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Chapter 6 Fever and joint pains. 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. Temperature: 38.9°C, pulse: 110/min, RR: 20/min; no cyanosis, capillary refill 1 second, SpO 2 93.
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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. Temperature: 38.9°C, pulse: 110/min, RR: 20/min; no cyanosis, capillary refill 1 second, SpO2 93
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
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
History and examination in a child with fever and joint pains • What are key questions to ask on history? (Ref. p. 150) • What are key things to look for on examination? (Ref. p. 150)
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 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.
Examination • Vital signs • Temp: 38.9ºC Pulse: 145/min RR: 22/min BP 115/65 mmHg, SpO2 95% • Chest and heart • Chest clear, systolic murmur loudest at the apex and radiating to the axilla. No thrill. Apex beat normally placed. • Abdomen • Soft to palpation, normal bowel sounds, no organomegaly • Neurology • AVPU = A (alert), no neck stiffness, pupils equal and reactive • Skin • No rashes • Nutrition • Height: 135 cm Weight: 34 kg → BMI = 34/1.352 = 18.7 • Limbs • Hot and swollen right knee that is very tender to touch • (Ref. p.150, p.154)
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
Differential diagnoses • Differential diagnoses: Septic arthritis Rheumatic fever Dengue Viral arthritis (reactive, e.g. Chikungunya) Chronic juvenile arthritis (onset) Others… (Tables 16, 17, 19 may be helpful)
Joint aspiration? If septic arthritis is suspected then x-ray and joint aspirate should be done What are the features of septic arthritis? ( Ref p. 186-187)
Investigations for acute rheumatic fever FBE ESR – 88 mm/hour ASOT ECG Chest x-ray Joint x-ray Throat swab Echocardiogram
Investigations Full blood examination: Haemoglobin: 10.2g/dl (11.5-14.0) Platelets: 450x109/l (150 – 400) WCC: 16.2x109/l (5.5 – 15.5) Neutrophils: 7.9x109/l (1.5 – 8.5) Lymphocytes: 7.0x109/l (2.0 – 8.0) Monocytes: 1.2x109/l (0.1 – 1.0) ESR: 88 mm/hour
Diagnosis Summary of findings: • History: 11 year old girl with fever and pains and inflammation in 2 joints (left ankle, resolved and now right knee) • Exam: fever but non-toxic, with right knee swelling, tenderness. A new heart murmur. • Investigations: mild anaemia, mild leukocytosis, elevated ESR • Likely acute rheumatic fever
Treatment Suspected acute rheumatic fever Aspirin (Ref p. 357) • Benzyl-penicillin G to treat acute Streptococcus infection • Oral penicillin V daily or Benzathine penicillin IM every 28 days as prevention (prophylaxis) (Ref p. 367)
Supportive Care • Fever control • Pain control • Bed rest • Nutrition
Monitoring • Using a monitoring chart (Ref. p. 320, 413) • Assess response to treatment (Ref .Chart 1 p.xxii; p. 319) • Follow-up results • ASOT 1600 • BC negative • ESR 88 mm/h
Discharge planning • Mere responds quickly to the aspirin and her joint pain and fever resolves by 2 days • She is able to walk adequately • She is eating well after 2 days • She has no problems taking her medication • Mere and her parents are educated about rheumatic fever and rheumatic heart disease and given printed information • Mere prefers to receive an IM dose of Benzathine penicillin every 28 days, as she thinks she will forget to take daily penicillin • A clear plan is made for follow-up visit
Follow-up • Benzathine penicillin G every 28 days (or daily oral) • Register the patient on the PNG RHD Register • Echocardiogram and paediatric review • Education, advise Mere and her mother when to come back if she has a fever, sore joints, breathlessness or chest pain • Tell Mere when she can return to school and normal activity
Diagnosis of acute rheumatic fever WHO Guidelines (Ref 6.11, page 193) Major manifestations • Polyarthritis • Carditis • Chorea • Erythema marginatum • Subcutaneous nodules Minor manifestations • Polyarthralgia • Fever, • Elevated inflammatory markers • Prolonged PR interval on ECG Evidence of Group A Streptococcus infection in the last 45 days • Elevated or rising streptococcal antibody titre (ASOT) • Positive throat swab Two major and one minor Or One major and 2 minor, PLUS Streptococcal infection