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Comparison of Clinical and Biological Characteristics of Septic Arthritis And Arch Dis Child: first published as 10.1136/archdischild-2016-310594 on 21 September 2016. Downloaded from Original article Arthritis in children: comparison of clinical and biological characteristics of septic arthritis and juvenile idiopathic arthritis Camille Aupiais,1,2,3 Romain Basmaci,3,4,5 Brice Ilharreborde,3,6 Audrey Blachier,7 Marie Desmarest,8 Chantal Job-Deslandre,9,10 Albert Faye,2,3,4 Stéphane Bonacorsi,3,5,11 Corinne Alberti,1,2,3 Mathie Lorrot2,3,4 1Unité d’Epidémiologie Clinique, ABSTRACT AP-HP, Hôpital Robert Debré, Aim Childhood arthritis arises from several causes. The What is already known on this topic? Paris, France aim of this observational study is to compare the clinical 2Inserm, U1123, ECEVE and and biological features and short-term outcome of CIC-EC 1426, Paris, France ▸ In a previous study, septic arthritis (SA) was the 3 different types of arthritis because they have different Univ Denis Diderot Paris 7, most frequent cause of arthritis among Sorbonne Paris Cité, Paris, treatment and prognoses. hospitalised children, followed by arthritis of France Methods Children <16 years of age hospitalised in a 4 unknown cause and JIA. Service de Pédiatrie Générale, French tertiary care centre for a first episode of arthritis AP-HP, Hôpital Robert Debré, ▸ Children with SA require early diagnosis and lasting for less than 6 weeks who underwent joint Paris, France hospital treatment so that septicaemia, growth 5Inserm, UMR1137, Infection, aspiration were retrospectively included. We performed problems and joint damage can be avoided. Antimicrobials, Modelling, non-parametrical tests to compare groups (septic arthritis ▸ A delay before the appropriate treatment of Evolution (IAME), Paris, France (SA), juvenile idiopathic arthritis ( JIA) and arthritis with 6Service d'Orthopédie juvenile idiopathic arthritis (JIA) may result in no definitive diagnosis). The time before apyrexia or C Pédiatrique, AP-HP, Hôpital additional disease progression and increased reactive protein (CRP) <10 mg/L was analysed using the Robert Debré, Paris, France joint erosion and disability. 7Département Informatique Kaplan-Meier method. Médicale, Hôpital Robert Debré Results We studied 125 children with a sex ratio (M/F) (APHP), Paris, France 8Service d'Accueil des Urgences of 1.1 and a median age of 2.2 years (range 0.3 to 14.6). SA was associated with a lower age at onset Pédiatriques, AP-HP, Hôpital What this study adds? Robert Debré, Paris, France (1.5 years, IQR 1.2–3.0 vs 3.6 years, IQR 2.2–5.6), 9Service de Rhumatologie, AP- shorter duration of symptoms before diagnosis (2 days, HP, Hôpital Cochin, Paris, France – – ▸ There are no sufficiently reliable predictors for 10 IQR 1 4 vs 7 days, IQR 1 19) and higher synovial white Université René Descartes 3 3 – Paris 5, Paris, France blood cell count (147 cells ×10 /mm , IQR 71 227, vs differentiating between SA and JIA at onset. 3 3 ▸ 11Service de Microbiologie, 51 cells ×10 /mm , IQR 12–113), than JIA. Apyrexia Joint aspiration is needed for microbiological AP-HP, Hôpital Robert Debré, occurred later in children with JIA (40% after 2 days, methods and to diagnose SA when a child has Paris, France 95% CI 17% to 75%) than children with SA (82%, monarthritis for less than 6 weeks. ▸ 95% CI 68% to 92%), as did CRP<10 mg/L (18% at JIA should be considered in cases of poor http://adc.bmj.com/ Correspondence to 7 days, 95% CI 6.3% to 29.6% vs 82.1%, 95% CI disease evolution after antibiotic treatment and Dr Camille Aupiais, Unité d'Epidémiologie clinique, 76.1% to 89.7%, p=0.01). joint aspiration. Hôpital Robert Debré (APHP), Conclusions There were no sufficiently reliable 48 boulevard Sérurier, Paris predictors for differentiating between SA and JIA at 75935, Cedex 19, France; onset. The outcomes were different; JIA should be [email protected] considered in cases of poor disease evolution after initiate specific treatment, including non-steroidal antibiotic treatment and joint aspiration. on September 28, 2021 by guest. Protected copyright. Received 28 January 2016 anti-inflammatory drugs and/or intra-articular glu- Revised 12 July 2016 Accepted 3 September 2016 cocorticoid injections and/or biological therapeu- 7–10 Published Online First tics. Joint drainage and immobilisation may 21 September 2016 delay appropriate treatment of JIA if it is misdiag- INTRODUCTION nosed, resulting in additional disease progression – Septic arthritis (SA) usually occurs in children as a and increased joint erosion and disability.11 14 complication of bacteraemia. Arthritis may also be The gold standard for the diagnosis of SA is iso- caused by transient synovitis, juvenile idiopathic lation of the causative agent from joint fluid or arthritis ( JIA), reactive arthritis or other inflamma- blood, but this is not always possible.15 16 JIA cor- tory diseases. responds to an arthritis of unknown aetiology that We previously reported that SA was the most persists for at least 6 weeks.17 During the 1st weeks frequent aetiology in children hospitalised for of disease, differentiation between JIA and SA can arthritis, followed by JIA; a further 40% was of be challenging, especially for cases of culture- unknown cause.1 Early differential diagnosis negative monarthritis.18 Many diagnostic criteria between SA and JIA is essential, since children with have been developed to differentiate between tran- 19–23 To cite: Aupiais C, SA require urgent treatment associating surgical sient synovitis and SA, but no such criteria Basmaci R, Ilharreborde B, joint drainage and intravenous antibiotics to avoid have been determined to distinguish JIA from SA. – et al. Arch Dis Child infectious complications.2 6 In opposition, children In this study, we compared the characteristics 2017;102:316–322. with JIA are usually referred to a specialist to of children with arthritis who underwent joint 316 Aupiais C, et al. Arch Dis Child 2017;102:316–322. doi:10.1136/archdischild-2016-310594 Arch Dis Child: first published as 10.1136/archdischild-2016-310594 on 21 September 2016. Downloaded from Original article aspiration who were divided into three groups: SA, JIA and arthritis according to the International Classification of arthritis with no definitive diagnosis. Diseases-Tenth Revision.24 Diagnosis was defined as the associ- ation of joint pain and/or functional disability with clinical and/ METHODS or radiological joint effusion. Children hospitalised between 1 Study population January 2008 and 31 December 2009 were screened using spe- Children hospitalised in a French tertiary referral centre for cific inclusion criteria. We expected a very low number of paediatric orthopaedics and rheumatology and who underwent inflammatory arthritis cases. Therefore, we also screened chil- joint aspiration for a first episode of arthritis were retrospect- dren who were followed for JIA in the same centre who were ively included. The French National Hospital Discharge recorded in the CEMARA (Centres Maladies rares) database, a Database (Le Programme de Médicalisation des Systèmes French information system which stores records of patients with d’Information) was used to identify children with a diagnosis of rare diseases.25 http://adc.bmj.com/ on September 28, 2021 by guest. Protected copyright. Figure 1 Flow chart for inclusion in children. CEMARA, Centres Maladies rares; JIA, juvenile idiopathic arthritis; SA, septic arthritis; PMSI, Le Programme de Médicalisation des Systèmes d’Information. Aupiais C, et al. Arch Dis Child 2017;102:316–322. doi:10.1136/archdischild-2016-310594 317 Arch Dis Child: first published as 10.1136/archdischild-2016-310594 on 21 September 2016. Downloaded from Original article Children with the following criteria were included: (1) under Table 1 Diagnoses of children included in the study the age of 16 years; (2) hospitalised for a first episode of arth- ritis; (3) onset of symptoms less than 6 weeks prior to hospital- Included isation; (4) underwent surgical joint aspiration at diagnosis. Per in the Group Diagnoses n cent comparison We excluded children younger than 3 months, children with documented sepsis and secondary arthritis, associated osteo- Group 1: SA ▸ Kingella kingae 50 79.4 Yes myelitis, associated fracture, underlying foreign body, prior anti- (n=63) ▸ Staphylococcus aureus 5 7.9 inflammatory treatment, or underlying conditions (sickle-cell ▸ Group A Streptococcus 4 6.3 ▸ anaemia, immunosuppression including renal failure and Streptococcus pneumoniae 2 3.2 ▸ Haemophilus sp 1 1.6 immunosuppressive therapy). ▸ Serogroup B Neisseria 1 1.6 meningitidis Management Group 2: No ▸ Children diagnosed as having 37 82.2 Yes definitive a SA with negative culture of All children with joint effusion associated with fever, high C diagnosis* synovial fluid reactive protein (CRP) levels or high white blood cell (WBC) (n=45) ▸ Children undiagnosed and 6 13.3 counts, were suspected to have SA and underwent joint aspir- cured without any antibiotic ation, performed by a paediatric orthopaedic surgeon under treatment, ▸ general anaesthesia. In Paris and the Ile-de-France region, the Children diagnosed as having 2 4.5 a reactive arthritis without orthopaedic departments of the three paediatric tertiary hospi- any positive serology tals are the major centres involved in management of children Group 3: JIA ▸ Oligoarticular JIA 6 35.3 Yes with bone and joint diseases. The hospital involved in this study (n=17) ▸ Psoriatic JIA 2 11.8 is one of those three. ▸ Systemic JIA 6 35.3 In France, all children with paediatric rheumatic diseases ▸ Enthesitis-related arthritis 3 17.6 (PRDs) are referred for their medical care in clinical centres Other ▸ Kawasaki disease 2 33.3 No diagnoses ▸ Haemarthrosis 2 33.3 (regional competence centres and national reference centres) (n=6) ▸ Villonodular synovitis 1 16.7 engaged in the research and clinical care of children with PRD ▸ Chronic recurrent multifocal 1 16.7 (http://www.cerhumip.fr). The hospital involved in this study is osteitis, one of the two national reference centres for JIA.
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