Pediatric Rheumatology, Department of Pediatrics, Olgahospital, Klinikum Stuttgart, Bismarckstr. 8, 70176 Stuttgart, Germany.
Rheumatol Int. 2011 Dec;31(12):1639-43. doi: 10.1007/s00296-009-1320-x. Epub 2009 Dec 16.
To report on the differential diagnosis of lyme arthritis and synovial hemangioma due to similar clinical and radiological signs and symptoms. A 15-year-old boy presented at the age of 9 with recurrent rather painless swelling of the right knee. Altogether four episodes lasting for 1-2 weeks each occurred over a period of 18 months before medical advice was sought. Physical examination revealed only a slightly limited range of motion. Living in an endemic area of borreliosis, he reported a tick bite 6 months prior to onset of his symptoms with erythema migrans and was treated for 10 days with amoxicillin. Serology revealed two positive unspecific bands in IgG immunoblot (p41 and 66) with slight positivity for ELISA. Ultrasound revealed synovial thickening and increased fluid. Despite the weak positive serology a diagnosis of lyme arthritis could not be excluded and intravenous antibiotic treatment with ceftriaxone was started. After two further relapses antiinflammatory therapy including intraarticular steroids were introduced with no long lasting effect. A chronical disease developed with alternate periods of swelling and almost complete remission. Ultrasound as well as MRI demonstrated ongoing signs of synovitis, therefore after further progression, a diagnostic arthroscopy was performed showing an inconspicuous knee joint. A second MRI showed focal suprapatellar enhancement and was followed by open arthrotomy revealing a histopathological proven synovial cavernous juxtaarticular hemangioma. To our knowledge, the differential diagnosis of lyme arthritis and synovial hemangioma has not yet been reported despite obvious clinical similarities. In conclusion, in children and adolescents synovial hemangioma has to be considered in differential diagnosis of recurrent knee swelling. Early diagnosis is important to prevent prolonged suffering from chronic joint swelling with probable joint damages, unnecessary treatment procedures and as well school and sports absenteeism.
报告莱姆关节炎和滑膜血管瘤的鉴别诊断，因为它们具有相似的临床和影像学表现。一名 15 岁男孩在 9 岁时出现右侧膝关节反复无痛性肿胀，共发作 4 次，每次持续 1-2 周，历时 18 个月后才寻求医疗建议。体格检查仅发现关节活动度略有限制。他生活在莱姆病流行区，在症状发作前 6 个月曾被蜱叮咬，出现游走性红斑，并用阿莫西林治疗 10 天。血清学检查显示 IgG 免疫印迹中有两条阳性非特异性带（p41 和 66），ELISA 有轻度阳性。超声显示滑膜增厚和关节腔积液增多。尽管血清学检查弱阳性，但不能排除莱姆关节炎的诊断，开始静脉用头孢曲松进行抗生素治疗。在另外两次复发后，采用包括关节内皮质类固醇在内的抗炎治疗，但没有持久效果。发展为慢性疾病，伴有交替的肿胀和几乎完全缓解期。超声和 MRI 均显示持续性滑膜炎表现，因此在进一步进展后，进行了诊断性关节镜检查，显示膝关节无明显异常。第二次 MRI 显示髌上囊局灶性强化，随后行开放性关节切开术，显示病理证实为滑膜海绵状关节旁血管瘤。据我们所知，尽管临床表现明显相似，但莱姆关节炎和滑膜血管瘤的鉴别诊断尚未见报道。总之，在儿童和青少年中，滑膜血管瘤在复发性膝关节肿胀的鉴别诊断中必须考虑。早期诊断很重要，可以预防因慢性关节肿胀而导致的关节损伤、不必要的治疗程序以及因缺课和缺赛而造成的长期痛苦。
