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Key Features

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  • Source varies according to the child's age

    • Infantile pyogenic arthritis often develops from adjacent osteomyelitis

    • In older children, it presents as an isolated infection, usually without bony involvement

    • In teenagers, an underlying systemic disease or an organism that has an affinity for joints (eg, Neisseria gonorrhoeae) may be present

  • The most frequent infecting organisms similarly vary with age

    • Group B Streptococcus and Staphylococcus aureus in those younger than 4 months

    • Haemophilus influenzae type b (if unimmunized) and S aureus in those aged 4 months to 4 years

    • S aureus and Streptococcus pyogenes in older children and adolescents

    • Streptococcus pneumoniae and Neisseria meningitis are occasionally implicated, and N gonorrhoeae is a cause in adolescents

    • Kingella kingae is a gram-negative bacterium that is increasingly recognized as a cause of pyarthrosis (and, occasionally, osteomyelitis) in children younger than 5 years

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Clinical Findings

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  • In infants,

    • Paralysis of the limb due to inflammatory pseudoparalysis may be evident

    • Infection of the hip joint should be suspected if decreased abduction of the hip is present in an infant who is irritable or feeding poorly

    • A history of umbilical catheter treatment in the newborn nursery should alert the physician to the possibility of pyogenic arthritis of the hip

  • In older children,

    • Fever

    • Malaise

    • Vomiting

    • Restriction of motion

    • Joint swelling, warmth, erythema, tenderness

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Diagnosis

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  • A joint effusion may accompany osteomyelitis in the adjacent bone, but a white cell count exceeding 50,000/μL in the joint fluid indicates a purulent infection involving the joint

  • Generally, spread of infection is from bone into a joint, but unattended pyogenic arthritis may also affect adjacent bone

  • Erythrocyte sedimentation rate (ESR) is often above 50 mm/h

  • Early distention of the joint capsule is nonspecific and difficult to measure by plain radiograph

  • In infants with unrecognized pyogenic arthritis, dislocation of the joint may follow within a few days as a result of distention of the capsule by pus

  • Destruction of the joint space, resorption of epiphysial cartilage, and erosion of the adjacent bone of the metaphysis occur later

  • Bone scan shows increased flow and increased uptake about the joint

  • MRI and ultrasonography are useful adjuncts for detecting joint effusions, which can be helpful in assessing potential joint sepsis

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Treatment

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  • Surgical drainage followed by the appropriate antibiotic therapy

  • Antibiotics can be selected based on the child's age and results of the Gram stain and culture of aspirated pus

    • Reasonable empiric therapy in infants and young children is nafcillin or oxacillin plus a third-generation cephalosporin

    • An antistaphylococcal agent alone is usually adequate for children older than 5 years, unless gonococcal or meningococcal infection is suspected.

    • Clindamycin or vancomycin may be needed if methicillin-resistant S aureus is suspected or isolated

  • Duration of antibiotic therapy

    • For staphylococcal infections, a minimum of 3 weeks of therapy and until examination and inflammatory markers are normal

    • For other organisms, a minimum of ...

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