Case Presentation
A 18 year old girl presents with Four day History of fever, Malaise, and Migratory joint pain which involves right knee, right ankle, right elbow, and left knee in turn. The affected Joints were tender and swollen ,But Non erythematous. There was no morning stiffness. She had a sore throat two weeks ago, which resolved spontaneously. Her Medical ,surgical, Drug and family histories are unremarkable. She is not on any Medications ,including over the counter medicines or supplements. She has no allergies. All the vaccinations are up to date. She denies recreational Drug use. She is currently a Single but sexually active. Her last episode of Intercourse was one month ago.
On Examinations :
Cardio vascular system
- Visible cardiac impulse in Mitral area
- Apex Hyperkynetic , in 5th ICS on the anterior axillary line
- Soft S1 and S2
- Pansystolic murmur in mitral area ,radiating to left axilla
- Pericardial Rub present
Looks Ill :
- Temperature : 100.2 degree F
- BP : 130/80 mmHg
- Pulse : 110bpm ,regular
- RR : 18 Breaths /min
- JVP : Not elevated
Musculoskeletal System :
- Left Knee Joint : Swollen and tender , But Non erythematous active and passive movement restricted. All other Joints appear Normal
Lungs ,abdomen and CNS : No abnormalities
CASE APPROACH BY EXPERTS WITH DIAGNOSING AND REASONING:
The Patient with Joint pain is an Important Presentation in Primary Care, With a wide range of both benign and sinister etiologies being possibilities. A Careful history and examination are essential, as is a structured approach to the evaluation. We are supposed to consider some key Points to elicit which includes the Pattern of Joint involvement i.e. large or small ,axial or peripheral and symmetric or assymetric; Presence or absence of Articular inflammation; Presence of systemic manifestations; and if there was recent preceding illness (sore throat ,Pharyngotonsillitis or cough ).
Now Look at this case , The Large Peripheral Joints were involved in an asymmetric manner ; and the Arthritis was migratory in nature i.e. affecting joints successively, rather than simultaneously. The latter findings significantly narrows down the possibilities, with the KEY DIFFERENTIALS to include being, Acute Rheumatic fever, Systemic lupus erythmatosus, Infective endocarditis, Lyme disease and Gonococcal arthritis.
Look at the EXAMINATION FINDINGS which reveals, Left knee joint to be swollen and tender, with restricted active and passive movements. Even More importantly examination also reveals apical deviation and murmur suggestive of MITRAL REGURGITATION. The Presence of cardiac findings narrows the differentials to either ACUTE RHEUMATIC FEVER or INFECTIVE ENDOCARDITIS. Of these , ARF is more likely, Given the Patients age, history of recent throat infection, and Compatible pattern of joint involvement.
Now, INVESTIGATIONS ARE KEY to establishing the diagnosis. Dear Medical warriors These should include Full blood count, C-Reactive Protein, An ECG and Echocardiogram to evaluate the Cardiac status; and the antistreptolysin O antibody titers and throat cultures to determine if her recent infection was due to GROUP A STREPTOCOCCUS.
As said, These Revealed us, Leukocytosis; elevated CRP levels; A prolonged PR interval ( first degree Heart block); Thickening of aortic and Mitral valve leaflets with moderate mitral valve insufficiency; and ASOT Positivity. When Considered Together , Clinical and Investigative findings satisfy Two Major criteria of Revised JONES CRITERIA 2015. This is sufficient to clinch the diagnosis.
Her IMMEDIATE MANAGEMENT should include Corticosteroids to Treat the Carditis and arthritis, and PENICILLINS to eradicate any Streptococci that may persist in upper respiratory tract. Note that Aspirin is indicated for treatment of arthritis , This is unnecessary if corticosteroids are already indicated. While Valve repair might end up being necessary down the line ,This is Not required Right Now.
