Pediatric Case Conference

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Pediatric Case Conference
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History

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History

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Physical Examination

• V/S T 38.3 RR 24 HR 100 BP 104/60
• GA active, moderately pale, no jaundice,
• HEENT pharynx not injected
• Heart pansystolic murmur gr III at apex, radiate
  to axilla, no heaving, no thrill, no pericardial
  rub
• Lung equal breath sounds, no adventitious sound

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Physical Examination

• Abd soft, not tender, liver and spleen not
  palpable
• Ext mild swelling, warmth, tender and pain on
  motion at Rt 1st MTP jt , swelling, warmth,
  tender and pain on motion at Lt wrist
• Skin no abnormal mucocutaneous manifestation
• NS good consciousness, no abnormal movement

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Problem Lists

• Prolong fever
• Acute migratory polyarthritis
• Pansystolic murmur at apex radiate to axilla

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Differential Diagnosis

• 1. Acute rheumatic fever
• 2. Juvenile rheumatoid arthritis
• 3. SLE
• 4. Infective endocarditis

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Approach to arthritis
chronic
acute
mono
mono
poly
poly
septic gout pseudogout RF traumatic psoriatic
RF septic
gout pseudogout septic TB OA
rheumatoid tophaceous gout pseudogout psoriatic AS
OA SLE scleroderma
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Approach to arthritis

• Pattern of onset
• Intermittent gout, pseudogout, Bechets disease
• Migratory rheumatic fever, GC (some)
• Additive GC, RA, OA

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Investigation

• CBC Hb 23.7 WBC 15,800 N 78 L 10.2 Plt 657,000
  MCV 74.5
• ESR 140
• EKG prolong PR interval
• ASO titer
• Throat swab culture
• Rheumatoid factor
• CXR normal heart size, no pulmonary congestion

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Acute rheumatic fever

• Most common aquired heart disease in childhood
  esp. developing country
• Cross reactive immunity between ß-hemolytic
  streptococcal group A to human cardiac tissue
• Strep sore throat high grade fever,
  tonsillopharyngeal erythema, tonsillopharyngeal
  exudate, soft palate petechiae

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Acute rheumatic fever

• Most 5-15 yr, low socioeconomic status
• Latent period 7-35 day
• Sign and symptoms
• Migratory polyarthritis involving knee, ankle,
  wrist, elbow, shoulder. Need not be symmetric.
  Dramatic response to anti-inflammatory drugs in
  12-24 hr.

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Acute rheumatic fever

• Carditis
• pancarditis most is mitral valve insufficiency
  (apical pansystolic murmur) and/or aortic valve
  insufficiency (basal diastolic murmur)
• congestive heart failure, pericardial rub

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Acute rheumatic fever

• Subcutaneous nodules
• occur infrequently
• pea-sized nodules, firm, non tender, no
  inflammation, extensor surfaces of joints and
  over spines

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Acute rheumatic fever

• Erythema marginatum
• occur infrequently, often occur with chronic
  carditis
• pink macules over trunk, blaching in the middle,
  sometimes in serpiginous-looking, not itch,
  characteristically evanescent

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Acute rheumatic fever

• Sydenhams chorea
• unpurposeful, irregular rapid movement affect all
  four extrimities or unilateral,
• Muscle weakness, deterioration in hand writing,
• emotional lability.
• Occur later than others

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Acute rheumatic fever

• Minor manifestations fever, arthralgia,
  first-degree AV block, elevated acute phase
  reactants (ESR, CRP)
• Evidence of group A Streptococcal infection
  positive throat culture, Hx of scarlet fever,
  elevated streptococcal Ab (ASO, Anti-DNase B)

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Exceptional criteria

• Sydenham chorea
• Indolent carditis
• History of rheumatic fever or rheumatic heart
  disease

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Treatment

• Eradicate streptococcal infection Benzathine
  Penicillin G 600,000 u and 1,200,000 u IM single
  dose for BW lt 27 and gt27 kg consecutively or Oral
  Penicillin V 125-250 mg in childs tid or 500 mg
  in adults qid for 10 days or eryhromycin 20-40
  mg/kg/d for 10 days

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Treatment

• Supportive therapy treat congestive heart
  failure, absolute bed rest
• Anti-inflammatory drugs prednisolone 2 mg/kg/d
  for 2-4 wks in severe carditis and tape off. ASA
  75-100 mg/kg/d before off prednisolone 2 wks.
  Continue until no inflammation (observe ESR, CRP)

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Secondary prophylaxis
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Secondary prophylaxis
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Juvenile rheumatoid arthritis

• Chronic disease
• Varied in clinical manifestation
• Major cause of chronic disability
• Pathology chronic inflammation of synovium
  tissue by unknown etiology

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Juvenile rheumatoid arthritis

• Criteria
• Age of onset lt 16 yr
• Arthritis (swelling or effusion, or presence of
  two or more of the following signs limitation
  of ROM, tenderness, or pain on motion, and
  increased heat) in one or more jts
• Duration of disease 6 wk or longer

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Juvenile rheumatoid arthritis

• Onset type defined by type of disease in first 6
  mo
• Polyarthritis 5 or more inflamed jts
• Oligoarthritis lt 5 inflamed jts
• Systemic arthritis with characteristic
  fever(intermittent fever in association with MP
  rash on trunk or palms)
• Exclusion of other forms of juvenile arthritis

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Plan of treatment

• Benzathine penicillin G 120,000 u IM single dose
• Bed rest
• ASA
• Echocardiogram
• F/U ESR
• Secondary prophylaxis