injuries, intravenous catheters, and systemic steroid administration (203–205). The lesions are
raised erythematous papules or nodules that are discrete, firm, and nontender (205–207).
Other fungi, such as blastomycosis, histoplasmosis, coccidioidomycosis, and sporo-
trichosis, can also produce skin nodules (5,208). Patients with AIDS may present with
umbilicated nodules that resembleMolluscum contagiosumbut are caused byCryptococcus
neoformans.
Rheumatic Fever
Rheumatic fever is a late inflammatory complication of acute group A streptococcal
pharyngitis (209,210). Rheumatic fever occurs two to four weeks following the pharyngitis.
This disease occurs most frequently in children between the ages of four to nine years. The
disease is self-limited, but resulting damage to the heart valves may be chronic and
progressive, leading to cardiac decompensation and death.
Rheumatic fever is an acute, systemic, febrile illness that can produce a migratory
arthritis, carditis, central nervous system deficits, and rash. The diagnosis is based on major
and minor criteria (i.e., modified Jones criteria) (211). The five major criteria are carditis,
polyarthritis, chorea, erythema marginatum, and subcutaneous nodules. The three minor
criteria are fever, arthralgia, and previous rheumatic fever or rheumatic heart disease.
Arthritis is the most frequent and least specific manifestation (212). Large joints are
affected most commonly. The arthritis is migratory, with the joints of the lower extremities
affected first, followed by those of the upper extremities.
Carditis associated with rheumatic fever manifests as pericarditis, myocarditis, and
endocarditis, most commonly involving the mitral valve, followed by the aortic valve
(213,214). Rheumatic heart disease is a late sequela of acute rheumatic fever, occurring 10 to
20 years after the acute attack, and is the most common cause of acquired valvular disease in
the world (215). The mitral valve is most commonly affected with resultant mitral stenosis that
often requires surgical correction.
Sydenham chorea (chorea minor; St. Vitus’ dance) is a neurological disorder that
manifests as abrupt, purposeless, involuntary movements, muscle weakness, and emotional
disturbances (216). The abnormal movements disproportionately affect one side of the body
and cease during sleep.
Subcutaneous nodules are firm and painless and are seen most often with patients who
have carditis (217). The overlying skin is not inflamed. The nodules can be as large as 2 cm and
are most commonly located over bony surfaces or near tendons.
The nodules may be present for one to four weeks.
Erythema marginatum (218) is a pink or faint-red, nonpruritic rash that affects the trunk
and proximal limbs and spares the face. Erythema marginatum occurs early in the disease and
may persist or recur. The rash is usually only seen in patients with concomitant carditis.
The diagnosis of rheumatic fever is supported by evidence of preceding group A
streptococcal infection. Evidence of increased antistreptolysin O antibodies, positive throat
culture for group A beta-hemolytic streptococci, positive rapid-direct group A streptococcus
carbohydrate antigen test, or recent scarlet fever along with the presence of one major and two
minor or two major criteria is considered adequate to make the diagnosis.
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LTJ, eds. The Skin and Infection: A Color Atlas and Text. Baltimore: Williams and Wilkins,
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