Today, we talked about the very interesting case of a middle-aged man who presented with acute migrating oligoarthritis, found to be febrile with an inflammatory synovial fluid and elevated ASO titers consistent with acute rheumatic fever!
Clinical Pearls
- Nonsuppurative manifestations of GAS infection include acute rheumatic fever (ARF), acute GN, and Scarlet fever.
- Use the modified Jones Criteria to help you diagnose ARF and treat early if high suspicion for the disease (do not wait for titers to come back).
- Late complications of ARF include rheumatic heart disease (10-20 years after infection) and Jaccoud arthropathy.
- Treatment of ARF involves NSAIDs for arthritis, PCN G IM x 1 dose for acute presentation and then monthly for prophylaxis, and patient education about oral hygiene to prevent endocarditis and need for prophylaxis before invasive procedures.
Differential diagnosis for a migratory arthritis
- Rheumatic fever
- Infective endocarditis
- Vasculitis (IgA, cryo, ANCA associated)
- SLE
- Acute leukemia
- Serum sickness
- Viral arthritis
- Bacteremia (staph, strep, mening/gonococcal)
- Pulmonary infections (mycoplasma, histoplasma)
- Lyme
- Whipple’s
Nonsuppurative complications of GAS infection
- ARF
- Scarlet fever
- Acute GN
Rheumatic fever
- Nonsuppurative sequela that occurs 2-4 weeks after GAS pharyngitis
- Epi
- More common in children 5-15 years of age
- More common in resource limited settings
- Pathogenesis:
- Poorly understood, ?molecular mimicry
- Clinical manifestations:
- Two primary manifestations of disease
(Table above from UpToDate)
- Late sequelae
- Rheumatic heart disease (10-20 years after infection), primary involves the mitral valve >aortic valve.
- Leading cause of cardiovascular death in the first 5 decades of life in resource limited settings
- Jaccoud arthropathy
- Rheumatic heart disease (10-20 years after infection), primary involves the mitral valve >aortic valve.
- Diagnosis:
- Revised Jones criteria (joint and cardiac manifestations can only be counted once).
- Major
- Carditis and valvulitis (clinical or subclinical) – 50-70%
- Usually pancarditis. Valvulitis especially of mitral and aortic valves, shown as regurg on echo.
- Carey Coombs murmur: short mid-diastolic murmur heard loudest at the apex
- Arthritis (migratory, involving large joints) – 35-66%, earliest symptom
- Several joints affected in quick succession, each inflamed for a day or two to one week. Most common are knees, ankles, elbows, and wrists.
- CNS involvement (Sydenham chorea) – 10-30%
- Subcutaneous nodules – 0-10%
- Erythema marginatum – <6%
- Carditis and valvulitis (clinical or subclinical) – 50-70%
- Minor
- Arthralgia
- Fever >38.5
- Elevated acute phase reactants (ESR, CRP)
- Prolonged PR interval on EKG
- Diagnosis requires evidence of prior GAS infection plus:
- 2 major OR
- 1 major + 2 minor criteria OR
- 3 minor criteria (only if patient has history of prior episode of ARF)
- In a high prevalence setting, slightly modified criteria are used.
- Major
- Labs:
- Prior GAS infection through either
- Throat culture
- Positive rapid strep antigen test
- Elevated or rising ASO titers
- Treatment
- Goals
- Symptomatic relief of acute disease manifestations
- Arthritis: NSAIDs
- Carditis: if severe, heart failure treatments
- Eradication of GAS
- IM PCN G benzathine x 1
- Contacts (throat culture test and treat if positive)
- Ppx against future GAS infection to prevent progression of cardiac disease
- PCN G IM once a month
- For 5 years or until 21 years of age (whichever is longer)
- If ARF with carditis and residual heart disease
- 10 years or until 40 years, sometimes even lifelong
- Education
- Oral health
- Ppx before any invasive procedures
- Symptomatic relief of acute disease manifestations
- Goals
- Prior GAS infection through either
- Revised Jones criteria (joint and cardiac manifestations can only be counted once).