&KNEE PAIN

FEVER

By: Dr Ir

fan

Ziad

AN 11-YEAR OLD PRESENTED WITHFEVERJOINT PAINAND SWELLING

SOB

O/E : tachypnea and tachycardia

T 38.2 P 160 RR 32

BP 100/60 SaO2 94%

Lungs clear CVS S1S2, pansystolic

murmur 3/6 heard at apex with radiation to axilla

Abdomen Soft, normoactive bowel sounds

Left knee is swollen and extremely tender with warmth & Limited ROM. His right ankle is very swollen and warm. He has limited subtalar motion. Both his knee and ankle are very tender even to touch. 

Enlarged, erythematosus tonsils with exudates

CNS : No abnormal movements of arms, hands, or tongue are noted. He is unable to walk due to pain.

P R

CARDIOMEGALY

Differentials?

RHEUMATICFEVER

DR IRFAN ZIAD

12 millionare affected by ARF and CRHD globally

150 times

developing countries are

more susceptible than the developed countries

5-14 yearsis the most frequent age group

AN INFLAMMATORY DISEASE OF CHILDHOOD

RESULTING FROMUNTREATED STREPTOCOCCOCCAL

PHARYNGEAL INFECTION

Streptococcus

Group ARheumatogenic strain

β-hemolytic

Streptococcus

Group A B-hemolytic

Rheumatogenic strain

Immune

response

M-

Protein

Heart SkinConnective tissue

Brain

Molecularmimicry

Joints-Athralgia-Migratory polyarthritis

Skin-Subcutaneous nodules-Erythema marginatum

Subcutaneous nodules

Erythema marginatum

CNSBasal Ganglia

CHOREA

syndenham

aka San Vitus Dancerapid involuntary movement affecting the hands, feet, tongue and face.

Pericardium

MyocardiumEndocardium

Heart

Myocardium

PericardiumEndocardium

Pancarditis

Myocarditis-heart is enlarged -may develop

CCF

PericarditisMyocardiumEndocardium

“Bread and Butter”Pericarditi

s

- Completely resolved- Heal with adhesion

MyocardiumEndocardium

In patients with critical stenosis, mitral valvulotomy, percutaneous balloon

valvuloplasty, or mitral valve replacement may be indicated.

polyarthritiserythema marginatum & nodulesSydenham choreaRheumatic myocarditis & pericarditisRheumatic endocarditis

MODIFIED JONES CRITERIA FOR ACUTE RHEUMATIC FEVERMAJOR CRITERIA MINOR CRITERIA

CarditisPolyarthritis,

aseptic monoarthritis or polyathralgiaErythema marginatum

Prolonged PR interval

Subcutaneous nodules

Chorea

Fever (Temp>38oC)ESR > 30

mm/h orCRP > 30 mg/L

INVESTIGATIONS

Echocardiogram

FBC: anaemia, leucocytosisThroat swab

CXR, ECG

ASOT

How to make the diagnosisInitial episode of ARF

2MAJOR CRITERIA

1MAJOR CRITERIA 2MINOR CRITERIA

OR

++ evidence of a preceding

group A streptococcal infection

How to make the diagnosisRecurrent attack of ARF

2MAJOR CRITERIA

OR

1MAJOR CRITERIA 2MINOR CRITERIA+

+ evidence of a preceding group A streptococcal infection

3MINOR CRITERIA

OR

Evidence of a preceding group Astreptococcal infection

Increased antistreptolysin O titre (ASOT)Positive throat culture for GABHSPositive rapid antigen detection test

JONES

ITERIA

oints - artritisbvious - cardiacodules - rheumaticrythema marginatumydenham chorea

nflammatory cells (leukocytosis)emperatureSR/CRP elevatedaised PR intervaltself (Previous Hx of Rheumatic fever)thralgia

MAJO

R

MINO

R

TREATMENT

Bedrest

TREATMENTAnti-Streptococcal

TherapyIV C. Penicillin 50 000U/kg/dose 6H or

Oral Penicillin V 250 mg 6H (<30kg),

500 mg 6H (>30kg) for 10 daysOral Erythromycin for 10 days if allergic to penicillin.

TREATMENTAnti-Inflammatory

Therapymild / no carditis:

Oral Aspirin 80-100 mg/kg/day in 4 doses for 2-4 weeks, tapering over

4 weeks.

TREATMENTAnti-Inflammatory

TherapyPericarditis, or moderate to severe carditis:

Oral Prednisolone 2 mg/kg/day in 2 divided doses for 2 - 4 weeks,

taper with addition of aspirin as above.

TREATMENTAnti-Inflammatory

TherapyMonitor Aspirin level and LFT

Watch out for

REYESSYNDROME

EncephalopathyFatty liver degenerationTransaminase elevation.

TREATMENTAnti-failure medication Diuretics, ACE inhibitors, digoxin (to

be used with caution).

TREATMENTSecondary prophylaxis

• IM Benzathine Penicillin 0.6 mega units (<30 kg)

or 1.2 mega units (>30 kg) every 3 to 4 weeks.

• Oral Penicillin V 250 mg twice daily.

• Oral Erythromycin 250 mg twice daily if allergic to Penicillin.

TREATMENTSecondary prophylaxis

Duration of prophylaxis• Until age 21 years or 5 years after last

attack of ARF whichever was longer • Lifelong for patients with carditis and

valvular involvement.

Accurate diagnosis is important.Jones Criteria is a good guidelineManagement include post-strep

therapy, anti-inflammatory therapy, anti-failure therapy and secondary

prophylaxisARF is a large physical, emotional and financial burden.

SummarySummary

In a case of knee swelling..

Don’t forget your stethoscope!

1.  Kumar, Vinay; Abbas, Abul K; Fausto, Nelson; Mitchell, Richard N (2007), Robbins Basic Pathology (8th ed.), Saunders Elsevier, pp. 403–6, ISBN 978-1-4160-2973-1.2. "rheumatic fever" at Dorland's Medical Dictionary3. Jones, T Duckett (1944). "The diagnosis of rheumatic fever". JAMA 126(8):481. doi:10.1001/jama.1944.02850430015005.4. Ferrieri, P (2002). "Proceedings of the Jones Criteria workshop".Circulation (Jones Criteria Working Group) 106 (19): 2521–3.doi:10.1161/01.CIR.0000037745.65929.FA. PMID 12417554.5. Parrillo, Steven J. "Rheumatic Fever". eMedicine. DO, FACOEP, FACEP. Retrieved 2007-07-14.6. Malaysian Paediatric Protocol, 3rd Edition

References

References