Arthritis In Pediatric Patients Research Articles

Does rickets carry an increased risk of osteomyelitis and septic arthritis? An aggregated electronic health record data study.

To investigate the prevalence of osteomyelitis and septic arthritis in pediatric patients with rickets, compared to the general population. A retrospective cohort study was conducted using the TriNetX analytics network, which aggregates deidentified electronic health record data from over 105 million US patients. We queried pediatric patients with rickets, based on ICD-10-CM (International Classification of Diseases, Tenth Revision, Clinical Modification) encounter diagnoses. Patients with any ICD-10-CM encounter diagnoses of osteomyelitis or septic arthritis were reported. We established a control cohort of pediatric patients without rickets. Of 7337 pediatric patients (≤18 years old) with a rickets diagnosis, 96 [1.31%, 95% confidence interval (CI): 1.05%-1.57%] had a diagnosis of osteomyelitis and 28 (0.38%, 95% CI: 0.24%-0.52%) had a diagnosis of septic arthritis. In comparison, of the 17 240 604 pediatric patients without a rickets diagnosis, 16 995 (0.10%, 95% CI: 0.10%-0.10%) had a diagnosis of osteomyelitis and 8521 (0.05%, 95% CI: 0.05%-0.05%) had a diagnosis of septic arthritis. The relative risk for an osteomyelitis diagnosis in pediatric patients with a rickets diagnosis was 13.27 (95% CI: 10.86-16.23), while the relative risk for a septic arthritis diagnosis was 7.72 (95% CI: 5.33-11.18). Pediatric patients with a diagnosis of rickets have over 10- and 5-times higher relative risks for having a diagnosis of osteomyelitis and septic arthritis, respectively, compared to those without a diagnosis of rickets. This is the first study to explore musculoskeletal infections in rickets patients, highlighting the importance of clinicians being vigilant about these conditions.

Сравнительная оценка соответствия клиническим рекомендациям объема обследования, выполненного в федеральных округах Российской Федерации на этапе первичной диагностики юношеского артрита с системным началом, по данным Федерального регистра Минздрава России

Juvenile arthritis with systemic onset (syn: systemic juvenile idiopathic arthritis; SJIA) is the most complex in pathogenesis, severe in course and unfavorable in prognosis variant of juvenile arthritis. The course of SJIA is characterized by the development of severe life-threatening complications, which in the future may lead to the progression of functional and multiple organ failure, delayed physical development and disability of the patient, therefore it is very important to diagnose this disease at an early stage, for which children with suspicion of SJIA must be examined in accordance with the Procedure for providing medical care for children in the profile "Rheumatology" in rheumatology departments of multidisciplinary hospitals, where it is possible to perform the entire complex of diagnostic measures, these are indicated in the clinical recommendations, since at the stage of diagnosis it is very important to exclude diseases appearing in the guise of SJIA, including infectious diseases, These are indicated in the clinical recommendations, because at the stage of diagnosis it is very important to exclude diseases appearing under the guise of SJIA, including infectious, oncologic, oncohematologic, lymphoproliferative, inflammatory bowel, autoinflammatory syndromes and other rheumatic diseases. Federal districts (FD) of the Russian Federation (RF) differ significantly in demographic, climatic, natural-geographical, sociocultural parameters, which cannot but determine differences in the processes of providing medical care to children in the profile of rheumatology. The analysis of these processes is a necessary condition for improving the quality of early diagnosis of juvenile arthritis in pediatric patients. Objective. To carry out a comparative assessment of compliance with clinical recommendations of the scope of examination performed in the Russian Federation at the stage of primary diagnosis of juvenile arthritis with systemic onset, according to the Federal Register of the Ministry of Health of the Russian Federation. Patients and Methods. A retrospective study of discharge records of 927 patients diagnosed with SJIA, receiving genetically engineered biological drugs, included in the Federal Register of persons with hemophilia, cystic fibrosis, pituitary nanism, Gaucher disease, malignant neoplasms of lymphoid, hematopoietic and related tissues, multiple sclerosis, hemolytic-uremic syndrome, juvenile arthritis with systemic onset, mucopolysaccharidosis types I, II and VI, persons after organ and/or tissue transplantation (Register). Results. Our study found that there were significant differences between the Russian Federation regions in the volume of investigations performed at the stage of diagnosis of SJIA and their compliance with clinical recommendations. In all regions of the Russian Federation we found a reliable dynamics of improvement in the quality of examination associated with the improvement of the regulatory and legal framework for the organization of medical care for children in the profile of rheumatology. Conclusion. Our study confirms the need for continuous monitoring of the work of pediatric rheumatology service of the FD, which will optimize the algorithms of early diagnosis of SJIA and other rheumatic diseases in children in order to timely start treatment, including on the basis of the introduction and modernization of digital health technologies, in particular, the system of electronic registers. Key words: Federal Register, juvenile arthritis with systemic onset, diagnosis, federal district, clinical recommendations

The Importance of Differentiating Oligoarticular Juvenile Idiopathic Arthritis From Lyme Arthritis in Pediatric Patients.

Objective This study aims to compare clinical and laboratory features between Lyme arthritis (LA) and oligoarticular juvenile idiopathic arthritis (oligoarticular JIA) by examining several potential predictors in pediatric patients. This study also aims to improve and increase awareness of ways to detectLA and oligoarticular JIA in pediatric patients who present with clinical features of joint pain. Methods A medical chart review was conducted among pediatric patients diagnosed with LA or oligoarticular JIA at John R. Oishei Children's Hospital of Buffalo between January 2014 and September 2018. Patients' diagnoses were identified using the International Classification of Disease10th Revision code for LA (ICD 10 code A69.23) and oligoarticular JIA (ICD 10 code M08.40). Patients with LA were only included in this study if they (1) exhibited arthritis, (2) tested positive for Lyme antibodies, (3) indicated a positive western blot (WB) of five or more out of 10 Borrelia burgdorferi proteins by IgG antibodies or at least two of three B. burgdorferi proteins by IgM antibodies, and (4) at the age of 16 or below at the time of diagnosis. Patients with oligoarticular JIA were included in this study if they (1) exhibited arthritis affecting one to four joints for at least six weeks in the first six months of diagnosis and (2) are at the age of 16 or below at the time of diagnosis after ruling out LA and reactive arthritis. In this study, clinical presentations, physical exam findings during initial healthcare visits, and demographics including age, sex, and race of patients were obtained. In addition, laboratory results including white blood cells (WBCs), hemoglobin (Hgb), platelet count, erythrocyte sedimentation rate (ESR), C-reactive protein (CRP) level, Lyme antibodies through enzyme-linked immunosorbent assay (ELISA) and WB, synovial fluid analysis for red blood cells (RBCs), nucleated cells, and polymerase chain reaction (PCR) for B. burgdorferi DNA were also collected and analyzed. Results In our data, ESR and CRP were significantly higher in LA compared to oligoarticular JIA (P=0.0053 and 0.0005, respectively). The mean WBC in the synovial joint fluid was significantly higher in LA compared to oligoarticular JIA (P=0.002). Conclusion LA shares features with oligoarticular JIA. This overlap prevents the creation of a clinically useful predictive model for LA. Therefore, Lyme testing should be performed on all patients presenting with monoarticular and oligoarticular arthritis. In addition, ESR, CRP, and WBC in the synovial joint fluid were significantly higher in LA compared to oligoarticular JIA in our findings. While this difference is not definitive by any means, it may help distinguish between the two in cases where the diagnosis is not clear-cut, and the values of ESR, CRP, and WBC in the joint aspirate may help guide clinical judgment in cases that lack a definitive diagnosis.

39 Pediatric monoarthritis of the elbow: atypical onset of a common disease

Abstract Background Oligoarticular type of juvenile idiopathic arthritis (oligoJIA) is considered the most common type of JIA. It usually affects one or < 4 joints. The knee is the most common affected joint followed by the ankle and wrist. Oligoarticular JIA presenting with erosive elbow monoarthritis as an initial sign of the disease is a rare condition which needs prompt diagnosis and management. Objective To recognize that isolated chronic elbow monoarthrits is an atypical presentation for oligoJIA. Case presentation: A 14-year-old volleyball player female child presented with chronic recurrent left elbow swelling of six months’ duration. No history of morning stiffness, constitutional symptoms, other joint swelling, uveitis, or skin manifestations were reported. On examination there was mild cubitus valgus with elbow effusion associated with limited last degree elbow extension with no other signs of inflammation or infection (redness, tenderness, hotness). Hypermobility was noted in both elbows and knees. Patient was advised to rest the elbow and symptomatic treatment was recommended. On follow up there was mild improvement of the swelling, so further investigations were ordered. Erythrocyte Sedimentation Rate (ESR), C-reactive protein (CRP), Rheumatoid factor (RF) and antinuclear antibody (ANA) showed average normal values. X-ray of the elbow showed degenerative changes. Musculoskeletal ultrasound showed mild elbow effusion and magnetic resonance imaging (MRI) was ordered revealing effusion and early joint erosion at the ulnar articular surface with no synovial hypertrophy. Arthroscopy was recommended to detect the underlying pathology and histopathology revealed chronic active synovitis suggesting JIA. Non-steroidal anti-inflammatory drugs (NSAIDs) were recommended but one month later knee arthritis was noted, so methotrexate was started and the condition started to improve. Results We report a 14-year-old female child who presented with atypical isolated chronic swelling of the elbow and was diagnosed by arthroscopy and histopathology. Non-steroidal anti-inflammatory drugs (NSAIDS) were tried as a first line treatment followed by methotrexate. Conclusion Chronic elbow monoarthritis is an atypical onset of oligoJIA and its diagnosis is important to prevent irreversible joint damage. Synovial biopsy can have a major role in the diagnosis of atypical monoarticular JIA and can help in early diagnosis and management improving the outcome. The implication to policy, practice, research, and advocacy: Monoarthritis of the elbow as initial sign of oligoJIA is an atypical onset of this disease and in the absence of systemic signs or other clinical indicators determining the exact cause of monoarthritis in children might be difficult. Synovial biopsy can have an important role in the diagnosis of monarticular arthritis in pediatric patients.

JAAD Game Changers∗: Inflammatory arthritis in pediatric patients with morphea

JAAD Game Changers∗: Inflammatory arthritis in pediatric patients with morphea

Fused Omics Data Models Reveal Gut Microbiome Signatures Specific of Inactive Stage of Juvenile Idiopathic Arthritis in Pediatric Patients.

Juvenile idiopathic arthritis (JIA) is the most common rheumatic disease in children. Herein, we evaluated the relationship between the gut microbiome (GM) and disease phenotype by an integrated omics fused approach. In a multicenter, observational cohort study, stools from Italian JIA patients were collected at baseline, active, and inactive disease stages, and their GM compared to healthy controls (CTRLs). The microbiota metabolome was analyzed to detect volatile- and non-volatile organic compounds (VOCs); the data were fused with operational taxonomic units (OTUs) from 16S RNA targeted-metagenomics and classified by chemometric models. Non-VOCs did not characterize JIA patients nor JIA activity stages compared to CTRLs. The core of VOCs, (Ethanol, Methyl-isobutyl-ketone, 2,6-Dimethyl-4-heptanone and Phenol) characterized patients at baseline and inactive disease stages, while the OTUs represented by Ruminococcaceae, Lachnospiraceae and Clostridiacea discriminated between JIA inactive stage and CTRLs. No differences were highlighted amongst JIA activity stages. Finally, the fused data discriminated inactive and baseline stages versus CTRLs, based on the contribution of the invariant core of VOCs while Ruminococcaceae concurred for the inactive stage versus CTRLs comparison. In conclusion, the GM signatures enabled to distinguish the inactive disease stage from CTRLs.

Can predictors of Pediatric Septic Hip be applied to the Knee

Purpose: The early diagnosis and treatment of septic arthritis in pediatric patients are paramount to the prevention of long-term sequela. While much of the literature has focused on markers of the hip, little is known of the application of these to the knee. The purpose of this study is to investigate if the Kocher criteria can be used for screening children suspicious to have septic arthritis of the knee. Methods: We retrospectively reviewed the charts of male and …

Diagnostic utility of inflammatory markers in septic arthritis in pediatric patients in atertiary care hospital in Bangalore

Objectives: Septic arthritis is a disease associated with serious morbidity to the patient. The causes of monoarticular arthritis are numerous, with septic arthritis being the most important entity. The diagnosis is rarely established by the history and physical examination, and the clinician is led to rely on ancillary tests.As there are very limited studies relating to the usefulness of CRP, synovial fluid WBCand ESR in diagnosing septic arthritis in the pediatric population, this study was donein pediatric population in a tertiary care hospital in Bangalore. Materials and Methods: This is a retrospective study done over a period of 24months from January 2017 to December 2018. The study population included all the suspected patients of septic arthritis.Their inflammatory markers like WBC count, ESR and CRP were compared with the culture of the synovial fluid. Results: Our records search identified 335 potential cases. 134 cases fulfilled the diagnostic criteria for septic arthritis out of the 335 included in the study. Sensitivity of ESR was: 98% using a cutoff of ≥10 mm/h and 94% using a cutoff of ≥15 mm/h. The sensitivity of CRP was 92% using a cutoff of ≥20 mg/L. synovial fluid sample with WBC of >50 000/μL of which >75% are polymorphonuclear cells is considered to suggest Septic arthritis. Conclusion: Using our data and comparing it with published data we propose that it is unnecessary to perform further investigation for septic arthritis in patients who have all three of: ESR value <15mm/h, WBC <50,000/μL and CRP value <20mg/l.

Inflammatory arthritis in pediatric patients with morphea.

Morphea or localized scleroderma is an inflammatory disorder resulting in fibrosis of the skin and subcutaneous tissues. Joint contractures, arthralgias, and functional compromise are recognized associations of pediatric morphea. The co-existence of inflammatory arthritis and morphea is not well-described in the literature. To investigate the relationship between pediatric morphea and inflammatory arthritis with regards to cutaneous, musculoskeletal, and laboratory findings and treatment regimens. A systematic retrospective chart review of 53 patients with pediatric morphea was performed and analyzed for morphea subtypes, arthritic joint involvement, serum autoantibodies, and therapeutic interventions. Eleven out of 53 patients had polyarthritis that involved joints unrelated to the site of the cutaneous morphea. These patients were mostly girls with either the linear or generalized subtypes of morphea. Serum levels of antinuclear antibodies were more significantly elevated in patients with arthritis. All children were treated with methotrexate in addition to other systemic or topical immunosuppressive agents. This was a small, single-center retrospective study. Pediatric morphea co-existed with inflammatory arthritis in 11 of 53 children. Further understanding and appreciation of this relationship may direct more intensive therapy and musculoskeletal screening.

Predictive Factors for Differentiating Between Septic Arthritis and Lyme Disease of the Knee in Children.

Differentiating between septic arthritis and Lyme disease of the knee in endemic areas can be challenging and has major implications for patient management. The purpose of this study was to identify a prediction rule to differentiate septic arthritis from Lyme disease in children presenting with knee pain and effusion. We retrospectively reviewed the records of patients younger than 18 years of age with knee effusions who underwent arthrocentesis at our institution from 2005 to 2013. Patients with either septic arthritis (positive joint fluid culture or synovial white blood-cell count of >60,000 white blood cells/mm(3) with negative Lyme titer) or Lyme disease (positive Lyme immunoglobulin G on Western blot analysis) were included. To avoid misclassification bias, undiagnosed knee effusions and joints with both a positive culture and positive Lyme titers were excluded. Historical, clinical, and laboratory data were compared between groups to identify variables for comparison. Binary logistic regression analysis was used to identify independent predictive variables. One hundred and eighty-nine patients were studied: 23 with culture-positive septic arthritis, 26 with culture-negative septic arthritis, and 140 with Lyme disease. Multivariate binary logistic regression identified pain with short arc motion, history of fever reported by the patient or a family member, C-reactive protein of >4 mg/L, and age younger than 2 years as independent predictive factors for septic arthritis. A simpler model was developed that showed that the risk of septic arthritis with none of these factors was 2%, with 1 of these factors was 18%, with 2 of these factors was 45%, with 3 of these factors was 84%, or with all 4 of these factors was 100%. Although septic arthritis of the knee and Lyme monoarthritis share common features that can make them difficult to distinguish clinically, the presence of pain with short arc motion, C-reactive protein of >4.0 mg/L, patient-reported history of fever, and age younger than 2 years were independent predictive factors of septic arthritis in pediatric patients. The more factors that are present, the higher the risk of having septic arthritis. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Predictors of arthritis in pediatric patients with lupus.

BackgroundArthritis is one of the most common manifestations of systemic lupus erythematosus (SLE). Although typically non-erosive and non-deforming, children with SLE arthritis can have significant morbidity with decreased quality of life. Our goal was to identify potential clinical and laboratory predictors of arthritis in a cohort of pediatric patients with SLE.MethodsWe performed a cohort study of incident and prevalent patients with SLE aged ≤ 19 years. In cross sectional analysis, we compared demographic and clinical characteristics at initial clinic presentation between patients with arthritis noted at any time during follow-up and those without arthritis. We performed time to event analysis using Cox proportional hazard ratios to identify predictors of arthritis, clustering for repeated measures.ResultsForty seven children and adolescents with SLE were followed in the cohort, 91 % female and 68 % Black. In cross-sectional analyses, presence of malar rash was associated with arthritis. In longitudinal analyses, controlling for gender and race, increased age (HR: 1.4, 95 % CI: 1.1–1.7), malar rash (HR: 2.1, 95 % CI: 1.1–3.6), and presence of RNP antibodies (HR: 1.9, 95 % CI: 1.1–3.4) were predictive of arthritis. When controlling for gender, race, and medication use, anemia (HR: 8.5, 95 % CI: 2.9–24.2) and thrombocytopenia (HR: 6.1, 95 % CI: 2.4–15.6) were associated with increased risk of arthritis.ConclusionsWe identified markers predictive of arthritis in a longitudinal cohort of children with SLE. The recognition of these markers may help clinicians identify patients at risk for arthritis before its onset thus improving quality of life in children with SLE.

Outcomes of Children Treated for Lyme Arthritis: Results of a Large Pediatric Cohort

Children often develop arthritis secondary to Lyme disease; however, optimal treatment of Lyme arthritis in pediatric patients remains ill-defined. We sought to characterize the outcomes of a large cohort of children with Lyme arthritis treated using the approach recommended by the American Academy of Pediatrics and the Infectious Diseases Society of America. Medical records of patients with Lyme arthritis seen by rheumatologists at a tertiary care children's hospital from 1997 to 2007 were reviewed. Patients were classified with antibiotic responsive or refractory arthritis based on absence or presence of persisting joint involvement 3 months after antibiotic initiation. Treatment regimens and outcomes in patients with refractory arthritis were analyzed. Of 99 children with Lyme arthritis, 76 had arthritis that responded fully to antibiotics, while 23 developed refractory arthritis. Most patients with refractory arthritis were successfully treated with nonsteroidal antiinflammatory drugs (6 patients), intraarticular steroid injections (4), or disease-modifying antirheumatic drugs (DMARD) (2). Five were lost to followup. Six patients with refractory arthritis were initially treated elsewhere and received additional antibiotic therapy, with no apparent benefit. Three subsequently required DMARD, while 3 had gradual resolution of arthritis without further therapy. Antibiotic responsiveness could not be predicted from our clinical or laboratory data. Lyme arthritis in children has an excellent prognosis. More than 75% of referred cases resolved with antibiotic therapy. Of patients with antibiotic refractory arthritis, none in whom followup data were available developed chronic arthritis, joint deformities, or recurrence of infection, supporting current treatment guidelines.

Candida albicans arthritis one year after successful treatment of fungemia in a healthy infant

Fungal arthritis in pediatric patients is rare and is most often associated with hematogenous spread to the affected joint. It is generally seen concomitant with, or shortly after, fungemia. We report a case of an immunocompetent patient in whom candidal arthritis developed 1 year after initial fungemia. The initial candidiasis was considered to be adequately treated with amphotericin B. The Candida isolates from the neonatal fungemia and subsequent arthritis were the same as identified by electrophoretic karyotype, restriction fragment length polymorphism analysis, and antifungal susceptibility testing. Pediatric candidal fungemia, arthritis, and their treatments are discussed.(J Pediatr 1996;129:688-94)

Pyogenic Arthritis Complicating Varicella Infection

Arthritis has not previously been reported as a complication in adult patients with chickenpox. In pediatric patients, the arthritis that complicates chickenpox is most commonly aseptic but does rarely result from bacterial infection. We report the case of a 21-year-old man who developed acute monoarticular septic arthritis due to Lancefield Group A beta-hemolytic streptococci. Despite the more common viral cause of arthritis in pediatric patients, physicians should not attribute arthritis associated with varicella in adults to a viral cause without diagnostic arthrocentesis.

INITIAL THERAPY FOR OSTEOMYELITIS AND SEPTIC ARTHRITIS WITH CEFOXITIN

Single drug therapy with a broad spectrum antibiotic is a desirable option for patients with bone and joint infections of unknown etiology. We initiated treatment for 23 children, ages 6 months-15 years (mean 6.5 years) with cefoxitin. The infecting organisms proved to be S. aureus-10, Strep. pneumoniae-2, H. influenzae b-2, and S. epidermidis, B. melaninogenicus, Moraxella sp. and Ps. fluorescens-1 each. No agent was identified in 6 cases. Initial clinical response was good in 21 cases (91%). One primary resistant organism (Ps. fluorescens) and one cephalosporin-tolerant S. aureus failed to respond. A third child with infection due to H. influenzae b developed meningitis after 3 days. These 3, and 6 patients with negative cultures, were dropped from the study. All other patients did well and received x̄ 15.7 days IV cefoxitin before switching to oral antimicrobials. Adverse reactions included allergic rash (1), mildeosinophilia (2) and mild elevation of SGOT (1). Cefoxitin was discontinued for reason of the rash; all other reactions resolved when the drug was discontinued at the completion of therapy. Neutropenia (PMN <1000/mm3) was seen in 2 patients but resolved spontaneously. Urinary reducing substances were detected in 5 cases (22%). Cefoxitin appears to be satisfactory initial therapy for osteomyelitis and septic arthritis in pediatric patients; it should not be used for infants <2 years of age where H. influenzae b is suspected, due to the possible development of meningitis.