5-98
Follow-up Actions
Return evaluation: Referral as needed.
Consultation Criteria: Failure to improve.
Zoonotic Disease Considerations
Principal Animal Hosts: Rodents
Clinical Disease in Animals: Arthritis, pericarditis
Probable Mode of Transmission: Rodent bites, water-or food-borne
Known Distribution: Worldwide; rare
ID: Acute Rheumatic Fever
COL Naomi Aronson, MC, USAIntroduction: Acute rheumatic fever (ARF) typically occurs approximately 19 days after untreated
streptococcal pharyngitis in 1-3% persons. Certain group A strep strains are more likely to cause ARF. Peak
incidence is from 5-20 years of age. Recurrences are common (50%).
Subjective: Symptoms
Fever; migratory polyarthralgias in knees, ankles, elbows or wrists; rash which can wax and wane over
months; subcutaneous nodules and chorea. If carditis is present, patient may have palpitations, chest pain,
or SOB.
Focused History: Have you had a sore throat in the last few weeks? (ARF follows a strep throat infection.)
Have you taken your temperature or do you feel hot? (expect to document a temperature >100° F) Have you
felt sick for a long time? (ARF may present with chronic signs such as Sydenham’ s chorea and the rash of
Erythema marginatum. Both are explained below.)
Objective: Signs
Using Basic Tools: Inspection: Fever to 102°F (up to 21 days); rapid respiratory rate (if carditis); E.
marginatum rash (irregularly edged, transient, lacy, macular rash [pink rimmed with internal blanching] found
on the trunk and extremities) which waxes and wanes for months; chorea (short, abrupt, non-purposeful
movements, which often disappear during sleep and grimacing). Palpation: migratory large joint inflammation
(arthritis); 10% have subcutaneous nodules on extensor elbows and forearms which last up to 4 weeks.
Auscultation: In carditis: bibasilar rales, aortic insufficiency or mitral regurgitation murmurs, pericardial friction
rub, S3 gallop.
Using Advanced Tools: In carditis, CXR may show cardiomegaly. EKG may have prolonged PR interval.
Assessment:
Diagnosis is based on clinical observation and application of the Jones criteria for diagnosis: 2 major criteria,
OR 1 major and 2 minor criteria AND evidence for prior streptococcal infections (prior scarlet fever, + throat
culture)
Major Criteria: Carditis, polyarthritis, subcutaneous nodules, and chorea, E. marginatum rash
Minor Criteria: Fever, arthralgias prior rheumatic fever, heart block seen on EKG
Differential Diagnosis
Polyarthritis is often the main presenting symptom. The differential diagnosis should include:
Gonococcal arthritis - sexual exposure; dysuria; urethral discharge; characteristic gun metal blue skin lesion
Subacute bacterial endocarditis - diagnose with blood cultures (if available); usually few joints involved; may
see embolic skin lesions
Lyme disease - fever less frequent; fewer joints involved; history of tick bite
Reiter’s syndrome - fever is unusual; prior history of sexually transmitted disease or acute diarrheal illness;
characteristic skin lesions (painless, superficial erosions) in genital area/soles of feet