Case Report

SEPTIC ARTRITIS IN PRETERM NEONATES

By:Ni Putu Mayasri WulandariSupervisor:Dr. I Wayan Dharma Artana, Sp.A(K)Dr. Made Sukmawati, Sp.A

Dr. I Wayan Subawa, Sp.OTDepartment of Child Health Medical School

Udayana University

Sanglah HospitalDenpasar

2014

SEPTIC ARTRITIS IN PRETERM NEONATES*Ni Putu Mayasri Wulandari, * I.W. Dharma Artana, *Made Sukmawati, ** I Wayan SubawaDepartment of Child Health*, Orthopedic Surgery**Medical School of Udayana University, Sanglah Hospital

ABSTRACT

Acute septic artritis in infancy and childhood is uncommon condition, the joint most commonly involved are the hip in infants and the knee or shoulder joint in older childen. In neonates, typical symptoms and signs of hip infection can be unclear or absent, which makes the diagnosis particularly difficult. It has an ongoing importance because of its sequele. Delayed or inadequate treatment can result joint destruction. Therefore, early diagnosis as well as prompt and effective treatment are essential for avoiding severe outcomesWe report a case of hip septic arthritis. A preterm neonate was treated with hyalin membrane disease grade 1 and clinically sepsis. On 1 month age, there were a swelling in right hip region that make very restricted movement of right lower extremity. The X-ray of right hip joint revealed widening of right hip joint with suspicion of joint effusion, and ultrasound examination showed widening joint space of right hip joint 0,86 cm and joint effusion with maximal thickness 0,48 cm. Patient treated with immobilization of right hip joint and first line antibiotic intravenously for 3 weeks with good result and no complication until discharge from hospital

Keywords: septic arthritis, neonatesINTRODUCTION

Septic arthritis is a bacterial infection of the synovium and subsequently of all the structures within the joint, which causes an intense inflammatory reaction, possibly leading to destruction of the articular cartilage and later of the complete joint. Most cases occur by haematogenous dissemination of bacteria, and only a few cases by direct inoculation of pathogens. It usually affects infants and toddlers.1 The joint most commonly involved are the hip in infants and the knee or shoulder joint in older childen. Ussually only one joint affected, and about 10 percent of patient have more than one joint involved.2,3Acute septic artritis in infancy and childhood is uncommon condition, the incidence approximately range from 5-12 cases per 100.000 person-years. In South Africa the incidence of hip septic artritis in pediatric estimated to be 1 : 20.000. Approximately one-third of the patients with septic artritis are children younger than 2 years age. 1,4 Eventhough septic artritis is a rare disease, it has an ongoing importance because of its sequele. Delayed or inadequate treatment can result joint destruction, especially when the hip joint of an infant is involved. Therefore, early diagnosis as well as prompt and effective treatment are essential for avoiding severe outcomes.2,4 There are significant differences between infection occuring in infancy and that in the older children. Neonatal disease, being the more frequent, the more deceptive in presentation and the more devastating merits spesial attention.2 The most common causative organism of septic artritis in all age groups is Staphylococcus aureus.3 A joint becomes infected when an infectious agent enters the synovium. The main routes by which pathogens accumulate in the joints are the following: (a) haematogenously, with the consequent lodging of the pathogen in synovial capillaries; (b) infected contiguous foci; (c) neighboring soft-tissue sepsis; and (d) by direct inoculation due to trauma or an iatrogenic event, such as diagnostic or therapeutic arthrocentesis or joint surgery. 4,5 The synovium is a well-vascularised structure with no limiting basement plate, and this allows easy access by bacteria. Once bacteria reach the joint space, the low fluid shear conditions allow bacterial adherence and infection. In addition, the production of host matrix proteins may promote the attachment of bacteria and the progression of the infection. Following colonization of the synovial fluid (SF), bacteria proliferate rapidly and generate an acute inflammatory response.4,6

Children with septic arthritis of the hip may present a variety of clinical symptoms. Systemic symptoms such as fever, malaise and poor appetite are often seen. In neonates typical symptoms and signs of hip infection can be unclear or absent, which makes the diagnosis particularly difficult.1 Toddlers may complain of a spontaneous onset of progressive hip, groin or thigh pain, demonstrate a limp or abnormal gait, or refuse to bear weight. Often the affected limb is held in a relieving posture (slightly flexed, externally rotated and abducted to reduce intracapsular pressure. While infant will show symptom such as swelling, warmth, erythema and pain on palpation or passive movement of the hip, unilateral edema, lack of active movement of the leg, asymmetrical buttock crease, and abnormal posture of the leg.1,2,5,7

The risk factors for this disease include prematurity, respiratory distress syndrome, low birth weight ( 50,000/mm3. Low joint-fluid glucose levels (