A 5-year-old girl is brought to the clinic with joint pain and rash. Last week, the patient developed pain in her knees. The pain resolved after a few days, but now her ankles and wrists are tender. She has also developed a nonpruritic, pink rash on her back. The patient had previously been healthy except for a sore throat a few weeks ago that resolved on its own. Temperature is 38.3 C (101 F), pulse is 85/min, and respirations are 20/min. Cardiac examination is normal. The lungs are clear to auscultation. The wrists and ankles are stiff and tender to manipulation. Multiple large, well-demarcated, erythematous, nonpruritic patches with a slightly raised outline are present on the trunk and proximal limbs. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

Question

A 5-year-old girl is brought to the clinic with joint pain and rash.  Last week, the patient developed pain in her knees.  The pain resolved after a few days, but now her ankles and wrists are tender.  She has also developed a nonpruritic, pink rash on her back.  The patient had previously been healthy except for a sore throat a few weeks ago that resolved on its own.  Temperature is 38.3 C (101 F), pulse is 85/min, and respirations are 20/min.  Cardiac examination is normal.  The lungs are clear to auscultation.  The wrists and ankles are stiff and tender to manipulation.  Multiple large, well-demarcated, erythematous, nonpruritic patches with a slightly raised outline are present on the trunk and proximal limbs.  Laboratory results are as follows:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d742_d1da_bc81_a1bb9159e9c4_MD0003_00 Acute rheumatic fever (ARF) is a complication that typically occurs 2-4 weeks after an episode of untreated group A streptococcal pharyngitis. Diagnosis is based on clinical or laboratory evidence of a preceding group A streptococcal infection along with 2 major, or 1 major plus 2 minor, Jones criteria. Joint pain is often the earliest finding; other major criteria include carditis, subcutaneous nodules, erythema marginatum (annular pink rash with sharp, raised edges and central clearing), and Sydenham chorea. erythema marginatum This patient's fever, rash, migratory polyarthritis (particularly in the wrists, ankles, and knees), and elevated acute-phase reactants (C-reactive protein [CRP] and erythrocyte sedimentation rate [ESR]) satisfy the diagnostic criteria for ARF. Supportive laboratory findings would include a positive streptococcal antigen test or elevated antistreptolysin O titer. ARF can be prevented with penicillin treatment of streptococcal pharyngitis. (Choice B) Henoch-Schönlein purpura is a vasculitis that can cause a transient, migratory arthritis and rash. However, the rash is purpuric, and the arthritis typically involves the lower extremity joints (hip/knee/ankle). (Choice C) Lyme disease is a tick-borne illness that can present with rash and arthritis. The rash consists of single or multiple bullseye lesions (erythema migrans) that slowly expand. However, in contrast to this patient, those with Lyme disease usually have monoarticular arthritis, typically involving the knee. In addition, this patient's recent history of pharyngitis makes ARF more likely. erythema migrans (Choice D) Systemic juvenile idiopathic arthritis is diagnosed when arthritis is present for >6 weeks. Systemic symptoms, including fever and rash, can be seen in children with systemic juvenile idiopathic arthritis, but the arthritis is usually not migratory, as in this patient. (Choice E) Systemic lupus erythematosus is an autoimmune disease that affects multiple organ systems and is rare in young children. Arthritis and elevated CRP and ESR can be seen, but the rash is usually present across the cheeks (malar rash). Educational objective: Acute rheumatic fever, a complication of streptococcal pharyngitis, is diagnosed clinically using the Jones criteria, which include fever, migratory polyarthritis, erythema marginatum, and elevated acute-phase reactants. References: Acute rheumatic fever and streptococci: the quintessential pathogenic trigger of autoimmunity. (http://www.ncbi.nlm.nih.gov/pubmed/24894108) Diagnostic criteria of acute rheumatic fever. (http://www.ncbi.nlm.nih.gov/pubmed/24424191)

A 5-Year-Old Girl Is Brought to the Clinic with Joint