Commentary and Perspective   |    
Commentary on an article by Matthew D. Milewski, MD, et al.: “Lyme Arthritis in Children Presenting with Joint Effusions”
R. Mervyn Letts, MD
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The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Copyright © 2011 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2011 Feb 02;93(3):e11 1-2. doi: 10.2106/JBJS.J.01515
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This commentary was updated on January 31, 2011, because of a previous error in the original article. In the second paragraph of this commentary, the values that had previously read ">101.5°F (>40.6°C)" now read ">101.5°F (>38.6°C)".

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    The authors of this Level-II study have presented us with the largest review to date in which Lyme disease-induced joint effusions were compared with septic arthritis. However, this contribution is more than just a comparison of two disease entities; it is an in-depth analysis of the effects of the increasing presence of Lyme disease in the endemic areas of North America. The reason why this analysis is important is that Lyme disease, since its discovery by Steere et al. in 1977, is caused by the spirochete Borrelia burgdorferi and is now the most common tick-borne disease in the United States. As the spirochete can be effectively treated with antibiotic administration, the accurate diagnosis of Lyme disease becomes more important to avoid an unnecessary surgical arthrotomy for the child.
    Although the authors tried to definitively distinguish between Lyme disease and septic arthritis with the goal of creating a reliable algorithm in order to enable us all to have a gold standard to differentiate the two, they were unable to do so. In their quest to do so, however, they demonstrated that a diagnosis of septic arthritis is more probable in children presenting with an inability to bear weight, a fever of >101.5°F (>38.6°C), an elevated peripheral white blood cell count of >10.3 × 1000/µL, and a synovial fluid nucleated cell count of >100,000 cells/mm3. However, there is still an overlapping gray zone where the only diagnostic test that will separate the two similar clinical presentations is serological testing of the synovial fluid aspirate for Lyme disease.
    Herein lies another important contribution of this paper. In endemic areas in the Northeast, Upper Midwest, and Pacific Northwest of the United States, all children with unexplained, nontraumatic joint effusions should have a joint aspiration followed by serological testing for Lyme disease. Why? Because in these areas, the incidence of Lyme disease has risen 101% over the last fifteen years. Also, once Lyme disease has been diagnosed, antibiotic treatment with use of amoxicillin for patients with an age of less than eight years and with use of doxycycline for those with an age of eight years or more is curative. As synovial involvement is a late manifestation of the disease, morbidity resulting from the involvement of other organs, especially chronic encephalopathy and keratitis, should be ruled out. The authors also reported that 31% of all children who had a joint aspiration were found to have Lyme disease on the basis of serological testing. This high percentage in itself emphasizes the importance of aspirating joint effusions at the time of presentation to the emergency department in endemic areas.
    This review also has highlighted a technical deficiency inhibiting our handling of Lyme disease—specifically, the fact that results of serological testing may take up to a week to obtain. We obviously need a quicker Lyme disease test if we are to avoid arthrotomies in children presenting with high synovial cell counts. In this series, 24% of children with Lyme disease and synovial cell counts of >100,000 cells/mm3 underwent an unnecessary arthrotomy simply because one cannot wait for a week for the results of the Lyme test if septic arthritis is suspected. A corollary to this is that, in an endemic area, the diagnosis of both septic arthritis and Lyme disease must be considered even for children with synovial cell counts of >100,000 cells/mm3. In many studies of septic arthritis, as many as 40% of patients have negative cultures. In endemic areas, undoubtedly some of these patients had Lyme disease.
    This paper showed no difference between children with Lyme disease and those with septic arthritis with regard to either the erythrocyte sedimentation rate or the C-reactive protein level. The data presented by the authors also indicate that we may not be diligent enough in pursuing the diagnosis of Lyme disease as serological testing was performed for only 64% of the patients who underwent joint aspirations in their hospital. Those of us practicing in endemic areas should ensure that our own hospital emergency departments are sending all joint aspirations for serological testing for Lyme disease routinely. An additional interesting finding was that Lyme disease presents throughout the entire year, and not just when the ticks are biting. Hence, we need to be as diligent in our pursuit of the diagnosis of Lyme disease in January as in July as its onset may be delayed weeks or months after the precipitating tick bite.
    Although this was a retrospective study from a single institution, it demonstrates the value of a well-done study concentrating on a specific entity. This well-documented study has increased our awareness of Lyme arthritis and has pointed out to those of us practicing in endemic areas how we can all improve our diagnosis and treatment of children presenting with a swollen joint due to Lyme disease.

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    Lawrence Zemel, MD
    Posted on May 13, 2011

    I would like to respond to the commentary on “Lyme arthritis in children presenting with joint effusions” by Dr. R. Mervyn Letts. His point is well taken that prompt diagnosis of Lyme arthritis is important, both to avoid arthrotomy, and to initiate antibiotic therapy. He recommends that joint aspirations be sent for serologic testing. The standard serologic testing, however, is the 2-tiered approach on serum, not synovial fluid.(1) The sensitivity of immunoblot on joint fluid has not been adequately studied. Since serum Lyme titers are positive in virtually all children with Lyme arthritis, blood work would be the first step in diagnosing Lyme. Polymerase chain reaction (PCR) testing of joint fluid is not usually necessary as a first-line test (2).

    Dr. Letts also states that all non-traumatic joint effusions should be aspirated. This is certainly true if the child is febrile, to exclude joint sepsis. However, the diagnostic usefulness is limited in other afebrile inflammatory arthropathies. In our pediatric rheumatology clinic, we more often inject joints for therapeutic reasons, rather than aspirate for diagnostic reasons. In distinguishing Lyme arthritis from septic arthritis, the history becomes critical (was there a transient arthritis earlier, was there a flu-like illness during the spring or summer?) I further agree that there is more Lyme disease in New England that septic arthritis, so we need constraint in recommending a surgical procedure when Lyme disease is likely.

    Lawrence Zemel, MD

    Chief, Pediatric Rheumatology, Connecticut Children’s Medical Center

    Prof of Pediatrics, University of Connecticut School of Medicine

    (1) GP Wormser et al., The clinical assessment, treatment, and prevention of Lyme disease: clinical practice guidelines by the Infectious Disease Society of America, Clin Infect Dis. 43 (2006) 1089-1134

    (2) JJ Nocton et al., Dectecction of Borrelia burgdorferi DNA by polymerase chain reaction in synovial fluid from patients with Lyme arthritis, N Engl J Med 330 (1994) 229-234

    Ram B. Dessau
    Posted on February 01, 2011

    Thank you for presenting a very nice article documenting a large consecutive series of children aspirated for joint effusion. Very interesting reading. It is important to document the clinical spectrum arthritis treated consecutively in the routine setting.

    It would be interesting to know the background seroreactivity for both the screening ELISA and the immunoblot of children in the uptake area, using preferably the same diagnostic assays, in order to asses specificity?

    Were positive IgG immunoblot results used to define a Lyme positive arthritis or were IgM results included as well? I cannot find if this is mentioned in the article. IDSA guidelines 2006 (CID 2006:43:1109) mention only IgG, as do European guidelines (CMI 2010) concerning the diagnosis of Lyme arthritis.

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