Acute monoarthritis in young children: comparing the characteristics of patients with juvenile idiopathic arthritis versus septic and undifferentiated arthritis.

Acute arthritis is a common cause of consultation in pediatric emergency wards. Arthritis can be caused by juvenile idiopathic arthritis (JIA), septic (SA) or remain undetermined (UA). In young children, SA is mainly caused by Kingella kingae (KK), a hard to grow bacteria leading generally to a mild clinical and biological form of SA. An early accurate diagnosis between KK-SA and early-onset JIA is essential to provide appropriate treatment and follow-up. The aim of this work was to compare clinical and biological characteristics, length of hospital stays, duration of intravenous (IV) antibiotics exposure and use of invasive surgical management of patients under 6 years of age hospitalized for acute monoarthritis with a final diagnosis of JIA, SA or UA. We retrospectively analyzed data from < 6-year-old children, hospitalized at a French tertiary center for acute mono-arthritis, who underwent a joint aspiration. Non-parametric tests were performed to compare children with JIA, SA or UA. Bonferroni correction for multiple comparisons was applied with threshold for significance at 0.025. Among the 196 included patients, 110 (56.1%) had SA, 20 (10.2%) had JIA and 66 (33.7%) had UA. Patients with JIA were older when compared to SA (2.7 years [1.8-3.6] versus 1.4 [1.1-2.1], p < 0.001). Presence of fever was not different between JIA and SA or UA. White blood cells in serum were lower in JIA (11.2 × 109/L [10-13.6]) when compared to SA (13.2 × 109/L [11-16.6]), p = 0.01. In synovial fluid leucocytes were higher in SA 105.5 × 103 cells/mm3 [46-211] compared to JIA and UA (42 × 103 cells/mm3 [6.4-59.2] and 7.29 × 103 cells/mm3 [2.1-72] respectively), p < 0.001. Intravenous antibiotics were administered to 95% of children with JIA, 100% of patients with SA, and 95.4% of UA. Arthrotomy-lavage was performed in 66.7% of patients with JIA, 79.6% of patients with SA, and 71.1% of patients with UA. In children less than 6 years of age with acute mono-arthritis, the clinical and biological parameters currently used do not reliably differentiate between JIA, AS and UA. JIA subgroups that present a diagnostic problem at the onset of monoarthritis before the age of 6 years, are oligoarticular JIA and systemic JIA with hip arthritis. The development of new biomarkers will be required to distinguish JIA and AS caused by Kingella kingae in these patients.

Management of an outbreak of invasive Kingella kingae skeletal infections in a day care center.

BACKGROUND: Kingella kingae (Kk) is frequently responsible for invasive skeletal infections in children aged 3-36months. However, few outbreaks of invasive Kk infections in day care centers have been reported. The objective of the present study was to describe (a) the clinical and laboratory data recorded during an outbreak of invasive Kk skeletal infections, and (b) the management of the outbreak. METHOD: Four children from the same day care center were included in the study May and June 2019. We retrospectively analyzed the children's clinical presentation and their radiological and laboratory data. We also identified all the disease control measures taken in the day care center. RESULTS: We observed cases of septic arthritis of the wrist (case #1), shoulder arthritis (case #2), knee arthritis (case #3) ans cervical spondylodiscitis (case #4). All cases presented with an oropharyngeal infection and concomitant fever prior to diagnosis of the skeletal infection. All cases were misdiagnosed at the initial presentation. The mean (range) age at diagnosis was 10.75months (9-12). The three patients with arthritis received surgical treatment. All patients received intravenous and then oral antibiotics. In cases 1 and 2, Kk was detected using real-time PCR and a ST25-rtxA1 clone was identified. The outcome was good in all four cases. Four other children in the day care center presented with scabies during this period and were treated with systemic ivermectin. The Regional Health Agency was informed, and all the parents of children attending the day care center received an information letter. The day care center was cleaned extensively. CONCLUSION: Our results highlight the variety of features of invasive skeletal Kk infections in children and (given the high risk of transmission in day care centers) the importance of diagnosing cases as soon as possible.

Necrotizing epiglottitis treated with early surgical debridement: A case report.

OBJECTIVE: Necrotizing supraglottitis is a rare but potentially morbid infection most often seen in immunocompromised patients. All reported cases have utilized intravenous antibiotic therapy as the mainstay of treatment and many have had associated morbidities. METHODS: We describe a case of a 50-year-old previously healthy female who presented with necrotizing epiglottis and was treated with immediate surgical debridement followed by directed antibiotic therapy. RESULTS: Our patient rapidly recovered with no further invasive interventions. On follow up she had no further complications or functional deficits. CONCLUSIONS: Although uncommon, providers should be aware of the potential benefits of early debridement when treating patients with similar pathology. Early surgical intervention should be considered to avoid local tissue loss, airway interventions, and long-term sequelae.

Improved Diagnosis and Treatment of Bone and Joint Infections Using an Evidence-based Treatment Guideline.

BACKGROUND: Our institution created a multidisciplinary guideline for treatment of acute hematogenous osteomyelitis (AHO) and septic arthritis (SA) in response to updates in evidence-based literature in the field and existing provider variability in treatment. This guideline aims to improve the care of these patients by standardizing diagnosis and treatment and incorporating up to date evidence-based research into practice. The primary objective of this study is to compare cases before versus after the implementation of the guideline to determine concrete effects the guideline has had in the care of patients with AHO and SA. METHODS: This is an Institutional Review Board-approved retrospective study of pediatric patients age 6 months to 18 years hospitalized between January 2009 and July 2016 with a diagnosis of AHO or SA qualifying for the guideline. Cohorts were categorized: preguideline and postguideline. Exclusion criteria consisted of: symptoms >14 days, multifocal involvement, hemodynamic instability, sepsis, or history of immune deficiency or chronic systemic disease. Cohorts were compared for outcomes that described clinical course. RESULTS: Data were included for 117 cases that qualified for the guideline: 54 preguideline and 63 postguideline. Following the successful implementation of the guideline, we found significant decrease in the length of intravenous antibiotic treatment (P<0.001), decrease in peripherally inserted central catheter use (P<0.001), and an increase in bacterial identification (P=0.040). Bacterial identification allowed for targeted antibiotic therapy. There was no change in length of hospital stay or readmission rate after the implementation of the guideline. CONCLUSION: Utilizing an evidence-based treatment guideline for pediatric acute hematogenous bone and joint infections can lead to improved bacterial diagnosis and decreased burden of treatment through early oral antibiotic use. LEVEL OF EVIDENCE: Level III- retrospective comparative study.

Particular surgical aspects of endocarditis due to Kingella kingae with cerebral complication.

We report 2 cases of Kingella kingae endocarditis leading to valvular mitral perforation in previously healthy children. Kingella kingae belongs to the HACEK (Haemophilus aphrophilus, Actiobacillus actinomycetemcomitans, Cardiobacterium hominis, Eikenella corrodens and K. kingae) group of organisms known to cause endocarditis.

Neisseria elongata endocarditis of a native aortic valve.

Neisseria elongata is a part of the common bacterial flora of the oropharynx but has caused sepsis, osteomyelitis and infective endocarditis on rare occasions. We report the case of a 56-year-old Caucasian woman who was admitted to hospital with a 5-week history of fever, malaise and fatigue. Two blood cultures grew Gram-negative rods which were confirmed to be N. elongata subspecies nitroreducens via bacterial DNA sequence analysis. An echocardiogram showed a large mobile vegetation on the right and non-coronary cusps of the aortic valve. The patient underwent aortic valve replacement and antibiotic therapy for 6 weeks. We suggest that clinicians should consider extended antibiotic treatment and early surgical evaluation based on the nature and aggressiveness of N. elongata.

Acute pediatric septic arthritis: a systematic review of literature and current controversies.

We present a review of the current literature and the author's opinion regarding Septic arthritis in the pediatric age group. The etiopathogenesis, clinical features, the laboratory parameters for diagnosis and monitoring of treatment, radiological features, are discussed along-with the debatable issues pertaining to the choice of antibiotics, their duration, and the need and mode of surgical drainage and mobilization of the joint.

Unusually severe cases of Kingella kingae osteoarticular infections in children.

BACKGROUNDS: With the development of molecular biology and specific polymerase chain reaction, Kingella kingae has become the primary diagnosis of osteoarticular infections in young children. Clinical features of these osteoarticular infections are typically mild, and outcome is almost always favorable. We report a series of unusually severe cases of K. kingae osteoarticular infections. METHODS: All patients with severe osteoarticular infections at presentation were reviewed retrospectively in 2 European pediatric centers. K. kingae was identified using real-time polymerase chain reaction in blood, fluid joint or osseous samples. Clinical, laboratory tests and radiographic data during hospitalization and follow-up were analyzed. RESULTS: Ten children (mean age 21 ± 12 months) with severe osteoarticular infections caused by K. kingae were identified between 2008 and 2011. Diagnostic delay averaged 13.2 ± 8 days. Only 1 patient was febrile at admission, and 50% children had normal C-reactive protein values (≤10 mg/dL) at presentation. Surgical treatment was performed in all cases. Intravenous antibiotic therapy by cephalosporins for an average of 8 ± 6 days was followed by oral treatment for 27 ± 6 days. Mean follow-up was 24.8 ± 9 months, and satisfactory outcomes were reported in all cases. Two patients (20%) developed a central epiphysiodesis of the proximal humerus during follow-up, but without significant clinical consequence for the moment. CONCLUSIONS: Because of their mild clinical features at onset, diagnosis of K. kingae osteoarticular infections can be delayed. Care should be taken for early detection and treatment of these infections because bony lytic lesions and potentially definitive growth cartilage damage can occur.

[Kingella kingae infections in the pediatric age]. / Infecciones por Kingella kingae en la edad pediátrica.

Kingella kingae infections have aroused great interest in the last few years because of the increasing number of identified cases. Although considered an emerging pathogen, the increase in diagnosis of these infections can probably be explained by better knowledge of the bacteria, improved microbiological diagnostic techniques and greater awareness among clinicians. K. kingae is an aerobic cocobacillus with high tropism for osteoarticular tissue, endocardium, and vascular space. This pathogen mainly produces osteomyelitis, endocarditis, septic arthritis and bacteriemias. First choice antibiotics are penicillins and cephalosporins. This article reviews the literature on this microorganism.

Subtle bacterial endocarditis due to Kingella kingae in an infant: a case report.

A 9-month-old infant presented with fever, dyspnoea, and a murmur. Echocardiography showed a mitral vegetation with significant regurgitation. Mitral valve plasty was performed on day 6, and was polymerase chain reaction positive for Kingella kingae. The cardiac outcome was favourable. This case illustrates a subtle presentation of K. kingae mitral valve infective endocarditis in a normal-cardaic infant, treated with early surgery, and the agent belonged to the HACEK (Haemophilus spp Actinobacillus actinomycetemcomitans, Capnocytophaga spp, Cardiobacterium hominis, Eikenella corrodens, and Kingella kingae) group.

Successful treatment of a localised CDC Group EF-4a infection in a cat.

Organisms classified within the Center for Disease Control (CDC) Group eugonic fermenter (EF)-4a are facultative anaerobic, Gram-negative coccobacilli, thought to be of the family Neisseriaceae. CDC Group EF-4a is considered a component of normal oral flora in cats and dogs and is most commonly isolated from bite injuries of human patients. Most previously reported cases in cats have involved fatal necrotising pneumonia. We report a localised infection of the retropharyngeal/mandibular tissues in a cat, which responded to surgical drainage and a 5-week course of amoxycillin clavulanate. There are no prior reports of successfully treated EF-4a infections in cats in the literature.

Endophthalmitis caused by Moraxella osloensis.

PURPOSE: To report the clinical presentation, antibiotic sensitivities, and treatment outcomes of endophthalmitis caused by Moraxella osloensis. CASE SERIES: retrospective review of the medical records of all patients treated for endophthalmitis at Bascom Palmer Eye Institute between 1 January 1991 and 31 December 2000. RESULTS: During the study interval, 757 eyes were treated for endophthalmitis. Moraxella osloensis was isolated from three eyes of two patients (3/757, or 0.39%). In all three eyes, the endophthalmitis was delayed-onset and bleb-associated; Moraxella osloensis was isolated on chocolate agar and 5% sheep's blood agar using a RapNH commercial Kit (by Remel) through an automated system (Vitek). Like most gram-negative organisms, Moraxella was sensitive to ceftazidime, ciprofloxacin, and the aminoglycosides. Although vision at presentation was poor, both patients regained baseline vision after treatment with pars plana vitrectomy and injection of intravitreal antibiotics. CONCLUSIONS: To our knowledge, this is the first report of endophthalmitis caused by Moraxella osloensis. Unlike most series of delayed-onset, bleb-associated endophthalmitis the visual prognosis following treatment for endophthalmitis caused by Moraxella osloensis appears to be generally favorable.

Fatal sepsis associated with acute pancreatitis caused by Moraxella catarrhalis in a child.

We describe a 4-year-old boy with Cornelia de Lange syndrome who died of septic shock caused by Moraxella catarrhalis bacteremia. At autopsy there was evidence of acute hemorrhagic pancreatitis with abscesses. Gram-negative diplococci were seen histologically in the abscesses and pancreatic ducts.

[Clinical and therapeutical correlations in Moraxella catarrhalis respiratory infection in children]. / Corelatii clinico-terapeutice în infectia respiratorie cu Moraxella catarrhalis la copil.

In childhood recurrent respiratory infection with Moraxella catarrhalis have high incidence demonstrated by multiple risk factors association (atopia, immunsuppresion, chronic diseases, malnutrition) that makes this common bacteria pathogen. The study was carried on 56 children (0-16 years old). Authors try to find correlations between clinical signs and microbiological markers that determine recurrent respiratory infection with Moraxella catarrhalis. Treatment consisted of association between "target" antibiotherapy and immunomodulation drugs. Efficacy of this treatment was proven by decreased numbers of recurrent infection (in 35% cases comparing to 53% selected cases for immunomodulation), improvement of evolution of chronic diseases, decreased number of days and price of hospitalisation.

Treatment outcome of Moraxella keratitis: our experience with 18 cases--a retrospective review.

PURPOSE: To analyze the clinical presentation, predisposing risk factors, in vitro antimicrobial susceptibility, and especially the outcome of therapy of Moraxella keratitis. METHODS: Retrospective review of 18 culture-proven cases of Morarella keratitis. RESULTS: Morarella keratitis was associated with Hansen's disease, uncontrolled diabetes mellitus, herpes zoster ophthalmicus, and chickenpox of the recent past and severe protein energy malnutrition. Other associated ocular conditions included lagophthalmos, blepharitis, steroid therapy, corneal degeneration, and scleritis. In four patients, no systemic or ocular predisposing factors could be identified. Three patients presented with an indolent peripheral, anterior stromal infiltrate while the remaining patients showed a central or paracentral ulceration with or without hypopyon. Moraxella species was the only pathogen isolated in 11 cases, whereas mixed infection was seen in seven cases. All isolates were sensitive to ciprofloxacin. Eight of 18 strains of Moraxella were resistant to cefazolin. All 14 eyes for which the follow-up data were available responded to medical treatment alone. CONCLUSIONS: Although considered to be associated with poor outcome, our experience suggests that a favorable outcome can be expected in Moraxella keratitis. Cefazolin resistance (as seen in our series) may pose a problem and, hence, monitoring of antimicrobial susceptibility would be beneficial. In view of cefazolin resistance, ciprofloxacin monotherapy appears to be an effective method in the medical management of these cases.

Newer pediatric pathogens.

Newer laboratory techniques have allowed the detection of previously unrecognized microbial agents that are now pathogenic in children, as well as newly recognized manifestations of previously known pathogens. Clinical reports of these newer agents or manifestations are reviewed so that pediatricians can become familiar with these emerging infectious diseases. Physicians need to consider these organisms in the differential diagnosis in appropriate clinical illnesses.