Ceptic Arthritis in New Born Babies

Septic Arthritis in newborn Babies is a well-known entity. If not treated at the right time can cause disasters. We present here a series of eight new born babies (six hips, one knee and one shoulder) between age group of 1 week to 3 weeks, these babies didn’t show all the classic signs2 of septic arthritis like fever, leucocytosis, ramification of bone seen on the x-ray. The only finding suggestive of septic arthritis was swelling over the joint and reduced movements of the affected extremity (pseudoparesis), and effusion seen of the involved joint on Ultrasonography.

INTRODUCTION

Septic arthritis is a serious disease and can cause irreversible damage of the cartilage, in the hip it can destroy the femoral head, neck, and the acetabulum. If not treated properly it can develop disastrous condition of the joint. We have treated 8 cases of pyogenic septic arthritis in the newborn, age varying from 1 week to 3 weeks. Most commonly due to Staph. Aureus, E coli, streptococci, klebsiella pneumoniae, and Accinobacter.

Clinical features

Locally the joint was swollen, passive movements were reduced (pseudoparesis), and induced pain, but there was no fever. One patient was Rh incompatible and was given exchange transfusion, following which he developed septic arthritis of the shoulder.

Investigations

CBC and ESR were normal in all the 8 cases; X-ray showed increased joint space but no ramification of the bones. Two patients showed subluxation of the hip. All patients showed collection of fluid in the joint on Ultrasonography.
Treatment

Before performing an arthrotomy, joints of all patients were aspirated under aseptic conditions by needle under general anaesthesia. Out of 8 patients 6 patients needle aspiration was pyogenic, and hence drained during the same anaesthesia, during arthrotomy the joint capsule was left open, thick pus was drained, the joint opened was thoroughly washed with saline and direct skin suturing was done, 2 patients had element of synovial fluid aspiration, hence they were only aspirated but later had to be drained by Arthrotomy of the joint, as they didn’t show any signs of recovery after needle aspiration. A course of 6 weeks of appropriate antibiotics was given as per the culture report. The principles of our treatment were early diagnosis and decompression, appropriate antibiotics, splinting of the joint in functional position.

DISCUSSION

Septic arthritis in the newborn has a good prognosis if it is drained within 3 days, but can lead to joint destruction if the treatment is delayed. Rapid destruction is the most striking feature in children under age of 1 year. Aetiology of cartilage destruction is spread of infection from metaphysis to the epiphysis as the physis doesn’t act as a barrier up to 1 1/2 years of age, proteolytic enzymes from leucocytosis cause cartilage destruction, immune deficient babies are also known to suffer from septic arthritis.[2,3]

Case No.	Age	Sex	Joint Affected	Causative Organism	X-ray	USG	Special Features
1.	3 weeks	Male	Shoulder	No Growth	Lytic lesion in neck Humerus	Synovitis	Rh Incompatible
2.	1 week	Male	Hip	Klebsiella Pneumonia	Subluxation	Pus	H/O Chest infection
3.	3 weeks	Male	Both Hips, 1Shoulder	Klebsiella Pneumonia, E. Coil	Subluxation	Pus
4.	2weeks	Male	Knee	Klebsiella Pneumonia	Flexion Deformity	Effusion	Pre term
5.	3 weeks	Male	Hip	E. Coil	Widened Joint Space	Normal	Premature 7m,Pneumonia, Ventilatory Support +
6.	2weeks	Female	Hip	Staph. Aureus	Widened Joint Space	Effusion	H/O Pneumonia
7.	3 weeks	Male	Hip	Streptococci	Subluxation	Pus	??
8.	3 weeks	Male	Hip	Acinobacter	Lytic lesion in neck Femur	Effusion	??

The patient can present in 2 groups, the first ones show acute signs of infection i.e. the child is ill, febrile, refuses feeds associated with vomiting and convulsions, the second ones show mild fever, but no constitutional symptoms. But our cases have presented in a different way i.e. there is no history of fever in any of the babies but the only positive features were painful range of movements, distension of joint space and positive ultrasound finding. Radiological feature in septic arthritis are swelling due to collection, periosteitis and translucency, which persists for a long time.

Septic arthritis can present as:
•Acute osteomyelitis which will show maximum point of tenderness and swelling over the metaphysis,
•Acute rheumatoid arthritis,
•Transient synovitis, which presents as mild restriction of joint movements.
•Tuberculosis,
•Acute rheumatic fever,
•Cellulitis presenting as local skin redness with generalized area of local tenderness and associated lymphadenopathy,
•Haemarthrosis with bleeding disorder.
MRI and Ultrasonography help in the diagnosis, special features being complete destruction of femoral head, arthritis, and delay in diagnosis as signs and symptoms are masked.

ACKNOWLEDGEMENT

Our acknowledgements to the Dean, Paediatrics, Department of Head of Department, Orthopaedics of Lokmanya Tilak Municipal Medical College and Hospital, Sion for allowing us to publish this data.

REFERENCES

1..Choi IH, Pizzutillo PD, Bowen R, et al. Sequelae and Reconstruction after septic arthritis of the hip in infants. JBJS 1990; 72A : 1150-65.

2.Lloyd Roberts GC. Suppurative arthritis of infancy - some observation upon prognosis and management. JBJS 1960; 42B : 706.

3.Skyhar MJ, Mubarak SJ. Arthroscopic treatment of septic knees in children. Journal of Paediatric Orthopaedics 1987; 7 : 647-51.