Fever, pain, and a heart murmur

Posted: February 09, 2014

After rushing around since before dawn to get his daughters ready for day care - dropping them off, running for the bus, then finally closing his eyes for a moment on the way to work - he realized his right knee had been throbbing with pain the whole time. What now? he wondered.

He looked back on a week of strange symptoms. Aches in his wrists had begun a week ago, lasted for more than a day, and went away. Then came pain and swelling in his left ankle. That lasted a few more days. And now the knee. On a typical day, between caring for his girls and trying to impress at his new custodial job, he felt he didn't even have time to eat, much less worry about joint pain or the sweat-drenched pajamas he'd awakened with the last few nights. But now, as he thought of it, he probably had been running a fever for a few days, too.

That night, he took some ibuprofen for the pain and felt a good deal better. It even seemed to knock out the fever. But after a few hours on the job the next day, he was exhausted. His supervisor saw him sweating and weak and insisted he see a doctor.

The nurse signed him in and measured his vital signs. His fever was high, his heart was racing, and his blood pressure was low, she said. The doctor rushed in to examine him while he explained his symptoms. Worried about his low blood pressure, she sent him to the emergency room, where it improved after he received some fluids. But without a clear picture of what was going on, the ER team recommended admitting him.

The patient refused. He had to pick up his girls. "We aren't sure what is going on and this could be serious," the ER physician told him. "Call someone to bring them in and stay here." The patient made some calls. Hours passed. It wasn't until he caught sight of them in the hall holding their day-care teacher's hands that he could relax.

At that point, he'd told his story to what seemed like five doctors and nurses. Now, in the relative quiet of his hospital room, the medicine resident came in to talk to him while his girls played close by.

After going over the patient's story yet again, the physician glanced over at the girls. "How have the girls been doing?" he asked. "When was the last time they were sick with anything?"

It was a month ago. The older child had high fever and complained that her mouth hurt. Her father had taken her to a pediatrician, who did a test, diagnosed her with strep throat, and gave her a course of antibiotics. "Did you get sick too?" the doctor asked the patient.

The patient thought back. "Actually, I guess I also had a sore throat for a few days after that, but it went away on its own and I ignored it."

Then came another physical exam. Is it abnormal? the patient wondered after the physician listened to his heart for what seemed an eternity.

"There is a murmur. Have you been told that before?"

He hadn't.

"It probably means that one of your heart valves has a little leakiness. We'll do an EKG and an echocardiogram - an ultrasound of the heart - to get a better idea as to what exactly it looks like. Meantime, we'll do a few more blood tests."


Solution:

After saying the patient needed more blood tests, the physician saw his eyes widen with anxiety.

He sat down to explain. "We'll get to the bottom of this. I think you could have something called acute rheumatic fever, but I'm not sure and I've never seen a case. I'll do some reading and call some experts."

When strep throat, caused by group A streptococcus, goes untreated, the majority of the time the sore throat gets better on its own within a week without consequences.

Rarely, though, the body's immune system reacts to the infection and forms antibodies that also react to native tissue - whether it's within joints or heart valves - leading several weeks after an untreated case of strep throat to acute rheumatic fever.

The disease has become exceedingly uncommon in the United States, but is still seen often in several areas of the world, most commonly in children.

Diagnosing rheumatic fever relies on a group of findings and tests rather than one single clincher.

The resident sat down to think about the patient and review the criteria.

"Migratory arthritis?" Clearly the patient had that. Right now, he had swelling in his right knee, and it seemed several other joints had been involved earlier in the week. He didn't have the classic rash or nodules or the abnormal movements seen more often in children. But he did have fever, and, with this new murmur, the resident was worried about heart involvement - carditis. He ordered an antibody blood test to check for the strep antibodies seen in rheumatic fever.

He also started the patient on aspirin, which reduced the inflammation and fever and dramatically eased his symptoms. The echocardiogram the next day confirmed carditis, and the blood test confirmed high antibody levels. All were consistent with rheumatic fever.

The biggest danger with rheumatic fever is recurrent episodes after being reexposed to group A strep. Over time, that can lead to severe damage to heart valves, eventually causing heart failure, the need for valve surgeries, and death. To avoid recurrence, preventive penicillin is recommended to prevent strep infection in these patients.

After hearing he would need to be on penicillin for many years, the patient was relieved to learn that he could go to a clinic for a monthly shot rather than take pills. He knew he had a good chance of forgetting the pills as he juggled his day.

"Don't worry, Daddy, we'd remind you," his older daughter whispered in his ear as the little one smiled in his lap. 


Valerianna Amorosa is an infectious-disease doctor at the Hospital of the University of Pennsylvania and the Philadelphia VA Medical Center. valerianna.amorosa@uphs.upenn.edu

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