Similar erythrocyte sedimentation rate and C-reactive protein sensitivities at the onset of septic arthritis, osteomyelitis, acute rheumatic fever

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

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.

Etiology of chronic atrioventricular block in young adults in a public university hospital in India

In young adults, chronic atrioventricular (AV) block has scant systematic documentation in India. This prospective study included patients 18–40 years old, presenting with AV block without a reversible cause. There were 27 patients, aged 32 +/- 6.3 years, with 16 males. All patients had complete AV block with a narrow QRS escape rhythm (rate 40.5 ± 6.5 beats/min). Three patients were ANA positive and of these, 2 patients were anti ds DNA positive. The ESR and CRP levels were mildly elevated in 12 and 8 patients respectively. The rest of the tests were unremarkable. Despite performing multiple tests, the etiology remained idiopathic in most.

First-4-week erythrocyte sedimentation rate variability predicts erythrocyte sedimentation rate trajectories and clinical course among patients with pyogenic vertebral osteomyelitis

BACKGROUND

The trajectory pattern of erythrocyte sedimentation rate (ESR) in patients with pyogenic vertebral osteomyelitis (PVO) and its clinical significance is unclear. We further evaluated whether the first-4-week ESR variability can predict the trajectory pattern, treatment duration and recurrence of PVO.

METHODS

The longitudinal ESR patterns of adults with PVO within the first 6 months were characterized through group-based trajectory modeling (GBTM). The ESR variability within the first 4 weeks was defined using the absolute difference (AD), coefficient of variation, percent change, and slope change. The first-4-week ESR variabilities were analyzed using ordinal logistic regression to predict the 6-month ESR trajectory and using logistic regression to predict treatment duration and recurrence likelihood. The discrimination and calibration of the prediction models were evaluated.

RESULTS

Three ESR trajectory patterns were identified though GBTM among patients with PVO: Group 1, initial moderate high ESR with fast response; Group 2, initial high ESR with fast response; Group 3, initial high ESR with slow response. Group 3 patients (initial high ESR with slow response) were older, received longer antibiotic treatment, and had more comorbidities and higher recurrence rates than patients in the other two groups. The initial ESR value and ESR - AD could predict the 6-month ESR trajectory. By incorporating the first-4-week ESR variabilities and the clinical features of patients, our models exhibited moderate discrimination performance to predict prolonged treatment (≥12 weeks; C statistic, 0.75; 95% confidence interval [CI], 0.70 to 0.81) and recurrence (C statistic, 0.69; 95% CI, 0.61 to 0.78).

CONCLUSIONS

The initial ESR value and first-4-week ESR variability are useful markers to predict the treatment duration and recurrence of PVO. Future studies should validate our findings in other populations.

Comparative Clinical Characteristics of Rheumatic Heart Disease Patients Undergoing Surgical Valve Replacement

Background

To assess the prevalence patterns of isolated/mixed rheumatic valvular lesions and associated risk factors among rheumatic heart disease (RHD) patients undergoing surgical valve replacement.

Methods

An analytical cross-sectional design was used. Purposive sampling was used to select 87 RHD patients who underwent a first-time valve replacement for mitral, aortic, or both valves between April 1 and October 20, 2016, at Punjab Institute of Cardiology, Lahore, Pakistan. Patients with systemic hypertension, diabetes mellitus type-II, congenital heart defects, coronary artery disease, non-rheumatic valvular degeneration, positive test for hepatitis C, or undergoing concomitant coronary artery bypass graft or a ‘redo’ valve replacement procedure were excluded.

A proforma was used to collect preoperative data on patients’ demographics, laboratory investigations, electrocardiogram (ECG), and transthoracic echocardiography reports.

Results

Age (mean ± S.D.) was 32.79 ± 13.06 years, which was divided into four quartile-based groups. Forty-six (52.9%) cases were males. The majority (56.3%) of patients underwent mitral valve replacement. Mitral regurgitation (MR, 80%) was the most common lesion. Of 71 available ECGs, atrial fibrillation was observed in 46.5% cases. Increasing age group was negatively correlated with MR severity (τ_c = -0.188, p-value = 0.033) and positively with aortic stenosis (AS) severity (τ_c = 0.141, p-value = 0.010).

No significant elevations were observed for anti-streptolysin O titer, C-reactive protein, and leukocyte count, though the erythrocyte sedimentation rate was abnormally high in 46.94% cases.

Conclusions

MR was the most common lesion. MR was more severe in younger patients whilst AS was more severe in older cases. There is little evidence of ongoing residual inflammation.

A prospective study of screening for musculoskeletal pathology in the child with a limp or pseudoparalysis using erythrocyte sedimentation rate, C-reactive protein and MRI

PURPOSE

To determine if the detection of musculoskeletal pathology in children with a limp or acute limb disuse can be optimized by screening with blood tests for raised inflammatory markers, followed by MRI.

METHODS

This was a prospective observational study. Entry criteria were children (0 to 16 years of age) presenting to our emergency department with a non-traumatic limp or pseudoparalysis of a limb, and no abnormality on plain radiographs. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) blood tests were performed. Children with ESR > 10 mm/hr or CRP > 10 mg/L underwent a MRI scan. When the location of the pathology causing the limp was clinically unclear, screening images (Cor t1 and Short Tau Inversion Recovery) of both lower limbs from pelvis to ankles ('legogram') was undertaken. Data was gathered prospectively from 100 consecutive children meeting the study criteria.

RESULTS

In all, 75% of children had a positive finding on their MRI. A total of 64% of cases had an infective cause for their symptoms (osteomyelitis, septic arthritis, pyomyositis, fasciitis, cellulitis or discitis). A further 11% had positive findings on MRI from non-infective causes (juvenile idiopathic arthritis, cancer or undisplaced fracture). The remaining 25% had either a normal scan or effusion due to transient synovitis. ESR was a more sensitive marker than CRP in infection, since ESR was raised in 97%, but CRP in only 70%.

CONCLUSION

In our opinion MRI imaging of all children with a limp and either raised ESR or CRP is a sensitive method to minimize the chance of missing important pathology in this group, and is an effective use of MRI resources. We advocate the use of both blood tests in conjunction.

LEVEL OF EVIDENCE

Level II.

The safety and efficacy of an enzyme combination in managing knee osteoarthritis pain in adults: a randomized, double-blind, placebo-controlled trial

This randomized, double-blind, placebo-controlled, and comparator-controlled trial evaluated the safety and efficacy of an enzyme combination, as Wobenzym, in adults with moderate-to-severe osteoarthritis (OA) of the knee. Adults (n = 150) received Wobenzym, diclofenac (a nonsteroidal anti-inflammatory drug, NSAID), or placebo for 12 weeks. Improvement in pain scores (Lequesne Functional Index) did not differ between subjects treated with Wobenzym or diclofenac, and both treatment groups improved compared to placebo (P < 0.05). Reduction in total WOMAC scores (secondary outcome measure) did not differ between Wobenzym and diclofenac, although only diclofenac emerged as different from placebo (P < 0.05). The median number of rescue medication (paracetamol) tablets consumed was less in the Wobenzym group compared to placebo (P < 0.05), while there was no difference between diclofenac and placebo. Adverse events were similar in frequency in Wobenzym and placebo groups (7.2% and 9.1% of subjects, resp.) and higher in diclofenac group (15.6%). Wobenzym is comparable to the NSAID diclofenac in relieving pain and increasing function in adults with moderate-to-severe painful knee OA and reduces reliance on analgesic medication. Wobenzym is associated with fewer adverse events and, therefore, may be appropriate for long-term use.

Erythrocyte sedimentation rate and C-reactive protein: how best to use them in clinical practice

Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are markers of inflammatory conditions and have been used extensively by clinicians both in outpatient and inpatient settings. It is important to understand the physiologic principles behind these two tests so clinicians may use them appropriately. For example, fibrinogen (for which ESR is an indirect measure) has a much longer half-life than CRP, making ESR helpful in monitoring chronic inflammatory conditions, whereas CRP is more useful in diagnosis as well as in monitoring responses to therapy in acute inflammatory conditions, such as acute infections. Many factors can result in falsely high or low ESR and CRP levels, and it is important to take note of these. Therefore, if used wisely, ESR and CRP can be complementary to good history taking and physical examination in the diagnosis and monitoring of inflammatory conditions.