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© Borgis - New Medicine 1/2001, s. 10-11
Zofia Konarska1, Piotr Kostrzewski2, Jaroslaw Waligóra1
Septic coxitis during the neonatal period the diagnosis and therapy of early-stage osteitis and arthritis
1Department of Neonatal PathologyThe Medical University of Warsaw
Head: Zofia Rajtar-Leontiew MD, PhD
2Department of Cardiosurgery and Paediatric Surgery
Head: Maciej A. Karolczak Md, PhD
The authors discuss the problem of neonatal arthritis and osteomyelitis. The initial symptoms and signs are not specific, which may result in a delayed diagnosis. An early diagnosis and adequate therapy may increase the efficacy of the treatment.
Bacterial, haematogenous osteitis and arthritis in neonates pose a vital diagnostic and therapeutic problem. Appropriate management at the acute phase of the inflammation improves the prognosis. A quick diagnosis facilitates early and efficient treatment. In the neonatal period osteitis and arthritis show nonspecific symptoms of a systemic infection varying in severity. The infant is apathetic, and hypotonic with decreased reflexes. Jaundice is a frequent initial sign. Vomiting, loss of appetite and a fever may be present. Within the next days the disease becomes localised. Typical symptoms of bacterial osteitis and arthritis include hyperaesthesia, painful movement, decreased movement of the involved joint, pseudoparesis, oedematous soft tissues and occasional redness of the skin. With the involvement of the hip joint, the mother may notice her child´s reaction to pain while changing nappies. It is vital to obtain the history of pregnancy and labour. A history suggestive of intrauterine infection allows a paediatrician to establish a faster diagnosis and to initiate treatment. Risk factors include vaginal bleeding, premature rupture of membranes, gestosis, infection and fever in the mother.
Laboratory examinations of the neonate reveal increased indicators of infection (ESR, CRP, leukocytosis with a shift to the left). An increased ESR is infrequent in sick neonates. Osteitis and meningitis may show an increased ESR. CRP control allows the assessment of inflammatory dynamics. Neonates with osteitis frequently have hyperbilirubinaemia and hypoglycaemia. In the diagnostic process it is important to make septic work up and determine the aetiological factor. Staphylococcus aureus is a common pathogen. Streptococci, particularly those of group B, and G(-) rods such a Klebsiella, Proteus, or rarely Citrobacter, may cause neonatal arthritis. The most vital material for bacteriological examination consists of a specimen collected from the involved joint and blood samples. Peripheral cultures from a purulent umbilicus or purulent lesions on the skin may be helpful in the diagnosis. With hip joint involvement, it is vital to perform an early decompression by puncture or surgical incision of the joint to provide better exploration of the joint cavity and thorough removal of the pus. Arthrotomy seems to be more efficient in that case than merely a joint puncture. Therefore, an early orthopaedic surgical consultation seems to be very important.
In a neonate with presumed osteitis and arthritis, diagnostic imaging examinations are done to provide evidence of the severity of the disease within the joint structures. The USG examination has an important role in determining the presence of fluid in the articular cavity, doing the joint puncture and evaluating the progress of treatment. Radiological examination shows osteolytic foci and periosteal proliferation. At a later stage of the treatment, scintigraphy and magnetic resonance may be helpful. The latter provides a reliable evaluation of the joint structure and long-term effects of infection when the radiological findings do not allow a thorough anatomical assessment of the involved joint. Treatment consists of intensive administration of antibiotics with respect to a particular aetiological factor. With a high frequency of staphylococcal infections, treatment includes generation II cephalosporins in combination with aminoglycosides, and also vancomycin and clindamycin. It is worth noting that the microorganisms show increasing resistance to generation cephalosporins, which means abandoning that group of drugs. Neonates with arthritis require the administration of analgesics and splinting. In case of premature infants, children with a low birth weight and muscular hypotonia, treatment consists merely of the application of a soft dressing or even abandoning the joint splinting. Consequently, supplementation therapy is given (hydration, electrolyte control, vitamin D3 supplementation, haematinic drugs or packed RBCs in anaemia). Additionally, immunoglobulins are administered to improve the immune response.
Overt the years 1994-1998, the Department of Neonatal Pathology admitted 13 neonates with diagnosed osteitis and arthritis. Five patients were recognised to have unifocal lesions, whereas multifocal lesions were found in 8 infants. The most frequent inflammatory processes involved the hip joint (6 cases - 46%) and the shoulder joint (5 cases - 38%), followed by the knee joint (4 cases - 30%) and there were also single cases of elbow involvement (2 cases - 15%) and the interphalangeal hand joint (1 case - 7%). The infection was confirmed by a positive blood culture in 10 children (76%); in 6 cases Staphylococcus aureus was the aetiological factor, 4 blood culture specimens grew a cutaneous staphylococcus, and in 2 cases Streptococcus virdans was the causative pathogen. In two children, two consecutive blood cultures grew staphylococcus and streptococcus and two strains of staphylococcus. Articular puncture was done in 4 patients. Splinting was performed in 12 children, applying the following: Dessault´ bandage for the involved shoulder joint for 10-14 days, and local immobilisation of the elbow and hip girdle (2-5 weeks) for arthritis of the elbow and hip joint. Antibiotic treatment was continued for 4-8 weeks, initially with intravenous administration and subsequently, at home, as oral medication.
In 6 cases with arthritis of the hip joint (2 girls and 4 boys) their gestational history was positive. It revealed premature rupture of the placenta, a threatened premature labour, incompetent uterine cervix, gestosis and maternal purulent bacterial infection. Four children had been born prematurely, at 30 to 36 weeks of gestation, with a body weight from 1500 g to 3250 g. One patient displayed features of significant intrauterine dystrophy. In each premature infant the inflammatory process was localised in the hip joint. Two infants were products of a twin pregnancy; however, the twin sibling did not show any evidence of infection. Perinatal infection was noted at 1 do 14 days prior to the onset of typical clinical manifestations characterised by limited movement, oedema, and tenderness. In all the neonates septic evaluation, radiological and USG examinations were done. Arthritis was confirmed by a positive blood culture in 5 patients. Cultures in 4 children showed a growth of Staphylococcus aureus (80% positive results), and in 2 cases the cultures were positive for Staphylococcus viridans (20% positive results). Laboratory investigations showed increased parameteres of infection and metabolic imbalance (hypoglycaemia and hyperbilirubinaemia).
Radiological evidence of demineralisation and periosteal reaction was found in 2 children at the beginning of treatment. A repeat X-ray film taken in the course of treatment revealed osteolytic lesions in 3 children. In the remaining patients radiological examination of the involved joints remained normal until the cessation of therapy. The USG examination showed evidence of a dysplastic hip joint in 1 case, lesions at the metaphysis of the femur in 1 patient and a trace amount of fluid in the articular cavity in 2 children. Two patients underwent a hip joint puncture showing a sterile content. In 4 children splinting was applied for 4-6 weeks. Medical treatment included lincomycin, vancomycin, amikin, cephalosporins, and augmentin. Following the cessation of hospital treatmen, the condition of 3 children was good. In the remaining 3 children the limb mobility was not satisfactory; splinting was continued after discharge from hospital and they received further orthopaedic care. The treatment of the acute stage of arthritis was continued in all children. Severity of the inflammatory process at the beginning of treatment was a distinguishing factor between groups with a better or worse prognosis.
In the group of 3 children with severe arthritis of the hip joint (2 premature babies, 1 full-term infant) the time period from the onset of the initial symptoms until the final diagnosis was 7-14 days. Radiological and USG examinations revealed evidence of demineralisation and trace fluid in the joint. Articular puncture was done in 1 child, antibiotic therapy was continued for 5-8 weeks, splinting was maintained for 3-4 weeks, two children were discharged with limb splinting.
In the group with a less severe course (2 premature infants, 2 full-term infant) the time from the onset of the initial symptoms until the diagnosis was significantly shorter (1-8 days). Radiological examination was normal, merely the USG examination showed evidence of odematous soft tissue and trace fluid in one patient. Articular puncture was carried out in one case. The course of the antibiotic therapy was 4-5 weeks. Splinting was continued for two weeks.
In conclusion it should be emphaissed that establishing an early diagnosis and initiating immediate treatment is vital for the therapeutic outcome and long--term prognosis. Treatment commenced at a severe stage of arthritis destroying the joint produces definitely worse results. The role of arthrotomy should also be considered in adequate cleansing of the joint of pus contents. The management of treatment of the neonate with arthritis should involve close co-operation between paediatricians and orthopaedic surgeons.
1. Hayani KC: Citrobacter hoser osteomyelitis in an infant, Acta Paed Jpn 1997 Jun, 39(3):390-1. 2. Leila Unkila-Kallio, et al.: Serum C-reactive protein, ESR and WBC in acute hematogenous osteomyelitis of children, Paediatrics 1994 Jun, 93(1):59-62. 3. Williams R, et al.: Neonatal osteomyelitis in Down´s Sy due to non-capsulated, H Infl J of Inf 1994, (29):203-5. 4. Wright NB, et al.: Ultrasound in Children with osteomyelitis, Clinical Radiology 1995, (50):623-7.
New Medicine 1/2001
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