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Renal failure
14%
17/123
Hepatomegaly
6%
7/123
Chorea
67%
83/123
Pleural effusion
3%
4/123
Butterfly rash
8%
10/123
Select Answer to see Preferred Response
The clinical picture of polyarthritis of the lower extremities and subcutaneous nodules following a pharyngitis is consistent with rheumatic fever (RF). RF may result in Sydenham's chorea, a characteristic series of rapid, purposeless movements of the face and arms. Sydenham’s chorea typically occurs 2-3 months after a group A beta-hemolytic streptococcal (GAS) throat infection and is reported to occur in 20-30% of patients with acute rheumatic fever. It is postulated that this chorea occurs as a result of an autoimmune cross-reaction between GAS antigen and cells within the basal ganglia. Additional clinical manifestations of rheumatic fever include carditis, arthritis, erythema marginatum, and subcutaneous nodules. Armstrong emphasizes that while the overall incidence of acute RF is low in the US, it, along with rheumatic heart disease, is the leading cause of cardiovascular death during the first five decades of life in developing countries. Rheumatic fever can be prevented with adequate antimicrobial therapy for GAS pharyngitis. Intramuscular penicillin G benzathine, oral penicillin V potassium, and oral amoxicillin are recommended agents for individuals without penicillin allergy. Zomorrodi and Wald, in a retrospective chart review in an area endemic for acute RF, noted that 99% of 53 children who presented with chorea and were tested were found to have an antecedent GAS infection documented. For most patients, the condition was self-limiting within 6-12 weeks. Illustration A depicts the multiple organ systems and symptoms associated with acute rheumatic fever. Incorrect Answers: Answer 1: Renal failure may result from post-streptococcal glomerulonephritis, but this clinical picture is more consistent with rheumatic fever and the associated conditions. Answers 2 & 4: Hepatomegaly and pleural effusions are not complications of rheumatic fever or related to group A strep pharyngitis. Answer 5: A malar, or butterfly rash, is a component of systemic lupus erythematosis. It is not related to infection with group A strep.
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