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?

Congratulations to Suzanne who correctly diagosed Sydenham’s chorea first. She was joined by a bunch of other clever clinicians with this answer.  I am gonna have to get tougher cases!  Suzanne is an ED reg in Hobart – but has worked in central and northern Australia – so has seen a few cases.  Hope the Jones criteria come up on your exams Suzanne!

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

  • Carditis—tissue inflammation or new changing murmur

  • Polyarthritis—migratory pain in limb joints

  • Chorea—abrupt, purposeless movements with or without emotional changes

  • Erythema marginatum—nonpruritic rash, spares face

  • Subcutaneous nodules—painless, firm, on bones or tendons

Minor criteria

  • Fever

  • Arthralgia

  • Previous acute rheumatic fever or rheumatic heart disease

  • Acute-phase reactants—erythrocyte sedimentation rate, C-reactive protein, leukocytosis

  • Electrocardiogram—prolonged PR interval

Evidence of streptococcal infection

  • Throat culture positive for the bacteria

  • Positive rapid antigen detection test results

  • Elevated antistreptolysin O titre

  • Scarlet fever 

Rheumatic fever is a marker of poverty and poor living conditions – it occurs in overcrowded homes with poor nutrition etc. So if you want to fix this problem – go and become a builder or a politician (left leaning), not a doctor.

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!

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