I have recently heard the quote, “the eyes do not see what the mind does not know” & feel it is incredibly applicable to this particular case, which some of you may have seen recently in one of my Tweets.
A 10 year old Samoan presents to our ED with ‘asthma.’ She is febrile (39.4*C), tachycardic at 124 / min (sinus), with a systolic BP of 124 mmHg & has room air saturations of 93%. She is wheezy, no doubt about it; and has a prolonged expiratory phase with pursed lip breathing. However, she is also clammy and pale. Her grandfather reports this is the first time she has had “asthma”, let alone any other respiratory illness. He also mentions that the GP has been treating her for “gout” over the past 1-2 years.
I am asked to review her at 5am as her salbutamol therapy does not appear to be helping. My routine is to xray all ‘first time wheezers’ especially if the story is a little odd. This is hers…
(No doubt, a film I’m used to seeing at 5am – but typically in a 75 year old with APO).
My interpretation was cardiomegaly, upper lobe diversion ?CCF. I took my trusty Sonosite to the bedside & tried my hand at a quick ECHO.
To my eyes, her LA appeared dilated (at least twice the size of her aorta on parasternal long axis). So we trialled some frusemide & she was breathing somewhat better by the time the Paediatricians had seen her in the AM & I went home to bed…
By the following evening, she had been transferred to PICU at our tertiary paediatric centre with a diagnosis of cardiac failure & severe mitral regurgitation, secondary to Rheumatic Fever. Presumably the “gout” she was being treated for was an aseptic monoarthritis.
This case led to me revisiting the diagnostic criteria of Rheumatic Fever. The following table can be found on the Heart Foundations free download (1).
The high-risk groups in Australia include Aboriginal and Torres Strait Islanders, Maoris & Pacific Islanders and those from developing countries.
What to look out for:
- Arthritis: Most common finding. Extremely painful. Mono-arthritis (usually large joints) in high-risk populations, otherwise asymmetrical & migratory. Resolves within 3 days of NSAID treatment.
- Sydenham’s chorea: present in ~25% of ARF (particularly Aboriginal females & adolescents). Jerky uncontrolled movements (hands, feet, tongue & face). Resolves with sleep.
- Carditis: usually an apical holosystolic murmur.
- Subcutaneous nodules: rare, but highly specific. Strongly associated with carditis. Crops of small, round & painless nodules (elbows, wrists, knees & ankles).
- Erythema marginatum: extremely rare.
Our goals for the ED:
Early identification and treatment of symptomatic group-A streptococcal pharyngitis in those at-risk populations. The mainstay of this therapy is benzylpenicillin.
- Not everything that wheezes is asthma (even in a 10 year old).
- Question your diagnosis if your therapy is not working.
- Consider your at-risk populations next time you see that sore throat.
I hope you found this useful…..