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Lyme Arthritis in Children Presenting with Joint Effusions
Matthew D. Milewski, MD1; Aristides I. Cruz, Jr., MD1; Christopher P. Miller, MD1; Ashley T. Peterson, BA1; Brian G. Smith, MD1
1 Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, P.O. Box 208071, New Haven, CT 06520-8071. E-mail address for M.D. Milewski: mdmilewski@gmail.com
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors, or a member of his or her immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Stryker Spine).

Investigation performed at the Department of Orthopaedics and Rehabilitation, Yale University School of Medicine, New Haven, Connecticut
A commentary by R. Mervyn Letts, MD, is available at www.jbjs.org/commentary and is linked to the online version of this article.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Feb 02;93(3):252-260. doi: 10.2106/JBJS.I.01776
A commentary by R. Mervyn Letts, MD, is available here
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This article was updated on January 31, 2011, because of a previous error. In the Abstract (page 252), Table I (page 254), and the Results section (page 257), the conversion of Fahrenheit into Celsius was incorrect. In all locations, the values that had previously read ">101.5°F (>40.6°C)" now read ">101.5°F (>38.6°C)".


The present study was designed to evaluate the prevalence of Lyme arthritis in children who had a joint aspiration at a tertiary care children's hospital in an endemic area and to identify clinical factors useful to differentiate Lyme arthritis from septic arthritis at the time of the initial presentation.


The records of all children with an age of eighteen years or less who were managed with aspiration for joint effusions at our institution from 1992 to 2009 were reviewed. Data collection included a review of aspirates; an analysis of cell count, culture results, and hematological inflammatory markers; and a review of surgical intervention.


A total of 506 joint aspirations were analyzed. One hundred and fifteen aspirations were excluded. In the remaining group of 391 patients, 123 (31%) were subsequently diagnosed with Lyme arthritis. Fifty-one patients had culture-positive septic arthritis. The two cohorts were significantly different in terms of the presence of a fever of >101.5°F (>38.6°C) at the time of presentation, the refusal to bear weight, the peripheral white blood-cell count, and joint fluid cell count. The erythrocyte sedimentation rate and the C-reactive protein level were not significantly different between the two cohorts. Multivariate analysis demonstrated that refusal to bear weight was the strongest predictor of the diagnosis of septic arthritis over Lyme arthritis.


For any child presenting with a joint effusion in a Lyme-endemic area of the Northeastern United States, the likely prevalence of Lyme arthritis is 31% overall and 45% in the presence of knee effusion. Children with joint effusions resulting from Lyme disease are more likely to have knee involvement, a lower peripheral white blood-cell count, and a lower joint fluid cell count, and they are less likely to have fever or complete refusal to bear weight, when compared with children with septic arthritis.

Level of Evidence: 

Diagnostic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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