Rheumatic fever case presentation

1. Case Presentation
Dr. Md. Seebat Masrur
D-card Student
Cardiology Department
SZMCH, Bogra

2. Demographic Details
• Name: Mamun
• Age: 16 years
• Sex: Male
• Religion: Islam
• Occupation: Student
• Marital status: Un-married
• Address: Vatakanda, Sirajgonj
• Date of admission: 18.07.2022
• Date of examination:
18.07.2022

3. Chief Complaints
1) Joint pain involving large joints left hip, right
knee and both ankles.
2) Swelling of joints for same duration

4. History of Present Illness
According to the statement of the patient, he
was reasonably well 12 days back. Then he
developed joint pain which was severe in
intensity involving Left hip, right knee and
both ankles. Initially involved left hip then
sequentially migrating to right knee and both
ankle joints. The joints were swollen, red , hot
and very painful even with slight movement.
The smaller joints were not involved. There
was no morning stiffness.

5. History of Present Illness (cont...)
There is no history of abnormal or involuntary
movement or skin changes. He denied any
fever, sore throat, breathlessness, palpitation,
chest pain, low back pain, malaise, fatigue,
weakness during this disease period. No
history of diarrhoea, mouth ulcer, uveitis or
any urinary complaints.

6. Past Medical History
No Significant past medical history.

7. Family History
His parents are alive. He has an elder sister. All
his family members are healthy.

8. Socioeconomic History
He belongs to a lower middle class family.He
lives in a tin shed house which has two rooms.
He shares his room with his sibling. Drinks
tube-well water.

9. Drug History
He took some painkiller during disease
period the name could not be mentioned
which partially relived his pain.

10. Immunization History
He was immunized according to EPI schedule.

11. Personal History
He is non smoker, non alcoholic. No H/O
intravenous drug abuse.

12. PHYSICAL EXAMINATION
General Examination
• Appearance: Ill-looking
• Co-operation: Co-operative
• Decubitus: On choice
• Build: Average
• Nutrition: Below average
• Intelligence: Normal
• Anemia: Absent
• Jaundice: Absent
• Cyanosis: Absent

13. General Examination (cont...)
• Oedema: Absent
• Dehydration: Absent
• Clubbing: Absent
• Koilonychia: Absent
• Leukonychia: Absent
• Neck vein: Not engorged
• Thyroid gland: Not enlarged
• Lymph nodes: Not palpable
• Skin condition: Normal
• Hair distribution: Normal

14. General Examination (cont...)
• Weight: 47 kg
• Pulse: 92/min
• Blood Pressure: 100/60mmHg
• Temperature: 98 F
• Respiratory rate: 16/min

15. SYSTEMIC EXAMINATION

16. Cardiovascular System
• Pulse: 92 B/mins
• BP: 100/60 mm hg
• JVP: Not Raised
• Precordium examination:
Inspection:
Shape: Normal
No visible cardiac impulse
No scar marks, no deformity.

17. Cardiovascular …
Palpation:
Apex beat: Left 5th ICS just lateral to mid
clavicular line.
Thrills: Absent
Left Parasternal heave: Absent
Epigastric Pulsation: Absent

18. Cardiovascular…
Ausculatation:
First and 2nd heart Sound: Normal
No murmur present
No Added sound

19. Locomotor examination
Inspection
Mildly swollen
Normal Skin condition
Palpation
Local temperature: Mildly
raised
Tenderness: Present
Fluctuation test: Negative
Movement: Restricted due to
pain

20. Other systemic examinations
revealed no abnormality.

21. Salient Feature
Mamun 16-year-old, student, normotensive,
nondiabetic, nonsmoker, hailing from
vatakanda, Sirajgonj he developed migrating,
inflammatory large joints severe pain which
sequentially involved the Left hip, right knee,
both ankles. He felt pain even with mild
movement. The small joints are not involved
and there was no morning stiffness.

22. Salient Feature…
There is no history of abnormal movement or
skin changes. The patient denied any prior fever,
sore throat, malaise fatigue. He denied any
history of diarrhea, sexual exposure, low back
pain, mouth ulcer, uveitis or any urinary
complaint. He used to take some painkillers
which partially relieved his symptoms. There is
no family history of such illness.

23. Salient Feature…
He belongs to a lower middle-class family,
Shares his room with his sibling. He was duly
immunized. No history of prior drug use.

24. CLINICAL DIAGNOSIS
?

25. Acute Rheumatic
fever

26. Differential Diagnosis
Infective arthritis (viral or bacterial).
Juvenile Idiopathic arthritis.
Seronegative arthritis.
Acute Gouty Arthritis
Rheumatoid Arthritis

27. INVESTIGATION PROFILE
Name of investigations Findings
CBC with ESR • Hb%: 11.30 gm/dl
• WBC: 14670/cumm
• Neutrophil: 76%
• Platelet: 598000/cumm
• ESR: 121 mm in 1st hour
CRP •139mg/L
ASO Titre • 400 IU/ml

28. 12 Lead ECG
• This is a 12-lead ECG with Rhythm strip showing rate 96
beats/min, rhythm is regular, PR interval is normal, T wave
inversion from v1-v4.

29. Investigation Profile (cont...)
Name of investigations Findings
CXR P/A View Normal findings
Throat Swap Culture Pending
Ra factor Negative
Uric Acid 4.30 mg/dl

30. Echocardiography
• Normal 2D & M-mode
echocardiography with Good LV
systolic function with EF 75%.

31. FINAL DIAGNOSIS
Acute Rheumatic Fever

32. Points In Favour
• Migrating, inflammatory arthritis involving the
large joints without any deformity.
• Leukocytosis
• Raised ASO titre.
• High ESR & CRP

33. Management
• Bed Rest until symptoms subsides.
• Oral Phenoxymethylpenicillin 250 mg 6 hrly
for 10 days
• Analgesic- Aspirin 60 to 100 mg/kg per day in
divided dosages.(not more than 8 gm/day)
• Prednisolone 1-2 mg/kg body weight for 2
weeks then gradually tapered over 2 weeks,

34. Monitoring of patient
• ESR
• CRP
• Serial ECHO
• ASO Titre is not required

35. Treatment on Discharge
• Tab Phenoxymethyl penicillin 250
mg…..1+0+1…….5 years
• Tab Aspirin 75 mg
• Tab Omeprazole 20mg….1+0+1(B/M)…….2
months
• Tab Prednisone 20 mg….2+0+0………7 days
then tab prednisolone 1+0+0……….7 days then
tab prednisone 20mg….1/2+0+0…….7 days

36. THANK YOU