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LACK OF ASSOCIATION OF TRANSIENT SYNOVITIS OF THE HIP JOINT WITH HUMAN PARVOVIRUS B19 INFECTION IN CHILDREN

1998; Lippincott Williams & Wilkins; Volume: 17; Issue: 9 Linguagem: Inglês

10.1097/00006454-199809000-00022

1532-0987

Avraham Zeharia, Shimon Reif, Shai Ashkenazi,

Bone and Joint Diseases

Transient synovitis of the hip is a common disorder in children characterized by acute pain in the thigh region with limping which resolves within 7 to 10 days. The cause is unknown, although the disorder is often preceded by a viral infection.1, 2 Human parvovirus B19 is a common cause of infection in children, presenting as mild, acute, typically exanthematous disease.3 In 8% of cases it is accompanied by rheumatologic manifestations.4-6 The aim of the present study was to determine whether human parvovirus B19 infection has a causal association with transient synovitis. Methods. Eighteen children (14 male, 4 female) ages 21 months to 9 years with transient synovitis of the hip (limping and pain for 1 to 5 days and clinical improvement within 7 days) who presented at our day-care clinic from January through June, 1996, were evaluated for IgG and IgM human parvovirus B19 antibodies by enzyme-linked immunosorbent assay, on admission (acute phase) of the disease and 3 weeks later (convalescence). The enzyme-linked immunosorbent assay results were reported as the ratio of the optical density of the test serum to the optical density of a serum with confirmed positivity. Positive and negative controls were 0.86 and 0.03 for IgG and 0.998 and 0.074 for IgM. Nested PCR was performed according to the method of Musiani et al.7 with two rounds of 35 cycles each (95° C for 1 min; 55°C for 1.5 min; 72°C for 1 min); the product of the first round served as the template DNA for the second. Results. Ten patients had had a transient viral disease 1 to 3 weeks before onset of the hip symptoms, but none had the typical rash of erythema infectiosum or other systemic presentation. All recovered after 3 weeks. None of the patients had laboratory evidence of acute severe inflammation. Fourteen children showed hip joint effusion on plain roentgenograms, and 15 had hip joint intracapsular effusion by ultrasonography; 3 patients with normal radiographs had pathologic ultrasonographic findings. Results for the IgM anti-human parvovirus B19 ranged from 0.012 to 0.239 (mean, 0.101 ± 0.07) in the acute phase and from 0.089 to 0.258 (mean, 0.101 ± 0.072) in the convalescent phase; corresponding figures for IgG were 0 to 0.002 (mean, 0.0015 ± 0.0042) and 0 to 0.017 (mean, 0.0016 ± 0.038). Both were below their respective positive control index. No seroconversion or increased titer was noted between the acute and convalescent sera. PCR, carried out for 10 patients, was negative. Discussion. The present study tested a possible causal association between transient synovitis of the hip and human parvovirus B19 in children. Our review of the literature yielded reports of 36 children with joint symptoms after recent human parvovirus B19 infection8-10; one-third had erythema infectiosum. Ninety-five percent had arthritis, polyarticular (5 or more joints) in 50% and pauciarticular or monoarticular in the others. Some also had a migratory component. The remaining 5% had arthralgia. Large joints were affected more often than small ones, and the knee was affected most often (82%). The hip was affected in ∼25% of the patients with arthritis, but never as the sole involved joint. One-half the patients recovered within 6 weeks, another 10% within 4 months and 40% had persistent joint symptoms for 6 to 13 months, fulfilling the criteria for juvenile rheumatoid arthritis. Our patients recovered clinically within 1 to 3 weeks like the subgroup of children with human parvovirus B19 infection that resolved within 6 weeks. In contrast to the other studies, however, the hip was the sole affected joint and there was no fever or other systemic symptoms. On the basis of the discrepancies in the clinical findings between our cohort and patients with arthritis known to be caused by parvovirus B19 infection and the absence of serologic and PCR evidence of this infection, we believe that transient synovitis of the hip is probably not caused by human parvovirus B19. Avraham Zeharia, M.D. Shimon Reif, M.D. Shai Ashkenazi, M.D. Emergency Medicine and Day Care Department (AZ); Unit of Infectious Diseases (SA); Schneider Children's Medical Center of Israel; Petah Tiqva Pediatric Gastroenterology Unit; Tel Aviv Sourasky Medical Center; Tel Aviv and Sackler Faculty of Medicine; Tel Aviv University; Tel Aviv (SR) Israel