Medical Emergencies · patient case question
What is the principal long-term consequence of the episode of acute rheumatic fever she had as a child?
Patient case: Childhood rheumatic fever, prosthetic valve and penicillin allergy
Patient: Female, 57 years old
Chief Complaint: “I was told I need this tooth out before anything else.”
Background: Rheumatic fever at age nine following untreated streptococcal pharyngitis. Prosthetic aortic valve placed one year ago. Documented anaphylaxis to penicillin.
Vital Signs: BP 124/76 mmHg · HR 72 bpm · T 98.2°F
Findings: Non-restorable tooth #14. Generalized gingivitis. No acute swelling.
Show answer and explanation
Correct answer: A. Chronic rheumatic heart disease with valvular scarring
- A. CORRECT. Acute rheumatic fever follows Group A streptococcal pharyngitis, when antibodies to the streptococcal M protein cross-react with host tissue. The carditis is what persists: repeated or severe valvulitis scars the valve leaflets, producing CHRONIC RHEUMATIC HEART DISEASE — most often MITRAL stenosis, then aortic disease. That valvular damage is why this patient has a prosthetic valve, and why she now falls into the highest-risk category for infective endocarditis.
- B. Systemic lupus erythematosus is an antinuclear-antibody-associated multisystem autoimmune disease with no causal link to streptococcal infection.
- C. Rheumatoid arthritis is a distinct, chronic, symmetric autoimmune polyarthritis associated with anti-CCP antibodies and rheumatoid factor. Despite the similar name it is NOT a sequela of rheumatic fever. The arthritis OF rheumatic fever is a migratory, large-joint arthritis that resolves completely and leaves no deformity.
- D. Ankylosing spondylitis is an HLA-B27-associated spondyloarthropathy of the axial skeleton, unrelated to rheumatic fever.
Note: ⚠️ SOURCE NOTE. The recall keyed this item to 'rheumatoid arthritis'. That is incorrect — the two conditions share a word and nothing else. The examinable sequela is chronic rheumatic HEART disease. Mnemonic for the Jones major criteria: J♥NES — Joints (migratory polyarthritis), ♥ carditis, Nodules (subcutaneous), Erythema marginatum, Sydenham chorea.
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