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Acute Arthritis 460 Archives of Disease in Childhood 1997;76:460–462 RHEUMATOLOGY Arch Dis Child: first published as 10.1136/adc.76.5.460 on 1 May 1997. Downloaded from Management of childhood arthritis. Part 1: acute arthritis P N Malleson This is the first article in a Arthritis in childhood is not uncommon. Esti- have been perfectly visible on a much cheaper series on rheumatology. mates of the annual incidence of arthritis vary radiograph!). widely, but for all forms of chronic arthritis it is probably between 5 and 10 per 100 000 12 Septic arthritis children aged 16 years or younger. Acute Septic arthritis is, of course, a medical forms of arthritis are perhaps four times more 3 emergency and if suspected must be investi- common. Most paediatricians will therefore gated with both blood cultures and arthrocen- see several patients with arthritis each year. 4 tesis for Gram stain, cultures, and tests for spe- The aim of this paper and part 2 of the series cific infectious antigens. Although a high is to give a concise, but moderately comprehen- peripheral white cell count, high erythrocyte sive, overview of this topic which will help in sedimentation rate, and high synovial fluid the management of this heterogeneous group white cell count (>5.0 × 109/l) is suggestive of of disorders. an infection, similar findings can occur in reac- Although chronic arthritis can present with a tive arthropathies and even in early chronic sudden and painful onset of one or more swol- arthropathies. Furthermore, synovial white cell len joints, such a presentation should raise sus- counts may be only mildly increased in proved picions that the arthritis is due to trauma or to septic joints. A significant proportion of a joint or contiguous bone infection. children with probable septic arthritis have persistently negative cultures (even without preceding antibiotic treatment) and negative 5 Trauma antigen tests. Therefore it is probably neces- http://adc.bmj.com/ A traumatic cause of joint swelling is usually sary to treat a few children who may not actu- obvious from the patient’s history, but parents ally have septic arthritis with intravenous anti- sometimes incorrectly presume that a swollen biotics so as not to miss a child who does have joint must have been due to an injury. It is this disorder. Although septic arthritis usually unlikely that an injury is the cause of a swollen aVects only a single joint (usually a knee) in joint if the child has not had a definite children, 4–6% of patients will have two or traumatic event that was painful enough to more joints aVected. Therefore the fact that immediately prevent the child continuing with several joints are swollen should not lead to the on September 29, 2021 by guest. Protected copyright. the activity. The exception to this is perhaps a exclusion of the possibility of sepsis. child with haemophilia, who might develop a It is fairly common, particularly in neonates, haemarthrosis after only mild trauma. for an osteomyelitis to have an associated If it is uncertain whether the swelling of a arthritis, which may or may not be septic. Bone joint is due to a joint eVusion or simply due to tenderness beyond the margins of the joint is soft tissue swelling, an ultrasound examination suggestive of osteomyelitis. Radiographs often of the joint can be helpful and may also be able show soft tissue changes adjacent to an infected to determine whether there is blood in the bone several days before bone changes become joint. Synovial fluid analysis of a traumatic visible. A bone scan is usually diagnostic of eVusion usually shows a low white cell count osteomyelitis even if the joint has already been (<0.2 × 109/l), but this can occasionally be aspirated. much higher and mimic fluid from a septic The initial treatment of septic arthritis joint. A haemarthrosis raises the possibility of should be with an antibiotic given intrave- Department of either a fracture into the joint or a torn anterior nously, such as cefuroxime, which is eVective Paediatrics, The cruciate ligament. The presence of marrow fat against streptococci, and, Research Centre, Staphylococcus aureus, Vancouver, Canada is indicative of a fracture. if the child has not been immunised, Haemo- Magnetic resonance imaging has revolution- philus influenzae type b, with the antibiotics Correspondence to: ised the investigation of musculoskeletal disor- being changed as appropriate once the organ- Dr P N Malleson, Paediatric ders and it has largely replaced arthrograms in ism has been cultured and its sensitivities Rheumatology, Faculty of Medicine, Department of the investigation of joints aVected by trauma. determined. In a child with septic arthritis of Paediatrics, The Research Magnetic resonance imaging should only be the foot, consideration should be given to using Centre, 950 West 28th performed after a plain radiograph has been an antibiotic eVective against Pseudomonas Avenue, Vancouver, British Columbia, Canada V5Z taken (it is embarrassing to diagnose a fracture aeruginosa. The total duration of treatment 4HA. on magnetic resonance imaging that would should be 4–6 weeks, guided by the clinical Acute arthritis in childhood 461 signs, peripheral white cell count, and erythro- that in areas where the disease is endemic, cyte sedimentation rate. The use of antibiotics many children diagnosed as having chronic Arch Dis Child: first published as 10.1136/adc.76.5.460 on 1 May 1997. Downloaded from given by mouth in high doses once the infection Lyme disease actually have fibromyalgia.13 is under control has been advocated, but requires careful monitoring of compliance Reactive and postinfectious arthritis (ideally with serum bactericidal titres) and An acute arthritis after an infection in which clinical progress.67 Although most authorities there is no evidence of a septic process of the advocate open drainage of a septic hip joint and joint is considerably more common than septic repeated aspirations of other joints, there is lit- arthritis.3 The classical postinfectious ar- tle evidence supporting repeat aspirations.8 thropathy is rheumatic fever. In recent years a They are probably unnecessary if the child’s form of poststreptococcal arthritis has been course progresses satisfactorily. recognised that is more polyarticular and more It is extremely important to provide ad- prolonged than in typical acute rheumatic fever equate pain relief (something that is often for- and which does not always fulfil the criteria for gotten); this should usually initially be with rheumatic fever, but which may be complicated intravenous morphine. The use of a splint to by carditis.14 It should be suspected in any child ‘rest’ and protect the joint is appropriate for a who has a sore throat or constitutional few days, but should not be prolonged as it will symptoms at the onset of the arthritis and encourage joint contractures and muscle wast- should be investigated with throat cultures and ing. The role of non-steroidal anti- antibodies to streptococcus. If a recent strepto- inflammatory drugs (NSAIDs) has not been coccal infection can be proved, then cardiac formally evaluated, but is probably helpful. evaluation with echocardiography should be Whether the use of corticosteroids early in the undertaken. Penicillin prophylaxis is manda- disease course might be of benefit, as has been tory in children with evidence of carditis, but is shown for bacterial meningitis,9 is unknown. controversial if there is no clinical or echocar- Occasionally the inflammatory response ap- diographic evidence that the heart is aVected. pears to persist long after it seems clear that the Arthritis secondary to various enteric infec- infection has been eradicated, and then the use tions is not rare in children. A family history of of NSAIDs or intra-articular corticosteroids, or spondyloarthropathy is often present and most both, seems justified, as it is probably the patients are positive for HLA-B27. The arthri- inflammatory response rather than the bacteria tis can be extremely painful, mimicking sepsis; themselves that is damaging to the joint it is usually relatively short lived, but may occa- cartilage. sionally become chronic. Although there is some evidence that there may be persisting Lyme arthritis antigens in the joint, there is no clear evidence Lyme arthritis is a form of infectious arthritis that antimicrobial treatment modifies the which is common in some areas of the world. It disease course. Treatment is with an NSAID occurs several weeks to months after the initial such as tolmetin until the joint inflammation http://adc.bmj.com/ infection with Borrelia burgdorferi. It has an has resolved clinically and the complete blood acute oligoarticular onset and tends to be epi- count and erythrocyte sedimentation rate have sodic, with each episode lasting a few days. The normalised. episodic nature of the arthritis is an important Chlamydia trachomatis infection of the geni- clue that this is not idiopathic chronic arthritis. tourinary tract should be considered in any Treatment with erythromycin 30 mg/kg/day or sexually active adolescent with new onset amoxicillin 30–50 mg/kg/day by mouth, both arthritis. Viable chlamydia may persist in the 15 divided twice a day, is usually eVective. If joints of patients with Reiter’s syndrome and on September 29, 2021 by guest. Protected copyright. untreated the arthritis can recur several times a antibiotic treatment of the initial infection as year for several years, but the episodes well of the subsequent arthritis can be gradually decrease in frequency and eventually beneficial.16 Therefore antibiotics as well as resolve completely.10 NSAIDs are justified if this diagnosis is proved. A few children, whether they have been Many acute transient arthritides are prob- treated appropriately or not, go on to develop ably due to viral infections. Rubella infection of chronic arthritis. This outcome is associated both the wild type and after immunisation is a with the presence of antibodies to HLA-DR4 common cause of arthralgias or arthritis in or HLA-DR2 and with high antibody titres to adolescents, but is a rare cause in young the outer surface protein A of Borrelia children.
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