Infecciones osteoarticulares en niños / Osteoarticular infections in children

Las infecciones osteorticulares (IOA) en el niño son una causa importante de morbilidad y secuelas. Su pesquisa oportuna y el tratamiento eficiente pueden lograr excelentes resultados. La mejoría en las condiciones de salud de la población, y el cambio de los agentes etiológicos han variado la forma de presentación y tratamiento. La existencia de gérmenes como Kingella kingae y Staphilococcus aureus multiresistente, contribuyen a la variabilidad de presentación de las infecciones osteoarticulares.El manejo de estas patologías requiere de un conocimiento del cuadro clínico, de los métodos de diagnóstico y las herramientas terapéuticas. Para obtener buenos resultados es requisito básico el enfrentamiento de estos pacientes en un equipo multidisciplinario de especialistas.En este manuscrito revisaremos los aspectos fundamentales de las infecciones osteoarticulares, según el enfoque que aplicamos en nuestros pacientes.

Osteoarticular infections are a substantial cause of morbidity and sequelae in children. Early diagnosis and efficient treatment can achieve excellent results. The improvement in the health conditions of the population and the change in the etiological agents have produced changes in their presentation and their required treatment. The existence of germs like Kingella kingae and Staphilococcus aureus multiresistant contribute to the variability of presentation of osteoarticular infections.The appropriate management of these pathologies requires knowledge of the clinical picture, diagnostic methods, and therapeutic tools. To obtain good results, it is a basic requirement that these patients be confronted by a multidisciplinary team of specialists.In this manuscript we will review the most fundamental aspects of osteoarticular infections according to the approach we apply to our patients

Infecciones osteoarticulares en niños: experiencia de cinco años

Resumen Introducción: Las infecciones osteoarticulares (IOA) son consideradas una urgencia infectológica en niños. Los principales microorganismos causales son Staphylococcus aureus y Streptococcus pyogenes. Objetivo: Describir las características bio-demográficas y clínicas de pacientes de 2 meses a 15 años hospitalizados entre 2012 y 2017 con diagnóstico de IOA. Pacientes y Métodos: Estudio retrospectivo en un hospital pediátrico. Se revisaron fichas clínicas de pacientes internados con diagnóstico de IOA. Resultados: Se incluyó a 146 pacientes. Un 60,3% fueron de sexo masculino, mediana de edad 3 años 11 meses. El síntoma más frecuente al ingreso fue dolor articular (90%) y la mediana de PCR fue de 43 mg/L. Se obtuvo identificación microbiológica en 48%; de ellos, 67,8 % S. aureus (10,2% resistentes a meticilina). El 94,5% de los pacientes recibió de forma empírica β-lactámico anti-estafilocócico. Un 70,5% de los niños requirió procedimiento quirúrgico. A las 72 h se observó respuesta clínica y a los 4,7 días descenso de parámetros inflamatorios de laboratorio. El 88% de los pacientes cursó sin complicaciones. Conclusiones: Las IOA son más frecuentes en varones, el agente infeccioso más frecuentemente identificado fue S. aureus, por lo cual se sugiere inicio del esquema antimicrobiano con un β-lactámico anti-estafilocócico, ampliando cobertura en pacientes bajo 5 años de edad. A los 5 días del tratamiento antimicrobiano ya hay respuesta clínica y descenso de parámetros inflamatorios.

Abstract Background: Osteoarticular infections (IOA) are considered infectious emergencies. The main microorganisms isolated are Staphylococcus aureus and Streptococcus pyogenes. Aim: To describe demographic and clinical characteristics of patients from 2 months to 15 years old, hospitalized between the years 2012 and 2017 with IOA diagnosis. Methods: Retrospective study in a pediatric hospital. Clinical records of hospitalized patients with IOA were reviewed. Results: 146 met inclusion criteria. 60.3% of the patients were male, median age 3 years 11 months. The main symptom at admission was joint pain (90%) and the median CRP was 43 mg/L. 48% of the patients had microbiological identification; 67.8% were positive for Staphylococcus aureus (10.2% SAMR). 94.5% of the sample received empirical antistaphylococcal beta-lactam treatment and 70,5% had a surgical intervention. Clinical response was observed 72 hours of beginning of treatment, and a decreased in inflammatory laboratory markers was observed at 4.7 days. 88% of patients attended without complications. Conclusions: IOA infections are more common in boys, S. aureus is the main isolated pathogen, so we suggest to initiate the antimicrobial scheme with an antistaphylococcal beta-lactam, adding broad spectrum antimicrobial in children under 5 years. After 5 days of treatment, clinical resolution and decreased inflammatory laboratory parameters were observed.

Determination of diagnostic value (validity) leukocyte esterase (urine dipstick strip) in differentiating inflammatory arthritis from bacterial arthritis

Abstract Background: The current diagnostic cornerstone for septic arthritis contains gram stains, bacterial culture, and cell count with a differential of aspirated synovial fluid. Recently, a synovial leukocyte esterase (LE) test has been used for diagnosing septic arthritis. Since this test measures the esterase activity of leukocytes, there is always a dilemma for using this test in patients with inflammatory arthritis. Methods: We collected the synovial fluid specimens as part of the general diagnostic protocol for patients suspected of Juvenile Idiopathic Arthritis (JIA) or Septic Arthritis (SA). Each group included 34 patients. We compared the result of the synovial LE test with the result of the culture of each patient. Results: The mean ages of patients were 64.14 ± 31.27 and 50.88 ± 23.19 months in the JIA group and septic arthritis group, respectively. The LE test results were positive in 30 specimens, trace in 3 and negative in one in the first-time test and were positive in 31 specimens and trace in 3 in the second-time test, while it was negative in all patients with JIA. Hence, the sensitivity of the synovial LE test was 80.8%, the specificity, PPV, and NPV were 78.6, 70.0, 86.8% respectively based on a positive culture. Conclusion: The leukocyte esterase strip test can be used as a rapid, bedside method for diagnosing or excluding bacterial infections in different body fluids. The synovial LE test can be used as an accurate test to rapidly rule in or out an acute articular bacterial infection, even in patients with concurrent inflammatory arthritis.(AU)

Septic arthritis caused by Salmonella enterica serotype Rubislaw: A case report

Abstract An eleven-year-old boy presented with fever and hip pain, with limited mobility of the right side of the hip. Computed tomography scan revealed an increased volume of the right coxo-femoral joint, requiring surgical drainage of purulent secretion, from which Salmonella enterica was isolated. After four weeks of treatment with third-generation cephalosporin, he was discharged with a favorable evolution. Invasive disease caused by Salmonella spp represents a small proportion of salmonellosis cases, although it is responsible for greater rates of hospitalization, morbidity and mortality. Children under 5 years, elders over 60 years and immunodeficient patients have greater risk for invasive salmonellosis.

Artritis séptica de rodilla por Staphylococcus warneri / Septic arthritis of the knee by Staphylococcus warneri

Resumen: La artritis séptica suele presentarse como un proceso articular agudo que puede provocar una rápida destrucción del cartílago, si no se toman las medidas terapéuticas necesarias. De manera poco frecuente, el Staphylococcus warneri puede ser la causa de esta patología aunque por su dificultad diagnóstica podemos cometer errores en su tratamiento. Presentamos el caso de un paciente con artritis séptica de rodilla por este germen y pretendemos remarcar cuáles son las medidas diagnósticas y recomendaciones a tener en cuenta para esta infección osteoarticular.

Abstract: Septic arthritis usually occurs as an acute joint process that can cause a rapid destruction of the cartilage, if the necessary therapeutic measures were not taken. Rarely, Staphylococcus warneri may be the cause of this pathology although due to its diagnostic difficulty we can make mistakes in its treatment. We present the case of a patient with septic arthritis of the knee by this germ and we intend to remark what are the diagnostic measures and recommendations to consider for this osteoarticular infection.

Septic arthritis of native hip joint by Staphylococcus lugdunensis: a case report

Abstract Staphylococcus lugdunensis is a rare virulent coagulase-negative staphylococcus (CoNS) that behaves similarly to Staphylococcus aureus in causing deep abscesses, skin and soft tissue infections, and central nervous system infections. Additionally, there can be certain blood stream infections including sepsis, septic shock, toxic shock syndrome, and endocarditis complicated by embolic events. Reports of septic arthritis of a native joint associated with this organism have been infrequent, justifying the presentation and discussion of this case.

Childhood pyogenic septic arthritis as seen in a teaching hospital South East Nigeria

Background: Childhood pyogenic septic arthritis and its associated musculoskeletal morbidity is an important health concern in developing countries. Its pattern of presentation that varies from and within subregions has implications on the early recognition, treatment, and outcome. The aim of this study was to determine the pattern and outcome of childhood septic arthritis in our environment. Materials and Methods: This was a retrospective study of all the children seen with pyogenic septic arthritis in Federal Teaching Hospital Abakaliki between January 2005 and December 2015. Results: Childhood septic arthritis accounted for 44 (83%) of the 53 patients seen with pyogenic septic arthritis. Female to male ratio was 1:1.75 and the mean age was 5.7 ± 0.73 years. Eight patients (18.2%) had polyarticular involvements. The right shoulder was significantly more involved than the left and the left hip more than right. Overall, there was a preponderance of onset of symptoms in the dry season. Children from the rural areas accounted for 85.7% of those with the onset of symptom in rainy season. Delayed presentation >6 days (in 68.2% of patients) was related to age (P < 0.042), and health seeking behavior (P < 0.036). Staphylococcus aureus was the commonest causative organism. Seventy-seven percent (77%) underwent open arthrotomy. Anemia, septic shock, and joint stiffness were three top complications observed. Mortality rate was 2.3%, and cause of death was overwhelming sepsis. Conclusion: In our setting, pyogenic septic arthritis is predominantly a childhood health problem and children under 5 years of age are the most vulnerable. Delayed presentation, an important factor in morbidity and mortality associated with septic arthritis was common among the patients, calls for a public enlightenment program on the importance of early presentation

Candida arthritis in a patient diagnosed with spondyloarthritis

Abstract Candida arthritis is an unusual manifestation that usually affects the knees. A 35-year-old man presented with a 2-month history of pain and swelling in the right knee. Swelling persisted after anti-inflammatory treatment. Peripheric spondyloarthritis was considered, but methotrexate, sulfasalazine, and methylprednisolone did not reduce the swelling. Direct examination of synovial fluid and a culture were positive for Candida albicans. Intravenous and intra-articular amphotericin-B were administered. The arthritis regressed and a culture and direct staining showed negative results. Candida arthritis should be considered in patients with arthritis that is resistant to treatment and prolonged, even if risk factors are absent.

Histoplasmosis diagnosed after arthroscopy of the knee: case report

ABSTRACTFungal arthritis is a rare complication of arthroscopic surgeries, but its possibility should always be considered due its deleterious effects on any joint. Infection caused by the fungus Histoplasma capsulatum is the most common cause of respiratory tract infections by fungi, meanwhile histoplasmosis arthritis is more rare than all other fungal infections. However, their atypical forms of arthritis and the importance of early diagnosis and treatment cannot be over-emphasized. Herein we report a case of knee monoarthritis in an immunocompetent patient with histoplasmosis arthritis following an arthroscopic meniscetomy, diagnosed by synovial biopsy and culture performed during a second arthroscopic procedure. The joint was debrided in this second intervention and the patient received itraconazole initially and fluconazole latter on. The arthritis subsided after 10 months of treatment.

Artritis infecciosa de la articulación temporomandibular consecutivo a otitis necrotizante: reporte de un caso / Septic arthritis of the temporomandibular joint: Report of one case

Septic arthritis of the temporomandibular joint (TMJ) is an uncommon condition, caused by hematic bacterial migration or direct migration of other head and neck infections. We report a 41 year old female who presented a right temporomandibular joint involvement, with bone destruction of the mandibular condyle and an infectious process spreading to the temporal space, following a necrotizing medial and external otitis with associated mastoiditis. A septic arthritis of the TMJ by continuity was diagnosed and treated with antimicrobials, TMJ arthrocentesis and occlusal stabilization, with a positive evolution. However, the patient remains in control due a secondary TMJ osteoarthritis caused by the septic arthritis.

Artritis seudoséptica presenta sinovitis por cuerpo extraño en un paciente con gota / Pseudoseptic arthritis with foreign body synovitis in a patient with gout

La monoartritis es un reto diagnóstico para el clínico, ya que es extensa la lista de patologías asociadas. En pacientes con diagnóstico establecido de enfermedad articular inflamatoria, se acepta que la monoartritis corresponde a la exacerbación de la enfermedad de base; sin embargo, ignorar el abordaje sistematizado de las monoartritis puede generar omisiones e implicaciones diagnósticas erróneas. En este reporte se analiza el abordaje de un caso de artritis seudoséptica, simulando un ataque agudo de artritis por urato monosódico recurrente en un paciente con retención de cuerpo extraño intraarticular.

Monoarthritis is a diagnostic challenge for the clinician, as the list of associated conditions is quite long. It is accepted that in patients with a diagnosis of inflammatory joint disease monoarthritis represents exacerbation of the underlying disease. However, ignoring the systematized approach to monoarthritides may lead to omissions and mistaken diagnostic implications. This report describes the approach to a case of pseudoseptic arthritis that mimicked an acute episode of recurrent arthritis due to monosodium urate in a patient with retention of an intraarticular foreign body.

Application of a Novel Diagnostic Rule in the Differential Diagnosis between Acute Gouty Arthritis and Septic Arthritis

Septic arthritis and gout are major diseases that should be suspected in patients with acute monoarthritis. These two diseases are clinically similar and often indistinguishable without the help of synovial fluid analysis. Recently, a novel diagnostic rule for gout without synovial fluid analysis was developed and showed relevant performances. This study aimed to determine whether this diagnostic rule could perform well in distinguishing gout from septic arthritis. The diagnostic rule comprises 7 clinical and laboratory variables, each of which is given a specified score. The probability of gout is classified into 3 groups according to the sum of the scores: high (> or = 8), intermediate (> 4 to < 8) and low probability (< or = 4). In this retrospective study, we applied this diagnostic rule to 136 patients who presented as acute monoarthritis and were subsequently diagnosed as acute gout (n = 82) and septic arthritis (n = 54) based on synovial fluid analysis. The mean sum of scores of acute gout patients was significantly higher than that of those with septic arthritis (8.6 +/- 0.2 vs. 3.6 +/- 0.32, P < 0.001). Patients with acute gout had significantly more 'high', and less 'low' probabilities compared to those with septic arthritis (Eta[eta]: 0.776). The prevalence of acute gouty arthritis, as confirmed by the presence of monosodium crystal, was 95.5% (61/64), 57.5% (19/33), and 5.1% (2/39) in high, intermediate and low probability group, respectively. The recently introduced diagnostic rule properly discriminates acute gout from septic arthritis. It may help physicians diagnose gout in cases difficult to be differentiated from septic arthritis.

Prognostic Factors of Septic Arthritis of Hip in Infants and Neonates: Minimum 5-Year Follow-up

BACKGROUND: The authors conducted the present study to identify clinical and radiological prognostic factors in infants and neonates with septic arthritis of the hip. METHODS: The authors retrospectively reviewed the records of 31 patients with septic arthritis of the hip. All of the patients were younger than 18 months old. Follow-up periods ranged from 5 to 17 years. The following potential variables for predicting the prognosis were included in the assessment: gender, age, underlying diseases, duration of symptoms, changes of hip joint in X-ray, concomitant osteomyelitis, elevation of erythrocyte sedimentation rate and C-reactive protein, sepsis, pus drainage, synovial fluid culture, and infecting organisms. Clinical and radiological prognoses were analyzed at the final follow-up. RESULTS: Univariate analysis demonstrated that radiological prognoses were poorer in patients who had underlying diseases, a longer duration of symptoms, and pus drainage. However, on multivariate analysis, only the variable-duration of symptoms-was found to be statistically related with a poor radiological prognosis. CONCLUSIONS: Although poor prognosis for patients with several underlying diseases and radiological changes has already been established, a favorable outcome might be expected with prompt surgical drainage and appropriate antibiotics.

Acromioclavicular Septic Arthritis and Sternoclavicular Septic Arthritis with Contiguous Pyomyositis

Acromioclavicular (AC) and sternoclavicular (SC) septic arthritis with contiguous pyomyositis are rare, especially in immunocompetent individuals. We report a case of septic AC joint with pyomyositis of the deltoid and supraspinatus muscles and a separate case with septic SC joint with pyomysitis of the sternocleidomastoid muscle. Both patients had similar presentations of infections with Staphylococcus aureus and were successfully treated with surgical incision and drainage followed by prolonged antibiotic therapy.

Artritis séptica en pacientes adultos en un hospital general de Chile / Septic arthritis in adult patients in a general hospital in Chile

Background: Septic arthritis is an infrequent condition of prolonged morbidity and there is no previous publications in Chile that allow orientate therapy. Aim: To characterize a group of adult patients with septic arthritis confirmed by culture. Material and Methods: Descriptive study of a case series. Results: From 2003 to august 2013, 24 patients with 25 events of septic arthritis were identified in a general hospital. Mean age was 68.3 years old (range 24-94). Predisposing conditions were harbored by 91.7%. Predominant clinical manifestations were pain (92%) and impaired joint movement (95.7%). Fever was present in 64%, hypotension in 28% of events, and C-reactive protein > 100 mg/L in 90.6%. Gram positive cocci were the most frequently isolated microorganisms (81.5%), predominating S. aureus (48.1%), and with 4 isolates methicillin resistant isolates (26.7%). Resistant isolates trend to be associated with previous surgery (p = 0.055) and all cases caused by non-fermentative Gram negative bacilli had recent hospitalization or surgery, a feature that did not reach a significant difference. Nine events were associated to bacteremia (36%). Outcome analysis indicated 32% of events with full recovery, 28% with a favorable evolution, 20% with therapy failure and 16.7% patients that died. A total of 24% of the series remained with significant sequels. Conclusions: Septic arthritis is an infrequent disease that affects in most cases patients with predisposing conditions. Associated symptoms include pain and impaired joint movement, sometimes fever, hypotension, positive blood cultures and frequently a C-reactive protein > 100 mg/L. Predominant agents are Gram positive cocci, specially S. aureus, including methicillin resistant isolates. Case-fatality ratio, treatment failure and sequels are important.

Antecedentes: Los cuadros de artritis séptica son esporádicos pero de elevada morbilidad y no hay publicaciones en Chile que permitan orientar el tratamiento de ellos. Objetivos: Caracterizar un grupo de pacientes con cuadros de artritis séptica confirmados microbiológicamente. Pacientes y Métodos: Serie de casos. Resultados: Un total de 24 pacientes con 25 eventos de artritis séptica fue identificado entre el 2003 y agosto de 2013. La edad promedio fue de 68,3 años (24-94) y 91,7% tuvo condiciones que predisponen. Las manifestaciones clínicas dominantes fueron dolor (92%) e impotencia funcional (95,7%), 64% presentó fiebre y 28% tuvo hipotensión arterial. Un 90,6% tuvo PCR > 100 mg/L. Las cocáceas grampositivas fueron los microorganismos más frecuentes (81,5%), predominando Staphylococcus aureus (48,1%) y cuatro cepas estafilocóccicas presentaron resistencia a cloxacilina (26,7%). Las cepas resistentes tendieron a estar asociadas a pacientes con cirugía articular previa (p: 0,055) y todos los casos asociados a bacilos gramnegativos no fermentadores tenían antecedentes de hospitalización reciente o cirugía articular previa. Nueve eventos (36%) se asociaron a bacteriemia. Un 32% de los pacientes tuvo curación, 28% un curso favorable, 20% fracaso y 16,7% falleció. Un 24% quedó con secuelas. Conclusiones: Los cuadros de artritis séptica son infrecuentes, afectan en su mayor parte a pacientes con factores que predisponen, se presentan con dolor e impotencia funcional, a veces fiebre, hipotensión arterial o bacteriemia y generalmente con PCR > 100 mg/L. Se asocian a cocáceas grampositivas, especialmente S. aureus, incluyendo aislados resistentes a cloxacilina. La letalidad, fracaso del tratamiento y secuelas no son despreciables.

Evaluation of a Real-Time PCR Assay for Simultaneous Detection of Kingella kingae and Staphylococcus aureus from Synovial Fluid in Suspected Septic Arthritis

Direct plating of synovial fluid (SF) on agar-based media often fails to identify pathogens in septic arthritis (SA). We developed a PCR assay for the simultaneous detection of Kingella kingae and Staphylococcus aureus from SF to evaluate molecular detection in SF and to estimate the incidence of K. kingae in SA in North America. The assay was based on detection of the cpn60 gene of K. kingae and the spa gene of S. aureus in multiplex real-time PCR. K. kingae was identified in 50% of patients between 0 and 5 yr of age (n=6) but not in any patients >18 yr old (n=105). Direct plating of SF on agar-based media failed to detect K. kingae in all samples. The PCR assay was inferior to the culture-based method for S. aureus, detecting only 50% of culture-positive cases. Our findings suggest that K. kingae is a common pathogen in pediatric SA in North America, in agreement with previous reports from Europe. PCR-based assays for the detection of K. kingae may be considered in children with SA, especially in those with a high degree of clinical suspicion.

Utilización de un método molecular para la detección de kingella kingae en muestras osteoarticulares / The Use of a molecular method for the detection of Kingella kingae in bone and joint samples

Kingella kingae es un agente causal de infecciones osteoarticulares especialmente en niños menores de 4 años. En este trabajo se ha realizado un estudio comparativo entre un método molecular [reacción en cadena de la polimerasa (PCR) en tiempo real y dos métodos microbiológicos habitualmente empleados para el estudio de las infecciones osteoarticulares. Sólo se obtuvo resultado positivo para K. kingae por el método de PCR en 3 de las 60 muestras analizadas. Los pacientes evolucionaron sin secuelas aparentes con tratamiento antibiótico. Es importante destacar, como ya lo han hecho otros autores, que adicionando métodos moleculares se puede aumentar sensiblemente la recuperación de este patógeno.