Baldwin Keith D, Brusalis Christopher M, Nduaguba Afamefuna M, Sankar Wudbhav N
The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.
The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
J Bone Joint Surg Am. 2016 May 4;98(9):721-8. doi: 10.2106/JBJS.14.01331.
Differentiating between septic arthritis and Lyme disease of the knee in endemic areas can be challenging and has major implications for patient management. The purpose of this study was to identify a prediction rule to differentiate septic arthritis from Lyme disease in children presenting with knee pain and effusion.
We retrospectively reviewed the records of patients younger than 18 years of age with knee effusions who underwent arthrocentesis at our institution from 2005 to 2013. Patients with either septic arthritis (positive joint fluid culture or synovial white blood-cell count of >60,000 white blood cells/mm(3) with negative Lyme titer) or Lyme disease (positive Lyme immunoglobulin G on Western blot analysis) were included. To avoid misclassification bias, undiagnosed knee effusions and joints with both a positive culture and positive Lyme titers were excluded. Historical, clinical, and laboratory data were compared between groups to identify variables for comparison. Binary logistic regression analysis was used to identify independent predictive variables.
One hundred and eighty-nine patients were studied: 23 with culture-positive septic arthritis, 26 with culture-negative septic arthritis, and 140 with Lyme disease. Multivariate binary logistic regression identified pain with short arc motion, history of fever reported by the patient or a family member, C-reactive protein of >4 mg/L, and age younger than 2 years as independent predictive factors for septic arthritis. A simpler model was developed that showed that the risk of septic arthritis with none of these factors was 2%, with 1 of these factors was 18%, with 2 of these factors was 45%, with 3 of these factors was 84%, or with all 4 of these factors was 100%.
Although septic arthritis of the knee and Lyme monoarthritis share common features that can make them difficult to distinguish clinically, the presence of pain with short arc motion, C-reactive protein of >4.0 mg/L, patient-reported history of fever, and age younger than 2 years were independent predictive factors of septic arthritis in pediatric patients. The more factors that are present, the higher the risk of having septic arthritis.
Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.
在流行地区，区分膝关节化脓性关节炎和莱姆病具有挑战性，且对患者的管理有重大影响。本研究的目的是确定一种预测规则，以区分出现膝关节疼痛和积液的儿童患者的化脓性关节炎与莱姆病。
我们回顾性分析了2005年至2013年在我院接受关节穿刺术的18岁以下膝关节积液患者的记录。纳入患有化脓性关节炎（关节液培养阳性或滑膜白细胞计数>60,000/mm³且莱姆滴度阴性）或莱姆病（免疫印迹分析莱姆免疫球蛋白G阳性）的患者。为避免错误分类偏倚，排除未确诊的膝关节积液以及培养阳性且莱姆滴度阳性的关节。比较两组之间的病史、临床和实验室数据，以确定用于比较的变量。采用二元逻辑回归分析确定独立预测变量。
共研究了189例患者：23例培养阳性的化脓性关节炎患者，26例培养阴性的化脓性关节炎患者，以及140例莱姆病患者。多变量二元逻辑回归确定短弧运动时疼痛、患者或家庭成员报告的发热史、C反应蛋白>4mg/L以及年龄小于2岁为化脓性关节炎的独立预测因素。开发了一个更简单的模型，结果显示无这些因素时化脓性关节炎的风险为2%，有1个因素时为18%，有2个因素时为45%，有3个因素时为84%，有所有4个因素时为100%。
虽然膝关节化脓性关节炎和莱姆单关节炎有一些共同特征，使得它们在临床上难以区分，但短弧运动时疼痛、C反应蛋白>4.0mg/L、患者报告的发热史以及年龄小于2岁是儿童患者化脓性关节炎的独立预测因素。存在的因素越多，患化脓性关节炎的风险越高。
诊断性III级。有关证据水平的完整描述，请参阅作者指南。
