Differentiating post-streptococcal reactive arthritis from acute rheumatic fever: a case report and review of literature

Abstract

Differentiating between acute rheumatic fever (ARF) and post-streptococcal reactive arthritis (PSRA) is crucial because, despite their similar presentations, there are immunological and genetic differences between them, and these two illnesses require different treatment approaches. Here, we report a case of an 8-year-old male child who presented with multiple large joint swellings and with a dilemma in diagnosis and approach to management. An 8-year-old male child with no previous family history of arthritis presented with bilateral knee and ankle joint swelling for 15 days, affecting his range of movements significantly, associated with high-grade fever with no antecedent respiratory/ throat infection. Investigations showed raised inflammatory markers and elevated anti-streptolycin O (ASO) titer and anti-DNAse levels. Electrocardiogram (ECG) and 2 D echocardiography were normal. The possibilities of ARF and PSRA were considered. Antibiotics and anti-inflammatory medications were started. After a few weeks of poor response, there was an improvement with a reduction in pain and swelling. On follow up the child was normal with normal echocardiography. PSRA was diagnosed based on clinical findings and the absence of cardiac involvement. The child is still being regularly followed up with a plan to repeat echocardiography till 2 years after initial presentation to rule out ARF. Current data supports the concept that PSRA is distinct from ARF based on clinical symptoms, response to therapy, and the low incidence of cardiac involvement in PSRA. It is currently unclear if prophylactic antibiotic use is advised for PSRA patients or if carditis develops later in the course of the illness. There is a need for improved identification and diagnostic criteria for diagnosing PSRA to gain a clearer understanding of its occurrence, especially in developing countries, and to better differentiate it from ARF. There is a need for improved identification and diagnostic criteria for diagnosing PSRA to gain a clearer understanding of its occurrence, especially in developing countries, and to better differentiate it from ARF. There is also a need for randomized placebo-controlled trials to further investigate prophylaxis in PSRA, as there is presently insufficient data to support this approach.