Infectious and Rheumatic Disease in Children

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Infectious and Rheumatic Disease in Children

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• Infectious disease in children
• Acute hematogenous osteomyelitis (AHO)
• Acute septic arthritis
• Special conditions
• Rheumatic disease in children
• Juvenile Idiopathic Arthritis (JIA)

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Introduction

• A relatively common problem in children
• Peak incidence in the first decade
• Can cause severe disability
• Pediatric orthopedic emergencies
• A timely accurate diagnosis is essential for
  effective tx.
• Early diagnosis treatment !

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Early Dx. Tx.
Pre op
Post op 10 M
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Delayed Dx. Tx.
Pre op
Post op 2 M
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Anatomy

• Cortical bone
• metaphysis easy communication btw.
  subperiosteal
• medullary space
• diaphysis dense compact bone
• Cancellous bone (more pronounced in long bone)
• medullary cavity rich RES, little bone
• metaphyseal region few RES, more bone

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• Periosteum
• thick, easily separated, not easily penetrated
• Vessels beneath the physeal plate
• small arterial loops into venous sinusoids
  (turbulence)
• gaps in the endothelial wall

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Changing anatomy of interosseous blood supply

• In infant
• Before the ossific nucleus is formed
• Metaphyseal vessel penetrate into epiphysis
• Early destruction and growth disturbance

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Changing anatomy of interosseous blood supply

• After the ossific nucleus is formed
• Epiphysis Metaphysis have separate blood supply
• Physeal plate provide barrier to the spread of
  infection into epiphysis

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Pathogenesis of Osteomyelitis

• Causes remain unknown
• Bacteremia a frequent (daily) event
• 50 occurrence following tooth brushing
• Begins in metaphysis of long bone

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Portals of Entry
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Why does acute hematogenous osteomyelitis
begin in the metaphysis ?

• Sluggish circulation favoring deposition of
  bacteria

• Trauma to metaphysis delays macrophage migration
  into area

• Poorly developed RES with lack of tissue-based
  macrophages

• Local edema and hematoma limits blood supply and
  provides medium for bacterial proliferation

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Subsequent course of metaphyseal abscess
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Metaphysis within the joint early septic
arthritis
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Risk factors

• Diabetes Mellitus
• Hemoglobinopathies
• Chronic renal disease
• Rheumatic arthritis
• Immune compromise

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Pathogenesis of Septic Arthritis

• Bacteremia
• Synovium (RES absence)
• Subperiosteal spread
• Direct innoculation

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• Synovitis fibrinous exudate
• Synovial necrosis
• Cartilage destruction
• Articular cartilage lacks blood supply,
• Enzymes degrade matrix collagen
• Immune response even after the bacteria are
  eliminated.
• Process continues until debris removed from joint

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Pathogens

• S. aureus -- still the predominant (6090)
• Beta Hemolytic streptococcus -- esp. Group B
• G(-) organisms -- less than 5
• H. influenzae esp those cases with negative
  cultures
• if below 3 yrs of ages
• P. aeruginosa after age nine, most common G(-)
  org.
• from puncture wound

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Diagnosis

• Suspicion key to Dx.
• History
• Physical Examination
• Laboratory
• Imaging study
• Aspiration - essential

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• History
• fever, malaise, limping
• Refusal to walk, to bear weight or disuse
• history of other infectious disease
• conditions that impair host immunity
• eg. Chicken Pox
• recent trauma
• risk factors DM, CRD, RA

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• Physical Examination
• Swelling, erythema warmth
• Tenderness, LOM.
• Pseudoparalysis, limp
• cf. Inability to log roll the hip (IR, ER) is
  90 predictive of hip joint effusion

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Laboratory test

• WBC not reliable esp. in early stage
• only 15 abnormal, shift to left in 65
• ESR best single test (reliable indicator, in
  90)
• not reliable in neonate, anemia, steroid, less
  than 48-72hrs
• return normal within 2- 4 wks
• CRP helpful in early diagnosis
• rise within 6 hrs return normal within 1 wk
• Blood culture even after antibiotics
• 30 50 positive culture

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Imaging studies

• Plain Radiographs
• Ultrasound
• Bone Scan
• Computed Tomography
• Magnetic Resonance Imaging

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1. Plain Radiographs

• Minimal usefulness early in infections
• Bone changes take 714 days to appear
• Soft tissue edema may obliterate soft tissue
  planes (3days)
• Bone resorption periosteal new bone formation

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• Joint space widening seen in only 40 septic
  arthritis
• Most useful to rule out tumor, trauma, other bony
  pathology

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2. Ultrasound

• Useful in detecting joint effusions,
  subperiosteal abscess, soft tissue swelling
• Best useful when diagnosis in question or need to
  confirm soft tissue edema or abscess
• Should not delay aspiration
• ( sono-guided aspiration )

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3. Bone scans

• Test of choice when multiple sites are in
  question or the site is unknown

• Technetium 99m diphosphonate bone scan
• 3 phase scan, pin hole or magnification
• Can rule out multifocal osteomyelitis
  malignancy
• Cold scan asso with devasc. subperiosteal
  abscess
• Should not delay aspiration

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Pin hole view
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Scans may be misleading

• Very early stage lt 24hours after onset
• Neonate
• Patient with sickle cell disease

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4. CT

• Decreased bone density, soft tissue masses or
  intraosseous gas
• Good for documentation of sequestration, abscess,
  S-I joint, spine
• Poor for early acute osteomyelitis, septic
  arthritis

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5. MRI

• Useful for detecting soft tissue and marrow
  abnormalities
• Poor bone detail, high cost, time consuming, may
  need sedation
• Probably best used when other data is conflicting
  or confusing

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F / 20D
F / 6M
F / 14Y
Incision Drainage instead of arthrotomy
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Aspiration

• Ultimate Diagnostic Test
• for
• Osteomyelitis and septic arthritis

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Indications for aspiration

• Bone tenderness
• Deep soft tissue swelling
• Bone changes on radiographs
• periosteal new bone, bone destruction
• Joint effusion

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Fluid analysis

• 1. Joint aspirate

Nl. Infl. (JIA)
Septic Clarity clear
translucent opaque Color
clear yellow(clear)
white(turbid) Mucin clot good
good to poor poor WBC
lt200(mm³) 2K-100K
50K-gt100K PMNs lt25
50 gt75 Gram S.
Neg. Neg.
30-40 pos.
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Septic Arthritis

• WBC gt 80,000
• Diff. count gt 75 neutrophils
• Mucin poor
• Sugar 50 mg
• Gram stain 1/3 positive
• culture positive in 70-80

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• 2. Osteomyelitis
• Metaphysis
• Subperiosteal bone aspiration
• Gram Stain, cultures
• Cultures positive 85-90 of cases
• Gram stain positive in 30-40

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Differential Diagnosis (AHO)

• Rheumatic fever
• Septic arthritis
• Cellulitis
• Malignancy (Ewings sarcoma and leukemia)
• Thrombophlebitis
• Sickle cell crisis
• Gauchers disease
• Toxic synovitis

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Differential diagnosis (Septic arthritis)

• Transient synovitis of the hip
• Pelvic, sacroiliac, vertebral osteomyelitis
• LCP
• SCFE
• Appendicitis
• Rheumatic fever
• Leukemia
• JIA.

• History of fever greater than 38.50
• Inability to bear weight
• ESR greater than 40mm/h
• WBC count greater than 12000/µL

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Principles of treatment (AHO)

• Identify the organism
• Select the correct antibiotics
• Deliver the antibiotics to the organism
• IV for 5-7days, oral for 4-5 wks.
• Stop the tissue destruction
• OP Ix. --- presence of pus
• bone destruction
  radiologically
• failure to resolve within
  36 to 48 hrs

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• Identify the organism
• Best done with cultures of
• aspirate, blood and tissue.
• This must be done before
• administering antibiotics.

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• 2. Select the correct antibiotics
• Based upon Gram stain, cultures
• and antimicrobial sensitivities.
• Best Guess guided by several factors
• - Gram stain
• - Age
• - Predisposing causes
• - Probable sensitivities of the suspected
  organism

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3. Deliver the antibiotic to the organism

• Initially all antibiotics should be intravenous
• Oral antibiotics can be used when
• Resolving clinical course
• Adequate surgical debride. of all necrotic
  tissue
• Adequate serum levels with oral antibiotics
• Reliable parents to assure compliance
• GI tolerance

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• IV antibiotics must be continued
• Inability to swallow or retain medication
• Lack of identification of etiologic agent
• Inability of lab. to obtain serum bactericidal
  levels
• Infection caused by an organism for which no
  effective oral antibiotics exists (e.g. Pseudo.)
• Lack of clinical response to IV antibiotics

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• Duration of treatment
• Depend on characters of infection
• In AHO, Intravenous antibiotics therapy for 1
  week if the clinical response is adequate Oral
  medication for at least 4 to 6 weeks
• In SA, IV antibiotics for 1week, oral
  antibiotics for additional 2 to 3 weeks

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4. Stop the Tissue Destruction

• Surgery
• remove all of dead bone and
• inflammatory products
• preserve blood supply to bone
• preserve periosteum and its
• attachment to the bone as best as
• possible

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Treatment of septic arthritis

• Aspiration and irrigation
• Antibiotics
• Arthrotomy
• in deep joint such as hip or shoulder
• Repeated aspiration and irrigation
• in superficial joint

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Some facts about septic arthritis

• Delay in Dx Tx is the most signif. cause of
  poor results
• Results associated with osteomyelitis are worse
• poorer prognosis in neonate than older children
• The hip is more likely to have poor result than
  other Jt.
• Hip infection is more common in neonate young
  infant
• Septic arthritis secondary to osteomyelitis is
  more common in the hip

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Open surgical vs arthroscopic debridement

• Arthroscopy shoulder, knee, elbow ankle
• Efficacy of arthroscopic vs open drainage
  controversial
• Repeated US guided aspiration good result in
  hip
• 
  (Givon U 2004)
• Anterior or medial approach gt posterior app. in
  hip jt.

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Special Conditions

• Neonatal osteomyelitis
• Subacute osteomyelitis
• Chronic recurrent multifocal osteomyelitis
• Pyogenic infection of spine
• Pelvic infection
• Tuberculosis

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Neonatal osteomyelitis

• Definition
• first 4 8 weeks of life
• Immature immune system
• susceptible to less virulent organism
• less able to produce inflammatory response
• difficult early diagnosis

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2 types of infection

• Premature infant
• In hospital, sick neonate, systemically ill
• invasive monitoring Staph. aureus or gram
  negative
• multiple sites gt 40
• Full term neonate
• After discharge, healthy infant not ill, normal
  development and feeding
• group B streptococcus
• single site

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• Transphyseal vessels
• until 12 to 18 Mos.
• contiguous bone and joint infection
• damage to physis

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• Diagnosis is not easy
• lack of sign symptoms
• Laboratory evaluation is of little value
• ESR not specific finding
• Blood culture 50
• Bone scan may be normal
• Swelling, psudoparalysis, tenderness

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• Aspiration is mandatory
• esp. at both hip joint
• Multiple sites common
• The proximal hip are frequently involved
• Symptom sign are subtle
• The hip is most difficult to exam
• The window of opportunity for effective tx. is
  small
• The hip is the most frequent site of permanent
  sequelae

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Subacute osteomyelitis

• No previous acute attack
• Insidious onset of pain
• Absence of systemic signs
• Radiographic bony lesion at presentation

(King Mayo 1969)
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Pathogenesis

• Reduced virulence of organism
• Increased host resistance
• Previous administration of antibiotic agents

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• Differential diagnosis is important step
• S. aureus most common organism
• Single course of antibiotics and curettage, but
  longer course IV therapy in compairing to AHO
• Positive culture or failure to respond to
  antibiotics indicates the need for curettage,
  drainage of abscess, and sequestrectomy

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Chronic Recurrent Multifocal Osteomyelitis

• Relatively rare condition of unknown etiology
  affecting children
• Characterized by symmetric juxtaphyseal
  sclerosis, pain and tenderness of insidious onset
• ESR mildly elevated

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• Culture negative. No organism identified
• Avoid biopsy if possible
• Symptomatic treatment. No indication for
  antibiotics
• May spontaneously resolve following skeletal
  maturity
• Growth arrest (/-)

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Pyogenic infection of the spine

• Vertebral osteomyelitis and discitis are the
  result of hematogenous infection beginning in the
  bone adjacent to cartilagenous vertebral end plate

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Three patterns of clinical presentation

• 1. Younger than 3 years of age
• hip pain w/ walking difficulty
• D/D septic hip
• 2. 7 to 15 years of age
• abdominal pain
• D/D intraabdominal condition
• 3. Back pain

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Pelvic infection
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Osteomyelitis of Pelvis SI joint

• 3 clinical types
• Gluteal syndrome
• Abdominal syndrome
• Lumbar disc syndrome
• DDx with septic hip joint
• MRI
• BR Antibiotics
• Surgery

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Tuberculosis

• Common under age of 5 years old
• Lung - the most common site
• If untreated, involvement of bone and joint
  occurs in 5-10
• Epiphysis or metaphysis - initial focus
• Spine - the most common skeletal tuberculosis
  (5060)

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Treatment

• Curettage (with or without bone graft)
• Combined antituberculosis chemotherapy
  (isoniazid, ethambutol, rifampin) should be
  continued for 1 year

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Juvenile Idiopathic Arthritis (JIA)

• Juvenile chronic arthritis JCA
• EULAR (European League Against Rheumatism)
• Juvenile rheumatoid arthritis JRA
• ACR (American College of Rheumatology)
• Juvenile idiopathic arthritis JIA
• ILAR (International League of Associations of
  Rheumatology)
• Durban Criteria (Petty, 1998)

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Etiology-unknown

• Infectious Immunologic

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Age at onset before 16th birthdayArthritis in
one or more jointsDuration of disease at least
6 weeks
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• Oligoarthritis
• Polyarthritis
• Systemic Arthritis
• Psoriatic Arthritis
• Enthesitis-related Arthritis
• Other Juvenile Idiopathic Arthritides

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Oligoarthritis

• 1.Persistent oligoarthritis
• no more than four joints involved
• 2.Extended oligoarthritis
• affects a cumulative total of five or more
  joints after the first 6 months of disease

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Oligoarthritis

• Most common type 50
• No more than 4 joints during first 6 months
• lt 6 yrs old
• Girl Boy41
• Knee, Ankle, Elbow joint..
• ESR, CRP slightly increased or normal
• RA factor (-)
• Antinuclear antibody () 40-80 risk of ant.
  uveitis

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• Benign clinical course in most cases
• Joint destruction in 15
• Chronic uveitis (13-34)

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Polyarthritis

• five or more joints during the first 6 Months
• 20 of JIA
• Girl boy 31
• Symmetric involvement knee, wrist, ankle
• PIP, MTP joint 20
• ESR disease activity
• ANA() risk of uveitis
• 2 types RF() RF(-) types

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• Polyarthritis RF(-)
• Any age (av. 6.5 yr)
• Uveitis risk () 5

• Polyarthritis RF()
• Over 8 yrs old
• Persistent and severe
• Uveitis risk (-)
• Joint destruction 30

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Systemic Arthritis

• Arthritis with or preceded by daily fever of at
  least 2 weeks duration, accompanied by one or
  more of the following1. Evanescent, nonfixed
  erythematous rash2. Generalized lymph node
  enlargement3. Hepatomegaly or splenomegaly4.
  Serositis

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Psoriatic Arthritis

• Arthritis psoriasis, or Arthritis at least
  two of a. dactylitis b. nail
  abnormalities (pitting or onycholysis) c.
  family history of psoriasis confirmed
  by a dermatologist in at least one first-
• degree relative

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Enthesitis-related Arthritis

• Arthritis enthesitis, or arthritis or
  enthesitis with at least two of 1. Sacroiliac
  joint tenderness and/or inflam. spinal pain2.
  Presence of HLA-B273. Family history of
  HLA-B27-associated disease in at least one
  first- or second-degree relative4. Anterior
  uveitis that is usually associated with
  pain, redness, or photophobia5. Onset of
  arthritis in a boy after the age of 8 years

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Other Arthritis

• Children with arthritis of unknown cause that
  persists for at least 6 weeks, but that either
• Does not fulfill criteria for any of the other
  categories, or
• Fulfills criteria for more than one of the other
  categories

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Differential Diagnosis

• Leukemia
• Acute rheumatic fever
• Pigmented villonodular synovitis
• Hypermobility syndrome
• Septic arthritis
• Lyme disease
• Henoch-Schönlein purpura
• Systemic lupus erythematosus

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Treatment

• Control inflammation
• Prevent contractures in nonfunctional position
• Encourage movement

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Medical therapy
DMARD
NSAID
Glucocorticoid
Step Down
Step Up
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NSAIDs

• - usually given for minimum 6 weeks
• if in 6 weeks all signs of arthritis are gone,
  
• medication should be discontinued
• if one fails, change to different NSAIDs
• naproxen ( 10 to 20 mg/kg/day, bid )
• indomethacin for systemic
• CBC, renal liver function test,
  urinalysis
• every 6 months

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Steroid

• severe or systemic
• oral steroid
• intra-articular steroid
• 0.1-1mg/kg/day for uncontrolled systemic
• disease

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Methotrexate (MTX)

• Most commonly used DMARD
• 0.5 to 1mg/kg ( with maximum 20 to 30 mg)
• Not systemic arthritis
• Decrease severity of uveitis
• Side effect
• gastrointestinal complication
• folic acid (1mg/day)
• liver fibrosis and cirrhosis

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Sulfasalazine

• Oligo and polyarticular JRA
• 50mg/kg/day bid
• Serious side effect in systemic

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Orthopadic surgical treatment

• Synovectomy - arthroscopic
• Soft tissue release
• Osteotomy
• Epiphysiodesis
• Arthroplasty
• Arthrodesis
• Joint excision

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