Distinguishing Pediatric Lyme Arthritis of the Hip from Transient Synovitis and Acute Bacterial Septic Arthritis: A Systematic Review and Meta-analysis

Cruz, Aristides I.; Anari, Jason B.; Ramı́rez, José M.; Sankar, Wudbhav N.; Baldwin, Keith

doi:10.7759/cureus.2112

Cited by 9 publications

(11 citation statements)

References 30 publications

(30 reference statements)

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“…However, we were unable to find an association between MSKI and serum WBC >12.0×10 9 /L. This is a similar finding to other studies in the pediatric ED, which have also found that WBC count was not significantly associated with MSKI diagnosis 6,9,10…”

Section: Discussionsupporting

confidence: 72%

“…This is a similar finding to other studies in the pediatric ED, which have also found that WBC count was not significantly associated with MSKI diagnosis. 6,9,10 Next, we evaluated the discriminative accuracy of the Kocher and Caird algorithms. Unsurprisingly, neither algorithm performed as well in the expanded population (MSKI vs. alternate joint pain) compared with the population in which they were developed (SA vs. TS).…”

Section: Discussionmentioning

confidence: 99%

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Novel Uses of Traditional Algorithms for Septic Arthritis

Nickel

Bretscher

Truong

et al. 2021

Journal of Pediatric Orthopaedics

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Background: Pediatric musculoskeletal infection (MSKI) is a bacterial infection of the bone, joint, and/or muscle that can be difficult to diagnose. The Kocher and Caird algorithms were developed to distinguish septic arthritis (SA) from transient synovitis (TS) in the hip. These algorithms have been applied to all patients presenting with painful, swollen monoarticular joints regardless of suspicion for SA. The aim of this analysis was to assess the test performance of Kocher and Caird to distinguish MSKI among all pediatric patients presenting with monoarticular joint pain. A secondary aim was to validate the original algorithms. Methods: We conducted a secondary analysis of a prospective cohort study evaluating the test performance of procalcitonin for suspected SA in a pediatric emergency department. Patients aged 0 to 16 years old who presented with a painful or swollen monoarticular joint were considered for enrollment. We compared the test performance of the traditional algorithms in an expanded population of MSKI versus alternate joint pain using sensitivity, specificity, and area under the curve (AUC). As a sensitivity analysis, missing data for predictors like temperature, erythrocyte sedimentation rate, C-reactive protein, and inability to bear weight were multiply imputed using the Stata program, mi impute, for changed equations. Results: The Caird algorithm had better test performance compared to the Kocher in all populations. Both algorithms were most discriminative in comparing SA to TS in all joints (AUC: 0.84 Caird and 0.75 Kocher). However, the Caird criteria performed almost as well discriminating MSKI from other causes of monoarticular joint pain in all joints (AUC: 0.79; 95% confidence interval: 0.72, 0.85) and nonhip joints (AUC: 0.80; 95% confidence interval: 0.71, 0.88). Conclusion:Based on the findings of this study, it is clinically reasonable to apply the Caird algorithm to pediatric patients presenting with monoarticular joint pain of medium and large joints such as the knee, ankle, shoulder, elbow, and wrist, in addition to the hip. Level of Evidence: Level III-retrospective study of novel applications of SA algorithms.

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Section: Discussionsupporting

confidence: 72%

Section: Discussionmentioning

confidence: 99%

Novel Uses of Traditional Algorithms for Septic Arthritis

Nickel

Bretscher

Truong

et al. 2021

Journal of Pediatric Orthopaedics

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“…Fourth, Lyme disease is not endemic in Australia and New Zealand. Therefore, our results are not generalisable to settings where Lyme disease-related septic arthritis occurs 33 . In addition, we were not able to perform a comprehensive external validation of the performance of these prediction rules in children with acute limb pain.…”

Section: Discussionmentioning

confidence: 79%

“…Therefore, our results are not generalisable to settings where Lyme disease-related septic arthritis occurs. 33 In addition, we were not able to perform a comprehensive external validation of the performance of these prediction rules in children with acute limb pain. The focus of our study was to study existing clinical prediction rules that aim to improve diagnosis in children with confirmed septic hip arthritis.…”

Section: Discussionmentioning

confidence: 99%

Comparison of Clinical Prediction Rules in Pre-school Aged Children With Septic Hip Arthritis Due to Different Pathogens

Hagedoorn

Olijve

Kang

et al. 2023

Journal of Pediatric Orthopaedics

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Background: Although differentiating between transient synovitis and septic hip arthritis is challenging, clinical prediction rules such as the Kocher criteria (KC) have been shown to help with the diagnosis of septic hip arthritis in children. Their performance in septic arthritis due to less virulent pathogens such as Kingella Kingae, however is unknown. We aimed to describe the performance of these clinical prediction rules in pre-school children with septic hip arthritis due to different pathogens. We hypothesised that the number of KC or modified KC met would be lower in children with septic hip arthritis caused by K. kingae, compared to those caused by Staphylococcus aureus. Methods: In this retrospective multicentre study conducted in Australia and New Zealand between 2012-2016, we included children with confirmed septic hip arthritis due to S. aureus (n=29), K. kingae (n=20), other pathogens (n=32), and no pathogen identified (n=48). We applied the KC (temperature, weight-bearing, erythrocyte sedimentation rate, white blood cell count) and the modified KC (C-reactive protein added) and assessed their sensitivity for septic hip arthritis, using cut offs of KC ≥ 3 and modified KC ≥ 4. Results: The score of the KC and the modified KC was not lower in K. kingae compared to S. aureus (P=0.27, P=0.21). In addition, both the sensitivity for the KC (S. aureus 18/29 (62.1%); K. kingae 12/20 (60.0%)), and for the modified KC (S. aureus 18/29 (62.1%); K. kingae 12/20 (60.0%)) did not differ between K. kingae and S. aureus. Of all children with septic hip arthritis, the sensitivity of both the KC and modified KC were 56.6% (95%CI 47.6-65.3). Conclusions: The clinical prediction rules had comparable performance in K. kingae infections to those caused by S. aureus. Concerningly, less than 60% of the children with confirmed septic hip arthritis met the cut-off values. These prediction rules lack sensitivity to rule-out septic hip arthritis in the early assessment of pre-school aged children with acute hip pain. Level of Evidence: Level III Diagnostic.

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“…Various factors may help differentiate between septic and Lyme arthritis but overall remain controversial. A higher synovial WBC count, absolute serum neutrophil percent, synovial neutrophil percent, ESR, and CRP as well as a negative anti-streptolysin-O, fever, refusal to weight bear, and knee involvement have all been proposed in various combinations as variables more associated with septic arthritis than Lyme arthritis [11,12,[24][25][26]. Even so, some studies showed no significant differences with most of these variables [13,17].…”

Section: Discussionmentioning

confidence: 99%

Surgical (over) treatment of pediatric Lyme arthritis: a need for faster Borrelia testing

Konopka

Sacks

Castañeda

et al. 2022

Journal of Pediatric Orthopaedics B

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Pediatric Lyme arthritis is described but not well-characterized in urban populations. Similarities in clinical features between Lyme and septic arthritis also results in some patients with Lyme arthritis undergoing surgical treatment. The aims of this study are to (1) characterize Lyme arthritis in an urban population and (2) determine what factors predispose patients with Lyme arthritis to undergoing surgery. We performed a retrospective review of children with Lyme arthritis at a single academic institution in New York City from 2016 to 2021. Inclusion criteria were age ≤18 years, involvement of a major joint, and positive Lyme serology. Patients treated with irrigation and debridement were compared to those treated non-surgically using Chi-squared tests with a significance of P < 0.05. A total of 106 children with Lyme arthritis were included. Mean age was 9.5 years; 61.3% were male, and 71.7% were Caucasian. 46.2% lived in regions with an average household income >$100 000; 70.8% had private insurance. Ten patients (9.4%) underwent surgery for suspected septic arthritis. The operative group was more likely to have an elevated heart rate, white blood cell count, C-reactive protein level, erythrocyte sedimentation rate level and synovial cell count (P < 0.05). Patients were more likely to undergo surgery if they presented to the emergency department than to the clinic (P = 0.03). The average time for a Lyme test to result was 43.5 h, averaging 8.7 h after the surgical start time. Lyme arthritis occurs commonly in an urban pediatric population. Surgery is performed in ~10% of Lyme arthritis patients. More efficient diagnostic tests may reduce this rate.

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Distinguishing Pediatric Lyme Arthritis of the Hip from Transient Synovitis and Acute Bacterial Septic Arthritis: A Systematic Review and Meta-analysis

Cited by 9 publications

References 30 publications

Novel Uses of Traditional Algorithms for Septic Arthritis

Novel Uses of Traditional Algorithms for Septic Arthritis

Comparison of Clinical Prediction Rules in Pre-school Aged Children With Septic Hip Arthritis Due to Different Pathogens

Surgical (over) treatment of pediatric Lyme arthritis: a need for faster Borrelia testing

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