Atypical arthritis revisited: Acute rheumatic fever
Jones criteria, first devised in 1944 for the diagnosis of acute rheumatic fever (ARF) and its subsequent modifications [American College of Cardiology/American Heart Association (ACC/AHA,1992)], did not provide any caveat for the unusual and atypical articular presentations of this disease that may lead to errors or to delays in diagnosis.[1] The fact that atypical form of the acute phase of the disease exists especially in the presence of atypical articular manifestations and passes unrecognized, is because of its heterogeneous presentation and lack of a specific pathognomonic diagnostic test.[2] This diagnostic difficulty is accentuated in patients who present with arthritis as the only clinical manifestation of the disease.
Atypical articular manifestations, such as in this case, poses a real challenge for the physician as overdiagnosis leads to undesirable stigma and exposure of patients to unnecessary prophylaxis while underdiagnosis leading to the development of rheumatic heart disease (RHD), which is preventable.
A 13-year-old boy presented with complaints of joint pain and fever on and off for the last 3 years. Initially, ankle joints were involved followed 6 months later by both knee and vertebral spine (cervical and lumbosacral region). Joint pain was bilaterally symmetrical, nonmigratory, and increased on rest and at terminal movements. He could not sit, move his neck, and had difficulty turning in bed. It got partially relieved on medication but the patient was really never off the pain. There was no swelling and deformity of the joints....