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• Re: Use Your Ears
  Robert W Marshall
  Published on: 23 March 2016
• Use your Ears
  Debajit Sen
  Published on: 23 March 2016
• Doubts about diagnosis
  Ulrich Heininger
  Published on: 23 March 2016

• Published on: 23 March 2016

  Re: Use Your Ears

  • Robert W Marshall, Specialist Registrar in Rheumatology
  • Other Contributors:
    • Richard G. Hull

  Dear Editor,

  We read with interest the article by O’Hare et al [1] and would like to congratulate the authors on their interesting case, but would like to make the following points:

  • Assessment of the musculoskeletal system is poorly performed not only by adult medical trainees [2,3] , but also by paediatric trainees: a recent survey showed that only 1.6% of general paediatric admissions...

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  Dear Editor,

  We read with interest the article by O’Hare et al [1] and would like to congratulate the authors on their interesting case, but would like to make the following points:

  • Assessment of the musculoskeletal system is poorly performed not only by adult medical trainees [2,3] , but also by paediatric trainees: a recent survey showed that only 1.6% of general paediatric admissions had any form of joint examination documented [4]. Thus musculoskeletal examination skills may be poor in trainees and physicians with no specialist knowledge. Consequently we are not reassured that the remainder of the musculoskeletal examination by the admitting team was normal.
  • The joint was never aspirated. The only way to make (or exclude) a diagnosis of septic arthritis is culture of synovial fluid.
  • If staphylococcal septic arthritis is suspected, then current recommendations suggest the use of two antibiotics active against this organism [5]. Clindamycin would be an appropriate choice to add to flucloxacillin, but oral fusidic acid is an alternative [6].
  • The “salmon pink rash” in juvenile arthritis is not seen in pauciarticular JIA but is a feature of systemic onset JIA.
  • In this case the Lyme IgG and IgM were both positive, thus supporting the diagnosis. We have in our own practice, however, encountered cases where a clinical diagnosis of Lyme arthritis was made despite initial negative assays for both IgG and IgM. Subsequent serology became positive. Beware the false negative!

  References

  (1). O’Hare BAM, Kader A, Powell CVE. Use Your Ears. Arch Dis Child Educ Pract Ed 2004; 89:ep9-ep14

  (2). Marshall RW, Hull RG. For crying out loud: musculoskeletal assessment of inpatients referred to rheumatology. In press (Rheumatology 2004)

  (3). Lillicrap MS, Byrne E, Speed CA. Musculoskeletal assessment of general medical in-patients—joints still crying out for attention. Rheumatology 2003;42:951–4.

  (4). Myers A, McDonagh JE, Gupta K et al. More ‘cries from the joints’: assessment of the musculoskeletal system is poorly documented in routine paediatric clerking. Rheumatology 2004 43: 1045-1049

  (5). The management of septic arthritis. Drugs and Therapeutics Bulletin 41(9) Sept 2003: 65-68

  (6). Atkins B, Gottlieb T. Fusidic acid in bone and joint infections. Int J Antimicrob Agents. 1999 Aug;12 Suppl 2:S79-93.

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  Conflict of Interest:
  None declared.

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• Published on: 23 March 2016

  Use your Ears

  • Debajit Sen, Honorary Consultant in Paediatric Rheumatology
  • Other Contributors:
    • Nathan Hasson, Consultant in Paediatric Rheumatology

  Dear Editor,

  We read with great interest the article by O’Hare et al [1]. We commend the general educational messages of the authors but feel compelled to highlight some important errors and omissions.

  In the table of differential diagnosis of monoarticular arthritis, it is also important to consider the diagnoses of trauma/non-accidental injury, the exclusion of which would be the prime indication for...

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  Dear Editor,

  We read with great interest the article by O’Hare et al [1]. We commend the general educational messages of the authors but feel compelled to highlight some important errors and omissions.

  In the table of differential diagnosis of monoarticular arthritis, it is also important to consider the diagnoses of trauma/non-accidental injury, the exclusion of which would be the prime indication for radiography. In addition, haemophilia should be considered as well as sarcoidosis, crystal arthritis, avascular necrosis, foreign body, pigmented villonodular synovitis and neuroblastoma.

  Table 2 considers the differential diagnosis of arthritis and rash. Monoarthritis in a child would be considered under the heading of oligoarticular juvenile idiopathic arthritis (JIA) [2]. Oligoarticular JIA is not characterised by a ‘salmon pink’ rash, lymphadenopathy or hepatosplenomegaly which are features of systemic onset JIA [2]. Reactive arthritis is also an important differential but neither hepatosplenomegaly or a compatible rash are typical features. Arthralgia is a common feature of the viral hepatitides. Hepatitis B is associated with polyarteritis nodosa and hepatitis C with cryoglobulinaemia. However, monoarthritis is not a feature of hepatitis B. Instead a flitting, self-limiting polyarthritis is more typical in up to 20% of patients infected with the virus [3].

  References

  (1). O’ Hare BAM, Kader A, Powell CVE. Use your ears.Arch Dis Child Educ Pract Ed 2004;89:ep9-ep14.

  (2). Petty RE, Southwood TR, Manners P et al. International League of Associations for Rheumatology classification of idiopathic arthritis: second revision, Edmonton, 2001. J Rheumatol 2004;31(2):390-2

  (3). Inman RD. Rheumatic manifestations of hepatitis B virus infection. Semin Arthritis Rheum 1982;11:406-20

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  Conflict of Interest:
  None declared.

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• Published on: 23 March 2016

  Doubts about diagnosis

  • Ulrich Heininger, Head of Paeditric Infectious Diseases and Vaccinology

  Dear Editor

  I enjoyed reading the first edition of the "Education and Practice Edition" a lot. However, after having read the article "Use your eyes" I was not convinced that Oliver's clinical presentation truely was caused by Borrelia burgdorferi infection, and I would like to challenge the authors for the following reasons:

  1. Erythema migrans usually is a mild disease that hardly ever leads to...

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  Dear Editor

  I enjoyed reading the first edition of the "Education and Practice Edition" a lot. However, after having read the article "Use your eyes" I was not convinced that Oliver's clinical presentation truely was caused by Borrelia burgdorferi infection, and I would like to challenge the authors for the following reasons:

  1. Erythema migrans usually is a mild disease that hardly ever leads to hospitalisation. Painful lesions and lymphadenopathy are also unusual features. Furthermore, although I am not aware of formal studies, markers of inflammation in blood specimens in my experience are only mildly elevated, if at all. Oliver's values of CRP (227 mg/l), ESR (98 mm) and white blood count (19,4 x 102. In the majority of patients, serological markers are negative on intial presentation but seroconversion may occur later during the disease. Furthermore, IgM and IgG antibody values may remain positive for many years after primary infection.[1] Also, asymptomatic infection will lead to development of serum antibodies.[2] Therefore, the presence of IgM and IgG (and a positive western blot) in Oliver's blood does not proof acute infection with B. burgdorferi. A diagnosis of "erythema migrans" is usually made on clinical grounds and, as stated above, clinical symptoms do not suggest early localized Lyme disease.

  3. Duration of antibiotic treatment for 28 days, as done in this patient, is recommended for Lyme arthritis, but not for early localized disease, where arthralgia (but not arthritis) may be present.

  Although results of blood culture were not reported (presumably negative), the inital diagnosis of "cellulitis" appears much more likely to me than erythema migrans and the patient's clinical improvement on prolonged antibiotic treatment (despite the delayed initial response) is consistent with this.

  References

  1) Kalish RA, McHugh G, Granquist J, Shea B, Ruthazer R, Steere AC. Persistence of immunoglobulin M or immunoglobulin G antibody responses to Borrelia burgdorferi 10-20 years after active Lyme disease. Clin Infect Dis. 2001;33:780-5.

  2) Heininger U, Zimmermann T, Schoerner C, Brade V, Stehr K. Tick bite and Lyme borreliosis. An epidemiologic study in the Erlangen area. Monatsschr Kinderheilkd. 1993;141:874-7.

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  Conflict of Interest:
  None declared.

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