Grand rounds in rheumatology: acute rheumatic fever or post-streptococcal reactive arthritis: a clinical problem revisited.

F several years, evidence of a resurgence of group A We concluded that this 42-yr-old female developed a pauciarticular migrating arthritis of the larger joints b-haemolytic streptococcal (GAS) infections and their non-suppurative sequelae has been reported. A new 10 days after a primary pharyngitis. Simultaneously, she had fever and an erythema nodosum as well as problem clinicians may currently encounter in practice is related to the suggestion that post-streptococcal erythema multiforme. For the differential diagnosis, one should focus on the triad fever, (oligo)arthritis reactive arthritis (PSRA) is an entity separate from acute rheumatic fever (ARF). We describe the clinical and erythema (see Table I ); sarcoidosis, inflammatory bowel disease and reactive arthritis, especially secondpresentation of three representative patients with PSRA, and discuss the clinical implications of dissimilary to bacterial infections with Yersinia or streptococci, are the main causes. As the chest X-ray was normal, arities from ARF. sarcoidosis was less likely. There were no signs or CASE REPORTS symptoms of inflammatory bowel disease. Yersiniosis was not very likely as serological screening and stool Patient 1 In 1992, a 42-yr-old Moroccan female was seen at culture were negative. The combination of erythema nodosum and erythema multiforme was suggestive of the out-patient department of rheumatology. She had been living in Holland for >10 yr, and had recently a preceding streptococcal infection. So far, this patient was most likely to have PSRA. spent her holidays in Morocco. She returned to the Netherlands and 2 weeks later she went to her general Treatment consisted of daily diclofenac 150 mg, and penicillin prophylaxis, 1.2 million U i.m. monthly, for practitioner (GP) because of a sore throat. Because of this sore throat, supposedly due to infection, feneticillin a period of 2 yr was advised. No complications were seen during follow-up. Within 2 weeks after treatment was prescribed. Ten days later, a migrating arthritis of the wrists and knees developed, and this immobilized was started, all complaints of arthritis subsided. Serological monitoring of ASO was obtained: ASO her. Her body temperature was 38°C. On physical examination, she had erythema multiforme on her became 470 U/l 2 months later, 250 U/l 6 months later, 220 U/l 1 yr later and 180 U/l 2 yr later. Antihands and erythema nodosum on the extensor side of the lower arms and legs. Both erythemas were conDNase-B titres were not measured in our laboratory at that time, except for the two latter time points, firmed by a consultant dermatologist. She also had pain of the right shoulder (capsular pattern), sternoclarevealing values that were not elevated. vicular joints and both ankles without signs of arthritis. There was no cardiac murmur and further physical Patient 2 examination revealed no relevant abnormalities. To In 1996, we saw a 29-yr-old female who worked as exclude septic arthritis and crystal arthropathy a joint a nurse. She had a sore throat with myalgia and fever puncture was performed, which was hardly productive. up to 39°C. She recovered spontaneously. Eleven days Both causes could be excluded though. Laboratory later, however, she complained about tenderness of investigations: erythrocyte sedimentation rate (ESR) several joints. Three weeks after the implicated throat 90 mm/h; leucocyte count 13× 109/l with normal infection, she started to complain about swelling and differentiation. Throat culture was negative. X-rays of tenderness of the left elbow with painful nodules at the thorax and electrocardiography showed no abnorthe extensor side of her lower arms. Several days later, malities. Serological tests were negative for Rose, latex, she had pain in both elbows, both knees, and in her IgM rheumatoid factor (RF), antinuclear antibodies left ankle, which was also swollen. Objective findings (ANA) and Yersinia. Anti-streptolysin-O antibodies on physical examination were erythema nodosum on (ASO) were 1040 U/ml at presentation; an antithe left lower leg and arthritis of the left ankle. Her DNase-B titre was not obtained. throat had a normal appearance. There was no cardiac murmur. Joint aspiration was hardly productive, but was performed to exclude septic arthritis and crystal Submitted 9 July 1997; revised version accepted 9 September 1997. arthropathy. Laboratory investigations: ESR 82 mm/h; Correspondence to: P. L. C. M. van Riel, Department of leucocyte count 8.5×109/l. Four and eight weeks later: Rheumatology, University Hospital Nijmegen, St Radboud, PO Box 9101, 6500 HB Nijmegen, The Netherlands. ESR, respectively, 46 and 10 mm/h; leucocyte count