July 03, 2024
THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
A 13 YR OLD MALE WITH REDNESS OF EYES, FEVER, BURNING MICTURITION AND SWELLING OF CHEEKS.
A 13yr old male who is a student, brought by parents with complaints of
Redness of eyes since the 5days
Fever since 4days
Burning micturition since 4days
History of present Illness:
Patient was apparently asymptomatic 5days back after which he developed Redness of eyes, followed by Fever which is high grade insidious onset, gradually progressive associated with burning micturition.
H/o yellowish discoloration of eyes 3days
H/o swelling in both cheeks since 2days
H/o pain and difficulty in flexing left knee since 2days associated with progressive swelling
No H/o recent travel
No H/o similar complaints in the past
PAST HISTORY
N/k/c/o DM, Hypertension, TB, Epilepsy, CVD, Asthama, Thyroid disorders
PERSONAL HISTORY
Single
Student
Diet: Mixed
Appetite: Lost
Sleep: adequate
Bowel and bladder regular
Addictions No
No known Allergies
GENERAL EXAMINATION
Pt is conscious coherent and cooperative
Icterus present
No pallor, cyanosis, clubbing generalized lymphadenopathy, edema
Vitals
Temp: 101F
Bp :110/70 mm Hg
PR :100 bpm
RR: 18cpm
SpO2: 98%
GRBS: 110mg/dl
SYSTEMIC EXAMINATION
Cardiovascular system:
No thrills
S1, S2 are heard
No Murmurs
Respiratory system:
No Dyspnea
No wheeze
Location of trachea: Central
Normal vesicular breath sounds
No adventitious sounds.
Abdomen:
Shape of Abdomen -Schaphoid
No tenderness, palpable mass,
Normal hernial orifice
No bruits, free fluid
No organomegaly
Bowel sounds present.
CNS:
No focal neurological deficit
GAIT: Limping Gait
Left eye
ASO titres: 311IU/ml
PROVISIONAL DIAGNOSIS::- -
Acute febrile Illness
?Acute Rheumatic fever
?Mumps
?Leptospira
Treatment:-
1.Iv fluids .9 Ns, RL @ 50ml /hr with optineuron
2.Inj.Ceftriaxone 1gm/IV/Bd
3.Inj.Doxycyclline 100mg/IV/Bd
4.Inj.Pan 40mg Iv/OD
5.Inj.Pcm 500mg IV/Stat
6.tab .Pcm 500mg /po/Tid
Problems list:-
Sub-conjunctival haemorrhages
Fever
Throat pain
Burning micturition
Parotid swelling
Cervical lymphadenopathy
Left knee pain followed by left inter-phalangeal joint pain.
CUE-normal
ASO titres raised (311.7IU/ml)
Raised ESR and positive CRP
[22-04-2025 10:44] PPM 1: Reviewed by @PPM3 in the OPD:
The previous and current question around the diagnostic uncertainty surrounding his acute rheumatic fever giving rise to this persistent therapeutic uncertainty that lingers after the 13th dose of benzathine penicillin, and he has come today for the 14th dose.
Previous case report is here: https://47chaitanya.blogspot.com/2024/07/a-13-yr-male-with-redness-of-eyesfever_3.html?m=1
Although it needs to be updated @PPM4 @PPM5 @CR
[22-04-2025 11:28] PPM 6: *Comprehensive Analysis and Recommendations for the 13-Year-Old Male with Diagnostic Uncertainty in Acute Rheumatic Fever (ARF)*
### *Key Considerations:*
1. *Diagnostic Reassessment Using Jones Criteria:*
- *Major Criteria:* Carditis, polyarthritis, chorea, erythema marginatum, subcutaneous nodules.
- *Minor Criteria:* Fever, arthralgia, elevated ESR/CRP, prolonged PR interval.
- *Requirement:* 2 major, or 1 major + 2 minor criteria + evidence of preceding streptococcal infection (e.g., elevated ASO titers, positive throat culture).
2. *Patient-Specific Factors:*
- Previous symptoms (red eyes, fever) suggest conjunctivitis (non-Jones) and fever (minor criterion). Need clarification on other symptoms (e.g., arthritis vs. arthralgia, cardiac findings).
- *Critical Gaps:* Documentation of carditis (echocardiogram results?), ASO titers, and exclusion of alternative diagnoses.
3. *Therapeutic Uncertainty:*
- Prolonged benzathine penicillin (13 doses) implies adherence to ARF prophylaxis. Duration depends on cardiac involvement:
- *With carditis/heart disease:* Continue until age 21 or 10 years (whichever longer).
- *Without carditis:* 5 years or until age 18.
### *Recommendations:*
1. *Re-evaluate Initial Diagnosis:*
- *Retrospective Review:* Confirm if Jones criteria were met, including streptococcal evidence (ASO titers, throat culture).
- *Echocardiogram:* Reassess for valvular changes (e.g., mitral regurgitation, rheumatic heart disease).
2. *Exclude Alternative Diagnoses:*
- *Reactive Arthritis:* Check for urethritis, GI symptoms, or HLA-B27.
- *Lyme Disease:* Consider in endemic areas (serology if indicated).
- *Kawasaki Disease:* Review historical criteria (e.g., prolonged fever, mucocutaneous signs).
- *Viral Myocarditis/Pericarditis:* Cardiac MRI if ambiguity persists.
3. *Laboratory Workup:*
- *ASO/anti-DNase B titers:* Confirm prior streptococcal infection.
- *Inflammatory Markers:* ESR/CRP trends.
- *ECG:* Assess for prolonged PR interval or arrhythmias.
4. *Shared Decision-Making:*
- *If ARF Confirmed:* Continue prophylaxis per guidelines based on cardiac status.
- *If ARF Unlikely:*
- Discontinue penicillin.
- Investigate alternative causes of initial symptoms (e.g., autoimmune panel, infectious workup).
5. *Psychosocial and Adherence Factors:*
- Address family/patient concerns about long-term injections.
- Ensure understanding of rationale for continuation/discontinuation.
### *Conclusion:*
Resolve diagnostic uncertainty by rigorously reapplying Jones criteria and excluding mimics. If ARF is validated, tailor prophylaxis duration to cardiac findings. If excluded, halt penicillin and pursue alternative diagnoses. This approach balances preventing rheumatic heart disease with avoiding unnecessary treatment. Engage the family in transparent discussion to mitigate anxiety and ensure compliance with next steps.
*Next Steps:*
- Update case details with echocardiogram, ASO titers, and symptom evolution.
- Multidisciplinary review with cardiology/rheumatology if ambiguity persists.
- Document shared decision-making process clearly.
Final Note: Clarity in diagnosis is paramount to ethical, evidence-based care. Uncertainty should prompt thorough reinvestigation rather than indefinite prophylaxis.
[22-04-2025 11:35] PPM 6: *Alternative Differential Diagnoses for the 13-Year-Old Male with Suspected Acute Rheumatic Fever (ARF):*
### *1. Infectious/Post-Infectious Causes*
- *Post-Streptococcal Reactive Arthritis (PSRA):*
- Arthritis after streptococcal infection, but lacks carditis and does not fulfill Jones criteria.
- Differentiated from ARF by longer duration of arthritis and absence of major ARF criteria.
- *Lyme Disease (Borrelia burgdorferi):*
- Endemic areas: Migratory arthritis, fever, and possible carditis (e.g., myocarditis, AV block).
- Key clues: History of tick bite, erythema migrans rash (may be absent in late stages).
- Confirm with Lyme serology (ELISA/Western blot).
- *Viral Myocarditis/Pericarditis (e.g., Coxsackievirus, Parvovirus B19):*
- Fever, chest pain, arrhythmias, or heart failure.
- Joint pain may mimic ARF.
- Viral PCR or serology to confirm.
- *Infective Endocarditis:*
- Persistent fever, new cardiac murmurs, embolic phenomena.
- Blood cultures, echocardiogram (vegetations) required.
---
### *2. Autoimmune/Inflammatory Disorders*
- *Systemic Lupus Erythematosus (SLE):*
- Fever, arthritis, malar rash, cytopenias, or renal involvement.
- Cardiac manifestations (pericarditis, Libman-Sacks endocarditis).
- Check ANA, anti-dsDNA, complement levels.
- *Juvenile Idiopathic Arthritis (JIA):*
- *Systemic-onset JIA (Still’s disease):* High spiking fevers, evanescent rash, arthritis, hepatosplenomegaly.
- *Oligoarticular/polyarticular JIA:* Chronic arthritis without fever.
- *Reactive Arthritis (Post-enteric/Post-chlamydial):*
- Triad: Arthritis, urethritis, conjunctivitis/uveitis.
- HLA-B27 association.
- Stool culture/PCR for enteric pathogens (e.g., Salmonella, Shigella).
- *Kawasaki Disease:*
- Prolonged fever, conjunctival injection, mucocutaneous involvement (e.g., rash, cracked lips, strawberry tongue).
- Coronary artery aneurysms on echocardiogram.
- Rare in adolescents but possible.
---
### *3. Other Inflammatory Conditions*
- *Sarcoidosis:*
- Rare in children. May present with uveitis (red eyes), arthritis, cardiac granulomas.
- Elevated ACE levels, chest X-ray (hilar lymphadenopathy).
- *Hereditary Periodic Fever Syndromes (e.g., Familial Mediterranean Fever):*
- Recurrent fevers, serositis (abdominal/chest pain), arthralgia.
- Ethnic predisposition (Mediterranean/Middle Eastern).
---
### *4. Non-Inflammatory Causes*
- *Leukemia/Lymphoma:*
- Fever, bone/joint pain, cytopenias, night sweats.
- Peripheral blood smear, bone marrow biopsy.
- *Acute HIV Infection:*
- Fever, rash, arthralgia, lymphadenopathy.
- HIV RNA PCR or antigen/antibody testing.
---
### *5. Miscellaneous*
- *Toxic Shock Syndrome (Staphylococcal/Streptococcal):*
- Acute-onset fever, rash, hypotension, multi-organ involvement.
- Less likely given chronicity in this case.
- *Chronic Fatigue Syndrome/Post-Viral Syndrome:*
- Persistent fatigue, myalgia, arthralgia after viral illness.
---
### *Key Investigations to Narrow Differential Diagnoses:*
1. *Laboratory:*
- *ASO/anti-DNase B titers* (confirm prior streptococcal infection).
- *Inflammatory markers* (ESR, CRP, procalcitonin).
- *Autoimmune panel* (ANA, RF, anti-CCP, HLA-B27).
- *Lyme serology*, viral PCR (e.g., parvovirus, EBV).
- *Blood cultures* (if endocarditis suspected).
2. *Imaging:*
- *Echocardiogram* (reassess for valvular lesions, pericardial effusion, or coronary aneurysms).
- *Cardiac MRI* (if myocarditis suspected).
3. *Exclusion of Mimics:*
- *Chest X-ray* (sarcoidosis, tuberculosis).
- *Joint imaging* (ultrasound/MRI for synovitis).
---
### *Clinical Takeaway:*
The diagnostic uncertainty underscores the need to:
- Re-examine the *Jones criteria* (were they truly met initially?).
- Rule out mimics with targeted testing (e.g., Lyme, SLE, PSRA).
- Reassess cardiac status with advanced imaging (echo/MRI).
- Engage rheumatology/cardiology for multidisciplinary input.
If ARF is excluded, discontinue penicillin and treat the underlying condition. If ARF is confirmed, continue secondary prophylaxis per guidelines.
Fits Reactive Arthritis?!
[22-04-2025 19:58] PPM 1: NoMost likely he had a single episode of viral arthritis
[15-07-2025 11:06] PPM 7: Reviewed this case in OPD today
No comments:
Post a Comment