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    A Case of Knee Swelling - Don't forget to bring your stethoscope! A Case of Knee Swelling - Don't forget to bring your stethoscope! Presentation Transcript

    • A Case of Knee Swelling – Don’t Forget Your Stethoscope! K.S. Chew, K.Hamizah School of Medical Sciences Universiti Sains Malaysia
    • Case History  A 10-year old boy  previously well  came to the emergency department, HUSM  complained of solitary right knee pain & swelling for 1/7; no other joints involved  the pain started after he woke up from his sleep  the pain was not migratory  able to walk without much of a limping gait and was able to bear his own weight
    • Case History  had history of mild fever started two days prior to the joint pain  denied any prior history of trauma  neither had similar episodes in the past  nor any prior recent episode of upper respiratory tract infection or sore throat  went to a health clinic, given paracetamol and antibiotics  fever settled; annoying joint pain and swelling persisted
    • On Arrival  afebrile  normal vital signs  right knee was warm, mildly swollen and tender over the anterolateral aspect  able to walk in the emergency department with a slight limping  triaged to the Green Zone
    • What Do You Think Is Wrong With The Patient At This Moment?
    • On Examination  clinically, appeared to have an early-onset suppurative arthritis  right knee examination revealed a slightly reduced range of movement to about 120°  no clinical evidence that he had gross joint effusion.  however, on cardiovascular examination, he had a grade III pan-systolic murmur over the apical area  acute rheumatic fever??  no other manifestations fulfilling other major Jones’ criteria
    • Jones Criteria (1992) Acute Rheumatic Fever Diagnosis Two major OR one major with two minor criteria PLUS Evidence of antecedent group A streptococcal infection -Positive throat culture or rapid antigen test for group A streptococcus -Raised or rising ASOT (>250 IU/ml) Major Criteria Minor Criteria Carditis Fever Polyarthritis Arthralgia Chorea C-RP or ESR elevated Erythema Marginatum Prolonged PR interval on ECG Subcutaneous nodules Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.
    • Investigation Full Blood Count  Hb: 10.2 g/dl  TWC: 12,900/mm3  Platelet count: 548,000/mm3  ESR: 140 mm/hr  Anti-streptolysin O titre (ASOT): 800 IU/mL (>250)  Blood C&S: No growth  Renal/Liver Function tests: within normal range  X-ray: No radiological evidence of septic arthritis
    • Provisional Diagnosis  His ECG revealed a sinus tachycardia with normal PR interval  Admitted to pediatric ward with a provisional diagnosis of acute rheumatic fever with carditis.  An echocardiogram done showing a severe mitral regurgitation with a mild aortic regurgitation and an ejection fraction (EF) of 35% Dx: Acute Rheumatic Fever
    • Discussion
    • Discussion  ARF is diagnosed by using the modified and updated Jones criteria  Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.  The current Jones criteria published in 1992 was modified, revised twice and updated from the original Jones criteria first proposed by Dr. T. Duckett Jones in 1944  Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005 Jul 9-15;366(9480):155-68.
    • Discussion  ARF is diagnosed by using the modified and updated Jones criteria  Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.  The current Jones criteria published in 1992 was modified, revised twice and updated from the original Jones criteria first proposed by Dr. T. Duckett Jones in 1944  Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005 Jul 9-15;366(9480):155-68.
    • Discussion  ARF is diagnosed by using the modified and updated Jones criteria  Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.  The current Jones criteria published in 1992 was modified, revised twice and updated from the original Jones criteria first proposed by Dr. T. Duckett Jones in 1944  Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005 Jul 9-15;366(9480):155-68.
    • Discussion  The reason for the many revisions is to increase the specificity of the criteria in response to the reducing number of ARF cases in developed countries.  For example, the original Jones criteria include arthralgia as a major criterion, whereas today, arthralgia is considered as a minor criterion.  however, the increased specificity has also resulted in decreased sensitivity as a trade-off.  unfortunately, following the Jones criteria strictly resulted in many subclinical valvular damage in ARF noted worldwide Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005 Jul 9-15;366(9480):155-68.
    • Clinical Features of Rheumatic Fever
    • Discussion  In this patient, he presented with monoarthritis rather than the classical migratory polyarthritis  Monoarthritis has been increasingly reported in the literature as a presenting feature in ARF.  Harlan GA, Tani LY, Byington CL. Rheumatic fever presenting as monoarticular arthritis. Pediatr Infect Dis J. 2006 Aug;25(8):743-6.  Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005 Jul 9-15;366(9480):155-68.  Carapetis JR, Currie BJ. Rheumatic fever in a high incidence population: the importance of monoarthritis and low grade fever. Arch Dis Child. 2001 Sep;85(3):223-7.  Wilson E, Wilson N, Voss L et al. Monoarthritis in rheumatic fever? Pediatr Infect Dis J 2007; 26 (4):369-70.
    • WHO Criteria For Rheumatic Fever (2002 - 2003) Chorea and indolent carditis do not require evidence of antecedent group A streptococcus infection First Episode As per Jones Criteria Recurrent Episode In a patient without established RHD: as per first episode In a patient with established RHD: requires two minor manifestations, plus evidence of antecedent group A streptococcus infection WHO. Rheumatic fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29 October–1 November 2001. Geneva: World Health Organization, 2004.
    • Jones Criteria (1992) Acute Rheumatic Fever Diagnosis Two major OR one major with two minor criteria PLUS Evidence of antecedent group A streptococcal infection -Positive throat culture or rapid antigen test for group A streptococcus -Raised or rising ASOT (>250 IU/ml) Major Criteria Minor Criteria Carditis Fever Polyarthritis Arthralgia Chorea C-RP or ESR elevated Erythema Marginatum Prolonged PR interval on ECG Subcutaneous nodules Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.
    • Jones Criteria (1992) Acute Rheumatic Fever Diagnosis Two major OR one major with two minor criteria PLUS Evidence of antecedent group A streptococcal infection -Positive throat culture or rapid antigen test for group A streptococcus -Raised or rising ASOT (>250 IU/ml) Major Criteria Minor Criteria Carditis Fever Polyarthritis Arthralgia Chorea C-RP or ESR elevated Erythema Marginatum Prolonged PR interval on ECG Subcutaneous nodules Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.
    • Jones Criteria (1992) Acute Rheumatic Fever Diagnosis Two major OR one major with two minor criteria PLUS Evidence of antecedent group A streptococcal infection -Positive throat culture or rapid antigen test for group A streptococcus -Raised or rising ASOT (>250 IU/ml) Major Criteria Minor Criteria Carditis Fever Polyarthritis Arthralgia Chorea C-RP or ESR elevated Erythema Marginatum Prolonged PR interval on ECG Subcutaneous nodules Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.
    • Jones Criteria (1992) Acute Rheumatic Fever Diagnosis Two major OR one major with two minor criteria PLUS Evidence of antecedent group A streptococcal infection -Positive throat culture or rapid antigen test for group A streptococcus -Raised or rising ASOT (>250 IU/ml) Major Criteria Minor Criteria Carditis Fever Polyarthritis Arthralgia Chorea C-RP or ESR elevated Erythema Marginatum Prolonged PR interval on ECG Subcutaneous nodules Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.
    • Jones Criteria (1992) Acute Rheumatic Fever Diagnosis Two major OR one major with two minor criteria PLUS Evidence of antecedent group A streptococcal infection -Positive throat culture or rapid antigen test for group A streptococcus -Raised or rising ASOT (>250 IU/ml) Major Criteria Minor Criteria Carditis Fever Polyarthritis Arthralgia Chorea C-RP or ESR elevated Erythema Marginatum Prolonged PR interval on ECG Subcutaneous nodules Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.
    • - earned: the classical ic fever essons l one of ## L though heumat l acute r s, 1. A sentations of arthriti re y feature p tory pol a presenting een is migrathritis as er has b monoar rheumatic fev in acute ngly reported. x of suspicion e increasi in a high inde our stethoscop ! 2. Mainta Don’t forget y knee swelling 3. Axiom: ging a solitary in mana