Atypical arthritis in a toddler: beware, save the heart
Keywords:Atypical arthritis, Children, Rheumatic fever
Acute rheumatic fever still poses a dreadful threat to pediatric morbidity and mortality. A 2 year old toddler presented to us with non migratory polyarticular joint pain and swelling. General physical and systemic examination was normal. Local examination revealed swelling and tenderness of multiple small and large joints. Further evaluation fulfilled Modified Jones criteria and she was diagnosed to have acute rheumatic fever. Other close differentials were simultaneously ruled out. Child was started on naproxen because of aspirin toxicity. There was significant response for therapy and complete resolution of joint involvement was noted on follow up. We report this case to emphasize the fact that rheumatic fever might have bizarre clinical presentation and may also affect infants and toddlers deviating the typical age of onset. There is a need for earliest possible initiation of adequate management and follow up to prevent permanent cardiac complications. This warrants high index of suspicion even in uncommon age group.
Collis WRF. Acute rheumatism and haemolytic streptococci. Lancet. 1931;217:1341-5.
Siegel AC, Johnson EE, Stollerman GH. Controlled studies of streptococcal pharyngitis in a pediatric population: factors related to the attack rate of rheumatic fever. N Engl J Med. 1961 Sep 21;265(12):559-66.
Beaudoin A, Edison L, Introcaso CE, Goh L, Marrone J, Mejia A, et al. Acute rheumatic fever and rheumatic heart disease among children—American Samoa, 2011–2012. MMWR. Morbidity Mortality Weekly Report. 2015 May 29;64(20):555.
Tani LY, Veasy LG, Minich LL, Shaddy RE. Rheumatic fever in children younger than 5 years: is the presentation different?. Pediatr. 2003 Nov 1;112(5):1065-8.
Aa C, Bb T, Jd M. Acute rheumatic fever: 27 year experience from the Montreal’s pediatric tertiary care centers. An Pediatr (Barc). 2007;67(1):5-10.
Gewitz MH, Baltimore RS, Tani LY. Revision of the Jones Criteria for the diagnosis of acute rheumatic fever in the era of Doppler echocardiography: a scientific statement from the American Heart Association. Circulation 2015;131: 1806-18.
World Health Organization. WHO expert consultation on rheumatic fever and rheumatic heart
disease. WHO Technical Report Series. 2004;923.
Omurzakova NA, Yamano Y, Saatova GM, Mirzakhanova MI, Shukurova SM, Kydyralieva RB, et al. High incidence of rheumatic fever and rheumatic heart disease in the republics of Central Asia. Inter J Rheumat Dis. 2009 Jul;12(2):79-83.
Kumar RK, Tandon R. Rheumatic fever & rheumatic heart disease: the last 50 years. Indian J Medical Res. 2013 Apr;137(4):643.
Joseph N, Madi D, Kumar GS, Nelliyanil M, Saralaya V, Rai S. Clinical spectrum of rheumatic fever and rheumatic heart disease: a 10 year experience in an urban area of South India. North Am J Medical Sci. 2013 Nov;5(11):647.
Sharma N, Toor D. Impact of Socio-Economic Factors on Increased Risk and Progression of Rheumatic Heart Disease in Developing Nations. Current Infect Dis Reports. 2019 Jun 1;21(6):21.
Saxena A, Kumar RK, Gera RP, Radhakrishnan S, Mishra S, Ahmed Z. Consensus guidelines on pediatric acute rheumatic fever and rheumatic heart disease. Indian Pediatr. 2008 Jul;45(7):565-73.
Shah B, Sharma M, Kumar R, Brahmadathan KN, Abraham VJ, Tandon R. Rheumatic heart disease: progress and challenges in India. Ind J Pediatr. 2013 Mar 1;80(1):77-86.
Canter B, Olguntu¨ rk R, Tunaoglu FS. Rheumatic fever in children under 5 years old [letter]. Pediatr. 2004;114:329–330.
Chockalingam A, Prabhakar D, Dorairajan S, Gnanavelu G, Venkatesan S, Chockalingam V. Rheumatic heart disease occurrence, patterns and clinical correlates in children aged less than five years. J Heart Valve Dis. 2004 Jan 1;13(1):11-4.
Shankar B, Bhutia E, Kumar D. Atypical arthritis revisited: Acute rheumatic fever. Ann Pediatri Cardiol. 2016 May;9(2):164.
Majeed HA, Yousof AM, Shaltout A, Khuffash FA. Acute rheumatic fever below the age of five years: a prospective study of the clinical profile. Ann Tropic Paediatr. 1984 Mar 1;4(1):37-40.
Pileggi GC, Ferriani VP. Atypical arthritis in children with rheumatic fever. J Pediatr (Rio J) 2000;76:49-54.
Bhutia E, Kumar D, Kundal M, Kishore S, Juneja A. Atypical articular presentations in Indian children with rheumatic fever. Heart, Lung Circulation. 2018 Feb 1;27(2):199-204.
Robazzi TC, de Araujo SR, de Araújo Costa S, de Oliveira Júnior AB, Nunes LS, Guimaraes I. Articular manifestations in patients with atypical rheumatic fever. Revista Brasileira Reumatol (English Edition). 2014 Jul 1;54(4):268-72.
Banna HH, Swelam RA. Clinical presentations of atypical arthritis in Egyptian children with acute rheumatic fever. J Am Sci. 2013;9:253-61.