illness in North America, with the majority of cases occurring in the Northeast and upper Midwest. Lyme arthritis is the most prevalent manifestation of late-stage Lyme disease. Lyme arthritis typically presents as a monoarthritis or oligoarthritis in large joints such as the knee. Accompanying positive 2-tier Lyme serologies or polymerase chain reaction from synovial fluid/tissue is considered diagnostic for patients from an endemic area. The mainstay of initial treatment is a prolonged course of oral antibiotics.
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29
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Gendelberg D, Hennrikus WL. Lyme Arthritis of the Pediatric Elbow: A Case Series. Orthopedics 2018; 41:e511-e515. [PMID: 29771396 DOI: 10.3928/01477447-20180511-01] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2017] [Accepted: 02/15/2018] [Indexed: 02/03/2023]
Abstract
Most patients with untreated Lyme disease will experience joint symptoms. Owing to their resemblance in clinical presentation, Lyme arthritis and septic arthritis are often difficult to differentiate. However, their treatment is different. The elbow is rarely the first joint to present with symptoms. Therefore, Lyme disease is not commonly included in the differential diagnosis for children presenting with isolated elbow pain. The authors report 4 cases of monoarticular Lyme arthritis presenting in the elbow. There was an average delay of diagnosis of 4.75 days. Three cases were treated with oral antibiotics alone; 1 case was treated with unnecessary surgery due to uncertainty of the diagnosis and the delay in the laboratory performing the Lyme serology tests. The authors strongly recommend that Lyme serology be performed on an emergent basis to prevent unneeded surgery. [Orthopedics. 2018; 41(4):e511-e515.].
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30
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Keane B, Top J, Burbridge M. Septic Arthritis Versus Lyme Arthritis: A Case of Diagnostic Difficulty. Hosp Pediatr 2018; 8:170-172. [PMID: 29467162 DOI: 10.1542/hpeds.2017-0142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- Brenna Keane
- Department of Pediatrics, Carilion Children's, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; and
| | - Jessica Top
- Department of Pediatrics, Carilion Children's, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; and.,Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
| | - Michael Burbridge
- Department of Pediatrics, Carilion Children's, Carilion Roanoke Memorial Hospital, Roanoke, Virginia; and.,Virginia Tech Carilion School of Medicine and Research Institute, Roanoke, Virginia
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31
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Denouement. Pediatr Infect Dis J 2018; 37:196. [PMID: 29319637 DOI: 10.1097/inf.0000000000001773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Cruz AI, Anari JB, Ramirez JM, Sankar WN, Baldwin KD. Distinguishing Pediatric Lyme Arthritis of the Hip from Transient Synovitis and Acute Bacterial Septic Arthritis: A Systematic Review and Meta-analysis. Cureus 2018; 10:e2112. [PMID: 29581924 PMCID: PMC5866113 DOI: 10.7759/cureus.2112] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Objective Lyme arthritis is an increasingly recognized clinical entity that often prompts orthopaedic evaluation in pediatric patients. While Lyme arthritis is most common in the knee, the clinical presentation of Lyme arthritis of the hip can be similar to both acute bacterial septic arthritis and transient synovitis. Accurately distinguishing these clinical entities is important since the definitive treatment of each is distinct. Because there is limited literature on monoarticular Lyme arthritis of the hip, the purpose of this study was to perform a systematic review and meta-analysis of clinical and laboratory parameters associated with Lyme arthritis (LA) of the hip and compare them to septic arthritis (SA) and transient synovitis (TS). Study design A systematic review of the literature was performed using the following search terms, including the variants and plural counterparts “hip” and “Lyme arthritis.” A final database of individual patients was assembled from the published literature and direct author correspondence, when available. A previously published cohort of patients with hip transient synovitis or septic arthritis was used for comparative analysis. A comparative statistical analysis was performed to the assembled database to assess differences in laboratory and clinical variables between the three diagnoses. Results Data on 88 patients diagnosed with Lyme arthritis of the hip was collected and consolidated from the 12 articles meeting inclusion criteria. The average age of patients presenting with Lyme arthritis was 7.5 years (± 3.5 years), the mean erythrocyte sedimentation rate (ESR), and the C-reactive protein (CRP) was 41 mm/hr and 3.9 mg/L, respectively. Peripheral white blood cell (WBC) count averaged 10.6 x 109cells/L with the synovial WBC count averaging 55,888 cells/mm3. Compared to a previous cohort of patients with confirmed transient synovitis or septic arthritis, the 95% confidence interval for ESR was 21 - 33 mm/hr in those diagnosed with toxic synovitis (TS), 37 - 46 mm/hr for Lyme arthritis (LA), and 44 - 64 mm/hr for septic arthritis (SA). Synovial WBC counts (cells/mm3) 95% confidence intervals (CI) were 5,644 - 15,388 cells/mm3 for TS, 47,533 - 64,242 cells/mm3 for LA, and 105,432 - 260,214 cells/mm3 for SA. There was a statistically significant difference in the incidence of fever > 38.5oC (P < 0.001) and refusal to bear weight (P < 0.01) between SA, LA, and TS. Conclusions Monoarticular Lyme arthritis can be a cause of hip pain in certain geographic areas and has clinical and diagnostic overlap with transient synovitis and acute bacterial septic arthritis. This study consolidates the available literature and represents the largest series of patients diagnosed with Lyme arthritis of the hip to date. We propose a diagnostic algorithm that serially incorporates ESR, followed by a synovial neutrophil count, when evaluating pediatric patients with an irritable hip in Lyme endemic areas.
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Affiliation(s)
| | - Jason B Anari
- Orthopaedic Surgery, Children's Hospital of Philadelphia
| | - Jose M Ramirez
- Orthopaedic Surgery, Warren Alpert Medical School of Brown University
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Abstract
Acute septic arthritis is a condition with the potential for joint destruction, physeal damage, and osteonecrosis, which warrants urgent identification and treatment. The organism most frequently responsible is Staphylococcus aureus; however, our understanding of pathogens continues to evolve as detection methods continue to improve. MRI has improved our ability to detect concurrent infections and is a useful clinical tool where available. The treatment course involves intravenous antibiotics followed by transition to oral antibiotics when clinically appropriate. The recommended surgical treatment of septic arthritis is open arthrotomy with decompression of the joint, irrigation, and debridement and treatment of concurrent infections.
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Kelly DM, Weiss JM, Martus JE. What's New in Pediatric Orthopaedics. J Bone Joint Surg Am 2017; 99:353-359. [PMID: 28196040 DOI: 10.2106/jbjs.16.01192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Derek M Kelly
- 1Campbell Clinic, Department of Orthopaedic Surgery and Biomechanical Engineering, University of Tennessee, Memphis, Tennessee 2Division of Orthopedic Surgery, Southern California Kaiser Permanente Medical Group, Los Angeles, California 3Division of Pediatric Orthopaedics, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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