Pyogenic sacroiliitis: Lessons learned from an atypical case series

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At the time of admission, the disease is initially not suspected in 50% of patients,<a class="elsevierStyleCrossRef" href="#bib0140">5</a> and this delay in diagnosis can result in increased morbidity and long-term disability. Pyogenic sacroiliitis commonly presents with fever and a limp with poorly localised pain and normal range of motion of the hip.<a class="elsevierStyleCrossRefs" href="#bib0140">5,6</a> The most sensitive clinical sign is the FABER test: pain is caused or exacerbated at the sacroiliac joint when positioning the contralateral hip in flexion (F), abduction (AB), and external rotation (ER).<a class="elsevierStyleCrossRef" href="#bib0150">7</a> Magnetic resonance imaging (MRI) has improved sensitivity in the diagnosis of PSI and is now considered the gold standard for the early diagnosis of sacroiliitis and osteoarticular infections in general.<a class="elsevierStyleCrossRefs" href="#bib0140">5,6</a> The laboratory findings are unspecific, and positive blood cultures, osteoarticular fluid aspiration or biopsy are still considered essential for identifying the causative microorganisms.<a class="elsevierStyleCrossRef" href="#bib0155">8</a> Historically, Staphylococcus aureus has been the most frequently identified aetiological agent .<a class="elsevierStyleCrossRefs" href="#bib0130">3,5</a> However, there has been increasing evidence that Kingella kingae is an important cause of PSI in children aged 6 months to 4 years.<a class="elsevierStyleCrossRefs" href="#bib0145">6,9</a> Identification of the causative agent is important, as an appropriate antibiotic regimen usually provides rapid resolution of symptoms and healing without the need to resort to invasive procedures.Our aim was to characterise the epidemiological, diagnostic and clinical profile of patients with PSI admitted to our tertiary care children's hospital.Patients and methodsWe performed a retrospective review of the hospital health records of all patients aged less than 18 years admitted to our tertiary care children's hospital in Lisbon, Portugal, with a diagnosis of PSI (ICD-9 720.2) between 2008 and 2016. We also analysed demographic and predisposing factors, clinical signs and symptoms, laboratory and imaging test results, type and duration of treatment, clinical outcome and sequelae.ResultsSix patients were identified. The distribution by sex was homogeneous, and the mean age was 6.3 years (range, 13 months–14 years). Three were toddlers aged 12–27 months, and three were older than 7 years (range, 7–14 years). All had been healthy before the episode, and half reported recent manifestations of an acute upper respiratory infection. All patients presented with fever, limping and pain at different locations (lower limb, lumbar region and ipsilateral iliac fossa) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Clinical documentation for the FABER test was available in 4 patients, all of whom had positive results. At admission, the mean leucocyte count was 14,933μL−1 (range, 9500–22,500), the mean C-reactive protein level was 99mg/L (range, 33–139mg/L), and the mean erythrocyte sedimentation rate (ESR) 39mm/h (range, 2–92mm/h). The results of blood cultures were negative in all patients.<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The findings of pelvic X-rays were normal in all patients. A computed tomography (CT) scan was performed in 3 patients, and in one of them revealed a small subchondral sequestrum of the lower third of the sacroiliac joint that was probably secondary to a subchondral osteomyelitis foci with cortical disruption and subsequent joint involvement. Skeletal scintigraphy was performed in 2 patients, both with sacroiliac increased uptake. The findings of T2-weighted and gadolinium-enhanced T1-weighted magnetic resonance imaging were abnormal in all patients, with signal hyperintensity in the sacroiliac joint line and adjacent muscles. In one patient (case 3), the gadolinium-enhanced image also revealed a small intra-articular abscess.When we compared children aged less than 4 years with older children, we found that they presented more often with a limp or difficulty bearing weight, received an earlier diagnosis (4.8 vs. 85.7 days), had higher mean leucocyte counts and CRP levels at admission, and had a shorter treatment duration (42 vs. 65 days). In younger infants, testing of oropharyngeal samples with PCR identified K. kingae in 2 patients, while no causative agent was identified in the third one (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). In the older group, different bacteria were identified in each case: Aggregatibacter aphrophilus (n=1) by joint fluid culture, and Bartonella henselae (n=1) and Brucella melitensis (n=1) by enzyme-linked immunoassay (ELISA). In older children, antimicrobial regimens were adjusted to target the specific aetiological agent—doxycycline plus rifampicin (16 weeks) for brucellosis and ceftriaxone followed by levofloxacin (6 weeks) for A. aphrophilus—based on susceptibility tests. For B. henselae, the antibiotic treatment was not adjusted because the patient exhibited complete clinical and radiological resolution on flucloxacillin and gentamicin. All patients showed a favourable clinical response and were free from sequelae during the follow-up (average, 11.7 months) (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).DiscussionWe have described six cases of sacroiliitis, which corresponded to 0.67 cases per year. This incidence is comparable to the one in a larger series published by Donzelli et al., who reported 16 cases in a review spanning of 25 years (0.64cases/year). Also consistently with their series, we noticed a biphasic age distribution, with 3 children aged less than 4 years and 3 aged 7–14 years.Due to the nonspecificity of the clinical features and laboratory findings of PSI, it is important to maintain a high level of suspicion for this diagnosis. Specific tests for the sacroiliac joint are frequently positive,<a class="elsevierStyleCrossRefs" href="#bib0125">2–4</a> but they are used unevenly in the physical examination due to the low level of suspicion.<a class="elsevierStyleCrossRef" href="#bib0120">1</a> An increased awareness of the importance of this test in the systematic evaluation of back pain complaints, especially in older children, could contribute to an earlier diagnosis. In very young children, however, the clinical assessment is particularly difficult and the FABER test rarely feasible, with limping and decreased weight bearing being the most frequent nonspecific complaints.<a class="elsevierStyleCrossRef" href="#bib0150">7</a> In our series, however, the FABER test was positive in the 4 cases it was performed, including those of 2 young children.The growing availability of MRI in recent years has improved the diagnostic process, with a reported sensitivity and specificity of 95% and 100%, respectively.<a class="elsevierStyleCrossRef" href="#bib0120">1</a> This technique can achieve an earlier diagnosis without exposure to radiation, while offering a good visualisation of the complex anatomy of the sacroiliac joint and the ability to identify the presence of fluid in the sacroiliac joint, bone marrow oedema, soft tissue abscess and spinal involvement.<a class="elsevierStyleCrossRefs" href="#bib0120">1,6</a> Bone scintigraphy is less sensitive, especially when performed earlier in the course of disease, and cannot detect local abscesses.<a class="elsevierStyleCrossRefs" href="#bib0130">3,6,10</a>Performing specific tests for less frequent agents was essential in the identification of the causative microorganism. The reliability on blood cultures for identification of the causative agent has been widely questioned in the literature, as positive results rates range between 27% and 50%.<a class="elsevierStyleCrossRefs" href="#bib0125">2,4,6,10</a> Culture of joint fluid aspiration samples can be considered as an alternative, but its poor diagnosis performance and the risks associated with surgery and anaesthesia preclude its indication, especially in younger children.<a class="elsevierStyleCrossRefs" href="#bib0140">5,6</a> Indeed, in our series, all blood cultures were negative and S. aureus was not isolated from any samples, even though it is usually the most common causative agent in all series reported <a class="elsevierStyleCrossRefs" href="#bib0125">2,4</a> and also in our hospital, for other osteoarticular infections (OAIs). Surprisingly, in case 3 A. aphrophilus was isolated from the synovial fluid. To our knowledge, there is only one other published case of sacroiliitis caused by this bacterium, which occurred in an adult patient.<a class="elsevierStyleCrossRef" href="#bib0170">11</a> The optimal antibiotic regimen for this aetiological agent has not been established, although based on antimicrobial susceptibility testing, our patient was treated with intravenous ceftriaxone followed by oral levofloxacin and achieved clinical improvement.K. kingae has emerged as a common cause of OAIs in children aged less than 4 years.<a class="elsevierStyleCrossRef" href="#bib0160">9</a> Specific PCR testing in oropharyngeal samples has been considered a reliable method for detection of K. kingae in OAIs, particularly when direct synovial fluid aspiration is unfeasible. Although we could not rule out the possibility of carriage state, it is fair to assume that this was the etiologic agent of PSI.Sacroiliitis is the predominant form of skeletal involvement in brucellosis, with an incidence that ranges between 4.8% and 48.7% in the paediatric population.<a class="elsevierStyleCrossRefs" href="#bib0175">12,13</a> Diagnosis is difficult due to the nonspecific clinical presentation and low sensitivity of blood cultures, especially in subacute and chronic presentations, with the overall positivity rate ranging from 15% to 70% despite the use of several enhancing techniques.<a class="elsevierStyleCrossRefs" href="#bib0185">14–16</a> Moreover, serological tests for brucellosis and more recently developed specific PCR assays have improved diagnosis sensitivity.<a class="elsevierStyleCrossRef" href="#bib0195">16</a> Although this infection is currently less common in Portugal ,<a class="elsevierStyleCrossRef" href="#bib0200">17</a> we have to keep it in mind, especially in rural areas, where there is contact with sheep through farming, and in insidious clinical presentations. According to most published guidelines, treatment with doxycycline plus rifampicin with gentamicin is successful.<a class="elsevierStyleCrossRefs" href="#bib0205">18,19</a>There is evidence that B. henselae can be involved in the aetiology of osteomyelitis.<a class="elsevierStyleCrossRefs" href="#bib0215">20,21</a> In these cases, blood and bone biopsy cultures typically remain sterile and the diagnosis depends on molecular amplification or serological techniques such as indirect fluorescence assay (IFA) and enzyme-linked immunoassay (ELISA), which are used to detect serum antibody to B. henselae.<a class="elsevierStyleCrossRef" href="#bib0215">20</a> Seroconversion confirms infection, as ocurred in our case. However, by the time Bartonella was confirmed, our patient was already asymptomatic and the antibiotic treatment was not modified. Although a multidrug regimen with doxycycline plus rifampicin or cotrimoxazole has been recommended for Bartonella-related OAIs, it is possible that treatment with gentamicin contributed to this improvement.<a class="elsevierStyleCrossRefs" href="#bib0225">22,23</a>ConclusionDespite the small sample size of our study, its findings emphasize the low effectiveness of blood culture for diagnosis of paediatric SIP. Consequently, it also highlighted the need for a high level of suspicion for atypical agents and the early use of appropriate diagnostic methods, including imaging tests,antibody and PCR blood analysis, and the implementation of an effective antimicrobial therapy. This seems to be particularly important in older children, in whom we found a more nonspecific and indolent presentation, which ultimately resulted in delayed diagnosis and longer duration of treatment.Conflicts of interestThe authors declare no conflicts of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1215044" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1130814" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1215045" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1130813" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Patients and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0065" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-06" "fechaAceptado" => "2018-07-30" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1130814" "palabras" => array:3 [ 0 => "Pyogenic sacroiliitis" 1 => "Atypical agents" 2 => "Paediatric osteoarticular infection" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1130813" "palabras" => array:3 [ 0 => "Sacroileítis piógena" 1 => "Agentes atípicos" 2 => "Infección osteoarticular pediátrica" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionPyogenic sacroiliitis (PSI) is a rare condition that accounts for 1–2% of all joint infections in the paediatric age group. Its diagnosis is often difficult and delayed due to its nonspecific signs, symptoms and physical findings. Also, the identification of the causative microorganism is frequently challenging due to a high rate of negative blood cultures and the risks involved in joint aspiration in this location. Patients and methodsWe performed a retrospective review of the health records of all patients aged less than 18 years admitted to a tertiary children's hospital due to PSI between 2008 and 2016. ResultsSix cases of paediatric PSI were identified. The blood cultures were negative, and identification of the causative agent required joint fluid aspiration in one case of Aggregatibacter aphrophilus infection and specific screening tests for other less frequent agents: Kingella kingae (n=2), Brucella melitensis (n=1) and Bartonella henselae (n=1). The patients were treated with specific antimicrobial regimens, and all had favourable clinical outcomes and were free from sequelae during the follow-up. ConclusionsDespite the small sample size, our study emphasizes the low effectiveness of blood cultures for diagnosis of paediatric PSI. It also highlights the need for a high level of suspicion for atypical agents and the early use of adequate diagnostic methods, including imaging and serological testing or polymerase chain-reaction (PCR) analysis of blood samples, as well as the prescription of an effective antimicrobial therapy." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Patients and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa sacroileítis piógena (SIP) es una entidad infrecuente que representa del 1 al 2% del total de las infecciones articulares en la edad pediátrica. Su diagnóstico a menudo se complica y retrasa debido a la inespecificidad de sus síntomas, signos y exploración física. Además, la identificación microbiológica puede resultar difícil debido a la alta proporción de hemocultivos negativos y los riesgos implicados en la aspiración de líquido articular en esta localización. Pacientes y métodosRevisión retrospectiva de las historias clínicas de todos los pacientes menores de 18 años ingresados en un hospital infantil terciario con SIP en el período 2008-2016. ResultadosSe identificaron 6 casos de SIP en niños. Los hemocultivos fueron negativos, y la identificación del agente etiológico requirió aspiración de líquido sinovial en un paciente con infección por Aggregatibacter aphrophilus y pruebas específicas para la detección de agentes menos frecuentes en los pacientes restantes: Kingella kingae (n=2), Brucella melitensis (n=1) y Bartonella henselae (n=1). Los pacientes recibieron regímenes de antibioterapia específica, y todos presentaron una evolución favorable y libre de secuelas durante el seguimiento. ConclusionesA pesar del reducido tamaño muestral, nuestro estudio puso de relieve la baja efectividad del hemocultivo en el diagnóstico de la SIP pediátrica. También evidenció la necesidad de mantener un elevado índice de sospecha de los agentes atípicos y de emplear precozmente métodos diagnósticos apropiados, como las pruebas de imagen y la reacción en cadena de la polimerasa (PCR) en muestras de sangre, así como la prescripción de antibioterapia efectiva." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Pacientes y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Arcângelo J, Norte Ramos S, Alves P, Tavares D, Gouveia C. Sacroileítis piógena: Lecciones aprendidas de una serie de casos atípicos. An Pediatr (Barc). 2019;91:42–46." ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "BC, blood culture; CPR, C-reactive protein; CT, computed tomography; ESR, erythrocyte sedimentation rate; IV, intravenous; F, female; M, male; MRI, magnetic resonance imaging; PCR, polymerase chain reaction; URTI, upper respiratory tract infection." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CaseYear \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Predisposing factor \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Time elapsed from onset to admission (days) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptoms \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Physical exam(FABER test) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Leukocytes(×106L−1) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRPmg/LESRmm/h(at admission) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Microbiology \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Imaging tests \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Abscess \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antibiotherapy \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sequelae \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Followup \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12010 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Contact with farm animals \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">240 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever, hip pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10,003 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3344 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BC−Brucella melitensisserology+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X-ray−Bone scan+MRI+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gentamicin (7d IV)+Doxycycline+Rifampicin (16 wks oral) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">24m \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22011 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">URTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever, hip pain, limpness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13,400 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11140 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BC− \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X-ray−CT−MRI+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flucloxacillin (30d IV+21d oral) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11m \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">32014 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">14yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever, back/hip/iliac fossa pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9311 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BC−Joint aspirate Aggregatibacter aphrophilus+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X-ray−CT+MRI+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flucloxacillin+Clindamycin (14d IV)– > Ceftriaxone+Gentamicin (21d IV)+21d Levofloxacin oral \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6m \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">42015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">26m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">URTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever, hip pain, limpness \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17,700 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11392 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BC−Kingella swab test+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X-ray−MRI+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Small dimension \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flucloxacillin (11d IV+30d oral)+Gentamicin (7d IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11m \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">52015 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7yr \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">F \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">URTI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">15 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever, upper and lower limb pain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16,500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">10247 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BC−Bartonella bloodPCR and serology+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X-ray−CT−Bone scan+MRI+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Flucloxacillin (7d IV+3 wks oral) Clindamycin (7d IV) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6m \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">62016 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13m \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">M \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="char" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Fever, lower limb pain, limpness, \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">NT \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">22,500 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1392 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">BC−Kingella swab test + \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">X-ray−MRI+ \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Cefuroxime+Clindamycin (8d IV)+Cefuroxime (3 wks oral) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">No \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">12m \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab2074240.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Epidemiological and clinical data; 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Original Article

Pyogenic sacroiliitis: Lessons learned from an atypical case series

Sacroileítis piógena: Lecciones aprendidas de una serie de casos atípicos

Joana Arcângeloa,

Corresponding author

joana.arcangelo@gmail.com

Corresponding author.

, Susana Norte Ramosb, Pedro Alvesc, Delfin Tavaresb, Catarina Gouveiad

a Unidad de Ortopedia, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa, Portugal

b Unidad de Ortopedia, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa, Portugal

c Departamento de Radiología, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa, Portugal

d Unidad de Infectología, Hospital de Dona Estefânia, Centro Hospitalar Universitário de Lisboa Central, EPE, Lisboa, Portugal

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    "cabecera" => "<span class="elsevierStyleTextfn">Original Article</span>"
    "titulo" => "Pyogenic sacroiliitis&#58; Lessons learned from an atypical case series"
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        "autoresLista" => "Joana Arc&#226;ngelo, Susana Norte Ramos, Pedro Alves, Delfin Tavares, Catarina Gouveia"
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            "entidad" => "Unidad de Ortopedia&#44; Hospital de Dona Estef&#226;nia&#44; Centro Hospitalar Universit&#225;rio de Lisboa Central&#44; EPE&#44; Lisboa&#44; Portugal"
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        "titulo" => "Sacroile&#237;tis pi&#243;gena&#58; Lecciones aprendidas de una serie de casos at&#237;picos"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Pyogenic sacroiliitis &#40;PSI&#41; is a rare condition that accounts for 1&#8211;2&#37; of all joint infections in the paediatric age group&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#8211;4</span></a> Its diagnosis may be difficult due to its nonspecific signs&#44; symptoms and physical findings&#44; often resembling other causes of back pain&#46; At the time of admission&#44; the disease is initially not suspected in 50&#37; of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">5</span></a> and this delay in diagnosis can result in increased morbidity and long-term disability&#46; Pyogenic sacroiliitis commonly presents with fever and a limp with poorly localised pain and normal range of motion of the hip&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;6</span></a> The most sensitive clinical sign is the FABER test&#58; pain is caused or exacerbated at the sacroiliac joint when positioning the contralateral hip in flexion &#40;F&#41;&#44; abduction &#40;AB&#41;&#44; and external rotation &#40;ER&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> Magnetic resonance imaging &#40;MRI&#41; has improved sensitivity in the diagnosis of PSI and is now considered the gold standard for the early diagnosis of sacroiliitis and osteoarticular infections in general&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;6</span></a> The laboratory findings are unspecific&#44; and positive blood cultures&#44; osteoarticular fluid aspiration or biopsy are still considered essential for identifying the causative microorganisms&#46;<a class="elsevierStyleCrossRef" href="#bib0155"><span class="elsevierStyleSup">8</span></a> Historically&#44; <span class="elsevierStyleItalic">Staphylococcus aureus</span> has been the most frequently identified aetiological agent &#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;5</span></a> However&#44; there has been increasing evidence that <span class="elsevierStyleItalic">Kingella kingae</span> is an important cause of PSI in children aged 6 months to 4 years&#46;<a class="elsevierStyleCrossRefs" href="#bib0145"><span class="elsevierStyleSup">6&#44;9</span></a> Identification of the causative agent is important&#44; as an appropriate antibiotic regimen usually provides rapid resolution of symptoms and healing without the need to resort to invasive procedures&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Our aim was to characterise the epidemiological&#44; diagnostic and clinical profile of patients with PSI admitted to our tertiary care children&#39;s hospital&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients and methods</span><p id="par0015" class="elsevierStylePara elsevierViewall">We performed a retrospective review of the hospital health records of all patients aged less than 18 years admitted to our tertiary care children&#39;s hospital in Lisbon&#44; Portugal&#44; with a diagnosis of PSI &#40;ICD-9 720&#46;2&#41; between 2008 and 2016&#46; We also analysed demographic and predisposing factors&#44; clinical signs and symptoms&#44; laboratory and imaging test results&#44; type and duration of treatment&#44; clinical outcome and sequelae&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0020" class="elsevierStylePara elsevierViewall">Six patients were identified<span class="elsevierStyleBold">&#46;</span> The distribution by sex was homogeneous&#44; and the mean age was 6&#46;3 years &#40;range&#44; 13 months&#8211;14 years&#41;&#46; Three were toddlers aged 12&#8211;27 months&#44; and three were older than 7 years &#40;range&#44; 7&#8211;14 years&#41;&#46; All had been healthy before the episode&#44; and half reported recent manifestations of an acute upper respiratory infection&#46; All patients presented with fever&#44; limping and pain at different locations &#40;lower limb&#44; lumbar region and ipsilateral iliac fossa&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; Clinical documentation for the FABER test was available in 4 patients&#44; all of whom had positive results&#46; At admission&#44; the mean leucocyte count was 14&#44;933<span class="elsevierStyleHsp" style=""></span>&#956;L<span class="elsevierStyleSup">&#8722;1</span> &#40;range&#44; 9500&#8211;22&#44;500&#41;&#44; the mean C-reactive protein level was 99<span class="elsevierStyleHsp" style=""></span>mg&#47;L &#40;range&#44; 33&#8211;139<span class="elsevierStyleHsp" style=""></span>mg&#47;L&#41;&#44; and the mean erythrocyte sedimentation rate &#40;ESR&#41; 39<span class="elsevierStyleHsp" style=""></span>mm&#47;h &#40;range&#44; 2&#8211;92<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#41;&#46; The results of blood cultures were negative in all patients&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The findings of pelvic X-rays were normal in all patients&#46; A computed tomography &#40;CT&#41; scan was performed in 3 patients&#44; and in one of them revealed a small subchondral sequestrum of the lower third of the sacroiliac joint that was probably secondary to a subchondral osteomyelitis foci with cortical disruption and subsequent joint involvement&#46; Skeletal scintigraphy was performed in 2 patients&#44; both with sacroiliac increased uptake&#46; The findings of T2-weighted and gadolinium-enhanced T1-weighted magnetic resonance imaging were abnormal in all patients&#44; with signal hyperintensity in the sacroiliac joint line and adjacent muscles&#46; In one patient &#40;case 3&#41;&#44; the gadolinium-enhanced image also revealed a small intra-articular abscess&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">When we compared children aged less than 4 years with older children&#44; we found that they presented more often with a limp or difficulty bearing weight&#44; received an earlier diagnosis &#40;4&#46;8 vs&#46; 85&#46;7 days&#41;&#44; had higher mean leucocyte counts and CRP levels at admission&#44; and had a shorter treatment duration &#40;42 vs&#46; 65 days&#41;&#46; In younger infants&#44; testing of oropharyngeal samples with PCR identified <span class="elsevierStyleItalic">K&#46; kingae</span> in 2 patients&#44; while no causative agent was identified in the third one &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46; In the older group&#44; different bacteria were identified in each case&#58; <span class="elsevierStyleItalic">Aggregatibacter aphrophilus</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; by joint fluid culture&#44; and <span class="elsevierStyleItalic">Bartonella henselae</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and <span class="elsevierStyleItalic">Brucella melitensis</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; by enzyme-linked immunoassay &#40;ELISA&#41;&#46; In older children&#44; antimicrobial regimens were adjusted to target the specific aetiological agent&#8212;doxycycline plus rifampicin &#40;16 weeks&#41; for brucellosis and ceftriaxone followed by levofloxacin &#40;6 weeks&#41; for <span class="elsevierStyleItalic">A&#46; aphrophilus</span>&#8212;based on susceptibility tests&#46; For <span class="elsevierStyleItalic">B&#46; henselae</span>&#44; the antibiotic treatment was not adjusted because the patient exhibited complete clinical and radiological resolution on flucloxacillin and gentamicin&#46; All patients showed a favourable clinical response and were free from sequelae during the follow-up &#40;average&#44; 11&#46;7 months&#41; &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0035" class="elsevierStylePara elsevierViewall">We have described six cases of sacroiliitis&#44; which corresponded to 0&#46;67 cases per year&#46; This incidence is comparable to the one in a larger series published by Donzelli et al&#46;&#44; who reported 16 cases in a review spanning of 25 years &#40;0&#46;64<span class="elsevierStyleHsp" style=""></span>cases&#47;year&#41;&#46; Also consistently with their series&#44; we noticed a biphasic age distribution&#44; with 3 children aged less than 4 years and 3 aged 7&#8211;14 years&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Due to the nonspecificity of the clinical features and laboratory findings of PSI&#44; it is important to maintain a high level of suspicion for this diagnosis&#46; Specific tests for the sacroiliac joint are frequently positive&#44;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#8211;4</span></a> but they are used unevenly in the physical examination due to the low level of suspicion&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> An increased awareness of the importance of this test in the systematic evaluation of back pain complaints&#44; especially in older children&#44; could contribute to an earlier diagnosis&#46; In very young children&#44; however&#44; the clinical assessment is particularly difficult and the FABER test rarely feasible&#44; with limping and decreased weight bearing being the most frequent nonspecific complaints&#46;<a class="elsevierStyleCrossRef" href="#bib0150"><span class="elsevierStyleSup">7</span></a> In our series&#44; however&#44; the FABER test was positive in the 4 cases it was performed&#44; including those of 2 young children&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The growing availability of MRI in recent years has improved the diagnostic process&#44; with a reported sensitivity and specificity of 95&#37; and 100&#37;&#44; respectively&#46;<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">1</span></a> This technique can achieve an earlier diagnosis without exposure to radiation&#44; while offering a good visualisation of the complex anatomy of the sacroiliac joint and the ability to identify the presence of fluid in the sacroiliac joint&#44; bone marrow oedema&#44; soft tissue abscess and spinal involvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0120"><span class="elsevierStyleSup">1&#44;6</span></a> Bone scintigraphy is less sensitive&#44; especially when performed earlier in the course of disease&#44; and cannot detect local abscesses&#46;<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">3&#44;6&#44;10</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">Performing specific tests for less frequent agents was essential in the identification of the causative microorganism&#46; The reliability on blood cultures for identification of the causative agent has been widely questioned in the literature&#44; as positive results rates range between 27&#37; and 50&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;4&#44;6&#44;10</span></a> Culture of joint fluid aspiration samples can be considered as an alternative&#44; but its poor diagnosis performance and the risks associated with surgery and anaesthesia preclude its indication&#44; especially in younger children&#46;<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">5&#44;6</span></a> Indeed&#44; in our series&#44; all blood cultures were negative and <span class="elsevierStyleItalic">S&#46; aureus</span> was not isolated from any samples&#44; even though it is usually the most common causative agent in all series reported <a class="elsevierStyleCrossRefs" href="#bib0125"><span class="elsevierStyleSup">2&#44;4</span></a> and also in our hospital&#44; for other osteoarticular infections &#40;OAIs&#41;&#46; Surprisingly&#44; in case 3 <span class="elsevierStyleItalic">A&#46; aphrophilus</span> was isolated from the synovial fluid&#46; To our knowledge&#44; there is only one other published case of sacroiliitis caused by this bacterium&#44; which occurred in an adult patient&#46;<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">11</span></a> The optimal antibiotic regimen for this aetiological agent has not been established&#44; although based on antimicrobial susceptibility testing&#44; our patient was treated with intravenous ceftriaxone followed by oral levofloxacin and achieved clinical improvement&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleItalic">K&#46; kingae</span> has emerged as a common cause of OAIs in children aged less than 4 years&#46;<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">9</span></a> Specific PCR testing in oropharyngeal samples has been considered a reliable method for detection of <span class="elsevierStyleItalic">K&#46; kingae</span> in OAIs&#44; particularly when direct synovial fluid aspiration is unfeasible&#46; Although we could not rule out the possibility of carriage state&#44; it is fair to assume that this was the etiologic agent of PSI&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">Sacroiliitis is the predominant form of skeletal involvement in brucellosis&#44; with an incidence that ranges between 4&#46;8&#37; and 48&#46;7&#37; in the paediatric population&#46;<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">12&#44;13</span></a> Diagnosis is difficult due to the nonspecific clinical presentation and low sensitivity of blood cultures&#44; especially in subacute and chronic presentations&#44; with the overall positivity rate ranging from 15&#37; to 70&#37; despite the use of several enhancing techniques&#46;<a class="elsevierStyleCrossRefs" href="#bib0185"><span class="elsevierStyleSup">14&#8211;16</span></a> Moreover&#44; serological tests for brucellosis and more recently developed specific PCR assays have improved diagnosis sensitivity&#46;<a class="elsevierStyleCrossRef" href="#bib0195"><span class="elsevierStyleSup">16</span></a> Although this infection is currently less common in Portugal &#44;<a class="elsevierStyleCrossRef" href="#bib0200"><span class="elsevierStyleSup">17</span></a> we have to keep it in mind&#44; especially in rural areas&#44; where there is contact with sheep through farming&#44; and in insidious clinical presentations&#46; According to most published guidelines&#44; treatment with doxycycline plus rifampicin with gentamicin is successful&#46;<a class="elsevierStyleCrossRefs" href="#bib0205"><span class="elsevierStyleSup">18&#44;19</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">There is evidence that <span class="elsevierStyleItalic">B&#46; henselae</span> can be involved in the aetiology of osteomyelitis&#46;<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">20&#44;21</span></a> In these cases&#44; blood and bone biopsy cultures typically remain sterile and the diagnosis depends on molecular amplification or serological techniques such as indirect fluorescence assay &#40;IFA&#41; and enzyme-linked immunoassay &#40;ELISA&#41;&#44; which are used to detect serum antibody to <span class="elsevierStyleItalic">B&#46; henselae&#46;</span><a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">20</span></a> Seroconversion confirms infection&#44; as ocurred in our case&#46; However&#44; by the time <span class="elsevierStyleItalic">Bartonella</span> was confirmed&#44; our patient was already asymptomatic and the antibiotic treatment was not modified&#46; Although a multidrug regimen with doxycycline plus rifampicin or cotrimoxazole has been recommended for <span class="elsevierStyleItalic">Bartonella</span>-related OAIs&#44; it is possible that treatment with gentamicin contributed to this improvement&#46;<a class="elsevierStyleCrossRefs" href="#bib0225"><span class="elsevierStyleSup">22&#44;23</span></a></p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusion</span><p id="par0070" class="elsevierStylePara elsevierViewall">Despite the small sample size of our study&#44; its findings emphasize the low effectiveness of blood culture for diagnosis of paediatric SIP&#46; Consequently&#44; it also highlighted the need for a high level of suspicion for atypical agents and the early use of appropriate diagnostic methods&#44; including imaging tests&#44;antibody and PCR blood analysis&#44; and the implementation of an effective antimicrobial therapy&#46; This seems to be particularly important in older children&#44; in whom we found a more nonspecific and indolent presentation&#44; which ultimately resulted in delayed diagnosis and longer duration of treatment&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Conflicts of interest</span><p id="par0215" class="elsevierStylePara elsevierViewall">The authors declare no conflicts of interest&#46;</p></span></span>"
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        "titulo" => "Abstract"
        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Pyogenic sacroiliitis &#40;PSI&#41; is a rare condition that accounts for 1&#8211;2&#37; of all joint infections in the paediatric age group&#46; Its diagnosis is often difficult and delayed due to its nonspecific signs&#44; symptoms and physical findings&#46; Also&#44; the identification of the causative microorganism is frequently challenging due to a high rate of negative blood cultures and the risks involved in joint aspiration in this location&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Patients and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We performed a retrospective review of the health records of all patients aged less than 18 years admitted to a tertiary children&#39;s hospital due to PSI between 2008 and 2016&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Six cases of paediatric PSI were identified&#46; The blood cultures were negative&#44; and identification of the causative agent required joint fluid aspiration in one case of <span class="elsevierStyleItalic">Aggregatibacter aphrophilus</span> infection and specific screening tests for other less frequent agents&#58; <span class="elsevierStyleItalic">Kingella kingae</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; <span class="elsevierStyleItalic">Brucella melitensis</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; and <span class="elsevierStyleItalic">Bartonella henselae</span> &#40;<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; The patients were treated with specific antimicrobial regimens&#44; and all had favourable clinical outcomes and were free from sequelae during the follow-up&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Despite the small sample size&#44; our study emphasizes the low effectiveness of blood cultures for diagnosis of paediatric PSI&#46; It also highlights the need for a high level of suspicion for atypical agents and the early use of adequate diagnostic methods&#44; including imaging and serological testing or polymerase chain-reaction &#40;PCR&#41; analysis of blood samples&#44; as well as the prescription of an effective antimicrobial therapy&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Patients and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La sacroile&#237;tis pi&#243;gena &#40;SIP&#41; es una entidad infrecuente que representa del 1 al 2&#37; del total de las infecciones articulares en la edad pedi&#225;trica&#46; Su diagn&#243;stico a menudo se complica y retrasa debido a la inespecificidad de sus s&#237;ntomas&#44; signos y exploraci&#243;n f&#237;sica&#46; Adem&#225;s&#44; la identificaci&#243;n microbiol&#243;gica puede resultar dif&#237;cil debido a la alta proporci&#243;n de hemocultivos negativos y los riesgos implicados en la aspiraci&#243;n de l&#237;quido articular en esta localizaci&#243;n&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Pacientes y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Revisi&#243;n retrospectiva de las historias cl&#237;nicas de todos los pacientes menores de 18 a&#241;os ingresados en un hospital infantil terciario con SIP en el per&#237;odo 2008-2016&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se identificaron 6 casos de SIP en ni&#241;os&#46; Los hemocultivos fueron negativos&#44; y la identificaci&#243;n del agente etiol&#243;gico requiri&#243; aspiraci&#243;n de l&#237;quido sinovial en un paciente con infecci&#243;n por <span class="elsevierStyleItalic">Aggregatibacter aphrophilus</span> y pruebas espec&#237;ficas para la detecci&#243;n de agentes menos frecuentes en los pacientes restantes&#58; <span class="elsevierStyleItalic">Kingella kingae</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>2&#41;&#44; <span class="elsevierStyleItalic">Brucella melitensis</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41; y <span class="elsevierStyleItalic">Bartonella henselae</span> &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>1&#41;&#46; Los pacientes recibieron reg&#237;menes de antibioterapia espec&#237;fica&#44; y todos presentaron una evoluci&#243;n favorable y libre de secuelas durante el seguimiento&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">A pesar del reducido tama&#241;o muestral&#44; nuestro estudio puso de relieve la baja efectividad del hemocultivo en el diagn&#243;stico de la SIP pedi&#225;trica&#46; Tambi&#233;n evidenci&#243; la necesidad de mantener un elevado &#237;ndice de sospecha de los agentes at&#237;picos y de emplear precozmente m&#233;todos diagn&#243;sticos apropiados&#44; como las pruebas de imagen y la reacci&#243;n en cadena de la polimerasa &#40;PCR&#41; en muestras de sangre&#44; as&#237; como la prescripci&#243;n de antibioterapia efectiva&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Pacientes y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
    "NotaPie" => array:1 [
      0 => array:2 [
        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Arc&#226;ngelo J&#44; Norte Ramos S&#44; Alves P&#44; Tavares D&#44; Gouveia C&#46; Sacroile&#237;tis pi&#243;gena&#58; Lecciones aprendidas de una serie de casos at&#237;picos&#46; An Pediatr &#40;Barc&#41;&#46; 2019&#59;91&#58;42&#8211;46&#46;</p>"
      ]
    ]
    "multimedia" => array:1 [
      0 => array:8 [
        "identificador" => "tbl0005"
        "etiqueta" => "Table 1"
        "tipo" => "MULTIMEDIATABLA"
        "mostrarFloat" => true
        "mostrarDisplay" => false
        "detalles" => array:1 [
          0 => array:3 [
            "identificador" => "at1"
            "detalle" => "Table "
            "rol" => "short"
          ]
        ]
        "tabla" => array:2 [
          "leyenda" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">BC&#44; blood culture&#59; CPR&#44; C-reactive protein&#59; CT&#44; computed tomography&#59; ESR&#44; erythrocyte sedimentation rate&#59; IV&#44; intravenous&#59; F&#44; female&#59; M&#44; male&#59; MRI&#44; magnetic resonance imaging&#59; PCR&#44; polymerase chain reaction&#59; URTI&#44; upper respiratory tract infection&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
              "tabla" => array:1 [
                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CaseYear&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Predisposing factor&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Time elapsed from onset to admission &#40;days&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Physical exam&#40;FABER test&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Leukocytes&#40;&#215;10<span class="elsevierStyleSup">6</span><span class="elsevierStyleHsp" style=""></span>L<span class="elsevierStyleSup">&#8722;1</span>&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">CRP<span class="elsevierStyleHsp" style=""></span>mg&#47;LESR<span class="elsevierStyleHsp" style=""></span>mm&#47;h&#40;at admission&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Microbiology&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Imaging tests&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Abscess&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Antibiotherapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Sequelae&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th><th class="td" title="\n
                  \t\t\t\t\ttable-head\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Followup&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12010&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Contact with farm animals&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">240&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&#44; hip pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&#44;003&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3344&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BC&#8722;<span class="elsevierStyleItalic">Brucella melitensis</span>serology&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-ray&#8722;Bone scan&#43;MRI&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Gentamicin &#40;7d IV&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Doxycycline<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Rifampicin &#40;16 wks oral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">24<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22011&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">27m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">URTI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&#44; hip pain&#44; limpness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13&#44;400&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11140&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BC&#8722;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-ray&#8722;CT&#8722;MRI&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Flucloxacillin &#40;30d IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>21d oral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">32014&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">14yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&#44; back&#47;hip&#47;iliac fossa pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">9311&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BC&#8722;Joint aspirate <span class="elsevierStyleItalic">Aggregatibacter aphrophilus</span>&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-ray&#8722;CT&#43;MRI&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Flucloxacillin<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Clindamycin &#40;14d IV&#41;&#8211; &#62; Ceftriaxone<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Gentamicin &#40;21d IV&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>21d Levofloxacin oral&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">42015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">26m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">URTI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&#44; hip pain&#44; limpness&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">17&#44;700&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11392&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BC&#8722;<span class="elsevierStyleItalic">Kingella</span> swab test&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-ray&#8722;MRI&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Small dimension&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Flucloxacillin &#40;11d IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>30d oral&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Gentamicin &#40;7d IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">11<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">52015&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">7yr&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">URTI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">15&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&#44; upper and lower limb pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">16&#44;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">10247&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BC&#8722;<span class="elsevierStyleItalic">Bartonella</span> bloodPCR and serology&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-ray&#8722;CT&#8722;Bone scan&#43;MRI&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Flucloxacillin &#40;7d IV<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>3 wks oral&#41; Clindamycin &#40;7d IV&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">6<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">62016&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">13m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Fever&#44; lower limb pain&#44; limpness&#44;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">NT&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">22&#44;500&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">1392&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">BC&#8722;<span class="elsevierStyleItalic">Kingella</span> swab test &#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">X-ray&#8722;MRI&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">Cefuroxime<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Clindamycin &#40;8d IV&#41;<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>Cefuroxime &#40;3 wks oral&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">No&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">12<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab2074240.png"
              ]
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        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Epidemiological and clinical data&#59; treatment and outcome of patients with pyogenic sacroiliitis &#40;January 2008&#8211;August 2016&#41;&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:23 [
            0 => array:3 [
              "identificador" => "bib0120"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pyogenic sacroiliitis in children&#58; two case reports"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "L&#46; Ghedira Besbes"
                            1 => "S&#46; Haddad"
                            2 => "A&#46; Abid"
                            3 => "C&#46; Ben Meriem"
                            4 => "M&#46;N&#46; Gueddiche"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Case Rep Med"
                        "fecha" => "2012"
                        "volumen" => "2012"
                        "paginaInicial" => "1"
                        "paginaFinal" => "4"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0125"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pyogenic sacroiliitis in children &#8212; a diagnostic challenge"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "A&#46; Molinos Quintana"
                            1 => "B&#46; Morillo Guti&#233;rrez"
                            2 => "M&#46;S&#46; Camacho Lovillo"
                            3 => "O&#46; Neth"
                            4 => "I&#46; Obando Santaella"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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Article information

ISSN: 23412879
Original language: English

DOI:10.1016/j.anpede.2018.07.006

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Year/Month	Html	Pdf	Total

2024 November	6	7	13
2024 October	61	37	98
2024 September	49	30	79
2024 August	79	50	129
2024 July	52	19	71
2024 June	67	24	91
2024 May	53	31	84
2024 April	50	34	84
2024 March	40	20	60
2024 February	38	30	68
2024 January	24	17	41
2023 December	33	21	54
2023 November	32	32	64
2023 October	40	20	60
2023 September	39	23	62
2023 August	31	20	51
2023 July	32	28	60
2023 June	28	20	48
2023 May	38	16	54
2023 April	25	14	39
2023 March	51	22	73
2023 February	35	18	53
2023 January	16	13	29
2022 December	52	22	74
2022 November	41	30	71
2022 October	69	48	117
2022 September	33	22	55
2022 August	61	49	110
2022 July	34	43	77
2022 June	43	31	74
2022 May	54	36	90
2022 April	34	34	68
2022 March	59	51	110
2022 February	33	22	55
2022 January	59	23	82
2021 December	41	44	85
2021 November	52	43	95
2021 October	66	72	138
2021 September	49	33	82
2021 August	40	32	72
2021 July	45	20	65
2021 June	50	45	95
2021 May	43	37	80
2021 April	121	55	176
2021 March	90	25	115
2021 February	47	25	72
2021 January	48	16	64
2020 December	58	25	83
2020 November	64	20	84
2020 October	45	19	64
2020 September	63	19	82
2020 August	60	9	69
2020 July	70	21	91
2020 June	63	11	74
2020 May	87	24	111
2020 April	47	17	64
2020 March	54	13	67
2020 February	71	11	82
2020 January	59	10	69
2019 December	68	20	88
2019 November	53	6	59
2019 October	64	17	81
2019 September	56	15	71
2019 August	50	15	65
2019 July	78	58	136
2019 June	31	21	52
2019 May	53	26	79
2019 April	57	56	113
2019 March	28	11	39
2019 February	15	10	25

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