Clincial Case 034: Paediatric Puzzler
Last time I put up a “tricky” case you guys were all too smart and got the answer too easy – so this one is stripped back bare – not many clues.
Setting: Broome – NW WA.
Patient: 9 yo girl, from local community. Presents with… OK, I am not gonna tell you – just describe what I saw when my colleague walked her through the ED. (sorry no video – you will just have to use your imaginations)
This young lady was happy & smiling, though kept her arms firmly crossed over her chest. Her wrist was moving constantly under the contralateral elbow.
When she walked she had a swagger – her hips moved like an exaggerated super-model catwalk strut. Then when she stood still, with knees locked in extension – one of her knees would intermittently “give way” – she would correct and reassume her stance for 10 – 20 secs then it would go again.
That is it! Do you know what is going on?
Sydenham’s chorea is one of the major Jones diagnostic criteria for rheumatic fever: to diagnose you need- 2 major criterion, OR 1 major and 2 minor, PLUS evidence of strept infection.
Major criteria
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Carditis—tissue inflammation or new changing murmur
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Polyarthritis—migratory pain in limb joints
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Chorea—abrupt, purposeless movements with or without emotional changes
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Erythema marginatum—nonpruritic rash, spares face
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Subcutaneous nodules—painless, firm, on bones or tendons
Minor criteria
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Fever
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Arthralgia
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Previous acute rheumatic fever or rheumatic heart disease
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Acute-phase reactants—erythrocyte sedimentation rate, C-reactive protein, leukocytosis
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Electrocardiogram—prolonged PR interval
Evidence of streptococcal infection
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Throat culture positive for the bacteria
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Positive rapid antigen detection test results
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Elevated antistreptolysin O titre
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Scarlet fever
The fact that ARF runs at about 50/100,000 in the northern parts of Australia is astonishing. The population live in one of the resource-richest parts of the only “western” country not to go into recession during the GFC. Ok, no more politics…
The Cochrane group did a review on acute pharyngitis and ABs for preventing ARF and showed you can decrease the rate by 2/3 – but there was a wide confidence interval [it is rare] and lets face it the NNT in the suburbs is probably >1,000,000. So not really good bang for the buck!
What do we do in Broome?? – well there are great guidelines on diagnosing & treating ARF (usually presents with large joint arthralgia) and getting good follow-up for IM penicillin and ECHO screening. Do I give every kid with a sore throat oral ABs? No. even here in the worst ARF territory in the world I do not use ABs that much – so you city folk – stop prescribing them! Go read Dr David Newman’s chapter from Hippocrate’s Shadow – you will feel better about the world!