Case PresentationCase Presentation

연세의대 강남세브란스병원 연세의대 강남세브란스병원 박 희 완박 희 완

1092823 1092823 김김 OO 균 균 M/14y9mM/14y9m

• C.C. : Intermittent left hip C.C. : Intermittent left hip pain pain

• D. : 2 wksD. : 2 wks

• PE : Painful limitation of motion Antalgic position

Initial X-ray(08.12.31)Initial X-ray(08.12.31)

Hip MRI(2009.3.10)Hip MRI(2009.3.10)T2 FS T1 FS

Culture studyCulture study

• Synovial fl. Cx: (-)Synovial fl. Cx: (-)

• Throat Cx: (-)Throat Cx: (-)

• Blood Cx: (-)Blood Cx: (-)

Lab profileLab profile

3-113-11 3-153-15 3-193-19 3-233-23 4-284-28ASOASO

(0~243(0~243))

1483.1483.22

1356.1356.44

1418.1418.88

1368.1368.11

1540.1540.88

ESRESR 1212 66 44 77 22CRPCRP 10.710.7 2.12.1 1.41.4 6.66.6

WBCWBC 53405340 39103910 46904690 48104810 59805980CefpirCefpir

anan

NSAiDNSAiDss

Progress noteProgress note

• HOD #1: skin traction apply (10 lb)HOD #1: skin traction apply (10 lb)

• HOD #11:HOD #11: Flx/Ext: full, Abd/Add: fullFlx/Ext: full, Abd/Add: full IR: 35/35, ER: 25/25IR: 35/35, ER: 25/25

• HOD #12: Cardio evaluation HOD #12: Cardio evaluation No specific findingsNo specific findings

• HOD #15: Discharge with mild HOD #15: Discharge with mild discomfortdiscomfort

F/U X-ray (2009.5.4)F/U X-ray (2009.5.4)

6279957 6279957 심심 OO 지 지 F/11F/11

• C.C. : Left hip pain & limpingC.C. : Left hip pain & limping• D. : 2 monthsD. : 2 months• P.H. : No recent URIP.H. : No recent URI• P.E. : Tenderness on lt. hip P.E. : Tenderness on lt. hip

areaarea

Painful LOM ( ER )Painful LOM ( ER )

Initial X-ray(08.12.31)Initial X-ray(08.12.31)

Hip MRI(2009.1.13)Hip MRI(2009.1.13)

WBBS(2009.1.28)WBBS(2009.1.28)

Lab. findingsLab. findings • WBC 5400 (Neutrophil 55.9%)WBC 5400 (Neutrophil 55.9%)• ESR / CRP : 7 / 0.3ESR / CRP : 7 / 0.3• ASO ASO : 1061.8 (0-243 IU/ml): 1061.8 (0-243 IU/ml)• RF (Rheumatoid factor) : 6.9 (0-33 IU/ml)RF (Rheumatoid factor) : 6.9 (0-33 IU/ml)• ANA : 1:40(speckled pattern) : negativeANA : 1:40(speckled pattern) : negative

• Throat culture : Throat culture : α-streptococcusα-streptococcus

TreatmentTreatment

• I.V. anti start : celoslin (1I.V. anti start : celoslin (1stst cefa)cefa)

• Change to Triaxone & Change to Triaxone & sulbacillinsulbacillin

• Skin traction : 5 poundsSkin traction : 5 pounds

F/U X-rayF/U X-ray

2008.12.31

2009.2.3

F/U X-ray (2009.2.3)F/U X-ray (2009.2.3)

1-211-21 1-281-28 2-12-1 2-52-5 2-72-7 2-92-9 2-182-18

ASOASO 1061.1061.88

866.866.55

887.887.55

955.955.77

916.916.33

968968 1055.1055.44

ESRESR 77 77 22 44 33 33 1010

CRPCRP 0.30.3 >0.7>0.788

>0.7>0.788

0.30.3 0.30.3 0.40.4 <0.09<0.09

CeloslinCeloslin

TriaxonTriaxon++

SulbacillSulbacillinin

Hip pain in childrenHip pain in children• Transient synovitisTransient synovitis• Juvenile idiopathic arthritisJuvenile idiopathic arthritis• LCPDLCPD• SCFE SCFE • Synovial membrane Synovial membrane

diseasedisease• Low grade infectionLow grade infection• Tumor (osteoid osteoma)Tumor (osteoid osteoma)• LeukemiaLeukemia• Growing painGrowing pain

Diseases of synovial Diseases of synovial membranemembrane

• Acute rheumatic feverAcute rheumatic fever• Post-streptococcal reactive Post-streptococcal reactive

arthritisarthritis

Acute rheumatic feverAcute rheumatic fever

• Nonsuppurative sequelae to Nonsuppurative sequelae to untreated untreated Group A streptococcal Group A streptococcal infection of infection of the upper respiratory the upper respiratory tract tract (pharyngitis)(pharyngitis)

• Antibodies made against group A Antibodies made against group A strep. strep. cross-react with human tissuecross-react with human tissue– heart valve and brain share common

antigenic sequences with GAS bacteria

Diagnosis: Jones Criteria• Major criteria

Arthritis Carditis Sydenham’s chorea Erythema marginatum Subcutaneous nodues

• Minor manifestations Fever Arthralgia Elevated CRP or ESR Prolonged PR interval on EKG

Post streptococcal Post streptococcal reactive arthritisreactive arthritis

• Reactive arthritis following a Reactive arthritis following a β-β-hemolytic streptococcal infectionhemolytic streptococcal infection in in the absence of sufficient Jones the absence of sufficient Jones criteria for acute rheumatic fever criteria for acute rheumatic fever (ARF)(ARF)

• Sterile inflammatory arthritis Sterile inflammatory arthritis associated with a primary infection associated with a primary infection at a distant site.at a distant site.

• Antibody formed in response to the Antibody formed in response to the infecting agent cross-react with infecting agent cross-react with joint cartilage and synovial tissuejoint cartilage and synovial tissue

Clinical featureClinical feature• Additive or non-migratory Additive or non-migratory

arthritisarthritis• Asymmetrical pattern with lower Asymmetrical pattern with lower

extremity predominanceextremity predominance• Knee, ankleKnee, ankle• Monoarticular involvement Monoarticular involvement • Arthalgia without clinical Arthalgia without clinical

evidence of swellingevidence of swelling• Antibiotic treatment does not Antibiotic treatment does not

alter the course of the arthritisalter the course of the arthritis

DiagnosisDiagnosis

• Antecedent streptococcal infection Antecedent streptococcal infection evidence : group A evidence : group A streptococcal Ab streptococcal Ab

anti-streptolysin O, anti-DNAse anti-streptolysin O, anti-DNAse B, B,

anti-hyaluronidase anti-hyaluronidase

TreatmentTreatment

• Anti-streptococcal antibiotic Tx. Anti-streptococcal antibiotic Tx.

Conventional : Conventional :

Oral penicillin (500mg bid) or Oral penicillin (500mg bid) or EM(250mg qid) within 10 daysEM(250mg qid) within 10 days

Benzathine penicillin G(120Benzathine penicillin G(120 만 만 U) U) IM IM

ProphylaxisProphylaxis

Prevention of colonization in upper resp. tract & carditis ----

Benzathine penicillin G. 120만 U q 4 wkks IM for more than 5 yrs

ConclusionConclusion

• Poor response to NSAID, aspirinPoor response to NSAID, aspirin• Some improvement afterSome improvement after

corticosteroidcorticosteroid treatmenttreatment• Penicillin prophylaxisPenicillin prophylaxis

May progress to ARF or carditis May progress to ARF or carditis

Pediatric, not proven in adultPediatric, not proven in adult