Approach To Joint Pain

Rheumatic Fever
Elisabeth Ojha
 Name: R.N | Age: 18 years | Ethnicity: AI | Address: Long Creek

C/C: Fever, Joint Pain, Swelling in both legs x 1/12

JointFever:
Swelling: pain:
Fever • High grade
Started aswith
numbness
• 1/52 after joint pain started in Lt. hand  generalized joint
chills, rigors
 Constant, both day andlower
pain in shoulders, night back, elbows, hands, knees,
• Located in the
 Temporarily
lower
alleviated by
limbs,
Panadol
from
but
therecur.
would
knees
Joint feet.
Pain downward.
• Pain was migratory
• Overlying
• No redness
Associated skin:
with: or no redness,
swelling ulcerations or other
at joints
• vomiting-
lesions postprandial,
Severe, constant, severalno
sharp, episodes per or
radiation day, contained
alleviating
Swelling food content, no blood/mucus, no foul odour.
• Associated
factors, worsened
with pain by in
movement-
the legs,ptworsened
mostly confined
by
 Sore
to throat: 1/52 after fever, severe, alleviated by lozenges.
bed
walking
No diarrhea
 • No Malaria, Dengue, Chikungunya, arthritic disease, asthma,
diabetes, HTN or CA
PMHx: • No surgeries, allergies, transfusions
• Medications: Panadal PRN pain

• G1P1001, no complications during pregnancy or labour, no

Obs/gyne: menses since birth of child, prior to that regular cycle no

dysmenorrhea or heavy bleeding; 1 partner, no hx of STI’s, no
pap smear/VIA

Personal & • No drinking or smoking, no recent travel history

Social:
• No known Hx of diabetes, HTN, Cancers, arthritic disease,
Family Hx: cardiac, renal or lung pathologies
 Review of Systems:
 General: No weight loss, but was very fatigued, had fever
 HEENT:
 Head: Mild Headaches
 Eyes: No vision changes, blurriness, use of spectacles, no double vision, discharge/excessive tearing.
 Ears: No Pain, tinnitus, itching, change in hearing acuity
 Nose: No Stuffiness, discharge, pain, ability to smell
 Throat: Had Sore throat
 Respiratory: had SOB, No orthopnea, Paroxysmal nocturne dyspnea, wheezing, mild chest pain, mild cough, no hemoptysis,
 Cardiovascular: mild chest pain, no palpitations, syncope, claudication
 Gastrointestinal: heart burn, abdominal pain, had N/V, no Hematemesis, Black/tarry stools, diarrhea/ constipation, bloody stools.
 Genito-urinary: no hematuria, burning upon urination, Nocturia, incontinence, urgency, frequency, straining and incomplete
emptying
 Genito- sores, bumps, itching, discharge.
 Neurological: no Loss of neurological function, loss/change in consciousness, seizures, had numbness, weakness, dizziness,
balance problems, headache
 Endocrine: no polyuria, polydipsia, polyphagia, heat/cold intolerance
 Immunological: not frequently ill?
 Hematological: healing time after a cut, easy bruising/ bleeding
 Musculoskeletal: had Joint pains/ swelling, muscle ache, low back pain, stiffness
 Psychiatric: hallucinations, delusions, depression, suicidal ideations/feelings
General Inspection:
CHEST ABDOMEN
Patient sitting in her bed, not • No structural abnormalities on the chest wall, • Slightly globulus, striae
ill-looking, no no hyperdynamic precordium seen to the lower
cardiopulmonary or painful
quadrants, no scars,
distress, acyanotic, anicteric. • PMI: 5th ICS MCL umbilicus inverted, no
Vitals: • Auscultation: S1 S2, Grade 2 systolic murmur visible masses
at left lower sternal border (at tricuspid valve),
BP- 110/80 Pulse: 72 no radiation • Soft and depressible to
Resp: 18 Temp: 94.6 palpation, non-tender, no
• Lungs: Resonant to percussion, expansion organomegaly
O2 Sat: 98% 1.5 cm equidistant from the midline, bilateral
air entry, equal breath sounds with no
adventitious sounds. EXTREMITIES
• No abnormal posturing,
HEENT structural deformity or
• No structural deformities noted on inspection swelling noted.
or palpation of the head.
• Joints did not appear
CNS
• No lymphadenopathy swollen or erythematous.
Conscious, oriented and
alert to person, place and
• Mucous membranes: pink and moist • No tenderness on
time
extension/flexion of limbs,
• Trachea midline, thyroid lobes not palpable normal tone and power: 5/5
in all muscle groups
 Workup done
CBC Biochemistry Abdomen & UA
Pelvis USG
DDx: Hb: 6.8 LDH: 323 (H) Hepatomegaly 2+ blood
- Rheumatic fever
WBC: 4.2 BUN: 16 Splenomegaly 3+ protein
- Infective Endocarditis
- Suspected lupus PTL: 303.0 CR: 0.5 Left Pleural + bacteria
effusion
- R/O malaria

SGOT: 112 (H) Mild Ascites +pus cells

SGPT: 91 (H)
Plan:
Na: 137.9 2+ epithelial
• Admit to ward K: 4.06 cells
• V/S q 8 hours Cl: 113.7
• Diet as tolerated
Albumin: 1.8 (L)
• Blood Culture Ca: 7.8 (L)
• Echocardiogram ALP: 503 (H)
• Abdominal ultrasound GGT: 175 (H)
• Malaria smear AST: 208 (H)
• Bedside V scan ALT: 136 (H)
 What do we want to know about the joint pain?

History: Physical Exam

 Site: Asymmetrical or symmetrical  Stiffness

 Number of joints involved (mono, oligo or  Decreased ROM
polyarticular)
 Tenderness
 Small or large joints?
 Axial or peripheral?  Erythema
 Is the pain migratory?  Swelling
 Any distinguishing features about the pain?  Warmth
 Are the symptoms acute or chronic
 Any other systemic symptoms?
 Risk factors for certain illnesses
What do we want to know about the joint pain?
Quick Diagnostic Approach
Differential Diagnoses
Fever and Joint pain
 Investigations

Labs: Imaging:
• CBC • X – ray of the joint
• Serum electrolytes • ECG
• BUN/ Cr • Echocardiogram
• Uric Acid
• ESR/ CRP
• Antibodies: ANA, anti-DNA
• Rheumatoid factor
• Blood culture
• Synovial fluid culture
• Throat Swab and Culture
Rheumatic Fever
Acute Inflammatory

Multi- Type II
systemic Hypersensitivity
 MOLECULAR
MIMICRY
Develops a few
weeks after an
episode of
streptococcal
pharyngitis

Highly
Streptococcal antigenic
pyogenes
(Group A strep) Beta-
hemolytic
 antibodies against M proteins of
certain streptococcal strains bind to
Infection
proteins in thewith Group and
myocardium A
β-hemolytic
cardiac valves
streptococci 
pharyngitis
activation of complement and
Fc receptor–bearing cells
Formation
(including macrophages).
of antistreptococc
al antibodies
CD4+ T cells that recognize
streptococcal peptides also can
cross-react with host antigens and MOLECULAR MIMICRY-
elicit cytokine-mediated inflammatory cross reaction with
responses. endogenous tissue
antigens (eg: cardiac myosin
and troponin)
 Main Complications

Acute: Chronic:

•conduction
system
valvular heart
aberrations: infectious
disease (mitral
-sinus tachy endocarditis ±
Myocarditis pericarditis and/or aortic
-atrial fibrillation thromboembolic
insufficiency/sten
-AV block) phenomenon
osis)
-valvulitis (acute
MR)
Clinical Features and Investigations
 Clinical Features & Diagnosis

N
E
S

Evidence of streptococcal infection:

• Recent Scarlet Fever
• Positive GAS culture
• Positive rapid antigen test
• Positive ASOT
 Management of Rheumatic Fever
For the Streptococcal Bed rest and supportive Cardiac issues:
infection: therapy • Treat cardiac failure (if present)
• Singsingle dose of benzyl • it lessens joint pain as appropriate
penicillin (1.2 million U IM) • reduces cardiac workload • If no response to medical mng
• oral phenoxymethylpenicillin: • Continuously monitor  valve replacement
(250 mg 4 times daily for 10 symptoms, vitals and labs • AV Block: seldom progressive,
days) (WBC, ESR) pacemaker rarely needed

Arhtritis:
• Aspirin: 60 mg/kg body
weight/day, divided into six
doses
• Corticosteroids: Prednisolone
(1.0–2.0 mg/kg per day in
divided doses)
Prevention:
• penicillin :benzathine penicillin
(1.2 million U IM monthly)
• oral phenoxymethylpenicillin
(250 mg twice daily).
• Penicillin allergy: Sulfadiazine
or erythromycin
 References:
 Kim, J., & Mukovozov, I. (2017). Toronto notes 2017 (33rd ed., p. 1071). Ontario:
Type & Graphics Inc.
 Ralston, S., Penman, I., Strachan, M., Hobson, R., Britton, R., & Davidson, S.
(2014). Davidson's principles and practice of medicine (22nd ed., pp. 614-617).
Edimburgh: Elsevier Limited.