Diagnostic dilemmas of pediatric osteoarticular infections and systemic inflammatory response syndrome

ORIGINAL ARTICLE

Diagnostic Dilemmas of Pediatric Osteoarticular Infections and Systemic Inflammatory Response Syndrome

Barbara Minkowitz¹, Jennifer R Ristic¹, Maria Iram Awan¹, Eileen Poletick¹, Elizabeth Baorto².

¹Department of Pediatric Orthopedics, Morristown Medical Center, Morristown, New Jersey, USA,
²Department of Pediatrics, Morristown Medical Center, Morristown, New Jersey, USA.

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Abstract
Objective and Aim: Delayed diagnosis of pediatric osteoarticular infections at initial presentation can lead to serious sequelae. Osteoarticular infections can be classified into categories dependent on presence of a septic joint or associated abscesses (simple or complex). A third group is identified; complex with systemic inflammatory response syndrome (SIRS). These patients are clinically unstable and require intensive care. The aim of the study was to determine factors associated with delayed care in patients with osteoarticular infections to prevent SIRS.

Methods and Materials: Retrospective chart review was conducted for various clinical parameters. Patients were classified into groups depending on magnetic resonance imaging (MRI) and clinical findings. Only infections requiring surgery were included. These fell into two categories: (1) complex clinically stable (non-SIRS) and (2) complex clinically unstable (SIRS). Factors associated with each group were analyzed.

Results: Common clinical features observed were increasing pain in 33 (100%) patients, decreased ambulatory status with lower extremity infections in 28 (100%) patients, soft tissue swelling in 16 (48.5%) patients. Four patients were in the SIRS group and 29 patients were in the non-SIRS group. Time from symptom presentation to the first medical contact averaged 3 days in both the groups (p=0.7367). Time from symptom onset to Emergency Department (ED) presentation averaged 2 days in the SIRS group and 1 day in the non-SIRS group (p=0.0717). Average number of medical contacts before diagnosis was 4 in the SIRS group and 3 in the non-SIRS group (p=0.0091). Time from onset of symptoms to operating room was 11.5 days in the SIRS group and 5 days in the non-SIRS group (p=0.0170). Hospital length of stay was 5 days for the clinically stable group and 12.5 days for SIRS group (p=0.0078). Higher CRP, higher ESR and higher body temperature were observed in the SIRS group as compared to non-SIRS group which was statistically significant. White cell count was similar in both the groups. Methicillin resistant staphylococcus aureus was isolated in 75% of patients in the SIRS group and Methicillin sensitive staphylococcus aureus was isolated in 55.2% of patients in the non-SIRS group.

Conclusion: Children with progressive osteoarticular pain should be considered for an infection with a low threshold for obtaining laboratory tests and an MRI. The goal is to halt progression of infection, complications, and need for hospitalization. Though most patients present to the 1st medical contact in time, further medical contacts and presentation to ED is usually delayed in patients with SIRS.

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