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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...
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.
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...
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
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...
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.
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:
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...
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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