Fever and Joint Pain: Case Study of 11-year-old Girl

1. Chapter 6Fever (and joint pain)

2. Case study: Mere Mere is an 11 year old girl brought to hospital after 4 days of fever. She has pain in her right knee that is preventing her from walking.

3. What are the stages in the management of Mere?

4. Have you noticed any emergency (danger) or priority (important) signs? Temperature: 38.90C, pulse: 110/min, RR: 20/min; no cyanosis, CR 1 second, alert

5. Stages in the management of a sick child(Ref. Chart 1, p. xxii) • Triage • Emergency treatment • History and examination • Laboratory investigations, if required • Main diagnosis and other diagnoses • Treatment • Supportive care • Monitoring • Discharge planning • Follow-up

6. Triage • Emergency signs (Ref. p. 2, 6) • Obstructed breathing • Severe respiratory distress • Central cyanosis • Signs of shock • Coma • Convulsions • Severe dehydration • Priority signs (Ref. p. 6) • Tiny baby • Temperature • Trauma • Pallor • Poisoning • Pain (severe) • Respiratory distress • Restless, irritable • Referral • Malnutrition • Oedema of both feet • Burns

7. What emergency treatment will Mere need? • Airway management? • Oxygen? • Intravenous fluids? • Immediate investigations?

8. (Ref. p. xxii, Chart 1)

9. History and examination in a child with fever • What are key questions to ask on history? • (Ref. p. 150) • What are key things to look for on examination? • (Ref. p. 150)

10. History • Mere was apparently well until 4 days ago when she developed a fever. She also had a painful left ankle for 2 days. Yesterday, she developed right knee pain with swelling and is now unable to walk. 2 weeks prior she had a sore throat that was treated by her aunty with a Fijian herbal remedy. She has had no rashes, no neck stiffness, no abdominal pain. She is not eating, but drinking OK. • Past history: Mere had a similar episode of sore joints 1 year ago. • Family history / social history: lives in a rural village with her large extended family.

11. Examination • Assess signs of systemic illness • Temp: 38.9ºC Pulse: 110/min RR: 20/min BP 115/65 mmHg • Assess chest and heart • Chest clear, systolic murmur loudest at the apex and radiating to the axilla. No thrill. Apex beat normally placed. • Assess abdomen • Soft to palpation, normal bowel sounds, no organomegaly • Assess neurological state • AVPU = A (alert), no neck stiffness, pupils equal and reactive • Assess skin • No rashes • Assess nutritional state • Height: 135 cm Weight: 30 kg • Assess MSK • Hot and swollen right knee that is very tender to touch • (Ref. p.150, p.154)

12. History and examination in a child with fever • What category of fever is Mere presenting with? • (Ref. p.152) • Fever with no localising signs (no rash) • Fever with localising signs (no rash) • Fever with rash • (Fever lasting longer than 7 days) • Fever plus arthritis

13. Differential diagnoses • List possible causes of the illness • Main diagnosis • Secondary diagnoses • (Tables 16, 17, 19 may be helpful) • Differential diagnoses: • Septic arthritis • Rheumatic fever • Dengue • Viral arthritis (reactive) • Other…

14. What investigations would you like to do to make your diagnosis?

15. Joint aspiration? If septic arthritis is suspected then a joint aspirate should be undertaken. What are the features of septic arthritis? ( Ref p. 186-187) Arthritis unaccompanied by other major manifestations of rheumatic fever deserves differential diagnosis from many clinical entities .

16. Investigations for acute rheumatic fever FBE ESR (CRP) ASOT ECG CXR Throat swab Echocardiogram

17. Investigations Full blood examination: Haemoglobin: 110g/l (115-140) Platelets: 450x109/l (150 – 400) WCC: 16.2x109/l (5.5 – 15.5) Neutrophils: 7.9x109/l (1.5 – 8.5) Lymphocytes: 4.0x109/l (2.0 – 8.0) Monocytes: 1.2x109/l (0.1 – 1.0)

18. Investigations (continued) • Blood culture: sent, awaiting cultures • ESR: sent, awaiting result • ECG: normal • CXR: normal • ASOT: sent, awaiting result

19. Diagnosis Summary of findings: • History: 11 yo girl with PHx of joint pains presents with polyarthritis • Exam: febrile but non-toxic with right knee arthritis and a cardiac murmur • Investigations : mild anaemia, mild leukocytosis, elevated ESR

20. Diagnosis • Likely acute rheumatic fever

21. Stages in the management of a sick child(Ref. Chart 1, p. xxii) • Triage • Emergency treatment, if required • History and examination • Laboratory investigations, if required • Differential diagnoses • Main diagnosis • Treatment • Supportive care • Monitoring • Plan discharge • Follow-up, if required

22. Treatment  Suspected acute rheumatic fever  Aspirin (Ref p. 357) • Benzathine penicillin G (Ref p. 367)

23. Supportive Care • Fever control • Pain control • Bed rest • Nutrition

24. Monitoring • Nurses should monitor the child's state using a monitoring chart (Ref. p. 320, 413) • Assess response to treatment (Ref .Chart 1 p.xxii; p. 319) • Expected response to treatment • Is there an alternate diagnosis • Consider the complications of the disease • Consider the complications of the treatment • Follow-up results • ASOT 1600 • BC –ve • ESR 88mm/h

25. Discharge plan • Mere responds quickly to the aspirin and her joint pain reduces significantly within 2 days; her fever also reduces • She is able to walk adequately • She is eating well after 2 days • She has no apparent problems with the medication • She and her parents are educated about rheumatic fever and rheumatic heart disease including being given printed information • Aspirin as an outpatient is provided with a clear dosage plan • Benzathine penicillin G already started • A clear plan is made for follow-up visit

26. Follow-up Regular benzathine penicillin G every 28 days Register the patient on the National RHD Register Echocardiogram and paediatric review Reinforce education Advise the mother when to bring the child back if unwell

27. Acute Rheumatic Fever: Extra detail

28. Diagnosis of acute rheumatic fever WHO Guidelines • Major manifestations • Polyarthritis • Carditis • Chorea • Erythema marginatum • Subcutaneous nodules • Minor manifestations • Polyarthralgia • Fever, • Elevated inflammatory markers • Prolonged PR interval on ECG • Evidence of antecedent Group A Streptococcus infection in the last 45 days • Elevated or rising streptococcal antibody titre (ASOT) • Positive throat swab

29. Diagnosis of acute rheumatic fever WHO Guidelines • Primary episode of acute rheumatic fever • Two major OR one major and two minor • Evidence of Group A Streptococcal antecedent • No History of RHD • Other forms exist • Recurrent episode with and without RHD • Rheumatic chorea (chorea only) • Insidious onset rheumatic carditis (carditis only) • Chronic valve lesions of RHD

30. Summary • Careful history taking, examination and the investigations pointed towards a diagnosis of acute rheumatic fever • However, more serious causes of fever and joint pain should be excluded AND/OR treated presumptively, e.g. Septic arthritis • In regions of where rheumatic heart disease is prevalent: • Acute rheumatic fever should be considered whenever a child presents with a history of joint pain. • Acute rheumatic fever confers a risk of progression to rheumatic heart disease and therefore long term secondary prevention is essential.