CASE: 5 year old boy presents to ER with mom complaining of left shoulder pain and fever x1 week. Temp is 102.3, HR 95, RR 24. On physical exam his shoulder is warm, tender, with decreased range of motion. Discuss the differentials, labs, work-up and what Tx you would provide for this patient:

INITIAL: fever + warm and tender shoulder= thinking some sort of infectious process vs. trauma/injury/abuse but would still keep that at the bottom of differential

Ddx:

**acute osteomyelitis  

**septic arthritis

-osteosarcoma (malignancy)

-frozen shoulder (adhesive capsulitis) 

-septic bursitis

-cellulitis

-injury/trauma/dislocation

-child abuse

-lyme arthritis

 

ACUTE OSTEOMYELITIS= fever, pain, warmth, swelling, tenderness, limitation of function

*LABS: CBC, ESR, CRP; blood culture

*Radiograph usually is the initial test [may see soft tissue swelling]

*MRI= sensitive in early disease

*bone aspiration= gold standard

TX: likely to be caused by MSSA or MRSA= either Nafcillin, Oxacillin, Cefazolin for MSSA or Vanco for the MRSA

 

SEPTIC ARTHRITIS= fever, swollen warm, painful, decreased ROM

*Arthrocentesis= best initial and most accurate= looking for WBC >50,000 with primarily neutrophils

*Also CBC, ESR, CRP and blood culture

*Radiograph may show soft tissue swelling

TX: depends on organism seen on gram stain but let’s say non seen= want to do an empiric antibiotic regimen [Ceftriaxone + Vanco]

 

OSTEOSARCOMA= if you were really concerned/need to rule this out= biopsy would be done (definitive diagnosis)

ADHESIVE CAPSULITIS= kind of young for it

CELLULITIS= clinical diagnosis 

 

Discuss the efficacy of IV vs. PO antibiotics in patient with pyelonephritis; what are the Abx of choice for pediatric patient with pyelonephritis?

-Pyelonephritis= upper urinary tract infection [ascending infection from lower urinary tract]

-Antibiotic therapy for children with presumed UTI; E coli most common cause, then Klebsiella, Proteus in kids so you would need to choose an antibiotic that provides adequate coverage.50% of E coli are resistant to amoxicillin/ampicillin, so you would more likely choose a second or third generation cephalosporin (cefuroxime, cefpodoxime, cefixime, cefdinir) or an aminoglycosides (gentamicin) as a first line agent for empiric treatment in children if there is risk of renal involvement.

-Most children who are not vomiting can be treated with oral therapy as long as you keep close contact with the family to make sure they understand the seriousness of the infection and the need to finish the entire regimen (confidence that they’ll continue to give the meds outpatient for its entire course)

-Preferred oral regimen= cephalosporin as first line oral; if the patient has a high likelihood of renal involvement (high fever, possibly back pain) then 2nd or 3^rd  generation in particular should be used due to suspicion of resistance to the first gen (Cefdinir 14mg/kg by mouth once daily would be the dosing). If you have a patient with low risk of renal involvement, and the specific community doesn’t have a high local resistance of E coli to first generation cephalosporins then you can give 1^st gen (cephalexin 50mg/kg per day by mouth in two divided doses). But overall you’re sticking with that 2^nd/3^rd gen.

-UpToDate: Randomized Controlled trial of 306 children aged 1 month to 24 months old all with febrile UTI. This was conducted to determine if oral therapy > IV therapy or vice versa. This study showed that oral therapy with Cefixime (3^rd gen) x 14 days was proven to be just as effective as IV therapy of Cefotaxime (also 3^rd gen) for 3 days followed by oral Cefixime. The rate of symptom resolution (time to eradication of fever), sterilization of the urine, reinfection, renal scarring, didn’t differ between the age groups.

-Inpatient parenteral therapy in the hospital would be required for age <2 months, presence of clinical urosepsis (eg. Toxic appearance, hypotension, poor capillary refill), immune compromise, vomiting or inability to tolerate PO meds, lack of adequate outpatient follow-up, failure to respond to initial outpatient therapy. Give either cephalosporin or aminoglycoside as first line parenteral agent for empiric treatment in kids. Possibility of having once daily parenteral administration in an outpatient treatment center (to avoid hospitalization).

 

Q: What is the differential diagnosis, workup & potential long term complications of SCFE?

 

When evaluating a pediatric patient with hip pain it is important to distinguish between infectious, inflammatory, orthopedic, and malignant causes:

Infectious= usually acute, localized, severe; accompanied by fever, elevated WBC + ESR + CRP

Inflammatory= chronic, insidious onset

Orthopedic= may have referred pain to thigh/knee; pain increases with activity and decreases with rest

Malignancy= worse at night, unrelated to activity; may see systemic symptoms

*Ddx:

-septic arthritis

-Lyme disease

-osteomyelitis

-trauma

-Legg-Calve Perthes disease

-juvenile idiopathic arthritis

*Physical Exam: focuses on determining if the pain is coming from inside or outside the hip joint, if it is an isolated problem, or if it a manifestation of some systemic condition. Therefore, the physical exam will heavily focus on the musculoskeletal system by incorporating observation, palpation, range of motion, as well as ability to bear weight to determine the appropriate diagnosis

*Labs: If septic arthritis and/or osteomyelitis is high up on the differential, a CBC with differential is warranted in addition to blood cultures, and arthrocentesis (to obtain synovial fluid).

*Imaging: The need for imaging in children with mild hip pain + normal physical exam/labs remains controversial. However, if specific bony lesions are suspected (i.e. trauma, tumor, Legg-Calve Perthes, SCFE) then plain radiographs can be ordered.

 

*Potential Long Term Complications of SCFE:

1) Osteonecrosis of the femoral head: most serious complication, worst prognosis, rate of occurrence increases with severity of the slip; Unstable SCFE is an important predictor for this complication, especially if vascular injury occurs at the time of the slip; Suspect this complication if a patient with a history of SCFE complains of persistent pain & stiffness of the hip

2) Chondrolysis: narrowing of the joint space and loss of articular cartilage; Patient will have pain and flexion deformity of the hip with restricted range of motion in all planes. Regional osteoporosis is seen on plain radiographs along with narrowing of articular cartilage

3) Femoroacetabular impingement (FAI): abnormal contact between proximal femoral metaphysis and the acetabular rim; SCFE is one of the most frequent underlying causes for FAI; Patient may be symptomatic, and this can ultimately lead to premature osteoarthritis of the hip