Septic arthritis of the paediatric hip - A review of current diagnostic approaches and therapeutic concepts.

A misdiagnosed septic arthritis (SA) of the paediatric hip is a nightmare for many physicians. The authors tried to trace the most recent information about this problem. A Medline search, using PubMed interface, was focused on the period from 01.01.2002 to 31.08. 2012. A total of 53 papers were included in the study. They led to the following statement, among others, about the differential diagnosis between SA and transient synovitis: "CRP > 20 mg/L, non-weight-bearing, temperature >38.5 degrees C and peripheral white blood cell count > 12 x 10(9) cells /L offers a predictive probability for septic arthritis of 87%". As soon as the clinical data point to septic arthritis, a diagnostic needle aspiration becomes mandatory : for cell count, Gram stain and culture. Immediately afterwards, antibiotics should be started, knowing that they need to be adapted to the antibiogram as soon as it is available. If the clinical picture and the CRP improve within 24 hours, antibiotics are continued, classically for 3 to 3.5 weeks. If not, some kind of surgical intervention becomes necessary: arthrotomy, or daily repeated ultrasound-guided aspiration and irrigation, or arthroscopic irrigatiop and drainage. A diagnostic and therapeutic algorithm is presented. Finnish current literature proposes to reduce the aggressiveness of the treatment of SA, at least in previously healthy children with a short medical history (less than 5 days) : antibiotic therapy of less than two weeks and avoidance of a surgical intervention, apart from a diagnostic needle aspiration, might be justifiable in these cases.

Anti-TNF Treatment for Extraintestinal Manifestations of Inflammatory Bowel Disease in the Swiss IBD Cohort Study.

BACKGROUND: Extraintestinal manifestations (EIMs) in patients with inflammatory bowel disease (IBD) are frequently observed. Little is known about the efficacy of anti-tumor necrosis factor (TNF) in EIM management. We assessed the effect of 3 anti-TNF agents (infliximab, adalimumab, and certolizumab pegol) on EIM evolution. METHODS: Data on 1249 patients from the Swiss IBD Cohort Study (SIBDCS) were analyzed. All EIMs were diagnosed by relevant specialists. Response was classified into improvement, stable disease, and clinical worsening based on the physician's interpretation. RESULTS: Of the 366 patients with at least 1 EIM, 213 (58.2%) were ever treated with an anti-TNF. A total of 299 treatments were started for 355 EIMs. Patients with EIM were significantly more often treated with anti-TNF compared with those without EIM (58.2% versus 21.0%, P < 0.001). Infliximab was the most frequently used drug (63.2%). In more than 71.8%, a clinical response of the underlying EIM to anti-TNF therapy was observed. In 92 patients (43.2%), anti-TNF treatments were started for the purpose of treating EIM rather than IBD. Response rates to anti-TNF were generally good and best for psoriasis, aphthous stomatitis, uveitis, and peripheral arthritis. In 11 patients, 14 EIM occurred under anti-TNF treatment. CONCLUSIONS: Anti-TNF was frequently used among patients with EIM. In more than 40%, anti-TNF treatments are started to treat EIM rather than IBD. Given the good response rates, anti-TNF seems to be a valuable option in the treatment of EIM, whereas appearance of EIM under anti-TNF does not seem to be a source of considerable concern.

Surgical treatment options for septic arthritis of the hip in children.

Septic arthritis is the result of bacterial infection of the hip joint and is often found in infants and toddlers. It is the most common septic joint condition during growth and may cause the most devastating complications without prompt and proper treatment. Early diagnosis and intervention are required to avoid irreversible complications. This review documents the systematic approach to diagnosis and management of septic arthritis in children.

Chronological Order of Appearance of Extraintestinal Manifestations Relative to the Time of IBD Diagnosis in the Swiss Inflammatory Bowel Disease Cohort.

BACKGROUND: Data evaluating the chronological order of appearance of extraintestinal manifestations (EIMs) relative to the time of inflammatory bowel disease (IBD) diagnosis is currently lacking. We aimed to assess the type, frequency, and chronological order of appearance of EIMs in patients with IBD. METHODS: Data from the Swiss Inflammatory Bowel Disease Cohort Study were analyzed. RESULTS: The data on 1249 patients were analyzed (49.8% female, median age: 40 [interquartile range, 30-51 yr], 735 [58.8%] with Crohn's disease, 483 [38.7%] with ulcerative colitis, and 31 [2.5%] with indeterminate colitis). A total of 366 patients presented with EIMs (29.3%). Of those, 63.4% presented with 1, 26.5% with 2, 4.9% with 3, 2.5% with 4, and 2.7% with 5 EIMs during their lifetime. Patients presented with the following diseases as first EIMs: peripheral arthritis 70.0%, aphthous stomatitis 21.6%, axial arthropathy/ankylosing spondylitis 16.4%, uveitis 13.7%, erythema nodosum 12.6%, primary sclerosing cholangitis 6.6%, pyoderma gangrenosum 4.9%, and psoriasis 2.7%. In 25.8% of cases, patients presented with their first EIM before IBD was diagnosed (median time 5 mo before IBD diagnosis: range, 0-25 mo), and in 74.2% of cases, the first EIM manifested itself after IBD diagnosis (median: 92 mo; range, 29-183 mo). CONCLUSIONS: In one quarter of patients with IBD, EIMs appeared before the time of IBD diagnosis. Occurrence of EIMs should prompt physicians to look for potential underlying IBD.