DrMahak Bhasin,DrSajitha Nair
DrSathyajith Nair DrSindhu Ambujakshi DrSreya Nair ,DrC Jayakumar
Dept of paediatrics
AIMS
Kochi
Kerala
Fifteen year old girl developed acute onset of fever of 102F of 6 days duration associated with erythematous pruritic rashes over bilateral upper and lower limbs. Child was treated symptomatically for the same and experienced improvement intermittently. However, on Day 6, she again developed high grade intermittent fever—
This time associated with left knee swelling, erythema, local rise of temperature and restriction of movement.
No history of sore throat, recent trauma, loose stools or blood per rectum ,petechiae, urinary complaints, weight loss, early morning stiffness, back pain, facial rashes, alopecia, oral ulcers, visual blurring, redness or pain in the eyes.
No previous history of such complaints.
No similar family history either. No family history of psoriasis.
Developmentally normal, immunised for the age
On examination, child was febrile and sick looking. Other vitals normal
Mild pallor was present.
She was obese with acanthosis nigricans. Throat was mildly congested and she had clinically palpable non tender liver with span of about 14cm. No spleen
Left knee joint was swollen with erythema and local rise of temperature. Flexion and extension movements of the joint were limited.
All other joints were normal.
At this point, our differentials were
Septic arthritis
EBV Infection
Dengue
Rickettsial infection
Salmonellosis
Chikungunya fever
SLE
Reactive Arthritis
Pauci articular Rheumatoid-arthritis
Rubella
Labs
Neutrophilic leukocytosis with Hb 11.6mg/dL. CRP was 38 and ESR 60.
ASO Titre/IgM EBV/ Dengue Panel/ IgM Brucella/ IgM Scrub Typhus/Widal/IgM Chikungunya were all negative.
ANA IFA and anti-dsDNA were normal. Blood and throat cultures were sterile. USG Knee and Xray knee were normal. 2D Echo showed an incidentally found small ostium secundum ASD Left to Right <4mm.
Child was started on Inj Augmentin and Tab Naproxen and over the course of one week,
her swelling and rashes subsided with inflammatory markers also becoming normal. HLA-B27 was sent and report is awaited.
She was thus discharged as case of Reactive Arthritis which is marked the acute nature of the disease.
It is characterized an interval of days-weeks between the antecedent fever and arthritis and typically manifests as a mono/oligo articular disease.
30-50% patients have elevated levels of HLA-B27. Radiological investigations are non-specific. Diagnosis is made on the basis of pattern of findings and exclusion of other diseases,.
Carry Home Message– Diagnosis of exclusion must be made only after excluding other causes.