04

Discussion
 Diagnosis of arthritis et causa acute rheumatic fever in this patient
based on anamnesis, physical examination and supporting examinations.

• A boy, aged 7 years 5 months, complained of pain in the joints since 2 weeks before
entering the hospital.
• Pain is felt in both elbows, knees, and ankles, with the most pain strong on the left knee.
ANAMNESIS
Complaints of pain are also accompanied by swelling and a feeling of heat these joints.
• 1 week of SMRS, the patient complained of fever and cough without phlegm. The fever is
felt up and down, but never reaches a normal temperature.
 Physical exam
• On examination of vital signs, the patient was found to
have a fever with a temperature of 38.9 C.
• In the upper extremities, signs of inflammation were
found on the right and left cubital joints.
• In the lower extremities, signs of inflammation were
also found on the right and left genu and right and
left ankles.
• Decrease in motor power in the patient's upper and
lower extremities.
• The clinical feature of arthritis is the effect of immune
complex formation by SGA infection.
• Arthritis findings in these patients are consistent with the
theory that arthritis is the most common clinical
manifestation in nearly 70% of ARF cases and usually
involves large joints which manifests as intense pain,
swelling, burning sensation, and limited range of motion.
 Laboratory exam
• Laboratory examination showed a quantitative • CRP is a pentameric protein synthesized by the liver
increase in CRP (123.5 mg/L) and neutrophilia whose levels can increase in response to inflammation.
(80.6%). Increased CRP ≥3 mg/dL is one of the minor criteria that
• Examination of the antistreptolysin O (ASTO) titer in is fulfilled in the diagnosis of ARF in this patient.
the patient also showed a positive result of 600 IU/mL. • ASTO is a standard diagnostic test for ARF as one of the
pieces of evidence supporting Streptococcus infection.
ASTO titers can be found in about 70% to 80% of cases
of ARF.
 ECG exam
• In patients, the PR interval was prolonged (0.20
seconds) with normal values ​according to age and heart
rate, namely 0.14 seconds with an upper limit value of
0.15 seconds.
• A prolonged PR interval indicates an abnormal delay of
the conduction system in the atrioventricular node, but
these ECG changes are not specific for ARF.

The Modified Jones Criteria (2015)

No Major criteria   Minor criteria  

1. Carditis   Polyarthralgia  
2. Polyarthritis ✓ Fever ≥38,5°C ✓
3. Sydenham chorea   LED ≥60mm/hours,CRP ≥3mg/dL ✓
4. Erythema marginatum   Prolonged PR interval (excluding minor ✓
criteria if arthritis is exist)
5. Subcutaneous nodules      
 Therapy
• The initial management : prophylactic antibiotics
Benzathine penicillin G 0.6 to 1.2 million IU/IM to
eradicate SGA.
• In this patient : Benzathine penicillin G 600,000/IU IM as
primary and secondary prevention. Secondary
prophylaxis was given 4 weeks after the first dose was
administered when the patient was in control at the poly.
• The duration of administration of Benzathine penicillin G
in DRA patients without carditis is at least 5 years or up
to the age of 21 years, or even longer.
 Therapy
• Anti-inflammatory or suppressive therapy with • In this patient : This patient was given Aspirin 520 mg/8
salicylates or steroids must not be started until a definite hours and found an improvement symptoms on delivery,
diagnosis is made. such as complaints of reduced pain and swelling as well
• For arthritis, aspirin therapy is continued for 2 weeks as strength improving motor skills
and gradually withdrawn over the following 2 to 3
weeks. Rapid resolution of joint symptoms with
aspirin within 24 to 36 hours is supportive evidence of
the arthritis of acute rheumatic fever.
Prevention
• Providing education to these patients is very important, especially to the patient's parents
regarding ongoing treatment.
• Penicillin Benzathine 600,000 IU/Im should be repeated every 4 weeks and given for at least 5
years after the last attack or until the age of 21 years.
• Therefore it is recommended for patients to routine control to the children's polyclinic so that the
development of this disease provides a better prognosis.
• In addition, patients are also given education regarding the importance of maintaining personal
hygiene, especially oral hygiene to prevent infective endocarditis.
 Other
• The patient also found moderate hypochromic • If found decreased serum iron with increased TIBC
microcytic anemia. In these patients, further and decreased ferritin generally indicates an iron
examination is needed in the form of serum Fe, TIBC, deficiency anemia, while decreased serum iron levels
and Ferritin examinations to determine the cause of with decreased TIBC and increased or normal ferritin
anemia. indicate an anemia of chronic disease
• The prognosis in this patient is dubia ad bonam
because it has improved with the therapy given.