Department of Orthopaedic Surgery, University of California, Los Angeles, Los Angeles, CA, USA.
Orthopedic Research Unit, Department of Orthopaedic Surgery, Red Cross Children's Hospital, University of Cape Town, 7925 Observatory, Cape Town, South Africa.
Int Orthop. 2020 Dec;44(12):2645-2652. doi: 10.1007/s00264-020-04815-3. Epub 2020 Sep 28.
In settings with limited access to specialist services, differentiating septic arthritis-a surgical emergency-from non-infectious atraumatic arthropathy in paediatric patients is challenging, especially in a setting with a high burden of tuberculosis (TB). We aimed to investigate the aetiologies of swollen, painful joints in an urban setting in South Africa and determine how clinical and laboratory findings varied with diagnosis.
A retrospective review of patients aged 12 or younger presenting to a paediatric hospital in Cape Town, South Africa, with atraumatic swollen, painful joints was conducted over a two year period from 2013 to 2015. Children were excluded if they did not have tissue culture or analysis conducted at our facility. Aetiology was classified as non-infectious, TB septic arthritis, or pyogenic arthritis from other bacterial causes.
One hundred and four children met inclusion criteria. Arthritis was classified as non-infectious in 43 (41%), TB in 15 (14%), and pyogenic in 40 (38%), with six (6%) patients never receiving a final diagnosis. Mean C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and white blood cell count (WCC) were all significantly higher in pyogenic infectious arthritis compared with TB and non-infectious arthritis. There were no significant differences in these parameters between non-infectious and TB arthritis. Using cut-point analysis, thresholds were identified predictive of the presence of pyogenic arthritis versus TB or non-infectious arthritis; these included the presence of fever, CRP > 50 mg/L, ESR > 65 mm/h and WCC > 12x10/L. The absence of all of these criteria resulted in a negative predictive value of 100% for pyogenic infection; the presence of three to four criteria resulted in a positive predictive value of 71%.
Despite insignificant differences in their clinical presentation compared with non-infectious arthidities, 15% of children were diagnosed with tissue-confirmed TB infection. Predictive values of clinical criteria are reduced in our population due to elevated levels of inflammatory markers in all patients. Synovial biopsy to rule out TB is recommended in all patients in a high-burden setting given clinical similarity to non-infectious aetiologies.
在专科服务获取受限的环境中，鉴别儿童脓毒性关节炎（一种紧急外科病症）与非感染性创伤性关节病极具挑战性，尤其是在结核病（TB）负担沉重的环境中。本研究旨在调查南非一个城市地区关节肿胀、疼痛的病因，并确定临床和实验室检查结果随诊断的变化情况。
我们对 2013 年至 2015 年期间在南非开普敦一家儿科医院就诊的 12 岁及以下、创伤性关节肿胀、疼痛的儿童进行了回顾性分析。如果患儿未在我院进行组织培养或分析，则将其排除在外。病因分类为非感染性、TB 脓毒性关节炎或其他细菌性化脓性关节炎。
104 名患儿符合纳入标准。43 例（41%）关节炎归类为非感染性，15 例（14%）为 TB，40 例（38%）为化脓性，6 例（6%）患儿始终未得到明确诊断。化脓性感染性关节炎患儿的 C 反应蛋白（CRP）、红细胞沉降率（ESR）和白细胞计数（WCC）均值均显著高于 TB 性关节炎和非感染性关节炎。非感染性关节炎与 TB 关节炎的这些参数无显著差异。通过截断点分析，确定了预测化脓性关节炎与 TB 或非感染性关节炎的参数阈值；这些参数包括发热、CRP>50mg/L、ESR>65mm/h 和 WCC>12x10/L。不存在所有这些标准时，化脓性感染的阴性预测值为 100%；存在 3-4 个标准时，阳性预测值为 71%。
尽管与非感染性关节炎相比，其临床表现无显著差异，但 15%的患儿被诊断为组织证实的 TB 感染。由于所有患儿的炎症标志物水平升高，我们人群中临床标准的预测值降低。鉴于与非感染性病因的临床相似性，在高负担环境中，建议对所有患者进行滑膜活检以排除 TB。
