1. Chapter 6 Fever
(and joint pain)

2. Case study: Mere
Mere is an 11 year old girl brought to hospital after 4 days of fever. She has pain in her right knee that is preventing her from walking.

3. What are the stages in the management of Mere?

4. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment
History and examination
Laboratory investigations, if required
Main diagnosis and other diagnoses
Treatment
Supportive care
Monitoring
Discharge planning
Follow-up

5. Have you noticed any emergency (danger) or priority (important) signs?
Temperature: 38.90C, pulse: 110/min, RR: 20/min; no cyanosis, CR 1 second, alert

6. Triage Emergency signs (Ref. p. 2, 6) Obstructed breathing
Severe respiratory distress
Central cyanosis
Signs of shock
Coma
Convulsions
Severe dehydration
Priority signs (Ref. p. 6)
Tiny baby
Temperature
Trauma
Pallor
Poisoning
Pain (severe)
Respiratory distress
Restless, irritable
Referral
Malnutrition
Oedema of both feet
Burns

7. (Ref. p. xxii, Chart 1)

8. History and examination in a child with fever
What are key questions to ask on history?
(Ref. p. 150)
What are key things to look for on examination?

9. History
Mere was apparently well until 4 days ago when she developed a fever. She also had a painful left ankle for 2 days. Yesterday, she developed right knee pain with swelling and is now unable to walk. 2 weeks prior she had a sore throat that was treated by her aunty with a Fijian herbal remedy. She has had no rashes, no neck stiffness, no abdominal pain. She is not eating, but drinking OK.
Past history: Mere had a similar episode of sore joints 1 year ago.
Family history / social history: lives in a rural village with her large extended family.

10. Examination Assess signs of systemic illness
Temp: 38.9ºC Pulse: 110/min RR: 20/min BP 115/65 mmHg
Assess chest and heart
Chest clear, systolic murmur loudest at the apex and radiating to the axilla. No thrill. Apex beat normally placed.
Assess abdomen
Soft to palpation, normal bowel sounds, no organomegaly
Assess neurological state
AVPU = A (alert), no neck stiffness, pupils equal and reactive
Assess skin
No rashes
Assess nutritional state
Height: 135 cm Weight: 30 kg
Assess MSK
Hot and swollen right knee that is very tender to touch
(Ref. p.150, p.154)

11. History and examination in a child with fever
What category of fever is Mere presenting with?
(Ref. p.152)
Fever with no localising signs (no rash)
Fever with localising signs (no rash)
Fever with rash
(Fever lasting longer than 7 days)
Fever plus arthritis

12. Differential diagnoses
List possible causes of the illness
Main diagnosis
Secondary diagnoses
(Tables 16, 17, 19 may be helpful)
Differential diagnoses:
Septic arthritis
Rheumatic fever
Dengue
Viral arthritis (reactive)
Other…

13. What investigations would you like to do?

14. Joint aspiration?
If septic arthritis is suspected then a joint aspirate should be undertaken.
What are the features of septic arthritis?
( Ref p )
Arthritis unaccompanied by other major
features of rheumatic fever requires differential diagnosis

15. Investigations for acute rheumatic fever
FBE
ESR (CRP)
ASOT
ECG
CXR
Throat swab
Echocardiogram

16. Investigations Full blood examination: Haemoglobin: 110g/l (115-140)
Platelets: 450x109/l (150 – 400)
WCC: x109/l (5.5 – 15.5)
Neutrophils: 7.9x109/l (1.5 – 8.5)
Lymphocytes: 4.0x109/l (2.0 – 8.0)
Monocytes: 1.2x109/l (0.1 – 1.0)

17. Investigations (continued)
Blood culture: sent, awaiting cultures
ESR: sent, awaiting result
ECG: normal
CXR: normal
ASOT: sent, awaiting result

18. Diagnosis Summary of findings:
History: 11 yo girl with past history of joint pains presents with polyarthritis
Exam: fever but non-toxic with right knee arthritis and a heart murmur
Investigations : mild anaemia, mild leukocytosis, elevated ESR

19. Diagnosis
Likely acute rheumatic fever

20. Stages in the management of a sick child (Ref. Chart 1, p. xxii)
Triage
Emergency treatment, if required
History and examination
Laboratory investigations, if required
Differential diagnoses
Main diagnosis
Treatment
Supportive care
Monitoring
Plan discharge
Follow-up, if required

21. Treatment  Aspirin (Ref p. 357) Benzathine penicillin G (Ref p. 367)
 Suspected acute rheumatic fever
 Aspirin (Ref p. 357)
Benzathine penicillin G (Ref p. 367)

22. Supportive Care
Fever control
Pain control
Bed rest
Nutrition

23. Monitoring Using a monitoring chart (Ref. p. 320, 413)
Assess response to treatment (Ref .Chart 1 p.xxii; p. 319)
Follow-up results
ASOT 1600
BC negative
ESR 88 mm/h

24. Discharge plan
Mere responds quickly to the aspirin and her joint pain reduces significantly within 2 days; her fever also reduces
She is able to walk adequately
She is eating well after 2 days
She has no problems with the medication
She and her parents are educated about rheumatic fever and rheumatic heart disease and given printed information
Aspirin is provided with a clear dosage plan
Benzathine penicillin G already started
A clear plan is made for follow-up visit

25. Follow-up Regular benzathine penicillin G every 28 days
Register the patient on the PNG RHD Register
Echocardiogram and paediatric review
Reinforce education
Advise Mere’s mother when to bring her back if unwell

26. Acute Rheumatic Fever

27. Diagnosis of acute rheumatic fever
WHO Guidelines
Major manifestations
Polyarthritis
Carditis
Chorea
Erythema marginatum
Subcutaneous nodules
Minor manifestations
Polyarthralgia
Fever,
Elevated inflammatory markers
Prolonged PR interval on ECG
Evidence of antecedent Group A Streptococcus infection in the last 45 days
Elevated or rising streptococcal antibody titre (ASOT)
Positive throat swab

28. Diagnosis of acute rheumatic fever
WHO Guidelines
Primary episode of acute rheumatic fever
Two major OR one major and two minor
Evidence of Group A Streptococcal antecedent
No History of RHD
Other forms exist
Recurrent episode with and without RHD
Rheumatic chorea (chorea only)
Insidious onset rheumatic carditis (carditis only)
Chronic valve lesions of RHD

29. Summary
Careful history taking, examination and the limited investigations pointed towards a diagnosis of acute rheumatic fever
However, other causes of fever and joint pain should be excluded or treated, e.g. Septic arthritis
Acute rheumatic fever should be considered whenever a child presents with a history of joint pain.
Acute rheumatic fever carries a risk of progression to rheumatic heart disease and therefore long term secondary prevention is essential.