Accepted Manuscript Acute Suppurative Oligoarthritis and Osteomyelitis: A Differential Diagnosis that Overlaps with Acute Rheumatic Fever Sato Satoshi, MD, Masako Chiyotanda, Tae Hijikata, Yu Ishida, Shingo Oana, Gaku Yamanaka, Hisashi Kawashima, Kosuke Kubo PII:

S1341-321X(15)00089-6

DOI:

10.1016/j.jiac.2015.04.005

Reference:

JIC 281

To appear in:

Journal of Infection and Chemotherapy

Received Date: 15 July 2014 Revised Date:

2 April 2015

Accepted Date: 8 April 2015

Please cite this article as: Satoshi S, Chiyotanda M, Hijikata T, Ishida Y, Oana S, Yamanaka G, Kawashima H, Kubo K, Acute Suppurative Oligoarthritis and Osteomyelitis: A Differential Diagnosis that Overlaps with Acute Rheumatic Fever, Journal of Infection and Chemotherapy (2015), doi: 10.1016/ j.jiac.2015.04.005. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

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ACCEPTED MANUSCRIPT

Acute Suppurative Oligoarthritis and Osteomyelitis: A Differential Diagnosis that Overlaps with Acute Rheumatic Fever

Gaku Yamanaka, Hisashi Kawashima, Kosuke Kubo*.

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Sato Satoshi MD, Masako Chiyotanda, Tae Hijikata, Yu Ishida, Shingo Oana,

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Department of Pediatrics, Tokyo Medical University, Tokyo, Japan

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*Department of Orthopedics, Tokyo Medical University, Tokyo, Japan Corresponding author: Satoshi Sato. Department of Pediatrics, Tokyo Medical University, 6-7-1 Nishishinjuku, Shinjuku-ku, Tokyo 160-0023, Japan E-mail: [email protected]

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Tel: +81-3-3342-6111, Fax: +81-3-3344-0643 Abbreviations. Acute rheumatic fever: ARF. group A strptococcus: GAS.

acute

rheumatic

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Keywords:

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anti-streptolysin O: ASO.

osteomyelitis, monoarthritis.

fever,

arthritis,

rheumatic

heart

disease,

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Abstract Background: Acute rheumatic fever (ARF) is an illness caused by group A

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sreptococcus (GAS) infection, and remains the leading cause of acquired heart disease in worldwide. Distinguishing between ARF and septic arthritis may be

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difficult. This report describes a case of suppurative arthritis overlapping with

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ARF.

Case presentation: A 4-year-old, previously healthy boy presented with fever and left leg pain. The level of anti-streptolysin O (ASO) was elevated. His throat swab cultures grew GAS, but none were detected in his synovial fluid. Magnetic

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resonance imaging revealed suspected arthritis and osteomyelitis. The patient was treated for septic arthritis, but was subsequently diagnosed with ARF, after

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the development of carditis.

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Conclusion: The clinical and laboratory features of ARF and suppurative arthritis demonstrate substantial overlap. Patients with an elevated ASO should undergo a careful cardiac examination for carditis associated with ARF by an echocardiogram.

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Introduction

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The incidence and severity of invasive, group A streptococcus (GAS) infections are well known. Several studies have reported that septic arthritis, osteomyelitis, and necrotizing fasciitis are complications of GAS infections occurring during

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childhood [1]. In children, arthritis is most often caused by a bacterial infection of

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the joint (suppurative septic arthritis), and up to 35% of septic arthritis cases demonstrate sterile synovial fluid cultures [2]. Oligoarthritis or monoarthritis have been reported in 3.3% to 36% of patients with acute rheumatic fever (ARF),

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although polyarthritis is the most frequent manifestation associated with ARF, developing in up to 75% of patients following the first attack [3-7]. Differentiating

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between oligoarthritis/monoarthritis and ARF may be particularly difficult [8,9]. We present an unusually complicated course of pediatric ARF in a patient with

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GAS infection following presumed septic arthritis and osteomyelitis.

Case Report

A previously healthy, 4-year-old Japanese boy was admitted to Tokyo Medical University with a 5-day history of high fever and left leg pain. Two weeks prior to admission, he had demonstrated a 4-day period of fever and erythema; no

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previous antibiotic use was reported. The patient’s medical history was unremarkable, without a history of a sore throat. Upon admission, he appeared ill,

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with left leg tenderness from the hip joint to the knee joint. He had a temperature of 39.5°C, a blood pressure of 104/64 mmHg, a pulse of 127/min, and a

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respiratory rate of 24/min. He had no rash. Examination of his throat revealed

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erythema and edema of the pharynx. He had restricted motion in his left hip and knee joint, but no other joints exhibited any signs of arthritis. There was also tenderness over his left femoral regions. Peripheral blood studies revealed leukocytosis (29,000/mm3; 89.6% neutrophils, 6.2% lymphocytes, 4.1%

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monocytes, 0.1% basophils, 0% eosinophils), and the levels of hemoglobin (11 g/dL), platelets (420,000/mm3), sodium (129 mEq/L), chlorine (93 mEq/L),

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potassium (3.9 mEq/L), and creatine kinase (37 U/L). Laboratory studies also

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included an anti-streptolysin O (ASO) titer of 4,460 IU/mL (age-adjusted normal,