Rheumatic fever with Sydenham's chorea

A 7 year old girl developed muscle soreness, trouble walking and a painful and swollen left ankle five months before this hospitalization. This resolved within 24 hours. Two weeks later, the patient developed stiffness in the right hand and inability to open it. This also resolved in one day. Two weeks prior to admission, the patient developed dysarthria, and difficulty with writing and using a spoon. On physical examination, she was found to be fidgety and to have choreiform movements and occasional facial grimaces. The physical examination was otherwise normal. The chorea was characteristic of Sydenham's chorea and the preceding history of fleeting migratory polyarthritis led to a diagnosis of acute rheumatic fever. There was no evidence of carditis. Echocardiography showed mild mitral and aortic regurgitation but that was considered probably unrelated to the rheumatic fever. Rheumatic fever is much less common than in the past but remains the most common cause of acute chorea seen in children. In rheumatic fever, the arthritis usually is a fleeting migratory polyarthritis, involving the large joints of the lower extremities, with pain out of proportion to the objective findings. Sydenham's chorea and arthritis in rheumatic fever do not occur at the same time. Most often, Sydenham's chorea follows the arthritis weeks, months or even years later. The cause of rheumatic fever is still Streptococcus pyogenes but 25 to 50% of cases follow a mild infection that does not lead the parents to seek medical treatment. Patients who have had rheumatic fever should receive penicillin prophyllaxis at least until their early adult years. Longer prophylaxis is indicated in individuals who have had an episode of carditis.