Vancouver IM LMR

In today’s noon report we worked through a case of a 52 year old man who presented with 3-4 week history of fever, malaise, and a migratory polyarthritis affecting the large joints.

Didactic slides can be found here.

Key takeaways:

• Approach to polyarthralgia/ polyarthritis:
  • Inflammatory
    • Systemic rheumatic condition
      • Rheumatoid arthritis
      • Seronegative spondyloarthropathies
      • Connective tissue diseases
      • Polymyalgia rheumatica
      • Systemic vasculitis
      • Inflammatory myopathy
      • Sarcoidosis
    • Post-infectious
      • Reactive arthritis
      • Post-streptococcal arthritis/ acute rheumatic fever
    • Infectious
      • Viral polyarthritis
      • Bacterial, fungal, sphirochete, mycobacterial infection
    • Crystal arthropathy (CPPD or gout)
    • Inflammatory OA
  • Non-inflammatory
• Acute rheumatic fever
  • Epidemiology: incidence has decreased significantly in high income countries like Canada. Typically affects children ages 5-15 but can also occur in adults.
  • Presents 2-3 weeks after acute GAS infection
  • Diagnosis: Revised Jones Criteria
    • Need 2 major criteria or 1 major + 2 minor criteria
    • Major criteria: polyarthritis, carditis (valvulitis MR > AR), Sydenham chorea, erythema marginatum, and subcutaneous nodules
    • Minor criteria: polyarthralgia, fever > 38.5, CRP > 30, prolonged PR interval
  • Treatment:
    • GAS eradication: penicillin G IM x 1 dose OR penicillin V PO x 10 days
    • ARF secondary prophylaxis: penicillin G IM q21-28 days x 5-10 YEARS

This patient ended up testing positive for GAS, syphilis, chlamydia, and hepatitis C! It’s nice when you can Occam’s razor your way into one diagnosis that ties everything neatly together but medicine is real life and real life can be messy.