Distinguishing Lyme From Septic Knee Monoarthritis in Lyme Disease–Endemic Areas

Abstract

OBJECTIVE: Because Lyme and septic arthritis may present similarly, we sought to identify children with knee monoarthritis at low risk for septic arthritis who may not require arthrocentesis. METHODS: We performed a retrospective study of children with knee monoarthritis presenting to 1 of 2 pediatric centers, both located in Lyme disease–endemic areas. Septic arthritis was defined by a positive result on synovial fluid culture or synovial fluid pleocytosis with a positive blood culture result. Lyme arthritis was defined as a positive Lyme serologic result or physician-documented erythema migrans rash. All other children were considered to have other inflammatory arthritis. A clinical prediction model was derived by using recursive partitioning to identify children at low risk for septic arthritis, and the model was then externally validated. RESULTS: We identified 673 patients with knee monoarthritis; 19 (3%) had septic arthritis, 341 (51%) had Lyme arthritis, and 313 (46%) had other inflammatory arthritis. The following predictors of knee septic arthritis were identified: peripheral blood absolute neutrophil count ≥10 × 103 cells per mm3 and an erythrocyte sedimentation rate ≥40 mm/hour. In the validation population, no child with a absolute neutrophil count <10 × 103 cells per mm3 and an erythrocyte sedimentation rate <40 mm/hour had septic arthritis (sensitivity: 6 of 6 [100%], 95% confidence interval [CI]: 54–100; specificity: 87 of 160 [54%], 95% CI: 46–62). Overall, none of the 19 children with septic arthritis were classified as low risk (10%, 95% CI: 0–17). CONCLUSIONS: Laboratory criteria can be used to identify children with knee monoarthritis at low risk for septic arthritis who may not require diagnostic arthrocentesis.