16-year old girl with complaints of high-grade fever, bilateral knee joints pain and skin rash

A 16-year old girl with complaints of high-grade fever, chest pain, SOB , and bilateral knee joints pain and rash over the arms/legs for 1 week

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History of presenting
Past Medical/Social hoistory
Past surgical history
Family history
Current Medication

A 16-year old girl seen in PC office with high-grade fever, LE joints pain, swelling and reddish skin rash over upper and lower Extremities for the past 10 days. symptoms started with throat pain, dry cough. . The pain in her joints started in her left elbow and then migrated to affect both her knees and ankles and limited her walking ability. The skin rash was maculo-papular erythematous. no recent dental extraction. She did have sore-throat frequently during her childhood, but there was no history of anoxic spells or squatting attacks while playing.

no history of purulent sputum, chest pain, dyspnea, wheezing or hemoptysis.
She also denied pain abdomen, vomiting, loose stools or burning sensation during micturition.
no petechial spots or history of pruritus

General

appeared toxic and anxious. RR 20, HR 112, BP of 114/76 mm Hg, Temperature was 102.6 o F. EOM's intact.Septum midline. Mucosa normal. No drainage or sinus tenderness.

Heent

PHARYNX CONGESTION/ ENLARGED TONSILS, FEW PUSTULES no thyromegaly, conjunctiva PALLOR , normal dentition, no JVD

Neck

no carotid bruits, trachea midline, no lymphadenopathy,

Cardiovascular

A LOW PITCH MID-DIASTOLIC MURMUR at the cardiac apex. NO OPENING SNAP / NO PRE SYSTOLIC accentuation auscultated. POSITIVE PERICARDIAL RUB

Lungs

CTAB, no respiratory distress or retractions. No wheezing.

Abdomen

Soft, Non tender on palpation , normal BS, no hepatosplenomegaly. No rebound

Extremities

Her extremities were WARM/DRY. NO TREMOR/ CLUBBING, no cyanosis or edema, pulses positive and symmetric

Skin

erythematous BLANCHING RASH over the extremities , SUBCUTANOUS NODULES

Neurological Exam

no focal neurological deficits, normal power, sensations normal. reflex within normal range

Bio Chemistry
Pathology
Microbiology
Hematology
Miscellaneous

Sodium: 136 meq/L( normal 135-145 meq/L)

Potassium: 4 meq/L (normal 3.5-5.0 meq/L)

Chloride: 100 meq/L(normal 96-108 meq/L)

Bicarb: 26 meq/L(normal 22-30 meq/L)

Magnesium: 1.9 mg/dl ( normal 1.7 to 2.2 mg/dL )

Phos.: 2.9mg/dl ( normal 2.8 to 4.5 mg/dL)

Bun: 22mg/dl ( normal 6-23 mg/dL)

Creat: 1.1 mg/dl ( normal 0.7 -1.3 mg/dL)

Liver Enzymes - SGOT/AST: 32U/L ( normal 1-35 )

SGPT/ ALT: 43U/L ( normal 1-45 )

GGT: 6 U/L ( normal 8-38 )

Direct Bilirubin: 0.2 mg/dl ( normal 0.1-0.3 )

Total Bilirubin: 1 mg/dl ( normal 0.1 - 1.2 )

NA

NO GROWTH - BLOOD OR URINE

Hemoglobin: 10.2 g/dl ( normal 13.9 -16.3)

Hematocrit: 34% ( normal 42-52 % )

White Count: 11.5 ( normal 4,500 to 11,000 WBCs per microliter) 73 PERCENT NEUTRO

Platelets: 160 ( normal 150,000 to 450,000 platelets per microliter)

Differential: 73 % NEUTROPHILS

CRP : 66 MG/ L - HIGH

CARDIOMEGALY, HILAR VASCULAR CONGESTION

NA

MITRAL REGURGITATION ON ECHO

SUBCUTANEOUS NODULE ON HAND

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The major sequel of acute rheumatic fever is chronic valvular heart disease. Antibodies against streptococcal polysaccharide (carbohydrate cell wall) crossreact with cardiac tissues (myosin and laminin) to cause valve damage by molecular mimicry. During the acute stage, the mitral valve leaflets are inflamed resulting in a diastolic Carey-Coomb’s murmur. Later on, due to smouldering disease, the valves are chronically damaged. Mitral stenosis, aortic regurgitation, mitral regurgitation and aortic stenosis, follow in that order of decreasing incidence.

A migratory or “fleeting” type of polyarthritis with fever and extreme weakness is the commonest manifestation of rheumatic fever. The arthritis typically involves the medium-sized joints such as the elbows, ankles and wrists. Chorea is usually observed in young children as an isolated entity, with rheumatic heart disease occuring a few days later. Erythema marginatum, which is hardly seen, is a pink rash on the trunk which blanches on pressure and is neither painful nor indurated. Rheumatic carditis is a pancarditis. Endocarditis manifests as a new murmur due to inflamed valve leaflets. Myocarditis presents as newly developed myocardial dysfunction. Evidence of pericarditis is a pericardial friction rub or presence of an effusion.

The major sequel of acute rheumatic fever is chronic valvular heart disease. Antibodies against streptococcal polysaccharide (carbohydrate cell wall) crossreact with cardiac tissues (myosin and laminin) to cause valve damage by molecular mimicry. During the acute stage, the mitral valve leaflets are inflamed resulting in a diastolic Carey-Coomb’s murmur. Later on, due to smouldering disease, the valves are chronically damaged. Mitral stenosis, aortic regurgitation, mitral regurgitation and aortic stenosis, follow in that order of decreasing incidence.

16-year old girl with complaints of high-grade fever, bilateral knee joints pain and skin rash

By: Medcase Editor