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2018

ANUÁRIO DO HOSPITAL DONA ESTEFÂNIA
REPOSITÓRIO MÉDICO CIENTÍFICO

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PEADIATRIC PYOGENIC SACROILLITIS : AN ATYPICAL CASE SERIES

Joana Arcângelo1, Catarina Gouveia2, André Grenho1, Susana Norte Ramos2, Delfin Tavares2

1. Hospital Curry Cabral - Centro Hospitalar Lisboa Central, Lisboa, Portugal
2. Hospital Dona Estefânia - Centro Hospitalar Lisboa Central, Lisboa, Portugal

- Poster, Congresso Europeu de Ortopedia, Viena, 29 de Maio a 1 de Junho de 2017

Sacroiliitis is rare and accounts for 1-2% of osteoarticular infections in paediatric age. Diagnosis may be difficult due to non-specific signs, symptoms, and physical findings. Staphylococcus aureus is the main responsible pathogen. Identification of the causative agent is important since appropriate antibiotic therapy normally provides rapid regression of symptoms and healing. Objectives Our purpose is to characterize patients with pyogenic sacroiliitis admitted to a paediatric hospital. A better understanding of the clinical profile of this rare entity, in such age group, may lead to optimization of diagnostic and treatment protocols. Study Design & Methods Hospital records from all patients aged < 18 yr. diagnosed with pyogenic sacroiliitis between 2008-2016 were reviewed. The diagnosis was established by the presence of characteristic history, physical and laboratory findings plus definite imaging evidence involving the sacroiliac joint on MRI. We further analysed the demographic and predisposing factors, clinical signs and symptoms, results of laboratory and radiological exams, type and duration of treatment, clinical response and complications. Results was 6,3 yr. (range 13mo.-14yr.). Although, the majority were previously healthy, half had recent evidence of an acute upper respiratory infection. Fever, limpness and pain in different locations (affected lower limb, lumbar and ipsilateral iliac fossa) were universal findings. Clinical documentation of FABER test was only available in 2 patients, who had a positive result. Mean leukocyte count was 14933/μL (range 9500-22500). Mean C- reactive protein (CRP) and erythrocyte sedimentation rate at admission were 99 mg/l (range 33- 139 mg/L) and 39 mm/h (range: 2-92 mm/h), respectively. Samples of joint aspirate were collected in one patient and returned positive for Aggregatibacter aphrophilus. Kingella kingae (n=2), Bartonella henselae (n=1) and Brucella mellitensis (n=1) were also identified . Excluding the patient with Brucellosis, mean duration of symptoms previous to diagnosis was 5,25 days (range 1,5-15 days). All patients were managed conservatively with parenteral antibiotic therapy for a median of 19 days (range 8-32 days) and median total duration of treatment (parenteral and oral) was 52,5 days (range 29-120 days). All patients showed favourable clinical response and no sequelae on follow-up. Conclusions Due to the unspecific clinical presentation of sacroiliitis, MRI findings play a critical role in early diagnosis establishment. No difference in clinical presentation and outcomes was observed, despite the atypical aetiology of our cases. Surprisingly, no S. aureus was isolated, although it is usually the most common causative agent in all series reported. Joint fluid aspiration and blood cultures are useful to identify the pathogen, nevertheless other rare microorganisms such as Brucella, Kingella and Bartonella, for which specific diagnostic tests are required, have to be considered in sacroiliitis. In paediatric sacroiliitis an elevated suspicion index for atypical agents is essential, for prompt implementation of specific screening and efficient antimicrobial therapy