Pediatric emergency medicine trisk 4019 4019

Common pathogens encountered in children include Staphylococcus
aureus, Kingella kingae, pneumococci, and salmonella species. The
prevailing hypotheses are that it is thought to arise from a prior site of
infection and spread via three possible routes: hematogenously, by direct
inoculation, or by direct extension. Almost 50% of children will have a
prior prodromal illness related to their disc space infection. In children,
blood vessels are present in the annulus fibrosus and the vessels within the
vertebral body typically are anastomotic. These anatomic variations have
been proposed as a reason explaining preferential localization of bacterial
infections to the intervertebral disc space. Spondylodiscitis in children has a
bimodal age distribution (0 to 2 years and >10 years) mostly affecting the
thoracic and lumbar spine. Diagnosis can often be delayed up to 4 to 6
months secondary to the low incidence and vague presentation in children.
Clinical Recognition. Children most commonly present with back pain,
but nonspecific symptoms may be the only presentation, often without
fevers. Very young children with discitis often may refuse to walk, regress
with ambulatory motor skills, display Gower sign, torticollis or refuse to sit.
Several authors have proposed categories of symptoms for children
presenting with discitis: back pain, hip and leg pain, meningeal symptoms,
abdominal symptoms, or “irritable child” syndrome.
Diagnostic Testing and Imaging. Laboratory values (CBC, ESR, CRP)
and blood cultures should be obtained, but are often normal or only mildly
elevated. Blood cultures will often be positive early in the course of the
illness but given the delay in diagnosis, often only 50% are diagnostic. Very
early in the course, plain radiographs may be negative as it typically takes 2
weeks to a month before disc space narrowing becomes apparent. Initial
evaluation should include an MRI of the entire spine with contrast.
Technetium-99, bone scans will identify the problem 7 to 12 days after
onset of symptoms, but are nonspecific and require distinction between
inflammatory and neoplastic etiology.
Management. Treatment is controversial as most spondylodiscitis

infections have a relatively benign course. If a pathogen is not identified, a
CT-guided biopsy should be considered prior to initiation of antibiotic
treatment unless clinically contraindicated in the unstable or critically ill
patient. More routinely however, a course of intravenous broad-spectrum
antibiotics followed by oral antibiotics for 6 to 8 weeks is prescribed.