UST Department of Pediatrics

Pediatrics 2-Module 1
Gastroenterology-Hematology-Cardiology module
Student’s guide on acquired heart diseases

“Jumping Jumbo Joints”

Case:
Ruru is a a previously healthy 9-year-old boy who presented to the emergency room with joint
pain and swelling. According to his parents, he had intermittent fever (Tmax 38.7C) 3 days prior
to consultation associated with pain & swelling on the R knee, the following day, the pain moved
to the L knee, this morning, he woke up with pain on his R ankle and had difficulty in
ambulation, this prompted consultation at the ER.
Review of systems revealed no weight loss, no anorexia, no diarrhea with good urine output.
Past medical history showed that he had a fever and sore throat (2 weeks prior to this illness)
that lasted for 5 days. He was given Paracetamol 250mg/5ml, 5 ml as needed for fever &
gargled with warm salt solution which apparently resolved the symptoms after a week. No
medical consultation was made.
He is a grade 3 student with average performance. Immunizations were completed at the local
health center up to 1 year of age. Family history was non-contributory.
PE upon arrival in the triage showed that Ruru was alert, oriented, wheelchair borne. He had an
axillary temperature of 38.5°C . His vital signs were as follows: BP 90/60, heart rate 120
beats/min; respiratory rate, 21 breaths/min; and oxygen saturation, 99% on room air. He
weighed 30 kgs. On further examination, he had no rash, tonsils were not enlarged nor
hyperemic, no enlarged cervical lymph nodes. His lungs were clear, chest was adynamic with a
grade 3/6 systolic murmur at the apex. Abdomen was benign with no hepatosplenomegaly. His
right ankle was warm, non-erythematous, non-tender, swollen with 1+ effusion and pain limited
range of motion. Other joints were normal with full range of motion. Neurologic examination was
normal as well.
Guide questions:
1. Give the salient features of the case
2. What is your primary impression and give the basis?
3. What are some of your differential diagnoses for a pediatric patient presenting with fever
associated with arthritis +/- carditis?

4. Interpret the diagnostic work ups that were done on Ruru.

CBC: Hgb 11.2 g/L, white blood cell count of 9 × 103 μ/L (9.9 × 109/L), segmenters .60,
lymphocytes .40, platelet count of 495 × 103/µL (495 × 109/L)
C-reactive protein level of 84.3 mg/L (reference range: < 1mg/dl)
Erythrocyte sedimentation rate of 93 mm/hr. (reference range: 0-20 mm/hr)
Antistreptolysin O titers were 4,133 IU/ml (reference range: <150 IU/ml)
Vetricular rate 120 bpm
PR interval 0.08 (NV for age .08-.16)

2D echo- severe mitral regurgitation

 5. Are the laboratory and ancillary tests results confirmatory of Acute Rheumatic Fever?
6. How will you manage Ruru?
7. Will your management change if the patient presents with cardiomegaly and signs of
congestive heart failure? If yes, what will be your treatment?
8. What is the recommended secondary prevention for Ruru?
9. Why is there a need for antibiotic prophylaxis in patients with acute rheumatic fever?

Reference: Nelson’s Textbook of Pediatrics 21st edition pages 1445-1450