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Pediatric Septic Arthritis Differential Diagnoses

  • Author: Richard J Scarfone, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Jun 09, 2016
 
 

Diagnostic Considerations

The differential diagnosis of a painful monoarthritis is rather extensive. In contrast to children with septic arthritis (SA), children with transient synovitis appear well and are usually afebrile with just a mild limp.[6] The American College of Radiology has established guidelines for the assessment of a limping child.[7]

In adolescents, a slipped capital femoral epiphysis may manifest as a painful hip, thigh, or knee. Most patients are afebrile and the onset of pain may be preceded by minor trauma.

Legg-Calve-Perthes disease, which is most common in boys, afflicts children aged 4-8 years. In contrast to SA, the pain is subacute, with a more indolent onset, and these children do not have fever.

One study demonstrated that children with SA were less likely to have knee involvement, a history of a tick bite, or a fever than were children with Lyme disease.[2] Additionally, median values of inflammatory markers were higher among those with SA; however, a large overlap was noted between the groups.

Aside from gonococcal arthritis or SA in the neonate, polyarthritis is not typically caused by bacteria in the joints. The differential for polyarthritis in children is broad and includes Lyme disease, acute rheumatic fever, serum sickness, Kawasaki disease, systemic lupus erythematosus, and Henoch-Schönlein purpura.

In a 2014 report from New Zealand, Mistry concluded that serological inflammatory markers and white cell count (WCC) on presentation differ significantly between children with acute rheumatic fever (ARF) and septic arthritis. Children with ARF displayed significantly higher erythrocyte sedimentation rate (ESR), higher serum C-reactive protein, and lower serum WCC than children with septic arthritis on presentation to hospital.[8]

A study by Horton et al found that only 35% of cases of C difficile infection-associated reactive arthritis were correctly diagnosed by treating health care professionals and that five affected children (19%) were treated for presumed culture-negative septic hip arthritis despite having prior postantibiotic diarrhea and/or other involved joints.[9]

Differential Diagnoses

 
 
Contributor Information and Disclosures
Author

Richard J Scarfone, MD Associate Professor, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania; Attending Physician, Division of Emergency Medicine and Medical Director of Emergency Preparedness, The Children's Hospital of Philadelphia

Richard J Scarfone, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, Phi Beta Kappa

Disclosure: Received research grant from: Pfizer;GlaxoSmithKline;AstraZeneca;Merck;American Academy of Pediatrics<br/>Received income in an amount equal to or greater than $250 from: Sanofi Pasteur;Astra Zeneca;Novartis<br/>Consulting fees for: Sanofi Pasteur; Novartis; Merck; Astra Zeneca.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Itzhak Brook, MD, MSc Professor, Department of Pediatrics, Georgetown University School of Medicine

Itzhak Brook, MD, MSc is a member of the following medical societies: American Association for the Advancement of Science, American College of Physicians-American Society of Internal Medicine, American Medical Association, American Society for Microbiology, Association of Military Surgeons of the US, Infectious Diseases Society of America, International Immunocompromised Host Society, International Society for Infectious Diseases, Medical Society of the District of Columbia, New York Academy of Sciences, Pediatric Infectious Diseases Society, Society for Experimental Biology and Medicine, Society for Pediatric Research, Southern Medical Association, Society for Ear, Nose and Throat Advances in Children, American Federation for Clinical Research, Surgical Infection Society, Armed Forces Infectious Diseases Society

Disclosure: Nothing to disclose.

References
  1. Welkon CJ, Long SS, Fisher MC, Alburger PD. Pyogenic arthritis in infants and children: a review of 95 cases. Pediatr Infect Dis. 1986 Nov-Dec. 5(6):669-76. [Medline].

  2. Thompson A, Mannix R, Bachur R. Acute pediatric monoarticular arthritis: distinguishing lyme arthritis from other etiologies. Pediatrics. 2009 Mar. 123(3):959-65. [Medline].

  3. Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. J Bone Joint Surg Am. 1999 Dec. 81(12):1662-70. [Medline].

  4. Caird MS, Flynn JM, Leung YL, et al. Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study. J Bone Joint Surg Am. 2006 Jun. 88(6):1251-7. [Medline].

  5. Kaplan SL. Challenges in the evaluation and management of bone and joint infections and the role of new antibiotics for gram positive infections. Adv Exp Med Biol. 2009. 634:111-20. [Medline].

  6. Taekema HC, Landham PR, Maconochie I. Towards evidence based medicine for paediatricians. Distinguishing between transient synovitis and septic arthritis in the limping child: how useful are clinical prediction tools?. Arch Dis Child. 2009 Feb. 94(2):167-8. [Medline].

  7. [Guideline] Fordham L, Gunderman R, Blatt ER, et al. Limping child--ages 0-5 years. American College of Radiology (ACR). 2007. 5. [Full Text].

  8. Mistry RM, Lennon D, Boyle MJ, Chivers K, Frampton C, Nicholson R, et al. Septic Arthritis and Acute Rheumatic Fever in Children: The Diagnostic Value of Serological Inflammatory Markers. J Pediatr Orthop. 2014 Aug 13. [Medline].

  9. Horton DB, Strom BL, Putt ME, Rose CD, Sherry DD, Sammons JS. Epidemiology of Clostridium difficile Infection-Associated Reactive Arthritis in Children: An Underdiagnosed, Potentially Morbid Condition. JAMA Pediatr. 2016 May 16. e160217. [Medline].

  10. Deanehan JK, Kimia AA, Tan Tanny SP, Milewski MD, Talusan PG, Smith BG, et al. Distinguishing Lyme from septic knee monoarthritis in Lyme disease-endemic areas. Pediatrics. 2013 Mar. 131(3):e695-701. [Medline].

  11. Kelly JC. Septic Arthritis in Children Ruled Out by New Test. Medscape. Available at http://www.medscape.com/viewarticle/779584. Accessed: September 17, 2014.

  12. Carter K, Doern C, Jo CH, Copley LA. The Clinical Usefulness of Polymerase Chain Reaction as a Supplemental Diagnostic Tool in the Evaluation and the Treatment of Children With Septic Arthritis. J Pediatr Orthop. 2015 Apr 7. [Medline].

  13. Pääkkönen M, Kallio MJ, Peltola H, Kallio PE. Pediatric septic hip with or without arthrotomy: retrospective analysis of 62 consecutive nonneonatal culture-positive cases. J Pediatr Orthop B. 2010 May. 19(3):264-9. [Medline].

  14. Fogel I, Amir J, Bar-On E, Harel L. Dexamethasone Therapy for Septic Arthritis in Children. Pediatrics. 2015 Oct. 136 (4):e776-82. [Medline].

 
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Emergency room photograph of an infant with septic arthritis of the left hip. The child holds his hip rigidly in the classic position of flexion, abduction, and external rotation, a position that maximizes capsular volume. The patient is relatively comfortable as long as the hip joint remains immobile in this position.
 
 
 
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