Polyarthritis following a streptococcal infection, a doctor's dilemma in treatment
A 25 year old male presented with two weeks of pain and swelling in knees and ankles. The symptoms began in right knee, after he experienced minor trauma. He sought emergency room care and was discharged home on ibuprofen after x-rays were negative. The pain and swelling gradually spread to his left knee and right ankle. At a follow up orthopedic visit, medication was continued. His symptoms worsened and impeded his ability to walk.
On admission, the patient also complained of new onset of some left metacarpophalangeal joint (MCP) and distal interphalangeal joint (DIP) joint tenderness. He denied fevers, chills, shortness of breath, or headaches, but described progressive fatigue over a few weeks. He reported a sore throat 6 weeks prior, treated with amoxicillin for 7days. This was followed by diarrhea which resolved in one week.
The most likely diagnosis of this presentation is
Acute Rheumatic Fever (ARF) disease is most commonly found in children, and it can manifest in different ways. ARF can present with migratory arthritis involving primarily the large joints, carditis and valvulitis, central nervous system involvement, rash, or any combination of these. For diagnosis of ARF, the presence of two major or one major and two minor manifestations and evidence of a preceding group A streptococcal infection is required. A positive throat culture for group A beta-hemolytic streptococci, positive rapid streptococcal antigen test, or elevated or rising streptococcal antibody titer are all acceptable.1 The treatment for ARF involves antibiotic therapy and anti-inflammatory agents.
The literature cites cases where arthritis following a streptococcal infection was not due to ARF. These patients generally presented with only arthritis, occurring up to 10 days after an episode of a streptococcal infection, compared with the average of 21 days seen in ARF.2 They experienced prolonged or recurrent arthritis, lasting an average of 2 months. The arthritis seen in ARF is found to last 1-5 days with complete resolution in 3 weeks. 2,3 In children, Post Streptococcal Reactive Arthritis (PSReA) is distinguished from ARF due to the presence of other major criteria including carditis, polyarthritis, chorea, Erythema marginatum, and subcutaneous nodules. The minor criteria includes arthralgia, fever, elevated erythrocyte sedimentation rate, elevated C-reactive protein, or prolonged PR interval. In adults, differentiating between two diseases is not as clear. 4 In regard to treatment the major difference between the two disease is that antibiotic prophylaxis is not recommended in adults diagnosed with PSReA due to lack of evidence of progression to ARF or development of cardiac sequelae, but required in managing ARF .2
He had no medical, surgical history, and family history. He denied the use of cigarettes, alcohol, or illicit drugs. He stated he was currently sexually active with other men. There was no recent travel history, or sick contacts.
The temperature was 100.6 F, synovitis and effusions in both knees L>R; right ankle and fifth DIP showed periarticular involvement, tenosynovitis and swelling over the dorsum of the left hand. All involved joints were erythematous and exquisitely tender with a decreased range of motion. There was no evidence of a rash, spine tenderness or cardiac murmur. CBC demonstrated a WBC count of 16.4 (84% polys), platelet count of 1084K, and ESR was 115. Knee arthrocentesis yielded cloudy yellow fluid (WBC 7,350 with 56% polys), with negative cultures. HIV, urethreal Gonococcal and Chlamydia testing, Rheumatoid Factor, Antinuclear Antibody (ANA), C. difficile toxins, blood cultures, stool cultures, and throat cultures were negative. The Anti Streptolysin O (ASLO) titer was elevated at 518 (normal <200). EKG demonstrated sinus tachycardia, with a normal PR interval. A transthoracic echocardiogram was unremarkable.
Sulindac 200 mg orally twice daily, the symptoms persisted and a taper of prednisone starting at 40 mg/d orally was required for relief. After discharge he continued to respond well to corticosteroid therapy, and regained strength.
The patient fulfilled the modified criteria for ARF (major: arthritis; minor: fever and elevated ESR), without fitting the typical disease presentation. He also fits the criteria for PSReA: adult, arthritis > 3 weeks, no carditis, poor response to NSAID therapy, and absence of other major Jones criteria. 4 It is difficult to distinguish ARF from PSReA, but necessary in determining the need for antibiotic prophylaxis. This patient would likely be exposed to streptococcus again due to his occupation as a teacher of young children, so our clinical judgment led us to place him on penicillin prophylaxis for at least five years.
Due to overlap in the diagnostic criteria for Acute Rheumatic Fever and Post Streptococcal Reactive Arthritis in adults, the need for penicillin prophylaxis should be individualized based on exposure risk.
- Carapetis JR, McDonald M, Wilson NJ: Acute Rheumatic Fever. The Lancet 2005, 366:155-168.
- Aviles RJ, Ramakrishna G, Mohr DN, Michet CJ Jr: Poststreptococcal reactive arthritis in adults: a case series. Mayo Clinic Proceedings 2000, 75:144-147.
- Jansen TL, Janssen M, de Jong AJ, Jeurissen ME: Post-streptococcal reactive arthritis: a clinical and serological description, revealing its distinction from acute rheumatic fever. J Intern Med 1999, 245:261-267.
- Gibofsky A, Zabriskie J: Rheumatic fever and poststreptococcal reactive arthritis. Current Science 1995, 7:299-305.