Case Presentation 연세의대 강남세브란스병원 박 희 완

김 O 균 M/14y9m C.C. : Intermittent left hip painC.C. : Intermittent left hip pain D. : 2 wksD. : 2 wks PE : Painful limitation of motion Antalgic position

Initial X-ray( )

Hip MRI( ) T2 FST1 FS

Culture study Synovial fl. Cx: (-) Synovial fl. Cx: (-) Throat Cx: (-) Throat Cx: (-) Blood Cx: (-) Blood Cx: (-)

Lab profile ASO(0~243) ESR CRP WBC Cefpiran NSAiDs

Progress note HOD #1: skin traction apply (10 lb)HOD #1: skin traction apply (10 lb) HOD #11:HOD #11: Flx/Ext: full, Abd/Add: full Flx/Ext: full, Abd/Add: full IR: 35/35, ER: 25/25 IR: 35/35, ER: 25/25 HOD #12: Cardio evaluationHOD #12: Cardio evaluation No specific findings No specific findings HOD #15: Discharge with mild discomfortHOD #15: Discharge with mild discomfort

F/U X-ray ( )

심 O 지 F/11 C.C. : Left hip pain & limping C.C. : Left hip pain & limping D. : 2 months D. : 2 months P.H. : No recent URI P.H. : No recent URI P.E. : Tenderness on lt. hip area P.E. : Tenderness on lt. hip area Painful LOM ( ER ) Painful LOM ( ER )

Initial X-ray( )

Hip MRI( )

WBBS( )

Lab. findings WBC 5400 (Neutrophil 55.9%) WBC 5400 (Neutrophil 55.9%) ESR / CRP : 7 / 0.3 ESR / CRP : 7 / 0.3 ASO : (0-243 IU/ml) ASO : (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) : negative ANA : 1:40(speckled pattern) : negative Throat culture : α-streptococcus Throat culture : α-streptococcus

Treatment I.V. anti start : celoslin (1 st cefa)I.V. anti start : celoslin (1 st cefa) Change to Triaxone & sulbacillinChange to Triaxone & sulbacillin Skin traction : 5 pounds Skin traction : 5 pounds

F/U X-ray

F/U X-ray ( )

ASO ESR CRP0.3>0.78> <0.09 Celoslin Triaxon+Sulbacillin

Hip pain in children Transient synovitis Transient synovitis Juvenile idiopathic arthritis Juvenile idiopathic arthritis LCPD LCPD SCFE SCFE Synovial membrane disease Synovial membrane disease Low grade infection Low grade infection Tumor (osteoid osteoma) Tumor (osteoid osteoma) Leukemia Leukemia Growing pain Growing pain

Diseases of synovial membrane Acute rheumatic fever Acute rheumatic fever Post-streptococcal reactive arthritis Post-streptococcal reactive arthritis

Acute rheumatic fever Nonsuppurative sequelae to untreated Group A streptococcal infection of the upper respiratory tract (pharyngitis) Nonsuppurative sequelae to untreated Group A streptococcal infection of the upper respiratory tract (pharyngitis) Antibodies made against group A strep. cross-react with human tissue Antibodies made against group A strep. cross-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 reactive arthritis Reactive arthritis following a β-hemolytic streptococcal infection in the absence of sufficient Jones criteria for acute rheumatic fever (ARF) Reactive arthritis following a β-hemolytic streptococcal infection in the absence of sufficient Jones criteria for acute rheumatic fever (ARF) Sterile inflammatory arthritis associated with a primary infection at a distant site. Sterile inflammatory arthritis associated with a primary infection at a distant site. Antibody formed in response to the infecting agent cross-react with joint cartilage and synovial tissue Antibody formed in response to the infecting agent cross-react with joint cartilage and synovial tissue

Clinical feature Additive or non-migratory arthritis Additive or non-migratory arthritis Asymmetrical pattern with lower extremity predominance Asymmetrical pattern with lower extremity predominance Knee, ankle Knee, ankle Monoarticular involvement Monoarticular involvement Arthalgia without clinical evidence of swelling Arthalgia without clinical evidence of swelling Antibiotic treatment does not alter the course of the arthritis Antibiotic treatment does not alter the course of the arthritis

Diagnosis Antecedent streptococcal infection evidence : group A streptococcal Ab Antecedent streptococcal infection evidence : group A streptococcal Ab anti-streptolysin O, anti-DNAse B, anti-streptolysin O, anti-DNAse B, anti-hyaluronidase anti-hyaluronidase

Treatment Anti-streptococcal antibiotic Tx. Anti-streptococcal antibiotic Tx. Conventional : Oral penicillin (500mg bid) or EM(250mg qid) within 10 days Oral penicillin (500mg bid) or EM(250mg qid) within 10 days Benzathine penicillin G(120 만 U) IM Benzathine penicillin G(120 만 U) IM

Prophylaxis Prevention of colonization in upper resp. tract & carditis ---- Benzathine penicillin G. 120 만 U q 4 wkks IM for more than 5 yrs

Conclusion Poor response to NSAID, aspirin Poor response to NSAID, aspirin Some improvement after corticosteroid treatment Some improvement after corticosteroid treatment Penicillin prophylaxis Penicillin prophylaxis May progress to ARF or carditis May progress to ARF or carditis Pediatric, not proven in adult Pediatric, not proven in adult