Good morning report!

Nora Switchenko MD R3
The Case
ID: 10 year old female presents to the emergency room
CC: Joint pain
HPI:
Subjective fevers on and off for about 2 weeks
Right ankle pain started about 10 days ago. There was ankle
swelling but no erythema. Pain was about 5/10. Constant. Ankle
swelling and pain has improved and barely present at time of
presentation.
Left knee pain started yesterday. +swelling but no erythema.
Pain is severe 8/10 and causes limp.
Joint pain improves with NSAID, but patient still does not want to
walk
Other symptoms: mild nausea
Negatives: no V/D, no URI/cold symptoms now or in the past few
weeks, no sore throat, no rash, no abnormal limb movements, no
SOB
Prior to presentation in the emergency room, patient had normal
xrays of right ankle and negative rapid strep testing.
The Case
PMedHx: Healthy
FamilyHx: No acute illnesses, no autoimmune diseases
SocialHx: Home with siblings for summer vacation. No
known sick contacts.
The Case
VITALS: TEMP 38.7, HR 105, RR 23, BP 102/50
PHYSICAL EXAM:
GENERAL: Comfortable, lying on exam table
HEENT: NC/AT, conjunctiva clear, no nasal drainage, OP with mild
erythema without exudate, no palatal petechiae, TMs gray with positive
light reflex bilaterally
RESP: CTAB, no increased WOB, no crackles, excellent air movement
CV: RRR, normal S1 and S2, pansystolic 2/6 murmur heard best at LLSB,
distal pulses 2+ in UEs and LEs
ABDO: Soft, NTND, no HSM, BS+
MSK: Right ankle has mild swelling without erythema or warmth and no
pain with palpation, Left knee has moderate swelling without erythema
and is warm to the touch. There is some pain with motion but patient has
FROM in right knee as well as all other joints. Able to stand but walks with
significant limp.
NEURO: CN 2-12 intact, 5/5 strength in UEs and LEs, normal tone, gait is
limited by limp on right knee
SKIN: No rash on face, extremities, abdomen, chest or back.
Differential diagnosis
10 year old female with fever, murmur, and polyarthritis.
Differential diagnosis
10 year old female with fever, murmur, and polyarthritis.
ID
Septic arthritis
Osteomyelitis
Endocarditis
Other bacterial infections
(TB, Gonococcus, Brucella,
Lyme)
Viral Infections (Hep B and
C, Rubella, Parvovirus)

Heme/Onc
Hemarthrosis
ALL
Neuroblastoma
Sickle cell anemia
Rheum
Post infectious reactive arthritis
Juvenile idiopathic arthritis
Rheumatic fever
Lupus
Familial Mediterranean fever
Juvenile dermatomyositis
Sarcoidosis
Henoch-Schonlein purpura
Ankylosing spondylitis
Psoriatic arthritis
Rheumatoid arthritis
Serum sickness
IBD associated arthritis

The Case
ED work up:
WBC 9.9, Hgb 9.9 (MCV80), Plts 483
CRP 18.9
ESR 131
ASO 545 H
AntiDNAaseB 478 H
Rapid strep positive
EKG showed normal sinus rhythm without PR prolongation
Diagnosis: Rheumatic Fever
Treatment: Amoxicillin for step throat, ibuprofen for joint
pain
Disposition: Cardiology clinic visit and ECHO scheduled for the
following morning
The Case
ECHO results:
Mild aortic valve regurgitation
Mild mitral valve regurgitation
Normal left and right ventricular size and qualitatively normal
systolic function

Plan of care:
Continue amoxicillin
High dose aspirin (80-100 mg/kg) until acute phase reactants
normalize
Following amoxicillin, start penicillin G IM q 4 weeks
Rest until carditis resolves
Follow up in one week for repeat labs, aspirin level (goal <30 mg/dl)


Rheumatic Fever : Diagnosis
Diagnosis is made clinically with evidence of preceding GAS infection and either 2
major or 1 major and 2 minor Jones criteria.

Jones Criteria
Evidence of preceding GAS infection
Positive throat culture
Positive rapid streptococcal antigen test
Elevated or rising streptococcal antibody titer (ASO, antiDNAase B)
Major
Migratory arthritis
Carditis
CNS effects (Sydenham chorea)
Erythema marginatum
Subcutaneous nodules
Minor
Arthralgia
Fever
Elevated inflammatory markers
Prolonged PR interval

Major Criteria: Migratory arthritis
Typically the first symptom present
Involves several joints in quick succession
Larger joints more commonly involved
LE usually involved first
May be severe enough to limit movement or
cause a limp
Synovial fluid demonstrates sterile
inflammation
NSAIDs may alter natural course of disease
Major Criteria: Carditis
Pancarditis including valvulitis
Mitral valve involved in nearly all cases
Aortic valve involved in 20-30% of cases
Severe carditis can lead to dilated
cardiomyopathy and heart failure
Conduction abnormalities possible
Recurrent episodes of rheumatic fever lead
to cumulative damage to heart and possible
to rheumatic heart disease

Major Criteria: CNS effects
Sydenhams chorea: abrupt,
nonrhythmic, involuntary
movements
Muscular weakness
Emotional lability
Can be a delayed manifestation of
RF
Improves gradually over 12-15
weeks
Full recovery seen in almost all
patients
Risk of recurrence 20-30% with
subsequent GAS infection
Major Criteria: Erythema marginatum and
Subcutaneous nodules
Rheumatic Heart Disease: Treatment
Primary prevention treat GAS pharyngitis
3 goals of treatment
Symptomatic relief
Aspirin 80-100 mg/kg/day
Eradication of GAS
Amoxicillin 50 mg/kg/day divided BID for 10 days
Prevention of future GAS infection to avoid further
cardiac damage (Secondary prevention
Penicillin injections until adulthood
Rheumatic heart disease
Valve replacement or repair
Congestive heart failure management

References
1. John, J. Arthritis in Children and Adolescents. Pediatrics
in Review Vol. 32 No. 11 November 1, 2011
2. WHO Expert Consultation on Rheumatic Fever and
Rheumatic Heart Disease 2001
3. Burke, RJ. Diagnostic criteria of acute rheumatic fever.
Autoimmun Rev. 2014 Apr-May;13(4-5):503-7
Pediatrics in Review