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攸特他塔喇
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1 國立成功大學醫學院附設醫院小兒部一般兒科常見疾病講習會小兒感染專題演講何宗憲沈靜芬王世敏劉清泉

2 難忘的病例 ( ㄧ ) A 8-month-old girl with left chest swelling

5 Present illness 4/20 fell from bed Limited ROM of left arm 4/22 visited chiropractor ( 國術館 ) for left shoulder swelling Suspect left shoulder dislocation manual manipulation Herb ointment patch topical use 4/25 visited local clinic for fever Suspect acute ottitis media antibiotic treatment Fever subsided keep herb patch use

6 Present illness 4/28 visited hospital A for progressive left chest swelling Limited ROM of left shoulder Shoulder plain X-ray films: no fracture Change to home-made herb ointment use 5/2 Visited hospital B for left chest swelling Limited ROM of left shoulder Referred to hospital C 5/2 ER of hospital C: left acromioclavicular joint dislocation with hematoma Analgesics and outpatient follow-up

7 5/2

8 5/2

9 5/6

10 Past medical history G2P2, full-term Growth: BW 9.5 kg (85-97th%), BH 72cm (85-97th%) Development: no delay Diet: breast-feeding with supplements Vaccination history: BCG (+), HBV(+)xIII, DaPT+Hib+IPV(+) x III, Pneumococcal vaccine(-), Rotavirus vaccine (-) Hospitalization: neonatal jaundice s/p phototherapy Denied ill contact, animal contact or recent travel history

11 What is your diagnosis? What will you do next?

12 CBC/DC WBC Band Meta Seg Mono Lym Aty-lym 44200/cmm 10% 2% 75% 5% 7% 1% Hb MCV RDW PLT PT aptt 8.3 g/dl 56 fl 15.6% 574K/cmm 14.25/11.1 S 32.9/29.2 S

13 Biochemistry Glucose BUN Crea GOT GPT Na K Cl Ca CRP

14 5/6

15 What is your diagnosis? What will you do next?

16 ~100 ml turbid fluid aspirated

17 Synovial fluid analysis APP. PUS TURBID. 4+ VISCO. LOW MUCIN. FAIR RBC - cmm WBC > cmm SEG. 98 % EOS. - % BASO. - % MACRO/MO 2 % LYM. - % ATY-LYM. - % ABN-LYM. - % MESOTHEL - % TUMOR - % BLAST - % REMARK - % CRYSTAL NF

18 Pus smear Gram stain: GPC & GPB

19 What is your diagnosis? What will you do next?

20 Left shoulder CT -C +C +C +C

21 Left shoulder CT Compatible with septic arthritis of the Lt shoulder with extensive adjacent soft tissue involvement; however, TB arthritis cannot be excluded. Pyomyositis with abscess formation of Lt axilla, chest wall and proximal Lt arm. Compressed Lt axillary and subclavian artery without occlusion.

22 What is your diagnosis? What will you do next?

23 Surgical intervention 5/7 Fasciotomy & joint capsule debridement. keep wet dressing

24 Culture results Blood culture: no growth Synovial fluid: S. pneumoniae Pus (needle aspirate): S. pneumoniae Vancomycin Ampicillin Clindamycin Erythromycin Levofloxacin Co-Trimoxazole Moxifloxacin S S S R S R S Minimal Inhibitory Concentration: (ug/ml) Penicillin S 2.0 Vancomycin S 0.25 Amox/Clavulnic S 1.5 Ceftriaxone S 1.0 Serotype: 19F

25 5/11 Debridement & closure 5/25 remove stitches

Hospital course & Laboratory series Date WBC Hb 5/06 44.2 8.

0 Plt ESR 574k 52 398k - 1066k 54 791k 19 610k 14 CRP 153.3 48.9 28.

26 Hospital course & Laboratory series Date WBC Hb 5/ / / / / Plt ESR 574k k k k k 14 CRP <7.0 <7.0 Vancomycin Gentamicin Penicillin Ceftriaxone 5/6 5/9 DC 5/19 6/6 DC DC DC

27 5/25 shoulder x-ray film

28 6/2 Ga67 Scan No osteomyelitis

29 Final Diagnosis Pneumococcal septic arthritis and pyomyositis

30 Discussion Septic arthritis in children

31 Septic Arthritis Infant and children < 2 y/o: 1/3-1/2 of all cases 1/3 of cases involve the hip joint pseudoparalysis in infants Pathogenesis: Hematogenous dissemination Contiguous extension Direct innoculation

32 Common bacterial causes of septic arthritis Shah S S in Pediatric infectious disease, 2008; p231-6

33 Pathogens of septic arthritis in 60 children in Taiwan (Taipei Veterans General Hospital ) J Microbiol Immunol Infect 2006;39:

34 Septic arthritis- Treatment Decompress the joint Remove inflammatory debris Sterilize the joint space At least 3-week antibiotic treatment

35 Management of bone and joint infections in previously healthy children Ped Infect Dis J 27:765-7

36 Septic Arthritis in Children in NCKUH during unpublished results

37 Pneumococcal Septic Arthritis S. pneumoniae was reported to cause up to 4-20% of bacterial joint infections in children. Most joint infections caused by S. pneumoniae occur in children below the age of 2 years, but the incidence has diminished with the increased use of pneumococcal vaccine PCV7. Pediatrics 38: ; Pediatrics 102 :

38 Pneumococcal vaccine coverage The serotype of isolated pneumococcus: 19F Serotypes covered by two different current pneumococcal vaccines : 7-valent conjugated (Prevnar ): 4, 6B, 9V, 14, 18C, 19F, 23F 23-valent polysaccharide (Pneumovax 23): 1, 2, 3, 4, 5, 6B, 7F, 8, 9N, 9V, 10A, 11A, 12F, 14, 15B, 17F, 18C, 19F, 19A, 20, 22F, 23F, 33F Vaccination: Preventing the preventable

39 Take Home Message Septic arthritis : fever, pain on motion and inflammation of a joint. Diagnostic tools: imaging, aspiration, culture. Most common pathogen: S aureus. Treatment: adequate drainage and antibiotics. Surgery: indicated in hip, shoulder joints. Serum CRP level: useful in monitoring responses.

40 Thank you for your attention

ºî½×2-p174-184

ºî½×2-p174-184 174 美國感染症醫學會 Methicillin 抗藥性金黃色葡萄球菌治療指引李倩瑜 1 鄭舒倖 2 行政院衛生署桃園醫院 1 小兒科 2 感染科 (IDSA) 2011 methicillin (methicillin-resistant Staphylococcus aureus; MRSA) (practice guidelines)[1]