A Patient with Migrating Polyarthralgias

A CLINICAL PROBLEM-SOLVING article by Jonathan Casey from Brigham and Women's Hospital, Boston.
A 28-year-old woman with no clinically significant medical history presented to the emergency department for evaluation of fatigue and joint pain. She initially noted pain and swelling in her right foot and ankle, which limited her ability to walk. These symptoms resolved, but pain in her knees and hips then developed, along with swelling and pain in her right elbow.
The physical examination was notable for a temperature of 38.3°C (101.0°F) and for diffuse tenderness of the joints on palpation.
The patient was born in Brazil and moved to the northeastern United States 10 years before presentation. The patient recalled that when growing up in Brazil, she became short of breath easily and was unable to play with other children.
Transthoracic echocardiography revealed severe mitral regurgitation and mild aortic insufficiency. There was thickening of the mitral valves and evidence of chronic mitral stenosis. Titers for antistreptolysin and antiDNase B antibodies were high.
The range of possible causes of joint pain and fatigue is broad, but the polyarticular, migratory nature of the joint pain in this patient helps to narrow the possibilities. The patient has no documented risk factors for infective endocarditis, but the fact that she was born in Brazil puts her at increased risk for rheumatic heart disease. 

リウマチ熱診断基準の覚え方　 J♡ NES PEACE

Major criteria

• Joints: A temporary migrating inflammation of the large joints, usually starting in the legs and migrating upwards. 
• ♡ (Carditis): Inflammation of the heart muscle (myocarditis) which can manifest as congestive heart failure with shortness of breath, pericarditis with a rub, or a new heart murmur. 
• Nodules, subcutaneous: Painless, firm collections of collagen fibers over bones or tendons. They commonly appear on the back of the wrist, the outside elbow, and the front of the knees. 
• Erythema marginatum: A long-lasting reddish rash that begins on the trunk or arms as macules, which spread outward and clear in the middle to form rings, which continue to spread and coalesce with other rings, ultimately taking on a snake-like appearance. This rash typically spares the face and is made worse with heat.
• Sydenham's chorea(St. Vitus' dance): A characteristic series of rapid movements without purpose of the face and arms. This can occur very late in the disease for at least three months from onset of infection.

 · Minor criteria:

• Prolonged PR interval 
• ESR elevated
• Arthralgias 
• CRP elevated 
• Elevated temperature