1. A Case of Knee Swelling – Don’t
Forget Your Stethoscope!
K.S. Chew, K.Hamizah
School of Medical Sciences
Universiti Sains Malaysia

2. Case History
 A 10-year old boy
 previously well
 came to the emergency department, HUSM
 complained of solitary right knee pain & swelling for
1/7; no other joints involved
 the pain started after he woke up from his sleep
 the pain was not migratory
 able to walk without much of a limping gait and was
able to bear his own weight

3. Case History
 had history of mild fever started two days prior to the
joint pain
 denied any prior history of trauma
 neither had similar episodes in the past
 nor any prior recent episode of upper respiratory
tract infection or sore throat
 went to a health clinic, given paracetamol and
antibiotics
 fever settled; annoying joint pain and swelling persisted

4. On Arrival
 afebrile
 normal vital signs
 right knee was warm, mildly swollen and tender
over the anterolateral aspect
 able to walk in the emergency department with a
slight limping
 triaged to the Green Zone

5. What Do You Think Is Wrong With The
Patient At This Moment?

6. On Examination
 clinically, appeared to have an early-onset suppurative
arthritis
 right knee examination revealed a slightly reduced
range of movement to about 120°
 no clinical evidence that he had gross joint effusion.
 however, on cardiovascular examination, he had a
grade III pan-systolic murmur over the apical area
 acute rheumatic fever??
 no other manifestations fulfilling other major Jones’
criteria

7. Jones Criteria (1992)
Acute Rheumatic Fever Diagnosis
Two major OR one major with two minor criteria PLUS
Evidence of antecedent group A streptococcal infection
-Positive throat culture or rapid antigen test for group A streptococcus
-Raised or rising ASOT (>250 IU/ml)
Major Criteria Minor Criteria
Carditis Fever
Polyarthritis Arthralgia
Chorea C-RP or ESR elevated
Erythema Marginatum Prolonged PR interval on ECG
Subcutaneous nodules
Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the
Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in
the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.

8. Investigation
Full Blood Count
 Hb: 10.2 g/dl
 TWC: 12,900/mm3
 Platelet count: 548,000/mm3
 ESR: 140 mm/hr
 Anti-streptolysin O titre (ASOT): 800 IU/mL (>250)
 Blood C&S: No growth
 Renal/Liver Function tests: within normal range
 X-ray: No radiological evidence of septic arthritis

9. Provisional Diagnosis
 His ECG revealed a sinus tachycardia with normal PR
interval
 Admitted to pediatric ward with a provisional
diagnosis of acute rheumatic fever with carditis.
 An echocardiogram done showing a severe mitral
regurgitation with a mild aortic regurgitation and an
ejection fraction (EF) of 35%
Dx:
Acute Rheumatic
Fever

10. Discussion

11. Discussion
 ARF is diagnosed by using the modified and updated Jones
criteria
 Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992
update. Special Writing Group of the Committee on Rheumatic Fever,
Endocarditis, and Kawasaki Disease of the Council on Cardiovascular
Disease in the Young of the American Heart Association. JAMA. 1992
Oct 21;268(15):2069-73.
 The current Jones criteria published in 1992 was modified,
revised twice and updated from the original Jones criteria
first proposed by Dr. T. Duckett Jones in 1944
 Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet.
2005 Jul 9-15;366(9480):155-68.

12. Discussion
 ARF is diagnosed by using the modified and updated Jones
criteria
 Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992
update. Special Writing Group of the Committee on Rheumatic Fever,
Endocarditis, and Kawasaki Disease of the Council on Cardiovascular
Disease in the Young of the American Heart Association. JAMA. 1992
Oct 21;268(15):2069-73.
 The current Jones criteria published in 1992 was modified,
revised twice and updated from the original Jones criteria
first proposed by Dr. T. Duckett Jones in 1944
 Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet.
2005 Jul 9-15;366(9480):155-68.

13. Discussion
 ARF is diagnosed by using the modified and updated Jones
criteria
 Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992
update. Special Writing Group of the Committee on Rheumatic Fever,
Endocarditis, and Kawasaki Disease of the Council on Cardiovascular
Disease in the Young of the American Heart Association. JAMA. 1992
Oct 21;268(15):2069-73.
 The current Jones criteria published in 1992 was modified,
revised twice and updated from the original Jones criteria
first proposed by Dr. T. Duckett Jones in 1944
 Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet.
2005 Jul 9-15;366(9480):155-68.

14. Discussion
 The reason for the many revisions is to increase the
specificity of the criteria in response to the reducing
number of ARF cases in developed countries.
 For example, the original Jones criteria include arthralgia as a
major criterion, whereas today, arthralgia is considered as a
minor criterion.
 however, the increased specificity has also resulted in
decreased sensitivity as a trade-off.
 unfortunately, following the Jones criteria strictly resulted
in many subclinical valvular damage in ARF noted
worldwide
Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet. 2005 Jul 9-15;366(9480):155-68.

15. Clinical Features of Rheumatic Fever

16. Discussion
 In this patient, he presented with monoarthritis rather than the
classical migratory polyarthritis
 Monoarthritis has been increasingly reported in the literature
as a presenting feature in ARF.
 Harlan GA, Tani LY, Byington CL. Rheumatic fever presenting as
monoarticular arthritis. Pediatr Infect Dis J. 2006 Aug;25(8):743-6.
 Carapetis JR, McDonald M, Wilson NJ. Acute rheumatic fever. Lancet.
2005 Jul 9-15;366(9480):155-68.
 Carapetis JR, Currie BJ. Rheumatic fever in a high incidence
population: the importance of monoarthritis and low grade fever.
Arch Dis Child. 2001 Sep;85(3):223-7.
 Wilson E, Wilson N, Voss L et al. Monoarthritis in rheumatic fever?
Pediatr Infect Dis J 2007; 26 (4):369-70.

17. WHO Criteria For Rheumatic Fever
(2002 - 2003)
Chorea and indolent carditis do not require evidence of antecedent group A
streptococcus infection
First Episode
As per Jones Criteria
Recurrent Episode
In a patient without established RHD: as per first episode
In a patient with established RHD: requires two minor manifestations, plus
evidence of antecedent group A streptococcus infection
WHO. Rheumatic fever and rheumatic heart disease: report of a WHO Expert Consultation, Geneva, 29
October–1 November 2001. Geneva: World Health Organization, 2004.

18. Jones Criteria (1992)
Acute Rheumatic Fever Diagnosis
Two major OR one major with two minor criteria PLUS
Evidence of antecedent group A streptococcal infection
-Positive throat culture or rapid antigen test for group A streptococcus
-Raised or rising ASOT (>250 IU/ml)
Major Criteria Minor Criteria
Carditis Fever
Polyarthritis Arthralgia
Chorea C-RP or ESR elevated
Erythema Marginatum Prolonged PR interval on ECG
Subcutaneous nodules
Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the
Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in
the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.

19. Jones Criteria (1992)
Acute Rheumatic Fever Diagnosis
Two major OR one major with two minor criteria PLUS
Evidence of antecedent group A streptococcal infection
-Positive throat culture or rapid antigen test for group A streptococcus
-Raised or rising ASOT (>250 IU/ml)
Major Criteria Minor Criteria
Carditis Fever
Polyarthritis Arthralgia
Chorea C-RP or ESR elevated
Erythema Marginatum Prolonged PR interval on ECG
Subcutaneous nodules
Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the
Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in
the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.

20. Jones Criteria (1992)
Acute Rheumatic Fever Diagnosis
Two major OR one major with two minor criteria PLUS
Evidence of antecedent group A streptococcal infection
-Positive throat culture or rapid antigen test for group A streptococcus
-Raised or rising ASOT (>250 IU/ml)
Major Criteria Minor Criteria
Carditis Fever
Polyarthritis Arthralgia
Chorea C-RP or ESR elevated
Erythema Marginatum Prolonged PR interval on ECG
Subcutaneous nodules
Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the
Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in
the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.

21. Jones Criteria (1992)
Acute Rheumatic Fever Diagnosis
Two major OR one major with two minor criteria PLUS
Evidence of antecedent group A streptococcal infection
-Positive throat culture or rapid antigen test for group A streptococcus
-Raised or rising ASOT (>250 IU/ml)
Major Criteria Minor Criteria
Carditis Fever
Polyarthritis Arthralgia
Chorea C-RP or ESR elevated
Erythema Marginatum Prolonged PR interval on ECG
Subcutaneous nodules
Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the
Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in
the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.

22. Jones Criteria (1992)
Acute Rheumatic Fever Diagnosis
Two major OR one major with two minor criteria PLUS
Evidence of antecedent group A streptococcal infection
-Positive throat culture or rapid antigen test for group A streptococcus
-Raised or rising ASOT (>250 IU/ml)
Major Criteria Minor Criteria
Carditis Fever
Polyarthritis Arthralgia
Chorea C-RP or ESR elevated
Erythema Marginatum Prolonged PR interval on ECG
Subcutaneous nodules
Guidelines for the diagnosis of rheumatic fever. Jones Criteria, 1992 update. Special Writing Group of the
Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the Council on Cardiovascular Disease in
the Young of the American Heart Association. JAMA. 1992 Oct 21;268(15):2069-73.

23. -
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3. Axiom: ging a solitary
in mana