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Infectious and Rheumatic Disease in Children

Infectious and Rheumatic Disease in Children. 박 수 성 울산대학교 의과대학 서울아산병원 정형외과. Infectious disease in children Acute hematogenous osteomyelitis (AHO) Acute septic arthritis Special conditions Rheumatic disease in children Juvenile Idiopathic Arthritis (JIA). Introduction.

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Infectious and Rheumatic Disease in Children

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  1. Infectious and Rheumatic Disease in Children 박 수 성 울산대학교 의과대학 서울아산병원 정형외과

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

  3. 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 !

  4. Early Dx. & Tx. Pre op Post op 10 M

  5. Delayed Dx. & Tx. Pre op Post op 2 M

  6. 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

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

  8. Changing anatomy of interosseous blood supply • In infant • Before the ossific nucleus is formed • Metaphyseal vessel penetrate into epiphysis • Early destruction and growth disturbance

  9. 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

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

  11. Portals of Entry

  12. 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

  13. Subsequent course of metaphyseal abscess

  14. Metaphysis within the joint : early septic arthritis

  15. Risk factors • Diabetes Mellitus • Hemoglobinopathies • Chronic renal disease • Rheumatic arthritis • Immune compromise

  16. Pathogenesis of Septic Arthritis • Bacteremia • Synovium (RES absence) • Subperiosteal spread • Direct innoculation

  17. 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

  18. Pathogens • S. aureus -- still the predominant (60~90%) • 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

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

  20. 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…

  21. 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

  22. 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

  23. Imaging studies • Plain Radiographs • Ultrasound • Bone Scan • Computed Tomography • Magnetic Resonance Imaging

  24. 1. Plain Radiographs • Minimal usefulness early in infections • Bone changes take 7~14 days to appear • Soft tissue edema may obliterate soft tissue planes (3days) • Bone resorption & periosteal new bone formation

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

  26. 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 )

  27. 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

  28. Pin hole view

  29. Scans may be misleading • Very early stage < 24hours after onset • Neonate • Patient with sickle cell disease

  30. 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

  31. 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

  32. F / 20D F / 6M F / 14Y Incision & Drainage instead of arthrotomy

  33. Aspiration Ultimate Diagnostic Test for Osteomyelitis and septic arthritis

  34. Indications for aspiration • Bone tenderness • Deep soft tissue swelling • Bone changes on radiographs • periosteal new bone, bone destruction • Joint effusion

  35. 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 <200(mm³) 2K-100K 50K->100K PMN’s <25% 50% >75% Gram S. Neg. Neg. 30-40% pos.

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

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

  38. Differential Diagnosis (AHO) • Rheumatic fever • Septic arthritis • Cellulitis • Malignancy (Ewing’s sarcoma and leukemia) • Thrombophlebitis • Sickle cell crisis • Gaucher’s disease • Toxic synovitis

  39. 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

  40. 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

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

  42. 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

  43. 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

  44. 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

  45. 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

  46. 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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