Acute Rheumatic Fever: An Evidence-Based Approach To Diagnosis And Initial Management
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Acute Rheumatic Fever: An Evidence-Based Approach To Diagnosis And Initial Management
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Publication Date: August 2016 (Volume 13, Number 8)

CME: This issue includes 4 AMA PRA Category 1 Credits™; 4 ACEP Category 1 credits, 4 AAP Prescribed credits, and 4 AOA Category 2A or 2B CME credits.

Authors
 
Kajal Khanna, MD, JD
Clinical Assistant Professor, Stanford University, Division of Emergency Medicine, Stanford, CA
 
Deborah R. Liu, MD
Assistant Professor of Pediatrics, Keck School of Medicine of University of Southern California; Division of Emergency Medicine, Children's Hospital Los Angeles, Los Angeles, CA
 
Peer Reviewers
 
Matthew Hollander, MD, MHA
Assistant Professor of Pediatrics, Eastern Virginia Medical School, Department of Pediatrics, Division of Rheumatology; Children’s Hospital of The King’s Daughters, Norfolk, VA
 
Sara Leibovich, MD
Attending Physician, Division of Emergency Medicine, UCSF Benioff Children's Hospital-Oakland, Oakland, CA

Abstract

Acute rheumatic fever is an inflammatory reaction involving the joints, heart, and nervous system that occurs after a group A streptococcal infection. It typically presents as a febrile illness with clinical manifestations that could include arthritis, carditis, skin lesions, or abnormal movements. Of these, the cardiac manifestations of acute rheumatic fever are most concerning, as children may present in acute heart failure and may go on to develop valvular insufficiency or stenosis. Because this is a rare presentation to emergency departments in developed countries, it is crucial for clinicians to keep a broad differential when presented with clinical presentations suspicious for acute rheumatic fever. This issue focuses on the clinical evaluation and treatment of patients with acute rheumatic fever by offering a thorough review of the literature on diagnosis and recommendations on appropriate treatment.

Excerpt From This Issue

A previously healthy 9-year-old boy who recently emigrated from Polynesia presents to the ED with joint pain and swelling. According to his parents, he has been sick for 4 days with intermittent fever and began experiencing trouble breathing over the past day. Initially, he had a painful and swollen left knee, but this seems to be better today. Upon arrival in triage, he has an axillary temperature of 39°C (102.2°F). His vital signs are as follows: heart rate, 160 beats/min; respiratory rate, 30 breaths/min; and oxygen saturation, 93% on room air. On examination, he appears tired and complains of trouble breathing when lying down. His right knee is swollen, warm, and very tender to the touch. His left ankle is also swollen and he is unable to walk because of the pain and swelling. On examination of his chest, his lung sounds are clear, but you hear a holosystolic murmur at the apex. His abdomen is soft, but you feel a liver edge 5 cm below the costal margin. The boy is alert and oriented throughout your examination. What are your first steps toward treating this child? How will you establish your diagnosis? Can this child be safely discharged from the ED? What are the potential long-term sequelae?

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