Pediatric Osteoarticular Infections Anil K Agarwal, Aditya N Aggarwal
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Pediatric Osteoarticular Infections—Epidemiology1

Bhavuk Garg,
Aditya N Aggarwal
Chapter Outline
  • ➢ Nontubercular osteoarticular infections
  • ➢ Osteoarticular tubercular infections
 
Introduction
Pediatric osteoarticular infections remain a significant cause of morbidity worldwide. Although many concepts regarding pathogenesis, diagnosis and treatment of pediatric osteoarticular infections have remained constant over the years, understanding regarding various other aspects and epidemiology have continued to evolve.1 Clinicians caring for children need to be especially well versed in these newer concepts as they can be used to guide evaluation and treatment.
 
Nontubercular Osteoarticular Infections
 
Acute Osteomyelitis
The incidence of osteomyelitis in children is 0.2-1.6/1000 children/year.2 Wide variations are observed globally with incidence rates as low as 1/1000 in US and 1/5000 in UK for neonatal osteomyelitis.3 Acute hematogenous osteomyelitis is most common in childhood with a peak incidence in neonates.4–8 A small peak also occurs in early school age.9 There is a seasonal variation, with the hospital admission rate for osteomyelitis peaking in late summer and autumn.10 The incidence is greater in boys than girls (2.5:1) and the male to female sex ratio increases with age.2,10–13 In a combined group of childhood osteoarticular infections, the approximate proportion of osteomyelitis to septic arthritis is approximately 1.8:1.14 A few studies indicate racial differences with disease being more common in Aboriginal (indigenous people of Australia) and New Zealand Maori than European children.10
A few studies from UK (Glasgow, Scotland, England and Wales) and Australia reported reduced incidence of acute hematogenous osteomyelitis labeling it as a rare disease and demonstrated significant change in its characteristics over the past 3 decades (Table 1-1). They listed improvements in living standards, personal hygiene and general health, greater awareness, earlier diagnosis and the use of more sophisticated diagnostic tools as the reasons for decreased incidence of acute osteomyelitis.5,10 The patients in the investigated centers were now more likely to present with less florid subacute disease than a classical presentation with high grade fever and raised blood counts. Methicillin resistant Staphylococcus aureus (MRSA) induced bone and joint infections were more in numbers and Haemophilus influenzae as a causative organism has vanished in western centers following vaccination. Less long-term sequelae were reported with this form of subacute osteomyelitis.
2
TABLE 1-1   Change in epidemiology of osteomyelitis in children over a period of 30 years in Glasgow (UK)4,5
Parameters
1970-19905
1990-19974
Mean age
6.8 years (2 weeks-12 years)
5.4 years (1 month-12 years)
Incidence
Acute osteomyelitis- 8.7/100000 population/year (1970) to 42/100000 population/year (1990)
Acute osteomyelitis- 2.9/100000 population/year (1997)
Site of osteomyelitis
Long bones 84% (1970) - 54% (1990)
Further decrease in osteomyelitis of long bones as a part of overall reduction in osteomyelitis
Bacteriology in positive isolates
Staphylococcus aureus 88%
Staphylococcus aureus 65%
Treatment
4 weeks (1-26)
Mean duration IV 1 day (0-4) followed by oral therapy of 4 weeks (1-32)
Number of children subjected to surgery
43%
22%
Complications
13.5%
12%
Hospital stay
21 days (7-300)
9 days (1-42)
These studies suggested that no antibiotic coverage was necessary for Haemophilus influenzae.
On the other hand, other developed countries (USA) in the North American continent are reporting overall increased incidence of musculoskeletal infections (osteomyelitis).14 In a study from Dallas (USA), the incidence of osteomyelitis increased from 11.7 cases per year to 70.7 cases per year indicating a 2.8 fold increase of the annualized per capita incidence. Moreover, the multifocal osteomyelitis variety is also on the rise. This trend is supposedly due to evolving organism potential to cause deep bone infection.14
The most commonly affected long bones are the tibia and femur but involvement of almost every bone in the body has been reported (Table 1-2).1,2,13 In a study of 163 infants and children with osteomyelitis, the femur, tibia, and humerus accounted for 68% of infections.6 Most cases were limited to a single site, with less than 10% involving two or more locations (multifocal). The metaphysis of long bones is the most usual site for acute hematogenous osteomyelitis.13,16
 
Septic Arthritis
Although septic arthritis can occur at any age and in any joint, it occurs predominantly in children, in the hip and knee (Table 1-2). Half of all cases of septic arthritis occur in those less than 20 years old.13,16 Rates of septic arthritis are estimated to be between 5.5 and 12 cases per 100,000 children with a peak incidence in the early years of the first decade.13 Incidence of septic arthritis is as less as 1/100,000 in US children-based studies.14 On the other side of spectrum, high incidences of 5-20/100,000 are found in African studies.17,18 Again boys are affected twice as girls as they are more likely to involve in activities leading to repetitive minor joint trauma.19
TABLE 1-2   Common sites in septic arthritis and osteomyelitis*#@
Septic arthritis
Osteomyelitis
Concomitant septic arthritis and osteomyelitis
Hip
Proximal femur
Femur, tibia and knee
Knee
Distal femur
Hip and femur
Shoulder$
Upper tibia
Humerus and shoulder
Ankle
Proximal humerus
Ankle and distal tibia
Elbow
Calcaneum
Elbow and proximal radius
Distal tibia
Ankle and distal fibula
Foot
Vertebrae
*Sometimes multiple sites are involved.
#The major impact of osteoarticular infections in lower extremities is probably due to increased incidence of minor trauma.
@Different series report variable percentage of concomitant septic arthritis and osteomyelitis (4.9-55.5%).
$Moyneux's series from Malawi, Africa reported common shoulder affection second only to knee. The reason may be that mothers in these African countries swing the child by arm while carrying them on their back.15
The most common sites of septic arthritis are hip and knee. In certain anatomical sites, the bony metaphysis is intracapsular and any bone infection may lead to septic arthritis (concomitant septic arthritis and osteomyelitis), e.g. upper end of femur, proximal humerus, proximal radius, lower tibia and distal fibula (Table 1-2). The bony metaphyses of children younger than 18 months are vascularized by the transphyseal vessels.
3
TABLE 1-3   Common organisms causing septic arthritis and osteomyelitis
  1. Staphylococcus aureus [methicillin sensitive (MSSA) or methicillin resistant (MRSA)] [25-70%]
  2. Gram-negative bacilli
    1. Escherichia coli
    2. Pseudomonas sp.
    3. Serratia sp.
    4. Enterobacter sp.
    5. Proteus sp.
    6. Klebsiella sp.
    7. Salmonella sp.
  3. Group B Streptococcus
  4. Group A Streptococcus
  5. Streptococcus pneumoniae
  6. Miscellaneous
    1. Coagulase negative Staphylococcus
    2. Kingella kingae
    3. Haemophilus influenzae type b
    4. Fungi, e.g. Candida
    1. Treponema pallidum
    2. Neisseria gonorrhoeae
    3. Anaerobes
  7. Unidentified pathogens (culture negative)
Because these vessels enter the epiphysis and ultimately the joint space, young children are believed to have a higher risk of joint space infection complicating osteomyelitis.1,20
 
Organisms
The type of infecting organism for osteoarticular infections depends on the age of the child and any associated medical problem (Tables 1-3 and 1-4).
Staphylococcus aureus is the most common cause of osteomyelitis in all age groups, accounting for 70-90% of infections. It is perhaps because of its capacity to express bacterial adhesions that promote attachment to extracellular bone matrix. This organism also is able to evade host defenses, attack host cells, and colonize bone persistently. However, 20-70% of osteoarticular infections cases may be culture negative despite collection of blood, joint fluid, and bone for culture.1,7,13
Since the initiation of the use of penicillin in the early 1940s, methicillin resistance has become increasingly common among strains of Staphylococcus aureus (methicillin resistant Staphylococcus aureus, MRSA). However, methicillin sensitive Staphylococcus aureus (MSSA) is still the most common pathogenic organism. More recently, the incidence of community acquired methicillin resistant Staphylococcus aureus (CA-MRSA) has increased globally (Table 1-5).
4
TABLE 1-4   Etiology of osteoarticular infections under special circumstances
Group
Organism
Neonates
Group B Streptococci, gram-negative enteric bacteria, MRSA, Candida spp.
<5 years
Staphylococcus aureus
Streptococcus pyogenes
Streptococcus pneumoniae
Kingella kingae
<5 years (if not vaccinated)
Haemophilus influenzae type b
>5 years
Staphylococcus aureus
Streptococcus pyogenes
Sickle cell disease
Salmonella spp., gram-negative bacilli
Area endemicity
Brucella spp., Salmonella spp.*, Borrelia burgdorferi
IV drug abusers/puncture wounds
Pseudomonas aeruginosa, Candida spp.
Hemodialysis
Staphylococcus epidermidis
Contiguous osteomyelitis
Multiple organisms
Human bite
Anaerobes, Eikenella corrodens
Dog or cat bite
Pasteurella multocida
Sexually active adolescents
Neisseria gonorrhoeae
Immunosuppressed
Gram-negative bacilli
Puncture wounds in foot
Mixed flora, Pseudomonas spp., Staphylococcus aureus
*Salmonella is the most common cause of septic arthritis in infants in developing African countries21
Infections caused by CA-MRSA have a more serious presentation than MSSA. A US study reported that osteomyelitis comprise 84% of the musculoskeletal MRSA infections, while septic arthritis and pyomyositis occurred in 10% and 6% respectively.22 More recently highly virulent strains USA 300 have been identified exhibiting as disseminated infections in pediatric age group.26
In neonates, besides Staphylococcus aureus, infections with gram-negative organisms, Group B Streptococcus and Candida are common (Table 1-3). Streptococcus pyogenes causes approximately 10% of cases of acute hematogenous osteomyelitis with a peak incidence of disease in preschool-age and early school-age children. Children with Streptococcus pyogenes osteomyelitis often have a recent history of varicella infection and present with higher fever and white blood cell (WBC) counts compared with children infected with Staphylococcus aureus.
TABLE 1-5   MRSA: Characteristics of infection in children7,22–25
Increasing incidence in some US cities: increased from 0.3-1.4 per 1000 hospital admissions between 2002-2007.# Overall more than 30-50% admitted were infected with MRSA. Rates of CA-MRSA in children's hospital account for 40-75% of all Staphylococcus aureus isolates.
MRSA is reportedly less prevalent in developing countries. In a review from Taiwan, MRSA accounted for 13-24% of all Staphylococcus aureus isolates. 93-100% retain their sensitivity to cotrimoxazole.
Extracellular toxin Panton-Valentine leukocidin (PVL) encoded by lukF and lukS genes may be present.
Risk factors for MRSA: Prolonged hospitalization, admission to intensive care unit, surgery, invasive procedures, implanted medical devices, exposure to infected persons, receipt of antibiotics in previous two months, presence of furuncles.
Reported resistances in pediatric HA-MRSA in US-based studies: Clindamycin (27-44%), erythromycin (91%), cotrimoxazole (0-11%).
Reported resistances in pediatric CA-MRSA in US-based studies: Clindamycin (3-33%), erythromycin (78-97%), cotrimoxazole (0.6-3%).
Infection characteristics
Severe infection/disseminated/multifocal disease
Subperiosteal abscess* requiring 1 or more surgical interventions
Septic thrombophlebitis
Endocarditis
Septic pulmonary emboli
Large muscle abscess
Pathological fractures
Duration of fever increased
Median hospital stay increased
#MRSA is considered to be hospital acquired (HA) when it is isolated 48 hours after a patient is admitted.
MRSA is considered to be community acquired (CA) when the isolate is grown at presentation or within 48 hours of admission.
*No association between delay in initiation of appropriate therapy and presence of subperiosteal abscess.
#The rate of MSSA osteomyelitis remained stable during that period.
Children with osteomyelitis caused by Streptococcus pneumoniae are younger than children infected with Staphylococcus aureus and Streptococcus pyogenes. They are more likely to have joint involvement.
The incidence of Haemophilus influenzae as a pathogen in children under four years is decreasing with the use of vaccination against Haemophilus influenzae type b. Incidence of septic arthritis due to Haemophilus influenzae type b (Hib) prior to introduction of vaccine was estimated to be 6/100,000 per year.27 It was the most common cause of septic arthritis in age group 6 months-5 years. International experience has shown that vaccination is effective and brings down the rate of septic arthritis attributable to Haemophilus influenzae drastically. In Finland, the Hib vaccination was introduced in 1986. Prior to introduction of vaccine, 36% of septic arthritis cases (1982-1988) were due to Hib. Following vaccination initiation, no cases due to Hib were reported after 1989.27 The conjugate vaccine against Haemophilus influenzae type b (Hib) was introduced in US in 1988 and thereafter incidence of invasive disease due to Hib (includes meningitis, pneumonia, septicemia, peritonitis, epiglottitis, osteoarticular infections, etc.) has decreased by more than 95%-1.6/100,000 children under 4 years of age by 1995.28

HAEMOPHILUS INFLUENZAE

The incidence of osteoarticular infection caused by Haemophilus influenzae type b has declined considerably after the use of effective vaccine against the organism, in children.
Newer fastidious organisms such as Kingella kingae are now being detected in increasing frequency. In fact, in a recent report it was found that Kingella kingae has become the most common cause of osteoarticular infections (septic arthritis > osteomyelitis) in French children younger than 3 years of age.29 Other European centers have confirmed these findings.23,30 The apparently increasing prevalence of Kingella seems more because of better isolation techniques rather than an overall change in epidemiology of bone and joint infections.31
Patients with sickle cell disease have been documented to be particularly susceptible to osteoarticular infections.1,13 Osteomyelitis and septic arthritis are two of the infectious complications of sickle cell disease. Organisms causing bone infection in children with sickle cell disease include Salmonella and Staphylococcus aureus and less commonly Escherichia coli, Shigella, and Streptococcus pneumoniae. The peculiar association of sickle cell anemia with Salmonella species osteomyelitis was documented by Carrington et al in 1925 and subsequently confirmed by many authors.32–34 Around 75% of osteoarticular infections in children without sickle cell disease have been attributed to Staphylococcus species. This is in contrast to osteomyelitis in children with sickle cell disease in which Salmonella species has been implicated in 60–80% of cases.
Anaerobes are a rare cause of pyogenic osteomyelitis in healthy children. Predominant organisms are Bacteroides, Fusobacterium, Clostridium, and Peptostreptococcus. Anaerobic osteomyelitis can occur as the result of a bite, chronic sinusitis, mastoiditis, or dental infection. Unusual causes of osteomyelitis include infection with Mycobacterium, Bartonella, Coxiella burnetii, or fungi (Table 1-4). Fungal osteomyelitis is occasionally seen in immunocompromised individuals and is usually 5caused by Coccidioides immitis, Blastomyces dermatitidis, Histoplasma capsulatum, Cryptococcus neoformans, Aspergillus, etc.1
Puncture wounds to the foot may result in osteomyelitis caused by mixed flora, including Pseudomonas, Staphylococcus aureus, enteric gram-negative bacteria, and anaerobes. A number of series describe osteomyelitis of the metatarsals occurring as a result of toothpick puncture injuries. The organisms isolated included skin and environmental organisms; others have reported infection with mouth organisms as a result of toothpick injuries.35
The infection rates in open pediatric fractures are somewhat lower than the adults. Patzakis and Wilkins evaluated seventy-seven infections in 1104 open fracture wounds.36 They reported just one infection (1.8%) in 55 open fractures in children compared to average infection rate of 72% in 1049 open adult fractures. Skaggs et al (1989-2000) conducted a retrospective, multicenter study of open fractures in children.37 The analysis included 554 open fractures in 536 consecutive patients, who were eighteen years of age or younger. The overall infection rate was 3%. Specifically, the infection rates when the fractures were dealt within 6 hours were 2% for Gustilo Anderson type I, 3% for type II and 10% for type III fractures. Typically the infecting organism was Staphylococcus aureus and aerobic or facultative gram-negative rods in fractures with less soft tissues injury and mixed flora was found in type IIIB and C fractures.37
 
Risk Factors
Preceding trauma is less common in septic arthritis than in osteomyelitis. Several risk factors for osteoarticular infections have being identified in children: young age, male gender, respiratory distress syndrome, umbilical artery catheterization, predisposition to infection, e.g. presence of sickle cell hemoglobinopathy, immunodeficiency, diabetes, prematurity, low birth weight or underdevelopment.21 However, even in developing as well as developed countries, socioeconomic deprivation was not considered an association.4 Most children who receive appropriate therapy for osteomyelitis have no long term sequelae. Complication rates following osteomyelitis are 11-29%.9 The reported incidence of sequelae in neonates with osteomyelitis are higher and ranges from 6-50%.1,13 Complications are reported in approximately 10-25% of all pyogenic arthritis. Common factors indicating poor outcome and sequelae are onset of disease in infancy, associated septic arthritis and osteomyelitis and infection caused by Staphylococcus aureus or gram-negative bacteria. Other poor prognosticating factors identified from African countries are delay in initiation of appropriate and timely treatment, initial misdiagnosis, involvement of hip, shoulder or polyarticular infections and circumferential periosteal stripping observed during surgery.17,18
Immunocompromised hosts may have a higher incidence, particularly those suffering from inflammatory arthritis of any type. Two reports have identified an increased incidence of septic arthritis in children who have hemophilia and are HIV positive.38,39
 
Pyomyositis
Pyomyositis is a bacterial infection of skeletal muscle with a predilection for large muscle groups, and it often results in localized abscess formation. Although relatively uncommon in more temperate areas, such as North America, pyomyositis accounts for up to 4% of surgical admissions in some tropical areas.13 This geographic distribution has led to the alternative name of pyomyositis tropicans. Within North America, the highest incidence of pyomyositis is in the southernmost regions. In children, the peak incidence occurs between 5 and 9 years of age.13,40
Pyomyositis most commonly affects the quadriceps, gluteal, and iliopsoas muscles. Other affected areas include the paraspinous, shoulder girdle, extremities (e.g. gastrocnemius), chest wall, and abdominal wall. Patients with psoas muscle involvement may present with limp, hip pain, or back pain. Multiple sites are involved in 11-43% of patients.41–46
 
Indian Scenario
Scanty data is available for epidemiology of osteoarticular infections in children in India. In India, the reported incidence of septic arthritis is 1/1500.47 In a combined adult and children study on osteomyelitis from northern India, Staphylococcus aureus (43%) was the most common causative organism in children. Methicillin resistance was observed in 30% Staphylococcus aureus isolates. Multidrug resistance (56%) and quinolone resistance (75%) was also common among Staphylococcus aureus strains.48
However, in a series of nosocomial neonatal osteomyelitis, joint fluid cultures were positive for gram-negative (33%) and fungus (7%) as well, besides gram-positive organisms (20%). The remaining 40% were culture negative.49 Prematurity and low birth weight were identified as risk factors in this Indian study. The authors reported a better outcome with early arthrotomy.
6A multicenter study on septic arthritis from northern Indian revealed that majority of subjects (42%) were below age of 1 month. Hip (42%) and knee joints (39%) were involved in maximum numbers. Associated osteomyelitis and joint destruction with instability was present in 35% of the cases each at presentation. A predominant male ratio and gram-positive (Staphylococcus aureus) causative organism was seen.50

INDIAN DATA ON OST EOARTICU LAR INFECTI ON

There is little data on the incidence of pediatric osteoarticular infection in children from India.
Regional variations are known. Exact, recent figures are not available.
The India Invasive Bacterial Infections Survillence (IBIS) project provided multicenter, hospital-based epidemiological data on the characteristics of Haemophilus influenzae invasive infections in India (1994-2005).51 The incidence of Haemophilus influenzae meningitis in India is 39-66/100,000 annually in 0-4 year olds. The study determined that meningitis (34%) was the predominant manifestations of all invasive diseases caused by Haemophilus influenzae and serotype b caused most of the invasive disease including bone and joint infections. Up to 5% of cases were Haemophilus influenzae bone and joint infections. Septic arthritis was more common than osteomyelitis with this organism. The disease could be prevented to a large extent by incorporation of Haemophilus influenzae (Hib) vaccine in the expanded immunization programme in India.52 Hib vaccination in India was introduced in India in 1997 and has been recommended by Indian Academy of Pediatrics since 1999.53 A study from South India documented the useful community effect of Hib vaccination.54 Prior to vaccination the annual mean number of Hib meningitis in the region was 10.7 (1994-1996), in less than 5 years age group. It fell to 3.8 (2001-2005) cases after vaccination.54 Corresponding decrease is expected in other invasive disease like septic arthritis caused by Haemophilus influenzae with effective vaccination although there is no data available pertaining to the reduction of osteoarticular infection by this organism.
 
Osteoarticular Tubercular Infections
 
Incidence
A number of studies have been published on the epidemiological aspects of tuberculosis in the past decade. Most of these studies focus on national trends and adult populations, but not much is known about the tuberculosis burden in children.
According to WHO estimations (2010), the incidence of new tuberculosis cases in 2009, was 9.4 million with 14 million prevalent cases, most of which occurred in the South-East Asia region.55 Mycobacterium tuberculosis is estimated to infect almost 30% of world's population. 50% of the reported cases occurred in five countries (Bangladesh, China, India, Indonesia and Nigeria). Yet by global and regional effort in case detection and implementation of DOTS in developing countries, the prevalence of tuberculosis decreased globally between 1990 and 2003 from 309-245/100,000 population.56 Tuberculosis is entering into new era with multidrug resistance (MDR) strains coming into vogue. According to WHO, 33% of all new tuberculosis cases have MDR tuberculosis.55 Extreme drug resistance (XDR) forms are also reported from 58 countries. An 11-13% of incident cases are HIV positive. The reported proportion of extrapulmonary tuberculosis—EPTB (including bone and joint tuberculosis) among all tuberculosis cases in developed countries ranges from 12-28.5%.57 Bone and joint tuberculosis constitutes approximately 10% of all EPTB cases.
The incidence and prevalence of pediatric tuberculosis worldwide varies significantly according to the burden of the disease in different countries. World Health Organization (WHO) has quoted that children with tuberculosis represent up to 20% of all tuberculosis cases. The majority of these cases occur in low income countries where the prevalence of Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) is high. In 2000, out of 8.3 million cases of tuberculosis worldwide, 11% occurred in children less than 15 years. This represents only children having active, symptomatic tuberculosis. Most children will, however, have asymptomatic latent infection which is difficult to detect as children are generally smear negative on sputum examination. This means that children can account for up to 25-40% of tubercular cases with incidence rates for pediatric tuberculosis ranging from 60-600/100000 children per year.58 Rough estimates of tuberculosis from 22 countries with highest load of tuberculosis, give it's occurrence in children in range from 2.7–25.3%. They can account for 10% of all hospital admissions in developing countries. An active surveillance study from South Africa reported incidences as high as 49% of new case notifications in children aged 0-14 years.58 In Europe and North America traditionally considered low burden countries, children account for 4-7% 7of cases and pediatric incidence rates vary from 1-15/100,000/year.58
The overall occurrence of extrapulmonary tuberculosis in children is unknown; approximate estimations range between 10-30%. Tuberculosis of bones and joints occur in 5-6% in cases of pediatric extrapulmonary tuberculosis. Symptomatic disease usually occurs 1-3 years after infection although tubercular dactylitis can be an early manifestation (1 month). The most common is vertebral involvement (thoracic > lumbar > cervical). Multiple vertebral involvement is common (80%). Other common sites are hip (20%), knee (10%), ankle and foot (5%), hand and wrist (3%), elbow (2%), shoulder (1%), bursal sheaths and other bones (8%).59,60
In areas where the prevalence of HIV infection is high, the children (both infected and affected) are at high-risk of tubercular infection due to close proximity with young adults who are most likely to be HIV-infected and in whom tuberculosis is the most common opportunistic infection. Further, due to the high prevalence of other opportunistic infections among HIV infected children and the lack of a gold standard, diagnosis of tuberculosis is often a challenge in this population. The deadly synergy of human immunodeficiency virus (HIV) and tuberculosis and the emergence of multidrug-resistant Mycobacterium tuberculosis have further complicated the issue.
Other Mycobacterium such as human Mycobacterium bovis also infects children. In developed countries, reported incidence of human Mycobacterium bovis infections is 1-2% of human tuberculosis cases. It is zoonosis with transmission mainly through unpasteurized contaminated dairy products. The risk factors include patients from endemic regions, hispanic patients, patient < 15 years, HIV infected, and extrapulmonary tuberculosis. A study in US indicated that human Mycobacterium bovis retains its susceptibility to pyrazinamide in significant number of patients.61 Isolated reports of other opportunistic mycobacterial infections are also available in literature.62,63
 
Coinfection with HIV
The effect of the HIV epidemic on the burden of tuberculosis in children is less well studied than for adults. However, children are supposed to be at high-risk of exposure as well as manifesting disease. The rate of HIV coinfection with tuberculosis varies from less than 5% in industrialized and developed areas to over 50% in high burden African countries.58 In developing countries, tuberculosis is now recognized as one of the most common opportunistic infection in patients seropositive for HIV. In African continent, positive HIV serology is associated in 17-55% of tuberculosis patients. Further, extrapulmonary tuberculosis and mediastinal lymphadenopathy is significantly more common in HIV positive (60-65%) compared to HIV negative (25%) patients. People infected with tubercle bacilli and HIV are 30 times more likely to develop active tuberculosis in a given year than those infected with tuberculosis alone.64
 
Indian Scenario
India accounts for one-third of the global tuberculosis burden with 1.8 million developing disease each year. According to WHO reports, India, China, Pakistan, the Philippines, Thailand, Indonesia, Bangladesh, and the Democratic Republic of the Congo account for nearly 75% of all cases of pediatric tuberculosis. The average prevalence of all forms of tuberculosis in India is estimated to be 5.05 /1000, prevalence of smear positive cases 2.27/1000 and annual incidence of smear positive cases at 84/100,000 annually. The annual risk of infection in various areas varies from 0.61-3.8%. Not much data is available on prevalence and incidence of tuberculosis and mortality rates in children in the Indian community. In most tuberculosis surveys carried out in India, children below 5 or even 9 years were excluded. Screening the children in mass surveys is difficult as children are generally smear negative.

PEDIATRIC OSTEOARTICULAR TUBERCULAR INFECTION IN INDIA

Scanty data is available of incidence and prevalence of pediatric tuberculosis in India. The burden of osteoarticular tuberculosis in this subset of population is not known.
Considerable differences exist in the infection rates among children from area to area within the country due to differences in socioeconomic conditions in the Indian population. Prevalence of tuberculosis infection in children in India in the age group of 0-14 years is reported to be between 2–10%. The incidence of infection (fresh infection in a year among those previously uninfected, also termed Annual Risk of Infection (ARI), has been observed to be 3% among the urban slum children in India. The risk of developing disease appeared to be the highest among the newly infected (20.0 per thousand per year) and the least among the initially noninfected children (1.2 per thousand per year). The risk among the initially infected children is approximately 8.8 per thousand per year. The magnitude of drug resistance among previously treated cases varies widely. With 8treatment failures and relapses, rifampicin resistance is 37.3% (Gujarat, 1986), isoniazid (55.8%) and MDR (30%). However drug resistance among fresh cases is relatively lower. The rates could be as low as 5-10% resistance to isoniazid and nil for rifampicin in Indian children.64 In India (2006) 1.2-6.6% of MDR cases were XDR.65
HIV seroprevalence (2006-2007) among Indian tubercular patients varies widely from 1% in Kochi (Bihar) to 13.8% in Guntur (Andhra Pradesh). The seroprevalence was more in males (8.4%), smear negative (8%), extrapulmonary (7.4%) patients. The prevalence was higher (>5%) in Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu.66 This has prompted Ministry of Health and Family Welfare (India) to adopt a policy of routinely offering voluntary HIV counseling and testing to all tuberculosis patients in these four states. Various other studies in India report 14-67.5% coinfection with HIV in tuberculosis infected children.56
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