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Published online March 2, 2009
PEDIATRICS Vol. 123 No. 3 March 2009, pp. 959-965 (doi:10.1542/peds.2008-1511)
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Lyme Disease (Lyme Borreliosis,...
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ARTICLE

Acute Pediatric Monoarticular Arthritis: Distinguishing Lyme Arthritis From Other Etiologies

Amy Thompson, MD, Rebekah Mannix, MD, Richard Bachur, MD

Division of Emergency Medicine, Children's Hospital Boston, Boston, Massachusetts

OBJECTIVE. Identify clinical predictors of Lyme arthritis among patients with acute monoarticular arthritis.

METHODS. A medical chart review was conducted of children ≤18 years of age with monoarticular arthritis who underwent arthrocentesis in a pediatric emergency department located in the northeast United States. Patients were classified into 3 categories of arthritis: septic, Lyme, or nonseptic non-Lyme arthritis. Historical, clinical, and laboratory data were compared to identify distinguishing features of Lyme arthritis.

RESULTS. One hundred seventy-nine patients were studied: 46 (26%) patients with septic arthritis, 55 (31%) patients with Lyme arthritis, and 78 (43%) patients with nonseptic non-Lyme arthritis. Compared with those with septic arthritis, patients with Lyme disease were more likely to have a tick-bite history, knee involvement, and less likely to have a history of fever or elevated temperature at triage. Erythrocyte sedimentation rate, C-reactive protein, joint white blood cell count, and joint neutrophil percentage were also statistically lower. In comparison to nonseptic non-Lyme arthritis, knee involvement and tick-bite history were predictors of Lyme. Erythrocyte sedimentation rate, joint white blood cell count, and joint neutrophil percentage were also statistically different. Multivariate analysis comparing Lyme to septic arthritis demonstrated fever history and elevated C-reactive protein level to be negative predictors of Lyme arthritis and knee involvement to be a positive predictor (model sensitivity: 88%; specificity: 82%).

CONCLUSIONS. Lyme arthritis shares features with both septic and nonseptic non-Lyme arthritis. This overlap prevents the creation of a clinically useful predictive model for Lyme arthritis. In endemic areas, Lyme testing should be performed on all patients presenting with acute monoarticular arthritis.

Key Words: arthritis • Lyme disease • septic arthritis • bacterial infection • reactive arthritis

Abbreviations: ED—emergency department • ESR—erythrocyte sedimentation rate • CRP—C-reactive protein • WBC—white blood cell • ANC—absolute neutrophil count • CI—confidence interval • IQR— interquartile range • OR—odds ratio

Accepted Aug 28, 2008.


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