Embedded Files
“classical presentation” of BJI is the sick child with fever$ , localizing signs of swelling, pain or redness, and limitation of movement or limping. This chapter provides an overview of the general and location-specific symptoms as well as age and frequency information (see Tables 5 and 6). Note - $ = While common, up to 30-40% of children may not initially develop fever (8,23,28,60) 5.1 General symptoms There is considerable overlap in the symptoms of OM, SA and pyomyositis: OM frequently has a more insidious onset; SA presents more frequently with fever, swelling and decreased range of motion, except when in occult joints, such as sacroiliac or vertebra. Pyomyosistis of the psoas may also be very difficult to diagnose. Other symptoms follow. · Limping or non-weight bearing · Refusal to use limb and/or decreased range of motion (28) · Acute or subacute onset of complaints: SA 2-4 days (7,8,61) and OM 6-7 days (7,8) · Fever and other systemic complaints or symptoms, such as malaise. In newborns and young infants only non-specific symptoms could be present such as irritability, vomiting or refusal to eat. 5.2 Location-specific symptoms In children with BJI, the infection can affect any bone, muscle, or joint. Most commonly the long bones and joints of the lower limbs are involved (8,27,28) (see Table 5). Single site infection is most common, but multifocal OM is seen in 5-10% of infants (especially in newborns and young infants) (28,35,62). Pain in OM tends to be more localised and is often characterised by tenderness, redness, and swelling; these symptoms are more common in SA. Pyomyositis, when it involves muscles around the hip joint, can mimic septic arthritis (63). A 2012 systematic literature review (60) of paediatric studies of patients with OM reported the following distribution of symptoms. · 81% pain · 70% localized signs and symptoms · 62% fever · 50% reduced range of motion · 50% reduced weight-bearing. © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 12 Table 5 - Skeletal distribution of BJI in children Bones Joints Femur 20-30% Knee 35-56% Tibia 19-26% Hip 25-30% Humerus 5-13% Ankle 12-15% Pelvis 3-14% Elbow 5-10% Calcaneus 4-11%$ Shoulder 4-5% Fibula 4-10% Radius 1-4% Clavicle 1-3% Metatarsal, hand, ulna, metacarsal, spondylodiscitis 1-2% Mandible, sternum, ribs, skull, maxilla, scapula, patella, talus < 5 years of age in selected regions or countries (66,67). The determination of bacterial PCR (discussed below) from biological samples may replace this technique. In recent years, nucleic acid amplification methods (e.g., conventional and real-time PCR) have also improved the detection of bacteria not isolated by culture (57,66,68). This may be very important when prior use of antibiotics (synovial fluid PCR remains diagnostic up to 6 days after antibiotic initiation) or for a pathogen in which conventional diagnostic methods remain suboptimal (13,40,43,44,57,59,66,67). K. kingae is identified mainly via eubacterial PCR using rRNA primers targeting the 16S rRNA gene. More specific primers may increase the sensitivity of PCR to detect Kingella (14,43,44). Specific for K. kingae quantitative polymerase chain reaction (qPCR) assays show no cross reactivity with other common osteoarticular pathogens, and exhibit 10-fold higher sensitivity compared to older seminested broad-ranged 16S rRNA gene PCR (14,58). · Real-time PCR identified K. kingae in 24/53 culture-negative cases of SA in a French study, and in another study in the same centre, K. kingae was identified in 69% of 75 children diagnosed with SA (69). · In a Madrid cohort, after PCR implementation, the aetiology of SA was identified in 68%; K. kingae was the causing agent in 48% of the proven etiologies (40). © ESPID 2017 – Practice Guideline – Bone and Joint Infections page 14 An aetiological diagnosis is highly recommended even though S. aureus is so common that an empirical anti MSSA/MRSA treatment would usually perform well, and may be acceptable for children >= 5 years of age, but less acceptable for younger children. Although most culture-negative cases of BJI can be successfully treated with empirical antibiotics, it is important to establish a microbiological diagnosis to tailor therapy to the responsible pathogen, thereby limiting the use of unnecessary broad-spectrum antibiotics. This may specially apply to regions with high rates of MRSA (18). Whereas arthrocentesis has a therapeutic aim in SA (see Section 7.5), the need for a bone aspiration for a suspected uncomplicated OM is more controversial. For most uncomplicated OM, bone aspiration does not seem to affect the outcome of these infections (27,36). 6.3 Imaging studies X-ray imaging is considered the most important baseline test in all patients for comparison of subsequent change if disease does not rapidly improve, and to rule out other underlying conditions. · Acute OM – normal in most baseline films. Repeat imaging shows late appearance of osteolytic changes or periosteal elevation: occur mostly 10–21 days after onset of symptoms (26) – once apparent, bony changes provide good correlation with disease severity. · Subacute OM – changes frequently seen can be confused with malignancies, e.g. Ewing’s sarcoma or osteoid osteoma (70) which usually requires biopsy for definitive diagnosis. · SA – limited usefulness; soft tissue swelling
Google Sites
Report abuse