Clinical Review

Lesson of the week Difficulties in diagnosing acute rheumatic fever—arthritis may be short lived and carditis silent

BMJ 2000; 320 doi: https://doi.org/10.1136/bmj.320.7231.362 (Published 05 February 2000) Cite this as: BMJ 2000;320:362
  1. Lyn Williamson, senior registrar ([email protected])a,
  2. Paul Bowness, senior registrara,
  3. Alastair Mowat, consultanta,
  4. Ingegerd Östman-Smith, consultantb
  1. a Department of Rheumatology, Nuffield Orthopaedic Centre, Oxford OX3 7LD
  2. b Department of Paediatric Cardiology, John Radcliffe Hospital, Oxford OX3 9DU
  1. Correspondence to: L Williamson, 17 Coxwell Road, Faringdon SN7 7EB
  • Accepted 25 May 1999

Think of rheumatic fever in all cases of acute childhood arthritis

The incidence of acute rheumatic fever has increased in the developed world.1-4 Although the criteria for diagnosis are well known, the clinical symptoms needed to make a diagnosis do not always arise concurrently and the initial illness may be mild and short lived. Isolated arthritis is the presenting symptom in 14-42% of patients.3-5 There may be no history of sore throat, or this symptom may not be mentioned by the patient,5 and the carditis may be silent. 6 7 The diagnosis will be missed if appropriate investigations are not carried out during the acute illness. These patients are susceptible to recurrent attacks of rheumatic fever, and damage to heart valves becomes increasingly severe with each subsequent attack. 8 9 Children are affected more than adults and may present to their general practitioners or to accident and emergency, orthopaedic, rheumatology, or paediatric departments. To highlight potential diagnostic problems, we describe three cases of rheumatic fever in young people who presented to one musculoskeletal centre in a six month period.

Case reports

Case 1

A 3 year old girl was taken to an accident and emergency department with a painful swelling of her right knee that came on quickly. She had had a mild cough, sore throat, and low grade temperature for 10 days. There was no history of trauma. No fracture was seen on a radiograph, and the girl was sent home. Two days later the girl's right wrist swelled. She was admitted to the Nuffield Orthopaedic Centre for assessment. When she was examined her temperature was 37.4°C and her pulse was regular (80 beats per minute). She had large infected tonsils, posterior cervical lymphadenopathy, and a grade 2/6 basal ejection systolic murmur. Her wrist and knee were warm, red, swollen, …

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