An 8-year-old girl is brought to the physician for abnormal behavior. She has been acting inappropriately, crying, and laughing without apparent reason for the past 2 weeks. At school, she was restless and easily distracted. Last week, her parents noted strange movements of the girl's hands that improved when she slept. On the day before presentation, her parents noticed rapid jerking movements of her face and feet. The girl has had minor, self-resolving upper respiratory infections but has otherwise been healthy. She takes no medications and her vaccinations are up-to-date. Examination shows an alert and cooperative girl with normal vital signs. Facial grimacing and tongue fasciculations are seen. The lungs are clear to auscultation and a II/VI holosystolic murmur is heard at the apex. When the girl speaks, distinct changes in the volume and pitch of her voice are noted. Muscular tone is mildly decreased globally. Pronator sign is positive, and the relaxation phase of the patellar reflex is delayed. The child's diagnosis is discussed with her parents, who would like to know more about treatment of the condition. Which of the following is the most appropriate medication for this patient?

Question

An 8-year-old girl is brought to the physician for abnormal behavior.  She has been acting inappropriately, crying, and laughing without apparent reason for the past 2 weeks.  At school, she was restless and easily distracted.  Last week, her parents noted strange movements of the girl's hands that improved when she slept.  On the day before presentation, her parents noticed rapid jerking movements of her face and feet.  The girl has had minor, self-resolving upper respiratory infections but has otherwise been healthy.  She takes no medications and her vaccinations are up-to-date.  Examination shows an alert and cooperative girl with normal vital signs.  Facial grimacing and tongue fasciculations are seen.  The lungs are clear to auscultation and a II/VI holosystolic murmur is heard at the apex.  When the girl speaks, distinct changes in the volume and pitch of her voice are noted.  Muscular tone is mildly decreased globally.  Pronator sign is positive, and the relaxation phase of the patellar reflex is delayed. The child's diagnosis is discussed with her parents, who would like to know more about treatment of the condition.  Which of the following is the most appropriate medication for this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfbd_56ff_8f63_1960700268de_MD0005_00 Streptococcal pharyngitis is the primary risk factor for acute rheumatic fever (ARF), and treatment with oral penicillin is the best method of primary prevention. Sydenham chorea (SC) is a cardinal feature of rheumatic fever, and affected patients should receive long-acting intramuscular penicillin until adulthood for secondary prevention, even if there is no active pharyngitis. The goal of antibiotic therapy is to eradicate group A streptococcus to prevent recurrent ARF and worsening rheumatic heart disease. Treatment of SC itself is primarily supportive with complete resolution occurring within months in most patients. Corticosteroids can reduce the duration of symptoms but are typically reserved for severe cases. (Choice A) Nonsteroidal anti-inflammatory agents such as ibuprofen or aspirin can be used for symptomatic relief of arthritis in patients with ARF. This patient has no symptoms of arthritis. In addition, aspirin is generally avoided in children due to the risk of Reye syndrome. (Choice B) Haloperidol is a powerful dopamine antagonist that can be used to control chorea in patients with severe symptoms that may result in self-injury. Haloperidol is not used in patients with mild-to-moderate symptoms due to the risk of extrapyramidal reactions. (Choice C) Methylphenidate is a stimulant medication for attention deficit hyperactivity disorder. It is inappropriate for SC as the neuropsychiatric symptoms should resolve spontaneously. (Choice E) Tetrabenazine is a dopamine antagonist used for Huntington disease but not SC. Educational objective: Patients with Sydenham chorea should be started on penicillin as soon as possible to eliminate carriage of group A streptococcus. Penicillin should be continued until adulthood with the goal of preventing recurrent rheumatic fever. References: Prevention of rheumatic fever and diagnosis and treatment of acute Streptococcal pharyngitis: a scientific statement from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, the Interdisciplinary Council on Functional Genomics and Translational Biology, and the Interdisciplinary Council on Quality of Care and Outcomes Research: endorsed by the American Academy of Pediatrics. (http://www.ncbi.nlm.nih.gov/pubmed/19246689) Discontinuing rheumatic fever prophylaxis in selected adolescents and young adults. a prospective study. (http://www.ncbi.nlm.nih.gov/pubmed/8439112) Comprehensive treatment of Huntington disease and other choreic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/22761268)

An 8-Year-Old Girl Is Brought to the Physician for Abnormal