A 12-year-old boy presents to the clinic with a two-week history of swelling and pain in multiple large joints, including the knees, elbows, and ankles. He also reports a fever that has been intermittent over the past week. The boy mentions that, about 3 weeks ago, he had a sore throat that was not treated, but he did not experience any significant symptoms afterward. On examination, the boy is febrile, and there is visible swelling and warmth in the affected joints. There is no history of trauma or any other chronic illness. Given this presentation, which of the following conditions is most likely?
A. Rheumatoid arthritis
B. Septic arthritis
C. Osteoarthritis
D. Rheumatic fever
E. Tuberculosis arthritis
Correct Answer: D. Rheumatic fever
Explanation:
This patient’s symptoms of swelling and pain in multiple large joints, accompanied by fever, and a recent history of sore throat, point strongly towards rheumatic fever. This condition occurs after a group A streptococcal (GAS) throat infection and can manifest with migratory arthritis, carditis, and sometimes chorea or erythema marginatum.
Key Features Supporting Rheumatic Fever:
- Recent Sore Throat:
- The patient’s recent sore throat that went untreated is a crucial factor, as rheumatic fever typically follows an untreated or inadequately treated streptococcal throat infection.
- Migratory Polyarthritis:
- Rheumatic fever is known to cause migratory arthritis, which often affects the large joints like the knees, elbows, ankles, and wrists. The fact that multiple joints are involved, and the symptoms have been present for two weeks, supports this diagnosis.
- Fever:
- The presence of fever, often intermittent, is another important clinical feature of rheumatic fever.
- Exclusion of Other Conditions:
- Rheumatic fever is often initially mistaken for other causes of arthritis in children, but the history of sore throat and the acute, migratory nature of the arthritis are key differentiators.
Why Other Conditions Are Less Likely:
A. Rheumatoid Arthritis:
- Rheumatoid arthritis (RA) in children (juvenile idiopathic arthritis) usually presents as chronic, with symmetrical involvement of small joints (like the wrists, hands, and feet), and does not typically follow a sore throat or present with fever in this acute manner.
- RA is more persistent, unlike the acute and migratory arthritis seen in rheumatic fever.
B. Septic Arthritis:
- Septic arthritis generally affects a single joint, and the onset is typically acute with severe pain, redness, and swelling. The involvement of multiple joints and the presence of a recent sore throat make septic arthritis less likely in this case.
- Additionally, septic arthritis usually does not present with a history of fever and migratory arthritis.
C. Osteoarthritis:
- Osteoarthritis (OA) is a degenerative joint disease that primarily affects older adults and involves chronic pain and stiffness rather than acute swelling and fever in children.
- OA is not associated with acute inflammatory responses and certainly does not follow an episode of sore throat.
E. Tuberculosis Arthritis:
- Tuberculosis arthritis typically affects a single large joint (often the hip or knee) and presents with chronic pain and swelling that gradually worsens over time.
- The history of sore throat and fever would be unusual in TB arthritis, which generally has a more insidious onset and does not involve multiple joints acutely.
Management of Rheumatic Fever:
- Antibiotic Therapy:
- The immediate management of rheumatic fever requires the eradication of any remaining group A streptococcus with appropriate antibiotics, such as penicillin or erythromycin if there is a penicillin allergy.
- Anti-inflammatory Treatment:
- NSAIDs (e.g., ibuprofen or aspirin) are used to reduce joint inflammation and pain. In some severe cases, corticosteroids may be used to control inflammation and reduce the risk of complications like carditis.
- Prophylaxis Against Future Streptococcal Infections:
- Long-term antibiotic prophylaxis (e.g., monthly penicillin injections) is recommended for at least 5 years or until the age of 21, whichever is longer, to prevent recurrent streptococcal infections and reduce the risk of rheumatic heart disease.
- Monitoring and Follow-Up:
- Regular follow-up with echocardiograms is needed to monitor for rheumatic heart disease (especially valvular damage), which can result from repeated episodes of rheumatic fever.
Conclusion:
The recent sore throat, fever, and migratory arthritis involving multiple large joints are classic symptoms of rheumatic fever. Early diagnosis and treatment with antibiotics and anti-inflammatory therapy are crucial to prevent long-term complications, particularly rheumatic heart disease. The management involves antibiotic prophylaxis, anti-inflammatory agents, and careful monitoring for cardiac involvement.