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Endgames Case Review

A boy with fever and arthralgia

BMJ 2017; 356 doi: (Published 29 March 2017) Cite this as: BMJ 2017;356:j1347
  1. Federico Poropat, paediatrician,
  2. Serena Pastore, paediatrician,
  3. Valentina Gesuete, paediatrician,
  4. Egidio Barbi,, paediatrician
  1. Institute for Maternal and Child Health, IRCCS Burlo Garofolo, Trieste, Italy
  1. Correspondence to S Pastore serena.pastore{at}

An eight year old boy was admitted to the emergency department with a seven day history of medium grade fever with mild headache, sore throat, arthralgia in his wrists, and pain in the soles of his feet. He had been evaluated on the second day by his general practitioner, who had prescribed amoxicillin, but this treatment had been ineffective. Physical examination on admission showed the boy to be well, with body temperature 37.4°C, mild pharyngeal erythema with a moderate enlargement of cervical lymph nodes, heart rate 107 beats per minute without murmurs, clear breath sounds, no liver or spleen enlargement, no skin rash, and no arthritis.

Blood tests showed white blood cell count 8.66 ×109/L (reference range: 4-11 ×109/L) with 60% neutrophils, haemoglobin 12.5 g/dL (reference range: 12-16 g/dL), platelet count 374.  ×109/L (reference range: 15-40 ×109/L), erythrocyte sedimentation rate 85 mm/h (normal value <20 mm/h), C reactive protein 11.5 mg/dl (normal value <0.5 mg/dL), and anti-streptolysin titre 854 UI/ml (normal value <100 UI/mL).

A two dimensional echocardiogram (fig 1, fig 2) showed a regurgitant jet, which was minimal, inconsistent, and visible only in a single projection. The regurgitation is a not uncommon finding in the paediatric population.12

Fig 1 Apical view with colour Doppler echocardiography of the four chambers of the heart showing minimal regurgitation, which is commonly seen in the paediatric population. LA=left atrium, LV=left ventricle, RA=right atrium, RV=right ventricle

Fig 2 Colour Doppler echocardiography on long axis projection with no pathological findings on the aortic valve. LA=left atrium, LV=left ventricle, …

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