Sore joints

Question 1

What are some signs of serious joint disease?

Answer 1

• Pain is usually the first sign of serious joint disease - swelling, warmth and redness generally present later.

Question 2

Rheumatic fever - major and minor manifestations?

Answer 2

Major manifestations

1. Carditis (including subclinical evidence of rheumatic valve disease on echocardiogram)
2. Polyarthritis or aseptic mono-arthritis or polyarthralgia
3. Sydenham chorea
4. Erythema marginatum
5. Subcutaneous nodulesCarditis (including subclinical evidence of rheumatic valve disease on echocardiogram)
6. Polyarthritis
7. Sydenham chorea
8. Erythema marginatum
9. Subcutaneous nodules

Minor manifestations

1. Fever
2. ESR ≥30 mm/hr or CPR ≥30 mg/L
3. Prolonged P-R interval on ECGFever
4. Polyarthralgia or aseptic mono-arthritis
5. ESR ≥30 mm/hr or CPR ≥30 mg/L
6. Prolonged P-R interval on ECG

Question 3

How do you diagnose initial episode of ARF? How do you diagnose a recurrent attack of ARF?

Answer 3

Initial episode of ARF

• Two major or one major and two minor manifestations
• plus
• Evidence of a preceding Group A streptococcus infection

Recurrent attack of ARF

• Two major or one major and two minor or three minor manifestations
• plus
• Evidence of a preceding Group A streptococcus infection

Question 4

Investigations for suspected ARF?

Answer 4

• Request FBC, ESR, CRP, Streptococcal titres (ASOT and AntiDNAse B), blood cultures, throat swab, ECG.
• Also antinuclear antibodies (some clinicians would not do these as part of the initial investigations).
• will also require a cardiology assessment with an echocardiogram to exclude carditis which may be missed clinically.

Question 5

Management of confirmed ARF?

Answer 5

• Patients with a well-documented history of acute rheumatic fever (ARF) should receive antibiotic prophylaxis against Streptococcus pyogenes*
• IM benzathine penicillin every 28 days

The minimum recommended duration is:

• 10 years after the most recent episode of ARF, or until 21 years of age (whichever is longer)
• until 35 years of age in patients with moderate rheumatic heart disease
• until 40 years of age or life-long in patients with severe rheumatic heart disease [Note 2] and in those who are having or have had cardiac valve surgery for rheumatic heart disease.

For arthritis/severe arthralgia

• aspirin (1st line)
• naproxen (2nd line)
• Dr White uses ibuprofen lol

Question 6

If diagnosis of ARF remains uncertain, what should you treat pain with?

Answer 6

If the diagnosis remains uncertain treat pain with

• paracetamol (not aspirin or NSAIDs which will mask the natural history of acute rheumatic fever) and seek specialist advice.

Question 7

How do you distinguish idiopathic recurrent limb pain from other causes of limb pain?

Answer 7

Recurrent idiopathic limb pain

• = growing pains
• common in childhood
• occurs in preschool and school aged children
• mostly at night
• usually bilateral
• The child is otherwise healthy and physical examination is normal
• A normal FBC and ESR or CRP is very reassuring.

When to suspect an alternative diagnosis:

• refusal to walk
• presence of a limp
• abnormalities on examination (warmth, tenderness, swelling)
• constitutional symptoms

Question 8

Why do children present with knee pain when they have a sore hip? What are some causes of hip/knee pain?

Answer 8

Pain in the hip is sometimes referred to the knee so children presenting with knee pain require a full examination of the leg and groin.

Developmental dysplasia, Perthe’s disease or slipped upper femoral epiphysis can cause hip or knee pain.

Question 9

What serology is used to confirm GAS infection?

Answer 9

• ASO titers
• Anti-Dnase B

Question 10

What are the common cardiac manifestations of rheumatic heart disease?

Answer 10

• mitral valve prolapse
• mitral stenosis
• aortic regurg?