Case Summary

Adam, an 11-year old Malay boy presented complain of swollen knee and ankle joints, along with
fever and shortness of breath.
He experiences shortness of breath when lying down flat, had a fever that comes and goes at
random times of the day. He also complains that his right knee was painful and swollen but
improved. After that, his left knee and right ankles are swollen and painful to touch.
He has a history of throat infection 3 weeks ago but doesn’t take any medications. He lives in a
remote community. He is a very active person before he experiences the illness.
Upon physical examination, he appears anxious, fatigue and tachypnoeic. For further investigation,
he has high body temperature (38.2°C), high pulse rate (160 beats per minute), high respiratory
rate (35 breath per minute) and low blood pressure (95/60 mmHg). He has normal oxygen
saturation (94%). Upon head, ears, nose and throat (ENT) examination, they are normal. For the
respiratory examination, there is bibasal lung crepitation. Upon cardiovascular examination, there
is heart sounds at S1 and S2 with pan-systolic murmur 3/6 heard at the apex with radiation to the
axilla. No gallops are heard. Apex beat is displaced at the 6th intercostal space in the mid-axillary
line. JVP is elevated. Upon the abdominal examination, the abdomen is soft with active bowel
sounds. Liver edge is 2 to 3 cm below the right costal margin. For examination of extremities, his
left knee is swollen and tender and warm. He also has difficulty with range of motion but can flex
his knee 30 degrees passively. Right ankle is swollen and warm. He has limited subtalar motion.
But his knees and ankles are tender to touch. Upon neurologic examination, there are no abnormal
movements of arms, hands or tongue are noted. He is unable to walk due to pain.
Upon laboratory findings, for the Full Blood count. He has high level of WBC (20x109 )/L, high
level of Lymphocytes (55%), normal level of RBC (4.5x1012 /L), normal level of HCT (39%),
normal level of HGB (12g/dL), normal level of MCV (85), normal level of MCH (26pg), normal
level of MCHC (33%), normal level of platelets (200x109 /L), high Erythrocyte sedimentation rate
(48mm/hr), high C-reactive protein (83 mg/dL). Upon imaging study, chest X-ray shows
cardiomegaly, with pulmonary oedema. Electrocardiogram shows prolonged PR interval.
Echocardiogram shows a severe degree of mitral valve regurgitation. Ejection fraction is low.
Upon anti-streptococcal antibodies, high level of Anti-streptolysin O titer (1541 IU/ml), high
amount of streptozyme (600 units), high amount of anti-deoxyribonuclease B antibody (2720
units). Unremarkable for urine analysis and negative throat culture.
In conclusion, he is diagnosed with Acute Rheumatic Fever (ARF). He is administered with
oxygen face mask, he is treated with oral penicillin G benzathine, corticoticosteroid and aspirin.
He also treated for congestive heart failure. He is discharged home with instruction to receive oral
penicillin G benzathine 250 mg twice a day for 10 years.